Pre-operative care intensity and cost for renal colic: implications for surgical value-based reforms.

OBJECTIVES: To identify pre-operative patient/facility factors associated with post-operative and total episode-related costs using renal colic as a model surgical condition to improve value-based payment models. METHODS: Using state Healthcare Cost and Utilization Project data, we performed a retrospective cohort study examining peri-operative costs for individuals presenting to an emergency department for renal colic and who ultimately underwent definitive surgical management. We estimated multivariable ordered and binary logistic regressions to examine the association between pre-operative and operative cost quartiles on the probability of specific post-operative cost quartiles after accounting for hospital and individual factors. We also performed logistic regressions to identify patients who deviated from predicted perioperative cost pathways. RESULTS: Among 2,736 individuals included in our analysis, episode-related costs ranged from $4,536 (bottom quartile) to $26,662 (top quartile). Individuals in the highest pre-operative cost quartile experienced an 11.7%-point higher probability of remaining in the highest post-operative cost quartile relative to those in the lowest pre-operative cost quartile (95% CI 0.0709, 0.163; p<0.001). Delays in surgery (95% CI 0.0869, 0.163; P<0.001) and Medicaid vs. private insurance (95% CI 0.01, 0.0728; P<0.01) were associated with a 12.5% and 4.1%-point higher probability of being in the top quartile of pre-operative costs, respectively. Treating facility experience with value-based payment models did not influence peri-operative costs. CONCLUSIONS: Using renal colic as a model surgical condition, our novel findings suggest that pre-operative costs are associated with both post-operative and total episode-related costs, and should be accounted for when designing future value-based payment models.

Policy Approaches for Increasing Adolescent HPV Vaccination Coverage: A Systematic Review.

CONTEXT: US jurisdictions have enacted a wide range of policies to address low human papillomavirus (HPV) vaccination coverage among adolescents, but it is unclear which policies are effective. OBJECTIVE: To systematically review the impact of governmental policies on adolescent HPV vaccination coverage. DATA SOURCES: PubMed, Embase, and Scopus databases. STUDY SELECTION: Eligible studies, published from 2009 to 2022, evaluated the impact of governmental policies on HPV vaccination coverage among adolescents ages 9 to 18. DATA EXTRACTION: Two investigators independently extracted data on study sample, study design and quality, policy characteristics, and HPV vaccination outcomes. We summarized findings by policy type: school-entry requirements (SERs), federally-funded policies related to the Vaccines for Children program and Medicaid, educational requirements, and others. RESULTS: Our search yielded 36 eligible studies. A majority of studies evaluating HPV vaccine SERs found positive associations between SERs and HPV vaccination coverage (8 of 14), particularly for SERs in Rhode Island and Washington, DC. All studies evaluating SERs for other adolescent vaccines observed positive spillover effects for HPV vaccination (7 of 7). Federally-funded policies related to Vaccines for Children and Medicaid were consistently associated with higher HPV vaccination coverage (7 of 9). Relatively few studies found associations between educational requirements and HPV vaccination coverage (2 of 8). LIMITATIONS: Studies used limited vaccination data sources and non- or quasi-experimental designs. Some studies had no or poorly matched comparison groups. CONCLUSIONS: Our findings suggest promise for SERs and federally-funded policies, but not educational requirements, for increasing HPV vaccination coverage among adolescents.

The association between primary care use and potentially-preventable hospitalization among dual eligibles age 65 and over.

BACKGROUND: Individuals dually-enrolled in Medicare and Medicaid (dual eligibles) are disproportionately sicker, have higher health care costs, and are hospitalized more often for ambulatory care sensitive conditions (ACSCs) than other Medicare beneficiaries. Primary care may reduce ACSC hospitalizations, but this has not been well studied among dual eligibles. We examined the relationship between primary care and ACSC hospitalization among dual eligibles age 65 and older. METHODS: In this observational study, we used 100% Medicare claims data for dual eligibles ages 65 and over from 2012 to 2018 to estimate the likelihood of ACSC hospitalization as a function of primary care visits and other factors. We used linear probability models stratified by rurality, with subgroup analyses for dual eligibles with diabetes or congestive heart failure. RESULTS: Each additional primary care visit was associated with an 0.05 and 0.09 percentage point decrease in the probability of ACSC hospitalization among urban (95% CI: - 0.059, - 0.044) and rural (95% CI: - 0.10, - 0.08) dual eligibles, respectively. Among dual eligibles with CHF, the relationship was even stronger with decreases of 0.09 percentage points (95% CI: - 0.10, - 0.08) and 0.15 percentage points (95% CI: - 0.17, - 0.13) among urban and rural residents, respectively. CONCLUSIONS: Increased primary care use is associated with lower rates of preventable hospitalizations for dual eligibles age 65 and older, especially for dual eligibles with diabetes and congestive heart failure. In turn, efforts to reduce preventable hospitalizations for this dual-eligible population should consider how to increase access to and use of primary care.

Provider communication and HPV vaccine uptake: A meta-analysis and systematic review.

Provider communication can be critically important to families as they consider HPV vaccination. We sought to characterize the association of provider communication and HPV vaccine uptake, and when communication better motivates vaccination. We searched four databases for studies published between 2006 and 2019. Eligible studies examined health care provider communication (defined as recommendation or discussion) and HPV vaccine uptake (defined as initiation, completion, or follow-through) in the US. Two coders independently identified eligible studies and coded effect sizes and study characteristics. We pooled effect sizes using random-effects meta-analysis. We identified 59 eligible studies of 265,083 patients. Receiving a provider recommendation was associated with higher HPV vaccine initiation (pooled OR = 10.1, 95% CI: 7.6-13.4). HPV vaccine initiation was 24% for patients without and 60% for patients with a provider recommendation. The pooled effect size for provider recommendation and initiation was smaller for probability samples, clinical records, and NIS-Teen (all p < 0.002). Recommendations were equally effective for males and females, for different patient ages, and over time. Provider recommendation was also associated with higher HPV vaccine series completion and follow-through. Provider discussion was similarly associated with higher HPV vaccine initiation (OR = 12.4, 95% CI: 6.3-24.3). In summary, provider communication was robustly associated with HPV vaccination initiation, completion, and follow-through. These findings suggest that US public health efforts to increase HPV vaccine coverage should continue to emphasize provider communication.