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Evaluation of treatment effects in randomized clinical trials typically focuses on the average difference in outcomes between arms of a trial. While this approach is the gold standard for establishing a causal relationship between treatment and outcome, reporting of average effects can mask important differences in benefits across various subpopulations, a phenomenon known as heterogeneity of treatment effects (HTE). The presence of HTE has been demonstrated in many settings and lack of consideration of HTE can lead to inappropriate treatment (or lack of treatment) for many patients. This paper describes approaches to analyzing and reporting trials with explicit consideration of heterogeneity, in order to improve our ability to treat individual patients more effectively. [ABSTRACT FROM AUTHOR]

Background: Most guidelines for major depressive disorder recommend initial treatment with either a second-generation antidepressant (SGA) or cognitive behavioral therapy (CBT). Although most trials suggest that these treatments have similar efficacy, their health economic implications are uncertain.Objective: To quantify the cost-effectiveness of CBT versus SGA for initial treatment of depression.Design: Decision analytic model.Data Sources: Relative effectiveness data from a meta-analysis of randomized controlled trials; additional clinical and economic data from other publications.Target Population: Adults with newly diagnosed major depressive disorder in the United States.Time Horizon: 1 to 5 years.Perspectives: Health care sector and societal.Intervention: Initial treatment with either an SGA or group and individual CBT.Outcome Measures: Costs in 2014 U.S. dollars, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.Results of Base-case Analysis: In model projections, CBT produced higher QALYs (3 days more at 1 year and 20 days more at 5 years) with higher costs at 1 year (health care sector, $900; societal, $1500) but lower costs at 5 years (health care sector, -$1800; societal, -$2500).Results of Sensitivity Analysis: In probabilistic sensitivity analyses, SGA had a 64% to 77% likelihood of having an incremental cost-effectiveness ratio of $100 000 or less per QALY at 1 year; CBT had a 73% to 77% likelihood at 5 years. Uncertainty in the relative risk for relapse of depression contributed the most to overall uncertainty in the optimal treatment.Limitation: Long-term trials comparing CBT and SGA are lacking.Conclusion: Neither SGAs nor CBT provides consistently superior cost-effectiveness relative to the other. Given many patients' preference for psychotherapy over pharmacotherapy, increasing patient access to CBT may be warranted.Primary Funding Source: Department of Veterans Affairs, National Institute of Mental Health. [ABSTRACT FROM AUTHOR]

Type 2 diabetes is a prevalent illness that causes major vascular, renal, and neurologic complications. Prevention and treatment of diabetes and its complications are of paramount importance. Many new treatments have emerged over the past 5-10 years. Recent evidence shows that newer treatments may substantially reduce risk for cardiac and renal disease, suggesting that it may be necessary to change existing treatment paradigms. This review summarizes the evidence supporting diabetes prevention and treatment, focusing on aspects that are commonly in the purview of primary care physicians. [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]

A well-designed and executed clinical trial is the gold standard of evidence-based medicine. It is important for readers to understand the rationale for the study design, identify common pitfalls, and scrutinize limitations. Herein, we present a brief overview of types of designs used for clinical trials and discuss the use of appropriate end points, the selection of study participants, randomization, sample size calculation, blinding, and analysis of data. Finally, we emphasize the importance of accurate and transparent reporting. Our goal is to provide a primer for practicing urologists to enhance their understanding of the clinical trial literature. [ABSTRACT FROM AUTHOR]

Abstract: Aims: To evaluate the risk from different insulin types on severe hypoglycaemia (SHG) events requiring inpatient (IP) or emergency department (ED) care in patients with type 2 diabetes. Methods: Type 2 diabetes patients newly started on insulin in a large commercial claims database were evaluated for SHG events. Patients were classified into an insulin group based on their most frequently used insulin type. Multivariable Cox models assessed the association between insulin type and the risk of SHG events. Results: We identified 8626 patients (mean age 53.5 years; 55% female) with type 2 diabetes followed for an average of 4.0 years after insulin initiation. Of these, 161 (1.9%) had a SHG event at an average of 3.1y after insulin initiation. Patients with SHG events were slightly older (56.4 vs. 53.4 years), used a similar number of OADs (1.1 vs. 1.2) but had more co-morbidities compared with those without SHG events. In multivariate Cox models, premixed insulin (HR 2.12; p <0.01), isophane insulin (NPH) (HR 2.02; p <0.01), and rapid acting insulin (HR 2.75; p <0.01) had significantly higher risks of SHG events compared with glargine. No statistically significant difference in SHG events was seen with detemir (HR 1.20; p =0.73). Conclusions: Among patients with type 2 diabetes, the use of newer basal insulin analogues was associated with lower rates of SHG events requiring IP or ED care compared with users of other insulin formulations. Future research should examine the impact of hypoglycaemia events of different severity levels. [Copyright &y& Elsevier]

Background--Current guidelines for prescribing antihypertensive medications focus on reaching specific blood pressure targets. We sought to determine whether antihypertensive medications could be used more effectively by a treatment strategy based on tailored estimates of cardiovascular disease events prevented. Methods and Results--We developed a nationally representative sample of American adults aged 30 to 85 years with no history of myocardial infarction, stroke, or severe congestive heart failure using the National Health and Nutrition Examination Survey III. We then created a simulation model to estimate the effects of 5 years of treatment with treat-to-target (treatment to specific blood pressure goals) and benefit-based tailored treatment (treatment based on estimated cardiovascular disease event reduction) approaches to antihypertensive medication management. All effect size estimates were derived directly from meta-analyses of randomized trials. We found that 55% of the overall population of 176 million Americans would be treated identically under the 2 treatment approaches. Benefit-based tailored treatment would prevent 900000 more cardiovascular disease events and save 2.8 million more quality-adjusted life-years, despite using 6% fewer medications over 5 years. In the 45% of the population treated differently by the strategies, benefit-based tailored treatment would save 159 quality-adjusted life-years per 1000 treated versus 74 quality-adjusted life-years per 1000 treated by the treat-to-target approach. The findings were robust to sensitivity analyses. Conclusions--We found that benefit-based tailored treatment was both more effective and required less antihypertensive medication than current guidelines based on treating to specific blood pressure goals. [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.

