Aging, Author Interviews, Cost of Health Care, JAMA, University of Michigan / 10.02.2020 Interview with: Renuka Tipirneni, MD, MSc, FACP Assistant Professor Holder of the Grace H. Elta MD Department of Internal Medicine Early Career Endowment Award 2019-2024 University of Michigan Department of Internal Medicine Divisions of General Medicine and Hospital Medicine and Institute for Healthcare Policy & Innovation Ann Arbor, MI 48109 What is the background for this study? Response: While U.S. adults age 50-64 previously had more limited options for health insurance before Medicare at age 65, the Affordable Care Act expanded the number of options, including Marketplace plans (e.g., through and Medicaid. This expanded set of options may complicate decisions about health insurance near retirement. In addition, several policy challenges to the Affordable Care Act may add uncertainty to the decision-making process. (more…)
Author Interviews, Cost of Health Care, Heart Disease, Inflammation, JAMA, Stanford / 17.01.2019 Interview with: Thomas S. G. Sehested MD Department of Cardiology Copenhagen University Hospital Gentofte   Jenny Bjerre, MD Department of Cardiology Copenhagen University Department of Health Research and Policy Stanford University School of Medicine Stanford, California What is the background for this study? Response: n 2017, the results from the much-awaited Canakinumab Anti-inflammatory Thrombosis Outcome Study (CANTOS) trial were published, confirming the inflammatory hypothesis, i.e. that targeting inflammation can reduce cardiovascular disease. The trial tested the monoclonal antibody canakinumab in a population of post-myocardial infarction patients with elevated inflammation markers (hs-CRP). Canakinumab is currently used for rare diseases and carries an orphan drug price: the 150mg dose used in CANTOS costs approximately $73,000 per year. Due to the high prevalence of cardiovascular disease, millions of patients could potentially be eligible for treatment with this high-priced anti-inflammatory drug. Therefore, we wanted to investigate the cost-effectiveness for canakinumab for secondary prevention of cardiovascular disease, using the reported results from CANTOS. (more…)
Author Interviews, Cost of Health Care, Dartmouth, JAMA, Pharmaceutical Companies / 09.01.2019 Interview with: Steven Woloshin, MD, MS Professor Co-director of the Center for Medicine and Media The Dartmouth InstituteSteven Woloshin, MD, MS Professor Co-director of the Center for Medicine and Media The Dartmouth Institute What is the background for this study? What are the main findings? What influence does medical marketing have on medical care and drug prices? Response: There are published studies looking at promotional spending mostly for drugs (DTC and professional).  This paper is unique because it is such a broad look including not just drugs but also marketing of disease (in "awareness campaigns"), health services and laboratory tests. What is new here is the size and scope of marketing.  For context, $29.9 billion spent on promoting prescription drugs, disease awareness campaigns, health services, and laboratory tests corresponds approximately to $1000 per American.    For context, FDA's total budget is around $5 billion – and NIH's total budget is about $30 billion. This figure is up from $17.7 billion in 1997, with the most rapid increase in DTC promotion of prescription drugs and health services.   Pharmaceutical marketing to professionals (detailing visits and samples) accounted for most spending and remained high despite policies to limit industry influence. $30 billion is of an underestimate (egg, we did not include monies spent on professional marketing (detailing) of laboratory tests, health services or devices, the value of drug coupons/discounts/rebates, company marketing budgets, lobbying or campaign contributions). Further it is just the tip of the iceberg – marketing works so promotional spending is an important driver of why medical care is so expensive:  it leads to more – and more expensive - tests and treatments. (more…)
Author Interviews / 11.12.2018

MedicalResearch.comInterview with:
Lisa M. Lines, PhD, MPH
University ofMassachusetts Medical School
RTI International,Waltham, MA  What is the background for this study?  What are the main findings?

Response: The problem of potentially avoidable emergency department (ED) visits has been linked to barriers in access to high-quality, timely primary care. In Massachusetts ,about half of all ED visits were considered potentially avoidable, or primary-care sensitive (PCS), in the mid-2000s. Indeed, improving access to primary care was a prime motive for the state’s – and the nation’s – first universal coverage health insurance program in 2006. Now, the state has the highest coverage rate in the country.

