A retrospective evaluation of glucagon-like peptide-1 receptor agonists in systemic lupus erythematosus patients.

OBJECTIVES: Glucagon-like peptide-1 receptor agonists (GLP1-RA) are an emerging class of medications with demonstrated promise in improving cardiometabolic outcomes. Whether these drugs may be useful in mitigating the cardiac risk associated with SLE remains unknown, and a recent case of drug induced lupus secondary to GLP1-RA use calls the safety of GLP1-RAs in SLE patients into question. Accordingly, this retrospective analysis was initiated to evaluate outcomes of GLP1-RAs in SLE. METHODS: All patients in the NYU Lupus Cohort who had used a GLP1-RA were eligible for inclusion. Patient characteristics were assessed at baseline (most recent rheumatology visit prior to starting GLP1-RA), 1-4 months, and 6-10 months after GLP1-RA initiation. RESULTS: Of the 1211 patients in the cohort, only 24 had received a GLP1-RA. Six were excluded due to insufficient documentation regarding duration of medication use. Of the remaining 18 (median age 50), 17 (94%) were female and 9 (50%) were white. There was one mild-to-moderate flare at 6-10 months, but no patients accumulated new SLE criteria during the follow up period. Compared with baseline, median BMI was reduced by 3% at 1-4 months (p= 0.002) and 13% at 6-10 months (p= 0.001). Nine (50%) patients were initially denied insurance coverage for a GLP1-RA. CONCLUSION: While limited by a small sample size, this descriptive study showed that GLP1-RAs did not trigger flares above expected background rates and were associated with significantly decreased BMI. Future studies exploring the potential benefits of GLP1-RAs in patients with SLE are warranted.

Extrarenal symptoms associate with worse quality of life in patients enrolled in the AMP RA/SLE Lupus Nephritis Network.

OBJECTIVE: Lupus nephritis (LN) can occur as an isolated component of disease activity or be accompanied by diverse extrarenal manifestations. Whether isolated renal disease is sufficient to decrease health related quality of life (HRQOL) remains unknown. This study compared Patient-Reported Outcomes Measurement Information System 29-Item (PROMIS-29) scores in LN patients with isolated renal disease to those with extrarenal symptoms to evaluate the burden of LN on HRQOL and inform future LN clinical trials incorporating HRQOL outcomes. METHODS: A total of 181 LN patients consecutively enrolled in the multicentre multi-ethnic/racial Accelerating Medicines Partnership completed PROMIS-29 questionnaires at the time of a clinically indicated renal biopsy. Raw PROMIS-29 scores were converted to standardized T scores. RESULTS: Seventy-five (41%) patients had extrarenal disease (mean age 34, 85% female) and 106 (59%) had isolated renal (mean age 36, 82% female). Rash (45%), arthritis (40%) and alopecia (40%) were the most common extrarenal manifestations. Compared with isolated renal, patients with extrarenal disease reported significantly worse pain interference, ability to participate in social roles, physical function, and fatigue. Patients with extrarenal disease had PROMIS-29 scores that significantly differed from the general population by > 0.5 SD of the reference mean in pain interference, physical function, and fatigue. Arthritis was most strongly associated with worse scores in these three domains. CONCLUSION: Most patients had isolated renal disease and extrarenal manifestations associated with worse HRQOL. These data highlight the importance of comprehensive disease management strategies that address both renal and extrarenal manifestations to improve overall patient outcomes.

Guideline concordant care for patients with locally advanced cervical cancer by disaggregated Asian American and Native Hawaiian/Pacific Islander groups: A National Cancer Database Analysis.

OBJECTIVE: Despite the within-group heterogeneity, Asian American (AA) and Native Hawaiian and Pacific Islander (NH/PI) patients are often grouped together. We compared the patterns of guideline-concordant care for locally advanced cervical cancer for disaggregated AA and NH/PI patients. METHODS: Patients with stage II-IVA cervical cancer between 2004 and 2020 were identified from the National Cancer Database. AA patients were disaggregated as East Asian (EA), South Asian (SA), and Southeast Asian (SEA). NH/PI patients were classified as a distinct racial subgroup. The primary outcome was the proportion undergoing guideline-concordant care, defined by radiation therapy with concurrent chemotherapy, brachytherapy, and completion of treatment within eight weeks. RESULTS: Of 48,116 patients, 2107 (4%) were AA and 171 (<1%) were NH/PI. Of the AA patients, 36% were SEA, 31% were EA, 12% were SA, and 21% could not be further disaggregated due to missing or unknown data. NH/PI patients were more likely to be diagnosed at an early age (53% NH/PI vs. 30% AA, p < 0.001) and have higher rates of comorbidities (18% NH/PI vs. 14% AA, p < 0.001). Within the AA subgroups, only 82% of SEA patients received concurrent chemotherapy compared to 91% of SA patients (p = 0.026). SA patients had the longest median OS (158 months) within the AA subgroups compared to SEA patients (113 months, p < 0.001). CONCLUSION: Disparities exist in the receipt of standard of care treatment for cervical cancer by racial and ethnic subgroups. It is imperative to disaggregate race and ethnicity data to understand potential differences in care and tailor interventions to achieve health equity.