Background: Resource barriers complicate diabetes care management. Support from peers may help patients manage their diabetes. Objective: To compare a reciprocal peer-support (RPS) program with nurse care management (NCM). Design: Randomized, controlled trial. (ClinicalTrials.gov registration number: NCT00320112) Setting: 2 U.S. Department of Veterans Affairs health care facilities. Patients: 244 men with hemoglobin A1c (HbA1c) levels greater than 7.5% during the previous 6 months. Measurements: The primary outcome was 6-month change in HbA1c level. Secondary outcomes were changes in insulin therapy; blood pressure; and patient reports of medication adherence, diabetes-related support, and emotional distress. Intervention: Patients in the RPS group attended an initial group session to set diabetes-related behavioral goals, receive peer communication skills training, and be paired with another age-matched peer patient. Peers were encouraged to talk weekly using a telephone platform that recorded call occurrence and provided reminders to promote peer contact. These patients could also participate in optional group sessions at 1, 3, and 6 months. Patients in the NCM group attended a 1.5-hour educational session and were assigned to a nurse care manager. Results: Of the 244 patients enrolled, 216 (89%) completed the HbA1c assessments and 231 (95%) completed the survey assessments at 6 months. Mean HbA1c level decreased from 8.02% to 7.73% (change, -0.29%) in the RPS group and increased from 7.93% to 8.22% (change, 0.29%) in the NCM group. The difference in HbA1c change between groups was 0.58% (P = 0.004). Among patients with a baseline HbA1c level greater than 8.0%, those in the RPS group had a mean decrease of 0.88%, compared with a 0.07% decrease among those in the NCM group (betweengroup difference, 0.81%; P < 0.001). Eight patients in the RPS group started insulin therapy, compared with 1 patient in the NCM group (P = 0.020). Groups did not differ in blood pressure, self-reported medication adherence, or diabetes-specific distress, but the RPS group reported improvement in diabetes social support. Limitation: The study included only male veterans and lasted only 6 months. Conclusion: Reciprocal peer support holds promise as a method for diabetes care management. [ABSTRACT FROM AUTHOR]

The article offers information on the screening, prevention, diagnosis and treatment for type 2 diabetes. It explains that the diabetes is one among the common illness encountered by internist, in which approximately 23.6 million persons have diabetes in the U.S. It discusses various topics related to diabetes including the importance screening for type 2 diabetes, how does it be prevented and which patient are likely to benefit from diabetes screening.

Context: Preventive medicine has historically favored reducing a risk factor by a small amount in the entire population rather than by a large amount in high-risk individuals. The use of multivariable risk prediction tools, however, may affect the relative merits of this strategy. Methods: This study uses risk factor data from the National Health and Nutrition Examination Survey III to simulate a population of more than 100 million Americans aged thirty or older with no history of CV disease. Three strategies that could affect CV events, CV mortality, and quality-adjusted life years were examined: (1) a population-based strategy that treats all individuals with a low- or moderate-intensity intervention (in which the low-intensity intervention represents a public health campaign with no demonstrable adverse effects), (2) a targeted strategy that treats individuals in the top 25 percent based on a single risk factor (LDL), and (3) a risk-targeted strategy that treats individuals in the top 25 percent based on overall CV risk (as predicted by a multivariable prediction tool). The efficiency of each strategy was compared while varying the intervention's intensity and associated adverse effects, and the accuracy of the risk prediction tool. Findings: The LDL-targeted strategy and the low-intensity population-based strategy were comparable for CV events prevented over five years (0.79 million and 0.75 million, respectively), as were the risk-targeted strategy and moderate-intensity population-based strategy (1.56 million and 1.87 million, respectively). The risk-targeted strategy, however, was more efficient than the moderate-intensity population-based strategy (number needed to treat [NNT] 19 vs. 62). Incorporating a small degree of treatment-related adverse effects greatly magnified the relative advantages of the risk-targeted approach over other strategies. Reducing the accuracy of the prediction tool only modestly decreased this greater efficiency. Conclusions: A population-based prevention strategy can be an excellent option if an intervention has almost no adverse effects. But if the intervention has even a small degree of disutility, a targeted approach using multivariable risk prediction can prevent more morbidity and mortality while treating many fewer people. [ABSTRACT FROM AUTHOR]

The article presents a literary review of available evidence for quality indicators (QI) that can be used to assess the prevention and management of diabetes mellitus (DM) in vulnerable elders (VE). The review included 105 articles about the prevalence and treatment of complications of DM. A description of the 10 QI which were judged by an expert panel as valid is presented, including measurement of glycated hemoglobin, improving glycemic control and foot examination. The supporting evidences for each QI are also explained.