We used Massachusetts All-Payer Claims Data to study characteristics of insured Massachusetts residents associated with primary-care sensitive ED use and compared such use among people under age 65 with public (Medicaid[MassHealth]) versus private insurance. We studied more than 2.2 million individuals in 2011-12; about 40% had public insurance in 2011, and the rest had private insurance. Our PCS ED measure included nonurgent, urgent but primary care treatable, and urgent but potentially avoidable ED visits.

We found that primary-care sensitive ED use was more than 4 times higher among the publicly insured (public insurees: 36.5 PCS ED visits per 100 person-years; private insurees: 9.0). After adjusting for a range of potential confounders, such as the vastly different morbidity burden of the two groups, public insurance in2011 was associated with about 150% more primary-care sensitive ED use. We also found that 70% of people with public insurance had at least 1 primary care visit, compared with 80% of those with private insurance. The public group also had fewer visits to their PCP of record, even though nearly all of them had an officially designated PCP.

Author Interviews, Cost of Health Care, Global Health, Infections, Vaccine Studies / 13.09.2018 Interview with: Veronica Toffolutti PhD Research Fellow in Health Economics Bocconi University What is the background for this study? What are the main findings? Response: Austerity has been linked to several health damaging effects such as suicides, increase in unmet needs, disease outbreaks that affect vulnerable peoples such as malaria in Greece, HIV in Greece and Romania during the current economic crises or in the earlier economic crisis cuts in public health expenditure have been linked with diphtheria and TB. Europe is experiencing declining vaccination rates and resurgences in measles incidence rates. Italy appears to be particularly affected reporting the second largest number, second to Romania, of infection in Europe in 2017. Starting from the point that the primary reason for the outbreak in the decline in the measles vaccination we test the hypothesis that large budget reductions in public health spending were also a contributing factor. Using data on 20 Italian regions for the period 2000-2014 we found that each 1% reduction in the real per capita public health expenditure was associated with a decrease of 0.5 percentage points (95% CI: 0.36-0.65 percentage points) in MMR coverage, after adjusting for time and regional-specific time-trends.  (more…)
Author Interviews, Brigham & Women's - Harvard, Cost of Health Care, JAMA / 22.08.2018 Interview with: Chana A. Sacks, MD, MPH Program On Regulation, Therapeutics, And Law (PORTAL) Division of Pharmacoepidemiology and Pharmacoeconomics Brigham and Women’s Hospital What is the background for this study? What are the main findings? Response: Combination pills combine multiple medications into a single dosage form. There have been case reports in recent years of high prices for certain brand-name combination drugs – even those that are made up of generic medications. Our study looks at this phenomenon in a systematic way using recently released Medicare spending data. We evaluated 29 combination drugs and found that approximately $925 million dollars could potentially have been saved in 2016 alone had generic constituents been prescribed as individual pills instead of using the combination products. For example, Medicare reported spending more than $20 per dose of the combination pill Duexis, more than 70 times the price of its two over-the-counter constituent medications, famotidine and ibuprofen. The findings in this study held true even for brand-name combination products that have generic versions of the combination pill. For example, Medicare reported spending more than $14 for each dose of brand-name Percocet for more than 4,000 patients, despite the existence of a generic combination oxycodone/acetaminophen product. (more…)
Author Interviews, Compliance, Cost of Health Care, University of Michigan / 05.08.2018 Interview with: A. Mark Fendrick, M.D. Professor, Division of General Medicine, Department of Internal Medicine and Department of Health Management and Policy Director, University of Michigan Center for Value-Based Insurance Design Ann Arbor, Michigan 48109-2800 What is the background for this study? What are the main findings? Response: As Americans are being asked to pay more for the medical care, in terms of copayments and deductibles, one in four Americans reports having difficulty paying for their prescription drugs. One potential solution is “value-based insurance design,” or V-BID. V-BID, is built on the principle of lowering or removing financial barriers to essential, high-value clinical services. V-BID plans align patients’ out-of-pocket costs, such as copayments and deductibles, with the value of services to the patient. They are designed with the tenet of “clinical nuance” in mind— in that the clinical benefit derived from a specific service depends on the consumer using it, as well as when, where, and by whom the service is provided. According to a literature review published in the July 2018 issue of Health Affairs,  The researchers found that value-based insurance design programs which reduced consumer cost-sharing for clinically indicated medications resulted in increased adherence at no change in total spending. In other words, decreasing consumer cost-sharing meant better medication adherence for the same total cost to the insurer. (more…)
Author Interviews, Breast Cancer, Cancer Research, Cost of Health Care, JAMA / 06.07.2018 Interview with:

Dr Nora Pashayan PhD

Clinical Reader in Applied Health Research

University College London

Dept of Applied Health Research

London  What is the background for this study?

