Author Interviews, BMJ, Cost of Health Care, Diabetes, Mayo Clinic / 09.12.2015

[caption id="attachment_19801" align="alignleft" width="150"]Rozalina G. McCoy, M.D. Senior Associate Consultant Division of Primary Care Internal Medicine Assistant Professor of Medicine Mayo Clinic Dr. McCoy[/caption] MedicalResearch.com Interview with: Rozalina G. McCoy, M.D. Senior Associate Consultant Division of Primary Care Internal Medicine Assistant Professor of Medicine Mayo Clinic Medical Research: What is the background for this study? What are the main findings? Dr. McCoy: Blood glucose monitoring is an integral component of managing diabetes.  Glycosylated hemoglobin (HbA1c) is a measure of average glycemia over approximately 3 months, and is used in routine clinical practice to monitor and adjust treatment with glucose-lowering medications.  However, monitoring and treatment protocols are not well defined by professional societies and regulatory bodies; while lower thresholds of testing frequencies are often discussed, the upper boundaries are rarely mentioned.  Most agree that for adult patients who are not using insulin, have stable glycemic control within the recommended targets, and have no history of severe hypoglycemia or hyperglycemia, checking once or twice a year should suffice. Yet in practice, there is a much higher prevalence of excess testing.  We believe that such over-testing results in redundancy and waste, adding unnecessary costs and burdens for patients and the health care system. We therefore conducted a large retrospective study among 31,545 adults across the U.S. with stable and controlled type 2 diabetes who had HbA1c less than 7% without use of insulin and without documented severe hypoglycemia or hyperglycemia.  We found that 55% of patients had their HbA1c checked 3-4 times per year, and 6% had it checked 5 times a year or more.  Such excessive testing had additional harms as well – we found that excessive testing was associated with greater risk of treatment intensification despite the fact that all patients in the study already met glycemic targets by having HbA1c under 7%.  Indeed, treatment was intensified by addition of more glucose lowering drugs or insulin in 8.4% of patients (comprising 13%, 9%, and 7% of those tested 5 or more times per year; 3-4 times per year; and 1-2 times per year, respectively).
Author Interviews, Colon Cancer, Cost of Health Care, Health Care Systems, Outcomes & Safety, Surgical Research / 06.12.2015

[caption id="attachment_19860" align="alignleft" width="200"]MedicalResearch.com Interview with: Johannes Govaert MD Department of Surgery Leiden University Medical Center Leiden, The Netherlands Medical Research: What is the background for this study? Dr. Govaert: The Value Based Health Care agenda of prof. Porter (Harvard Business School) suggests that focus in healthcare should shift from reducing costs to improving quality: where quality of healthcare improves, cost reduction will follow. One of the cornerstones of potential cost reduction, as mentioned by Porter, could be availability of key clinical data on processes and outcomes of care. Despite the important societal and economical role the healthcare system fulfils, it still lags behind when it comes to standardised reporting processes. With the introduction of the Dutch Surgical Colorectal Audit (DSCA) in 2009, robust quality information became available enabling monitoring, evaluation and improvement of surgical colorectal cancer care in the Netherlands. Since the introduction of the DSCA postoperative morbidity and mortality declined. Primary aim of this study was to investigate whether improving quality of surgical colorectal cancer care, by using a national quality improvement initiative, leads to a reduction of hospital costs. Detailed clinical data was obtained from the 2010-2012 population-based Dutch Surgical Colorectal Audit. Costs at patient-level were measured uniformly in all 29 participating hospitals and based on Time-Driven Activity-Based Costing. Medical Research: What are the main findings? Dr. Govaert: Over three consecutive years (2010-2012) severe complications and mortality after colorectal cancer surgery respectively declined with 20% and 29%. Simultaneously, costs during primary admission decreased with 9% without increase in costs within the first 90 days after discharge. Moreover, an inverse relationship (at hospital level) between severe complication rate and hospital costs was identified among the 29 participating hospitals. Hospitals with increasing severe complication rates (between 2010 and 2012) were associated with increasing costs whereas hospitals with declining severe complication rates were associated with cost reduction. Medical Research: What should clinicians and patients take away from your report? Dr. Govaert: This report presents evidence for simultaneously quality improvement and cost reduction. By participation in a nationwide quality improvement initiative with continuous quality measurement and benchmarked feedback, opportunities for targeted improvements are revealed and therefore bringing the medical field forward in improving value of healthcare delivery. Medical Research: What recommendations do you have for future research as a result of this study? Dr. Govaert: This is the first study outside the United States to describe such inverse relationship based on original financial and clinical data. Our conclusions provide additional evidence for cost reduction by quality improvement programs as seen in the American College of Surgeons National Surgical Quality Improvement Program. Therefore, we believe that our findings should be impetus for healthcare providers to focus on improving quality, which will catalyze costs savings as well. Citation: Nationwide Outcome-Measurement in Colorectal Cancer Surgery: Improving Quality and Reducing Costs Govaert, Johannes A. et al. Journal of the American College of Surgeons DOI: http://dx.doi.org/10.1016/j.jamcollsurg.2015.09.020 Dr. Grovaert[/caption] MedicalResearch.com Interview with: Johannes Govaert MD Department of Surgery Leiden University Medical Center Leiden, The Netherlands Medical Research: What is the background for this study? Dr. Govaert: The Value Based Health Care agenda ofPprof. Porter (Harvard Business School) suggests that focus in healthcare should shift from reducing costs to improving quality: where quality of healthcare improves, cost reduction will follow. One of the cornerstones of potential cost reduction, as mentioned by Porter, could be availability of key clinical data on processes and outcomes of care. Despite the important societal and economical role the healthcare system fulfils, it still lags behind when it comes to standardised reporting processes. With the introduction of the Dutch Surgical Colorectal Audit (DSCA) in 2009, robust quality information became available enabling monitoring, evaluation and improvement of surgical colorectal cancer care in the Netherlands. Since the introduction of the DSCA postoperative morbidity and mortality declined. Primary aim of this study was to investigate whether improving quality of surgical colorectal cancer care, by using a national quality improvement initiative, leads to a reduction of hospital costs. Detailed clinical data was obtained from the 2010-2012 population-based Dutch Surgical Colorectal Audit. Costs at patient-level were measured uniformly in all 29 participating hospitals and based on Time-Driven Activity-Based Costing. Medical Research: What are the main findings? Dr. Govaert: Over three consecutive years (2010-2012) severe complications and mortality after colorectal cancer surgery respectively declined with 20% and 29%. Simultaneously, costs during primary admission decreased with 9% without increase in costs within the first 90 days after discharge. Moreover, an inverse relationship (at hospital level) between severe complication rate and hospital costs was identified among the 29 participating hospitals. Hospitals with increasing severe complication rates (between 2010 and 2012) were associated with increasing costs whereas hospitals with declining severe complication rates were associated with cost reduction.
Author Interviews, Cost of Health Care, Health Care Systems, JAMA, Outcomes & Safety / 25.11.2015

