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A critical step toward tailoring effective interventions for heterogeneous and medically complex patients is to identify clinically meaningful subgroups on the basis of their comorbid conditions. We applied Item Response Theory (IRT), a potentially useful tool to identify clinically meaningful subgroups, to characterize phenotypes within a cohort of high-risk patients. This was a retrospective cohort study using 68,400 high-risk Veteran’s Health Administration (VHA) patients. Thirty-one physical and mental health diagnosis indicators based on ICD-9 codes from patients’ inpatient, outpatient VHA and VA-paid community care claims. Results revealed 6 distinct subgroups of high-risk patients were identified: substance use, complex mental health, complex diabetes, liver disease, cancer with cardiovascular disease, and cancer with mental health. Multinomial analyses showed that subgroups significantly differed on demographic and utilization variables which underscored the uniqueness of the groups. Using IRT models with clinical diagnoses from electronic health records permitted identification of diagnostic constellations among otherwise undifferentiated high-risk patients. Recognizing distinct patient profiles provides a framework from which insights into medical complexity of high-risk patients can be explored and effective interventions can be tailored. [ABSTRACT FROM AUTHOR]

Background: Anticoagulation decreases a patient’s risk of ischemic stroke and increases the risk of hemorrhage. Decision analyses regarding anticoagulation therefore require that different outcomes be weighted in comparison to one another. Most decision analyses to date have weighted intracranial hemorrhage (ICH) as 1.5 times worse than ischemic stroke, but because death and disability have lifelong impact, the expected impact should vary by life expectancy. Therefore, a fixed weighting ratio leads to age-related bias decision analyses of anticoagulation. We aimed to quantify the relative impact of ICH and ischemic stroke and derive a ratio that allows decision analysis without microsimulation. Methods: We created a microsimulation model to predict QALYs lost due to ICH and ischemic stroke. We then applied a meta-model to predict the ratio of QALYs lost from ICH relative to ischemic stroke. Results: Previously-used weighting ratios (1.5) are close to our derived mean weighting ratio (1.60). However, the weighting ratio of QALYs lost from ICH relative to ischemic stroke is sensitive to age and discount rate. Patients at younger ages have higher mean weighting ratios, as do patients with higher discount rates. Conclusions: The ratio of QALYs lost to ICH relative to ischemic stroke varies with age and discount rate. We present a set of such ratios here for use in decision analyses that do not incorporate full microsimulation models. Use of weighting ratios that vary with age, rather than the current fixed ratios, has the potential to reduce age-based bias in decision-making regarding events with lifelong implications. In this case, use of dynamic ratios may change anticoagulation recommendations for patients with nonvalvular atrial fibrillation at relatively low stroke risk. [ABSTRACT FROM AUTHOR]

Background: Bridging anticoagulation is commonly prescribed to patients with atrial fibrillation who are initiating warfarin or require interruption of anticoagulation. Current guidelines recommend bridging for patients at high risk of stroke. Among patients with atrial fibrillation and one or more risk factors for ischemic stroke, the recently published BRIDGE trial found forgoing bridging during interruption to be, on average, noninferior to bridging with respect to ischemic complications, with significantly fewer hemorrhagic complications.Objective: We sought to examine the benefits and harms of bridging anticoagulation across the spectrum of ischemic and hemorrhagic stroke risk and thereby enable more nuanced, risk-stratified decision-making when bridging is considered during initiation or interruption of vitamin K antagonists.Design: A Monte Carlo simulation, using a combination of literature-derived estimates, registry data, and trial data.Main Measures: Net clinical benefit, weighting for ischemic strokes, intracranial hemorrhages, and extracranial major hemorrhages.Key Results: The benefits and harms of bridging anticoagulation vary according to underlying patient risk profiles for both thromboembolic stroke and major intracranial bleeding. Patients at high risk of ischemic stroke and low risk of hemorrhage derive benefit from bridging during initiation or interruption of warfarin therapy. Patients at similarly high or low risk of both outcomes may receive benefit from bridging during initiation and bridging during interruption, but this was sensitive to underlying assumptions. The need for stratification along both axes of risk was robust to a wide range of parameters.Conclusions: Bridging anticoagulation may provide benefit to patients at high risk of ischemic stroke and low risk of intracranial hemorrhage who are initiating or interrupting warfarin therapy, while patients at high or low risk of both complications may be harmed. The use of bridging anticoagulation in patients with non-valvular atrial fibrillation should be considered only after stratification by risk of ischemic and hemorrhagic complications. [ABSTRACT FROM AUTHOR]

