Annals of Internal Medicine: High Value Care Topic Collection

Comparative Effectiveness of Warfarin and New Oral Anticoagulants for the Management of Atrial Fibrillation and Venous Thromboembolism A Systematic Review

Adam SS, McDuffie JR, Ortel TL, et al. — Tue, 04 Dec 2012 00:00:00 GMT

Background:

New oral anticoagulants (NOACs), including direct thrombin inhibitors (DTIs) and factor Xa (FXa) inhibitors, are emerging alternatives for prophylaxis and treatment of atrial fibrillation (AF) and venous thromboembolism (VTE).

Purpose:

To compare the benefits and harms of NOACs versus warfarin for AF and VTE.

Data Sources:

MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews from January 2001 through July 2012; U.S. Food and Drug Administration (FDA) database for adverse event reports.

Study Selection:

English-language, randomized, controlled trials (RCTs) comparing NOACs with warfarin for management of AF or VTE and observational studies and FDA reports on adverse effects.

Data Extraction:

Two independent reviewers abstracted data and rated study quality and strength of evidence.

Data Synthesis:

Six good-quality RCTs compared NOACs (2 DTI studies, 4 FXa inhibitor studies) with warfarin. In AF, NOACs decreased all-cause mortality (risk ratio [RR], 0.88 [95% CI, 0.82 to 0.96]); in VTE, NOACs did not differ for mortality or VTE outcomes. Across indications, adverse effects of NOACs compared with warfarin were fatal bleeding (RR, 0.60 [CI, 0.46 to 0.77]), major bleeding (RR, 0.80 [CI, 0.63 to 1.01]), gastrointestinal bleeding (RR, 1.30 [CI, 0.97 to 1.73]), and discontinuation due to adverse events (RR, 1.23 [CI, 1.05 to 1.44]). Subgroup analyses suggest a higher risk for myocardial infarction with DTIs than with FXa inhibitors. Bleeding risk for NOACs may be increased in persons older than 75 years or those receiving warfarin who have good control.

Limitation:

There were no head-to-head comparisons of NOACs and limited data on harms.

Conclusion:

New oral anticoagulants are a viable option for patients receiving long-term anticoagulation. Treatment benefits compared with warfarin are small and vary depending on the control achieved by warfarin treatment.

Primary Funding Source:

Department of Veterans Affairs.

Design and Use of Performance Measures to Decrease Low-Value Services and Achieve Cost-Conscious Care

Baker DW, Qaseem A, Reynolds P, et al. — Tue, 01 Jan 2013 00:00:00 GMT

Improving quality of care while decreasing the cost of health care is a national priority. The American College of Physicians recently launched its High-Value Care Initiative to help physicians and patients understand the benefits, harms, and costs of interventions and to determine whether services provide good value. Public and private payers continue to measure underuse of high-value services (for example, preventive services, medications for chronic disease), but they are now widely using performance measures to assess use of low-value interventions (such as imaging for patients with uncomplicated low back pain) and using the results for public reporting and pay-for-performance. This paper gives an overview of performance measures that target low-value services to help physicians understand the strengths and limitations of these measures, provides specific examples of measures that assess use of low-value services, and discusses how these measures can be used in clinical practice and policy.

Endoscopy for Gastroesophageal Reflux Disease: Choose Wisely

Allen JI. — Tue, 04 Dec 2012 00:00:00 GMT

In this issue, the ACP Clinical Guidelines Committee provides best practice advice for using endoscopy to help manage GERD and makes it clear that endoscopy often is not needed. The editorialist discusses how physicians must work to avoid low-value care that generates unnecessary costs if our health care system is to remain dedicated to both quality and economic viability.