MedicalResearch.com Interview with: Anup Das Medical Scientist Training Program Department of Health Management and Policy University of Michigan, Ann Arbor Medical Research: What is the background for this study? What are the main findings? Response: The Centers for Medicare & Medicaid Services (CMS) recently added a new measure of episode spending to the Hospital Value Based Purchasing program. Participation in this program allows hospitals to receive a financial bonus if they perform well on the included measures. This is the first spending measure in the program, and this change now incentivizes hospitals to improve their quality as well as their spending. The measure evaluates spending from three days before a hospitalization through 30 days post-discharge. In this study, we find that while high-cost hospitals had higher spending levels in each of the three components of an episode of care (pre-admission, index admission, and post-discharge), differences in post-discharge spending were the main determinants of hospital performance on this measure. High-cost hospitals spent on average $4,691 more than low-cost hospitals in post-discharge care. The majority of post-discharge spending comes from skilled nursing facility or readmission costs. Similarly, hospitals that did worse on this new measure of spending over time did so because of increases in their post-discharge spending.
Author Interviews, Cancer Research, Cost of Health Care / 25.11.2015

[caption id="attachment_19626" align="alignleft" width="98"]Xuesong Han, PhD Director, Surveillance and Health Services Research American Cancer Society, Inc. Atlanta, GA 3030 Dr. Han[/caption] MedicalResearch.com Interview with: Xuesong Han, PhD Director, Surveillance and Health Services Research American Cancer Society, Inc. Atlanta, GA 3030 Medical Research: What is the background for this study? What are the main findings? Dr. Han: People with private insurance are more likely to be screened and more likely to be diagnosed at an early stage of cancer. An early provision of the Affordable Care Act implemented in September 2010 allows young adults to remain on their parents’ health insurance plan until age 26 years, following which there has been an increase in private insurance coverage among young adults aged 19-25 years. For young adults, the uterine cervix is the only cancer site for which screening is recommended with a starting age of 21 years, and diagnosis of cervical cancer at early stages allows use of fertility-sparing treatment. Using data before and after the dependent coverage expansion provision of ACA, we found that compared with 26-34 year-olds who were not affected by the policy change, women 21-25 years of age experienced a net increase of 9 percentage points in early stage disease and 11.9 percentage points in receipt of fertility-sparing treatment.
Author Interviews, Cost of Health Care, Dermatology / 10.11.2015

[caption id="attachment_9739" align="alignleft" width="106"]Dr. Jonathan L. Silverberg MD PhD MPH Assistant Professor in Dermatology, Medical Social Sciences and Preventive Medicine Northwestern University, Chicago, Illinois Dr. Silverberg[/caption] MedicalResearch.com Interview with: Dr. Jonathan L. Silverberg MD PhD MPH Assistant Professor in Dermatology Medical Social Sciences and Preventive Medicine Northwestern University, Chicago, Illinois Medical Research: What is the background for this study? What are the main findings? Dr. Silverberg: We previously showed that adults with eczema are more likely to smoke cigarettes, drink alcohol and have sedentary lifestyle. We wondered whether chronic eczema might negatively impact upon other health behaviors, such as seeking preventive care and vaccinations. On the other hand, previous studies from our group and others found that both children and adults with eczema have a number of comorbid medical and mental health conditions. One potential reason for this is detection bias from since eczema patients are “plugged into” the healthcare system because of their skin disease, which allows them to be diagnosed more frequently with other health problems. We sought to understand the routine and preventive healthcare behaviors of children and adults with eczema. We found that adults with eczema were more likely to be vaccinated for tetanus, influenza, hepatitis A and B viruses, human papilloma virus and pneumonia. Moreover, they were more likely to undergo age-appropriate health screenings, such as blood pressure and cholesterol checks, but not cancer screening. Adults with eczema were more likely to interact with a variety of general doctors and specialists. Similarly, childhood eczema was associated with higher rates of vaccination for influenza, well child checkups and interaction with most types of healthcare providers.
Author Interviews, Cost of Health Care, JAMA, Pharmacology, Sloan Kettering / 04.11.2015

MedicalResearch.com Interview with: Dr. Elizabeth D. Kantor PhD MPH Assistant Attending Epidemiologist Memorial Sloan Kettering Cancer Center

