Cost-effective clinical decision making

PEDIATRICS ◽  
1977 ◽  
Vol 60 (5) ◽  
pp. 756-759
Author(s):  
Duncan Neuhauser
Keyword(s):  
Decision Making ◽  
Hospital Stay ◽  
Clinical Decision Making ◽  
Cost Effective ◽  
Clinical Decision ◽  
Inappropriate Therapy ◽  
X Ray ◽  
Scarce Resources ◽  
Chest X Ray ◽  
The Cost

Are pediatric preoperative chest x-ray examinations worth doing? Sane et al. (p. 669) conclude that they are "medically and economically justified and essential." To answer this question requires at least the following information. What is the cost of the examination (dollars, radiation exposure, cost of further testing and perhaps inappropriate therapy resulting therefrom, and possible prolongation of hospital stay)? What is the benefit? What percent of patients have unsuspected findings; of these, the percent with modified treatment; and of these, what percent benefited therefrom? What was the cost per unit of benefit received? Is there some other use of these scarce resources that would have yielded greater benefits?

scholarly journals LUNG ULTRASOUND DURING COVID-19 PANDEMICS: WHY, HOW AND WHEN?

2021 ◽  
Vol 74 (8) ◽  
pp. 1783-1788
Author(s):  
Khrystyna O. Pronyuk ◽  
Liudmyla O. Kondratiuk ◽  
Andrii D. Vysotskyi ◽  
Olga A. Golubovska ◽  
Iryna M. Nikitina
Keyword(s):  
Hospital Stay ◽  
Clinical Decision Making ◽  
Lung Ultrasound ◽  
Limited Resource ◽  
Clinical Decision ◽  
Lung Damage ◽  
Dynamic Monitoring ◽  
Initial Assessment ◽  
X Ray ◽  
Chest X Ray

The aim: To optimize diagnostic of pathological processes in lungs affected by COVID-19, dynamic monitoring and clinical decision making using lung ultrasound in limited resources settings. Materials and methods: Between the onset of pandemics and January 2021, approximately 9000 patients have been treated for confirmed COVID-19 in the Olexandrivska Clinical Hospital. Assessment of all hospitalized patients included hematology, chemistries and proinflammatory cytokines – IL-6, CRP, procalcitonin, ferritin. Diagnosis was confirmed by PCR for SARS-CoV-2 RNA. Chest X-ray was performed in all hospitalized cases, while CT was available approximately in 30% of cases during hospital stay. Lung ultrasound was proactively utilized to assess the type and extent of lung damage and to monitor the progress of disease in patients hospitalized into the ICU and Infection Unit (n=135). Ultrasound findings were recorded numerically based on scales. Results: In the setting of СOVID-19, bedside lung ultrasound has been promptly recognized as a tool to diagnose and monitor the nature and extent of lung injury. Lung ultrasound is a real time assessment, which helps determine the nature of a pathologic process affecting lungs. In this paper the accuracy of bedside LUS, chest X-ray and computer tomography are compared based on clinical cases, typical for COVID-19 lung ultrasound appearance is evaluated. Described in article data is collected in one of the biggest facility that deals with COVID-19. Chest X-ray was performed in all hospitalized cases, while CT was available approximately in 30% of cases during hospital stay. The cases presented in the paper indicate potential advantages to the use of ultrasound in limited resource healthcare settings, especially when the risk of transportation to CT outweighs the value of information obtained. Conclusions: Grading of ultrasonographic findings in the lungs was sufficient for both initial assessment with identification of high risk patients, and routine daily monitoring. Hence, lung ultrsound may be used to predict deterioration, stratify risks and make clinical decisions.

scholarly journals Cost-Effectiveness Analysis of Direct Oral Anticoagulants Versus Vitamin K Antagonists for Venous Thromboembolism in China

2021 ◽  
Vol 12 ◽  
Author(s):  
Ke-Xin Sun ◽  
Bin Cui ◽  
Shan-Shan Cao ◽  
Qi-Xiang Huang ◽  
Ru-Yi Xia ◽  
...  
Keyword(s):  
Decision Making ◽  
Sensitivity Analysis ◽  
Cost Effectiveness ◽  
Markov Model ◽  
Clinical Decision Making ◽  
Cost Effective ◽  
Clinical Decision ◽  
Base Case ◽  
Effectiveness Analysis ◽  
The Cost