This guidance statement is derived from other organizations' guidelines and is based on an evaluation of the strengths and weaknesses of the available guidelines. We used the Appraisal of Guidelines, Research and Evaluation in Europe (AGREE) appraisal instrument to evaluate the guidelines from various organizations. On the basis of the review of the available guidelines, we recommend: Statement 1: To prevent microvascular complications of diabetes, the goal for glycemic control should be as low as is feasible without undue risk for adverse events or an unacceptable burden on patients. Treatment goals should be based on a discussion of the benefits and harms of specific levels of glycemic control with the patient. A hemoglobin A1c level less than 7% based on individualized assessment is a reasonable goal for many but not all patients. Statement 2: The goal for hemoglobin A1c level should be based on individualized assessment of risk for complications from diabetes, comorbidity, life expectancy, and patient preferences. Statement 3: We recommend further research to assess the optimal level of glycemic control, particularly in the presence of comorbid conditions. [ABSTRACT FROM AUTHOR]

BACKGROUND: We examined the cost-effectiveness of 2- and 3-dimensional computerized tomography (CT) colonography as a screening test for colorectal neoplasia. METHODS: We created a Markov model of the natural history of colorectal cancer. Effectiveness of screening was based upon the diagnostic accuracy of tests in detecting polyps and cancer. RESULTS: CT colonography every 5 or 10 yr was effective and cost-effective relative to no screening. Optical colonoscopy dominates 2-dimensional CT colonography done every 5 or 10 yr. Optical colonoscopy is weakly dominant over 3-dimensional CT colonography done every 10 yr. 3-D CT colonography done every 5 yr is more effective than optical colonoscopy every 10 yr, but costs an incremental $156,000 per life-year gained. Sensitivity analyses show that test costs, accuracy, and adherence are critical determinants of incremental cost-effectiveness. 3-D CT colonography every 5 yr is a dominant strategy if optical colonoscopy costs 1.6 times more than CT colonography. However, optical colonoscopy is a dominant strategy if the sensitivity of CT colonography for 1 cm adenomas is 83% or lower. CONCLUSIONS: CT colonography is an effective screening test for colorectal neoplasia. However, it is more expensive and generally less effective than optical colonoscopy. CT colonography can be reasonably cost-effective when the diagnostic accuracy of CT colonography is high, as with primary 3-dimensional technology, and if costs are about 60% of those of optical colonoscopy. Overall, CT colonography technology will need to improve its accuracy and reliability to be a cost-effective screening option. [ABSTRACT FROM AUTHOR]

Objectives: We sought to compare the cost-effectiveness of left atrial catheter ablation (LACA), amiodarone, and rate control therapy in the management of atrial fibrillation (AF). Background: Left atrial catheter ablation has been performed to eliminate AF, but its cost-effectiveness is unknown. Methods: We developed a decision-analytic model to evaluate the cost-effectiveness of LACA in 55- and 65-year-old cohorts with AF at moderate and low stroke risk. Costs, health utilities, and transition probabilities were derived from published literature and Medicare data. We performed primary threshold analyses to determine the minimum level of LACA efficacy and stroke risk reduction needed to make LACA cost-effective at $50,000 and $100,000 per quality-adjusted life-year (QALY) thresholds. Results: In 65-year-old subjects with AF at moderate stroke risk, relative reduction in stroke risk with an 80% LACA efficacy rate for sinus rhythm restoration would need to be ≥42% and ≥11% to yield incremental cost-effectiveness ratios (ICERs) <$50,000 and $100,000 per QALY, respectively. Higher and lower LACA efficacy rates would require correspondingly lower and higher stroke risk reduction for equivalent ICER thresholds. In the 55-year-old moderate stroke risk cohort, lower LACA efficacy rates or stroke risk reduction would be needed for the same ICER thresholds. In patients at low stroke risk, LACA was unlikely to be cost-effective. Conclusions: The use of LACA may be cost-effective in patients with AF at moderate risk for stroke, but it is not cost-effective in low-risk patients. Our threshold analyses may provide a framework for the design of future clinical trials by providing effect size estimates for LACA efficacy needed. [Copyright &y& Elsevier]

Management of diabetes, and in particular blood glucose, can be complex and burdensome. To evaluate patient views of the burdens of therapy and its impact on self-management. Veteran patients with type 2 diabetes. Mailed survey. Patients described their views of the burden of diabetes treatments, adherence, and clinical and demographic status. Factors associated with ratings of burden and adherence to therapy were examined using multivariate regression methods. The response rate was 67% ( n=1,653). Patients viewed pills as the least burdensome treatment and insulin as the most burdensome. Ratings of the burden of insulin were lower if a patient had prior experience with therapy. Adherence to prescribed therapy varied substantially; for example, patients followed medication recommendations more closely than other areas of self-management. Multivariate analyses showed that the main predictor of adherence was patients' ratings of the burden of therapy. Injected insulin regimens are viewed as highly burdensome by patients, although this burden is attenuated by experience. Adherence to self-management is strongly and independently correlated with views of treatment burden. The burden of diabetes-related treatments may be a source of suboptimal glucose control seen in many care settings. Providers should consider the burden of treatment for a particular patient and its impact on adherence as part of a decision-making process to design effective treatment regimens. [ABSTRACT FROM AUTHOR]

In-home automated external defibrillators (AEDs) are increasingly recommended as a means for improving survival of cardiac arrests that occur at home. The current study was conducted to explore the relationship between individuals' risk of cardiac arrest and cost-effectiveness of in-home AED deployment. Markov decision model employing a societal perspective. Four hypothetical cohorts of American adults 60 years of age at progressively greater risk for sudden cardiac death (SCD): 1) all adults (annual probability of SCD 0.4%); 2) adults with multiple SCD risk factors (probability 2%); 3) adults with previous myocardial infarction (probability 4%); and 4) adults with ischemic cardiomyopathy unable to receive an implantable defibrillator (probability 6%). Strategy 1: individuals suffering an in-home cardiac arrest were treated with emergency medical services equipped with AEDs (EMS-D). Strategy 2: individuals suffering an in-home cardiac arrest received initial treatment with an in-home AED, followed by EMS. Assuming cardiac arrest survival rates of 15% with EMS-D and 30% with AEDs, the cost per quality-adjusted life-year gained (QALY) of providing in-home AEDs to all adults 60 years of age is$216,000. Costs of providing in-home AEDs to adults with multiple risk factors (2% probability of SCD), previous myocardial infarction (4% probability), and ischemic cardiomyopathy (6% probability) are$132,000,$104,000, and$88,000, respectively. The cost-effectiveness of in-home AEDs is intimately linked to individuals' risk of SCD. However, providing in-home AEDs to all adults over age 60 appears relatively expensive. [ABSTRACT FROM AUTHOR]