Medical Research: What is the background for this study? What are the main findings? Dr. Kantor: We know that use of prescription drugs represents a major expenditure in the United States and research suggests that use of prescriptions has increased. However, much of what we know is derived from information on expenditures, is outdated, or is limited to certain populations, such as older adults or those with a given clinical condition. For example, a number of studies have looked at things like use of drugs used to control condition x among persons with condition x, but that doesn't tell us about use of that class of drugs in the population. It’s important that we continue to monitor use of prescription drugs in the population, as practice patterns are continually evolving as the population ages, the health needs of the population change, drugs enter/exit the market, scientific knowledge advances, and policies change. We therefore sought to create an updated comprehensive reference on prescription drug use among US adults using nationally representative data from the National Health And Nutrition Examination Survey, a continuous survey conducted by the Centers for Disease Control and Prevention. We examined trends in use of prescription drugs over 7 cycles, ranging from 1999-2000 to 2011-2012 (the sample size per cycle ranged from 4,861 to 6,212).Participants were asked about use of prescription medications over the prior 30 days, from which we were able to estimate the prevalence of use within each survey cycle. We then looked at trends in prescription drug use, both overall and within drug classes. In our study, we observed that use of any prescription medications increased over the study period, with 51% of adults reporting any prescription medication use in 1999-2000 and 59% reporting any use in 2011-2012. We also observed an increase in polypharmacy (or use of 5 or more prescription drugs) over the study period, with approximately 8% of adults reporting use of 5 or more drugs in 1999-2000, as compared to 15% in 2011-2012. Polypharmacy was much more common among older adults: 24% of adults ages 65 and older reported use of 5 or more drugs in 1999-2000 and 39% reported use of 5 or more drugs in 2011-2012. At first glance, one might take a look at these results and think that this is probably because the US population is aging and people tend to take more drugs as they age. But we found that the increase in overall prescription drug use and polypharmacy persisted even after accounting for the aging of the US population. This means that something else is driving the observed increase in use of prescription drugs. We also found that use of the majority of drug classes increased over the study period. For example, among commonly used drug classes, we observed marked increases in use of drugs taken to control high cholesterol, high blood pressure, and diabetes. We also observed marked increases in some less commonly used drug classes, such as muscle relaxants. Interestingly, if we look at the ten most commonly used drugs in 2011-2012, we can see that most are taken for conditions associated with cardiometabolic disease This raises the question of how much of this increase in prescription drug use may be attributable to overweight/obesity, as we know that the prevalence of obesity has increased among US adults.
Author Interviews, CDC, Cost of Health Care, HPV, Vaccine Studies / 30.10.2015

[caption id="attachment_18919" align="alignleft" width="300"]Shannon Stokley, MPH Epidemiologist in the CDC Immunization Services Division Shannon Stokley MPH[/caption] MedicalResearch.com Interview with: Shannon Stokley, MPH Epidemiologist in the CDC Immunization Services Division Medical Research: What is the background for this study? What are the main findings? Response: To determine whether the recommended HPV vaccination series is currently being administered to adolescents with health insurance, CDC and the National Committee for Quality Assurance (NCQA) assessed 2013 data from the Healthcare Effectiveness Data and Information Set (HEDIS). The HEDIS HPV Vaccine for Female Adolescents performance measure evaluates the proportion of female adolescent members in commercial and Medicaid health plans who complete the recommended HPV vaccination series by age 13 years. In 2013, in the United States, the median HPV vaccination coverage level for female adolescents among commercial and Medicaid plans was 12% and 19%, respectively (ranges = 0%–34% for commercial plans, 5%–52% for Medicaid plans). The results of this study indicate that there are significant opportunities for improvement as HPV vaccination coverage among female adolescents was low for both commercial and Medicaid plans.
Annals Internal Medicine, Author Interviews, Cognitive Issues, Cost of Health Care, End of Life Care / 28.10.2015

[caption id="attachment_18871" align="alignleft" width="130"]Amy S. Kelley, MD, MSHS Department of Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai New York, NY Dr. Kelley[/caption] MedicalResearch.com Interview with: Amy S. Kelley, MD, MSHS Department of Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai New York, NY Medical Research: Why is it so important to understand the financial burdens families may face in providing end-of-life care for a loved one and why do you think the burdens may be greater for dementia than for other medical conditions? Dr. Kelley: Understanding the financial risks that older adults face in the last years of life is important for individuals and families, in order to plan and save, if possible. It is also important for our policy makers, in particular, to know about these costs so that this information can help shape health and social policy that will best serve our society. Households of those with dementia face the greatest burden of costs, on average, particularly with regard to out-of-pocket expenses and the costs of caregiving.  Many costs related to daily care for patients with dementia are not covered by health insurance, and these care needs, including everything from supervision, to bathing and feeding, may span several years.
Author Interviews, Cost of Health Care, Critical Care - Intensive Care - ICUs, Johns Hopkins / 26.10.2015

[caption id="attachment_18835" align="alignleft" width="160"]Joseph M Carrington DO, MHA Department of Medicine - PGY3 Johns Hopkins University/Sinai Hospital Dr. Carrington[/caption] MedicalResearch.com Interview with: Joseph M Carrington DO, MHA Department of Medicine - PGY3 Johns Hopkins University/Sinai Hospital Medical Research: What is the background for this study? What are the main findings? Dr. Carrington: This study looked at a total of 886 patients at a community hospital. We were faced with the dilemma that our ICU beds were frequently over utilized with severely ill patients for whom our interventions had minimal impact. This prevented patients who were less ill from coming to the ICU who may have benefited from our services. We made a hospital wide culture change to lower ICU admission thresholds. Any patient felt to be "borderline" received an automatic ICU evaluation without any push-back. The result of these earlier interventions was a decrease in complications from patients decompensating in the ED and floors. In turn, the overall ICU length of stay, mortality, and ICU transfers all decreased. By decreasing these overall complications and mortality, our number of ICU over-utilizes decreased. This saved our hospital an annualized amount of over $2 million and freed up ICU beds and resources.
Aging, Author Interviews, Cost of Health Care, Pharmacology / 26.10.2015

MedicalResearch.com Interview with: Sue Dong, DrPH Data Center Director CPWR-The Center for Construction Research and Training Silver Spring, MD, 20910 Medical Research: What is the background for this study? What are the main findings? Response: The Center for Construction Research and Training (CPWR) is a nonprofit organization funded by NIOSH and several other federal government agencies. The aging workforce study is part of our NIOSH projects. According to our surveillance data (using the Current Population Survey), more than 30% of US workers were baby boomers in 2014, and about 63% of those baby boomers were aged 55 and up. Overall, the baby boomer generation is composed of 75 million Americans who have reached or will soon reach their retirement years. Despite the impending magnitude of societal disruption, information on health status among baby boomers and the potential burden faced by this cohort is still scarce. We hope this study can provide some needed information on the aging population in the US. To address this concern, we used data from the Health and Retirement Study (HRS). HRS is a national longitudinal survey of Americans aged 50 and over, which started in 1992. The baby boomer cohort (including Early Baby Boomers and Mid Baby Boomers who were born between 1948 and 1959) was added to the survey in recent years. HRS collects information on demographics, employment, health, health expenditures, etc. The rich information and relatively consistent survey instruments used over time allowed us to conduct this study. Medical Research: What are the main findings? Response: We estimated medical conditions and expenditures among the baby boomer cohort and compared them with the original HRS cohort (born between 1931 and 1941). We found that the baby boomers were more likely to report chronic conditions than the previous generation (HRS cohort) at similar ages. For example, at age 51-61, about 70% of the baby boomer cohort had at least one chronic condition, while 60% of the HRS cohort had at least one chronic condition. By detailed condition, 42.2% of baby boomers had high blood pressure, compared to 32.1% of the HRS cohort; 14.4% of the baby boomers had diabetes, nearly twice the proportion for the HRS cohort (7.8%). Overall, baby boomers had higher prevalence of chronic conditions for the nine conditions we measured compared to the HRS cohort at the same age. We also found that the baby boomers were more likely to be overweight compared to the previous generation. The prevalence of obesity was 37% among baby boomers, but it was 21.9% among the HRS cohort when they were at similar ages In terms of medical expenditures, the average out-of-pocket expenditure (OOPE) for the past two years for those aged 51-61 was $2,156 for the HRS cohort, but $3,118 for the baby boomers. Dollar value was adjusted to 2012 dollars for even comparison. The findings will be presented at the recent APHA annual conference in Chicago.
Author Interviews, Cost of Health Care, Gastrointestinal Disease, Weight Research / 22.10.2015