Response: Not all women have the same risk of developing breast cancer and not all women have the same potential to benefit from screening.


If the screening programme takes into account the individual variation in risk, then evidence from different studies indicate that this could improve the efficiency of the screening programme. However, questions remain on what is the best risk-stratified screening strategy, does risk-stratified screening add value for money, and what are benefit and harm trade-offs.

Author Interviews, Cost of Health Care, Education, JAMA / 14.11.2017 Interview with: Victoria Valencia, MPH Assistant Director for Healthcare Value Dell Medical SchoolThe University of Texas at Austin What is the background for this study? What are the main findings? Response: We were surprised to find that despite the common anecdote that resident physicians in teaching environments order more lab tests, there was a lack of empirical data to support the claim that more lab tests are ordered for patients at teaching hospitals than at non-teaching hospitals. Our study of 43,329 patients with pneumonia or cellulitis across 96 hospitals  in the state of Texas found that major teaching hospitals order significantly more lab tests than non-teaching hospitals.  We found this to be true no matter how we looked at the data, including when restricting to the least sick patients in our dataset. We also found that major teaching hospitals that ordered more labs for pneumonia tended to also more labs for cellulitis, indicating there is some effect from the environment of the teaching hospital that affects lab ordering overall. (more…)
Author Interviews, Cost of Health Care, Health Care Systems / 14.11.2017 Interview with: Barbara L. McAneny MD, CEO New Mexico Oncology Hematology Consultants, Ltd. Albuquerque, NM 87109   What is the meant by value-based care? Response: There are a lot of people using this term to mean a variety of things, confusion is not surprising.  Generally it means a move to pay more for better patient outcomes and less for worse patient outcomes.  Currently in our Fee for Service system, there are a lot of services for which there are no fees. That deficiency keeps physicians from looking at non face-to-face delivery methods or the use of other health professionals to augment the care they give, because we can’t afford to give services that we aren’t paid to give. (more…)
Author Interviews, CDC, Cost of Health Care, Pediatrics / 06.10.2017 Interview with: Scott D. Grosse, PhD National Center on Birth Defects and Developmental Disabilities CDC What is the background for this study? What are the main findings? Response: The U.S. Institute of Medicine (IOM) in 2007 published estimates of the economic costs associated with preterm birth. That report is publicly available: The total societal cost over a lifetime of a single year’s cohort of infants born preterm was estimated as $26 billion in 2005 US dollars. The study in Pediatrics sought to provide more current estimates of one component of those costs: medical care between birth and 12 months and to answer two additional questions:
  1. What costs are specifically incurred by employer-sponsored private health plans?
  2. How much of the overall cost burden of prematurity is attributable to infants born preterm with major birth defects (congenital malformations and chromosome abnormalities)?
