AHA Journals, Author Interviews, Blood Pressure - Hypertension, Columbia, Cost of Health Care / 19.05.2016

MedicalResearch.com Interview with: Nathalie Moise, MD, MS Assistant Professor Center for Behavioral Cardiovascular Health Department of Medicine Columbia University Medical Center New York, NY 10032 MedicalResearch.com: What is the background for this study? Dr. Moise:  Our research aimed to compare the number of lives saved and changes in medical costs expected if intensive blood pressure goals of less than 120 mmHg were implemented in high cardiovascular disease risk patients. In 2014, the 8th Joint National Committee (JNC8) on Detection, Evaluation, and Treatment of High Blood Pressure issued new guidelines recommending that physicians aim for a systolic blood pressure (SBP) of 140 mmHg in adults with diabetes and/or chronic kidney disease and 150 mmHg in healthy adults over age 60. The new guidelines represented a major departure from previous JNC7 guidelines recommending SBPs of 130 mmHg and 140, mmHg for these groups, respectively. Under the 2014 guidelines, over 5 million fewer individuals annually would receive drug treatment to lower their blood pressure, compared with the prior 2003 guidelines. Recently, the Systolic Blood Pressure Intervention Trial (SPRINT) found that having a more intensive systolic blood pressure (SBP) goal of 120 mmHg in patients at high risk for cardiovascular disease reduced both cardiovascular events and mortality by about one quarter, compared with the current goal of 140 mmHg. These recent studies and guidelines have created uncertainty about the safest, most effective and high-value blood pressure goals for U.S. adults with hypertension, but no prior study has compared the cost-effectiveness of adding more intensive blood pressure goals in high cardiovascular disease risk groups to standard national primary prevention hypertension guidelines like JNC8 and JNC7. Our team at Columbia University Medical Center conducted a computer simulation study to determine the value of adding the lower, life-saving  systolic blood pressure goal identified in SPRINT to the JNC7 and JNC8 guidelines for high-risk patients between the ages of 35 and 74 years. (High risk was defined as existing cardiovascular disease, chronic kidney disease, or a 10-year cardiovascular disease risk greater than 15 percent in patients older than 50 years and with a pre-treatment SBP greater than 130 mmHg) (more…)
Author Interviews, Cost of Health Care, JAMA / 17.05.2016

MedicalResearch.com Interview with: Andrew M. Ibrahim, MD Robert Wood Johnson Clinical Scholar (VA Scholar), Institute for Healthcare Policy & Innovation, University of Michigan Ann Arbor, MI MedicalResearch.com: What is the background for this study? Dr. Ibrahim: Critical access hospital designation was created to help ensure access to the more than 59 million people living in rural populations. Hospitals were eligible for critical access designation if they had less than 25 beds and were located more than 35 miles away from another hospital. With this designation they were paid above total cost for the care they provided. Previous reports suggest these centers provide lower quality of care for common medical admissions, however little was known about surgical conditions.  MedicalResearch.com: What are the main findings? Dr. Ibrahim: This study included a review of 1,631,904 Medicare beneficiary admissions to critical access hospitals (n = 828) and non-critical access hospitals (n = 3,676) for 1 of 4 common types of surgical procedures: appendectomy, gall bladder removal, removal of all or part of the colon, and hernia repair. Patient who underwent surgery at critical access hospitals were, on average, less medically complex. Compared to larger urban hospitals, these small rural hospitals (i.e. critical access hospitals) had the same 30-day mortality rates and lower complications rates. In addition, critical access hospitals costs on average $1400 less per patient to Medicare, despite being paid in an alternative payment system. These findings remained significant after accounting for the patient’s pre-operation health condition.   (more…)
Author Interviews, Cost of Health Care, Gastrointestinal Disease, Hepatitis - Liver Disease / 16.05.2016

MedicalResearch.com Interview with: Darius Lakdawalla PhD Quintiles Chair in Pharmaceutical Development and Regulatory Innovation School of Pharmacy Professor in the Sol Price School of Public Policy University of Southern California  MedicalResearch.com: What is the background for this study? Dr. Lakdawalla: New treatments for hepatitis-C are highly effective but also involve high upfront costs.  Because they effectively cure the disease, all the costs of treatments are paid over a short period of time – about three months – but the benefits accrue for the rest of a patient’s life.  This creates problems for the private health insurance system, where patients switch insurers.  The insurer that pays the bill for the treatment might not be around to enjoy the benefits of averting liver damage, liver transplants, and other costly complications associated with hepatitis-C. (more…)
Author Interviews, Brigham & Women's - Harvard, Cost of Health Care, JAMA, Race/Ethnic Diversity / 16.05.2016

MedicalResearch.com Interview with: Benjamin D. Sommers, MD, PhD Assistant Professor of Health Policy & Economics Harvard T. H. Chan School of Public Health / Brigham & Women's Hospital Boston, MA 02115  Molly E. Frean Data Analyst Department of Health Policy and Management Harvard T.H. Chan School of Public Health Boston, MA 02115 MedicalResearch.com: What is the background for this study? Dr. Sommers: We conducted this study in an effort to see how Native Americans have fared under the Affordable Care Act. In addition to the law's expansion of coverage via Medicaid and tax credits for the health insurance marketplaces, the law also provided support for Native Americans’ health care specifically through continued funding of the Indian Health Service (IHS). We sought to see how both health insurance coverage patterns and IHS use changed in the first year of the law's implementation. (more…)
Author Interviews, Breast Cancer, Cost of Health Care, Radiation Therapy / 11.05.2016