[wysija_form id="5"]Salman Nusrat M.D. Assistant Professor, Section of Digestive Diseases and Nutrition University of Oklahoma Health Sciences CenterMedicalResearch.com Interview with: Salman Nusrat M.D. Assistant Professor, Section of Digestive Diseases and Nutrition University of Oklahoma Health Sciences Center Medical Research: What is the background for this study? What are the main findings? Dr. Nusrat: Obesity is a global epidemic and is one of the most taxing issues affecting healthcare in the United States. It is a well-established risk factor for increased morbidity and mortality. We looked at how morbid obesity (BMI>40) affected inpatient health care utilization over the last two decades. We found that:
  • From 1997 to 2012, the number of patients discharged with a diagnosis of morbid obesity increased 11 folds from 10,883 to 124,650
  • The majority of these patients were female (~80%) and aged between 18-44 years.
  • Southern States accounted for majority of these admissions (37%). Majority of these patients were insured (~90%) and about three quarters of these admissions were in area with mean income above the 25 percentile.
  • The number of hospitalizations for patients aged >45 years increased from 33% to 50%.
  • -Even though the length of stay decreased from 5 days (1997) to 2.1 days (2012), the aggregate charges increased from $198 Million (1997) to $5.9 Billion (2012).
Author Interviews, Brigham & Women's - Harvard, Cost of Health Care, Health Care Systems, JAMA / 20.10.2015

MedicalResearch.com Interview with: Hannah Neprash PhD student Health Policy program Harvard University. Medical Research: What is the background for this study? Response: Hospitals are increasingly employing or purchasing physician practices. This trend started before the Affordable Care Act, as our study documents, but there is a concern that these trends may accelerate as providers reorganize to meet the challenges of new payment models that hold providers accountable for the entire spectrum of patient care, spanning inpatient and outpatient settings. It’s not clear how this change in provider market structure should affect spending. It could lead to lower spending, if care is better coordinated, reducing waste and unnecessary utilization. But, it could also lead to higher spending if larger provider groups have more market power and can negotiate higher prices with insurers. Medical Research: What are the main findings? Response: We used Medicare claims to quantify the share of physicians in major metropolitan markets that were owned or employed by a hospital. Most markets saw an increase in physician-hospital integration from 2008 to 2012. The average market saw a 3% increase in physician-hospital integration; the 75th percentile market saw a 5% increase; and the 95th percentile market saw a 15% increase. An increase in physician-hospital integration equivalent to the 75th percentile was associated with a $75 per person (or 3%) increase in annual outpatient spending among a non-elderly commercially insured population. This was driven by price increases – as we found no change in utilization. We did not find a similar association between physician-hospital integration and inpatient hospital spending. This is likely because hospital markets were already less competitive than physician markets at the beginning of our study period. When a hospital system buys a physician practice, the hospitals might not gain much bargaining power against an insurer in negotiating prices for inpatient care, but the hospital’s bargaining power could be used to negotiate higher fees for the outpatient physician practice.  That is, an insurer may not be persuaded by the threat of excluding the physician practice from its network, but the threat of excluding the entire hospital system from the insurer’s network is likely to carry more weight.
Author Interviews, Cost of Health Care, Emergency Care, Health Care Systems / 17.10.2015

[caption id="attachment_18476" align="alignleft" width="200"]James Galipeau PhD Ottawa Hospital Research Institute Ottawa, Ontario, Canada James Galipeau PhD[/caption] MedicalResearch.com Interview with: James Galipeau PhD Ottawa Hospital Research Institute Ottawa, Ontario, Canada  Medical Research: What is the background for this study? Dr. Galipeau: Overcrowding in emergency departments (EDs) is becoming more and more commonplace in Canada. The issue of overcrowding is complex and multidimensional with three distinct but interdependent components: input, throughput (processing), and output. At the processing level, one solution to overcrowding that has emerged is the establishment of observation/short stay units. A short-stay unit is a physical location in a hospital, usually in close proximity to the ED. Patients needing treatments or observation that may take several hours to resolve (e.g., blood transfusions, diagnostic testing, arranging social services) can be accommodated in a short-stay unit without occupying ED beds or needing to be admitted. In theory, ED-based short-stay units can lessen ED overcrowding by influencing outcomes such as ED wait times and hospital costs (if patients are moved from the ED to inpatient care). Although a recent report by the American College of Emergency Physicians recommends pursuing the use of short-stay units to alleviate ED overcrowding, there is a lack of evidence syntheses summarizing their effectiveness, safety, and value for money. Our objective was to conduct a systematic review to evaluate the effectiveness and safety of ED short-stay units compared with care not involving short-stay units.
Author Interviews, Cost of Health Care, JAMA, Surgical Research / 16.10.2015