Author Interviews, Cost of Health Care, Emergency Care, Health Care Systems, Hospital Readmissions, Primary Care / 03.10.2017 Interview with: Roberta Capp MD Assistant Professor Director for Care Transitions in the Department of Emergency Medicine University of Colorado School of Medicine Medical Director of Colorado Access Medicaid Aurora Colorado What is the background for this study? What are the main findings? Response: Medicaid clients are at highest risk for utilizing the hospital system due to barriers in accessing outpatient services and social determinants. We have found that providing care management services improves primary care utilization, which leads to better chronic disease management and reductions in emergency department use and hospital admissions. (more…)
Author Interviews, Cancer Research, Cost of Health Care, Duke, JAMA / 11.08.2017 Interview with: Dr. Fumiko Chino, MD Duke Radiation Oncology Duke School of Medicine What is the background for this study? What are the main findings? Response: The financial burden of cancer treatment is a growing concern. Out-of-pocket expenses are higher for patients with cancer than for those who have other chronic illnesses. Fifty percent of elderly cancer patients spend at least 10% of their income on treatment-related out-of-pocket expenses. Additionally, high financial burden is associated with both increased risk of poor psychological well-being and worse health-related quality of life. A cancer diagnosis has been shown to be an independent risk factor for declaring personal bankruptcy, and cancer patients who declare personal bankruptcy are at greater risk for mortality. These potentially harmful outcomes resulting from financial burden have been recognized as the financial toxicity of cancer therapy, analogous to the more commonly considered physical toxicity. We conducted an IRB approved study of financial distress and cost expectations among patients with cancer presenting for anti-cancer therapy. In this cross-sectional, survey based study of 300 patients, over one third of patients reported higher than expected financial burden. Cancer patients with highest financial distress are underinsured, paying nearly 1/3 of income in cancer-related costs. In adjusted analysis, experiencing higher than expected financial burden was associated with high/overwhelming financial distress (OR 4.78; 95% CI 2.02-11.32; p<0.01) and with decreased willingness to pay for cancer care (OR 0.48, 95% CI 0.25-0.95, p=0.03). Sambla, a Scandinavian lender, has been working with many patients to prevent any financial distress resulting from unexpected medical bills. As a result of customer feedback, it has modified the terms of all loans it issues to allow for jumbo loan sizes and reduced interest rates, combined with longer repayment times to help its borrowers. (more…)
AHRQ, Author Interviews, Cost of Health Care / 22.07.2017 Interview with: Ruirui Sun, Service Fellow, Economist Center for Delivery, Organization and Markets Agency for Healthcare Research and Quality What is the background for this study? Response: Hospital inpatient care has experienced changes due to factors such as population growth, rising of prevalence of chronic disease and efforts to reduce unnecessary hospitalizations. We generated information from the National Hospital Utilization and Costs path on Fast Stats ( ), to present the trends on national hospitalization and costs from 2005 to 2014, as well as the most common diagnoses among inpatient stays over the 10-year period. What are the main findings?
  • Between 2005 and 2014, the inflation-adjusted mean cost per inpatient stay increased by 12.7 percent, from $9,500 to $10,900.
  • Inflation-adjusted cost per stay for patients covered by private insurance or Medicaid increased 16-18 percent. Cost per stay for Medicare-covered patients and the uninsured changed minimally.
  • The rate of inpatient stays decreased the most among patients in the highest income quartiles (15-20 percent decrease).
  • The proportion of Medicaid-covered inpatient stays increased by 15.7 percent, whereas the proportion paid by private insurance and that were uninsured decreased by 12.5 and 13.0 percent, respectively.
  • Mental health/substance use accounted for nearly 6 percent of all inpatient stays in 2014, up 20.1 percent from 2005.
  • Between 2005 and 2014, septicemia and osteoarthritis became two of the five most common reasons for inpatient stays. Septicemia hospital stays almost tripled.
  • Nonspecific chest pain and coronary atherosclerosis decreased by more than 60 percent from 2005 to 2014, falling off the list of top 10 reasons for hospitalization. 
