Biomedical subjects

Emmett B Keeler

Publications and source records attributed to Emmett B Keeler.

14 recordsLinked to original sources

PubMed2006

Perceived causes of disability added prognostic value beyond medical conditions and functional status.

OBJECTIVE: This study's objective was to determine the incremental benefit of respondent subjective attribution of functional decline beyond relying solely on disease burden in predicting survival. STUDY DESIGN AND SETTINGS: A total of 9447 older adults from the Second Longitudinal Study on Aging, a probability sample of community dwelling adults aged 70 or older, were evaluated. Survival was based on status at follow-up interview 3-4 years after baseline interview. Logistic regression was performed using demographic variables and coexisting diseases as a baseline, then adding functional status measures (ADL, IADL) and individual subjective attribution of functional limitation in subsequent models. RESULTS: The predictions improved significantly with the addition of functional status measures (P<0.001) and the individual subjective attribution of functional limitation (P<0.001). For example, the probability of mortality for individuals with cancer was 17.3%, but 28.8% of those with cancer and functional limitations died as did 50% of those with cancer who reported functional limitations attributable to cancer. CONCLUSION: Among persons who can make a specific attribution of their functional limitation, the attribution may have value as a marker of severity of disease and serve as a good predictive measure for mortality, especially in specific illnesses such as cancer.

Activities of Daily Living↗

PubMed2006

Is cataract surgery cost-effective among older patients with a low predicted probability for improvement in reported visual functioning?

INTRODUCTION: Although cataract surgery has been demonstrated to be effective and cost-effective, 5% to 20% of patients do not benefit functionally from the procedure. This study examines the cost-effectiveness of cataract surgery versus watchful waiting in a subgroup of patients who had less than a 30% predicted probability of reporting improvements in visual function after surgery. METHODS: Randomized trial (first eye surgery vs. watchful waiting) of 250 patients who based on a cataract surgery index (CSI) were felt to have less than a 30% probability of reporting improvements in visual functioning after surgery. Cost was estimated using monthly resource utilization surveys and Medicare billing and payment data. Effectiveness was evaluated at 6 months using the Activities of Daily Vision Scale (ADVS) and the Health Utilities Index, Mark 3 (HUI3). RESULTS: In terms of overall utility, the incremental cost-effectiveness of surgery was Dollars 38,288/QALY. In the subgroup of patients with a CSI score > 11 (< 20% probability of improvement), the cost-effectiveness of cataract surgery was Dollars 53,500/QALY. Sensitivity analysis demonstrated that often this population of patients may not derive a utility benefit with surgery. CONCLUSION: Cataract surgery is cost-effective even in a subpopulation of patient with a lower, < 30%, predicted probability of reporting improved visual functioning after surgery. There may be a subgroup of patients, CSI > 11, for whom a strategy of watchful waiting may be equally effective and considerably less expensive.

Activities of Daily Living↗

PubMed2005

Is adjuvant therapy for older patients with node (+) early breast cancer cost-effective?

BACKGROUND: Node (+) breast cancer represents over 40% of cases in older women and currently there is a debate whether adjuvant therapy for all older women is cost-effective. PURPOSE: To evaluate if adjuvant treatment for early-stage (Stage I-IIIa) node (+) breast cancer with hormone therapy, chemotherapy, or combination therapy is cost-effective in older patients. DESIGN: A decision-analysis model for 65, 75, and 85 year-old female breast cancer patients using life tables integrated the cost of treatment in dollars and impact in length and quality of life. Both estrogen receptor (ER) (-) and (+) patients were considered. The primary data sources were meta-analysis from the Early Breast Cancer Trialists' Collaborative Group and the Red Book Average Wholesale Price for drugs. The cost of treatment in dollars and impact of quality of life was examined. Scenarios were used when treatment benefit was uncertain. The incremental cost-effectiveness of different treatment strategies were then compared and mapped graphically. RESULTS: Adjuvant therapy is cost-effective in 65 year-old women with early breast cancer. In a 75 year-old ER (+) patient, hormone therapy is cost-effective, $10,965/quality-adjusted life years (QALY), but chemotherapy was more cost-effective, $27,406/QALY, if one assumed it was as efficacious as in a 65 year-old woman. In a 75 year-old ER (-) patient, chemotherapy was cost-effective at $42,605 with the same assumption. In an 85 year-old ER (+) patient, hormone therapy was cost-effective, $26,463/QALY, if efficacy is not age-sensitive, but chemotherapy was not as cost-effective for either ER (+) or ER (-) patients. CONCLUSION: Treatment decisions for older breast cancer patients suffer from the lack of sufficient clinical trial data. Decision-analytic models can help policy makers who are faced with decisions about whether to support adjuvant therapy in older breast cancer patients and also outline the important parameters that need to be considered in such a decision.

