Abstract Background Pharmacogenomics (PGx) was one of the first genomics applications to hold promise in precision medicine. The cost-effectiveness of PGx has been estimated for many disease states, with the strongest evidence supporting the use of PGx-guided testing to inform prescribing for cardiovascular diseases. Most studies do not consider the presentation of test results in clinical workflow using a clinical decision support (CDS) system. We previously developed a cost model that found that implementation costs of a PGx-CDS system may constitute a non-trivial proportion of the cost of a PGx program. We recently extended that model to include clinical and cost-effectiveness outcomes, using clopidogrel and warfarin as prototypes. In contrast to CDS that occurs at the level of the individual patient, our approach delivers “administrative decision support”, which can help leaders make informed decisions about the programmatic costs of PGx-CDS implementation. In this manuscript, we describe our efforts to develop an interactive version of our model and host it on a publicly available, interactive web platform. We built the web application of the PhaRmacogEnomics ClInical Support Economic Value (PRECISE-Value) model using shiny/shinydashboard packages in the R software environment. We incorporated user defined, customizable input values expected to differ between health-systems: population size, age/race distribution, number of patients tested, and information technology costs. Dynamic, user manipulation of these values reveals the designated outcomes of adverse drug events and deaths averted, costs, and an incremental cost-effectiveness ratio. Summary and detail tabs, a data dictionary and a cost-effectiveness primer are provided. Six PGx decision makers tested and provided feedback on our web application. Results Users suggested the application is easy to use and accomplishes the stated goals of presenting useful information for decision-makers. Given the prevalence of PGx test panels, all panel members expressed the desire to add additional drug-gene pairs and further tailor inputs by health-system-specific parameters. Conclusions Our interactive, web-based application of our prototype model of the cost-effectiveness of implementing a PGx-CDS system for clopidogrel and warfarin was deemed useful by an expert panel for informing decision makers as they consider the value of implementing a CDS program based on PGx test results.
Objective: The Ross procedure is considered to be the gold standard for aortic valve replacement in neonates/infants; however, there are few studies reporting outcomes of the Ross procedure in large cohorts of this population. We performed a meta-analysis to compare early and late outcomes in neonate/infant patients who undergo a Ross/Ross-Konno procedure in the current era. Methods: In accordance with PRISMA and MOOSE guidelines, we systematically searched Ovid versions of MEDLINE and PubMed using ("Ross"OR"Autograft")AND ("Aortic Valve Replacement") AND ("Neonate and Infant"OR"Infant"OR"Neonate"). Included were English-written observational studies presenting outcomes of the Ross/Ross-Konno procedure in neonates/infants including early mortality, late mortality, autograft and/or homograft reinterventions. Figure 1 shows the PRISMA flow chart. Meta-analysis was undertaken in MetaXL add-in for Microsoft Excel using random-effect model combined with double arscine transformation. A point estimate of a pooled prevalence along with its 95%CI was calculated. Results: 24 studies were included in the metanalysis. The outcomes of 603 neonates/infants having a Ross/Ross-Konno were extracted and analyzed. Follow-up range was 5 days-23 years. 22 studies reported 104 cases of early mortality out of 567 neonates/infants and 39 cases of late mortality out of 418 neonates/infants. The estimated early mortality prevalence was 18.28% (95%Cl:13.55%-23.54%). The late mortality prevalence was 9.67% (95%CI:5.85%-14.27%). 17 studies reported that 74 out of 380 neonates/infants presented with autograft failure, defined as greater than moderate stenosis or regurgitation. The estimated autograft reintervention is 20.27% (95%CI:7.74%-36.40%). The estimated prevalence of homograft reintervention is 32.03% (95%CI:20.98%-44.18%). Conclusions: A neonatal or infant Ross procedure still carries a significant risk of mortality in the current era. Studies of neonatal/infant Ross patients with longer follow-up are warranted to investigate the rate of autograft reintervention and the impact of the Ross on long-term survival.
Cognitive impairment and dementia have rising prevalence and impact the health care utilization and lives of older adults. Receipt of low-value (LV) care and underutilization of high-value (HV) care by individuals with these cognitive disorders may have negative consequences for patient health, health system efficiency, and societal welfare. Evidence on health care value among cognitively impaired individuals is limited; we thus ascertained receipt of LV and HV health care in older adults with normal cognition, cognitive impairment without dementia (CIND), and dementia.
Long-term health utility scores and costs used in cost-effectiveness analyses of cardiovascular disease prevention and management can be inconsistent, outdated, or invalid for the diverse population of the United States. Our aim was to develop a user friendly, standardized, publicly available code and catalog to derive more valid long-term values for health utility and expenditures following cardiovascular disease events.Individual-level Short Form-12 version 2 health-related quality of life and expenditure data were obtained from the pooled 2011 to 2016 Medical Expenditure Panel Surveys. We developed code using the R programming language to estimate preference-weighted Short Form-6D utility scores from the Short Form-12 for quality-adjusted life year calculations and predict annual health care expenditures. Result predictors included cardiovascular disease diagnosis (myocardial infarction, ischemic stroke, heart failure, cardiac dysrhythmias, angina pectoris, and peripheral artery disease), sociodemographic factors, and comorbidity variables.The cardiovascular disease diagnoses with the lowest utility scores were heart failure (0.635 [95% CI, 0.615-0.655]), angina pectoris (0.649 [95% CI, 0.630-0.667]), and ischemic stroke (0.649 [95% CI, 0.635-0.663]). The highest annual expenditures were for heart failure ($20 764 [95% CI, $17 500-$24 027]), angina pectoris ($18 428 [95% CI, $16 102-$20 754]), and ischemic stroke ($16 925 [95% CI, $15 672-$20 616]).The developed code and catalog may improve the quality and comparability of cost-effectiveness analyses by providing standardized methods for extracting long-term health utility scores and expenditures from Medical Expenditure Panel Survey data, which are more current and representative of the US population than previous sources.
Abstract As pharmacists work to ensure reimbursement for chronic disease management services on the national (e.g., Medicare) level, summative evidence of their impact on important health metrics, such as medication adherence, is needed. The objective of this study was to assess the effectiveness of pharmacist-led interventions on medication adherence in older adults. In April 2020, a comprehensive search was conducted in six databases for publications of randomized clinical trials of pharmacist-led interventions to improve medication adherence in older adults. English-language studies with codable data on medication adherence and diverse adherence-promoting interventions targeting older adults (age 65+) were eligible. A standardized mean difference effect size (intervention vs. control) was calculated for the medication adherence outcome in each study. Study effect sizes were pooled using a random-effects meta-analysis model. Moderator analyses were then conducted to explore for differences in effect size due to intervention, sample, and study characteristics. The primary outcome was medication adherence using any method of measurement. This meta-analysis included 40 unique randomized trials of pharmacist-led interventions with data from 8,822 unique patients (mean age, range: 65 to 85 years). The mean effect size was 0.57 (95% Confidence Interval [CI]: 0.38-0.76). When two outlier studies were excluded from the analysis, the mean effect size decreased to 0.41 (95% CI: 0.27-0.54). Moderator analyses showed larger effect sizes for interventions containing medication education and when interventions had components delivered at least partly in patients’ homes. In conclusion, this meta-analysis found a significant improvement in medication adherence among older adults receiving pharmacist-led interventions.
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