Publications
20 results found
Dadwani RS, Wan W, Skandari MR, et al., 2023, Expected health benefits of SGLT-2 inhibitors and GLP-1 receptor agonists in older adults, MDM Policy & Practice, Vol: 8, Pages: 1-11, ISSN: 2381-4683
Background. Older and sicker adults with type 2 diabetes (T2D) were underrepresented in randomized trials of glucagon-like peptide 1 receptor-agonist (GLP1RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2I), and thus, health benefits are uncertain in this population. Objective. To assess the impact of age, health status, and life expectancy in older adults with T2D on health benefits of GLP1RA and SGLT2I. Design. We used the United Kingdom Prospective Diabetes Study (UKPDS) model to simulate lifetime health outcomes. We calibrated the UKPDS model to improve mortality prediction in older adults using a common geriatric prognostic index. Participants. National Health and Nutrition Examination Survey 2013–2018 participants 65 y and older with T2D, eligible for GLP1RA or SGLT2I according to American Diabetes Association guidelines. Interventions. GLP1RA or SGLT2I use versus no additional medication. Main Measures. Lifetime complications and weighted life-years (LYs) and quality-adjusted life-years (QALYs) across overall treatment arms and life expectancies. Key Results. The overall older adult population was predicted to experience significant health benefits from GLP1RA (+0.29 LY [95% confidence interval: 0.27, 0.31], +0.15 QALYs [0.14, 0.16]) and SGLT2I (+0.26 LY [0.24, 0.28], +0.13 QALYs [0.12, 0.14]) as compared with no added medication. However, expected benefits declined in subgroups with shorter life expectancies. Participants with <4 y of life expectancy had minimal gains of <0.05 LY and <0.03 QALYs from added medication. Accounting for injection-related disutility, GLP1RA use reduced QALYs (−0.03 QALYs [−0.04, −0.02]). Conclusions. While GLP1RA and SGLT2I have substantial health benefits for many older adults with type 2 diabetes, benefits are not clinically significant in patients with <4 y of life expectancy. Life expectancy and patient preferences are important considerations when prescribing newer dia
Porter J, Boyd C, Skandari MR, et al., 2023, Revisiting the time needed to provide adult primary care, Journal of General Internal Medicine, Vol: 38, Pages: 147-155, ISSN: 0884-8734
BackgroundMany patients do not receive guideline-recommended preventive, chronic disease, and acute care. One potential explanation is insufficient time for primary care providers (PCPs) to provide care.ObjectiveTo quantify the time needed to provide 2020 preventive care, chronic disease care, and acute care for a nationally representative adult patient panel by a PCP alone, and by a PCP as part of a team-based care model.DesignSimulation study applying preventive and chronic disease care guidelines to hypothetical patient panels.ParticipantsHypothetical panels of 2500 patients, representative of the adult US population based on the 2017–2018 National Health and Nutrition Examination Survey.Main MeasuresThe mean time required for a PCP to provide guideline-recommended preventive, chronic disease and acute care to the hypothetical patient panels. Estimates were also calculated for visit documentation time and electronic inbox management time. Times were re-estimated in the setting of team-based care.Key ResultsPCPs were estimated to require 26.7 h/day, comprising of 14.1 h/day for preventive care, 7.2 h/day for chronic disease care, 2.2 h/day for acute care, and 3.2 h/day for documentation and inbox management. With team-based care, PCPs were estimated to require 9.3 h per day (2.0 h/day for preventive care and 3.6 h/day for chronic disease care, 1.1 h/day for acute care, and 2.6 h/day for documentation and inbox management).ConclusionsPCPs do not have enough time to provide the guideline-recommended primary care. With team-based care the time requirements would decrease by over half, but still be excessive.