Aged↗

PubMed2005

A telephone survey to measure communication, education, self-management, and health status for patients with heart failure: the Improving Chronic Illness Care Evaluation (ICICE).

BACKGROUND: Many aspects of quality of care for heart failure cannot be reliably obtained by chart review. METHODS AND RESULTS: We created and tested a telephone survey to measure provider-patient communication; satisfaction; patient education, knowledge, and self-management; and health status for the Improving Chronic Illness Care Evaluation. A total of 781 patients participated in the survey; 62% were age 65 or older, 66% had a history of coronary artery disease, and 59% were cared for by a cardiologist. The measures of communication, satisfaction, patient education, knowledge, and self-management performed very well with low rates of missing values and good psychometric properties. The self-efficacy scale had acceptable reliability (Cronbach's alpha 0.69); however, it was weakly correlated with objective measures of knowledge about self-management. The Heart Failure Symptom Scale (HFSS) showed high reliability (Cronbach's alpha 0.88) and good correlation with the SF-12 Physical Health Summary Scale (r=0.63); the HFSS was also moderately correlated with measures of mental health. CONCLUSIONS: Reliable information about processes of care and health outcomes that cannot be reliably assessed by chart can be obtained by telephone. This tool should be useful for measuring quality of care for large patient populations and determining the effectiveness of quality improvement activities.

Aged↗

PubMed2005

Differences in education, knowledge, self-management activities, and health outcomes for patients with heart failure cared for under the chronic disease model: the improving chronic illness care evaluation.

BACKGROUND: The objective of this study was to determine whether participation in a quality improvement (QI) collaborative for heart failure (HF) was associated with better interpersonal aspects of care and health outcomes. METHODS AND RESULTS: We conducted a cross-sectional telephone survey of patients in 6 organizations who participated in a QI collaborative for HF (participants, n = 387) and 6 comparable control organizations (controls, n = 414) and measured provider-patient communication, education received, knowledge of HF, self-management behaviors, satisfaction, and quality of life. The participant group patients were more likely to report their doctor and nurse discussed treatment options and reviewed self-management (P < .01 for both). A total of 88% of participants were told to weigh themselves daily and record their weight compared with 34% of controls (P < .01). Participants were more likely to know how often to check their weight (P < .01), recognize symptoms of worsening HF (P < or = .01 for all), have a scale (P = .002), and monitor their weight daily (P < .001). Participants had similar quality of life but fewer emergency department visits and hospitalizations. CONCLUSION: Participation in a QI collaborative for HF was associated with better communication, education, and knowledge, and lower health care use. Collaboratives may be a useful method for disseminating quality improvement strategies.

Adolescent↗

PubMed2005

Is adjuvant therapy for older patients with node (-) early breast cancer cost-effective?