Diabetes is a highly prevalent condition that results in substantial morbidity and premature mortality. We investigated how diabetes-associated mortality, disability, early retirement, and work absenteeism impacts workforce participation.We used the Health and Retirement Study (HRS), a national household sample of adults aged 51–61 in 1992, as a data source.We conducted cross-sectional analyses on the baseline HRS data, and longitudinal analyses using data from eight years of follow-up. We used two-part regression models to estimate the adjusted impact of diabetes on workforce participation, and then estimated the economic impact of diabetes-related losses in productivity.Diabetes is a significant predictor of lost productivity. The incremental lost income due to diabetes by 1992 was$60.0 billion over an average diabetes duration of 9.7 years. From 1992 to 2000, diabetes was responsible for$4.4 billion in lost income due to early retirement,$0.5 billion due to increased sick days,$31.7 billion due to disability, and$22.0 billion in lost income due to premature mortality, for a total of$58.6 billion dollars in lost productivity, or$7.3 billion per year.In the U.S. population of adults born between 1931 and 1941, diabetes is associated with a profound negative impact on economic productivity. By 1992, an estimated$60 billion in lost productivity was associated with diabetes; additional annual losses averaged$7.3 billion over the next eight years, totaling about$120 billion by the year 2000. Given the rising prevalence of diabetes, these costs are likely to increase substantially unless countered by better public health or medical interventions. [ABSTRACT FROM AUTHOR]

Objective: We sought to explore the patient-specific cost-effectiveness in a community-based sample for a therapy for which the average cost-effectiveness in a clinical trial has been well-described.Study design and setting: Based on a validated multivariate model, we generated predictions of the effectiveness and cost-effectiveness of t-PA compared to streptokinase on 921 consecutive patients who received thrombolytic therapy for acute myocardial infarction.Results: The average cost-effectiveness of t-PA was $40,140 per life-year saved. For the quartile of patients most likely to benefit, the incremental cost-effectiveness of t-PA was $15,396. However, only 44% of patients who received thrombolytic therapy had an estimated cost-effectiveness ratio below $50,000 per year of life saved; the ratio was greater than $100,000 in 37% of treated patients. Patients in the lowest quartile of expected benefit are, overall, more likely to be harmed than to benefit from t-PA.Conclusion: Compared to the pattern of thrombolytic agent choice observed, targeting t-PA to the half of patients most likely to benefit could save 247 lives and $174 million nationally per year. [Copyright &y& Elsevier]

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]

Background: For patients with chronic illnesses, it is hypothesized that effective patient-provider collaboration contributes to improved patient self-care by promoting greater agreement on patient-specific treatment goals and strategies. However, this hypothesis has not been tested in actual encounters of patients with their own physicians.Objective: To assess the extent to which patients with type 2 diabetes agree with their primary care providers (PCPs) on diabetes treatment goals and strategies, the factors that predict agreement, and whether greater agreement is associated with better patient self-management of diabetes.Design: One hundred twenty-seven pairs of patients and their PCPs in two health systems were surveyed about their top 3 diabetes treatment goals (desired outcomes) and strategies to meet those goals. Using several measures to evaluate agreement, we explored whether patient characteristics, such as education and attitudes toward treatment, and patient-provider interaction styles, such as shared decision making, were associated with greater agreement on treatment goals and strategies. We then examined whether agreement was associated with higher patient assessments of their diabetes care self-efficacy and self-management.Results: Overall, agreement on top treatment goals and strategies was low (all kappa were less than 0.40). In multivariable analyses, however, patients with more education, greater belief in the efficacy of their diabetes treatment, and who shared in treatment decision making with their providers were more likely to agree with their providers on treatment goals or strategies. Similarly, physician reports of having discussed more content areas of diabetes self-care were associated with greater agreement on treatment strategies. In turn, greater agreement on treatment goals and strategies was associated both with higher patient diabetes care self-efficacy and assessments of their diabetes self-management.Conclusion: Although patients and their PCPs in general had poor agreement on goals and strategies for managing diabetes, agreement was associated with higher patient self-efficacy and assessments of their diabetes self-management. This supports the hypothesis that enhancing patient-provider agreement on both overall treatment goals and specific strategies to meet these goals may lead to improved patient outcomes. [ABSTRACT FROM AUTHOR]

For patients with chronic illnesses, it is hypothesized that effective patient-provider collaboration contributes to improved patient self-care by promoting greater agreement on patient-specific treatment goals and strategies. However, this hypothesis has not been tested in actual encounters of patients with their own physicians. To assess the extent to which patients with type 2 diabetes agree with their primary care providers (PCPs) on diabetes treatment goals and strategies, the factors that predict agreement, and whether greater agreement is associated with better patient self-management of diabetes. One hundred twenty-seven pairs of patients and their PCPs in two health systems were surveyed about their top 3 diabetes treatment goals (desired outcomes) and strategies to meet those goals. Using several measures to evaluate agreement, we explored whether patient characteristics, such as education and attitudes toward treatment, and patient-provider interaction styles, such as shared decision making, were associated with greater agreement on treatment goals and strategies. We then examined whether agreement was associated with higher patient assessments of their diabetes care self-efficacy and self-management. Overall, agreement on top treatment goals and strategies was low (all κ were less than 0.40). In multivariable analyses, however, patients with more education, greater belief in the efficacy of their diabetes treatment, and who shared in treatment decision making with their providers were more likely to agree with their providers on treatment goals or strategies. Similarly, physician reports of having discussed more content areas of diabetes self-care were associated with greater agreement on treatment strategies. In turn, greater agreement on treatment goals and strategies was associated both with higher patient diabetes care self-efficacy and assessments of their diabetes self-management. Although patients and their PCPs in general had poor agreement on goals and strategies for managing diabetes, agreement was associated with higher patient self-efficacy and assessments of their diabetes self-management. This supports the hypothesis that enhancing patient-provider agreement on both overall treatment goals and specific strategies to meet these goals may lead to improved patient outcomes. J GEN INTERN MED 2003; 18:893–902. [ABSTRACT FROM AUTHOR]