Upper Endoscopy for Gastroesophageal Reflux Disease: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians

Shaheen NJ, Weinberg DS, Denberg TD, et al. — Tue, 04 Dec 2012 00:00:00 GMT

Also available: Consumer Reports Patient Resource on High-Value Care for GERD

Background:

Upper endoscopy is commonly used in the diagnosis and management of gastroesophageal reflux disease (GERD). Evidence demonstrates that it is indicated only in certain situations, and inappropriate use generates unnecessary costs and exposes patients to harms without improving outcomes.

Methods:

The Clinical Guidelines Committee of the American College of Physicians reviewed evidence regarding the indications for, and yield of, upper endoscopy in the setting of GERD, and to highlight how clinicians can increase the delivery of high-value health care.

Best Practice Advice 1:

Upper endoscopy is indicated in men and women with heartburn and alarm symptoms (dysphagia, bleeding, anemia, weight loss, and recurrent vomiting).

Best Practice Advice 2:

Upper endoscopy is indicated in men and women with:

Typical GERD symptoms that persist despite a therapeutic trial of 4 to 8 weeks of twice-daily proton-pump inhibitor therapy.

Severe erosive esophagitis after a 2-month course of proton-pump inhibitor therapy to assess healing and rule out Barrett esophagus. Recurrent endoscopy after this follow-up examination is not indicated in the absence of Barrett esophagus.

History of esophageal stricture who have recurrent symptoms of dysphagia.

Best Practice Advice 3:

Upper endoscopy may be indicated:

In men older than 50 years with chronic GERD symptoms (symptoms for more than 5 years) and additional risk factors (nocturnal reflux symptoms, hiatal hernia, elevated body mass index, tobacco use, and intra-abdominal distribution of fat) to detect esophageal adenocarcinoma and Barrett esophagus.

For surveillance evaluation in men and women with a history of Barrett esophagus. In men and women with Barrett esophagus and no dysplasia, surveillance examinations should occur at intervals no more frequently than 3 to 5 years. More frequent intervals are indicated in patients with Barrett esophagus and dysplasia.

The Association Between Health Care Quality and Cost A Systematic Review

Hussey PS, Wertheimer S, Mehrotra A. — Tue, 01 Jan 2013 00:00:00 GMT

Background:

Although there is broad policy consensus that both cost containment and quality improvement are critical, the association between costs and quality is poorly understood.

Purpose:

To systematically review evidence of the association between health care quality and cost.

Data Sources:

Electronic literature search of PubMed, EconLit, and EMBASE databases for U.S.-based studies published between 1990 and 2012.

Study Selection:

Title, abstract, and full-text review to identify relevant studies.

Data Extraction:

Two reviewers independently abstracted data with differences reconciled by consensus. Studies were categorized by level of analysis, type of quality measure, type of cost measure, and method of addressing confounders.

Data Synthesis:

Of 61 included studies, 21 (34%) reported a positive or mixed-positive association (higher cost associated with higher quality); 18 (30%) reported a negative or mixed-negative association; and 22 (36%) reported no difference, an imprecise or indeterminate association, or a mixed association. The associations were of low to moderate clinical significance in many studies. Of 9 studies using instrumental variables analysis to address confounding by unobserved patient health status, 7 (78%) reported a positive association, but other characteristics of these studies may have affected their findings.

Limitations:

Studies used widely heterogeneous methods and measures. The review is limited by the quality of underlying studies.

Conclusion:

Evidence of the direction of association between health care cost and quality is inconsistent. Most studies have found that the association between cost and quality is small to moderate, regardless of whether the direction is positive or negative. Future studies should focus on what types of spending are most effective in improving quality and what types of spending represent waste.

Primary Funding Source:

Robert Wood Johnson Foundation.

Waste Not, Want Not: Promoting Efficient Use of Health Care Resources

Chien AT, Rosenthal MB. — Tue, 01 Jan 2013 00:00:00 GMT

In this issue, Hussey and colleagues reviewed the limited evidence on the relationship between health care costs and quality and Weeks and colleagues discuss moving from fee-for-service to bundled payments. The editorialists discuss the articles and outline what we need to learn to develop payment models that produce value in health care.