BACKGROUND: Node (-) breast cancer represents over 60% of cases in older women and currently there is a debate whether adjuvant therapy for these women is cost-effective. PURPOSE: Evaluate if adjuvant treatment for early-stage node (-) breast cancer with hormone therapy, chemotherapy, or combination therapy is cost-effective in older patients. DESIGN: Decision-analysis modeling using life tables integrated the cost of treatment in dollars and impact in length and quality of life. The primary data sources were meta-analysis from the Early Breast Cancer Trialists' Collaborative Group and the Red Book Average Wholesale Price for drugs. The incremental cost-effectiveness of different treatment strategies were then compared and mapped graphically. RESULTS: Adjuvant therapy is cost-effective in 65-year-old women with early breast cancer. In a 75-year-old estrogen receptor, ER (+) patient, hormone therapy, specifically tamoxifen, is cost-effective, 19,530 dollars/QALY. In a 75-year-old ER (-) the use of chemotherapy (AC or CMF) or 85-year-old ER (+) the use of hormone therapy was only marginally cost-effective, 54,000-76,000 dollars/QALY, only if efficacy was assumed to be age-insensitive (similar to a 65-year-old woman). CONCLUSION: Decision-analytic models can help policy makers who are faced with decisions about whether to support adjuvant therapy in older breast cancer patients and also outline the important parameters that need to be considered in such a decision.

Aged↗

PubMed2005

Does the collaborative model improve care for chronic heart failure?

BACKGROUND: Organizationally based, disease-targeted collaborative quality improvement efforts are widely applied but have not been subject to rigorous evaluation. We evaluated the effects of the Institute of Healthcare Improvement's Breakthrough Series (IHI BTS) on quality of care for chronic heart failure (CHF). RESEARCH DESIGN: We conducted a quasi-experiment in 4 organizations participating in the IHI BTS for CHF in 1999-2000 and 4 comparable control organizations. We reviewed a total of 489 medical records obtained from the sites and used a computerized data collection tool to measure performance on 23 predefined quality indicators. We then compared differences in indicator performance between the baseline and post-intervention periods for participating and non-participating organizations. RESULTS: Participating and control patients did not differ significantly with regard to measured clinical factors at baseline. After adjusting for age, gender, number of chronic conditions, and clustering by site, participating sites showed greater improvement than control sites for 11 of the 21 indicators, including use of lipid-lowering and angiotensin converting enzyme inhibition therapy. When all indicators were combined into a single overall process score, participating sites improved more than controls (17% versus 1%, P < 0.0001). The improvement was greatest for measures of education and counseling (24% versus -1%, P < 0.0001). CONCLUSIONS: Organizational participation in a common disease-targeted collaborative provider interaction improved a wide range of processes of care for CHF, including both medical therapeutics and education and counseling. Our data support the use of programs like the IHI BTS in improving the processes of care for patients with chronic diseases.

Chi-Square Distribution↗

PubMed2005

Assessing the implementation of the chronic care model in quality improvement collaboratives.

OBJECTIVE: To measure organizations' implementation of Chronic Care Model (CCM) interventions for chronic care quality improvement (QI). DATA SOURCES/STUDY SETTING: Monthly reports submitted by 42 organizations participating in three QI collaboratives to improve care for congestive heart failure, diabetes, depression, and asthma, and telephone interviews with key informants in the organizations. STUDY DESIGN: We qualitatively analyzed the implementation activities of intervention organizations as part of a larger effectiveness evaluation of yearlong collaboratives. Key study variables included measures of implementation intensity (quantity and depth of implementation activities) as well as fidelity to the CCM. DATA COLLECTION/EXTRACTION METHODS: We developed a CCM-based scheme to code sites' intervention activities and criteria to rate their depth or likelihood of impact. PRINCIPAL FINDINGS: The sites averaged more than 30 different change efforts each to implement the CCM. The depth ratings for these changes, however, were more modest, ranging from 17 percent to 76 percent of the highest rating possible. The participating organizations significantly differed in the intensity of their implementation efforts (p<.001 in both quantity and depth ratings). Fidelity to the CCM was high. CONCLUSIONS: Collaborative participants were able, with some important variation, to implement large numbers of diverse QI change strategies, with high CCM fidelity and modest depth of implementation. QI collaboratives are a useful method to foster change in real world settings.

