Published atrial fibrillation (AF) guidelines and decision tools offer oral anticoagulant (OAC) recommendations; however, they consider stroke and bleeding risk differently. The aims of our study are: (i) to compare the variation in OAC recommendations by the 2012 American College of Chest Physicians guidelines, the 2012 European Society of Cardiology (ESC) guidelines, the 2014 American Heart Association (AHA) guidelines and two published decision tools by Casciano and LaHaye; (ii) to compare the concordance with actual OAC use in the overall study population and the population stratified by stroke/bleed risk. A cross-sectional study using the 2001–2013 Lifelink claims data was used to contrast the treatment recommendations by these decision aids. CHA2DS2-VASc and HAS-BLED algorithms were used to stratify 15,129 AF patients into nine stroke/bleed risk groups to study the variation in treatment recommendations and concordance with actual OAC use/non-use. The AHA guidelines which were set to recommend OAC when CHA2DS2-VASc = 1 recommended OAC most often (86.30%) and the LaHaye tool recommended OAC the least often (14.91%). OAC treatment recommendations varied considerably when stroke risk was moderate or high (CHA2DS2-VASc > 0). Actual OAC use/non-use was highly discordant (>40%) with all of the guidelines or decision tools reflecting substantial opportunities to improve AF OAC decisions.
BACKGROUND The 2012 CHEST, the 2012 European Society of Cardiology (ESC) and the 2014 American Heart Association guidelines and published decision tools by LaHaye and Casciano offer oral anticoagulant (OAC) recommendations for patients with atrial fibrillation (AF). The aim of our study was to compare the net clinical benefit (NCB) of OAC prescribing that was concordant with these decision aids. METHODS A cohort study of the 2001–2013 Lifelink claims data was used. NCB of concordance with each decision aid was defined as adverse events (thromboembolic and major bleed events) prevented per 10,000 person-years. Cox proportional hazard models were used to assess the relative risk of AF adverse events associated with concordance with each decision aid adjusted for potential confounders. FINDINGS The study included 15,129 AF patients, contributing 33,512 person-years. The NCB of the CHEST guidelines was the highest (NCB=30.07; 95%CI=28.66, 31.49) and the ESC guidelines the lowest (NCB=7.38; 95%CI=5.97, 8.80). Significant unadjusted decreases in the risk of AF adverse events associated with concordant OAC use/non-use were found for the CHEST guidelines (HR=0.825; 95%CI=0.695, 0.979), Casciano tool (HR=0.838; 95%CI=0.706, 0.995), and LaHaye tool (HR=0.841; 95%CI=0.709, 0.999), however none were significant after multivariate adjustment. CONCLUSION Concordant OAC use with any of the decision aids except the aggressive LaHaye tool led to a positive NCB. The decision aids based on CHA2DS2VASc algorithm did not consistently improve the NCB compared to CHADS2 based aids. Recommending OAC use when CHA2DS2−VASc=1 resulted in a lower NCB when all other factors guiding recommendations were held constant.
Background Hepatitis C, caused by a single stranded RNA virus, has become a global health problem. Infecting millions of individuals in the United States alone, chronic Hepatitis C viral infection can lead to devastating medical problems including cirrhosis and hepatocellular carcinoma. These problems create millions of dollars in health care costs for treatment and management. This study determines the cost effectiveness of Hepatitis C treatment with the new generation of oral protease inhibitors. Methods A Markov Model was constructed to simulate the progression of genotype 1 chronic hepatitis C disease in a cohort of 50-year-old patients. A decision tree, along with the Markov Model, was then used to determine duration of disease, treatment success, progression of disease, and mortality. At the end of each stage in the model, the cost and quality-adjusted life years (QALY) were summed for each individual. These were then used to calculate the overall cost effectiveness ratio (CER) using QALY as the unit of effectiveness. Four treatment options were modeled: Sofosbuvir with Pegylated interferon-alfa & Ribavirin (SOF/pegIFN&RBV), Sofosbuvir with Ribavirin (SOF/RBV), Simeprevir with Pegylated interferon-alfa & Ribavirin (SMV/pegINF&RBV), and Simeprevir with Sofosbuvir (SMV/SOF). Results SOF/pegIFN&RBV, yielded a CER ratio of $6,796.22/QALY, SMV/pegINF&RBV of $7,642.60/QALY, and SMV/SOF of $8,959.11/QALY. SOF/RBV had a higher CER of $16,295.30/QALY. It is important to note however that SMV/SOF had the highest QALY at 19.08. Conclusions After consideration of quality of life, treatment regimens and treatment side effects, the simeprevir and sofosbuvir regimen yields acceptable cost-effective ratios with high quality-adjusted life years.
Objectives: In order to investigate real-world values data; blood pressure, LDL-c, and HbA1c, in Japan from various perspectives and to assess the degree to which health condition in Japan is reflected in database, we conducted a comparative assessment using three databases: Minacare database, a large database containing health care checkup results from employment-based health insurance recently developed, and the publicly available two nation-wide databases. MethOds: A retrospective, cross sectional study using the Japanese health care checkup database developed by MinaCare Co. Ltd. was designed to investigate the distribution of the real-world values of BP, LDL-c, and HbA1c in Japan. The data were compared to those in Specific Health Checkups and Specific Health Guidance (MHLW-SH) and National Health and Nutrition Survey (MHLW-H&N). Results: There were 232,515 subjects with health care checkup results in 2011 MinaCare database. The proportion of subjects with SBP≥ 140 mmHg, LDL-c≥ 140 mg/dL, and HbA1c≥ 6.1% generally increase with age; in the 55-60 year age range, the proportions were 19.0% (males) and 12.2% (females) for SBP, 27.2% and 42.7% for LDL-c, and 13.5% and 5.4% for HbA1c, respectively. The MinaCare database was mostly comparable to MHLW-SH and MHLW-H&N databases. However, some notable differences were seen for MHLW-H&N compared to MinaCare and MHLW-SH in the values of BP and lipid parameters. cOnclusiOns: Analysis of MinaCare database indicated that substantial proportions of subjects have BP, LDL and HbA1c levels that are not well controlled in accordance with the Japanese guidelines. The results were generally consistent to the national databases. In light of the characteristics of MinaCare database such as the low selection bias, large sample size, wide age distribution, and high flexibility in the analysis of subject-level data, the database is highly valuable in studying the health status of the population insured by the employment-based health insurance.
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