Background: The drug therapy of venous thromboembolism (VTE) presents a significant economic burden to the health-care system in low- and middle-income countries. To understand which anticoagulation therapy is most cost-effective for clinical decision-making , the cost-effectiveness of apixaban (API) versus rivaroxaban (RIV), dabigatran (DAB), and low molecular weight heparin (LMWH), followed by vitamin K antagonist (VKA), in the treatment of VTE in China was assessed.Methods: To access the quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs), a long-term cost-effectiveness analysis was constructed using a Markov model with 5 health states. The Markov model was developed using patient data collected from the Xijing Hospital from January 1, 2016 to January 1, 2021. The time horizon was set at 30 years, and a 6-month cycle length was used in the model. Costs and ICERs were reported in 2020 U.S. dollars. One-way sensitivity analysis and probabilistic sensitivity analysis (PSA) were used to test the uncertainties. A Chinese health-care system perspective was used.Results: In the base case, the data of 231 VTE patients were calculated in the base case analysis retrospectively. The RIV group resulted in a mean VTE attributable to 95% effective treatment. API, DAB, and VKA have a negative ICER (−187017.543, −284,674.922, and −9,283.339, respectively) and were absolutely dominated. The Markov model results confirmed this observation. The ICER of the API and RIV was negative (−216176.977), which belongs to the absolute inferiority scheme, and the ICER value of the DAB and VKA versus RIV was positive (110,577.872 and 836,846.343). Since the ICER of DAB and VKA exceeds the threshold, RIV therapy was likely to be the best choice for the treatment of VTE within the acceptable threshold range. The results of the sensitivity analysis revealed that the model output varied mostly with the cost in the DAB on-treatment therapy. In a probabilistic sensitivity analysis of 1,000 patients for 30 years, RIV has 100% probability of being cost-effective compared with other regimens when the WTP is $10973 per QALY. When WTP exceeded $148,000, DAB was more cost-effective than RIV.Conclusions: Compared with LMWH + VKA and API, the results proved that RIV may be the most cost-effective treatment for VTE patients in China. Our findings could be helpful for physicians in clinical decision-making to select the appropriate treatment option for VTE.

scholarly journals Slumped posture on chest X-ray—association with mortality and length of hospital stay in older hospitalised patients

2019 ◽  
Vol 48 (4) ◽  
pp. 588-591
Author(s):  
Aled Lloyd ◽  
Elin Thomas ◽  
Hasan Haboubi
Keyword(s):  
Length Of Stay ◽  
Hospital Stay ◽  
Clinical Decision Making ◽  
Length Of Hospital Stay ◽  
Clinical Decision ◽  
Health Board ◽  
X Ray ◽  
Shortest Distance ◽  
Hospitalised Patients ◽  
Chest X Ray

Abstract Introduction frail, older patients are occasionally incapable of keeping their head out of the field of view of a chest radiograph (CXR) resulting in a ‘slumpogram’. This study aims to explore a possible link between a slumped appearance on a CXR; mortality and length of hospital stay. Methods the CXRs of patients aged over 65 admitted to a Health Board with a catchment area of approximately 300,000 were investigated in a retrospective analysis of all CXRs taken during the first week of January 2015. Slumped patients were compared to age matched controls. The degree of slumping was measured by the number of ribs covered and the MA/C factor (the shortest distance between the angle of the mandible and a line drawn between the heads of both acromion divided by the length of the patient’s clavicle). Outcomes investigated included length of hospital stay and 18-month mortality. Results 806 CXRs were viewed with 53 slumped patients and 53 matched controls identified. In all patients aged over 65 there was a statistically significant correlation between the length of stay and the number of ribs covered by the patients’ head (P = 0.038). The MA/C factor was also associated with length of stay (P = 0.025). In patients over 80 there was a significant association between the number of ribs covered and death (P = 0.015). Conclusion a slumped CXR may be associated with longer hospitalisation or death. The results of this small study require further revalidation but if true could help inform clinical decision making.

scholarly journals Does imbalance in chest X-ray datasets produce biased deep learning approaches for COVID-19 screening?