The COVID-19 pandemic's intersectional impact on work life, home life and wellbeing: an exploratory mixed-methods analysis of Georgia women's experiences during the pandemic.

BACKGROUND: Women have been especially impacted by the COVID-19 pandemic. This exploratory study aimed to characterize women's adverse experiences related to their work, home lives, and wellbeing during the height of the COVID-19 pandemic and to describe demographic differences of those lived experiences. METHODS: Using the validated Epidemic-Pandemic Impacts Inventory, we collected data from reproductive-aged women in the state of Georgia about their exposure to adverse events during the pandemic. A latent class analysis (LCA) was performed to identify subgroups of women reporting similar adverse experiences and describe their sociodemographic characteristics. An optional open-ended question yielded qualitative data that were analyzed thematically and merged with subgroup findings. Data were collected from September 2020 to January 2021. RESULTS: 423 individuals aged 18-49 completed the survey with 314 (74.2%) providing qualitative responses. The LCA yielded 4 subgroups: (1) a "low exposure" subgroup (n = 123, 29.1%) with relatively low probability of adverse experiences across domains (e.g. financial insecurity, health challenges, barriers to access to healthcare, intimate partner violence (IPV)); (2) a "high exposure" subgroup (n = 46, 10.9%) with high probability of experiencing multiple adversities across domains including the loss of loved ones to COVID-19; (3) a "caregiving stress" subgroup (n = 104, 24.6%) with high probability of experiencing challenges with home and work life including increased partner conflict; and (4) a "mental health changes" subgroup (n = 150, 35.5%) characterized by relatively low probability of adverse experiences but high probability of negative changes in mental health and lifestyle. Individuals in subgroups 1 and 4, which had low probabilities of adverse experiences, were significantly more likely to be non-Hispanic white. Individuals in subgroup 2 were more likely to identify with a sexual or racial/ethnic minority population. Inductive coding of qualitative data yielded themes such as stress, mental health, financial impact, and adaptation/resilience, providing context for pandemic-related adversity. CONCLUSION: Though many individuals in our sample experienced hardship, minority populations were unequally impacted by pandemic-related adversity in work life, home life, and wellbeing. Recovery and future emergency preparedness efforts in Georgia must incorporate support mechanisms for mental health and IPV, focusing especially on the intersectional needs of racial, ethnic, and sexual minorities.

Epidemiological evaluation of the outcomes of initial root canal therapy in permanent teeth of a publicly insured paediatric population.

BACKGROUND: Previously published epidemiological outcome studies of nonsurgical root canal therapy (NSRCT) in the United States utilize data only from a single, private dental insurer for adult populations. AIM: This study aimed to investigate the outcomes of initial NSRCT, performed on permanent teeth, in a publicly insured paediatric population. DESIGN: New York State Medicaid administrative claims were used to follow 77 741 endodontic procedures in 51 545 patients aged 6-18, from the time of initial NSRCT until the occurrence of an untoward event (retreatment, apicoectomy, and extraction). The initial treatment and untoward events were identified by Current Dental Terminology codes. The Kaplan-Meier survival estimates were calculated at 1, 3, and 5 years. Hazard ratios for time to permanent restoration and restoration type were calculated using the Cox proportional hazards model. RESULTS: The median follow-up time was 44 months [range: 12-158 months]. Procedural, NSRCT, survival was 98% at 1 year, 93% at 3 years, and 88% at 5 years. Extraction was the most common untoward event. Teeth permanently restored with cuspal coverage had the most favorable treatment outcomes. CONCLUSIONS: Overall, 89% of teeth were retained and remained functional over a minimum follow-up time of 5 years. These results elucidate the expected outcomes of NSRCT in permanent teeth for paediatric patients with public-payer dental benefits.