Richard S. Hoehn, MD Division of Transplant Surgery Department of Surgery, University of Cincinnati School of Medicine Cincinnati, OHMedicalResearch.com Interview with: Richard S. Hoehn, MD Division of Transplant Surgery Department of Surgery University of Cincinnati School of Medicine Cincinnati, OH Medical Research: What is the background for this study? What are the main findings? Dr. Hoehn: Safety-net hospitals are hospitals that either have a stated purpose of maintaining an “open door policy” to all patients, regardless of their ability to pay, or simply have a significantly high burden of patients with Medicaid or no insurance. As healthcare policy and reimbursement change to focus on both “quality” metrics as well as cost containment, these hospitals may find themselves in a precarious situation. Current literature suggests that increased safety-net burden corresponds to inferior surgical outcomes. If this is true, safety-net hospitals will have inferior outcomes and suffer more financial penalties than other centers. This decrease in resources may adversely affect patient care, leading to even worse outcomes and further financial penalties, potentially creating a downward spiral that exacerbates disparities in surgical care that already exist in our country. Medical Research: What are the main findings? Dr. Hoehn: Our study analyzed 9 major surgical operations using the University HealthSystem Consortium clinical database, which represents 95% of academic medical centers in the United States. We sought to determine the effect of patient and hospital characteristics on the inferior outcomes at safety-net hospitals. As expected, we found that safety-net hospitals had higher rates of patients who were of black race, of lowest socioeconomic status, had government insurance, had extreme severity of illness, and needed emergent operations. They also had the highest rates of post-operative mortality, 30-day readmissions, and highest costs associated with care. Next we performed a multivariate analysis controlling for patient age, race, socioeconomic status, and severity of illness, as well as hospital procedure-specific volume. Using this model, we found that the increased mortality and readmission rates at safety-net hospitals were somewhat reduced, but the increased costs were not affected. Safety-net hospitals still provided surgical care that was 23-35% more expensive, despite controlling for patient characteristics. This suggests that intrinsic hospital characteristics may be responsible for the increased costs at safety-net hospitals. To further investigate this finding, we analyzed Medicare Hospital Compare data and found that safety-net hospitals performed worse on Surgical Care Improvement Project (SCIP) measures, had higher rates of reported surgical complications, and also had much slower measures of emergency department throughput (time from arrival to evaluation, treatment, admission, etc). This corresponded with our finding that hospital characteristics may be driving increased costs at safety-net hospitals.
Author Interviews, Brigham & Women's - Harvard, Cost of Health Care, PLoS / 14.10.2015

[caption id="attachment_18390" align="alignleft" width="150"]James E. Stahl, MD Senior Scientist Assistant Professor of Medicine, Harvard Medical School MGH Institute for Technology Assessment Dr. James E. Stahl[/caption] MedicalResearch.com Interview with: James E. Stahl, MD Senior Scientist Assistant Professor of Medicine, Harvard Medical School MGH Institute for Technology Assessment Medical Research: What is the background for this study? What are the main findings? Dr. Stahl: Poor psychological and physical resilience in response to stress drives a great deal of health care utilization. Mind-body interventions can reduce stress and build resiliency. Over the last few decades we have seen substantial evidence that evoking the relaxation response helps the heart, blood pressure, reduces inflammation and creates changes all the way down to the epigenetic level. We have not until now had a broad look at the effect at the health systems level. The rationale for this study is therefore to estimate the effect of mind-body interventions on healthcare utilization. The main findings are that looking at a broad population these tools, and specifically the relaxation response and resiliency training offered at the BHI, results in real world reductions in health care utilization.
Author Interviews, Cost of Health Care, Race/Ethnic Diversity / 13.10.2015

MedicalResearch.com Interview with: Jeffrey Rhoades, Ph.D. Agency for Healthcare Research and Quality Medical Research: What is the background for this study? Dr. Rhoades: The Medical Expenditure Panel Survey (MEPS) – Household Component (HC) which began in 1996 and is administered annually collects data from a sample of families and individuals in selected communities across the United States, drawn from a nationally representative subsample of households that participated in the prior year's National Health Interview Survey (conducted by the National Center for Health Statistics). During the household interviews, MEPS collects detailed information for each person in the household on the following: demographic characteristics, health conditions, health status, use of medical services, charges and source of payments, access to care, satisfaction with care, health insurance coverage, income, and employment. The panel design of the survey, which features several rounds of interviewing covering two full calendar years, makes it possible to determine how changes in respondents' health status, income, employment, eligibility for public and private insurance coverage, use of services, and payment for care are related. Medical Research: What are the main findings? Dr. Rhoades: In 2013, Hispanics were more likely to be uninsured for the entire year or sometime during the year than other racial/ethnic groups. In 2013, persons living in the South and West regions were more likely to be uninsured for the entire year or sometime during the year than people living in the Northeast or Midwest. Approximately 50 percent of individuals with the lowest hourly wage (less than $10 per hour) were uninsured sometime during the year in 2013. This fraction decreased with increasing wages.
Author Interviews, Cost of Health Care, Surgical Research / 12.10.2015

Kathleen Carey, Ph.D. Professor Department of Health Law, Policy and Management Boston University School of Public Health Boston MA 02118MedicalResearch.com Interview with: Kathleen Carey, Ph.D. Professor Department of Health Law, Policy and Management Boston University School of Public Health Boston MA  02118 Medical Research: What is the background for this study? Dr. Carey: Ambulatory surgery centers (ASCs) are a growing alternative to hospital outpatient departments (HOPDs) for patients undergoing surgeries that do not require an overnight stay. The number of ASCs increased 49% between 2002 and 2012 and now exceeds the number of acute care hospitals. Most Ambulatory surgery centers are specialized in the areas of gastroenterology, ophthalmology or orthopedic surgery. Because of specialization and limitations on the services they provide, it generally is assumed that ASCs can perform the same procedures at a lower cost than HOPDs. In fact, Medicare reimburses ASCs at a rate of roughly 60% of what they reimburse HOPDs. Yet since Medicare doesn’t require ASCs to submit cost reports, this policy is based on little information about the relative costs of ASCs and HOPDs. The cost advantage may offer an explanation for rapid ASC growth. But financial margins are explained by both costs and revenues, and high returns on investment might also be explained by high prices. Here there is even less information, as prices negotiated between commercial health insurers and providers are ordinarily considered highly confidential. In this study, I took advantage of MarketScan Commercial Claims and Encounters, a large national database distributed by Truven Health Analytics that contains information on actual prices paid to ASCs and HOPDs to explore the revenue side of ASC expansion. Medical Research: What are the main findings? Dr. Carey: For this study, I examined six common surgical procedures that are high volume, provided in both ASCs and in HOPDs, and represent the three main ASC specialties: colonoscopy, upper GI endoscopy, cataract surgery, post cataract surgery (capsulotomy), and two knee arthroscopy procedures. Over the period 2007-2012, the ratio of what insurers paid ASCs compared to HOPDs differed considerably across specialty: For colonoscopy and endoscopy, ASCs received 22% less than HOPDS. But for cataract surgery, the payments were relatively comparable, and for knee arthroscopy payments to ASCs exceeded payments to HOPDs by 28% to 30%. Private insurers paid ASCs considerably more than Medicare did – anywhere from 25% more to over twice as much for post cataract surgery. The other interesting finding was that HOPD prices grew much faster than ASC prices between 2007 and 2012. While some  Ambulatory surgery centers prices grew more than others, ASC prices on the whole rose roughly in line with medical care prices generally. HOPD prices for these services, however, rose from 32% to 76% during the same time period.
Author Interviews, Cost of Health Care, Dermatology, JAMA / 12.10.2015