2021 ◽  
Author(s):  
Lorena Alvarez-Rodríguez ◽  
Joaquim de Moura ◽  
Jorge Novo ◽  
Marcos Ortega
Keyword(s):  
Decision Making ◽  
Deep Learning ◽  
Clinical Decision Making ◽  
Patient Characteristics ◽  
Clinical Decision ◽  
Decision Making Process ◽  
Health Crisis ◽  
X Ray ◽  
Reliable Analysis ◽  
Chest X Ray

Abstract Background: The health crisis resulting from the global COVID-19 pandemic highlighted more than ever the need for rapid, reliable and safe methods of diagnosis and monitoring of respiratory diseases. To study pulmonary involvement in detail, one of the most common resources is the use different lung imaging modalities (like chest radiography) to explore the possible affected areas. Methods: In this work, we performed a comprehensive analysis of sex and age factors in chest X-ray images. The study of these recurrent patient characteristics in pathologies of this type is crucial, since there is a clear scarcity of data that may lead to biases when trying to develop systems that are as representative as possible, as well as to gain knowledge of the disease itself. To identify possible biases, we analyzed 3 different computational approaches for automatic COVID-19 screening: Normal vs COVID-19, Pneumonia vs COVID-19 and Non-COVID-19 vs COVID-19. The presented study was validated using two public chest X-ray datasets, allowing a reliable analysis to support the clinical decision-making process in the context of this dramatic global pandemic. Results: The obtained results for the sex-related imbalance analysis indicate that this factor slightly affects the system performance in the Normal VS COVID-19 and Pneumonia VS COVID-19 approaches, although the identified differences are not relevant enough to worsen considerably the system’s response. Regarding the age-related imbalance analysis, this factor was observed to be again influencing the system in a more consistent way than the sex factor, as it was present in all the approaches. Once again, this worsening is not a major problem for our data and system, as it is not of great magnitude. Conclusions: Multiple studies have been conducted in other fields in order to determine if certain patient characteristics such as sex or age influenced these deep learning systems. However, to the best of our knowledge, this study has not been done for COVID-19 despite the urgency and lack of COVID-19 chest x-ray images. The presented results evidenced that the proposed methodology and tested approaches allow a robust and reliable analysis to support the clinical decision-making process in this pandemic scenario.

Cost-Effective Clinical Decision Making

PEDIATRICS ◽  
1980 ◽  
Vol 65 (2) ◽  
pp. 371.1-371
Author(s):  
Edward J. O'Boyle
Keyword(s):  
Decision Making ◽  
Clinical Decision Making ◽  
Cost Effective ◽  
Clinical Decision

scholarly journals Impact of 123I-MIBG Scintigraphy on Clinical Decision-Making in Pheochromocytoma and Paraganglioma

2019 ◽  
Vol 104 (9) ◽  
pp. 3812-3820 ◽  
Author(s):  
Dipti Rao ◽  
Anouk van Berkel ◽  
Ianthe Piscaer ◽  
William F Young ◽  
Lucinda Gruber ◽  
...  
Keyword(s):  
Decision Making ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Diagnostic Value ◽  
Mibg Scintigraphy ◽  
Cross Sectional ◽  
First Choice ◽  
Cross Sectional Imaging ◽  
The Cost ◽  
The Impact

Abstract Context Cross-sectional imaging with CT or MRI is regarded as a first-choice modality for tumor localization in patients with pheochromocytoma and paraganglioma (PPGL). 123I-labeled metaiodobenzylguanidine (123I-MIBG) is widely used for functional imaging but the added diagnostic value is controversial. Objective To establish the virtual impact of adding 123I-MIBG scintigraphy to CT or MRI on diagnosis and treatment of PPGL. Design International multicenter retrospective study. Intervention None. Patients Two hundred thirty-six unilateral adrenal, 18 bilateral adrenal, 48 unifocal extra-adrenal, 12 multifocal, and 26 metastatic PPGL. Main Outcome Measures Patients underwent both anatomical imaging (CT and/or MRI) and 123I-MIBG scintigraphy. Local imaging reports were analyzed centrally by two independent observers who were blinded to the diagnosis. Imaging-based diagnoses determined by CT/MRI only, 123I-MIBG only, and CT/MRI combined with 123I-MIBG scintigraphy were compared with the correct diagnoses. Results The rates of correct imaging-based diagnoses determined by CT/MRI only versus CT/MRI plus 123I-MIBG scintigraphy were similar: 89.4 versus 88.8%, respectively (P = 0.50). Adding 123I-MIBG scintigraphy to CT/MRI resulted in a correct change in the imaging-based diagnosis and ensuing virtual treatment in four cases (1.2%: two metastatic instead of nonmetastatic, one multifocal instead of single, one unilateral instead of bilateral adrenal) at the cost of an incorrect change in seven cases (2.1%: four metastatic instead of nonmetastatic, two multifocal instead of unifocal and one bilateral instead of unilateral adrenal). Conclusions For the initial localization of PPGL, the addition of 123I-MIBG scintigraphy to CT/MRI rarely improves the diagnostic accuracy at the cost of incorrect interpretation in others, even when 123I-MIBG scintigraphy is restricted to patients who are at risk for metastatic disease. In this setting, the impact of 123I-MIBG scintigraphy on clinical decision-making appears very limited.