Objective: The American Heart Association (AHA) recommends an automated external defibrillator (AED) be considered for a specific location if there is at least a 20% annual probability the device will be used. We sought to evaluate the cost-effectiveness of the AHA recommendation and of AED deployment in selected public locations with known cardiac arrest rates.Design: Markov Decision Model employing a societal perspective.Setting: Selected public locations in the United States.Patients: A simulated cohort of the American public.Intervention: Strategy 1: individuals experiencing cardiac arrest were treated by emergency medical services equipped with AEDs (EMS-D). Strategy 2: individuals were treated with AEDs deployed as part of a public access defibrillation program. Strategies differed only in the initial availability of an AED and its impact on cardiac arrest survival.Results: Under the base-case assumption that a deployed AED will be used on 1 cardiac arrest every 5 years (20% annual probability of AED use), the cost per quality-adjusted life year (QALY) gained is $30,000 for AED deployment compared with EMS-D care. AED deployment costs less than $50,000 per QALY gained provided that the annual probability of AED use is 12% or greater. Monte Carlo simulation conducted while holding the annual probability of AED use at 20% demonstrated that 87% of the trials had a cost-effectiveness ratio of less than $50,000 per QALY.Conclusions: AED deployment is likely to be cost-effective across a range of public locations. The current AHA guidelines are overly restrictive. Limited expansion of these programs can be justified on clinical and economic grounds. [ABSTRACT FROM AUTHOR]

Abstract Objective: Traditional cost–utility analysis assumes that all benefits from health-related interventions are captured by the quality-adjusted life-years (QALYs) gained by the few individuals whose outcome is improved by the intervention. However, it is possible that many individuals who do not directly benefit from an intervention receive utility, and therefore QALYs, because of the passive benefit (aka sense of security) provided by the existence of the intervention. The objective of this study was to evaluate the impact that varying quantities of passive benefit have on the cost-effectiveness of airline defibrillator programs. Methods: A decision analytic model with Markov processes was constructed to evaluate the cost-effectiveness of defibrillator deployment on domestic commercial passenger aircraft over 1 year. Airline passengers were assigned small incremental utility gains (.001–.01) during an estimated 3-hour flight to evaluate the impact of passive benefit on overall cost-effectiveness. Results: In the base case analysis with no allowance for passive benefit, the cost-effectiveness of airline automated external defibrillator deployment was $34,000 per QALY gained. If 1% of all passengers received utility gain of .01, the cost-effectiveness declined to $30,000. Cost-effectiveness was enhanced when the quantity of passive benefit was raised or the percentage of individuals receiving passive benefit increased. Conclusions: Automated external defibrillator deployment on passenger aircraft is likely to be cost-effective. If a small percentage of airline passengers receive incremental utility gains from passive benefit of automated external defibrillator availability, the impact on overall cost-effectiveness may be substantial. Further research should attempt to clarify the magnitude and percentage of patients who receive passive benefit. [ABSTRACT FROM AUTHOR]

Evaluates goals and optimal agents for treatment of hypertension in type 2 diabetes. Review of the medical literature to obtain data; Extraction and synthesis of data for the study; Benefits of blood pressure control; Recommended blood pressure level and hypotensive agents.

Focuses on a study that examined physician practices and the use of aspirin therapy by individuals with diabetes. Research design and methods; Results; Conclusions.

Assesses the level of informal caregiving for diabetic complications among elderly in the U.S. Determination on the weekly hours of informal caregiving; Estimation on the total cost of informal caregiving; Identification on the cost-effectiveness of diabetes interventions.

Examines the cost-utility of screening primary care patients for depression. Annual cost to society of annual screening versus no screening; Cost of 5-year interval screening per quality adjusted life year versus no screening; Cost-effectiveness of one-time screening; Estimates of sensitivity and specificity of screening instruments; Estimates of prevalence of depression.

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.

Presents a study to evaluate the efficacy of glycemic control in type 2 diabetes. How benefits of intensive glycemic control is quantified in patients; Methodology of the study; Most common feared complications of diabetes; Results and conclusions of the study.

The article discusses the randomized clinical trial which assessed the effect of personalized diabetic risk assessment on glycemic control during opthalmologic visits. Topics mentioned include the importance in reducing the related complications on diabetes mellitus like blindness, the result that the assessment intervention has no effect to blood glucose control, and the relation of the unsuccessful intervention to asymptomatic outcome of retinopathy.

