Publications by authors named "Alexander S Misono"

20 Publications

  • Page 1 of 1

Big Data and Machine Learning: A Resident's Perspective of the 2016 Intersociety Conference.

J Am Coll Radiol 2018 01 9;15(1 Pt A):114-115. Epub 2017 Sep 9.

Department of Interventional Radiology, Miami Cardiac and Vascular Institute, Miami, Florida.

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http://dx.doi.org/10.1016/j.jacr.2017.07.021DOI Listing
January 2018

Abdominal Aortic Aneurysm Screening Practices: Impact of the 2014 U.S. Preventive Services Task Force Recommendations.

J Am Coll Radiol 2017 Jul 17;14(7):868-874. Epub 2017 Apr 17.

Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Purpose: To assess changes in abdominal aortic aneurysm (AAA) ultrasound screening associated with the release of revised U.S. Preventive Services Task Force (USPSTF) recommendations on June 24, 2014.

Methods: All AAA screening ultrasound examinations performed in the Massachusetts General Hospital radiology department in the 15 months before and after the new guidelines were retrospectively reviewed to assess changes in examination volume and appropriateness, demographics, aneurysm detection rate and size at diagnosis, frequency and type of incidental findings, and radiologist recommendations. Examinations were considered "definitely appropriate" if meeting USPSTF grade "B" evidence and "possibly appropriate" if meeting grade "C" or "I" evidence, based on available guidelines. Means were compared with the t test.

Results: A total of 831 examinations were reviewed, 417 (50.2%) performed before and 414 (49.8%) after the new guidelines, with overall mean (SD) subject age 67.9 (6.8) years, 89.2% male. Appropriate examinations increased from 289 of 417 (69.3%) to 313 of 414 (75.6%) after the new guidelines (P = .04), mostly due to definitely appropriate examinations (253/417 [60.7%] versus 286/414 [69.1%], P = .01). Aneurysm detection rates increased from 23 of 417 (5.5%) to 39 of 414 (9.4%), P = .03. Mean (SD) aneurysm size (cm) at diagnosis decreased from 3.8 (0.7) to 3.3 (0.6), P = .01. Examination volume, demographics, and rates of incidentals and recommendations remained similar. Incidentals arose in 15.4% of all examinations, often iliac artery aneurysms or renal masses. Recommendations were made in 5.1%, mostly for cross-sectional imaging.

Conclusions: The revised USPSTF guidelines have been associated with increased AAA screening appropriateness and aneurysm detection in our practice, with smaller aneurysm size at diagnosis.
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http://dx.doi.org/10.1016/j.jacr.2017.02.020DOI Listing
July 2017

Improving Access to Image-guided Procedures at an Integrated Rural Critical Access Hospital: Ultrasound-guided Thyroid Biopsy Program.

Curr Probl Diagn Radiol 2017 Nov - Dec;46(6):419-422. Epub 2017 Feb 16.

Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA. Electronic address:

Purpose: Critical access hospitals face difficulty providing all services locally and may need to refer patients off-site for additional care. Providing on-site minimally invasive biopsies, may obviate visits to tertiary or quaternary care centers. This study aims to assess feasibility and outcomes of an ultrasound-guided thyroid biopsy program in a critical access hospital.

Methods: In this HIPAA compliant, IRB approved study, the Interventional Radiology (IR) database of a 19-bed, island, rural, critical access hospital without onsite pathology services affiliated with our quaternary care institution was retrospectively reviewed to identify all thyroid biopsies that were performed on site since inception of the service in April 2014 through August 2016. A specialized biopsy and specimen collection protocol was created as each specimen was transferred to and analyzed by the pathology department at our affiliated quaternary care institution.