Chronic Disease↗

PubMed2005

The lifetime burden of chronic disease among the elderly.

The high costs of treating chronic diseases suggest that reducing their prevalence would improve Medicare's financial stability. In this paper we examine the impact of selected chronic diseases on the distribution of health spending and its variation over the course of disease. We also use a microsimulation model to estimate these conditions' impact on life expectancy and health spending from age sixty-five to death. A sixty-five-year-old with a serious chronic illness spends 1000-2000 dollars more per year on health care than a similar adult without the condition. However, cumulative Medicare payments are only modestly higher for the chronically ill because of their shorter life expectancy.

Aged↗

PubMed2005

A meta-analysis of interventions to improve care for chronic illnesses.

OBJECTIVE: To use empirical data from previously published literature to address 2 research questions: (1) Do interventions that incorporate at least 1 element of the Chronic Care Model (CCM) result in improved outcomes for specific chronic illnesses? (2) Are any elements essential for improved outcomes? STUDY DESIGN: Meta-analysis. METHODS: Articles were identified from narrative literature reviews and quantitative meta-analyses, each of which covered multiple bibliographic databases from inception to March 2003. We supplemented this strategy by searching the MEDLINE database (1998-2003) and by consulting experts. We included randomized and nonrandomized controlled trials of interventions that contained 1 or more elements of the CCM for asthma, congestive heart failure (CHF), depression, and diabetes. We extracted data on clinical outcomes, quality of life, and processes of care. We then used random-effects modeling to compute pooled standardized effect sizes and risk ratios. RESULTS: Of 1345 abstracts screened, 112 studies contributed data to the meta-analysis: asthma, 27 studies; CHF, 21 studies; depression, 33 studies; and diabetes, 31 studies. Interventions with at least 1 CCM element had consistently beneficial effects on clinical outcomes and processes of care across all conditions studied. The effects on quality of life were mixed, with only the CHF and depression studies showing benefit. Publication bias was noted for the CHF studies and a subset of the asthma studies. CONCLUSIONS: Interventions that contain at least 1 CCM element improve clinical outcomes and processes of care--and to a lesser extent, quality of life--for patients with chronic illnesses.

Chronic Disease↗

PubMed2004

An evaluation of collaborative interventions to improve chronic illness care. Framework and study design.

The author's dual-purpose evaluation assesses the effectiveness of formal collaboratives in stimulating organizational changes to improve chronic illness care (the chronic care model or CCM). Intervention and comparison sites are compared before and after introduction of the CCM. Multiple data sources are used to measure the degree of implementation, patient-level processes and outcomes, and organizational and team factors associated with success. Despite challenges in timely recruitment of sites and patients, data collection on 37 participating organizations, 22 control sites, and more than 4,000 patients with diabetes, congestive heart failure, asthma, or depression is nearing completion. When analyzed, these data will shed new light on the effectiveness of collaborative improvement methods and the CCM.

Chronic Disease↗

PubMed2003

Development and validation of a grading system for the quality of cost-effectiveness studies.

PURPOSE: To provide a practical quantitative tool for appraising the quality of cost-effectiveness (CE) studies. METHODS: A committee comprising [corrected] of health economists selected a set of criteria for the instrument from an item pool. Data collected with a conjoint analysis survey on 120 international health economists were used to estimate weights for each criterion with a random effects regression model. To validate the grading system, a survey was sent to 60 individuals with health economics expertise. Participants first rated the quality of three CE studies on a visual analogue scale, and then evaluated each study using the grading system. Spearman rho and Wilcoxon tests were used to detect convergent validity and analysis of covariance (ANCOVA) for discriminant validity. Agreement between the global rating by experts and the grading system was also examined. RESULTS: Sixteen criteria were selected. Their coefficient estimates ranged from 1.2 to 8.9, with a sum of 93.5 on a 100-point scale. The only insignificant criterion was "use of subgroup analyses." Both convergent validity and discriminant validity of the grading system were shown by the results of the Spearman rho (correlation coefficient = 0.78, P < 0.0001), Wilcoxon test (P = 0.53), and ANCOVA (F(3,146) = 5.97, p = 0.001). The grading system had good agreement with global rating by experts. CONCLUSIONS: The instrument appears to be simple, internally consistent, and valid for measuring the perceived quality of CE studies. Applicability for use in clinical and resource allocation decision-making deserves further study.