Detecting Somatic Mutations in Normal Cells.

Somatic mutations have been studied extensively in the context of cancer. Recent studies have demonstrated that high-throughput sequencing data can be used to detect somatic mutations in non-tumor cells. Analysis of such mutations allows us to better understand the mutational processes in normal cells, explore cell lineages in development, and examine potential associations with age-related disease. We describe here approaches for characterizing somatic mutations in normal and non-tumor disease tissues. We discuss several experimental designs and common pitfalls in somatic mutation detection, as well as more recent developments such as phasing and linked-read technology. With the dramatically increasing numbers of samples undergoing genome sequencing, bioinformatic analysis will enable the characterization of somatic mutations and their impact on non-cancer tissues.

Cost and healthcare utilization analysis of culturally sensitive, shared medical appointment model for Latino children with type 1 diabetes.

OBJECTIVE: This study evaluated costs and healthcare utilization associated with a culturally-sensitive, medical and education program for pediatric Latino patients with type 1 diabetes. RESEARCH DESIGN AND METHODS: Program participants included Latino children ages 1-20 years old diagnosed with type 1 diabetes (n = 57). Control subjects with type 1 diabetes were matched by age, sex, and zip code to intervention participants from the Colorado All Payer Claims Database. Data included emergency department (ED) visits, hospitalizations, demographic information, and health insurance claims data 180 days prior to program start/index date through 1 year after program start/index date. We tracked program staff time and estimated costs for healthcare utilization using data from the scientific literature. Generalized Estimating Equation (GEE) models with logit link were used to estimate group differences in probabilities of ED visits and hospitalizations over 6-month periods pre/post-study, accounting for correlation of within-subject data across time points. Sensitivity analyses modeled longer-term cost differences under different assumptions. RESULTS: The intervention group had fewer hospitalizations, 2% versus 12% of controls (p = 0.047,OR = 0.13;95%CI: 0.02-0.97) for 6 months following start date. The intervention group had fewer ED visits, 19% versus 32% in controls (n.s.; p = 0.079,OR = 0.52;95%CI:0.25-1.08) and significantly fewer hospitalizations, 4% versus 15% of controls (p = 0.039,OR = 0.21;95%CI: 0.05-0.93) 6-12 months post-start date. One-year per-patient program costs of $633 and healthcare cost savings of $2710 yielded total per-patient savings of $2077, or a 5-year cost savings of $14,106. CONCLUSION: This unique type 1 diabetes management program altered health service utilization of program participants, reducing major healthcare cost drivers, ED visits, and hospitalizations.

Implementation of a multi-level community-clinical linkage intervention to improve glycemic control among south Asian patients with uncontrolled diabetes: study protocol of the DREAM initiative.

BACKGROUND: A number of studies have identified patient-, provider-, and community-level barriers to effective diabetes management among South Asian Americans, who have a high prevalence of type 2 diabetes. However, no multi-level, integrated community health worker (CHW) models leveraging health information technology (HIT) have been developed to mitigate disease among this population. This paper describes the protocol for a multi-level, community-clinical linkage intervention to improve glycemic control among South Asians with uncontrolled diabetes. METHODS: The study includes three components: 1) building the capacity of primary care practices (PCPs) to utilize electronic health record (EHR) registries to identify patients with uncontrolled diabetes; 2) delivery of a culturally- and linguistically-adapted CHW intervention to improve diabetes self-management; and 3) HIT-enabled linkage to culturally-relevant community resources. The CHW intervention component includes a randomized controlled trial consisting of group education sessions on diabetes management, physical activity, and diet/nutrition. South Asian individuals with type 2 diabetes are recruited from 20 PCPs throughout NYC and randomized at the individual level within each PCP site. A total of 886 individuals will be randomized into treatment or control groups; EHR data collection occurs at screening, 6-, 12-, and 18-month. We hypothesize that individuals receiving the multi-level diabetes management intervention will be 15% more likely than the control group to achieve ≥0.5% point reduction in hemoglobin A1c (HbA1c) at 6-months. Secondary outcomes include change in weight, body mass index, and LDL cholesterol; the increased use of community and social services; and increased health self-efficacy. Additionally, a cost-effectiveness analysis will focus on implementation and healthcare utilization costs to determine the incremental cost per person achieving an HbA1c change of ≥0.5%. DISCUSSION: Final outcomes will provide evidence regarding the effectiveness of a multi-level, integrated EHR-CHW intervention, implemented in small PCP settings to promote diabetes control among an underserved South Asian population. The study leverages multisectoral partnerships, including the local health department, a healthcare payer, and EHR vendors. Study findings will have important implications for the translation of integrated evidence-based strategies to other minority communities and in under-resourced primary care settings. TRIAL REGISTRATION: This study was registered with clinicaltrials.gov: NCT03333044 on November 6, 2017.