Choi JG, Winn AN, Skandari MR, et al., 2022, First-line therapy for Type 2 Diabetes with sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists: a cost-effectiveness sStudy., Annals of Internal Medicine, ISSN: 0003-4819
BACKGROUND: Guidelines recommend sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP1) receptor agonists as second-line therapy for patients with type 2 diabetes. Expanding their use as first-line therapy has been proposed but the clinical benefits may not outweigh their costs. OBJECTIVE: To evaluate the lifetime cost-effectiveness of a strategy of first-line SGLT2 inhibitors or GLP1 receptor agonists. DESIGN: Individual-level Monte Carlo-based Markov model. DATA SOURCES: Randomized trials, Centers for Disease Control and Prevention databases, RED BOOK, and the National Health and Nutrition Examination Survey. TARGET POPULATION: Drug-naive U.S. patients with type 2 diabetes. TIME HORIZON: Lifetime. PERSPECTIVE: Health care sector. INTERVENTION: First-line SGLT2 inhibitors or GLP1 receptor agonists. OUTCOME MEASURES: Life expectancy, lifetime costs, incremental cost-effectiveness ratios (ICERs). RESULTS OF BASE-CASE ANALYSIS: First-line SGLT2 inhibitors and GLP1 receptor agonists had lower lifetime rates of congestive heart failure, ischemic heart disease, myocardial infarction, and stroke compared with metformin. First-line SGLT2 inhibitors cost $43 000 more and added 1.8 quality-adjusted months versus first-line metformin ($478 000 per quality-adjusted life-year [QALY]). First-line injectable GLP1 receptor agonists cost more and reduced QALYs compared with metformin. RESULTS OF SENSITIVITY ANALYSIS: By removing injection disutility, first-line GLP1 receptor agonists were no longer dominated (ICER, $327 000 per QALY). Oral GLP1 receptor agonists were not cost-effective (ICER, $823 000 per QALY). To be cost-effective at under $150 000 per QALY, costs for SGLT2 inhibitors would need to be under $5 per day and under $6 per day for oral GLP1 receptor agonists. LIMITATION: U.S. population and costs not generalizable internationally. CONCLUSION: As first-line agents, SGLT2 inhibitors and GLP1 receptor agonists would
Nair V, Auger S, Kochanny S, et al., 2022, Development and validation of a decision analytical model for posttreatment surveillance for patients with oropharyngeal carcinoma, Jama Network Open, Vol: 5, ISSN: 2574-3805
Importance Clinical practice regarding posttreatment radiologic surveillance for patients with oropharyngeal carcinoma (OPC) is neither adapted to individual patient risk nor fully evidence based.Objectives To construct a microsimulation model for posttreatment OPC progression and use it to optimize surveillance strategies while accounting for both tumor stage and human papillomavirus (HPV) status.Design, Setting, and Participants In this decision analytical modeling study, a Markov model of 3-year posttreatment patient trajectories was created. The training data source was the American College of Surgeon’s National Cancer Database from 2010 to 2015. The external validation data set was the 2016 International Collaboration on Oropharyngeal Cancer Network for Staging (ICON-S) study. Training data comprised 2159 patients with OPC treated with primary radiotherapy who had known HPV status and disease staging information. Patients with American Joint Committee on Cancer, 7th edition stage III to IVB disease and those with clinical metastases during the time of primary treatment were included. Data were analyzed from August 1 to October 31, 2020.Main Outcomes and Measures Main outcomes included disease stage and HPV status, specific disease transition probabilities, and latency of surveillance regimens, defined as time between recurrence incidence and disease discovery.Results Training data consisted of 2159 total patients (1708 men [79.1%]; median age, 59.6 years [range, 40-90 years]; 401 with stage III disease, 1415 with stage IVA disease, and 343 with stage IVB disease). Cohorts predominantly had HPV-negative disease (1606 [74.4%]). With model-optimized regimens, recurrent disease was discovered a mean of 0.6 months (95% CI, 0.5-0.8 months) earlier than with a standard surveillance regimen based on current clinical guidelines. Recurrent disease was discovered using the optimized regimens without significant reduction in sensitivity. Compared with strategies
Alexander JT, Staab EM, Wan W, et al., 2021, Longer-term benefits and risks of sodium-glucose cotransporter-2 inhibitors in Type 2 diabetes: a systematic review and meta-analysis, Journal of General Internal Medicine, Vol: 37, Pages: 439-448, ISSN: 0884-8734