Author Interviews, Cost of Health Care / 24.06.2017 Interview with: Nitin Mehta PhD Associate Professor in Marketing Rotman School What is the background for this study? Response: The focus of this paper is an investigation of the increase in health care costs associated with chronic disease in the context of consumers enrolled in employer sponsored insurance plans. Chronic illnesses – including conditions such as heart disease, cancer, hypertension, rheumatoid arthritis, respiratory diseases, diabetes, and kidney disease – account for nearly 75 percent of health care expenditures in the U.S. Treatments vary widely in terms of cost and impact: expensive “frontier” treatments provide the best outcome for only the seriously ill, while cheaper, established treatments prove effective for most other patients. As an example, the annual cost to an insurer for “biologics” – novel genetically modified protein drugs – is upwards of $20,000, while the more established drug – methotrexate – costs only $1,000 a year. We investigate whether a part of the increase in healthcare costs stems from consumers opting for the more expensive treatments even when the lesser expensive treatments may have worked well. To do so, we examined data from a health insurer in the United States on the insurance plan and treatment options for 3,000 chronically ill patients over a three year period. (more…)
Author Interviews, Brigham & Women's - Harvard, Cost of Health Care / 17.05.2017 Interview with: Eric Roberts, PhD Post-doctoral fellow Department of Health Care Policy Harvard Medical School What is the background for this study? What are the main findings? Response: Increasing consolidation of health care providers has raised regulatory concerns that less competition will lead to higher health care prices and possibly lower quality care for patients. On the other hand, some industry observers have contended that larger and higher-priced practices are better able invest in systems to support care management, and ultimately, better patient care. In this study, we examined whether larger and higher-priced physician practices provided better and more efficient care to their patients. Higher-priced physician groups were paid an average of 36% more by commercial insurers, and were substantially larger than lower-priced practices located within the same geographic areas. Despite large differences in practices’ prices and size, we found few differences in their patients’ quality and efficiency of care. For example, when we compared patients who received care in high-priced versus low-priced practices, we found no differences in patients’ overall care ratings, physician ratings, access to care, physician communication, and use of preventive services. We also found no differences in patients’ hospital admissions or total spending, suggesting that higher-priced practices were not managing their patients’ care more efficiently than their lower-priced counterparts. We did find that patients in higher-priced practices were more likely to receive recommended vaccinations, review of their medications, and results of medical tests, and that they spent less time in the waiting room for a scheduled doctor’s appointment. However, once practice prices exceeded the average for their geographic area, we observed no further gains in quality on most of these measures. (more…)
Author Interviews, Cost of Health Care, JAMA, Macular Degeneration, Ophthalmology, Telemedicine / 02.04.2017 Interview with: John Wittenborn Senior research scientist NORC's Public Health Analytics University of Chicago What is the background for this study? What are the main findings? Response:The emergence of anti-VEGF treatment for wet-form AMD (choroidal neovascularization) has had a dramatic impact on preserving vision for many Americans. However, community-based studies show that most patients are not diagnosed with wet-form AMD until they have already lost a significant, and largely unrecoverable amount of their vision.  Early detection of wet-form AMD is key to effective treatment and the preservation of vision. The ForeseeHome telemonitoring technology provides patients with a means to check their own eyes on a daily basis to detect the earliest signs of vision loss from wet-form AMD. This is a novel technology that has the potential to improve visual health outcomes for AMD patients.  A prior clinical trial (the AREDS-2 HOME study) demonstrated that this technology can detect wet-form AMD earlier, and with less vision loss than standard care alone. However, that is exactly where that study ended as it reported no cost information nor follow-up. Since the end of this study, the device has been cleared by the FDA and approved for reimbursement by Medicare for certain higher risk patients, but no study has yet considered the long-term implications of adoption of this technology. In our analysis, we use a computer simulation model to essentially estimate what will come next, after patients realize earlier detection of wet-form AMD by utilizing home monitoring. Basically, we follow simulated patients from the time they begin monitoring for the rest of their lives, recording the likely impacts of home monitoring on patients’ long term outcomes including visual status, costs and quality of life. We find that home telemonitoring among the population indicated for reimbursement by Medicare would cost $35,663 per quality adjusted life year (QALY) gained.  Medicare would expect to incur $1,312 in net budgetary costs over 10 years for each patient who initiates monitoring.  However, Medicare patients may expect to achieve lifetime net savings when accounting for the chance of avoided vision loss and its associated costs later in life. (more…)