Diabetes mellitus and colorectal carcinoma outcomes: a meta-analysis.

OBJECTIVES: The impact of diabetes mellitus (DM) on colorectal cancer (CRC) outcomes remains unknown. We studied this by conducting a meta-analysis to evaluate (1) CRC outcomes with and without DM and (2) treatment patterns. METHODS: We searched PubMed, EMBASE, Google Scholar, and CINAHL for full-text English studies from 1970 to 12/31/2017. We searched keywords, subject headings, and MESH terms to locate studies of CRC outcomes/treatment and DM. Studies were evaluated by two oncologists. Of 14,332, 48 met inclusion criteria. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method, we extracted study location, design, DM definition, covariates, comparison groups, outcomes, and relative risks and/or hazard ratios. We utilized a random-effects model to pool adjusted risk estimates. Primary outcomes were all-cause mortality (ACM), disease-free survival (DFS), relapse-free survival (RFS), and cancer-specific survival (CSS). The secondary outcome was treatment patterns. RESULTS: Forty-eight studies were included, 42 in the meta-analysis, and 6 in the descriptive analysis, totaling > 240,000 patients. ACM was 21% worse (OR 1.21, 95% CI 1.15-1.28) and DFS was 75% worse (OR 1.75, 95% CI: 1.33-2.31) in patients with DM. No differences were detected in CSS (OR 1.10, 95% CI 0.98-1.23) or RFS (OR 1.12, 95% CI 0.91-1.38). Descriptive analysis of treatment patterns in CRC and DM suggested potentially less adjuvant therapy use in cases with DM and CRC. CONCLUSIONS: Our meta-analysis suggests that patients with CRC and DM have worse ACM and DFS than patients without DM, suggesting that non-cancer causes of death in may account for worse outcomes.

Outcomes of a First Total Knee Arthroplasty Are Associated With Outcomes of the Subsequent Contralateral Total Knee Arthroplasty.

BACKGROUND: To determine if preoperative characteristics and postoperative outcomes of a first total knee arthroplasty (TKA) were predictive of characteristics and outcomes of the subsequent contralateral TKA in the same patient. METHODS: Retrospective administrative claims data from (SPARCS) database were analyzed for patients who underwent sequential TKAs from September 2015 to September 2017 (n = 5,331). Hierarchical multivariable Poisson regression (length of stay [LOS]) and multivariable logistic regression (all other outcomes), controlling for sex, age, and Elixhauser comorbidity scores were performed. RESULTS: The cohort comprised 65% women, with an average age of 66 years and an average duration of 7.3 months between surgeries (SD: 4.7 months). LOS was significantly shorter for the second TKA (2.6 days) than for the first TKA (2.8 days; P < .001). Patients discharged to a facility after their first TKA had a probability of 76% of discharge to facility after the second TKA and were significantly more likely to be discharged to a facility compared with those discharged home after the first TKA (odds ratio [OR]: 63.7; 95% confidence interval [CI]: 52.1-77.8). The probability of a readmission at 30 and 90 days for the second TKA if the patient was readmitted for the first TKA was 1.0% (OR: 3.70; 95% CI: 0.98-14.0) and 6.4% (OR: 9; 95% CI: 5.1-16.0), respectively. Patients with complications after their first TKA had a 27% probability of a complication after the second TKA compared with a 1.6% probability if there was no complication during the first TKA (OR: 14.6; 95% CI: 7.8.1-27.2). CONCLUSION: The LOS, discharge disposition, 90-day readmission rate, and complication rate for a second contralateral TKA are strongly associated with the patient's first TKA experience. The second surgery was found to be associated with an overall shorter LOS, fewer readmissions, and higher likelihood of home discharge. LEVEL OF EVIDENCE: Level 3-retrospective cohort study.

Diabetes and differences in detection of incident invasive breast cancer.