BackgroundSodium-glucose cotransporter-2 inhibitors (SGLT2Is) are a recent class of medication approved for the treatment of type 2 diabetes (T2D). Previous meta-analyses have quantified the benefits and harms of SGLT2Is; however, these analyses have been limited to specific outcomes and comparisons and included trials of short duration. We comprehensively reviewed the longer-term benefits and harms of SGLT2Is compared to placebo or other anti-hyperglycemic medications.MethodsWe searched PubMed, Scopus, and clinicaltrials.gov from inception to July 2019 for randomized controlled trials of minimum 52 weeks’ duration that enrolled adults with T2D, compared an SGLT2I to either placebo or other anti-hyperglycemic medications, and reported at least one outcome of interest including cardiovascular risk factors, microvascular and macrovascular complications, mortality, and adverse events. We conducted random effects meta-analyses to provide summary estimates using weighted mean differences (MD) and pooled relative risks (RR). The study was registered a priori with PROSPERO (CRD42018090506).ResultsFifty articles describing 39 trials (vs. placebo, n = 28; vs. other anti-hyperglycemic medication, n = 12; vs. both, n = 1) and 112,128 patients were included in our analyses. Compared to placebo, SGLT2Is reduced cardiovascular risk factors (e.g., hemoglobin A1c, MD − 0.55%, 95% CI − 0.62, − 0.49), macrovascular outcomes (e.g., hospitalization for heart failure, RR 0.70, 95% CI 0.62, 0.78), and mortality (RR 0.87, 95% CI 0.80, 0.94). Compared to other anti-hyperglycemic medications, SGLT2Is reduced cardiovascular risk factors, but insufficient data existed for other outcomes. About a fourfold increased risk of genital yeast infections for both genders was observed for comparisons vs. placebo and other anti-hyperglycemic medications.DiscussionWe found that SGLT2Is led to dura
Alexander JT, Staab EM, Wan W, et al., 2021, The longer-term benefits and harms of glucagon-like peptide-1 receptor agonists: a systematic review and meta-analysis, Journal of General Internal Medicine, Vol: 37, Pages: 415-438, ISSN: 0884-8734
BackgroundPrevious meta-analyses of the benefits and harms of glucagon-like peptide-1 receptor agonists (GLP1RAs) have been limited to specific outcomes and comparisons and often included short-term results. We aimed to estimate the longer-term effects of GLP1RAs on cardiovascular risk factors, microvascular and macrovascular complications, mortality, and adverse events in patients with type 2 diabetes, compared to placebo and other anti-hyperglycemic medications.MethodsWe searched PubMed, Scopus, and clinicaltrials.gov (inception–July 2019) for randomized controlled trials ≥ 52 weeks’ duration that compared a GLP1RA to placebo or other anti-hyperglycemic medication and included at least one outcome of interest. Outcomes included cardiovascular risk factors, microvascular and macrovascular complications, all-cause mortality, and treatment-related adverse events. We performed random effects meta-analyses to give summary estimates using weighted mean differences (MD) and pooled relative risks (RR). Risk of bias was assessed using the Cochrane Collaboration risk of bias in randomized trials tool. Quality of evidence was summarized using the Grading of Recommendations, Assessment, Development, and Evaluation approach. The study was registered a priori with PROSPERO (CRD42018090506).ResultsForty-five trials with a mean duration of 1.7 years comprising 71,517 patients were included. Compared to placebo, GLP1RAs reduced cardiovascular risk factors, microvascular complications (including renal events, RR 0.85, 0.80–0.90), macrovascular complications (including stroke, RR 0.86, 0.78–0.95), and mortality (RR 0.89, 0.84–0.94). Compared to other anti-hyperglycemic medications, GLP1RAs only reduced cardiovascular risk factors. Increased gastrointestinal events causing treatment discontinuation were observed in both comparisons.DiscussionGLP1RAs reduced cardiovascular risk factors and increased gastrointestinal events compared to placebo and other
Skandari MR, Shechter SM, 2021, Patient-Type Bayes-Adaptive Treatment Plans, Operations Research, Vol: 69, Pages: 574-598, ISSN: 0030-364X
<jats:p> Treatment decisions that explicitly consider patient heterogeneity can lower the cost of care and improve outcomes by providing the right care for the right patient at the right time. “Patient-Type Bayes-Adaptive Treatment Plans” analyzes the problem of designing ongoing treatment plans for a population with heterogeneity in disease progression and response to medical interventions. The authors create a model that learns the patient type by monitoring patient health over time and updates a patient's treatment plan according to the information gathered. The authors formulate the problem as a multivariate state space partially observable Markov decision process (POMDP). They provide structural properties of the optimal policy and develop several approximate policies and heuristics to solve the problem. As a case study, they develop a data-driven decision-analytic model to study the optimal timing of vascular access surgery for patients with progressive chronic kidney disease. They provide further policy insights that sharpen existing guidelines. </jats:p>
