Author Interviews, Cost of Health Care, Fertility, OBGYNE / 09.05.2016

MedicalResearch.com Interview with: [caption id="attachment_24169" align="alignleft" width="200"]Dr. Scott Sills MD, PhD Medical Director at the Center for Advanced Genetics an IVF program based in Carlsbad, California Dr. E. Scott Sills[/caption] Dr. Scott Sills MD, PhD Medical Director at the Center for Advanced Genetics an IVF program based in Carlsbad, California  MedicalResearch.com: What is the background for this study? What are the main findings? Dr. Sills: Often regarded as a miracle procedure by many infertile couples, in vitro fertilization (IVF) can be financially difficult for those without insurance coverage for the treatment. This prohibitive cost leads many would-be parents who pursue IVF to transfer multiple embryos at once, to increase their chances of getting a baby and minimize the need for additional attempts. This new study now reports that the economic impact of IVF deserves a closer look. As corresponding author E. Scott Sills, MD PhD noted, rates of cesarean-section deliveries, premature births, and low birth weight of babies are all greater with two or more embryos transferred to the mother at once, compared to a lower risk, single-embryo pregnancy. The data derived from a comprehensive analysis of all IVF cases in Vermont (UVM) and was recently published in the journal Applied Health Economics & Health Policy. It is believed to be the first effort to calculate the difference in infant hospital costs based on the number of embryos transferred. Sills and his team had access to UVM Medical Center records of patients who conceived through IVF and delivered at least 20 weeks into their pregnancies between 2007 and 2011.
Author Interviews, Cancer Research, Cost of Health Care / 28.04.2016

MedicalResearch.com Interview with: [caption id="attachment_23882" align="alignleft" width="200"]Stacie B. Dusetzina, PhD Assistant Professor Division of Pharmaceutical Outcomes and Policy Eshelman School of Pharmacy University of North Carolina at Chapel Hill Chapel Hill, NC Dr. Stacie Dusetzina[/caption] Stacie B. Dusetzina, PhD Assistant Professor Division of Pharmaceutical Outcomes and Policy Eshelman School of Pharmacy University of North Carolina at Chapel Hill Chapel Hill, NC  MedicalResearch.com: What is the background for this study? What are the main findings? Dr. Dusetzina: Drug prices are of significant policy interest, particularly the prices for so-called “specialty” medications which are used to treat rare and/or complex conditions like cancer. In this study I estimated monthly price for orally-administered cancer treatments that were approved between 2000 and 2014. First I looked at the price of the drug during the year of initial FDA approval and then I looked at annual changes in the price after the year of approval. The main findings are that, even after inflation adjustment, the monthly price paid for orally-administered cancer treatments is increasing rapidly both at the time of approval and in subsequent years. As an example, if you compare average monthly prices during the first year post-approval for treatments approved between 2000-2010 to those approved after 2010 there was a major increase in launch prices from $5,529 per month to $9,013 per month. Year-to-year changes in price after launch varied a lot by drug ranging from decreases in price of -2.7% per year to increases of 11.4% per year. However, nearly all of the products studied increased in price over time.
Author Interviews, Cost of Health Care, Heart Disease, NYU/NYMC / 06.04.2016

MedicalResearch.com Interview with: [caption id="attachment_14972" align="alignleft" width="120"]Joseph A. Ladapo, MD, PhD Assistant Professor of Medicine Section on Value and Effectiveness Department of Population Health NYU School of Medicine Dr. Joseph Ladapo[/caption] Joseph A. Ladapo, MD, PhD Assistant Professor of Medicine and Population Health Section on Value and Effectiveness Department of Population Health NYU Langone School of Medicine New York NY 10016 MedicalResearch.com: What are the main findings? Dr. Ladapo: While cardiac implantable electronic devices (CIEDs) are increasingly used to treat patients with arrhythmias, heart failure, and other risk factors for sudden cardiac death, these implantable devices require life-long follow-up to assess their performance and functionality. This need for continuous monitoring has galvanized the development of remote monitoring technologies for patients with CIEDs. Although randomized studies have shown that remote monitoring may reduce healthcare utilization and expenditures when compared to in-office monitoring, little is known about whether these findings generalize to day-to-day clinical practice. We aimed to address this uncertainty by evaluating healthcare utilization and expenditures in a cohort of patients with newly-implanted CIEDs who were followed remotely or with in-office monitoring. MedicalResearch.com: What is the background for this study? Dr. Ladapo: Remote monitoring is associated with a reduction in patients’ utilization of ambulatory and acute care and a reduction in expenditures associated with this utilization—at least over 24 months. This reduction was most pronounced among remotely monitored patients with implantable cardioverter defibrillators (ICDs).  Although many of our comparisons between remote and office monitoring were not statistically significant, they trended toward favoring remote monitoring.
Annals Internal Medicine, Author Interviews, Cost of Health Care / 04.04.2016

