Journal of evaluation in clinical practice
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Diagnostic uncertainty is often encountered in a medical practice. Patients with ambiguous, uncertain, and undiagnosed problems are frequently referred for second opinions. Comparing referral diagnoses to final diagnoses provides an opportunity to determine how frequently final diagnoses vary and changes the direction of medical care. ⋯ Referrals to advanced specialty care for undifferentiated problems are an essential component of patient care. Without adequate resources to handle undifferentiated diagnoses, a potential unintended consequence is misdiagnoses resulting in treatment delays and complications leading to more costly treatments.
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Comparative Study
A comparison of approaches for stratifying on the propensity score to reduce bias.
Stratification is a popular propensity score (PS) adjustment technique. It has been shown that stratifying the PS into 5 quantiles can remove over 90% of the bias due to the covariates used to generate the PS. Because of this finding, many investigators partition their data into 5 quantiles of the PS without examining whether a more robust solution (one that increases covariate balance while potentially reducing bias in the outcome analysis) can be found for their data. Two approaches (referred to herein as PSCORE and PSTRATA) obtain the optimal stratification solution by repeatedly dividing the data into strata until balance is achieved between treatment and control groups on the PS. These algorithms differ in how they partition the data, and it is not known which is better, or if either is better than a 5-quantile default approach, for reducing bias in treatment effect estimates. ⋯ Investigators should routinely use stratification approaches that obtain the optimal stratification solution, rather than simply partitioning the data into 5 quantiles of the PS. Moreover, MMWS (in conjunction with an optimal stratification approach) should be considered as an alternative to IPTW in studies that use PS weights.
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Clinical Trial
Remote control improves quality of life in elderly pacemaker patients versus standard ambulatory-based follow-up.
Health-related quality of life (HRQoL) improves shortly after pacemaker (PM) implantation. No studies have investigated the HRQoL trend for elderly patients with a remote device monitoring follow-up system. ⋯ Remote device monitoring has a significant impact on HRQoL in pacemaker patients, increasing its levels up to 6 months after implant.
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Recent years have seen an increasing shift towards providing care in the community, epitomised by the role of Children's Community Nursing (CCN) teams. However, there have been few attempts to use robust evaluative methods to interrogate the impact of such services. This study sought to evaluate whether reduction in secondary care costs, resulting from the introduction of 2 CCN teams, was sufficient to offset the additional cost of commissioning. ⋯ The study represents an important first step in understanding the role of such teams as a means of providing a high quality of paediatric care in an era of limited resource. While the cost saving from released paediatric bed days was not sufficient to demonstrate cost-effectiveness, the analysis does not incorporate wider measures of health care utilisation and nonmonetary benefits resulting from the CCN teams.