Dadwani RS, Skandari MR, GoodSmith MS, et al., 2020, Alternative type 2 diabetes screening tests may reduce the number of US adults with undiagnosed diabetes, DIABETIC MEDICINE, Vol: 37, Pages: 1935-1943, ISSN: 0742-3071
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Miksanek TJ, Skandari M, Ham SA, et al., 2020, The productivity requirements of implementing a medical scribe program, Annals of Internal Medicine, ISSN: 0003-4819
Background: Economic analyses of medical scribes have been limited to individual, specialty-specific clinics.Objective:To determine the number of additional patient visits various specialties would need to recover the costs of implementing scribes in their practice at one year. Design: Modeling study based on 2015 Centers for Medicare and Medicaid Services (CMS) and National Ambulatory Medical Care Survey (NAMCS) data. Scribe costs were based on literature review and a third-party contractor model. Revenue was calculated from direct visit billing, Current Procedural Terminology(CPT) billing, and NAMCS data.Data Sources:2015 CMS and NAMCSdata.Target Population:Health care providers.Perspective:Office-based clinic.Intervention: n/aOutcome Measures: The number of additional patient visits a physician must have to recover the costs of a scribe program at one year. Results: Base-Case Analysis: An average of 1.34 additional new patient visits per day(295 per year) was 2 required to recover scribe costs(range, 0.89 (cardiology) to 1.80 (orthopedic surgery) new patient visits per day). For returning patient visits, an average of 2.15 additional visits per day (472 per year) was required(range, 1.65 (cardiology) to 2.78 (orthopedic surgery) returning visits per day).Two additional new patient (or three additional returning) visits per day was profitable for all specialties.Sensitivity Analysis: Results were not sensitive to most inputs, with exceptions of hourly scribe cost and inclusion of CPT revenue.Limitations:Use of Medicare data and failure to account for indirect costs, downstream revenue, or changes in documentation quality.Conclusion: For all specialties, modest increases in productivity due to scribes may allow physicians to see more patients and offset scribe costs, making scribe programs revenue neutral.
GoodSmith MS, Skandari M, Huang E, et al., 2019, The impact of biomarker screening and cascade genetic testing on the cost-effectiveness of MODY genetic testing, Diabetes Care, Vol: 42, Pages: 2247-2255, ISSN: 0149-5992
OBJECTIVE In the U.S., genetic testing for maturity-onset diabetes of the young (MODY) is frequently delayed because of difficulty with insurance coverage. Understanding the economic implications of clinical genetic testing is imperative to advance precision medicine for diabetes. The objective of this article is to assess the cost-effectiveness of genetic testing, preceded by biomarker screening and followed by cascade genetic testing of first-degree relatives, for subtypes of MODY in U.S. pediatric patients with diabetes.RESEARCH DESIGN AND METHODS We used simulation models of distinct forms of diabetes to forecast the clinical and economic consequences of a systematic genetic testing strategy compared with usual care over a 30-year time horizon. In the genetic testing arm, patients with MODY received treatment changes (sulfonylureas for HNF1A- and HNF4A-MODY associated with a 1.0% reduction in HbA1c; no treatment for GCK-MODY). Study outcomes included costs, life expectancy (LE), and quality-adjusted life years (QALY).RESULTS The strategy of biomarker screening and genetic testing was cost-saving as it increased average quality of life (+0.0052 QALY) and decreased costs (−$191) per simulated patient relative to the control arm. Adding cascade genetic testing increased quality-of-life benefits (+0.0081 QALY) and lowered costs further (−$735).CONCLUSIONS A combined strategy of biomarker screening and genetic testing for MODY in the U.S. pediatric diabetes population is cost-saving compared with usual care, and the addition of cascade genetic testing accentuates the strategy’s benefits. Widespread implementation of this strategy could improve the lives of patients with MODY while saving the health system money, illustrating the potential population health benefits of personalized medicine.
