We sought to determine the modifying effects of age and multimorbidity on the association between First Nations status and hospitalizations for diabetes-specific ambulatory care sensitive conditions ...(ACSC).
We identified 183,654 adults with diabetes from Alberta Canada, and followed them for one year for the outcome of hospitalization or emergency department (ED) visit for a diabetes-specific ACSC. We used logistic regression to determine the association between First Nations status and the outcome, assessing for effect modification by age and multimorbidity with interaction terms. In a model adjusting for age, age(2), baseline A1c, duration of diabetes, and multimorbidity, First Nations people were at greater risk than non-First Nations to experience a diabetes-specific hospitalization or ED visit (unadjusted odds ratio OR 3.74; 95% confidence interval CI: 3.45-4.07). After adjustment for relevant covariates, this association varied by age (interaction: p = 0.018): adjusted OR 3.94 (95% CI: 3.11-4.99) and 5.74 (95% CI: 3.36-9.80) for First Nations compared to non-First Nations at ages 30 and 80 years, respectively.
Compared with non-First Nations, older First Nations patients with diabetes are at greater risk for diabetes-specific hospitalizations. Older First Nations patients with diabetes should be given priority access to primary care services as they are at greatest risk for requiring hospitalization for stabilization of their condition.
There is randomised controlled trial (RCT) evidence that neuromuscular training (NMT) programmes can reduce the risk of injury in youth soccer. We evaluated the cost-effectiveness of such an NMT ...prevention strategy compared to a standard of practice warm-up.
A cost-effectiveness analysis was conducted alongside a cluster RCT. Injury incidence rates were adjusted for cluster using Poisson regression analyses. Direct healthcare costs and injury incidence proportions were adjusted for cluster using bootstrapping. The joint uncertainty surrounding the cost and injury rate and proportion differences was estimated using bootstrapping with 10 000 replicates.
Along with a 38% reduction in injury risk (rate difference=-1.27/1000 player hours (95% CI -0.33 to -2.2)), healthcare costs were reduced by 43% in the NMT group (-$689/1000 player hours (95% CI -$1741 to $234)) compared with the control group. 90% of the bootstrapped ratios were in the south-west quadrant of the cost-effectiveness plane, showing that the NMT programme was dominant (more effective and less costly) over standard warm-up. Projecting results onto 58 100 Alberta youth soccer players, an estimated 4965 injuries and over $2.7 million in healthcare costs would be conservatively avoided in one season with implementation of a neuromuscular training prevention programme.
Implementation of an NMT prevention programme in youth soccer is effective in reducing the burden of injury and leads to considerable reduction in costs. These findings inform practice and policy supporting the implementation of NMT prevention strategies in youth soccer nationally and internationally.
Kaplan–Meier survival analysis overestimates cumulative incidence in competing risks (CRs) settings. The extent of overestimation (or its clinical significance) has been questioned, and CRs methods ...are infrequently used. This meta-analysis compares the Kaplan–Meier method to the cumulative incidence function (CIF), a CRs method.
We searched MEDLINE, EMBASE, BIOSIS Previews, Web of Science (1992–2016), and article bibliographies for studies estimating cumulative incidence using the Kaplan–Meier method and CIF. For studies with sufficient data, we calculated pooled risk ratios (RRs) comparing Kaplan–Meier and CIF estimates using DerSimonian and Laird random effects models. We performed stratified meta-analyses by clinical area, rate of CRs (CRs/events of interest), and follow-up time.
Of 2,192 identified abstracts, we included 77 studies in the systematic review and meta-analyzed 55. The pooled RR demonstrated the Kaplan–Meier estimate was 1.41 95% confidence interval (CI): 1.36, 1.47 times higher than the CIF. Overestimation was highest among studies with high rates of CRs RR = 2.36 (95% CI: 1.79, 3.12), studies related to hepatology RR = 2.60 (95% CI: 2.12, 3.19), and obstetrics and gynecology RR = 1.84 (95% CI: 1.52, 2.23).
The Kaplan–Meier method overestimated the cumulative incidence across 10 clinical areas. Using CRs methods will ensure accurate results inform clinical and policy decisions.