Pinar Karaca-Mandic, PhD on behalf of the authors Associate Professor Division of Health Policy and Management University of MinnesotaMedicalResearch.com Interview with: Pinar Karaca-Mandic, PhD on behalf of the authors Associate Professor Division of Health Policy and Management University of Minnesota  Medical Research: What is the background for this study? What are the main findings? Dr. Pinar Karaca-Mandic: Lymphedema is a common disease affecting several million people in the U.S, in particular cancer patients. The disease is associated with edema, recurrent cellulitis, loss of physical function, stress, and of course diminished quality of life. It is also associated with high health care costs. While there is no cure for lymphedema currently, it can be managed well with proper care. Pneumatic compression devices offer a valuable lymphedema self-management option. However, there is limited information on the effectiveness of these devices using data from real world settings.   In this paper, we used administrative and claims-based data from a major national insurer to examine the effectiveness of an advanced pneumatic compression device. We examined health economics costs as well as clinical health utilization outcomes associated with the use of the device. We found that the receipt of the device is associated with large declines in cellulitis rates. For example, among the cancer patients, cellulitis infection rates by 79% (from 21% to 4.5%). We saw similar reductions for patients without cancer (75%). We also observed large reductions in the use of manual therapy and in lymphedema related outpatient hospital visits. Finally, lymphedema related outpatient costs decreased substantially – for example for the cancer patients, they halved reducing from about $1,500 to $700 among cancer patients, and they declined by 65% from about $1,700 to $600 for patients without cancer. Among cancer patients, total lymphedema-related costs per patient, excluding medical equipment, declined by 37% and declined by 36% in patients without cancer.
Author Interviews, Brigham & Women's - Harvard, Cost of Health Care, Pancreatic, Surgical Research / 09.10.2015

MedicalResearch.com Interview with: Andrew P. Loehrer, MD David Torchiana Fellow in Health Policy and Management Massachusetts General Physicians Organization Research Fellow Codman Center for Clinical Effectiveness in Surgery Department of Surgery Massachusetts General Hospital Andrew P. Loehrer, MD David Torchiana Fellow in Health Policy and Management Massachusetts General Physicians Organization Research Fellow Codman Center for Clinical Effectiveness in Surgery Department of Surgery Massachusetts General Hospital Medical Research: What is the background for this study? What are the main findings? Dr. Loehrer: The incidence of pancreatic cancer is increasing and is on pace to become the second leading cause of cancer mortality by the year 2020. While surgery remains the only chance for long-term survival, significant and persistent disparities in evaluation for and receipt of surgery remain for underinsured patients across the United States. The Affordable Care Act aims to increase access to care through expansion of health insurance coverage and was modeled on previous reform in the Commonwealth of Massachusetts. We evaluated the impact of the 2006 Massachusetts health reform on rates of surgery for pancreatic cancer. We found the insurance expansion to be independently associated with a 67% increased rate of resection for pancreatic cancer. While disparities in resection rates by insurance status decreased after the health reform, significant gaps remain between privately-insured patients and government-subsidized/self-pay patients.
Author Interviews, Brigham & Women's - Harvard, Cost of Health Care, JAMA, Pediatrics / 06.10.2015

Susan Gray MD Division of Adolescent Medicine Boston Children's Hospital Boston, MAMedicalResearch.com Interview with: Susan Gray MD Division of Adolescent Medicine Boston Children's Hospital Boston, MA Medical Research: What is the background for this study? What are the main findings? Dr. Gray: This is a study of the health care costs of 13,000 privately insured adolescents (13 to 21 years old) cared for in an association of pediatric primary care practices. We found that a tiny fraction (1%) of adolescents accounted almost a quarter of the expenses of the whole cohort. Mental health disorders were the most common diagnosis among these high cost adolescents. The characteristics most strongly associated with high cost were complex chronic medical conditions, behavioral health disorders, and obesity, but many high cost adolescents had no chronic conditions. Pharmacy costs, especially orphan drug costs, were a surprisingly large contributor to high costs for these privately insured adolescents. Primary care costs were very small in high cost patients.
Author Interviews, BMJ, Cost of Health Care, Education, Health Care Systems, University of Pittsburgh / 30.09.2015

Timothy Anderson, M.D. Chief medical resident University of Pittsburgh’s Department of Internal MedicineMedicalResearch.com Interview with: Timothy Anderson, M.D. Chief medical resident Department of Internal Medicine University of Pittsburgh Medical Research: What is the background for this study? What are the main findings? Dr. Anderson: My coauthors and I analyzed the public disclosures of all publicly traded U.S. health care companies listed on the NASDAQ exchange and New York Stock Exchange in January 2014 that specialized in pharmaceuticals, biotechnology, medical equipment and providing health care services.  Of the 442 companies with publicly accessible disclosures on boards of directors, 180 – or 41 percent – had one or more academically affiliated directors in 2013. These individuals included chief executive officers, vice presidents, presidents, provosts, chancellors, medical school deans, professors and trustees from 85 non-profit academic research and health care institutions. These individuals received compensation and stock shares from companies which far exceeds payment for other relationships such as consulting. In some cases compensation approaches or exceeds average professor and physician salaries.
Author Interviews, Cleveland Clinic, Cost of Health Care, Herpes Viruses, Vaccine Studies / 24.09.2015