Results: Two IR physicians carried out thyroid biopsies on 34 nodules in 29 patients during the study period. The mean age of patients was 56.5 ± 14.0, with a range of 35-85 and 86% female, 14% male. 94.1% of nodules had adequate material for interpretation on the first biopsy and 97.1% upon repeat biopsy. Ultimately, 5 patients (with 6 nodules) underwent surgical resection at the integrated quaternary care center. Surgical resection identified one atypical follicular adenoma, one follicular variant of papillary thyroid carcinoma, two papillary carcinomas, and two Hürthle cell tumors.

Conclusion: IR thyroid biopsy services may be successfully provided in the rural setting without onsite pathology analysis and adequacy checks, enhancing patient access and streamlining care while also expanding the reach of tertiary care centers.
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http://dx.doi.org/10.1067/j.cpradiol.2017.02.004DOI Listing
February 2018

Changing Medicare Utilization of Minimally Invasive Procedures for the Treatment of Chronic Venous Insufficiency.

J Vasc Interv Radiol 2017 Jun 7;28(6):818-824. Epub 2017 Apr 7.

Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia.

Purpose: To examine changes in the utilization of procedures related to treatment of chronic venous insufficiency (CVI) in the Medicare population.

Materials And Methods: Service-specific claims data for phlebectomy, sclerotherapy, and radiofrequency (RF) and laser ablation were identified by using Medicare Physician Supplier Procedure Summary master files from 2005 through 2014. Longitudinal national utilization rates were calculated by using annual Medicare enrollment data from 2005 through 2013. Procedure volumes by specialty group and site of service were analyzed.

Results: Total annual claims for these procedures in the Medicare fee-for-service beneficiaries increased from 95,206 to 332,244 (Compound Annual Growth Rate [CAGR], 15%) between 2005 and 2014. Per 1,000 beneficiaries, overall utilization increased annually from 2.8 in 2005 to 9.4 in 2013. Most procedures were performed in the private office setting (92% in 2014). In 2014, radiologists had a 10% relative market share, compared with vascular surgeons, other surgeons, and cardiologists, who had 26%, 25%, and 14% market shares, respectively. Cardiologists had the fastest relative growth, with a CAGR of 51% compared with 23% for radiology, 12% for vascular surgery, and 13% for other surgery. Total venous RF ablation services grew with a CAGR of 31%, with radiology and cardiology growing most rapidly (40% and 79%, respectively). Total venous laser ablation services grew with a CAGR of 22%, with radiology growing 15% and cardiology growing most rapidly at 44%.

Conclusions: Utilization of CVI procedures in the Medicare population increased markedly from 2005 through 2014. The overwhelming majority are performed in the private office setting by nonradiologists.
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http://dx.doi.org/10.1016/j.jvir.2017.02.034DOI Listing
June 2017

Medicare Utilization of CT Angiography from 2001 through 2014: Continued Growth by Radiologists.

J Vasc Interv Radiol 2016 Oct 25;27(10):1554-60. Epub 2016 Jul 25.

Harvey L. Neiman Health Policy Institute, Reston, Virginia; Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia.

Purpose: To examine changes in utilization of computed tomography (CT) angiography nationally and changing relative specialty roles in examination interpretation.

Materials And Methods: Service-specific claims data for region-specific CT angiography examinations were identified using Medicare Physician Supplier Procedure Summary Master Files from 2001 through 2014. Longitudinal national utilization rates were calculated using annual Medicare enrollment data for 2001-2013. Procedure volumes by specialty group and site of service were analyzed.

Results: Total annual claims for CT angiography for Medicare fee for service beneficiaries increased from 64,846 to 1,709,088 (compound annual growth rate [CAGR] 29%) between 2001 and 2014. Per 1,000 beneficiaries, overall CT angiography utilization increased annually from 2.1 in 2001 to 47.6 in 2013. Overall interpretation market share increased 4% (91%-95%) for radiology. Cardiology increased from 1% in 2001 to 6% in 2007 but decreased annually to 2% in 2014. Vascular surgery market share remained < 1% throughout the study period. Growth of CT angiography in the emergency department (ED) outpaced all other sites of service, increasing from 11% to 28% (CAGR 38%). The chest was the dominant body region imaged with CT angiography, increasing from 36,984 to 914,086 (CAGR 28%).