Cost-Benefit Analysis↗

PubMed2002

A model for a smallpox-vaccination policy.

BACKGROUND: The new reality of biologic terrorism and warfare has ignited a debate about whether to reintroduce smallpox vaccination. METHODS: We developed scenarios of smallpox attacks and built a stochastic model of outcomes under various control policies. We conducted a systematic literature review and estimated model parameters on the basis of European and North American outbreaks since World War II. We assessed the trade-offs between vaccine-related harms and benefits. RESULTS: Nations or terrorists possessing a smallpox weapon could feasibly mount attacks that vary with respect to tactical complexity and target size, and patterns of spread can be expected to vary according to whether index patients are hospitalized early. For acceptable results, vaccination of contacts must be accompanied by effective isolation. Vaccination of contacts plus isolation is expected to result in 7 deaths (from vaccine or smallpox) in a scenario involving the release of variola virus from a laboratory, 19 deaths in a human-vector scenario, 300 deaths in a building-attack scenario, 2735 deaths in a scenario involving a low-impact airport attack, and 54,729 deaths in a scenario involving a high-impact airport attack. Immediate vaccination of the public in an attacked region would provide little additional benefit. Prior vaccination of health care workers, who would be disproportionately affected, would save lives in large local or national attacks but would cause 25 deaths nationally. Prior vaccination of health care workers and the public would save lives in a national attack but would cause 482 deaths nationally. The expected net benefits of vaccination depend on the assessed probability of an attack. Prior vaccination of health care workers would be expected to save lives if the probability of a building attack exceeded 0.22 or if the probability of a high-impact airport attack exceeded 0.002. The probability would have to be much higher to make vaccination of the public life-saving. CONCLUSIONS: The analysis favors prior vaccination of health care workers unless the likelihood of any attack is very low, but it favors vaccination of the public only if the likelihood of a national attack or of multiple attacks is high.

Bioterrorism↗

PubMedDate not supplied

Options for handling missing data in the Health Utilities Index Mark 3.

BACKGROUND: The Health Utilities Index Mark 3 (HUI3) is a tool composed of 41 questions, covering 8 attributes: vision, hearing, speech, ambulation, dexterity, emotion, cognition, and pain. Responses to these questions can define more than 972,000 health situations. This tool allows respondents to answer "Don't Know," for which there is no scoring instruction, to any given question. This situation creates a break in the scoring algorithm and leads to considerable amounts of missing data. The goal of this study is to develop strategies to deal with HUI3 scores for participants who have missing data. METHODS: The authors used data from 248 individuals enrolled in the Cataract Management Trial, focusing on the HUI3 vision and ambulation attributes, which had 19% and 10% of attribute levels missing, respectively. Inspection and deduction were used to fill in values independent of the value of the missing data, then alternative analytic techniques were compared, including mean substitution, model scoring, hot deck, multiple imputation, and regression imputation. RESULTS: Inspection and logical deduction reduced the percentage of missing information in the HUI3 by 49% to 87%. A comparison of analytic techniques used for the remaining HUI3 vision data missing demonstrated the value of building models based on internal response patterns and that simple analytic techniques fare as well as more complicated ones when the number of missing cases is small. CONCLUSION: Analyzing the pattern of responses in cases where the attribute level score is missing reduces the amount of missing data and can simplify the analytic process for the remaining missing data.

Activities of Daily Living↗