Author Interviews, Cost of Health Care, JAMA / 17.05.2016

MedicalResearch.com Interview with: Andrew M. Ibrahim, MD Robert Wood Johnson Clinical Scholar (VA Scholar), Institute for Healthcare Policy & Innovation, University of Michigan Ann Arbor, MI MedicalResearch.com: What is the background for this study? Dr. Ibrahim: Critical access hospital designation was created to help ensure access to the more than 59 million people living in rural populations. Hospitals were eligible for critical access designation if they had less than 25 beds and were located more than 35 miles away from another hospital. With this designation they were paid above total cost for the care they provided. Previous reports suggest these centers provide lower quality of care for common medical admissions, however little was known about surgical conditions.  MedicalResearch.com: What are the main findings? Dr. Ibrahim: This study included a review of 1,631,904 Medicare beneficiary admissions to critical access hospitals (n = 828) and non-critical access hospitals (n = 3,676) for 1 of 4 common types of surgical procedures: appendectomy, gall bladder removal, removal of all or part of the colon, and hernia repair. Patient who underwent surgery at critical access hospitals were, on average, less medically complex. Compared to larger urban hospitals, these small rural hospitals (i.e. critical access hospitals) had the same 30-day mortality rates and lower complications rates. In addition, critical access hospitals costs on average $1400 less per patient to Medicare, despite being paid in an alternative payment system. These findings remained significant after accounting for the patient’s pre-operation health condition.  
Author Interviews, Brigham & Women's - Harvard, Cost of Health Care, Medicare, OBGYNE / 04.01.2016

[caption id="attachment_20403" align="alignleft" width="120"]Dr. Sarah Elizabeth Little, MD Obstetrics/Gynecology Department of Obstetrics and Gynecology Brigham and Women's Hospital Dr. Little[/caption] MedicalResearch.com Interview with: Dr. Sarah Elizabeth Little, MD Obstetrics/Gynecology Department of Obstetrics and Gynecology Brigham and Women's Hospital Medical Research: What is the background for this study? What are the main findings? Dr. Little: This study investigates the variation in cesarean delivery rates across hospital services areas (a geographic unit designed by the Dartmouth Atlas to represent local markets for primarily hospital-based medical services). We looked at whether variation in cesarean delivery rates was related to broader variation in overall medical spending and utilization in that area, which we measured with Medicare spending and hospital use at the end-of-life. We found that an area’s cesarean delivery rate was correlated with these other measures; in other words, the hospital services areas that are doing the most cesarean deliveries are the same ones that are spending more and doing more to non-obstetric patients as well.
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).
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, 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, 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, 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.
Author Interviews, BMJ, Cost of Health Care / 04.07.2015

Igho Onakpoya MD MSc Clarendon Scholar University of Oxford Centre for Evidence-Based Medicine Nuffield Department of Primary Care Health Sciences Oxford UKMedicalResearch.com Interview with: Igho Onakpoya MD MSc Clarendon Scholar University of Oxford Centre for Evidence-Based Medicine Nuffield Department of Primary Care Health Sciences Oxford UK MedicalResearch: What is the background for this study? What are the main findings? Dr. Onakpoya: Several orphan drugs have been approved for use in Europe. However, the drugs are costly, and evidence for their clinical effectiveness are often sparse at the time of their approval. We found inconsistencies in the quality of the evidence for approved orphan drugs. We could not identify a clear mechanism through which their prices drugs are determined. In addition, the costs of the branded drugs are much higher than their generic or unlicensed versions. MedicalResearch: What should clinicians and patients take away from your report? Dr. Onakpoya: Because of inconsistencies in the evidence regarding the benefit-to-harm balance of orphan medicines, coupled with their high prices, clinicians and patients should assess whether the orphan drugs provide real value for money before making a decision about their use for a medical condition.
Author Interviews, Cost of Health Care, Hepatitis - Liver Disease / 10.04.2015

Brian Montague, DO MS MPH Assistant Professor of Medicine and of Health Services, Policy and Practice Division of Infectious Diseases Brown University / The Miriam HospitalMedicalResearch.com Interview with: Brian Montague, DO MS MPH Assistant Professor of Medicine and of Health Services, Policy and Practice Division of Infectious Diseases Brown University / The Miriam Hospital Medical Research: What is the background for this study? Dr. Montague: Hepatitis C is in an important public health problem affecting 4-5 million persons in the US alone.  Given the risk of infection associated with drug use, the prevalence of hepatitis C in corrections has been significantly higher than in the general population. Prior to 2013, the available treatment options were both expensive and of significant toxicity and limited efficacy.  Uptake to these therapies were low.  Starting in 2013, new therapeutics options offering shorter course treatments and efficacies greater than 90% became available.  These therapies offer new possibilities to increase uptake to treatment, however the cost of the therapies has made rapid scale up of treatment impossible.  Given the risk of serious harms to patients with advanced liver disease if not treated, insurance has begun to approve these new therapies for patients with more advanced disease. Departments of corrections are obliged to provide the same standard of care to persons in corrections as they would receive in the community.  Unlike Medicaid and community insurance providers, correctional systems worker under a fixed budget. Large increases in expenditures for treatment of hepatitis C without establishing mechanisms to offset these costs risks compromising other essential programs and functions in the correctional health system. Medical Research: What are the main findings? Dr. Montague: In a cross-sectional analysis we estimated the burden of hepatitis C within the department of corrections.  At the time of the study, an estimated 836 persons have chronic hepatitis C.  Among these an estimated 119 have advanced liver disease, stage 3 or 4 fibrosis, and would meet criteria for treatment under most insurance programs.  Even a conservative approach of restricting treatment in corrections to those with stage 3 or 4 fibrosis would incur costs of over $15 million, which is greater than 6 times the current correctional health budget for pharmaceuticals and 76% of the overall correctional health budget.
Author Interviews, Cancer Research, Cost of Health Care, JAMA / 10.04.2015