Description: The American College of Physicians (ACP) developed this guideline to provide clinical recommendations based on the current evidence of the benefits and harms of testosterone treatment in adult men with age-related low testosterone. This guideline is endorsed by the American Academy of Family Physicians.Methods: The ACP Clinical Guidelines Committee based these recommendations on a systematic review on the efficacy and safety of testosterone treatment in adult men with age-related low testosterone. Clinical outcomes were evaluated by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system and included sexual function, physical function, quality of life, energy and vitality, depression, cognition, serious adverse events, major adverse cardiovascular events, and other adverse events.Target Audience and Patient Population: The target audience includes all clinicians, and the target patient population includes adult men with age-related low testosterone.Recommendation 1a: ACP suggests that clinicians discuss whether to initiate testosterone treatment in men with age-related low testosterone with sexual dysfunction who want to improve sexual function (conditional recommendation; low-certainty evidence). The discussion should include the potential benefits, harms, costs, and patient's preferences.Recommendation 1b: ACP suggests that clinicians should reevaluate symptoms within 12 months and periodically thereafter. Clinicians should discontinue testosterone treatment in men with age-related low testosterone with sexual dysfunction in whom there is no improvement in sexual function (conditional recommendation; low-certainty evidence).Recommendation 1c: ACP suggests that clinicians consider intramuscular rather than transdermal formulations when initiating testosterone treatment to improve sexual function in men with age-related low testosterone, as costs are considerably lower for the intramuscular formulation and clinical effectiveness and harms are similar.Recommendation2: ACP suggests that clinicians not initiate testosterone treatment in men with age-related low testosterone to improve energy, vitality, physical function, or cognition (conditional recommendation; low-certainty evidence). [ABSTRACT FROM AUTHOR]

Background: Bridging anticoagulation is commonly prescribed to patients with atrial fibrillation during initiation and interruption of warfarin. Guidelines recommend bridging patients at high risk of stroke, while a recent randomized trial demonstrated overall harm in a population at comparatively low risk of ischemic stroke. Theory suggests that patients at high risk of stroke and low risk of hemorrhage may benefit from bridging, but data informing patient selection are scant.Objective: To estimate the utility and cost-effectiveness of bridging anticoagulation among patients with nonvalvular atrial fibrillation, stratified by thromboembolic and hemorrhagic risk DESIGN: Cost-effectiveness analysis with lifelong time horizon, from the perspective of a third-party payer MAIN MEASURES: Quality-adjusted life years (QALYs) per bridged patient; US dollars per QALY gained KEY RESULTS: Unselected patients with nonvalvular atrial fibrillation may be harmed by bridging anticoagulation. Hospital admission for bridging is almost never cost-effective, and generally harmful. Among patients carefully selected by both thromboembolic and hemorrhagic risks, outpatient bridging can be beneficial and cost-effective. Results were sensitive to how effectively heparin products reduce stroke risk.Conclusions: Outpatient bridging anticoagulation can be beneficial and cost-effective for a subset of patients with nonvalvular atrial fibrillation during interruption or initiation of warfarin. Admission for bridging should be avoided. [ABSTRACT FROM AUTHOR]

A response from the author of the article "In the clinic. Type 2 diabetes" in the previous issue is presented.

Even with the development of the serotonin 5-HT3 receptor antagonists in recent years, postoperative nausea and vomiting (PONV) remains a significant concern for clinicians and patients. For the selection of an appropriate antiemetic strategy for PONV, economic considerations should be taken into account. A literature search covering the period from September 1996 to August 2005 yielded 16 economic evaluations on antiemetics used for the prevention or treatment of PONV. In these studies, a variety of different antiemetic regimens were evaluated, with different doses and timing of administration, in many different populations, for various types of surgery, and in different settings. In addition, there were many differences in the design of these economic evaluations in terms of the extent of the costs considered and the decision rules used when forming conclusions. Therefore, despite the availability of economic evaluations on antiemetics in PONV, it is difficult to draw clear conclusions with such disparate information.In spite of these limitations, key learning can be drawn from these economic evaluations. From studies where a placebo was used as a comparator, we can conclude that there is clinical benefit in using an antiemetic for the prevention of PONV versus no therapy. The dose of the 5-HT3 receptor antagonist seems more important in determining cost effectiveness than the selection of the agent itself, and less expensive agents such as droperidol, dexamethasone and prochlorperazine may also represent cost-effective alternatives to 5-HT3 receptor antagonists.In an additional six studies where a willingness to pay (WTP) to avoid or reduce the incidence of PONV was estimated, the average WTP amounts varied from $US29 to $US117.Many questions remain unanswered about the cost effectiveness of existing antiemetics and their regimens, and little is known about the impact of new agents, such as the neurokinin-1 receptor antagonists, in the control of PONV. [ABSTRACT FROM AUTHOR]

Presents a response by Vijan and Hayward to a letter to the editor about their article on blood pressure control in Type 2 Diabetes Mellitus published in an earlier issue.

A letter to the editor is presented in response to an article by Rury Holman and colleagues about glucose-lowering strategies in type 2 diabetes, published in the June 7, 2008 issue.

The article discusses the results of a study that examined the role of quality measurement in the inappropriate use of screening for colorectal cancer. Topics discussed include stability of screening use from age 50 to 75 with abrupt decline in use after 75 and the likelihood that a 75-year-old man with poor health will undergo screening than a 76-year-old in good health.