Many women diagnosed with breast cancer have chronic conditions such as diabetes that may impact other health behaviors. Our purpose was to determine if breast cancer screening and detection differs among women with and without diabetes. We conducted a cross-sectional analysis of a retrospective cohort of women aged 52-74 years diagnosed with incident stages I-III breast cancer enrolled in an integrated health plan between 1999 and 2014 with linkage to the Surveillance, Epidemiology and End Results registry (n = 2040). Screening data were taken from electronic health records. We used multivariable modified Poisson regression models with robust standard errors to estimate relative risks (RR) and 95% confidence intervals (CI) for outcomes of (i) receipt of screening in the 2 years prior to diagnosis; (ii) symptom-detected breast cancer; and (iii) diagnosis of locally advanced stage III breast cancer. Compared to women without diabetes, women with diabetes were similar with respect to receipt of screening mammography (78% and 77%), symptom-detected breast cancer (46% and 49%), and stage III diagnosis (7% and 7%). In multivariable models adjusting for age and year of diagnosis, race, BMI, Charlson comorbidity score and depression diagnosis no differences were observed in the outcomes by presence of diabetes. Further investigation is warranted to determine how diabetes acts as a mediating factor in adverse breast cancer outcomes.

Clinical and patient-reported outcomes after image-guided intra-articular therapeutic hip injections for osteoarthritis-related hip pain: a retrospective study.

OBJECTIVE: To evaluate change in patient-reported outcomes following image-guided intra-articular therapeutic steroid hip injections for pain and assess correlations of outcomes with patient- and injection-specific factors. MATERIALS AND METHODS: We retrospectively reviewed consecutive patients treated for hip pain who completed outcomes assessments from October 2011 to September 2017 at an outpatient orthopedic surgery clinic. Only patients with radiographic hip osteoarthritis (Tönnis grade ≥ 1) who underwent steroid hip injections were included. Outcomes assessments included EuroQol-5 domain (EQ5D), EQ5D-visual analog scale (VAS), and hip disability and osteoarthritis outcome score (HOOS), obtained before and within 1-6 months post-injection. Among 113 patients who completed surveys, the mean age was 59 years (±13.7 years), including 77 women (68%) and 36 men (32%). Time to repeat injection or arthroplasty was recorded. Exact Wilcoxon signed rank test assessed score differences and Spearman correlation, Kruskal-Wallis, and Mann-Whitney tests assessed correlations. RESULTS: Of 113 patients, 34 had outcomes measured at <8 weeks and 79 at ≥8 weeks. There was no significant change among any of the patients, short- or long-term follow-up subgroups in EQ5D (p = 0.450, 0.770, 0.493 respectively), EQ5D-VAS (p = 0.581, 0.915, 0.455), average-HOOS (p = 0.478, 0.696, 0.443) or total-HOOS (p = 0.380, 0.517, 0.423) scores. Forty-nine patients underwent hip arthroplasty within 1 year. Positive correlation was found between days from injection to surgery and change in EQ5D (r = 0.29, p = 0.025), average-HOOS (r = 0.33, p = 0.019), and total-HOOS (r = 0.37, p = 0.008). CONCLUSION: We demonstrated no significant change in patient-reported outcomes measured at short- and long-term intervals up to 6 months after therapeutic steroid hip injections.

Impact of socioeconomic status on survival for patients with anal cancer.

BACKGROUND: Although outcomes for patients with squamous cell carcinoma of the anus (SCCA) have improved, the gains in benefit may not be shared uniformly among patients of disparate socioeconomic status. In the current study, the authors investigated whether area-based median household income (MHI) is predictive of survival among patients with SCCA. METHODS: Patients diagnosed with SCCA from 2004 through 2013 in the Surveillance, Epidemiology, and End Results registry were included. Socioeconomic status was defined by census-tract MHI level and divided into quintiles. Multivariable Cox proportional hazards models and logistic regression were used to study predictors of survival and radiotherapy receipt. RESULTS: A total of 9550 cases of SCCA were included. The median age of the patients was 58 years, 63% were female, 85% were white, and 38% were married. In multivariable analyses, patients living in areas with lower MHI were found to have worse overall survival and cancer-specific survival (CSS) compared with those in the highest income areas. Mortality hazard ratios for lowest to highest income were 1.32 (95% confidence interval [95% CI], 1.18-1.49), 1.31 (95% CI, 1.16-1.48), 1.19 (95% CI, 1.06-1.34), and 1.16 (95% CI, 1.03-1.30). The hazard ratios for CSS similarly ranged from 1.34 to 1.22 for lowest to highest income. Older age, black race, male sex, unmarried marital status, an earlier year of diagnosis, higher tumor grade, and later American Joint Committee on Cancer stage of disease also were associated with worse CSS. Income was not found to be associated with the odds of initiating radiotherapy in multivariable analysis (odds ratio of 0.87 for lowest to highest income level; 95% CI, 0.63-1.20). CONCLUSIONS: MHI appears to independently predict CSS and overall survival in patients with SCCA. Black race was found to remain a predictor of SCCA survival despite controlling for income. Further study is needed to understand the mechanisms by which socioeconomic inequalities affect cancer care and outcomes. Cancer 2018;124:1791-7. © 2018 American Cancer Society.