scholarly journals Clinical decision-making in older adults following emergency admission to hospital. Derivation and validation of a risk stratification score: OPERA

PLoS ONE ◽  
2021 ◽  
Vol 16 (3) ◽  
pp. e0248477
Author(s):  
Khushal Arjan ◽  
Lui G. Forni ◽  
Richard M. Venn ◽  
David Hunt ◽  
Luke Eliot Hodgson
Keyword(s):  
Older Adults ◽  
Decision Making ◽  
Risk Stratification ◽  
Hospital Mortality ◽  
Hospital Stay ◽  
Risk Score ◽  
Clinical Decision Making ◽  
External Validation ◽  
Clinical Decision ◽  
Early Warning Score

Objectives of the study Demographic changes alongside medical advances have resulted in older adults accounting for an increasing proportion of emergency hospital admissions. Current measures of illness severity, limited to physiological parameters, have shortcomings in this cohort, partly due to patient complexity. This study aimed to derive and validate a risk score for acutely unwell older adults which may enhance risk stratification and support clinical decision-making. Methods Data was collected from emergency admissions in patients ≥65 years from two UK general hospitals (April 2017- April 2018). Variables underwent regression analysis for in-hospital mortality and independent predictors were used to create a risk score. Performance was assessed on external validation. Secondary outcomes included seven-day mortality and extended hospital stay. Results Derivation (n = 8,974) and validation (n = 8,391) cohorts were analysed. The model included the National Early Warning Score 2 (NEWS2), clinical frailty scale (CFS), acute kidney injury, age, sex, and Malnutrition Universal Screening Tool. For mortality, area under the curve for the model was 0.79 (95% CI 0.78–0.80), superior to NEWS2 0.65 (0.62–0.67) and CFS 0.76 (0.74–0.77) (P<0.0001). Risk groups predicted prolonged hospital stay: the highest risk group had an odds ratio of 9.7 (5.8–16.1) to stay >30 days. Conclusions Our simple validated model (Older Persons’ Emergency Risk Assessment [OPERA] score) predicts in-hospital mortality and prolonged length of stay and could be easily integrated into electronic hospital systems, enabling automatic digital generation of risk stratification within hours of admission. Future studies may validate the OPERA score in external populations and consider an impact analysis.

scholarly journals Lung Ultrasound in COVID-19 pandemic: Why? How? And When?

2020 ◽  
pp. 3-12
Author(s):  
Khrystyna Pronyuk ◽  
Andriy Vysotskyi
Keyword(s):  
Critically Ill ◽  
Computer Tomography ◽  
Critically Ill Patients ◽  
Clinical Decision Making ◽  
Lung Ultrasound ◽  
Clinical Decision ◽  
X Rays ◽  
Lung Involvement ◽  
X Ray ◽  
Chest X Ray

During COVID-19 pandemic Lung ultrasound has rapidly become a tool for diagnosis and monitoring of lung involvement and it’s severity. Accurate evaluation of lung pathologic entities at the bedside, especially in critically ill patients, and those on mechanical ventilation, remains problematic. CT should not be frequently repeated and is not available everywhere, especially for critically ill patients. Limitations of bedside chest X-ray have been well described and lead to poor-quality X-ray films with low sensitivity.The lung ultrasound has been shown to be a useful tool in intensive care patients with adult respiratory distress syndrome (ARDS) and can be used forassessing severity of lung involvement in COVID-19. In this paper the accuracy of bedside LUS, chest X-ray and computer tomography are compared based on clinical cases, typical for COVID-19 lung ultrasound appearance is evaluated. There have been shown that lung ultrasound can predict the deterioration of the patient's conditionand can be used for risk stratification and clinical decision making, reducethe use of both chest x‐rays and computer tomography, what is very important especially in limited resources settings.

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