MedicalResearch.com Interview with: Jayant S Vaidya MBBS MS DNB FRCS PhD Professor of Surgery and Oncology, Scientific Director, Clinical Trials Group, Division of Surgery and Interventional Science, University College London Whittington Health - Clinical Lead for Breast Cancer Royal Free Hospital University College London HospitalJayant S Vaidya MBBS MS DNB FRCS PhD  Professor of Surgery and Oncology, Scientific Director, Clinical Trials Group, Division of Surgery and Interventional Science, University College London Whittington Health - Clinical Lead for Breast Cancer Royal Free Hospital University College London Hospital  MedicalResearch.com: What is the background for this study? What are the main findings? Prof. Vaidya: TARGIT-A randomised clinical trial (ISRCTN34086741) compared giving TARGIT IORT during lumpectomy vs. traditional EBRT given over several weeks after lumpectomy for breast cancer; local-recurrence-free-survival was similar in the two arms of the trial, particularly when TARGIT was given simultaneously with lumpectomy. Also, there were significantly fewer deaths from other causes with TARGIT IORT. This study calculated journeys made by patients with breast cancer to receive their radiotherapy, using the geographic and treatment data from a large randomised trial. The study then assessed the same outcomes (travel distances, travel time and CO2emissions) in two semi-rural breast cancers—the results of this assessment confirm and reinforce the original results: the benefit of the use of TARGIT for patients from two semi=rural breast centres was even larger (753 miles (1212 km), 30 h, 215 kg CO2 per patient). (more…)
Author Interviews, Cost of Health Care, Education, JAMA / 11.05.2016

MedicalResearch.com Interview with: Dr. James Song-Jeng Yeh, MD Brigham and Women's Hospital Boston MA MedicalResearch.com: What is the purpose for this study? Dr. Yeh: A number of factors influence physicians’ prescribing behavior, including physician’s knowledge and understanding of the drugs.  Pharmaceutical detailing and financial incentives may affect such behavior.  My interest in evidence-based medicine and how medical knowledge is translated into practice lead me to think about how physicians’ financial relationships with the pharmaceutical industry may affect prescribing patterns. In our study, we linked the Massachusetts physicians open payment database with the Medicare drug prescription claims database to determine if financial relationships with the industry are associated with increased brand-name statin drug prescribing.  The open payment database reports payments that physicians receive from pharmaceutical and medical device industries.  The open payment database when linked to the drug prescription claims database allowed us to answer this question. We looked at year 2011, when two of the most commonly prescribed brand-name statin drugs (Lipitor and Crestor) were not yet available in generic formulation. The outcome measured was what percentage of all statin prescription claims (both generic and brand-name) were brand-names. (more…)
Author Interviews, Cost of Health Care, Fertility, OBGYNE / 09.05.2016

MedicalResearch.com Interview with: Dr. Scott Sills MD, PhD Medical Director at the Center for Advanced Genetics an IVF program based in Carlsbad, California  MedicalResearch.com: What is the background for this study? What are the main findings? Dr. Sills: Often regarded as a miracle procedure by many infertile couples, in vitro fertilization (IVF) can be financially difficult for those without insurance coverage for the treatment. This prohibitive cost leads many would-be parents who pursue IVF to transfer multiple embryos at once, to increase their chances of getting a baby and minimize the need for additional attempts. This new study now reports that the economic impact of IVF deserves a closer look. As corresponding author E. Scott Sills, MD PhD noted, rates of cesarean-section deliveries, premature births, and low birth weight of babies are all greater with two or more embryos transferred to the mother at once, compared to a lower risk, single-embryo pregnancy. The data derived from a comprehensive analysis of all IVF cases in Vermont (UVM) and was recently published in the journal Applied Health Economics & Health Policy. It is believed to be the first effort to calculate the difference in infant hospital costs based on the number of embryos transferred. Sills and his team had access to UVM Medical Center records of patients who conceived through IVF and delivered at least 20 weeks into their pregnancies between 2007 and 2011. (more…)
Author Interviews, Cancer Research, Cost of Health Care / 28.04.2016

MedicalResearch.com Interview with: Stacie B. Dusetzina, PhD Assistant Professor Division of Pharmaceutical Outcomes and Policy Eshelman School of Pharmacy University of North Carolina at Chapel Hill Chapel Hill, NC  MedicalResearch.com: What is the background for this study? What are the main findings? Dr. Dusetzina: Drug prices are of significant policy interest, particularly the prices for so-called “specialty” medications which are used to treat rare and/or complex conditions like cancer. In this study I estimated monthly price for orally-administered cancer treatments that were approved between 2000 and 2014. First I looked at the price of the drug during the year of initial FDA approval and then I looked at annual changes in the price after the year of approval. The main findings are that, even after inflation adjustment, the monthly price paid for orally-administered cancer treatments is increasing rapidly both at the time of approval and in subsequent years. As an example, if you compare average monthly prices during the first year post-approval for treatments approved between 2000-2010 to those approved after 2010 there was a major increase in launch prices from $5,529 per month to $9,013 per month. Year-to-year changes in price after launch varied a lot by drug ranging from decreases in price of -2.7% per year to increases of 11.4% per year. However, nearly all of the products studied increased in price over time. (more…)
Author Interviews, Cost of Health Care / 28.04.2016

