Medical care
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Comparative Study
Comparison of meta-analytic results of indirect, direct, and combined comparisons of drugs for chronic insomnia in adults: a case study.
Our Center recently conducted a systematic review of the manifestations and management of chronic insomnia in adults. The efficacy and safety of benzodiazepines and nonbenzodiazepines, relative to placebo, were compared indirectly. ⋯ Results of indirect comparisons made in the review, accurately reflected the current evidence. Frequentist and Bayesian methods of analysis of indirect comparisons should be considered when performing meta-analyses.
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Randomized controlled trials (RCTs) remain the accepted "gold standard" for determining the efficacy of new drugs or medical procedures. Randomized trials alone, however, cannot provide all the relevant information decision makers need to determine the relative risks and benefits when choosing the best treatment of individual patients or weighing the implications of particular policies affecting medical therapies. ⋯ Even the most rigorously designed RCTs leave many questions central to medical decision making unanswered. Research using cohort and case-control designs, disease and intervention registries, and outcomes studies based on administrative data can all shed light on who is most likely to benefit from the treatment, and what the important tradeoffs are. This suggests the need to revise the traditional evidence hierarchy, whereby evidence progresses linearly from basic research to rigorous RCTs. This revised hierarchy recognizes that other research designs can provide important evidence to strengthen our understanding of how to apply research findings in practice.
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Multicenter Study
Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative data.
Because of uniform availability, hospital administrative data are appealing for surveillance of adverse drug events (ADEs). Expert-generated surveillance rules that rely on the presence of International Classification of Diseases, 9th Revision Clinical Modification (ICD-9-CM) codes have limited accuracy. Rules based on nonlinear associations among all types of available administrative data may be more accurate. ⋯ Hierarchically optimal classification tree analysis is a promising method for rapidly developing clinically meaningful surveillance rules for administrative data. The resultant model for drug-induced bleeding and anticoagulation problems may be useful for retrospective ADE screening and rate estimation.
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Centralized administrative databases enable low-cost pragmatic randomized trials (PRTs) of drug effectiveness and safety. We simplified the PRT strategy by using designed delays (DD) to evaluate drug policies. ⋯ DD trials can be negotiated with policymakers. Low cost and simplicity of DD trials partly compensate for some limitations for evaluating drug safety and effectiveness. The ethics question of whether a DD is routine evaluation or research depends on its purpose and generalizability.
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Small studies suggest that the quality of healthcare provided to older patients needs improvement. However, measuring the quality of care for larger groups of older adults is difficult. ⋯ The use of claims data-derived quality-of-care process measures is feasible for the vulnerable older population, but requires development of data elements focused on geriatric care. QIs that could be applied to the older patients included in this study identified several areas of care that need improvement.