Medical care
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Evidence-based medicine is increasingly expected in health care decision-making. The Centers for Medicare and Medicaid have initiated efforts to understand the applicability of Bayesian techniques for synthesizing evidence. As a case study, a Bayesian analysis of clinical trials of implantable cardioverter defibrillators was undertaken using patient-level data not typically available for analysis. ⋯ Bayesian meta-analyses based on literature surveys can effectively inform coverage decisions. Bayesian modeling for endpoints such as mortality can elucidate treatment effects over time. The Bayesian approach used in a sequential manner over time can predict results and help assess the utility of future clinical trials.
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Comparative effectiveness research analyzes groups of patients and looks for associations between medical treatments and patient outcomes. To make meaningful comparisons of medical interventions, one must consider clinical heterogeneity of patient populations, intervention combinations, and outcomes. ⋯ PBE study designs address comparative effectiveness by creating a comprehensive set of patient, treatment, and outcome variables, and analyzing them to identify treatments associated with better outcomes for specific types of patients. PBE studies are an alternative to randomized controlled trials, well suited to determine what works best for specific patient types, and provide clinicians with a rational basis for treatment recommendations for individual patients. They provide a holistic picture of patients, treatments, and outcomes, with no preset limits to the number of variables that can be included. Such an approach is needed for high quality comparative effectiveness research.
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The Washington State workers' compensation agency funded a coverage with evidence development study to evaluate spinal cord stimulation (SCS) for chronic back and leg pain after spine surgery (failed back surgery syndrome). We previously published the study outcomes. We now report results from a second patient cohort; study costs; and industry, provider, and payer responses. ⋯ Coverage with evidence development studies may yield important information not apparent from randomized clinical trials concerning long-term risks and benefits of a therapy in clinical practice for specific subpopulations, but are likely to be met with criticism from interested parties.
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Health-related quality of life (HRQL) assessment is frequently used in comparative effectiveness research, but low-literacy patients are often excluded. Appropriately translated and user-friendly HRQL measures are essential to ensure inclusion of low-literate and non-English-speaking patients in comparative effectiveness research. ⋯ This study demonstrates the feasibility of this multimedia touch screen program for low-literacy patients. The program will provide opportunities to evaluate the effectiveness of interventions in more diverse patient populations.
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Despite ethical implications, there are anecdotal reports of health practitioners withholding services from patients who do not pay their bills. We surveyed physicians about their attitudes and experiences regarding nonpaying patients. ⋯ A majority of primary care practitioners responding to our survey would be willing to withhold medical care from patients who do not pay their bills; some have actually done so despite ethical and legal mandates to the contrary. Physicians should be educated about the importance of the patient-physician relationship and their ethical obligations to patients.