Gabriel Brooks, MD Gastrointestinal Cancer Center Dana-Farber Cancer Institute MedicalResearch.com Interview with: Gabriel Brooks, MD Gastrointestinal Cancer Center Dana-Farber Cancer Institute Medical Research: What is the background for this study? What are the main findings? Dr. Brooks: The background for our study is that hospitalizations in patients with cancer are common, costly, and distressing to patients.  Acute hospital care is the single largest expenditure category in cancer care, accounting for substantially greater costs than even chemotherapy. However, patients generally wish to avoid hospitalization, and they certainly want to avoid complications of treatment that can lead to hospitalization. For these reasons, we sought to identify the extent to which hospitalizations are perceived as potentially avoidable by clinicians who are directly involved in patient care. We interviewed three physicians for each of 103 patients with cancer who experienced a hospitalization. For 24 patients (23%) two or more of the three physicians agreed that hospitalization had been potentially avoidable.
Author Interviews, Cost of Health Care, JAMA, Medical Imaging, NYU/NYMC / 12.03.2015

Danil Makarov, MD Lead Investigator Assistant Professor, Departments of Urology, Population Health and Health Policy Member, Laura and Isaac Perlmutter Cancer Center NYU Langone Medical Center, New York, NYMedicalResearch.com Interview with: Danil Makarov, MD Lead Investigator Assistant Professor, Departments of Urology, Population Health and Health Policy Member, Laura and Isaac Perlmutter Cancer Center NYU Langone Medical Center, New York, NY Medical Research: What is the background for this study? Dr. Makarov: The background for this study is that regional variation in patterns of care and healthcare spending is widely known.  The drivers of this regional variation, though, are poorly understood.  Certain policy groups like the IOM have suggested that policy efforts be focused on individual providers and patients. Programs such as Choosing Wisely, which encourage a dialogue between physicians and patients, are a great example of such efforts.  However, some of our prior research suggests that regional variation is not random and that there might be are regional-level factors which drive variation. To test out our hypothesis, we wanted to see whether inappropriate imaging for two unrelated cancers was associated at a regional level (it should not be). Medical Research: What are the main findings? Dr. Makarov: We found that, at a regional level, inappropriate breast cancer imaging was associated with inappropriate prostate cancer imaging.
Author Interviews, Cost of Health Care, Education, JAMA, University of Pennsylvania / 19.12.2013

Mitesh Patel, MD, MBA RWJF Clinical Scholar, University of Pennsylvania Mitesh Patel, MD, MBA is a Robert Wood Johnson Clinical Scholar the University of Pennsylvania and primary care physician at the Philadelphia VA Medical CenterMedicalResearch.com Interview with: Mitesh Patel, MD, MBA RWJF Clinical Scholar, University of Pennsylvania Mitesh Patel, MD, MBA is a Robert Wood Johnson Clinical Scholar the University of Pennsylvania and primary care physician at the Philadelphia VA Medical Center MedicalResearch.com: What are the main findings of the study? Dr. Patel: We evaluated survey responses from nearly 300 internal medicine residency programs directors to assess whether residency programs were teaching residents the fundamental concepts of practicing high-value, cost-conscious care.  We found that 85% of program directors feel that graduate medical education has a responsibility to help curtail the rising costs of health care.  Despite this, about 6 out of every 7 internal medicine residency programs have not yet adopted a formal curriculum teaching new physicians these important concepts.
Author Interviews, Cost of Health Care, Duke / 29.08.2013

S. Yousuf Zafar, MD, MHS Assistant Professor of Medicine Duke Cancer Institute twitter: @yzafarMedicalResearch.com Interview with: S. Yousuf Zafar, MD, MHS Assistant Professor of Medicine Duke Cancer Institute twitter: @yzafar MedicalResearch.com: What are the main findings of the study? Dr. Zafar: We found that cost-related medication non-adherence was prevalent among cancer patients who sought financial assistance. Nearly half of participating cancer patients were non-adherent to medications as a result of cost. Patients  used different cost-coping strategies, for example, trying to find less expensive medications, borrowing money to pay for medications, and otherwise reducing spending. We found that non adherent participants were more likely to be young, unemployed, and without a prescription medication insurance plan.