Background
Although Kaplan-Meier survival analysis is commonly used to estimate the cumulative incidence of revision after joint arthroplasty, it theoretically overestimates the risk of revision in ...the presence of competing risks (such as death). Because the magnitude of overestimation is not well documented, the potential associated impact on clinical and policy decision-making remains unknown.
Questions/purposes
We performed a meta-analysis to answer the following questions: (1) To what extent does the Kaplan-Meier method overestimate the cumulative incidence of revision after joint replacement compared with alternative competing-risks methods? (2) Is the extent of overestimation influenced by followup time or rate of competing risks?
Methods
We searched Ovid MEDLINE, EMBASE, BIOSIS Previews, and Web of Science (1946, 1980, 1980, and 1899, respectively, to October 26, 2013) and included article bibliographies for studies comparing estimated cumulative incidence of revision after hip or knee arthroplasty obtained using both Kaplan-Meier and competing-risks methods. We excluded conference abstracts, unpublished studies, or studies using simulated data sets. Two reviewers independently extracted data and evaluated the quality of reporting of the included studies. Among 1160 abstracts identified, six studies were included in our meta-analysis. The principal reason for the steep attrition (1160 to six) was that the initial search was for studies in any clinical area that compared the cumulative incidence estimated using the Kaplan-Meier versus competing-risks methods for any event (not just the cumulative incidence of hip or knee revision); we did this to minimize the likelihood of missing any relevant studies. We calculated risk ratios (RRs) comparing the cumulative incidence estimated using the Kaplan-Meier method with the competing-risks method for each study and used DerSimonian and Laird random effects models to pool these RRs. Heterogeneity was explored using stratified meta-analyses and metaregression.
Results
The pooled cumulative incidence of revision after hip or knee arthroplasty obtained using the Kaplan-Meier method was 1.55 times higher (95% confidence interval, 1.43–1.68; p < 0.001) than that obtained using the competing-risks method. Longer followup times and higher proportions of competing risks were not associated with increases in the amount of overestimation of revision risk by the Kaplan-Meier method (all p > 0.10). This may be due to the small number of studies that met the inclusion criteria and conservative variance approximation.
Conclusions
The Kaplan-Meier method overestimates risk of revision after hip or knee arthroplasty in populations where competing risks (such as death) might preclude the occurrence of the event of interest (revision). Competing-risks methods should be used to more accurately estimate the cumulative incidence of revision when the goal is to plan healthcare services and resource allocation for revisions.
Aims
To examine the cost‐effectiveness of a nurse practitioner‐family physician model of care compared with family physician‐only care in a Canadian nursing home.
Background
As demand for long‐term ...care increases, alternative care models including nurse practitioners are being explored.
Design
Cost‐effectiveness analysis using a controlled before‐after design.
Methods
The study included an 18‐month ‘before’ period (2005–2006) and a 21‐month ‘after’ time period (2007–2009). Data were ed from charts from 2008–2010. We calculated incremental cost‐effectiveness ratios comparing the intervention (nurse practitioner‐family physician model; n = 45) to internal (n = 65), external (n = 70) and combined internal/external family physician‐only control groups, measured as the change in healthcare costs divided by the change in emergency department transfers/person‐month. We assessed joint uncertainty around costs and effects using non‐parametric bootstrapping and cost‐effectiveness acceptability curves.
Results
Point estimates of the incremental cost‐effectiveness ratio demonstrated the nurse practitioner‐family physician model dominated the internal and combined control groups (i.e. was associated with smaller increases in costs and emergency department transfers/person‐month). Compared with the external control, the intervention resulted in a smaller increase in costs and larger increase in emergency department transfers. Using a willingness‐to‐pay threshold of $1000 CAD/emergency department transfer, the probability the intervention was cost‐effective compared with the internal, external and combined control groups was 26%, 21% and 25%.
Conclusion
Due to uncertainty around the distribution of costs and effects, we were unable to make a definitive conclusion regarding the cost‐effectiveness of the nurse practitioner‐family physician model; however, these results suggest benefits that could be confirmed in a larger study.
