Both life expectancy in quality-adjusted life years (QALYs) and lifetime costs were higher for dabigatran than for warfarin (10.84 vs. 10.28 QALYs and $168,398 vs. $143,193, respectively). The incremental cost per QALY for dabigatran was $45,372. Limitations include dependence on data from a single-manufacturer-sponsored trial with limited follow-up.
Retail costs for dabigatran are now known to be about $8 per day. When the model is adjusted to that price, an additional QALY would cost $12,000, well below the commonly accepted threshold of $50,000.
Bottom line: Dabigatran is likely a cost-effective alternative to warfarin in nonvalvular atrial fibrillation.
Citation: Freeman JV, Zhu RP, Owens DK, et al. Cost-effectiveness of dabigatran compared with warfarin for stroke prevention in atrial fibrillation. Ann Intern Med. 2011;154(1):1-11.
Effects of New ACGME Mandates on Patients and Residents Unclear
Clinical question: How will new intern duty-hour standards impact patient care, residents’ health, and education?
Background: The Accreditation Council for Graduate Medical Education (ACGME) has mandated new duty-hour standards that limit interns’ shifts to 16 hours and night float to six consecutive nights. They also strongly recommend a nighttime nap.
Study design: Systematic review of English-language, original research studies addressing shift length, night float, or protected sleep time, published from 1989 to 2010.
Synopsis: Sixty-four out of 5,345 articles met eligibility criteria, including four randomized controlled trials and five multi-institutional studies. Although 73% of studies examining shift length supported reducing hours, optimal shift duration was not determined. All studies addressing night float examined five to seven consecutive nights of work; data were too heterogeneous for generalization. Data on protected sleep time were too limited to determine effect on residents and patients.
The majority of studies were conducted at single institutions and study designs carried high risk for interpretation bias. Additionally, publication bias might have influenced the results of this review of English-language-only studies.
Bottom line: The available studies that attempt to elucidate the effects of major changes in residency training have significant limitations, and the potential impact of the new standards on patients and residents remains uncertain.
Citation: Reed DA, Fletcher KE, Arora VM. Systematic review: association of shift length, protected sleep time, and night float with patient care, residents’ health, and education. Ann Intern Med. 2010;153:829-842.
Admission to Stroke Centers for Acute Ischemic Stroke Might Improve Mortality
Clinical question: Does admission to a certified stroke center improve survival in patients with acute ischemic stroke?
Background: Since 2003, the Joint Commission has designated fewer than 700 acute-care hospitals as certified stroke centers. However, no large studies have examined whether patients with acute stroke admitted to stroke centers have lower mortality than those admitted to noncertified acute-care hospitals.
Study design: Observational cohort study.
Setting: All acute-care hospitals in New York state.