[caption id="attachment_23142" align="alignleft" width="200"]Quinn Grundy, Dr. Quinn Grundy[/caption] MedicalResearch.com Interview with: Quinn Grundy, PhD, RN Postdoctoral Research Associate Charles Perkins Centre Faculty of Pharmacy The University of Sydney MedicalResearch.com: What is the background for this study? Dr. Grundy: In 2010, United States (US) lawmakers passed the Physician Payments Sunshine Act as part of the Affordable Care Act. The goal of this legislation was to make publicly transparent the financial relationships between physicians and pharmaceutical and medical device companies. These relationships are associated with increased prescribing of high cost, brand name medications with limited track records for safety. Policymakers hoped that increased transparency would help to deter relationships between physicians and industry that could bias treatment decision-making in this way. What caught our attention was that nurses, though they represent the largest proportion of health professionals, are omitted from the US Sunshine legislation. We questioned whether policymakers believed that nurses did not have the same kinds of relationships with industry as their physician counterparts, or, whether they did not believe that the consequences of nurse-industry interactions would warrant regulation. Rather than assuming that nurses interacted with industry in the same way that physicians do, we conducted an exploratory, in-depth qualitative study of nurses’ interactions with industry representatives in day-to-day clinical practice. At 4 hospitals in the western US, we interviewed 72 nurses, hospital administrators, supply chain professionals and industry representatives. Over a period of 2 years, we also directly observed nurses’ interactions with what we call “medically-related” industry, including pharmaceutical, medical equipment and device, infant formula, and health technology companies.
Author Interviews, Cost of Health Care, JAMA, Prostate Cancer / 30.03.2016

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

MedicalResearch.com Interview with: Steffie Woolhandler MD, MPH, FACP and David U. Himmelstein MD, FACP CUNY School of Public Health at Hunter College MedicalResearch.com: What is the background for this study? What are the main findings? Response: The Cadillac Tax aims to eventually eliminate tax subsides to employer-sponsored coverage.  When an employer provides health benefits to an employee, the employee pays no income or FICA tax on the value of those benefits, although the benefits are obviously part of the employee's compensation.  In other words, the taxpayers are currently picking up part of the employee's health insurance costs. Economists and politicians have been justifying the ACA's Cadillac Tax by portraying it as a "Robin Hood" tax that would take from the rich and give to the poor. That view of the Cadillac Tax is untrue.   We found that the main beneficiaries of the current tax subsidies to employer sponsored coverage are middle class families (defined by a family income between $39,000 and $100,000 in 2009 dollars) for whom the subsidies boost their effective income by about 5%.   These middle class people are the ones who would be most harmed when the Cadillac Tax kicks-in and curtails the current tax subsidies.
Author Interviews, Cost of Health Care, Social Issues / 08.03.2016

MedicalResearch.com Interview with: [caption id="attachment_22448" align="alignleft" width="200"]Dr. LeaAnne DeRigne MSW Ph.D. FAU School of Social Work Dr. LeaAnne DeRigne[/caption] Dr. LeaAnne DeRigne MSW Ph.D. FAU School of Social Work MedicalResearch.com: What is the background for this study? What are the main findings? Dr. DeRigne: 49 million U.S. employees work without paid sick leave, causing an even greater divide in health care disparities as well as undesirable health care outcomes.   This study examined the relationship between paid sick leave benefits and delays in medical care and forgone medical care for both working adults and their family members. We also analyzed the risk of emergency department use and the risk of missing work because of illness or injury by paid sick leave status, as well as the interaction effects between paid sick leave and family income and health insurance.
Author Interviews, Cost of Health Care, Pediatrics / 22.02.2016