The risk of injury among Pee Wee (ages 11-12 years) ice hockey players in leagues that allow body checking is threefold greater than in leagues that do not allow body checking. We estimated the ...cost-effectiveness of a no body checking policy versus a policy that allows body checking in Pee Wee ice hockey.
Cost-effectiveness analysis alongside a prospective cohort study during the 2007-2008 season, including players in Quebec (n=1046), where policy did not allow body checking, and in Alberta (n=1108), where body checking was allowed. Injury incidence rates (injuries/1000 player-hours) and incidence proportions (injuries/100 players), adjusted for cluster using Poisson regression, allowed for standardised comparisons and meaningful translation to community stakeholders. Based on Alberta fee schedules, direct healthcare costs (physician visits, imaging, procedures) were adjusted for cluster using bootstrapping. We examined uncertainty in our estimates using cost-effectiveness planes.
Associated with significantly higher injury rates, healthcare costs where policy allowed body checking were over 2.5 times higher than where policy disallowed body checking ($C473/1000 player-hours (95% CI $C358 to $C603) vs $C184/1000 player-hours (95% CI $C120 to $C257)). The difference in costs between provinces was $C289/1000 player-hours (95% CI $C153 to $C432). Projecting results onto Alberta Pee Wee players registered in the 2011-2012 season, an estimated 1273 injuries and $C213 280 in healthcare costs would be avoided during just one season with the policy change.
Our study suggests that a policy disallowing body checking in Pee Wee ice hockey is cost-saving (associated with fewer injuries and lower costs) compared to a policy allowing body checking. As we did not account for long-term outcomes, our results underestimate the economic impact of these injuries.
A limited number of randomized controlled trials (RCTs) including economic analysis have supported the cost-effectiveness of nurse practitioners and clinical nurse specialists delivering care in a ...variety of settings. Our objective was to examine the quality of economic evaluations in this body of literature using the Quality of Health Economic Studies (QHES) tool, and highlight which questions of the quality assessment tool are being addressed adequately or require further attention within this body of literature. Of 43 RCTs included in our systematic review, the majority (77%) fell in the poor study quality quartile with an average total QHES score of 39 (out of 100). Only three studies (7%) were evaluated as high quality. Inter-rater agreement (prior to consensus process) was high (83% agreement). Four criteria for the quality of economic evaluations were consistently addressed: specification of clear, measurable objectives; pre-specification of subgroups for subgroup analyses; justified conclusions based on study results; and disclosure of study funding source. A clear statement of the primary outcome measures, incremental analysis, and assessment of uncertainty were often unclear or missing. Due to poor methodological quality, we currently lack a solid evidence base to draw clear conclusions about the cost-effectiveness of nurse practitioners and clinical nurse specialists. Higher quality economic evaluations are required to inform these questions.
BACKGROUNDWe sought to determine the modifying effects of age and multimorbidity on the association between First Nations status and hospitalizations for diabetes-specific ambulatory care sensitive ...conditions (ACSC). FINDINGSWe identified 183,654 adults with diabetes from Alberta Canada, and followed them for one year for the outcome of hospitalization or emergency department (ED) visit for a diabetes-specific ACSC. We used logistic regression to determine the association between First Nations status and the outcome, assessing for effect modification by age and multimorbidity with interaction terms. In a model adjusting for age, age(2), baseline A1c, duration of diabetes, and multimorbidity, First Nations people were at greater risk than non-First Nations to experience a diabetes-specific hospitalization or ED visit (unadjusted odds ratio OR 3.74; 95% confidence interval CI: 3.45-4.07). After adjustment for relevant covariates, this association varied by age (interaction: p = 0.018): adjusted OR 3.94 (95% CI: 3.11-4.99) and 5.74 (95% CI: 3.36-9.80) for First Nations compared to non-First Nations at ages 30 and 80 years, respectively. CONCLUSIONSCompared with non-First Nations, older First Nations patients with diabetes are at greater risk for diabetes-specific hospitalizations. Older First Nations patients with diabetes should be given priority access to primary care services as they are at greatest risk for requiring hospitalization for stabilization of their condition.
PDF
