Insight from a genius...

If I have ever made any valuable discoveries, it has been owing more to patient observation than to any other reason. -Isaac Newton (1642-1727) 


Happy Holidays!


-Ben

Benefits, Harms, and Cost-Effectiveness of Supplemental Ultrasonography Screening for Women With Dense Breasts

Congratulations to UVM Assistant Professor of Surgery Brian Sprague, PhD on publication of his latest work on the importance of mammographic breast density in Annals of Internal Medicine.

Sprague BL, Stout NK, Schechter C, van Ravesteyn NT, Cevik M, Alagoz O, et al. Benefits, Harms, and Cost-Effectiveness of Supplemental Ultrasonography Screening for Women With Dense Breasts. Ann Intern Med. [Epub ahead of print 9 December 2014] doi:10.7326/M14-0692
Background: Many states have laws requiring mammography facilities to tell women with dense breasts and a negative screening mammography result to discuss supplemental screening tests with their providers. The most readily available supplemental screening method is ultrasonography, but little is known about its effectiveness.
Objective: To evaluate the benefits, harms, and cost-effectiveness of supplemental ultrasonography screening for women with dense breasts.
Design: Comparative modeling with 3 validated simulation models.
Data Sources: Surveillance, Epidemiology, and End Results Program; Breast Cancer Surveillance Consortium; and medical literature.
Target Population: Contemporary cohort of women eligible for routine screening.
Time Horizon: Lifetime.
Perspective: Payer.
Intervention: Supplemental ultrasonography screening for women with dense breasts after a negative screening mammography result.
Outcome Measures: Breast cancer deaths averted, quality-adjusted life-years (QALYs) gained, biopsies recommended after a false-positive ultrasonography result, and costs.
Results of Base-Case Analysis: Supplemental ultrasonography screening after a negative mammography result for women aged 50 to 74 years with heterogeneously or extremely dense breasts averted 0.36 additional breast cancer deaths (range across models, 0.14 to 0.75 deaths), gained 1.7 QALYs (range, 0.9 to 4.7 QALYs), and resulted in 354 biopsy recommendations after a false-positive ultrasonography result (range, 345 to 421 recommendations) per 1000 women with dense breasts compared with biennial screening by mammography alone. The cost-effectiveness ratio was $325 000 per QALY gained (range, $112 000 to $766 000 per QALY gained). Supplemental ultrasonography screening for only women with extremely dense breasts cost $246 000 per QALY gained (range, $74 000 to $535 000 per QALY gained).
Results of Sensitivity Analysis: The conclusions were not sensitive to ultrasonography performance characteristics, screening frequency, or starting age.
Limitation: Provider costs for coordinating supplemental ultrasonography were not considered.
Conclusion: Supplemental ultrasonography screening for women with dense breasts would substantially increase costs while producing relatively small benefits.

Full report here.
UVM Bog report here.

Peter Durda's abstract accepted for poster presentation

A recent abstract submitted by Peter Durda to the American Heart Association has been accepted for a poster presentation at the EPI/Lifestyle 2015 Scientific Sessions, scheduled March 3 - 6, 2015 at the Baltimore Marriott in Baltimore, Maryland.  The presentation title is Circulating Soluble CD163 and Risk of Cardiovascular Disease and All-Cause Mortality in Older Persons: The Cardiovascular Heart Study (CHS).

Congratulations Peter!

Clinical Research Oriented Workshop (CROW) Meeting: Dec 11, 2014

Present:  Marianne Burke, Nancy Gell, Kairn Kelley, Connie van Eeghen

Start Up:  Watch out for undelivered emails (Nancy’s current problem) and new levels of unwanted spam (Connie’s)

1.                  Discussion Karen’s Results section of her Dichotic Listening Test-Retest Draft   

a.       To be submitted to a journal for speech/language, one of 3 requirements for Kairn’s degree

b.      This draft focused on the differences among 3 tests; the next will look at the clinical implications of the change in scores – how the difference might affect diagnosis.

c.       Results reporting includes group and individual test reliability, which may begin to get into the clinical implications – save this discussion for committee.

d.      No subgroup analysis is expected; the group discussed the value of how detailed the characteristics reported in Table 1 might be.  If there are unusual characteristics that might affect the results (such as children receiving special services), consider conducting a sensitivity test to see how much those subjects affected the results.

e.       Group level results: the group discussed how to include raw and percentage scores in a single table, and how the same information is presented in the narrative.

2.                  Discussion: Next semester’s meeting plan for CROW

a.       Results from Kairn’s Doodle Poll: change to Fridays, starting January 9, from 10:45 – 11:45.