MedicalResearch.com Interview with: [caption id="attachment_21916" align="alignleft" width="200"]Joanna Thomson MD MPH Assistant Professor Division of Hospital Medicine Cincinnati Children’s Hospital Medical Center Dr. Joanna Thomson[/caption] Joanna Thomson MD MPH Assistant Professor Division of Hospital Medicine Cincinnati Children’s Hospital Medical Center Medical Research: What is the background for this study? What are the main findings? Response: Children with medical complexity have lifelong and complex illnesses. These children account for a disproportionate amount of pediatric health care use.  The lives of families are affected – both financially and socially.  We sought to characterize the challenges these families face through examination of financial and social hardships. In a cohort of families with children who receive care at Cincinnati Children’s Complex Care Center, four out of five families reported experiencing at least one hardship. The striking frequencies observed, despite relatively high measures of household socioeconomic status, suggest that these families face great challenges.  For example, families frequently experienced the need to borrow money and expected little to no help from family or friends. In order to benchmark the hardships experienced by families of children with medical complexity, we compared the hardships they experienced to those faced by the families of children with asthma in the Greater Cincinnati Asthma Risks Study. After accounting for key demographic and socio-economic differences between the two groups, families of children with medical complexity experienced similar to higher levels of financial and social hardship.  For instance, families of children with medical complexity were over two times as likely to report the inability to pay their rent or mortgage than families of children with asthma.
Author Interviews, Cancer Research, Cost of Health Care, End of Life Care / 19.02.2016

MedicalResearch.com Interview with: [caption id="attachment_21847" align="alignleft" width="130"]Melissa Garrido, PhD Assistant Professor / Research Health Science Specialist GRECC, James J Peters VA Medical Center, Bronx, NY Brookdale Department of Geriatrics & Palliative Medicine Icahn School of Medicine at Mount Sinai, New York, NY Dr. Melissa Garrido[/caption] Melissa Garrido, PhD Assistant Professor / Research Health Science Specialist GRECC, James J Peters VA Medical Center, Bronx, NY Brookdale Department of Geriatrics & Palliative Medicine Icahn School of Medicine at Mount Sinai, New York, NY Medical Research: What is the background for this study? What are the main findings? Response: Medical costs for people with serious illnesses are rapidly rising in the United States. Concerns about medical debt and bankruptcy are especially relevant when deciding whether to begin or maintain a treatment that may have limited benefit to a patient’s survival or quality of life. Among patients with advanced cancer, one such decision is the choice of whether to use additional chemotherapy when the disease has not responded to an initial line or lines of chemotherapy. In this study, we used data from a prospective study of patients with advanced cancer and their caregivers to examine the relationship between chemotherapy use at study entry (median of four months before death) and estimated costs of healthcare other than chemotherapy in the last week of life. Medical Research: What is the background for this study? What are the main findings? Dr. Garrido: Among patients with end-stage cancer, those who received chemotherapy in the months before death had higher estimated costs of care in the last week of life.  We did not find evidence that this relationship was explained by patients’ preferences for care, do-not-resuscitate orders, or discussions of care preferences.
Author Interviews, Cost of Health Care / 08.02.2016

MedicalResearch.com Interview with: [caption id="attachment_21388" align="alignleft" width="160"]Peter M. Yarbrough MD Department of Internal Medicine Division of General Internal Medicine University of Utah Medical Center and George E. Whalen Veteran Affairs Medical Center Salt Lake City, Utah Dr. Peter Yarbrough[/caption] Peter M. Yarbrough MD Department of Internal Medicine Division of General Internal Medicine University of Utah Medical Center and George E. Whalen Veteran Affairs Medical Center Salt Lake City, Utah Medical Research: What is the background for this study? What are the main findings? Dr. Yarbrough: Waste is a major contributor to healthcare costs, accounting for an estimated $910 billion/year. Part of this waste includes unnecessary testing and routine laboratory testing has been recognized as frequently unnecessary for inpatients with an estimated 30-50% of tests not being needed.  Through implementation of a multifaced quality improvement initiative including accurate cost feedback through the Value Driven Outcomes (VDO) the University of Utah Healthcare Internal Medicine hospitalist group was able to demonstrate a significant reduction in cost per day ($138 to $123) and cost per visit ($618 to $558) without adverse effect on length of stay or 30-day readmissions.  A major component of the intervention included the use of a rounding checklist with discussion of tests required during rounds.  Supporting that common laboratory tests were affected, the analysis showed a significant decrease in the number of BMP, CMP, and CBC tests per day compared to an institutional control.  Estimated cost savings for this intervention were approximately $250,000 over the first year of the intervention.
Author Interviews, Cost of Health Care, Emergency Care / 30.01.2016