Phuc Le, Ph.D., M.P.H. Center for Value-Based Care Research, Medicine Institute Cleveland, OHMedicalResearch.com Interview with: Phuc Le, Ph.D., M.P.H. Center for Value-Based Care Research, Medicine Institute Cleveland, OH  Medical Research: What is the background for this study? What are the main findings? Dr. Phuc Le: The live attenuated herpes zoster vaccine is approved by the FDA for persons aged 50 years and above. However, the Advisory Committee on Immunization Practices recommends it for only persons aged 60 years and older. Therefore, we aimed to analyze the vaccine’s cost-effectiveness among persons aged 50-59 years to see if ACIP’s recommendation is reasonable. We found that the vaccine is not cost-effective among people at aged 50 years, having an incremental costs of $323,000 per QALY gained, which is 3 times more than a commonly accepted threshold ($100,000/QALY).
Author Interviews, Brigham & Women's - Harvard, Cost of Health Care, JAMA / 24.09.2015

Aaron L. Schwartz, PhD Department of Health Care Policy Harvard Medical School Boston, Massachusetts MedicalResearch.com Interview with: Aaron L. Schwartz, PhD Department of Health Care Policy Harvard Medical School Boston, Massachusetts   Medical Research: What is the background for this study? What are the main findings? Dr. Schwartz: It is widely believed that much health care spending is devoted to services that provide little or no health benefit to patients. In previous work, we demonstrated that low-value services were commonly delivered to the Medicare population. In this study, we examined whether a new form of paying physicians and hospitals was effective in discouraging the use of low-value services. The payment reform we studied was the Medicare Pioneer Accountable Care Organization (ACO)  Program, a feature of the Affordable Care Act. This program financially rewards health care provider groups who keep spending under a specified budget and achieve high performance on measures of quality of care. This voluntary program employs a similar ACO payment model that some private insurers have adopted.  The hope is that such models can encourage providers to be more efficient by allowing them to share in the savings generated by lower health care spending. In previous work, we demonstrated that the Pioneer ACO Program was associated with lower overall health care spending and steady or improved performance on health care quality measures. However, it was unclear whether providers were focusing on low-value services in their attempts to reduce spending. We examined  2009-2012 Medicare claims data and measured the use of, and spending on, 31 services often provided to patients that are known to provide minimal clinical benefit. We found that patients cared for in the ACO model experienced a greater reduction in the use of low-value services when compared to patients who were not served by ACOs. We attributed a 4.5 percent reduction in low-value service spending to the ACO program. Interestingly, this was a greater reduction than the 1.2 percent reduction in overall spending attributed to the program, which suggests that providers were targeting low-value services in their efforts to reduce spending. In addition, we found that providers with the greatest rate of low-value services prior to the ACO program showed the greatest reduction in these services. We also found similar reductions in service use between services that are more likely to be requested by patients (i.e. early imaging for lower-back pain) and other services.
Author Interviews, Cancer Research, Cost of Health Care / 21.09.2015

Steven L. D'Amato, BSPharm, BCOP President and Executive Director New England Cancer Specialists Scarborough, Maine Association of Community Cancer CenteMedicalResearch.com Interview with: Steven L. D'Amato, BSPharm, BCOP President and Executive Director New England Cancer Specialists Scarborough, Maine Association of Community Cancer Centers Medical Research: What is the background for this study? What are the main findings? Response: The Trends in Cancer Programs annual survey, which began in 2009, provides key insight into nationwide developments in the business of cancer care. It’s a joint project between the Association of Community Cancer Centers and Lilly Oncology.  The goals of the survey are to:
  • Provide ACCC with information to help guide its education and advocacy mission
  • Assist member organizations to understand nationwide developments in the business of cancer care
  • Assist members in evaluating their own cancer program’s performance relative to similar organizations through a consistent and meaningful benchmark.
This year’s key findings show that patient-centered services – like nurse navigation, psychological counseling, survivorship care and palliative care – are continuing to grow in U.S. cancer programs. However, the biggest challenge facing cancer centers is reimbursement for these types of services. Additionally, mirroring what we are seeing in the industry in general, measurement is becoming more and more important. More cancer programs are now using quality metrics to show payers the value of care provided. More information about our findings can be viewed here: http://www.accc-cancer.org/surveys/pdf/Trends-in-Cancer-Programs-2015.pdf.
Author Interviews, Cost of Health Care, Flu - Influenza, Geriatrics, Lancet, Vaccine Studies / 20.09.2015

Dr Ayman Chit PhD Sanofi Pasteur Swiftwater, PA 18370MedicalResearch.com Interview with: Dr Ayman Chit PhD Sanofi Pasteur Swiftwater, PA 18370 Medical Research: What is the background for this study? What are the main findings? Dr. Chit: Our analysis used data from a large-scale, multi-center efficacy trial, in which a higher-dose split-virus inactivated influenza vaccine (IIV-HD, Fluzone® High-Dose vaccine, Sanofi Pasteur) was compared to a standard-dose split-virus inactivated influenza vaccine (IIV-SD, Fluzone vaccine, Sanofi Pasteur) in persons 65 years of age and older.  These data were supplemented with US healthcare cost data. In the efficacy trial, a total of 31,989 adults 65 years of age and older were randomly assigned in a 1:1 ratio to receive either IIV-HD or IIV-SD and followed for six to eight months post-vaccination for the occurrence of influenza, serious adverse events, and medical encounters. Healthcare utilization (HCU) data were captured for all participants through a surveillance program that covered each influenza season, including the following events occurring within 30 days after any respiratory illness: use of prescription and non-prescription medications (limited to antipyretics/analgesics/non-steroidal anti-inflammatory drugs, antivirals and antibiotics), emergency room visits, non-routine or urgent care visits, and hospitalizations. In addition, all hospitalizations were captured for participants for the entire duration of the study. The primary results from the efficacy trial were published in The New England Journal of Medicine, which reported that IIV-HD was 24.2% (95% confidence interval [CI], 9.7% to 36.5%) more effective in preventing laboratory-confirmed influenza-like illness compared to IIV-SD.1 In the current supplemental analysis of the trial, we used US healthcare cost data to evaluate economic impacts of using IIV-HD compared to IIV-SD within the efficacy trial participants. In this analysis, total healthcare payer costs (the combined costs of study vaccine, prescription drugs, emergency room visits, non-routine and urgent-care visits, and hospital admissions) were about $116 less per person.
  1. DiazGranados et al, NEJM, 2014;14;371(7):635-45 
Author Interviews, Cost of Health Care, Primary Care / 17.09.2015