Conclusions: Utilization of CT angiography in the Medicare population increased markedly for 2001-2014, particularly in the ED, with radiologists remaining dominant providers. The chest is the most common body region imaged with CT angiography.
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http://dx.doi.org/10.1016/j.jvir.2016.05.031DOI Listing
October 2016

Use of Magnetic Resonance Venography in Screening Patients With Cryptogenic Stroke for May-Thurner Syndrome.

Curr Probl Diagn Radiol 2016 Nov - Dec;45(6):370-372. Epub 2016 Apr 27.

Department of Medicine, Biomaterials Innovation Research Center, Brigham and Women׳s Hospital, Harvard Medical School, Cambridge, MA; Division of Interventional Radiology, Mayo Clinic, Scottsdale, AZ. Electronic address:

The purpose of this study was to determine the prevalence of May-Thurner syndrome (MTS) in patients with cryptogenic stroke and to determine the incidence of patent foramen ovale. Magnetic resonance venography of 214 patients with cryptogenic stroke and 50 control patients with abdominopelvic computed tomography scans were evaluated for MTS. Incidence of patent foramen ovale and MTS in the stroke group were significantly greater than the control group (P = 0.0001, P = 0.0023, respectively). In addition, there was significantly greater compression of the left common iliac vein in the stroke group (32%) compared with the control group (13%) (P < 0.00001). In conclusion, there is a significantly higher prevalence of MTS and left common iliac vein compression in patients with cryptogenic stroke. These results indicate that magnetic resonance venography of the pelvis may be appropriate in the evaluation of stroke.
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http://dx.doi.org/10.1067/j.cpradiol.2016.04.006DOI Listing
May 2017

Revenue Potential for Inpatient IR Consultation Services: A Financial Model.

J Vasc Interv Radiol 2016 May 11;27(5):658-664.e1. Epub 2016 Apr 11.

Department of Radiology, 55 Fruit St., Gray 2, Boston, MA 02114; Division of Interventional Radiology Harvard Medical School, Massachusetts General Hospital, 55 Fruit St., Gray 2, Boston, MA 02114.

Purpose: Interventional radiology (IR) has historically failed to fully capture the value of evaluation and management services in the inpatient setting. Understanding financial benefits of a formally incorporated billing discipline may yield meaningful insights for interventional practices.

Materials And Methods: A revenue modeling tool was created deploying standard financial modeling techniques, including sensitivity and scenario analyses. Sensitivity analysis calculates revenue fluctuation related to dynamic adjustment of discrete variables. In scenario analysis, possible future scenarios as well as revenue potential of different-size clinical practices are modeled.

Results: Assuming a hypothetical inpatient IR consultation service with a daily patient census of 35 patients and two new consults per day, the model estimates annual charges of $2.3 million and collected revenue of $390,000. Revenues are most sensitive to provider billing documentation rates and patient volume. A range of realistic scenarios-from cautious to optimistic-results in a range of annual charges of $1.8 million to $2.7 million and a collected revenue range of $241,000 to $601,000. Even a small practice with a daily patient census of 5 and 0.20 new consults per day may expect annual charges of $320,000 and collected revenue of $55,000.

Conclusions: A financial revenue modeling tool is a powerful adjunct in understanding economics of an inpatient IR consultation service. Sensitivity and scenario analyses demonstrate a wide range of revenue potential and uncover levers for financial optimization.
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http://dx.doi.org/10.1016/j.jvir.2016.01.144DOI Listing
May 2016

Imaging Decision Support Does Not Drive Out-of-Network Leakage of Referred Imaging.

J Am Coll Radiol 2016 Jun 19;13(6):606-10. Epub 2016 Feb 19.

Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Purpose: Leakage (out-of-network referral) is undesirable because it limits ability to control costs of services. Clinical decision support (CDS) systems seek to ensure appropriate imaging of patients but theoretically could drive leakage if ordering providers attempt to circumvent CDS recommendations and obtain studies from other imaging providers. This study assessed the incidence of leakage of imaging studies that had low appropriateness scores.

Methods: We queried our outpatient CDS system over a three-year period (2011-2013) for studies that received a low CDS appropriateness score and were canceled by the ordering physician. For patients meeting these criteria and participating in risk-shared contracts, we cross-referenced their imaging utilization reports in the risk-contract insurance payment database to determine if they received outpatient imaging within 60 days of the index order, contrary to the decision support recommendation.

Results: The risk-shared insurance database contained an average of 63,378 patients who had 18,008 MRIs and 18,014 CTs. A total of 11,234 (31.2%) studies were leaked: 3,513 (9.8%) to affiliated institutions; 7,721 (21.4%) to unaffiliated imaging facilities. Overall, 111 imaging studies received a low appropriateness score in the risk-shared patient population and were performed within 60 days despite the low score. Of these studies, 106 of 111 (95.5%) were ultimately performed within our hospital system (104 at the home institution; 2 at affiliated institutions); only 5 of 111 (4.5%) were performed outside of our hospital system.

Conclusions: Decision support systems for ordering providers do not seem to drive imaging referrals out of hospital systems to other institutions. Hospital systems can implement decision support without fear of this occurring.
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http://dx.doi.org/10.1016/j.jacr.2016.01.004DOI Listing
June 2016

What Radiology Can Learn From the Management Consulting Industry.

J Am Coll Radiol 2016 Feb;13(2):222-5

Steward Health Care Network, Boston, Massachusetts, and the Department of Radiology, St Elizabeth's Medical Center, Boston, Massachusetts.

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http://dx.doi.org/10.1016/j.jacr.2015.09.023DOI Listing
February 2016

Radiology Jobs: Uncovering Hidden and Not-So-Hidden Opportunities From the ACR Jobs Board.

J Am Coll Radiol 2016 Apr 17;13(4):471-6. Epub 2015 Dec 17.

Department of Radiology, Division of Cardiovascular Imaging, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts. Electronic address:

Purpose: The radiology job market remains daunting. Trainees choosing fellowships benefit from understanding employers' likely future needs. Radiology practices may similarly refine recruiting practices. This study quantitatively analyzes the current radiology job landscape.

Methods: Job postings on the ACR Career Center online portal between June 2014 and June 2015 were reviewed. As entries are frequently added and removed, posts were manually collected weekly. Postings were recorded in a database and included date, practice, location, specialty/subspecialty, job type, years of experience, salary, and job description. The database was analyzed to characterize employer needs, salary, partnership track availability, and job availability by geography.

Results: A total of 1,778 jobs were posted during the study period. Of these, 1,529 (86.0%) were diagnostic; 240 (13.5%) were interventional; and 9 (0.5%) were administrative. Most jobs were in private practice (75.7%), compared with academic (16.3%) and other (7.9%). Although many did not require a specific specialty (46%), the most-frequent needs were breast (17%), neuroradiology (11%), musculoskeletal (8%), and body (7%). Of non-breast-imaging jobs, roughly 30% indicated an interest in breast-imaging skills. A minority (13%) requested prior experience of greater than 1 year, with some seeking 7-10 years of experience. Although most (87%) were full-time positions, part-time, temporary, and contractor roles were described in the remaining 13%. Salary data were rarely reported (7%), with a range of $98,967-$1,000,000. The most jobs were based in California (11%); New York (7%); Pennsylvania (7%); and Illinois (6%). However, when indexed per million population, the highest job rates were in Nevada (14.1); Washington DC (13.7); Hawaii (13.4); Montana (9.8); and Pennsylvania (9.1). Roughly 31% of postings described partnership tracks, with the highest rates in New England (58%), the Pacific Northwest (56%), the Midwest (40%), and Southern (40%) regions; the lowest were in the Mountain (26%), Mid-Atlantic (25%), and Southwest (21%) regions.