3.                  Next Workshop Meeting(s): Thursdays, 11:30 a.m. – 12:45 p.m., at Given Courtyard South Level 4.   Remember: the first 15 minutes are for checking in with each other.

a.       Dec 18: Marianne: progress on IRB proposal and recruitment methods (no Ben)

b.      Jan 9: Nancy– topic TBD

c.       Jan 16: Kairn – topic TBD

Recorder: Connie van Eeghen

Cohorts for Heart and Aging Research in Epidemiology

Posted on behalf of Peter Durda

Cohorts for Heart and Aging Research in Epidemiology; Investigator meeting

Translational Collaboration

Steven Cummings, M.D. University of California, San Francisco

Dr. Cummings presented his thoughts on translational collaborations and his history with these endeavors.  Through his work as a principle investigator of the Health, Aging, and Body Composition study (an NIH funded cohort) he has been instrumental in leading the Longevity Consortium – a number of cohorts studying the genetics of longevity and aging.  Dr. Cummings emphasized that collaborations are nothing more than relationships; and they are tough and they take work.  When scientists from different disciplines are brought together they must overcome differing views on experimental design and funding priorities as well as different languages.  Epidemiologists, basic scientists, and statisticians do not speak the same language and they need to understand each other.  Dr. Cummings sees future mechanistic studies with basic scientist resulting from these consortia.  Another point of emphasis of the talk was the need to find/have alternative funding.  One example of private funding sources is Calico; a Google company established in 2013 for the purpose of identifying drugs to extend longevity.  Calico will fund a ‘super’ cohort of >5000 participants over the age of 95.  The two take home messages from this talk were: 1) Translational collaboration involves hard work on relationships; and 2) There is a funding shift to private sources and there are funds available, Dr. Cummings cited the Nature 2012 article entitled “Alternative funding: Sponsor my science”.

Clinical Research Oriented Workshop (CROW) Meeting: Dec 4, 2014

Present:  Marianne Burke, Sylvie Frisbie, Nancy Gell, Juvena Hitt, Kairn Kelley, Amanda Kennedy, Ben Littenberg, Connie van Eeghen

Start Up:  (Connie was trapped in Hewlett-Packard land, and missed this.)

1.                  Discussion Ben Littenberg reviewed the PROMIS29 survey, planned as the primary outcome measure of a PCORI research study for which the application is due in February.   

a.       The survey read well, although the presentation of raw scores is hard to interpret and may be misleading.  Version 2 has updated questions that include family and friends (matching a comment made in a recent patient feedback group working on this grant).

b.      The T-scores present the percentiles related to the individual responses (not the  number of standard deviations from the mean).  However, these totals appear to provide artificial ceilings and perhaps artificial floors for scores.  (Ben later corrected this: the T-scores represent a standardized score in 10ths of a sd with the mean set to 50. Given the T-score, you get the percentile by looking it up in the cumulative normal distribution.) 

c.       Ben and Juvena to explore further.  Face validity is good, content flow decent, format acceptable; scoring is mysterious.  Further research needed: website, NIH staff. Nancy has a colleague who might be of assistance.

2.                  Discussion: Connie shared the abstract of a manuscript in the process of a re-write after re-running all the data.  She shared 2 tables: description of patient-subjects (Table 3) and outcomes (Table 4).

a.       Table 3 data, describing the underlying population, is unusual in that it compares two time periods.  Consider one table for the 17 month period.  Move the bottom row (visits pppm) to the top of the result table. 

b.      The 12 month pre-window provides a conservative approach to assessing the change, relative to the 5 month post-window.  The 5 month post-window has a higher prevalence of older, sicker, and higher level of visits (i.e. frequent flyers) than the 12 month window has.

c.       Briefly discuss the new Table 3, then focus the discussion on Table 4.  Then discuss (without a new table) the changes in the population attributed to the intervention.

d.      Limitations: secular changes induced by the intervention

e.       Kaplan Meier plots: makes the lines show up differently when viewed in black and white

f.       Thank you, everyone!

3.                  Discussion: Next semester’s meeting plan for CROW

a.       Kairn to send out DoodlePoll

4.                  Next Workshop Meeting(s): Thursdays, 11:30 a.m. – 12:45 p.m., at Given Courtyard South Level 4.   Remember: the first 15 minutes are for checking in with each other.

a.       Dec 11: Kairn: manuscript (no Ben)

b.      Dec 18: Marianne: data collection tools (no Ben)

c.       Jan 8: TBD

d.      Jan 15: TBD

Recorder: Connie van Eeghen

PCP as secret therapist

Here's a NYT opinion piece, explaining the intricacies of PCP and young adult patients.  Any reactions?
http://opinionator.blogs.nytimes.com/2014/12/01/the-secret-therapist/?hp&action=click&pgtype=Homepage&module=c-column-top-span-region&region=c-column-top-span-region&WT.nav=c-column-top-span-region&_r=1

Connie

Report by Marianne Burke, PhD student

I attended a presentation by Richard Platt MD, Chair of Population Health at Harvard Pilgrim Health Care (HPHC) Institute, November 8 2014. Chicago Ill AAMC Conference, Matheson Lecture entitled “On a Clear Day You Can See the Learning Health System.”