The article presents a study which aimed to determine whether the approach by which colorectal cancer (CRC) screening is recommended influences adherence. The study found variation in overall and strategy-specific adherence between racial/ethnic groups. The researchers suggest that patient preferences be considered when making CRC screening recommendations.

OBJECTIVE -- Knowledge of one's actual and target health outcomes (such as HbA[sub 1c] values) is hypothesized to be a prerequisite for effective patient involvement in managing chronic diseases such as diabetes. We examined 1) the frequency and correlates of knowing one's most recent HbA[sub 1c] test result and 2) whether knowing one's HbA[sub 1c] value is associated with a more accurate assessment of diabetes control and better diabetes self-care understanding, self-efficacy, and behaviors related to glycemic control. RESEARCH DESIGN AND METHODS -- We conducted a cross-sectional survey of a sample of 686 U.S. adults with type 2 diabetes in five health systems who had HbA[sub 1c] checked in the previous 6 months. Independent variables included patient characteristics, health care provider communication, and health system type. We examined bivariate and multivariate associations between each variable and the respondents' knowledge of their last .HbA[sub 1c] values and assessed whether knowledge of HbA[sub 1c] was associated with key diabetes care attitudes and behaviors. RESULTS -- Of the respondents, 66% reported that they did not know their last HbA[sub 1c] value and only 25% accurately reported that value. In multivariate analyses, more years of formal education and high evaluations of provider thoroughness of communication were independently associated with HbA[sub 1c] knowledge. Respondents who knew their last HbA[sub 1c] value had higher odds of accurately assessing their diabetes control (adjusted odds ratio 1.59, 95% CI 1.05-2.42) and better reported understanding of their diabetes care (P < 0.001). HbA[sub 1c] knowledge was not associated with respondents' diabetes care self-efficacy or reported self-management behaviors. CONCLUSIONS -- Respondents who knew their HbA[sub 1c] values reported better diabetes care understanding and assessment of their glycemic control than those who did not. Knowledge of one's HbA[sub 1c] level alone, however, was not sufficient to translate increased understanding of diabetes care into the increased confidence and motivation necessary to improve patients' diabetes self-management. Strategies to provide information to patients must be combined with other behavioral strategies to motivate and help patients effectively manage their diabetes. [ABSTRACT FROM AUTHOR]