MedicalResearch.com Interview with: Andrew L. Pecora, M.D., F.A.C.P., C.P.E.
COTA Founder and Executive Chairman
Chief Innovations Officer and Vice President of Cancer Services at Hackensack University Medical Center
  Background: Key leadership of health care informatics company, COTA, Inc., will travel to Vatican City after being invited to speak at The Vatican’s Third International Conference on the Progress of Regenerative Medicine and Its Cultural Impact. COTA’s founder, Dr. Andrew Pecora, will discuss health care inequality and how new therapies only exacerbate the problem due to high costs. He will talk about the approaches COTA takes to address the problem, increasing access and affordability.  MedicalResearch.com: What is the background and mission of COTA? Dr. Pecora: Right now, up to 30 percent of health care delivered in the United States is not ideal, meaning doctors are providing treatments that do not necessarily need to be provided or do not precisely align with what is best for the client – a factor called ‘adverse variance.’ The fundamental problem we’re facing today is that we haven’t been able to successfully recognize and predict adverse variance. This is an issue that the entire world is dealing with, and COTA’s mission is to remove that variance and make the best care completely clear to patients, doctors, hospitals, payers and the government. COTA’s aim is to ensure patients are getting the best possible care, leading to the best possible outcome at the best possible price. (more…)
Author Interviews, Cancer Research, Cost of Health Care, Radiology / 20.04.2016

MedicalResearch.com Interview with: Dr. Christine Fisher MD, MPH Department of Radiation Oncology University of Denver MedicalResearch.com: What is the background for this study? Dr. Fisher: Screenable cancers are treated by oncologists every day, including many in invasive, advanced, or metastatic settings.  We aimed to determine how health insurance status might play into this, with the hypothesis that better access to health care would lead to presentation of earlier cancers.  While this sounds intuitive, there is much debate over recent expansions in coverage through the Affordable Care Act and how this may impact health in our country. MedicalResearch.com: What are the main findings? Dr. Fisher: The findings confirm that those without health insurance present with more advanced disease in breast, cervix, colorectal, and prostate cancers, including tumor stage, grade and elevated tumor markers.  That is to say, all else being equal for risk of cancer, lack of health insurance was an independent risk factor for advanced presentation.  (more…)
Author Interviews, Cost of Health Care, Heart Disease, NYU / 06.04.2016

MedicalResearch.com Interview with: Joseph A. Ladapo, MD, PhD Assistant Professor of Medicine and Population Health Section on Value and Effectiveness Department of Population Health NYU Langone School of Medicine New York NY 10016 MedicalResearch.com: What are the main findings? Dr. Ladapo: While cardiac implantable electronic devices (CIEDs) are increasingly used to treat patients with arrhythmias, heart failure, and other risk factors for sudden cardiac death, these implantable devices require life-long follow-up to assess their performance and functionality. This need for continuous monitoring has galvanized the development of remote monitoring technologies for patients with CIEDs. Although randomized studies have shown that remote monitoring may reduce healthcare utilization and expenditures when compared to in-office monitoring, little is known about whether these findings generalize to day-to-day clinical practice. We aimed to address this uncertainty by evaluating healthcare utilization and expenditures in a cohort of patients with newly-implanted CIEDs who were followed remotely or with in-office monitoring. MedicalResearch.com: What is the background for this study? Dr. Ladapo: Remote monitoring is associated with a reduction in patients’ utilization of ambulatory and acute care and a reduction in expenditures associated with this utilization—at least over 24 months. This reduction was most pronounced among remotely monitored patients with implantable cardioverter defibrillators (ICDs).  Although many of our comparisons between remote and office monitoring were not statistically significant, they trended toward favoring remote monitoring. (more…)
Author Interviews, Cost of Health Care, Heart Disease, JACC / 05.04.2016