Wan W, Nathan AG, Zarei P, et al., 2019, Cost-effectiveness of shared telemedicine appointments in young adults with T1D: CoYoT1 trial, Diabetes Care, Vol: 42, Pages: 1589-1592, ISSN: 0149-5992
OBJECTIVE: Young adults(YAs)with type 1 diabetes (T1D) often struggle to achieve glycemic control and maintain routine clinic visits. We aimed to evaluate the societal cost-effectiveness of the Colorado YAswith T1D (CoYoT1) Clinic, an innovative caremodel ofshared medical appointments through home telehealth.RESEARCH DESIGN AND METHODS: Patients self-selected into the CoYoT1 (N=42) or usual care (N=39) groups. RESULTS: Within the trial, we foundno significant differences in 9-month quality-adjusted life; however,the control group had a larger decline from baseline inutility than the CoYoT1 group, indicating a quality of life(QoL) benefit of the intervention (difference in difference mean ± SD: +0.04 ± 0.09, P=0.03). There was no significant difference in total costs. The CoYoT1 group had more study-related visits but fewer non-study office visits and hospitalizations. CONCLUSIONS: The CoYoT1 care model may help YAs with T1D maintain a higher QoLwith no increase in costs.
Skandari M, Wan W, Minc A, et al., 2018, Cost-effectiveness of initiating an insulin pump in T1D adults using continuous glucose monitoring compared with multiple daily insulin injections: the DIAMOND Randomized Trial, Medical Decision Making, Vol: 38, Pages: 942-953, ISSN: 0272-989X
Background. The economic impact of both continuous glucose monitoring (CGM) and insulin pumps (continuous subcutaneous insulin infusion [CSII]) in type 1 diabetes (T1D) have been evaluated separately. However, the cost-effectiveness of adding CSII to existing CGM users has not yet been assessed. Objective. The aim of this study was to evaluate the societal cost-effectiveness of CSII versus continuing multiple daily injections (MDI) in adults with T1D already using CGM. Methods. In the second phase of the DIAMOND trial, 75 adults using CGM were randomized to either CGM+CSII or CGM+MDI (control) and surveyed at baseline and 28 weeks. We performed within-trial and lifetime cost-effectiveness analyses (CEAs) and estimated lifetime costs and quality-adjusted life-years (QALYs) via a modified Sheffield T1D model. Results. Within the trial, the CGM+CSII group had a significant reduction in quality of life from baseline (−0.02 ± 0.05 difference in difference [DiD]) compared with controls. Total per-person 28-week costs were $8,272 (CGM+CSII) versus $5,623 (CGM+MDI); the difference in costs was primarily attributable to pump use ($2,644). Pump users reduced insulin intake (−12.8 units DiD) but increased the use of daily number of test strips (+1.2 DiD). Pump users also increased time with glucose in range of 70 to 180 mg/dL but had a higher HbA1c (+0.13 DiD) and more nonsevere hypoglycemic events. In the lifetime CEA, CGM+CSII would increase total costs by $112,045 DiD, decrease QALYs by 0.71, and decrease life expectancy by 0.48 years. Conclusions. Based on this single trial, initiating an insulin pump in adults with T1D already using CGM was associated with higher costs and reduced quality of life. Additional evidence regarding the clinical effects of adopting combinations of new technologies from trials and real-world populations is needed to confirm these findings.