Background The impact of surgical risk on the relationship between hospital volume and outcomes in coronary artery bypass grafting (CABG) is uncertain. We assessed (1) whether in-hospital mortality rates differ across lower- and higher-volume hospitals by expected surgical risk and (2) whether high-risk patients are more likely to undergo CABG at low-volume centers. Methods We used clinical data on 27 355 adults who underwent CABG at 68 hospitals in California between 1997 and 1998. Hospitals were divided into low-volume (n = 44), medium-volume (n = 19), and high-volume (n = 5) categories on the basis of tertiles of annual CABG volume. Using hierarchical logistic regression and log-binomial regression models, we assessed for differences in in-hospital mortality rates across hospital volume categories and the likelihood of CABG being performed in each hospital volume category after adjusting for expected surgical risk. Results Differences in adjusted in-hospital mortality rates between low- and high-volume centers rose as the expected risk of in-hospital death increased: 0.8% vs 0.4% at the 20th risk percentile and 3.8% vs 2.5% at the 80th risk percentile (P<.001 for all comparisons). While a similar trend was seen between medium- and high-volume centers, absolute differences were substantially smaller. The likelihood of patients having surgery at a low-volume center also rose significantly with expected surgical risk (relative risk of undergoing CABG at a low-volume center for patients at 80th vs 20th risk percentile, 1.29 [95% confidence interval, 1.14-1.51; P<.001]). Conclusion High-risk patients are more likely to undergo CABG at low-volume facilities where their risk of dying is higher. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular disease is the primary complication and cause of death in patients with type 2 diabetes mellitus. Modification of cardiovascular risk factors may improve patient outcomes. Purpose: To evaluate the effectiveness of pharmacologic lipid-lowering therapy on outcomes in type 2 diabetes mellitus. Data Sources: Review of the literature. Study Selection: Randomized trials evaluating clinical outcomes of lipid-lowering treatment in patients with diabetes. Data Extraction: Studies were identified by searching the Cochrane Library, MEDLINE, meta-analyses, review articles, and inquiries to experts. The Cochrane Library and MEDLINE searches were done in September 2002. Data were abstracted onto stan-dardized forms by a single reviewer and were confirmed by a second reviewer. Data Synthesis: Meta-analysis of 6 primary prevention studies showed that lipid-lowering medications reduced risks for cardio-vascular outcomes (relative risk, 0.78 [95% CI, 0.67 to 0.89]; absolute risk reduction, 0.03 [CI, 0.01 to 0.04] in 4.3 years of treatment); 1 major cardiovascular event was prevented by treat- ing 34 to 35 patients. Meta-analysis of 8 studies of secondary prevention showed a similar relative risk (0.76 [CI, 0.59 to 0.93]) but more than twice the absolute risk reduction (0.07 [CI, 0.03 to 0.12] in 4.9 years of treatment) and a number needed to treat for benefit of 13 to 14. Most studies compared a lipid-lowering drug with placebo but did not evaluate the effect of reaching specific cholesterol levels. The benefit of lipid lowering with a fixed dose of a statin appeared to be similar regardless of starting cholesterol levels. Limitations: Target cholesterol levels and the effectiveness of dose titration (or the use of multiple agents) have not been rig-orously examined. Conclusions: In patients with type 2 diabetes, treatment with lipid-lowering agents reduces cardiovascular risk. Most patients, including those... [ABSTRACT FROM AUTHOR]

Presents a study on the efficiency and cost-effectiveness of screening for retinopathy in patients with type 2 diabetes. Setting and participants; Main outcome measure; Results; Conclusions.

Abstract: Background. : Relatively little is known about the experiences and preferences of users and those who attempt colorectal cancer (CRC) screening. This study describes factors influencing CRC screening decisions among users, attempters, attempter users (individuals who both attempted and completed at least one screening procedure), and non-users; identifies factors interfering with test completion; and describes correlates of screening preferences. Methods. : A primarily stratified random sample of patients from the University of Michigan Health System clinics, Ann Arbor, Michigan, with oversampling of FOBT attempters, completed a mailed questionnaire in fall, 2003. Descriptive and multivariate approaches evaluated factors influencing screening use and preferences. Results. : “Accuracy of results” was reported most often as important when deciding about CRC screening regardless of screening status. The importance of psychological decisional factors differed significantly by screening status (P <0.05). Among factors interfering with test completion, 38.5% attempting FOBT reported they “forgot” whereas 29.8% attempting colonoscopy were “afraid of pain.” Approximately 56.3% indicated a preference for a CRC test: respondents who considered “discomfort” important preferred FOBT (OR: 0.39, 95% CI: 0.17, 0.87); those with a prior colonoscopy preferred an invasive test (OR: 6.50, 95% CI: 2.90, 14.50). Conclusions. : To improve adherence to CRC screening recommendations, physicians should tailor discussions to patients'' prior experiences and test-specific concerns and elicit preferences for screening. [Copyright &y& Elsevier]

Results of randomized clinical trials are the preferred "evidence" for establishing the benefits and safety of medical treatments. We present evidence suggesting that the conventional approach to reporting clinical trials has fundamental flaws that can result in overlooking identifiable subgroups harmed by a treatment while underestimating benefits to others. A risk-stratified approach can dramatically reduce the chances of such errors. Since professional and economic incentives reward advocating treatments for as broad a patient population as possible, we suggest that payers and regulatory bodies might need to act to motivate prompt, routine adoption of risk-stratified assessments of medical treatments' safety and benefits. [ABSTRACT FROM AUTHOR]