MedicalResearch.com Interview with: Dr. Jordan B. King Post Doctoral Fellow Pharmacotherapy Outcome Resctr, University of Utah MedicalResearch.com: What is the background for this study? What are the main findings? Response: The cornerstone of treatment in heart failure with reduced ejection fraction (HFrEF) revolves around low-cost generic medications such as angiotensin converting enzyme inhibitors (ACEIs) and beta-blockers (BBs). However, recently the dual-acting angiotensin receptor neprilysin inhibitor (ARNI) sacubitril-valsartan, demonstrated improved survival and reduction in heart failure hospitalizations relative to enalapril, an ACEI, and optimal background therapy. This creates a situation in which we have a new medication which improves outcomes, but carries a high price tag ($4,560 per year) compared with ACEIs, the standard of care over the last 20 years, and are available as generic medications for <$50 per year. We set out to determine the incremental cost-effectiveness ratio (ICER) per quality adjusted life year gained (QALY) from the perspective of a health care payer in the U.S. The ICER is a measure of how much we have to pay for sacubitril-valsartan to gain 1 unit of health relative to enalapril. In this case the unit of health is a year of life adjusted for quality. We used a Markov model to estimate the costs and effectiveness of the two treatment options over a lifetime. In the base case, the ICER for sacubitril-valsartan was $50,959 per QALY gained. Health care interventions which cost <$50,000 per QALY are generally considered cost-effective, but some argue that <$100,000 per QALY is a more appropriate threshold in the U.S. In a probabilistic sensitivity analysis, 57% and 80% of all simulations fell below the $50,000 and $100,000 per QALY thresholds, respectively. Sacubitril-valsartan was the less costly treatment arm in 5% of simulations, and enalapril dominated (less costly and more effective) in 17% of simulations. (more…)
Annals Internal Medicine, Author Interviews, Cost of Health Care / 04.04.2016

MedicalResearch.com Interview with: Quinn Grundy, PhD, RN Postdoctoral Research Associate Charles Perkins Centre Faculty of Pharmacy The University of Sydney MedicalResearch.com: What is the background for this study? Dr. Grundy: In 2010, United States (US) lawmakers passed the Physician Payments Sunshine Act as part of the Affordable Care Act. The goal of this legislation was to make publicly transparent the financial relationships between physicians and pharmaceutical and medical device companies. These relationships are associated with increased prescribing of high cost, brand name medications with limited track records for safety. Policymakers hoped that increased transparency would help to deter relationships between physicians and industry that could bias treatment decision-making in this way. What caught our attention was that nurses, though they represent the largest proportion of health professionals, are omitted from the US Sunshine legislation. We questioned whether policymakers believed that nurses did not have the same kinds of relationships with industry as their physician counterparts, or, whether they did not believe that the consequences of nurse-industry interactions would warrant regulation. Rather than assuming that nurses interacted with industry in the same way that physicians do, we conducted an exploratory, in-depth qualitative study of nurses’ interactions with industry representatives in day-to-day clinical practice. At 4 hospitals in the western US, we interviewed 72 nurses, hospital administrators, supply chain professionals and industry representatives. Over a period of 2 years, we also directly observed nurses’ interactions with what we call “medically-related” industry, including pharmaceutical, medical equipment and device, infant formula, and health technology companies. (more…)
Author Interviews, Cost of Health Care, Hospital Readmissions, Outcomes & Safety, UT Southwestern / 04.04.2016

MedicalResearch.com Interview with: Oanh Kieu Nguyen, MD, MAS | Assistant Professor UT Southwestern Medical Center Divisions of General Internal Medicine and Outcomes and Health Services Research Dallas, TXOanh Kieu Nguyen, MD, MAS | Assistant Professor UT Southwestern Medical Center Divisions of General Internal Medicine and Outcomes and Health Services Research Dallas, TX MedicalResearch.com: What is the background for this study? What are the main findings? Dr. Nguyen: The impetus for this study was Steven Brill’s 2013 Time magazine award-winning article, “Bitter Pill: Why Medical Bills Are Killing Us.” This report investigated inflated charges for hospital bills, and and suggested that a major driver of irrationally high charges was the disproportionate negotiating power of hospitals, as evidenced through their high profit margins. As hospital physicians, our reaction was “But what if hospitals that make more money are delivering more value and better outcomes to patients? If that’s the case, wouldn’t most people say that their profits justifiably earned?” Surprisingly, we found that no one had really looked at this issue in a systematic way. We set out to answer this question using hospital financial data from California’s Office of Statewide Health Planning and Development (OSHPD) and outcomes data on 30-day readmissions and mortality for congestive heart failure, acute myocardial infarction (‘heart attacks’), and pneumonia from the Centers for Medicare and Medicaid Services (CMS) Hospital Compare website. California has more hospitals than any other state other than Texas, and also has a wide diversity of hospital types. The OSHPD financial data are also audited, so we thought these would be more reliable than using data from other sources. Because the outcomes reported on Hospital Compare are viewable by the general public, we thought hospitals would be most motivated to target improvements in these outcomes. We found that there was almost no association between how much money a hospital made and its subsequent performance on outcomes. The exception to this was we found that hospitals that had better finances reported higher rates of 30-day mortality for congestive heart failure, which was counterintuitive. We’re not sure why this was the case but speculate that it is possible that hospitals with better finances take care of sicker heart failure patients because they have more advanced (and more expensive) treatments available. Additionally, we looked to see if hospitals with lower readmissions rates subsequently made less money. This is a specific area of policy concern given federal penalties in the U.S. for excessive hospital readmissions. Many critics of these penalties have argued that reducing readmissions makes no financial sense for hospitals, since readmissions still generate hospital revenue despite the penalties. Thus, reducing readmissions would reduce a key source of hospital revenue and lead to poorer hospital finances. However, our analysis showed that lower readmissions rates were not associated with poorer hospital finances, as has been feared.  (more…)
Author Interviews, Cost of Health Care, JAMA, Prostate Cancer / 30.03.2016