MedicalResearch.com Interview with: [caption id="attachment_21141" align="alignleft" width="200"]Jonathan Pinkney MD FRCP Professor of Medicine Plymouth University and Peninsula Schools of Medicine and Dentistry Centre for Clinical Trials and Population Studies Plymouth Science Park Phase 1 Honorary Consultant Physician Diabetes and Endocrinology University Medicine Derriford Hospital Plymouth Hospitals NHS Trust Plymouth UK Prof. Jonathan Pinkney[/caption] Jonathan Pinkney MD FRCP Professor of Medicine Plymouth University and Peninsula Schools of Medicine and Dentistry Centre for Clinical Trials and Population Studies Plymouth Science Park Phase 1 Honorary Consultant Physician Diabetes and Endocrinology University Medicine Derriford Hospital Plymouth Hospitals NHS Trust Plymouth UK Medical Research: What is the background for this study? Dr. Pinkney: The background is that the study was funded by the National Institute for Health Research in response to a call for research on the problem of unscheduled emergency admissions to hospitals in the UK. The rates of patient attendance at emergency departments and subsequent acute admissions to hospitals have risen year on year. Rising numbers of admissions have significant knock-on effects for acute hospitals including crowding in emergency departments, pressures on staffing, and disruption of elective treatment because of high rates of bed occupancy. The increase in admissions has been associated largely with increased short stay admissions. As a result, there has been an increasing view that a significant proportion of acute medical admissions may not be necessary, and in this respect may be said to be avoidable. There had been relatively limited research on how hospitals can best reduce these avoidable admissions. The main aims of the study were to investigate how senior staff in four major acute hospitals in south west England endeavour to avoid unnecessary acute admissions, and to examine a range of different systems in place in different hospitals to avoid unnecessary admissions. We called this project the "3A" or Avoidable Acute Admissions study. The 3A study was a mixed methods study with a strong emphasis on the narrative experience of patients, carers and healthcare professionals in the emergency departments and associated units of these four acute hospitals. The quantitative component of the study was an application of Value Stream Mapping (VSM), a technique from lean theory, and this was used to identify and measure points of delay in the patient journey.
Author Interviews, Columbia, Cost of Health Care, JAMA, Ophthalmology / 15.01.2016

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

[caption id="attachment_20562" align="alignleft" width="180"]Paul Barr MSc, PhD Assistant Professor of Health Policy and Clinical Practice The Dartmouth Institute for Health Policy & Clinical Practice Dr. Paul Barr[/caption] MedicalResearch.com Interview with: Paul Barr MSc, PhD Assistant Professor of Health Policy and Clinical Practice The Dartmouth Institute for Health Policy & Clinical Practice  Medical Research: What is the background for this study? What are the main findings? Dr. Barr: I belong to the Preference Laboratory, a group of researchers in The Dartmouth Institute for Health Policy & Clinical Practice, who focus on research to improve patient engagement in their health care. One of our areas of interest is mental health, especially depression given the high and increasing prevalence of this condition in America and worldwide. Previous research has found that individuals with depression are not fully engaged in the treatment decision making process and may not be aware of their options. Decision aids are short tools that provide information on available treatment options and information about those options that is important to patients and clinicians, which can facilitate greater patient engagement through shared decision making.  To develop these tools, it is important to identify the information important to patients and clinicians when making treatment decisions. By conducting a national survey of individuals with depression and clinicians who treat depression across the US, we found that patients and clinicians felt that the effectiveness of treatment, potential side-effects and time to recovery were important to discuss. However, where patients wanted to know about about cost and insurance coverage of treatment, clinicians did not focus on these priorities. Yet when asked to take the patient’s perspective, clinicians had the same priorities as patients, including cost and insurance coverage. In addition, only 18% of patient respondents reported experiencing a high level of shared decision making on the CollaboRATE survey (www.collaboratescore.org). 
Author Interviews, Cost of Health Care, Primary Care / 07.01.2016

