Browsing by Author "Keeler, Emmett B."

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    Economic Evaluation of Quality Improvement Interventions Designed to Prevent Hospital Readmission A Systematic Review and Meta-analysis
    Morton, Sally C.; Nuckols, Teryl K.; Keeler, Emmett B.; Anderson, Laura J.; Doyle, Brian J.; Pevnick, Joshua; Booth, Marika; Shanman, Roberta; Arifkhanova, Aziza; Shekelle, Paul G. (AMA, 2017-05-30)
    IMPORTANCE Quality improvement (QI) interventions can reduce hospital readmission, but little is known about their economic value. OBJECTIVE To systematically review economic evaluations of QI interventions designed to reduce readmissions. DATA SOURCES Databases searched included PubMed, Econlit, the Centre for Reviews & Dissemination Economic Evaluations, New York Academy of Medicine's Grey Literature Report, andWorldcat (January 2004 to July 2016). STUDY SELECTION Dual reviewers selected English-language studies from high-income countries that evaluated organizational or structural changes to reduce hospital readmission, and that reported program and readmission-related costs. DATA EXTRACTION AND SYNTHESIS Dual reviewers extracted intervention characteristics, study design, clinical effectiveness, study quality, economic perspective, and costs.We calculated the risk difference and net costs to the health system in 2015 US dollars.Weighted least-squares regression analyses tested predictors of the risk difference and net costs. MAIN OUTCOMES AND MEASURES Main outcomes measures included the risk difference in readmission rates and incremental net cost. This systematic review and data analysis is reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. RESULTS Of 5205 articles, 50 unique studies were eligible, including 25 studies in populations limited to heart failure (HF) that included 5768 patients, 21 in general populations that included 10 445 patients, and 4 in unique populations. Fifteen studies lasted up to 30 days while most others lasted 6 to 24 months. Based on regression analyses, readmissions declined by an average of 12.1% among patients with HF (95%CI, 8.3%-15.9%; P < .001; based on 22 studies with complete data) and by 6.3%among general populations (95%CI, 4.0%-8.7%; P < .001; 18 studies). The mean net savings to the health system per patient was $972 among patients with HF (95%CI, −$642 to $2586; P = .23; 24 studies), and the mean net loss was $169 among general populations (95%CI, −$2610 to $2949; P = .90; 21 studies), reflecting nonsignificant differences. Among general populations, interventions that engaged patients and caregivers were associated with greater net savings ($1714 vs −$6568; P = .006). CONCLUSIONS AND RELEVANCE Multicomponent QI interventions can be effective at reducing readmissions relative to the status quo, but net costs vary. Interventions that engage general populations of patients and their caregivers may offer greater value to the health system, but the implications for patients and caregivers are unknown.
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    A Model for a Smallpox-Vaccination Policy
    Bozzette, Samuel A.; Boer, Rob; Bhatnagar, Vibha; Brower, Jennifer L.; Keeler, Emmett B.; Morton, Sally C.; Stoto, Michael A. (NEJM Group, 2003-01-30)
    Background: The new reality of biologic terrorism and warfare has ignited a debate about whether to reintroduce smallpox vaccination. Methods: We developed scenarios of smallpox attacks and built a stochastic model of outcomes under various control policies. We conducted a systematic literature review and estimated model parameters on the basis of European and North American outbreaks since World War II. We assessed the trade-offs between vaccine-related harms and benefits. Results: Nations or terrorists possessing a smallpox weapon could feasibly mount attacks that vary with respect to tactical complexity and target size, and patterns of spread can be expected to vary according to whether index patients are hospitalized early. For acceptable results, vaccination of contacts must be accompanied by effective isolation. Vaccination of contacts plus isolation is expected to result in 7 deaths (from vaccine or smallpox) in a scenario involving the release of variola virus from a laboratory, 19 deaths in a human-vector scenario, 300 deaths in a building-attack scenario, 2735 deaths in a scenario involving a low-impact airport attack, and 54,729 deaths in a scenario involving a high-impact airport attack. Immediate vaccination of the public in an attacked region would provide little additional benefit. Prior vaccination of health care workers, who would be disproportionately affected, would save lives in large local or national attacks but would cause 25 deaths nationally. Prior vaccination of health care workers and the public would save lives in a national attack but would cause 482 deaths nationally. The expected net benefits of vaccination depend on the assessed probability of an attack. Prior vaccination of health care workers would be expected to save lives if the probability of a building attack exceeded 0.22 or if the probability of a high-impact airport attack exceeded 0.002. The probability would have to be much higher to make vaccination of the public life-saving. Conclusions: The analysis favors prior vaccination of health care workers unless the likelihood of any attack is very low, but it favors vaccination of the public only if the likelihood of a national attack or of multiple attacks is high.