MedicalResearch.com Interview with: HICOR portraits, Nov. 4, 2014 Joshua A. Roth, PhD, MHA Assistant Member AHRQ Patient-Centered Outcomes Research K12 Scholar Hutchinson Institute for Cancer Outcomes ResearchJoshua A. Roth, PhD, MHA Assistant Member AHRQ Patient-Centered Outcomes Research K12 Scholar Hutchinson Institute for Cancer Outcomes Research MedicalResearch.com: What is the background for this study? What are the main findings? Dr. Roth: PSA prostate cancer screening is controversial because of uncertainty about the overall benefit-risk balance of screening and conflicting recommendations from a variety of prominent national panels. For example, there is debate about whether the cancer early-detection benefits of screening outweigh potential harms related to overdiagnosis of prostate cancer and associated overtreatment (for example, surgery and/or radiation therapy). However, this benefit-risk balance largely depends on how screening programs are structured (for example, the age range over which screening occurs, how often screened occurs, and the PSA level that triggers biopsies) and how screening detected prostate cancers are managed. With these factors in mind, we developed a simulation model to estimate the morbidity, mortality, and cost outcomes of many PSA screening approaches that have been proposed by national panels or discussed in the peer-reviewed literature. The model calculates these outcomes using inputs from national databases and major PSA screening clinical trials. The primary outcome of our model was the cost per quality-adjusted life year gained—a measure that reflects the value of medical interventions through impacts on cost, survival, and health-related quality of life. We don’t have explicit rules for willingness to pay per quality-adjusted life year in the United States, but interventions that cost $100,000 to $150,000 per quality-adjusted life year are generally considered to be of at least low to moderate value (whereas, for example, an intervention that costs $400,000 per quality-adjusted life year would be generally considered to be of very poor value). Using the model, we found that more conservative PSA screening strategies (that is, those with less frequent screening and higher PSA level thresholds for biopsy referral) tended to be more cost-effective than less conservative strategies. Importantly, we found that no strategy was likely to be of high value under contemporary treatment patterns where many men with low-risk prostate cancer (that is, those with a Gleason score lower than 7 and clinical T2a stage cancer or lower) receive treatment with surgery or radiation therapy, but several strategies were likely to be of at least moderate value (cost per qualityadjusted life-year=$70 831-$136 332) with increased use of conservative management (that is, treating only after clinical progression) for low-risk, screen-detected cancers. (more…)
Author Interviews, Cost of Health Care / 14.03.2016

MedicalResearch.com Interview with: Steffie Woolhandler MD, MPH, FACP and David U. Himmelstein MD, FACP CUNY School of Public Health at Hunter College MedicalResearch.com: What is the background for this study? What are the main findings? Response: The Cadillac Tax aims to eventually eliminate tax subsides to employer-sponsored coverage.  When an employer provides health benefits to an employee, the employee pays no income or FICA tax on the value of those benefits, although the benefits are obviously part of the employee's compensation.  In other words, the taxpayers are currently picking up part of the employee's health insurance costs. Economists and politicians have been justifying the ACA's Cadillac Tax by portraying it as a "Robin Hood" tax that would take from the rich and give to the poor. That view of the Cadillac Tax is untrue.   We found that the main beneficiaries of the current tax subsidies to employer sponsored coverage are middle class families (defined by a family income between $39,000 and $100,000 in 2009 dollars) for whom the subsidies boost their effective income by about 5%.   These middle class people are the ones who would be most harmed when the Cadillac Tax kicks-in and curtails the current tax subsidies. (more…)
Author Interviews, Cancer, Cancer Research, Cost of Health Care / 14.03.2016

MedicalResearch.com Interview with: Hrishikesh Kale School of Pharmacy Virginia Commonwealth University MedicalResearch.com: What is the background for this study? What are the main findings? Response: The cost of cancer care in the United States is extremely high and escalating every year. Because of increased cost sharing, patients are paying higher out-of-pocket costs for their treatments. Along with high medical expenses, cancer survivors face problems such as loss of employment and reduced productivity. It has been well-established in the literature that because of high out-of-pocket costs, many cancer survivors forgo or delay medical care and mental health-related services and avoid filling prescriptions. This puts their physical and mental health at risk. A related issue is the growing number of cancer survivors in the U.S. As of January 2014, there were approximately 14.5 million cancer survivors in the U.S. By 2024, this number is expected to reach 19 million as a result of improved survival among patients with cancer along with an aging population. Therefore, we decided to investigate the prevalence and sources of financial problems reported by a nationally representative sample of cancer survivors from the 2011 Medical Expenditure Panel Survey. We also studied the impact of cancer-related financial burden on survivors’ health-related quality of life and psychological health. (more…)
Author Interviews, Cost of Health Care, Social Issues / 08.03.2016

MedicalResearch.com Interview with: Dr. LeaAnne DeRigne MSW Ph.D. FAU School of Social Work MedicalResearch.com: What is the background for this study? What are the main findings? Dr. DeRigne: 49 million U.S. employees work without paid sick leave, causing an even greater divide in health care disparities as well as undesirable health care outcomes.   This study examined the relationship between paid sick leave benefits and delays in medical care and forgone medical care for both working adults and their family members. We also analyzed the risk of emergency department use and the risk of missing work because of illness or injury by paid sick leave status, as well as the interaction effects between paid sick leave and family income and health insurance. (more…)
Author Interviews, Brigham & Women's - Harvard, Cost of Health Care, Hand Washing, Health Care Systems, JAMA, UCSF / 07.03.2016