AHA Journals, Author Interviews, Cost of Health Care, Geriatrics, Heart Disease / 15.02.2017 Interview with: Olga Khavjou RTI International What is the background for this study? What are the main findings? Response: Cardiovascular disease (CVD) is the leading cause of death in the United States and is one of the costliest chronic diseases. As the population ages, CVD costs are expected to increase substantially. To improve cardiovascular health and control health care costs, we must understand future prevalence and costs of CVD. In 2015, 41.5% (more than 100 million people) of the U.S population was estimated to have some form of CVD. By 2035, the number of people with CVD is projected to increase to over 130 million people, representing a 30% increase in the number of people with CVD over the next 20 years. Between 2015 and 2035, real total direct medical costs of CVD are projected to more than double from $318 billion to $749 billion and real indirect costs (due to productivity losses) are projected to increase from $237 billion to $368 billion. Total costs (medical and indirect) are projected to more than double from $555 billion in 2015 to $1.1 trillion in 2035. (more…)
Author Interviews, Cost of Health Care, Diabetes, JAMA / 05.01.2017 Interview with: Joseph Dieleman, PhD Institute for Health Metrics and Evaluation University of Washington Seattle, WA 98121 What is the background for this study? What are the main findings? Response: The objective of this study was to provide a estimate of total health care spending in the United States for an exhaustive list of health conditions, over an extended period of time – from 1996 to 2013. The study primarily focuses on personal health spending, which includes both individual out-of-pocket costs as well as spending by private and government insurance programs on care provided in inpatient and outpatient facilities, emergency departments, nursing care facilities, dentist offices, and also on pharmaceuticals. There were 155 conditions included in the analysis, and spending was also disaggregated by type of care, and age and sex of the patient. In 2013, we accounted for $2.1 trillion in personal health spending in the U.S. It was discovered that just 20 health conditions made up more than half of all dollars spent on health care in the U.S. in 2013, and spending for each condition varied by age, sex and type of care. Diabetes was the most expensive condition, totaling $101 billion in diagnoses and treatments, growing at an alarmingly rate – a 6.5% increase per year on average. Ischemic heart disease, the number one killer in the U.S., ranked the second most expensive at $88.1 billion, followed by low back and neck pain at $87.6, treatment of hypertension at $83.9 billion, and injury from falls at $76.3. Women aged 85 and older spent the most per person in 2013, at more than $31,000 per person. More than half of this spending (58%) occurred in nursing facilities, while 20% was expended on cardiovascular diseases, 10% on Alzheimer’s disease, and 7% on falls. Men ages 85 and older spent $24,000 per person in 2013, with only 37% on nursing facilities, largely because women live longer and men more often have a partner at home to provide care. (more…)
Author Interviews, Cancer Research, Cost of Health Care, JAMA, Johns Hopkins / 02.12.2016 Interview with: Dr. Amol K. Narang, MD Instructor of Radiation Oncology and Molecular Radiation Sciences Johns Hopkins Sidney Kimmel Comprehensive Cancer Center What is the background for this study? Response: We know that cancer care is becoming increasingly expensive in the U.S., but the financial impact on patients in the form of out-of-pocket expenses is not well understood, in part because of the lack of data sources that track this information. As such, we used the Health and Retirement study, a national panel study that closely tracks the out-of-pocket medical expenditures of older Americans, to understand the level of financial strain that Medicare patients experience after a new diagnosis of cancer. We further investigated what factors were associated with high financial strain and what type of health services were driving high costs in this population. (more…)
Author Interviews, Cost of Health Care, Pharmacology / 04.10.2016 Interview with: Kevin Bowen MD MBA Senior Health Outcomes Researcher Prime Therapeutics LLC 1305 Corporate Center Drive Eagan, MN 55121 What is the background for this study? What are the main findings? • Autoimmune specialty drugs now account for about one of every 10 dollars of combined drug expense through the medical and pharmacy benefits in a commercially insured population. • The autoimmune drug class is one of the fastest growing, with this study finding a doubling in autoimmune drug expenditures and a 38 percent increase in utilization, in the most recent four years. • Integrated analysis of medical and pharmacy claims is essential for this category of drugs because more than 25 percent of autoimmune specialty drug use is paid through the medical benefit and medical claims diagnosis coding provides a means of determining what conditions were treated with drugs covered by pharmacy claims. (more…)