Delivery of adjuvant chemotherapy among stage III colon cancer patients at a public versus private hospital in New York City.

PURPOSE: Prior studies of timeliness of adjuvant chemotherapy (AC) initiation in stage III colon cancer have suggested longer time to AC at public compared with private hospitals. Few studies have explored differences in AC completion. We investigated whether timely initiation and completion of AC differed between a public and private hospital, affiliated with the same academic institution in a large, urban setting. METHODS: We conducted a retrospective cohort study of stage III colon cancer patients who had surgery and AC at the same medical center between 2008 and 2015, either at its affiliated public hospital (n = 43) or private hospital (n = 79). We defined timely initiation as receiving AC within 60 days postoperatively, and completion as receiving ≥ 75% of planned AC. Univariate and stepwise multivariable logistic regressions were used to identify factors associated with AC delivery. RESULTS: Median number of days to AC was significantly greater among patients at the public (53, range 31-231) compared with the private hospital (43, range 25-105; p = 0.002). However, the percentage of patients with timely AC initiation did not differ substantially by hospital (74 vs 81%, p = 0.40). In multivariable analysis, age (OR 0.95/year, 95% CI 0.91-0.99) and laparoscopic versus open surgery (OR 5.65, 95% CI 1.92-16.62) were significant factors associated with timely AC initiation. Moreover, AC completion did not differ significantly between public (83.7%) and private (89.9%) hospital patients (p = 0.32). CONCLUSIONS: The proportions of patients with timely initiation and completion of AC were similar at a public and private hospital affiliated with a large, urban medical center. Future research should investigate how specific system-level factors help alleviate this expected difference in timely care delivery.

Comparison Between Image-Guided and Landmark-Based Glenohumeral Joint Injections for the Treatment of Adhesive Capsulitis: A Cost-Effectiveness Study.

OBJECTIVE: The purpose of this study was to determine the cost-effectiveness of landmark-based and image-guided intraarticular steroid injections for the initial treatment of a population with adhesive capsulitis. MATERIALS AND METHODS: A decision analytic model from the health care system perspective over a 6-month time frame for 50-year-old patients with clinical findings consistent with adhesive capsulitis was used to evaluate the incremental cost-effectiveness of three techniques for administering intraarticular steroid to the glenohumeral joint: landmark based (also called blind), ultrasound guided, and fluoroscopy guided. Input data on cost, probability, and utility estimates were obtained through a comprehensive literature search and from expert opinion. The primary effectiveness outcome was quality-adjusted life years (QALY). Costs were estimated in 2017 U.S. dollars. RESULTS: Ultrasound-guided injections were the dominant strategy for the base case, because it was the least expensive ($1280) and most effective (0.4096 QALY) strategy of the three options overall. The model was sensitive to the probabilities of getting the steroid into the joint by means of blind, ultrasound-guided, and fluoroscopy-guided techniques and to the costs of the ultrasound-guided and blind techniques. Two-way sensitivity analyses showed that ultrasound-guided injections were favored over blind and fluoroscopy-guided injections over a range of reasonable probabilities and costs. Probabilistic sensitivity analysis showed that ultrasound-guided injections were cost-effective in 44% of simulations, compared with 34% for blind injections and 22% for fluoroscopy-guided injections and over a wide range of willingness-to-pay thresholds. CONCLUSION: Ultrasound-guided injections are the most cost-effective option for the initial steroid-based treatment of patients with adhesive capsulitis. Blind and fluoroscopy-guided injections can also be cost-effective when performed by a clinician likely to accurately administer the medication into the correct location.

Treatment for Symptomatic SLAP Tears in Middle-Aged Patients Comparing Repair, Biceps Tenodesis, and Nonoperative Approaches: A Cost-Effectiveness Analysis.