MedicalResearch.com Interview with: Dr. Andrew Auerbach MD Professor of Medicine in Residence Director of Research Division of Hospital Medicine UCSF and Jeffrey L. Schnipper, MD, MPH Associate Physician, Brigham and Women's Hospital Associate Professor of Medicine, Harvard Medical School Department of Medicine Brigham and Women's Hospital     MedicalResearch.com: What is the background for this study? Response: The Affordable Care Act required the Department of Health and Human Services to establish a program to reduce what has been dubbed a “revolving door of re-hospitalizations.” Effective October 2012, 1 percent of every Medicare payment was deducted for a hospital that was determined to have excessive readmissions. This percentage has subsequently increased to up to 3 percent. Penalties apply to readmitted Medicare patients with some heart conditions, pneumonia, chronic lung disease, and hip and knee replacements. Unfortunately, few data exist to guide us in determining how many readmissions are preventable, and in those cases how they might have been prevented. MedicalResearch.com: What are the main findings? Response: Our main findings were that 27 percent of readmissions were preventable, and that the most common contributors to readmission were being discharged too soon, poor coordination between inpatient and outpatient care providers, particularly in the Emergency Departments and in arranging post acute care. (more…)
Author Interviews, Cost of Health Care, Medicare, NYU, Orthopedics / 04.03.2016

MedicalResearch.com Interview with: Richard Iorio, MD Dr. William and Susan Jaffe Professor of Orthopaedic Surgery Chief of the Division of Adult Reconstructive Surgery NYU Langone Medical Center  MedicalResearch.com: What is the background for this study? What are the main findings? Dr. Iorio: NYU Langone Medical Center’s Department of Orthopaedic Surgery realized early that alternate payment strategies based on value rather than volume were going to be increasing in prevalence and represent the future of compensation strategies  As leaders in orthopaedics, we knew that we must embrace this change and develop strategies and effective protocols to successfully navigate this alternative payment universe. In 2011, NYU Langone’s Hospital for Joint Diseases was chosen as a pilot site for CMS’s Bundled Payment Care Initiative, focusing on Medicare patients undergoing a total joint replacement. Beginning in 2013, we implemented protocols developed at our hospital focusing on preoperatiive patient selection criteria in an effort to ensure better outcomes for Medicare patients who underwent total joint replacements. Under a bundled payment program, hospitals assume financial responsibility for any complications over the entire episode of care 90 days after surgery, including postsurgical infections and hospital readmissions. We compared year over year outcomes from year 1 to year 3 of this program, and found:
  • Average hospital length of stay decreased from 3.58 days to 2.96 days;
  • Discharges to inpatient rehabilitation or care facilities decreased from 44 percent to 28 percent;
  • Average number of readmissions at 30 days decreased from 7 percent to 5 percent; from 11 percent to 6.1 percent at 60 days; and from 13 percent to 7.7 percent at 90 days;
  • The average cost to CMS of the episode of care decreased from $34,249 to $27,541 from year one to year three of the program.
(more…)
Author Interviews, Cost of Health Care, Health Care Systems, Hospital Readmissions, Technology / 25.02.2016

MedicalResearch.com Interview with: Andrey Ostrovsky, MD CEO | Co-Founder Care at Hand  Medical Research: What is the background for this study? Dr. Ostrovsky: Hospital readmissions are a large source of wasteful healthcare spending, and current care transition models are too expensive to be sustainable. One way to circumvent cost-prohibitive care transition programs is complement nurse-staffed care transition programs with those staffed by less expensive nonmedical workers. A major barrier to utilizing nonmedical workers is determining the appropriate time to escalate care to a clinician with a wider scope of practice. The objective of this study is to show how mobile technology can use the observations of nonmedical workers to stratify patients on the basis of their hospital readmission risk. (more…)
Author Interviews, Cost of Health Care, Pediatrics / 22.02.2016

MedicalResearch.com Interview with: Joanna Thomson MD MPH Assistant Professor Division of Hospital Medicine Cincinnati Children’s Hospital Medical Center Medical Research: What is the background for this study? What are the main findings? Response: Children with medical complexity have lifelong and complex illnesses. These children account for a disproportionate amount of pediatric health care use.  The lives of families are affected – both financially and socially.  We sought to characterize the challenges these families face through examination of financial and social hardships. In a cohort of families with children who receive care at Cincinnati Children’s Complex Care Center, four out of five families reported experiencing at least one hardship. The striking frequencies observed, despite relatively high measures of household socioeconomic status, suggest that these families face great challenges.  For example, families frequently experienced the need to borrow money and expected little to no help from family or friends. In order to benchmark the hardships experienced by families of children with medical complexity, we compared the hardships they experienced to those faced by the families of children with asthma in the Greater Cincinnati Asthma Risks Study. After accounting for key demographic and socio-economic differences between the two groups, families of children with medical complexity experienced similar to higher levels of financial and social hardship.  For instance, families of children with medical complexity were over two times as likely to report the inability to pay their rent or mortgage than families of children with asthma. (more…)
Author Interviews, Cancer Research, Cost of Health Care, End of Life Care / 19.02.2016