Author Interviews, Cost of Health Care, JAMA / 31.08.2016 Interview with: Dr. Rachel O. Reid MD MS Associate Physician Policy Researcher RAND Corporation What is the background for this study? What are the main findings? Response:  Waste in the US health care system is both common and expensive, estimated to be in the range of $750 billion annually. Contributing to this waste is over-treatment and use of low value services that offer little or no clinical benefit to patients. We studied 1.46 million adults from across the US with commercial insurance and found that spending on 28 low value services totaled $32.8 million in 2013, accounting for 0.5% of their medical spending or $22 per person annually. The most commonly received low-value services included hormone tests for thyroid problems, imaging for low-back pain and imaging for uncomplicated headache. The greatest proportion of spending was for spinal injection for lower-back pain at $12.1 million, imaging for uncomplicated headache at $3.6 million and imaging for nonspecific low-back pain at $3.1 million. Low-value spending was lower among patients who were older, male, black or Asian, lower-income or enrolled on consumer-directed health plans, which have high member cost-sharing. (more…)
Author Interviews, Cost of Health Care, Heart Disease / 19.08.2016 Interview with: Leo F. Buckley, PharmD Virginia Commonwealth University Richmond, Virginia What is the background for this study? Response: As the prevalence and costs of heart failure are expected to increase through the year 2030, significant efforts have been devoted towards devising alternatives to inpatient hospitalization for the management of heart failure decompensations. Since loop diuretics are the mainstay of treatment during the majority of hospitalizations, administration of high doses of loop diuretics in the outpatient setting has increased in popularity. We intended to answer two questions with his study: first, can a patient-specific dosing protocol based on a patient’s usual diuretic dose achieve safe decongestion? and second, does this strategy alter the usual course of heart failure decompensation, which oftentimes culminates in inpatient hospitalization? (more…)
Author Interviews, Brigham & Women's - Harvard, Cost of Health Care, Education, Heart Disease, JAMA / 16.08.2016 Interview with: Rory Brett Weiner, MD Assistant Professor of Medicine Harvard Medical School What is the background for this study? What are the main findings? Response: The increased use of noninvasive cardiac imaging and Medicare spending in the late 1990s and early 2000s has led to several measures to help optimize the use of cardiac imaging. One such effort has been the Appropriate Use Criteria (AUC) put forth by the American College of Cardiology Foundation. The AUC for echocardiography have been useful to characterize practice patterns and more recently been used as a tool to try to improve ordering of echocardiograms. Our research group previously conducted a randomized study of physicians-in-training (cardiovascular medicine fellows) and showed that an AUC based educational and feedback intervention reduced the rate of rarely appropriate transthoracic echocardiograms (TTEs). The current study represents the first randomized controlled trial of an AUC education and feedback intervention attending level cardiologists. In this study, the intervention group (which in addition to education received monthly feedback emails regarding their individual TTE ordering) ordered fewer rarely appropriate TTEs than the control group. The most common reasons for rarely appropriate TTEs in this study were ‘surveillance’ echocardiograms, referring to those in patients with known cardiac disease but no change in their clinical status. (more…)
Author Interviews, Breast Cancer, Cost of Health Care, Johns Hopkins / 11.08.2016 Interview with: Pedram Argani, M.D. Professor of Pathology and Principal consultant of the Breast Pathology Service Johns Hopkins Medicine What is the background for this study? What are the main findings? Response: Most pathology laboratories, at the request if clinicians, automatically (reflexively) test needle core biopsies containing ductal carcinoma in situ (DCIS) for estrogen receptor (ER) and progesterone receptor (PR). The logic for testing DCIS for these hormone receptors is that, for patients who have pure DCIS that is ER positive after surgical excision, treatment with estrogen blockers like Tamoxifen can decrease the recurrence of DCIS by a small amount, though overall survival (which is excellent) is not impacted. However, there are several factors which suggest that this reflex testing unnecessarily increases costs. • First, the ER/PR results on core needle biopsy do not impact the next step in therapy; namely, surgical excision. • Second, a subset of excisions performed for DCIS diagnosed on core needle biopsy will harbor invasive breast carcinoma, which would than need to be retested for ER/PR. • Third, because ER and PR labeling is often variable in DCIS, negative