PURPOSE: To evaluate the cost-effectiveness of nonoperative management, primary SLAP repair, and primary biceps tenodesis for the treatment of symptomatic isolated type II SLAP tear. METHODS: A microsimulation Markov model was constructed to compare 3 strategies for middle-aged patients with symptomatic type II SLAP tears: SLAP repair, biceps tenodesis, or nonoperative management. A failed 6-month trial of nonoperative treatment was assumed. The principal outcome measure was the incremental cost-effectiveness ratio in 2017 U.S. dollars using a societal perspective over a 10-year time horizon. Treatment effectiveness was expressed in quality-adjusted life-years (QALY). Model results were compared with estimates from the published literature and were subjected to sensitivity analyses to evaluate robustness. RESULTS: Primary biceps tenodesis compared with SLAP repair conferred an increased effectiveness of 0.06 QALY with cost savings of $1,766. Compared with nonoperative treatment, both biceps tenodesis and SLAP repair were cost-effective (incremental cost-effectiveness ratio values of $3,344/QALY gained and $4,289/QALY gained, respectively). Sensitivity analysis showed that biceps tenodesis was the preferred strategy in most simulations (52%); however, for SLAP repair to become cost-effective over biceps tenodesis, its probability of failure would have to be lower than 2.7% or the cost of biceps tenodesis would have to be higher than $14,644. CONCLUSIONS: When compared with primary SLAP repair and nonoperative treatment, primary biceps tenodesis is the most cost-effective treatment strategy for type II SLAP tears in middle-aged patients. Primary biceps tenodesis offers increased effectiveness when compared with both primary SLAP repair and nonoperative treatment and lower costs than primary SLAP repair. LEVEL OF EVIDENCE: Level III, economic decision analysis.

New Breast Cancer Radiotherapy Technology Confers Higher Complications and Costs Before Effectiveness Proven: A Medicare Data Analysis.

A new breast cancer treatment, brachytherapy-based accelerated partial breast radiotherapy (RT), was adopted before long-term effectiveness evidence, potentially increasing morbidity and costs compared with whole breast RT. The aim of this study was to estimate complication rates and RT-specific and 1-year costs for a cohort of female Medicare beneficiaries diagnosed with breast cancer (N = 47 969). We analyzed 2005-2007 Medicare claims using multivariable logistic regression for complications and generalized linear models (log link, gamma distribution) for costs. Overall, 11% (n = 5296) underwent brachytherapy-based RT; 9.4% had complications. Odds of any complication were higher (odds ratio [OR]: 1.62; 95% confidence interval [CI]: 1.49-1.76) for brachytherapy versus whole breast RT, similarly to seroma (OR: 2.85; 95% CI: 1.97-4.13), wound complication/infection (OR: 1.72; 95% CI: 1.52-1.95), cellulitis (OR: 1.48; 95% CI: 1.27-1.73), and necrosis (OR: 2.07; 95% CI: 1.55-2.75). Mean RT-specific and 1-year total costs for whole breast RT were $6375, and $19 917, $4886, and $4803 lower than brachytherapy ( P < .0001). Multivariable analyses indicated brachytherapy yielded 76% higher RT costs (risk ratio: 1.76; 95% CI: 1.74-1.78, P < .0001) compared with whole breast RT. Brachytherapy had higher complications and costs before long-term evidence proved its effectiveness. Policies should require treatment registries with reimbursement incentives to capture surveillance data for new technologies.

Time Trends in Characteristics of Patients Undergoing Primary Total Hip and Knee Arthroplasty in California, 2007-2010.

BACKGROUND: As the number of total hip and knee arthroplasty cases increases, it is important to understand the burden of factors that impact patient outcomes of these procedures. This article examined the time trends in key demographics, clinical characteristics, comorbidity burden (Deyo-Charlson Comorbidity Index [CCI]), and presence of depression in patients undergoing primary total hip arthroplasty and total knee arthroplasty using population-based, all-payer inpatient database, California Healthcare Cost and Utilization Project, from 2007 to 2010. METHODS: Chi-square tests and analysis of variance were used. Multivariate logistic regression analyses were also performed to compare the prevalence of depression in 2007 to later years. RESULTS: In the primary total hip arthroplasty cohort, the prevalence of depression significantly increased by 20%, mean age decreased by 0.4 years, mean length of stay (LOS) decreased by 0.5 days, and having a CCI score of ≥3 increased by 30% (P value < .001 for all) over the study period. Similarly, in the primary total knee arthroplasty cohort, the prevalence of depression increased by 23%, the mean age decreased by 0.4 years, mean LOS decreased by 0.4 days, and the prevalence of CCI score of ≥3 increased by 35% (P value < .001 for all). CONCLUSION: Despite the younger age of the joint arthroplasty population over time, we found increased prevalence of depression and comorbidity scores but shorter LOS. Further study is needed to determine the impact of the changing demographics of the total joint population and the best strategies to optimize their outcome with these procedures.