MedicalResearch.com Interview with: Melissa Garrido, PhD Assistant Professor / Research Health Science Specialist GRECC, James J Peters VA Medical Center, Bronx, NY Brookdale Department of Geriatrics & Palliative Medicine Icahn School of Medicine at Mount Sinai, New York, NY Medical Research: What is the background for this study? What are the main findings? Response: Medical costs for people with serious illnesses are rapidly rising in the United States. Concerns about medical debt and bankruptcy are especially relevant when deciding whether to begin or maintain a treatment that may have limited benefit to a patient’s survival or quality of life. Among patients with advanced cancer, one such decision is the choice of whether to use additional chemotherapy when the disease has not responded to an initial line or lines of chemotherapy. In this study, we used data from a prospective study of patients with advanced cancer and their caregivers to examine the relationship between chemotherapy use at study entry (median of four months before death) and estimated costs of healthcare other than chemotherapy in the last week of life. Medical Research: What is the background for this study? What are the main findings? Dr. Garrido: Among patients with end-stage cancer, those who received chemotherapy in the months before death had higher estimated costs of care in the last week of life.  We did not find evidence that this relationship was explained by patients’ preferences for care, do-not-resuscitate orders, or discussions of care preferences. (more…)
Author Interviews, Cost of Health Care / 08.02.2016

MedicalResearch.com Interview with: Peter M. Yarbrough MD Department of Internal Medicine Division of General Internal Medicine University of Utah Medical Center and George E. Whalen Veteran Affairs Medical Center Salt Lake City, Utah Medical Research: What is the background for this study? What are the main findings? Dr. Yarbrough: Waste is a major contributor to healthcare costs, accounting for an estimated $910 billion/year. Part of this waste includes unnecessary testing and routine laboratory testing has been recognized as frequently unnecessary for inpatients with an estimated 30-50% of tests not being needed.  Through implementation of a multifaced quality improvement initiative including accurate cost feedback through the Value Driven Outcomes (VDO) the University of Utah Healthcare Internal Medicine hospitalist group was able to demonstrate a significant reduction in cost per day ($138 to $123) and cost per visit ($618 to $558) without adverse effect on length of stay or 30-day readmissions.  A major component of the intervention included the use of a rounding checklist with discussion of tests required during rounds.  Supporting that common laboratory tests were affected, the analysis showed a significant decrease in the number of BMP, CMP, and CBC tests per day compared to an institutional control.  Estimated cost savings for this intervention were approximately $250,000 over the first year of the intervention. (more…)
Author Interviews, Cost of Health Care, Emergency Care / 30.01.2016

MedicalResearch.com Interview with: Jonathan Pinkney MD FRCP Professor of Medicine Plymouth University and Peninsula Schools of Medicine and Dentistry Centre for Clinical Trials and Population Studies Plymouth Science Park Phase 1 Honorary Consultant Physician Diabetes and Endocrinology University Medicine Derriford Hospital Plymouth Hospitals NHS Trust Plymouth UK Medical Research: What is the background for this study? Dr. Pinkney: The background is that the study was funded by the National Institute for Health Research in response to a call for research on the problem of unscheduled emergency admissions to hospitals in the UK. The rates of patient attendance at emergency departments and subsequent acute admissions to hospitals have risen year on year. Rising numbers of admissions have significant knock-on effects for acute hospitals including crowding in emergency departments, pressures on staffing, and disruption of elective treatment because of high rates of bed occupancy. The increase in admissions has been associated largely with increased short stay admissions. As a result, there has been an increasing view that a significant proportion of acute medical admissions may not be necessary, and in this respect may be said to be avoidable. There had been relatively limited research on how hospitals can best reduce these avoidable admissions. The main aims of the study were to investigate how senior staff in four major acute hospitals in south west England endeavour to avoid unnecessary acute admissions, and to examine a range of different systems in place in different hospitals to avoid unnecessary admissions. We called this project the "3A" or Avoidable Acute Admissions study. The 3A study was a mixed methods study with a strong emphasis on the narrative experience of patients, carers and healthcare professionals in the emergency departments and associated units of these four acute hospitals. The quantitative component of the study was an application of Value Stream Mapping (VSM), a technique from lean theory, and this was used to identify and measure points of delay in the patient journey. (more…)
Author Interviews, Cost of Health Care, Nutrition / 29.01.2016

