Assessing Patterns of Telehealth Use Among People with Sickle Cell Disease Enrolled in Medicaid During the Start of the COVID-19 Pandemic.

Background: Telehealth can be defined as using remote technologies to provide health care. It may increase access to care among people with sickle cell disease (SCD). This study examined (1) telehealth use, (2) characteristics of telehealth use, and (3) differences between telehealth users and nonusers among people with SCD during the COVID-19 pandemic. Methods: This was a retrospective analysis of Medicaid claims among four states [California (CA), Georgia (GA), Michigan (MI), Tennessee (TN)] participating in the Sickle Cell Data Collection program. Study participants were individuals ≥1 year old with SCD enrolled in Medicaid September 2019-December 2020. Telehealth encounters during the pandemic were characterized by provider specialty. Health care utilization was compared between those who did (users) and did not (nonusers) use telehealth, stratified by before and during the pandemic. Results: A total of 8,681 individuals with SCD (1,638 CA; 3,612 GA; 1,880 MI; and 1,551 TN) were included. The proportion of individuals with SCD that accessed telehealth during the pandemic varied across states from 29% in TN to 80% in CA. During the pandemic, there was a total of 21,632 telehealth encounters across 3,647 users. In two states (MI and GA), over a third of telehealth encounters were with behavioral health providers. Telehealth users had a higher average number of health care encounters during the pandemic: emergency department (pooled mean = 2.6 for users vs. 1.5 for nonusers), inpatient (1.2 for users vs. 0.6 for nonusers), and outpatient encounters (6.0 for users vs. 3.3 for nonusers). Conclusions: Telehealth was frequently used at the beginning of the COVID-19 pandemic by people with SCD. Future research should focus on the context, facilitators, and barriers of its implementation in this population.

Association Between Delivery System Structure and Intensity of End-of-Life Cancer Care.

PURPOSE: To determine whether the type of delivery system is associated with intensity of care at the end of life for Medicare beneficiaries with cancer. PATIENTS AND METHODS: We used SEER registry data linked with Medicare claims to evaluate intensity of end-of-life care for patients who died of one of ten common cancers diagnosed from 2009 through 2014. Patients were categorized as receiving the majority of their care in an integrated delivery system, designated cancer center, health system that was both integrated and a certified cancer center, or health system that was neither. We evaluated adherence to seven nationally endorsed end-of-life quality measures using generalized linear models across four delivery system types. RESULTS: Among 100,549 beneficiaries who died of cancer during the study interval, we identified only modest differences in intensity of end-of-life care across delivery system structures. Health systems with no cancer center or integrated affiliation demonstrated higher proportions of patients with multiple hospitalizations in the last 30 days of life (11.3%), death in an acute care setting (25.9%), and lack of hospice use in the last year of life (31.6%; all P < .001). Patients enrolled in hospice had lower intensity care across multiple end-of-life quality measures. CONCLUSION: Intensity of care at the end of life for patients with cancer was higher at delivery systems with no integration or cancer focus. Maximal supportive care delivered through hospice may be one avenue to reduce high-intensity care at the end of life and may impact quality of care for patients dying from cancer.

Proton therapy for prostate cancer online: patient education or marketing?

INTRODUCTION: Proton therapy (PT) for prostate cancer is an expensive treatment with limited evidence of benefit over conventional radiotherapy. We sought to study whether online information on PT for prostate cancer was balanced and whether the website source influenced the content presented. MATERIALS AND METHODS: We applied a systematic search process to identify 270 weblinks associated with PT for prostate cancer, categorized the websites by source, and filtered the results to 50 websites using predetermined criteria. We then used a customized version of the DISCERN instrument, a validated tool for assessing the quality of consumer health information, to evaluate the remaining websites for balance of content and description of risks, benefits and uncertainty. RESULTS: Depending on the search engine and key word used, proton center websites (PCWs) made up 10%-47% of the first 30 encountered links. In comparison, websites from academic and nonacademic medical centers without ownership stake in proton centers appeared much less frequently as a search result (0%-3%). PCWs scored lower on DISCERN questions compared to other sources for being balanced/unbiased (p < 0.001), mentioning areas of uncertainty (p < 0.001), and describing risks of PT (p < 0.001). PCWs scored higher for describing the benefits of treatment (p = 0.003). CONCLUSIONS: Patients should be aware that online information regarding PT for prostate cancer may represent marketing by proton centers rather than comprehensive and unbiased patient education. An awareness of these results will also better prepare clinicians to address the potential biases of patients with prostate cancer who search the Internet for health information.

Five-year experience with metallic stents for chronic ureteral obstruction.

PURPOSE: We present 5 years of outcome data on metallic ureteral stents in a cohort of patients treated for chronic ureteral obstruction. MATERIALS AND METHODS: We retrospectively identified and analyzed the records of all patients in whom a Resonance® Metallic Ureteral Stent was placed between early 2007 and late 2011 at our institution. We performed a descriptive analysis of key outcomes, including the failure and death rates, and stenting duration, defined as the time from initial stent placement to last stent failure or patient death. We also performed a secondary comparative analysis of patients with a benign vs malignant etiology of obstruction. RESULTS: A total of 139 metallic stents were placed in 47 patients, including 27 (57%) with malignant and 20 (43%) with a benign etiology. Of the patients 15 (32%) had bilateral obstruction. Maximum followup was 59 months (mean 20, median 13, IQR 4-31). Stent failure occurred in 13 patients (28%), including 4 in the benign and 9 in the malignant group (p = 0.35). The median duration of stenting for benign and malignant obstruction was 22 (IQR 9-39) vs 7 months (IQR 3-25) (p = 0.106). Stenting duration was equivalent when controlling for the higher death rate in the malignant group. CONCLUSIONS: Resonance metallic stents are an adequate management strategy for benign and malignant ureteral obstruction. A subset of patients in each group continued to do well at more than a 3-year overall duration of stenting. Failure rates were similar for benign and malignant etiologies.