[caption id="attachment_20486" align="alignleft" width="160"]Sapna Kaul, Ph.D Huntsman Cancer Institute 2000 Circle of Hope Salt Lake City, UT 84112 Dr. Sapna Kaul[/caption] MedicalResearch.com Interview with: Sapna Kaul, Ph.D Huntsman Cancer Institute 2000 Circle of Hope Salt Lake City, UT 84112 Medical Research: What is the background for this study? What are the main findings? Dr. Kaul: The United States has the highest healthcare expenditures in the world, and close to one-third of these expenditures are believed to be unnecessary. One potential reason for these unnecessary expenditures is that patients may ask for medical services that are unnecessary. At the same time, primary care physicians (PCP) could find it difficult to refuse to prescribe unnecessary medical services as they may worry that it may compromise patient satisfaction. Also, there is a shortage of primary care workforce in the U.S. and PCPs may have insufficient time to effectively address patient requests. We investigated 2 types of unnecessary medical practices initiated by patient requests: (1) providing unnecessary specialty referrals, and (2) prescribing brand-name drugs when generic alternatives were available. To explore these practices, we used data on 840 U.S. PCPs from a national survey of physicians conducted in 2009. Over 50% of primary care physicians reported providing unnecessary specialty referrals and 39% prescribed brand-name drugs at patient requests. Several provider and organizational factors, such as physician specialty and solo/2-person practice, were related to reporting unnecessary practices.
Author Interviews, Cost of Health Care, Health Care Systems, Pediatrics / 14.12.2015

[caption id="attachment_20068" align="alignleft" width="261"]Dr. Eric W. Christensen, PhD Health Economist Children’s Hospitals and Clinics of Minnesota Minneapolis, MN Dr. Eric Christensen[/caption] MedicalResearch.com Interview with: Dr. Eric W. Christensen, PhD Health Economist Children’s Hospitals and Clinics of Minnesota Minneapolis, MN Medical Research: What is the background for this study? Dr. Christensen: National healthcare expenditures are up from 5.0% of gross domestic product in 1960 to 17.4% in 2013. We must find ways to control cost while maintaining quality. Accountable care organizations (ACOs) were designed to control a population’s health care cost while maintaining or improving quality. This study was an examination of one ACO exclusively covering a pediatric Medicaid population. Medical Research: What are the main findings? Dr. Christensen: We found that health care utilization and cost patterns were associated with the length of time patients were attributed to this ACO, where attribution length can be thought of as a proxy for consistent primary care from ACO providers. Specifically, attribution length of 2 or more years was associated with a 40.6% decrease in inpatient days. This decrease was partially offset by increases in outpatient visits (as one would expect with a primary care focus), emergency department visits, and use of pharmaceuticals. Combined these utilization changes resulted in a cost reduction 15.7% for those attributed 2 or more years. These changes were achieved while meeting quality benchmarks.
Author Interviews, Cancer Research, Cost of Health Care, Medicare / 14.12.2015

[caption id="attachment_19958" align="alignleft" width="200"]Dr. Stacie B. Dusetzina, PhD Assistant professor in the Division of Pharmaceutical Outcomes and Policy Eshelman School of Pharmacy University of North Carolina Dr. Dusetzina[/caption] MedicalResearch.com Interview with: Dr. Stacie B. Dusetzina, PhD Assistant professor in the Division of Pharmaceutical Outcomes and Policy Eshelman School of Pharmacy University of North Carolina  Medical Research: What is the background for this study? What are the main findings? Dr. Dusetzina: As part of the Affordable Care Act the Medicare Part D “doughnut hole” is closing – reducing Medicare beneficiaries out-of-pocket expenses during this phase of coverage from 100% of drug costs to 25% between 2010 and 2020.  In this study we analyzed 3,344 Medicare formularies that spell out how insurers cover prescription drugs. We found that in 2010, a typical course of oral chemotherapy drugs costs patients on average up to $8,100 per year. When the doughnut hole closes in 2020, patients will still have to pay on average $5,600 out of pocket per year, more than what the average Medicare beneficiary’s household spends on food each year. Even after the doughnut hold is closed oral chemotherapy drugs will still be out of reach for millions of Americans.
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, Clots - Coagulation, Heart Disease, Stroke, University of Michigan / 10.11.2015