Cost-effectiveness of magnetic resonance imaging versus ultrasound for the detection of symptomatic full-thickness supraspinatus tendon tears.

BACKGROUND: The purpose of this study was to determine the value of magnetic resonance imaging (MRI) and ultrasound-based imaging strategies in the evaluation of a hypothetical population with a symptomatic full-thickness supraspinatus tendon (FTST) tear using formal cost-effectiveness analysis. METHODS: A decision analytic model from the health care system perspective for 60-year-old patients with symptoms secondary to a suspected FTST tear was used to evaluate the incremental cost-effectiveness of 3 imaging strategies during a 2-year time horizon: MRI, ultrasound, and ultrasound followed by MRI. Comprehensive literature search and expert opinion provided data on cost, probability, and quality of life estimates. The primary effectiveness outcome was quality-adjusted life-years (QALYs) through 2 years, with a willingness-to-pay threshold set to $100,000/QALY gained (2016 U.S. dollars). Costs and health benefits were discounted at 3%. RESULTS: Ultrasound was the least costly strategy ($1385). MRI was the most effective (1.332 QALYs). Ultrasound was the most cost-effective strategy but was not dominant. The incremental cost-effectiveness ratio for MRI was $22,756/QALY gained, below the willingness-to-pay threshold. Two-way sensitivity analysis demonstrated that MRI was favored over the other imaging strategies over a wide range of reasonable costs. In probabilistic sensitivity analysis, MRI was the preferred imaging strategy in 78% of the simulations. CONCLUSION: MRI and ultrasound represent cost-effective imaging options for evaluation of the patient thought to have a symptomatic FTST tear. The results indicate that MRI is the preferred strategy based on cost-effectiveness criteria, although the decision between MRI and ultrasound for an imaging center is likely to be dependent on additional factors, such as available resources and workflow.

Incidence and Risk Factors for Blood Transfusion in Total Joint Arthroplasty: Analysis of a Statewide Database.

BACKGROUND: Significant attempts have been made to adopt practices to minimize blood transfusion after total joint arthroplasty (TJA) because of transfusion cost and potential negative clinical consequences including allergic reactions, transfusion-related lung injuries, and immunomodulatory effects. We aimed to evaluate risk factors for blood transfusion in a large cohort of TJA patients. METHODS: We used the all-payer California Healthcare Cost and Utilization Project data from 2006 to 2011 to examine the trends in utilization of blood transfusion among arthroplasty patients (n = 320,746). We performed descriptive analyses and multivariate logistic regression clustered by hospital, controlling for Deyo-Charlson comorbidity index, age, insurance type (Medicaid vs others), gender, procedure year, and race/ethnicity. RESULTS: Eighteen percent (n = 59,038) of TJA patients underwent blood transfusion during their surgery, from 15% with single knee to 45% for bilateral hip arthroplasty. Multivariate analysis indicated that compared with the referent category of single knee arthroplasty, single hip had a significantly higher odds of blood transfusion (odds ratio [OR], 1.76; 95% confidence interval [CI], 1.68-1.83), as did bilateral knee (OR, 3.57; 95% CI, 3.20-3.98) and bilateral hip arthroplasty (OR, 6.17; 95% CI, 4.85-7.85). Increasing age (eg, age ≥80 years; OR, 2.99; 95% CI, 2.82-3.17), Medicaid insurance (OR, 1.36; 95% CI, 1.27-1.45), higher comorbidity index (eg, score of ≥3; OR, 2.33; 95% CI, 2.22-2.45), and females (OR, 1.75; 95% CI, 1.70-1.80) all had significantly higher odds of blood transfusion after TJA. CONCLUSION: Primary hip arthroplasties have significantly greater risk of transfusion than knee arthroplasties, and bilateral procedures have even greater risk, especially for hips. These factors should be considered when evaluating the risk for blood transfusions.