Michael K. Magill, MD Professor and Chairman, Family and Preventive Medicine University of Utah School of Medicine Salt Lake City, UT 84108MedicalResearch.com Interview with: Michael K. Magill, MD Professor and Chairman, Family and Preventive Medicine University of Utah School of Medicine Salt Lake City, UT  84108   Medical Research: What is the background for this study? What are the main findings? Dr. Magill: The Patient Centered Medical Home (PCMH) model of primary care is becoming more common. The model focuses on team delivery of care with other medical staff joining the primary care provider/clinician to provide for all patients’ healthcare needs.  However, the cost of sustaining PCMH functions is not well understood. This  study assessed direct personnel cost of delivering PCMH services in 20 diverse primary care practices in Utah and Colorado. The main finding is that PCMH services cost on average around $105,000 per clinician FTE per year, or around $4.00 per member per month for an imputed panel size of 2000 patients per FTE clinician. 
Author Interviews, Cleveland Clinic, Cost of Health Care, Heart Disease, JAMA, Radiology / 16.09.2015

Wael A. Jaber, MD FACC, FAHA Professor of Medicine Cleveland Clinic Lerner College of Medicine Fuad Jubran Endowed Chair in Cardiovascular Medicine Heart and Vascular Institute Cleveland Clinic Cleveland, OH MedicalResearch.com Interview with: Wael A. Jaber, MD FACC, FAHA Professor of Medicine Cleveland Clinic Lerner College of Medicine Fuad Jubran Endowed Chair in Cardiovascular Medicine Heart and Vascular Institute Cleveland Clinic  Cleveland, OH Medical Research: What is the background for this study? What are the main findings? Prof. Jaber: Risk stratification of patients presenting with atrial fibrillation often includes a non-invasive evaluation for coronary artery disease. However, the yield of such testing in patients without angina or anginal-equivalent symptoms is uncertain. That is, how often do we find silent myocardial ischemia? In our cohort of 1700 consecutive patients with atrial fibrillation, less than 5% had ischemia on nuclear stress testing, even though comorbidities were prevalent. Moreover, in patients with ischemia that had invasive coronary angiography, less than half had obstructive coronary artery disease.
Author Interviews, Cost of Health Care, JAMA / 08.09.2015

James C. Robinson PhD MPH Leonard D. Schaeffer Professor of Health Economics Director, Berkeley Center for Health Technology Head, Division of Health Policy & Management School of Public Health, University of California– Berkeley University Hall, Berkeley, CA MedicalResearch.com Interview with: James C. Robinson PhD MPH Leonard D. Schaeffer Professor of Health Economics Director, Berkeley Center for Health Technology Head, Division of Health Policy & Management School of Public Health, University of California– Berkeley University Hall, Berkeley, CA   Medical Research: What is the background for this study? What are the main findings? Dr. Robinson: Employers and insurers face wide variation in the prices of similar tests and procedures within the same local communities, resulting from the indifference to price on the part of well-insured patients.  They are raising deductibles to increase price sensitivity, but deductibles mostly target low-cost primary care services whereas their concerns often center on high-cost specialty and facility services.  Some are adopting reference pricing, which sets a maximum insurer contribution for a particular type of test or procedure and then requires consumers selecting more expensive options to pay the difference themselves.  The insurers contribution limit typically is set at the median or other midpoint in the market distribution of prices. We studied the implementation of reference pricing for colonoscopy, using data from the California Public Employees Retirement System (CalPERS) from 2009-13, with a control group from Blue Cross of California.  Our data include detailed claims from almost 300,000 colonoscopy procedures and patients.  We find that patients who must pay the extra fees themselves are much more likely to select cheaper ambulatory facilities for their colonoscopies, compared to consumers who do not face reference pricing.  This leads to lower prices being paid by the employer and significant savings.  Detailed analyses of gastroenterological and cardiovascular complications of the colonoscopy procedures found no adverse effect of reference pricing on quality.
Author Interviews, Cost of Health Care, Infections, JAMA, Pharmacology / 19.08.2015

Jerome A. Leis, MD MSc FRCPC Division of Infectious Diseases, Sunnybrook Health Sciences Centre Physician Lead, Antimicrobial Stewardship Team Faculty Quality Improvement Advisor, Centre for QuIPS Assistant Professor, Department of Medicine, University of Toronto Sunnybrook Health Sciences Centre Toronto, OntarioMedicalResearch.com Interview with: Jerome A. Leis, MD MSc FRCPC Division of Infectious Diseases Sunnybrook Health Sciences Centre Physician Lead, Antimicrobial Stewardship Team Faculty Quality Improvement Advisor, Centre for QuIPS Assistant Professor, Department of Medicine University of Toronto Sunnybrook Health Sciences Centre Toronto, Ontario Medical Research: What is the background for this study? What are the main findings? Dr. Leis: We know that urinary tract infections are frequently diagnosed among general medicine patients who lack symptoms of this infection.  We wondered whether urinalysis ordering practices in the Emergency Department influence diagnosis and treatment for urinary tract infection among these asymptomatic patients.  We found that over half of patients admitted to the general medicine service underwent a urinalysis in the Emergency Department of which over 80% lacked a clinical indication for this test.  Urinalysis results among these asymptomatic patients did influence diagnosis as patients with incidental positive results were more likely to undergo urine cultures and treatment with antibiotics for urinary tract infection.  The study suggests that unnecessary urinalysis ordering contributes to over-diagnosis and treatment of urinary tract infection among patients admitted to general medicine service.