In this article, the American College of Physicians updates its 2017 recommendations on pharmacologic treatment of primary osteoporosis or low bone mass to prevent fractures in adults. These updated guidelines examine new evidence comparing therapies among all at-risk populations, including men. Description: This guideline updates the 2017 American College of Physicians (ACP) recommendations on pharmacologic treatment of primary osteoporosis or low bone mass to prevent fractures in adults. Methods: The ACP Clinical Guidelines Committee based these recommendations on an updated systematic review of evidence and graded them using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Audience and Patient Population: The audience for this guideline includes all clinicians. The patient population includes adults with primary osteoporosis or low bone mass. Recommendation 1a: ACP recommends that clinicians use bisphosphonates for initial pharmacologic treatment to reduce the risk of fractures in postmenopausal females diagnosed with primary osteoporosis (strong recommendation; high-certainty evidence). Recommendation 1b: ACP suggests that clinicians use bisphosphonates for initial pharmacologic treatment to reduce the risk of fractures in males diagnosed with primary osteoporosis (conditional recommendation; low-certainty evidence). Recommendation 2a: ACP suggests that clinicians use the RANK ligand inhibitor (denosumab) as a second-line pharmacologic treatment to reduce the risk of fractures in postmenopausal females diagnosed with primary osteoporosis who have contraindications to or experience adverse effects of bisphosphonates (conditional recommendation; moderate-certainty evidence). Recommendation 2b: ACP suggests that clinicians use the RANK ligand inhibitor (denosumab) as a second-line pharmacologic treatment to reduce the risk of fractures in males diagnosed with primary osteoporosis who have contraindications to or experience adverse effects of bisphosphonates (conditional recommendation; low-certainty evidence). Recommendation 3: ACP suggests that clinicians use the sclerostin inhibitor (romosozumab, moderate-certainty evidence) or recombinant PTH (teriparatide, low-certainty evidence), followed by a bisphosphonate, to reduce the risk of fractures only in females with primary osteoporosis with very high risk of fracture (conditional recommendation). Recommendation 4: ACP suggests that clinicians take an individualized approach regarding whether to start pharmacologic treatment with a bisphosphonate in females over the age of 65 with low bone mass (osteopenia) to reduce the risk of fractures (conditional recommendation; low-certainty evidence). [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]

A letter to the editor is presented in response to the article "Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis," by K. G. Shojania, S. R. Ranji and K. M. McDonald.

Background: The ability of latent class models to identify clinically distinct groups among high-risk patients has been demonstrated, but it is unclear how healthcare data can inform group-specific intervention design.Objective: Examine how utilization patterns across latent groups of high-risk patients provide actionable information to guide group-specific intervention design.Design: Cohort study using data from 2012 to 2015.Patients: Participants were 934,787 patients receiving primary care in the Veterans Health Administration, with predicted probability of 12-month hospitalization in the top 10th percentile during 2014.Main Measures: Patients were assigned to latent groups via mixture-item response theory models based on 28 chronic conditions. We modeled odds of all-cause mortality, hospitalizations, and 30-day re-hospitalizations by group membership. Detailed outpatient and inpatient utilization patterns were compared between groups.Key Results: A total of 764,257 (81.8%) of patients were matched with a comorbidity group. Groups were characterized by substance use disorders (14.0% of patients assigned), cardiometabolic conditions (25.7%), mental health conditions (17.6%), pain/arthritis (19.1%), cancer (15.3%), and liver disease (8.3%). One-year mortality ranged from 2.7% in the Mental Health group to 14.9% in the Cancer group, compared to 8.5% overall. In adjusted models, group assignment predicted significantly different odds of each outcome. Groups differed in their utilization of multiple types of care. For example, patients in the Pain group had the highest utilization of in-person primary care, with a mean (SD) of 5.3 (5.0) visits in the year of follow-up, while the Substance Use Disorder group had the lowest, with 3.9 (4.1) visits. The Substance Use Disorder group also had the highest rates of using services for housing instability (25.1%), followed by the Liver group (10.1%).Conclusions: Latent groups of high-risk patients had distinct hospitalization and utilization profiles, despite having comparable levels of predicted baseline risk. Utilization profiles pointed towards system-specific care needs that could inform tailored interventions. [ABSTRACT FROM AUTHOR]

Background: Proton-pump inhibitors (PPIs) are commonly used among medical inpatients, both for prophylaxis against upper gastrointestinal bleeding (UGIB) and continuation of outpatient use. While PPIs reduce the risk of UGIB, they also appear to increase the risk of hospital-acquired pneumonia (HAP) and Clostridium difficile infection (CDI). Depending upon the underlying risks of these conditions and the changes in those risks with PPIs, use of proton-pump inhibitors may lead to a net benefit or net harm among medical inpatients. Objective: We aimed to determine the net impact of PPIs on hospital mortality among medical inpatients. Design: A microsimulation model, using literature-derived estimates of the risks of UGIB, HAP, and CDI among medical inpatients, along with the changes in risk associated with PPI use for each of these outcomes. The primary outcome was change in inpatient mortality. Participants: Simulated general medical inpatients outside the intensive care unit (ICU). Main Measure: Change in overall mortality during hospitalization. Key Results: New initiation of PPI therapy led to an increase in hospital mortality in about 90% of simulated patients. Continuation of outpatient PPI therapy on admission led to net increase in hospital mortality in 79% of simulated patients. Results were robust to both one-way and multivariate sensitivity analyses, with net harm occurring in at least two-thirds of patients in all scenarios. Conclusions: For the majority of medical inpatients outside the ICU, use of PPIs likely leads to a net increase in hospital mortality. Even in patients at particularly high risk of UGIB, only those at the very lowest risk of HCAP and CDI should be considered for prophylactic PPI use. Continuation of outpatient PPIs may also increase expected hospital mortality. Apart from patients with active UGIB, use of PPIs in hospitalized patients should be discouraged. [ABSTRACT FROM AUTHOR]