Conclusions: Most radiology jobs remain in private practice general radiology. Breast, neuroradiology, and musculoskeletal radiology were most frequently desired among areas of subspecialty training. Advertised partnership tracks were less common and varied widely geographically.
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http://dx.doi.org/10.1016/j.jacr.2015.09.027DOI Listing
April 2016

Medicare Utilization of Vascular Ultrasound From 1998 to 2013: Continued Growth in Both Radiologist and Nonradiologist Imaging.

J Am Coll Radiol 2016 Mar 8;13(3):255-64. Epub 2015 Dec 8.

Harvey L. Neiman Health Policy Institute, Reston, Virginia; Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia.

Purpose: The aim of this study was to assess national trends in the utilization of vascular ultrasound (VUS) and changing relative specialty roles in examination interpretation.

Methods: Service-specific claims data for VUS studies were identified using Medicare Physician Supplier Procedure Summary Master Files for the period from 1998 to 2013. Longitudinal national utilization rates were calculated using annual Medicare enrollment data for 1998 to 2012. Procedure volumes by specialty group and site of service were analyzed.

Results: Total annual claims for VUS studies for Medicare fee-for-service beneficiaries increased from 4,422,360 to 8,599,677 (+94.5%) between 1998 and 2013. Per 1,000 beneficiaries, overall utilization rose from 145.93 in 1998 to 264.26 in 2012 (+81.1%). However, this peaked in 2009 at 270.43 and has been slowly declining each year since. Overall market share decreased from 43% to 41% for radiology and increased from 10% to 16% and from 9% to 17% for vascular surgery and cardiology, respectively. Compound adjusted growth rate increases were 4.2% for radiology, 7.8% for vascular surgery, and 8.7% for cardiology.

Conclusions: Utilization of VUS in the Medicare population increased from 1998 through 2009 but has been declining ever since. Although radiology has maintained the dominant market share over time, relative growth by cardiology and vascular surgery has outpaced that by radiology.
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http://dx.doi.org/10.1016/j.jacr.2015.09.035DOI Listing
March 2016

Imaging utilization from the ED: no difference between observation and admitted patients.

Am J Emerg Med 2015 Aug 22;33(8):1076-9. Epub 2015 Apr 22.

Division of Vascular Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.

Objectives: This study aims to determine the use of diagnostic imaging in emergency department (ED) observation units, particularly relative to inpatients admitted from the ED.

Study Design: Retrospective, descriptive analysis.

Methods: Our database of ED patients was retrospectively reviewed to identify patients managed in the observation unit or admitted to inpatient services. In February 2014, we randomly selected 105 ED observation patients and 108 patients admitted to inpatient services from the ED. Electronic medical records were reviewed to assess diagnosis as well as type and quantity of imaging tests obtained.

Results: Eighty (76%) ED observation patients underwent imaging tests (radiographs, 39%; computed tomography, 25%; magnetic resonance imaging (MRI), 24%; ultrasound, 8%; other, 4%); 85 inpatients (79%) underwent imaging tests while in the ED (radiographs, 52%; computed tomography, 30%; MRI, 8%; ultrasound, 9%; other, 1%). There was no significant difference in overall imaging use between ED observation patients and inpatients, but ED observation patients were more likely to undergo MRI (P=.0243). The most common presenting diagnoses to the ED observation unit were neurologic complaints (25%), abdominal pain (17%), and cardiac symptoms (16%).

Conclusion: There is no difference in the overall use of imaging in patients transferred to the ED observation unit vs those directly admitted from the ED. However, because ED observation unit patients tend to be accountable for a higher proportion of their health care bill, the impact of imaging in these patients is likely substantive.
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http://dx.doi.org/10.1016/j.ajem.2015.04.025DOI Listing
August 2015

Time-driven activity-based costing trumps traditional cost accounting for radiologists.