MedicalResearch.com Interview with: Rajan Anthony Sonik Lurie Institute for Disability Policy Heller School for Social Policy and Management Brandeis University Waltham, MA Medical Research: What is the background for this study? What are the main findings? Response: We know that food insecurity (experiencing hunger, insufficient food, or concerns about having enough food) is associated with a host of health problems, ranging from behavior health conditions to iron deficiencies. However, understanding the relationship between food insecurity and healthcare utilization and cost patterns has been more difficult to assess with available data. Presumably, rises in food insecurity should worsen health, which in turn should increase healthcare utilization and ultimately costs. To examine this topic, I actually looked at this in the opposite way by asking if a decrease in food insecurity might lead to decrease in costs. The opportunity to do so arose in the form of the April 2009 increase in benefit levels for the Supplemental Nutrition Assistance Program (SNAP; formerly the Food Stamps Program) that were part of the American Recovery and Reinvestment Act (commonly referred to as the “stimulus package”). SNAP has been shown to alleviate food insecurity, and so this increase in benefits created the chance to explore my question. I analyzed Massachusetts data from October 2006 to August 2012 using interrupted time series models and found that inpatient Medicaid cost growth in Massachusetts fell by 73% (p = 0.003) after the increase in SNAP benefits. Moreover I found that decreased admissions were the primary driver of this outcome rather any patterns in health care inflation. In addition, I found that, for people with selected chronic illnesses that create heightened sensitivity to food insecurity, the drop in cost growth was even greater (the diseases studied were sickle cell disease, diabetes, malnutrition/failure to thrive, inflammatory bowel disease, asthma, and cystic fibrosis). (more…)
Author Interviews, Columbia, Cost of Health Care, JAMA, Ophthalmology / 15.01.2016

More on Health Care Costs on MedicalResearch.com MedicalResearch.com Interview with: Alisa Prager BS Bernard and Shirlee Brown Glaucoma Research Laboratory Department of Ophthalmology Edward S. Harkness Eye Institute Columbia University Medical Center, New York, New York MedicalResearch: What is the background for this study?  Response: The goal of this research was to better understand the impact of glaucoma on non-ophthalmic healthcare use and costs. While there have been other studies assessing costs associated with glaucoma, these studies were primarily derived from either claims data or chart review. Our study used the Medicare Current Beneficiary Survey, which is a dataset that links claims data with survey results. The advantage of this is that the survey data allowed us to assess patient reported outcomes that did not necessarily prompt an encounter with the health care system, such as recent falls or feelings of sadness. The MCBS also provides complete expenditure and source of payment data on health services, including those not covered by Medicare, which allowed us to look at a more full spectrum of both private and public healthcare use and costs among Medicare beneficiaries. MedicalResearch: What are the main findings? Response: We found that Medicare beneficiaries with glaucoma have 27% higher likelihood of inpatient hospitalizations and home health aide visits compared to those without glaucoma, even after adjusting for covariates and excluding individuals who were admitted to the hospital with a diagnosis of glaucoma. When we stratified glaucoma patients based on self-reported visual disability, we found that those with self-reported visual disability were more likely to complain of depression, falls and difficulty walking compared to those without. We also found that glaucoma patients incurred a predicted $2,903 higher mean annual total healthcare costs from all sources compared to those without glaucoma after adjusting for socioeconomic factors and comorbidities. Costs were higher among those who reported visual disability, and remained higher after excluding outpatient payments. (more…)
Author Interviews, Cost of Health Care / 12.01.2016

MedicalResearch.com Interview with: Paul Barr MSc, PhD Assistant Professor of Health Policy and Clinical Practice The Dartmouth Institute for Health Policy & Clinical Practice  Medical Research: What is the background for this study? What are the main findings? Dr. Barr: I belong to the Preference Laboratory, a group of researchers in The Dartmouth Institute for Health Policy & Clinical Practice, who focus on research to improve patient engagement in their health care. One of our areas of interest is mental health, especially depression given the high and increasing prevalence of this condition in America and worldwide. Previous research has found that individuals with depression are not fully engaged in the treatment decision making process and may not be aware of their options. Decision aids are short tools that provide information on available treatment options and information about those options that is important to patients and clinicians, which can facilitate greater patient engagement through shared decision making.  To develop these tools, it is important to identify the information important to patients and clinicians when making treatment decisions. By conducting a national survey of individuals with depression and clinicians who treat depression across the US, we found that patients and clinicians felt that the effectiveness of treatment, potential side-effects and time to recovery were important to discuss. However, where patients wanted to know about about cost and insurance coverage of treatment, clinicians did not focus on these priorities. Yet when asked to take the patient’s perspective, clinicians had the same priorities as patients, including cost and insurance coverage. In addition, only 18% of patient respondents reported experiencing a high level of shared decision making on the CollaboRATE survey (www.collaboratescore.org).  (more…)
Author Interviews, Cost of Health Care, JAMA, Stanford, Surgical Research / 08.01.2016

MedicalResearch.com Interview with: Sam P. Most, M.D., F.A.C.S. Professor, Departments of Otolaryngology-Head & Neck Surgery and Surgery (Division of Plastic Surgery, by courtesy) Chief, Division of Facial Plastic & Reconstructive Surgery Stanford University School of Medicine Stanford, CA  Medical Research: What is the background for this study? What are the main findings? Dr. Most: Insurance companies often require patients to try a 6 or more week treatment with nasal steroids prior to allowing nasal surgery to proceed. This is true even in cases of physician-documented severe or extreme anatomic nasal obstruction that we know will not respond to medical therapy. We sought to examine this from a cost and quality-of-life perspective. We found that while the up-front cost of surgery is obviously much higher than medical therapy, when viewed from an effect on improvement of quality of life (or lack thereof, in the case of medical therapy), the surgical therapy became more cost effective as years passed by. (more…)