Dr. Platt discussed the work of the HPHC Institute as the Coordinating Center of the National Patient-Centered Clinical Research Network funded with a 9 million grant from PCORI (Patient Centered Clinical Research Institute). He introduced the presentation by stating that there are so many patient care questions for which there are no evidence-based answers, and that we (medical professionals) have overestimated what we know. He stated that less than 15% of medical guidelines are supported by firm evidence. Most are expert opinion or consensus of practice. He made the case for finding the problems in large data surveillance sets even as we try use these sets more often and try to combine them to answer patient centered questions.

The Matheson Lecture “at the juncture of Technology, Informatics and Medical Library Science” occurs annually at AAMC (Association of American Medical Colleges) co-sponsored by the AAMC Group on Information Resources and the Association of Academic Health Sciences Libraries.

This lecture was interesting and well-documented though not surprising to me as a CTS student (of our excellent faculty) and medical librarian.

Clinical Research Oriented Workshop (CROW) Meeting: Nov 13, 2014

Present:  Marianne Burke, Nancy Gell, Kairn Kelley (by phone), Connie van Eeghen

Start Up:  Welcome Nancy!  Nancy is a new Assistant Professor in RMS, teaching in the PT program (public policy in Spring 2014; cardio-pulmonary – next year; health promotion – next year). Her background is PT, Public Health – Health Behavior and Health Education, Exercise Science.

1.                  Discussion Marianne Burke shared her updated draft application to the Lindberg Research Fellowship offered by the Medical Library Association

a.       Marianne made many substantial changes regarding organization and language.  We focused on grantsman(woman)ship issues:

b.      Bring out the applicant – make her easy to see.  Include voice, roles, and management responsibility (the grant pays for research assistant(s)) as appropriate

c.       Move the goals of the research grant forward – it’s buried on the second page

d.      Make the language in the new diagram consistent with the narrative

e.       Next step: submission deadline is tomorrow – good luck!

2.                  Next Workshop Meeting(s): Thursdays, 11:30 a.m. – 12:45 p.m., at Given Courtyard South Level 4.   Remember: the first 15 minutes are for checking in with each other.

a.       Nov 20: Nancy – project proposal on physical activity maintenance

b.      Nov 27: Thanksgiving! No CROW; eat turkey instead J

c.       Dec 4: Connie – manuscript: findings and discussion

Recorder: Connie van Eeghen

Clinical Research Oriented Workshop (CROW) Meeting: Oct 30, 2014

Present:  Marianne Burke, Kairn Kelley, Amanda Kennedy, Ben Littenberg, Connie van Eeghen

Start Up:  (Missed this!) 

1.                  Discussion Marianne Burke shared her draft application to the Lindberg Research Fellowship offered by the Medical Library Association

a.       Concise, clear language

                                                  i.      Literature review

                                                ii.      Significance – three specific ideas leading to the need for evidence-based information about library-based services, using dermatology because… leading to a cluster randomized trial. (Minimizes bias and strengthen validity…)

1.      Software attached to outcomes

2.      Library services attached to outcomes

3.      Cost may be affected

b.      Consistent headings and outline form: help the reader understand, using terms from the application instructions

                                                  i.      What each topic is (headers)

                                                ii.      Flow of information: why this is important before what the details are

c.       Aims: aims are broad; hypotheses are specific (e.g. there is no difference in time to resolution for patients in the intervention group compared to patients in the control group)

                                                  i.      One aim

                                                ii.      Two hypotheses   

d.      Budget: present the entire budget?  Or just the portion paid for by the fellowship?

e.       Research design:

                                                  i.      Sub-headings to support flow

                                                ii.      Diagram of recruitment, randomization, patient visits, recruitment, and interviews

f.       Limitations: watch for tone

g.      Timeline: make consistent with application; remember final report

h.      Research Dissemination Plan: this is a separate criterion in the reviewer’s instructions.  Buff this up!

i.        Next steps

                                                  i.      Letter of support (set up for Ben)

                                                ii.      Revise

2.                  Next Workshop Meeting(s): Thursdays, 11:30 a.m. – 12:45 p.m., at Given Courtyard South Level 4.   Remember: the first 15 minutes are for checking in with each other.

a.       Oct 30: Marianne’s topic – doctoral fellowship application(s)

b.      Nov 6: Connie to check with Ben on BHI data analysis (No Marianne, Charlie, or Amanda)

c.       Nov 13: Marianne – grant applications

Recorder: Connie van Eeghen