results for ER/PR in a small core biopsy specimen should logically be repeated in a surgical excision specimen with larger amounts of DICS to be sure that the result is truly negative. • Fourth, many patients with pure DCIS which is ER/PR positive after surgical excision will decline hormone therapy, so any ER/PR testing of their DCIS is unnecessary. • Fifth, PR status in DCIS has no independent value. We reviewed the Johns Hopkins experience with reflex ER/PR testing of DCIS on core needle biopsies over 2 years. We found that reflex core needle biopsy specimen testing unnecessarily increased costs by approximately $140.00 per patient. We found that ER/PR testing in the excision impacted management in only approximately one third of cases, creating an unnecessary increased cost of approximately $440.00 per patient. Extrapolating the increased cost of reflex ER/PR testing of DCIS to the 60,000 new cases of DCIS in the United States each year, reflex core needle biopsy ER/PR testing unnecessarily increased costs by approximately 35 million dollars. (more…)
Author Interviews, Cost of Health Care, Health Care Systems, JAMA, Surgical Research / 28.07.2016 Interview with: Richard Hoehn, MD Resident in General Surgery College of Medicine University of Cincinnati What is the background for this study? What are the main findings? Response: A recent study from our research group (Hoehn et al, JAMA Surgery, 2015) found that safety-net hospitals perform complex surgery with higher costs compared to other hospitals, and that these higher costs are potentially due to intrinsic differences in hospital performance. In this analysis, we decided to simulate different policy initiatives that attempt to reduce costs at safety-net hospitals. Using a decision analytic model, we analyzed pancreaticoduodenectomy performed at academic hospitals in the US and tried to reduce costs at safety-net hospitals by either 1) reducing their mortality, 2) reducing their patients’ comorbidities and complications, or 3) sending their patients to non-safety-net hospitals for their surgery. While reducing mortality had a negligible impact on cost and reducing comorbidities/complications had a noticeable impact on cost, far and away the most successful way to reduce costs at safety-net hospitals, based on our model, was to send patients away from safety-net hospitals for their pancreaticoduodenectomy. (more…)
Author Interviews, Cost of Health Care, JAMA / 25.07.2016 Interview with: James C. Robinson PhD Leonard D. Schaeffer Professor of Health Economics Director, Berkeley Center for Health Technology Division Head, Health Policy and Management University of California School of Public Health Berkeley, CA What is the background for this study? Response: To moderate the increase in insurance premiums, employers are increasing consumer cost sharing requirements. Under reference pricing, the employer establishes a limit to what it will contribute towards each service or product, typically set at the 60th percentile or other midpoint in the distribution of prices in the market. If the patient selects a facility charging less than or equal to this contribution, he/she receives full coverage, but if a more expensive facility is chosen, the patient must pay the full difference. (more…)
Author Interviews, Beth Israel Deaconess, Biomarkers, Cost of Health Care, Medical Imaging, Ovarian Cancer / 22.07.2016 Interview with: Katharine Mckinley Esselen, M.D. Instructor in Obstetrics, Gynecology and Reproductive Biology Beth Israel Deaconess Medical Center Brigham and Womens Hospital What is the background for this study? Response: There is no consensus on how to follow a patient in remission from ovarian cancer in order to detect recurrent disease. However, a 2009 randomized clinical trial demonstrated that using CA-125 blood tests for routine surveillance in ovarian cancer increases the use of chemotherapy and decreases patient’s quality of life without improving survival compared with clinical observation. Published guidelines categorize CA-125 tests as optional and discourage the use of radiographic imaging for routine surveillance. Thus, this study aims to examine the use of CA-125 tests and CT scans at 6 Cancer Centers and to estimate the economic impact of this surveillance testing for ovarian cancer. (more…)
Author Interviews, Cost of Health Care, Geriatrics, Pharmacology / 13.07.2016 Interview with: Leigh Purvis, MPA Director of Health Services Research AARP Public Policy Institute Editors’ note: In conjunction with the AARP’s new investigative piece, 'Supplement Pills That Promise Too Much', Leigh Purvis, Director of the AARP Health Services Research program discussed the issue of the proliferation of supplements, often with labels that make extraordinary health benefit claims. How many Americans use nutritional supplements? How big is the business of supplements? Response: Supplements are very popular in the United States. This is particularly true for older adults. A recent study found that the proportion of older adults using supplements increased from 52 percent in 2005 to 64 percent in 2011, and the share using multiple supplements grew by nearly 50 percent. According to the National Institutes of Health, American spent an estimated $36.7 billion on dietary supplements in 2014. (more…)