[caption id="attachment_19214" align="alignleft" width="144"]Geoffrey Barnes, MD, MSc Clinical Lecturer Cardiovascular Medicine and Vascular Medicine University of Michigan Health System Dr. Barnes[/caption] MedicalResearch.com Interview with: Geoffrey Barnes, MD, MSc Clinical Lecturer Cardiovascular Medicine and Vascular Medicine University of Michigan Health System Medical Research: What is the background for this study? Dr. Barnes: Although warfarin has been the primary anticoagulant used for stroke prevention in atrial fibrillation for over 60 years, four new direct oral anticoagulants (DOACs) have been introduced into the market since 2010. Dabigatran, which directly inhibits thrombin, was found to have better prevention of ischemic stroke and a significant reduction in hemorrhagic stroke (bleeding strokes) for patients with atrial fibrillation at intermediate and high risk of stroke.  Prior cost-effectiveness studies have shown that dabigatran is cost-effective from both the societal and payer (usually Medicare) perspectives.  However, none of those studies looked at the patient’s out-of-pocket costs and the impact of prescription drug coverage Medical Research: What are the main findings? Dr. Barnes: We found that patients with prescription drug coverage (Medicare Part D) had significant cost savings when choosing dabigatran over warfarin.  This is primarily because of the reduction in both types of stroke as well not needing to have frequent blood draws, as are required by warfarin.  However, when patients do not have prescription drug coverage, the costs for dabigatran are quite high. 
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.
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, 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, 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, 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.
Cost of Health Care / 13.08.2015

Noam Y. Kirson, Ph.D. Vice President Analysis Group, Inc. Economic, Financial, and Strategy Consulting Boston, MA 02199MedicalResearch.com Interview with: Noam Y. Kirson, Ph.D.  Vice President Analysis Group, Inc. Economic, Financial, and Strategy Consulting Boston, MA 02199 Medical Research: What is the background for this study? What are the main findings? Dr. Kirson: Developments in diagnostic technology now support ruling out Alzheimer’s disease (AD) among patients presenting with symptoms of cognitive decline, possibly facilitating earlier and more accurate diagnosis of non-Alzheimer’s dementias. Our study assessed potential economic benefits of timely rule out of Alzheimer’s disease among U.S. Medicare beneficiaries eventually diagnosed with vascular dementia (VD) or Parkinson’s disease (PD) by estimating excess medical costs among those previously misdiagnosed withAlzheimer’s. We found that approximately one in six beneficiaries with VD and one in twelve beneficiaries with PD had a prior Alzheimer’s disease diagnosis. Further, we found that VD and PD patients previously diagnosed with Alzheimer’s disease incurred substantially higher medical costs in periods leading up to and including their VD/PD diagnoses, compared with matched counterparts with no prior AD diagnosis during the same timeframe. Perhaps most interestingly, excess costs declined – and eventually dissipated – following the confirmed VD/PD diagnoses.
Aging, Author Interviews, Cost of Health Care, Electronic Records, Geriatrics / 27.07.2015

MedicalResearch.com Interview with: Nisha C. Hazra MSc Department of Primary Care and Public Health Sciences, King's College London, London, UK Medical Research: What is the background for this study? What are the main findings? Response: Our study was motivated by limited evidence about the health status of very old people, the fastest growing group of the UK population with significant implications for future NHS health-care costs. Our findings indicated an increasing number of people reaching the age of 100 years, with the increase being higher among women comparing to men (a ratio of 4 to 1). Another interesting finding was that men reaching 100 years tended to be healthier than their female counterparts. In particular, women were more likely to present multiple chronic diseases compared to men and tended to be more frail, experiencing more falls, fractures, incontinence and hearing/visual impairments.
Author Interviews, CDC, Cost of Health Care, Tobacco Research / 24.07.2015

healtMedicalResearch.com Interview with: Sajal Chattopadhyay, Ph.D. Economic Advisor, The Community Guide Branch Division of Public Health Information Dissemination Center for Surveillance, Epidemiology, and Laboratory Services Office of Public Health Scientific Services Centers for Disease Control and Prevention Medical Research: What is the background for this study? What are the main findings? Dr. Chattopadhyay: Based on an updated review of all of the available scientific studies, the Community Preventive Services Task Force (CPSTF) reiterated its recommendation for tobacco price increases based on strong evidence of their effectiveness in reducing tobacco use and its harmful consequences. This study expands on the conclusions on effectiveness of price increases by systematically reviewing the evidence on the economic impact of policies that raise the unit price of tobacco products in the U.S. and other high-income countries, primarily through taxation. The findings indicate that tobacco price increases generate substantial healthcare cost savings and can generate additional gains from improved workplace productivity.