Background: Like a growing number of rapidly developing countries, India has begun to develop a system for large-scale community-based screening for diabetes. We sought to identify the implications of using alternative screening instruments to detect people with undiagnosed type 2 diabetes among diverse populations across India. Methods and Findings: We developed and validated a microsimulation model that incorporated data from 58 studies from across the country into a nationally representative sample of Indians aged 25–65 y old. We estimated the diagnostic and health system implications of three major survey-based screening instruments and random glucometer-based screening. Of the 567 million Indians eligible for screening, depending on which of four screening approaches is utilized, between 158 and 306 million would be expected to screen as “high risk” for type 2 diabetes, and be referred for confirmatory testing. Between 26 million and 37 million of these people would be expected to meet international diagnostic criteria for diabetes, but between 126 million and 273 million would be “false positives.” The ratio of false positives to true positives varied from 3.9 (when using random glucose screening) to 8.2 (when using a survey-based screening instrument) in our model. The cost per case found would be expected to be from US$5.28 (when using random glucose screening) to US$17.06 (when using a survey-based screening instrument), presenting a total cost of between US$169 and US$567 million. The major limitation of our analysis is its dependence on published cohort studies that are unlikely fully to capture the poorest and most rural areas of the country. Because these areas are thought to have the lowest diabetes prevalence, this may result in overestimation of the efficacy and health benefits of screening. Conclusions: Large-scale community-based screening is anticipated to produce a large number of false-positive results, particularly if using currently available survey-based screening instruments. Resource allocators should consider the health system burden of screening and confirmatory testing when instituting large-scale community-based screening for diabetes. [ABSTRACT FROM AUTHOR]

Description: The American College of Physicians (ACP) developed this guideline to provide clinical recommendations on the role of colonoscopy for diagnostic evaluation of colorectal cancer (CRC) after a presumed diagnosis of acute left-sided colonic diverticulitis and on the role of pharmacologic, nonpharmacologic, and elective surgical interventions to prevent recurrence after initial treatment of acute complicated and uncomplicated left-sided colonic diverticulitis. This guideline is based on the current best available evidence about benefits and harms, taken in the context of costs and patient values and preferences.Methods: The ACP Clinical Guidelines Committee (CGC) based these recommendations on a systematic review on the role of colonoscopy after acute left-sided colonic diverticulitis and pharmacologic, nonpharmacologic, and elective surgical interventions after initial treatment. The systematic review evaluated outcomes rated by the CGC as critical or important. This guideline was developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method.Target Audience and Patient Population: The target audience is all clinicians, and the target patient population is adults with recent episodes of acute left-sided colonic diverticulitis.Recommendation1: ACP suggests that clinicians refer patients for a colonoscopy after an initial episode of complicated left-sided colonic diverticulitis in patients who have not had recent colonoscopy (conditional recommendation; low-certainty evidence).Recommendation2: ACP recommends against clinicians using mesalamine to prevent recurrent diverticulitis (strong recommendation; high-certainty evidence).Recommendation3: ACP suggests that clinicians discuss elective surgery to prevent recurrent diverticulitis after initial treatment in patients who have either uncomplicated diverticulitis that is persistent or recurs frequently or complicated diverticulitis (conditional recommendation; low-certainty evidence). The informed decision whether or not to undergo surgery should be personalized based on a discussion of potential benefits, harms, costs, and patient's preferences. [ABSTRACT FROM AUTHOR]

Description: The American College of Physicians (ACP) developed this guideline to provide clinical recommendations on the diagnosis and management of acute left-sided colonic diverticulitis in adults. This guideline is based on current best available evidence about benefits and harms, taken in the context of costs and patient values and preferences.Methods: The ACP Clinical Guidelines Committee (CGC) developed this guideline based on a systematic review on the use of computed tomography (CT) for the diagnosis of acute left-sided colonic diverticulitis and on management via hospitalization, antibiotic use, and interventional percutaneous abscess drainage. The systematic review evaluated outcomes that the CGC rated as critical or important. This guideline was developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology.Target Audience and Patient Population: The target audience is all clinicians, and the target patient population is adults with suspected or known acute left-sided colonic diverticulitis.Recommendation1: ACP suggests that clinicians use abdominal CT imaging when there is diagnostic uncertainty in a patient with suspected acute left-sided colonic diverticulitis (conditional recommendation; low-certainty evidence).Recommendation2: ACP suggests that clinicians manage most patients with acute uncomplicated left-sided colonic diverticulitis in an outpatient setting (conditional recommendation; low-certainty evidence).Recommendation3: ACP suggests that clinicians initially manage select patients with acute uncomplicated left-sided colonic diverticulitis without antibiotics (conditional recommendation; low-certainty evidence). [ABSTRACT FROM AUTHOR]

Background: Behavioral weight-loss treatment can improve health, yet it is underutilized. Factors leading to initiation of weight-loss treatment are not well characterized. In particular, it is unknown whether changes in obesity-related health status contribute to weight-loss treatment initiation. Purpose: To determine if recent weight change or diagnosis of an obesity-related comorbidity was associated with utilization of a behavioral weight-loss program in an integrated healthcare setting. Methods: In a retrospective cohort study of 45,272 Veterans Affairs (VA) patients with BMI >30, logistic regression was used to examine whether recent weight change or obesity-related comorbidities newly diagnosed in the past 6 months were associated with initiation of a VA behavioral weight management program (called MOVE!) in 2010 or sustained MOVE! use (eight or more sessions). Weight change in prior year was categorized as >3% weight loss; weight stable (<3% change); or weight gain of 3%–4.9%, 5%–9.9%, or ≥10%. Data were analyzed in 2013. Results: Patients were 91% male, 68% white, and had a mean age of 58 years. Patients were more likely to initiate treatment if they had ≥3% weight gain (3%–4.9%: OR=1.64, 95% CI=1.52, 1.77; 5%–9.9%: OR=1.99, 95% CI=1.84, 2.16; ≥10%: OR=2.68, 95% CI=2.32, 3.10) or were newly diagnosed with any obesity-related comorbidity (ORs: 2.14–3.59). Weight change and new comorbidity diagnoses were not associated, however, with sustained MOVE! use. Conclusions: Adverse obesity-related health events were associated with initiation of behavioral weight-loss treatment offered in an integrated healthcare setting. [Copyright &y& Elsevier]