AJR Am J Roentgenol 2015 Feb;204(2):W217

1 Massachusetts General Hospital, Harvard Medical School Boston, MA.

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http://dx.doi.org/10.2214/AJR.14.13258DOI Listing
February 2015

Cervical presentation of peripheral T-cell lymphoma not otherwise specified.

Ear Nose Throat J 2014 Dec;93(12):E31-4

Department of Radiology, Massachusetts General Hospital, Boston, MA, USA.

Peripheral T-cell lymphoma not otherwise specified (PTCL-NOS) is an uncommon type of lymphoma with a clinically aggressive course and a relatively poor prognosis. Many affected patients present with nodal involvement, and there is also potential for extranodal involvement of the liver, gastrointestinal tract, bone marrow, and/or skin. We describe the case of a 68-year-old woman who presented with a 6-week history of an intermittently tender left-sided neck mass. Findings on imaging and fine-needle aspiration biopsy were inconclusive. Pathologic studies of excisional biopsy specimens ultimately revealed the diagnosis of PTCL-NOS. Of the lymphomas, neither PTCL nor the PTCL-NOS subtype is frequently discussed or studied in prospective trials. However, these cases should be identified because of their substantial clinical management implications.
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December 2014

Variations in pill appearance of antiepileptic drugs and the risk of nonadherence.

JAMA Intern Med 2013 Feb;173(3):202-8

Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02120, USA.

Background: Generic prescription drugs are bioequivalent to brand-name versions but may not have consistent color or shape, which can cause confusion and lead to interruptions in medication use. We sought to determine whether switching among different-appearing antiepileptic drugs (AEDs) is associated with increased rates of medication nonpersistence, which can have serious medical, financial, and social consequences.

Methods: We designed a nested case-control study of commercially insured patients in the United States who initiated an AED. Cases were patients who became nonpersistent, defined as failure to fill a prescription within 5 days of the elapsed days supplied. Controls had no delay in refilling and were matched by sex, age, number of refills, and the presence of a seizure disorder diagnosis. We evaluated the 2 refills preceding nonpersistence and determined whether pill color and/or shape matched ("concordant") or did not match ("discordant"). We compared the odds of discordance among cases and controls using multivariate conditional logistic regression, adjusting for baseline characteristics, and drug type. We repeated our analysis among patients with a seizure diagnosis.

Results: The AEDs dispensed had 37 colors and 4 shapes. A total of 11,472 patients with nonpersistence were linked to 50,050 controls. Color discordance preceded 136 cases (1.20%) but only 480 controls (0.97%) (adjusted odds ratio [OR], 1.27 [95% CI, 1.04-1.55]). Shape discordance preceded 18 cases (0.16%) and 54 controls (0.11%) (OR, 1.47 [95% CI, 0.85-2.54]). Within the seizure disorder diagnosis subgroup, the risk of nonpersistence after changes in pill color was also significantly elevated (OR, 1.53 [95%, CI 1.07-2.18]).

Conclusions: Changes in pill color significantly increase the odds of nonpersistence; this may have important clinical implications. Our study supports a reconsideration of current regulatory policy that permits wide variation in the appearance of bioequivalent drugs.
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http://dx.doi.org/10.1001/2013.jamainternmed.997DOI Listing
February 2013

Pathology quiz case 3. Diagnosis: plexiform neurofibroma of the larynx.

Arch Otolaryngol Head Neck Surg 2011 Jun;137(6):637, 640-1

Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1001/archoto.2011.73-aDOI Listing
June 2011

Utilization of lipid-laden macrophage index in evaluation of aerodigestive disorders.

Laryngoscope 2011 May;121(5):1055-9

Children's Hospital Boston, Boston, Massachusetts, USA.