Wan W, Skandari MR, Minc A, et al., 2018, Cost-effectiveness of Continuous Glucose Monitoring for Adults With Type 1 Diabetes Compared With Self-Monitoring of Blood Glucose: The DIAMOND Randomized Trial, DIABETES CARE, Vol: 41, Pages: 1227-1234, ISSN: 0149-5992
Laiteerapong N, Cooper JM, Skandari MR, et al., 2018, Individualized glycemic control for U. S. adults with type 2 diabetes. A cost-effectiveness analysis, Annals of Internal Medicine, Vol: 168, Pages: 170-178, ISSN: 0003-4819
Background:Intensive glycemic control in type 2 diabetes (glycated hemoglobin [HbA1c] level <7%) is an established, cost-effective standard of care. However, guidelines recommend individualizing goals on the basis of age, comorbidity, diabetes duration, and complications.Objective:To estimate the cost-effectiveness of individualized control versus uniform intensive control (HbA1c level <7%) for the U.S. population with type 2 diabetes.Design:Patient-level Monte Carlo–based Markov model.Data Sources:National Health and Nutrition Examination Survey 2011–2012.Target Population:The approximately 17.3 million persons in the United States with diabetes diagnosed at age 30 years or older.Time Horizon:Lifetime.Perspective:Health care sector.Intervention:Individualized versus uniform intensive glycemic control.Outcome Measures:Average lifetime costs, life-years, and quality-adjusted life-years (QALYs).Results of Base-Case Analysis:Individualized control saved $13 547 per patient compared with uniform intensive control ($105 307 vs. $118 854), primarily due to lower medication costs ($34 521 vs. $48 763). Individualized control decreased life expectancy (20.63 vs. 20.73 years) due to an increase in complications but produced more QALYs (16.68 vs. 16.58) due to fewer hypoglycemic events and fewer medications.Results of Sensitivity Analysis:Individualized control was cost-saving and generated more QALYs compared with uniform intensive control, except in analyses where the disutility associated with receiving diabetes medications was decreased by at least 60%.Limitation:The model did not account for effects of early versus later intensive glycemic control.Conclusion:Health policies and clinical programs that encourage an individualized approach to glycemic control for U.S. adults with type 2 diabetes reduce costs and increase quality of life compared with uniform intensive control. Additional research is needed to confirm the risks and benefits of this strategy
Shechter SM, Chandler T, Skandari MR, et al., 2017, Cost-effectiveness Analysis of Vascular Access Referral Policies in CKD, AMERICAN JOURNAL OF KIDNEY DISEASES, Vol: 70, Pages: 368-376, ISSN: 0272-6386
Skandari MR, Shechter SM, Zalunardo N, 2015, Optimal vascular access choice for patients on hemodialysis, M&SOM-Manufacturing & Service Operations Management, Vol: 17, Pages: 608-619, ISSN: 1523-4614
Which vascular access to use is considered one of the most important questions in the care of patients on hemodialysis (HD). An arteriovenous fistula (AVF) is often considered the gold standard for delivering HD due to better patient survival, higher quality of life, and fewer complications. However, AVFs have some limitations: they require surgery, it takes approximately three months to know whether the surgery was successful, and a majority of these surgeries end in failure. Conversely, another common vascular access, the central venous catheter, can be inserted via a simple procedure and used immediately after placement. In this research, we address the question of whether and when to perform AVF surgery on incident and established HD patients, with the aim of finding individualized policies that maximize a patient’s probability of survival and remaining quality-adjusted life expectancy. Using a continuous-time dynamic programming model and under certain data-driven assumptions, we establish structural properties of the optimal policy for each objective. We provide further insights for policy makers through our numerical experiments.
Shechter SM, Skandari MR, Zalunardo N, 2014, Timing of Arteriovenous Fistula Creation in Patients With CKD: A Decision Analysis, AMERICAN JOURNAL OF KIDNEY DISEASES, Vol: 63, Pages: 95-103, ISSN: 0272-6386
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- Citations: 47
Salmasi N, Logendran R, Skandari MR, 2011, Makespan minimization of a flowshop sequence-dependent group scheduling problem, The International Journal of Advanced Manufacturing Technology, Vol: 56, Pages: 699-710, ISSN: 0268-3768
Azadeh A, Skandari MR, Maleki-Shoja B, 2010, An integrated ant colony optimization approach to compare strategies of clearing market in electricity markets: Agent-based simulation, ENERGY POLICY, Vol: 38, Pages: 6307-6319, ISSN: 0301-4215
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- Citations: 20
Salmasi N, Logendran R, Skandari MR, 2010, Total flow time minimization in a flowshop sequence-dependent group scheduling problem, Computers & Operations Research, Vol: 37, Pages: 199-212, ISSN: 0305-0548
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