Objectives/hypothesis: The utility of the lipid-laden macrophage index (LLMI) in the evaluation of airway inflammatory processes remains controversial. There is a paucity of normative data in both pediatric and adult populations, and there is wide variability in the reported cases. The goal of this project was to review the LLMI levels in a large series of patients with a wide range of well-documented pulmonary and airway diseases (cystic fibrosis, aspiration, tracheo/bronchomalacia, recurrent pneumonia, asthma, immunosuppressed conditions, and laryngeal clefts) to develop a better understanding of the clinical utility of the LLMI.

Study Design: This study is a retrospective analysis of patients who underwent initial bronchoscopy with broncheoalveolar lavage (BAL) and had specimens sent for determination of LLMI. This study was performed at a major pediatric tertiary care medical center from April 12, 2006 to July 13, 2009.

Methods: Medical charts were reviewed for major diagnoses, indications for bronchoscopy, the side of lung (right versus left), documented aspiration, suspected aspiration, neutrophil counts, and patient age. These qualitative and quantitative variables were considered in relation to the LLMI.

Results: The cohort of patients examined were 4.9 ± 4.3 years (4 days to 18 years of age). Forty-two percent were female and 58% were male. The highest median LLMI was in immunocompromised patients with a median of 78. Recurrent pneumonia, aspiration, tracheo/bronchomalacia, and cystic fibrosis had median LLMI levels of 55, 49, 40, and 50, respectively. There was a wide range of LLMI within each primary diagnosis. There was no significant correlation between neutrophils percentage in the BAL and LLMI. There were no significant differences between BAL specimens obtained from the right or left side.

Conclusions: To our knowledge, this is the largest series of patients reported in the literature to have an LLMI compared with underlying diagnoses. Based on our data and analyses, there is wide variability between the range of LLMI and the primary diagnosis. As such, the diagnostic utility of the LLMI is limited and should be interpreted with caution.
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http://dx.doi.org/10.1002/lary.21467DOI Listing
May 2011

Healthcare information technology interventions to improve cardiovascular and diabetes medication adherence.

Am J Manag Care 2010 Dec;16(12 Suppl HIT):SP82-92

Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, MA 02120, USA.

Objective: To determine the efficacy of healthcare information technology (HIT) interventions in improving adherence.

Study Design: Systematic search of randomized controlled trials of HIT interventions to improve medication adherence in cardiovascular disease or diabetes.

Methods: Interventions were classified as 1-way patient reminder systems, 2-way interactive systems, and systems to enhance patient-provider interaction. Studies were subclassified into those with and without real-time provider feedback. Cohen's d effect sizes were calculated to assess each intervention's magnitude of effectiveness.

Results: We identified 7190 articles, only 13 of which met inclusion criteria. The majority of included studies (54%, 7 studies) showed a very small ES. The effect size was small in 15%, large in 8%, and was not amenable to calculation in the remainder. Reminder systems were consistently effective, showing the largest effect sizes in this review. Education/counseling HIT systems were less successful, as was the addition of realtime adherence feedback to healthcare providers. Interactive systems were rudimentary and not integrated into electronic health records; they exhibited very small effect sizes. Studies aiming to improve patient-provider communication also had very small effect sizes.

Conclusions: There is a paucity of data about HIT's efficacy in improving adherence to medications for cardiovascular disease and diabetes, although simple patient reminder systems appear effective. Future studies should focus on more sophisticated interactive interventions that expand the functionality and capabilities of HIT and better engage patients in care.
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December 2010

Seizure outcomes following the use of generic versus brand-name antiepileptic drugs: a systematic review and meta-analysis.

Drugs 2010 Mar;70(5):605-21

Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02120, USA.

The automatic substitution of bioequivalent generics for brand-name antiepileptic drugs (AEDs) has been linked by anecdotal reports to loss of seizure control. To evaluate studies comparing brand-name and generic AEDs, and determine whether evidence exists of superiority of the brand-name version in maintaining seizure control. English-language human studies identified in searches of MEDLINE, EMBASE and International Pharmaceutical Abstracts (1984 to 2009). Randomized controlled trials (RCTs) and observational studies comparing seizure events or seizure-related outcomes between one brand-name AED and at least one alternative version produced by a distinct manufacturer. We identified 16 articles (9 RCTs, 1 prospective nonrandomized trial, 6 observational studies). We assessed characteristics of the studies and, for RCTs, extracted counts for patients whose seizures were characterized as 'controlled' and 'uncontrolled'. Seven RCTs were included in the meta-analysis. The aggregate odds ratio (n = 204) was 1.1 (95% CI 0.9, 1.2), indicating no difference in the odds of uncontrolled seizure for patients on generic medications compared with patients on brand-name medications. In contrast, the observational studies identified trends in drug or health services utilization that the authors attributed to changes in seizure control. Although most RCTs were short-term evaluations, the available evidence does not suggest an association between loss of seizure control and generic substitution of at least three types of AEDs. The observational study data may be explained by factors such as undue concern from patients or physicians about the effectiveness of generic AEDs after a recent switch. In the absence of better data, physicians may want to consider more intensive monitoring of high-risk patients taking AEDs when any switch occurs.
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http://dx.doi.org/10.2165/10898530-000000000-00000DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3056509PMC
March 2010

Clinical equivalence of generic and brand-name drugs used in cardiovascular disease: a systematic review and meta-analysis.

JAMA 2008 Dec;300(21):2514-26

Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA.

Context: Use of generic drugs, which are bioequivalent to brand-name drugs, can help contain prescription drug spending. However, there is concern among patients and physicians that brand-name drugs may be clinically superior to generic drugs.

Objectives: To summarize clinical evidence comparing generic and brand-name drugs used in cardiovascular disease and to assess the perspectives of editorialists on this issue.

Data Sources: Systematic searches of peer-reviewed publications in MEDLINE, EMBASE, and International Pharmaceutical Abstracts from January 1984 to August 2008.

Study Selection: Studies compared generic and brand-name cardiovascular drugs using clinical efficacy and safety end points. We separately identified editorials addressing generic substitution.

Data Extraction: We extracted variables related to the study design, setting, participants, clinical end points, and funding. Methodological quality of the trials was assessed by Jadad and Newcastle-Ottawa scores, and a meta-analysis was performed to determine an aggregate effect size. For editorials, we categorized authors' positions on generic substitution as negative, positive, or neutral.

Results: We identified 47 articles covering 9 subclasses of cardiovascular medications, of which 38 (81%) were randomized controlled trials (RCTs). Clinical equivalence was noted in 7 of 7 RCTs (100%) of beta-blockers, 10 of 11 RCTs (91%) of diuretics, 5 of 7 RCTs (71%) of calcium channel blockers, 3 of 3 RCTs (100%) of antiplatelet agents, 2 of 2 RCTs (100%) of statins, 1 of 1 RCT (100%) of angiotensin-converting enzyme inhibitors, and 1 of 1 RCT (100%) of alpha-blockers. Among narrow therapeutic index drugs, clinical equivalence was reported in 1 of 1 RCT (100%) of class 1 antiarrhythmic agents and 5 of 5 RCTs (100%) of warfarin. Aggregate effect size (n = 837) was -0.03 (95% confidence interval, -0.15 to 0.08), indicating no evidence of superiority of brand-name to generic drugs. Among 43 editorials, 23 (53%) expressed a negative view of generic drug substitution.

Conclusions: Whereas evidence does not support the notion that brand-name drugs used in cardiovascular disease are superior to generic drugs, a substantial number of editorials counsel against the interchangeability of generic drugs.
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http://dx.doi.org/10.1001/jama.2008.758DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2713758PMC
December 2008
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