A Randomized Comparative Study of the Use of Individual Modality and Combination of Endoscopic Retrograde Cholangiopancreatography (ERCP) and Digital Single-Operator Cholangioscopy (DSOC) for Diagnosis of Indeterminate Biliary Strictures.

Background: To determine the superiority of the combination of endoscopic retrograde cholangiopancreatography (ERCP) and digital single-operator cholangioscopy (DSOC) in the same sitting over the individual modality alone in patients with indeterminate biliary strictures. Materials and Methods: A randomized study enrolled 60 adult patients with biliary strictures who were randomized into two groups: ERCP + DSOC and ERCP/DSOC. Histopathologic or cytologic assessment was performed in terms of benign, indeterminate, or malignant nature of the strictures. Procedural adverse events were documented. Accuracy in terms of sensitivity (Sn), specificity (Sp), and predictive value [positive (PPV) and negative (NPV)] were noted. Results: As per final diagnosis, in ERCP/DSOC group, there were 12 (40%) benign cases and 18 (60%) malignant cases, and in group ERCP + DSOC, there were 8 (26.67%) benign cases and 22 (73.33%) malignant cases. ERCP/DSOC labeled 16 (53.33%) patients as benign, 8 (26.67%) as malignant, and 6 (20%) as indeterminate, while ERCP + DSOC labeled 8 (26.67%) as benign, 17 (56.67%) as malignant, and 5 (16.67%) as indeterminate. The Sn, Sp, PPV, and NPV of ERCP/DSOC were 44.4%, 75%, 100%, and 56.25%, and for ERCP + DSOC was 77.27%, 62.50%, 100%, and 62.5%, respectively (P = 0.033). Side effects were statistically similar in both the groups (P > 0.05). Conclusion: To conclude, the combination of ERCP with DSOC is safe and effective with higher diagnostic sensitivity (77.27%) in comparison to standard ERCP or DSOC alone (44.4%) for the diagnosis of biliary strictures.

A dosimetric comparison of systemic peptide receptor radionuclide therapy and intra-arterial peptide receptor radionuclide therapy in patients with liver dominant gastroenteropancreatic neuroendocrine tumours.

OBJECTIVES: Intra-arterial radionuclide therapy (IART) treatment allows direct delivery of 177 Lu-DOTATATE to the overexpressed somatostatin-positive neuroendocrine liver metastases, which led to higher tumour concentration compared with systemic radionuclide therapy (SRT). The aim was to evaluate and compare the absorbed doses of both IART and SRT to organs and hepatic metastatic sites. METHODS: A total of 48 patients received SRT and IART. In SRT, activity was administered intravenously, whereas in IART, activity was administered directly into hepatic arteries. The sequential whole-body images were acquired at 2, 4, 24, 72 and 160 h. The reconstructed whole-body planar and single-photon emission computed tomography-computed tomography images were processed using the Dosimetry Toolkit for the estimation of normalized cumulated activity in the organs and tumour lesions. The absorbed dose was computed using OLINDA EXM 2.0 software. RESULTS: The median absorbed dose (mGy/MBq) of kidneys and spleen in IART was compared with SRT and found to be decreased by 30.7% ( P  = 0.03) and 37.5% ( P  = 0.08), whereas it was found to be increased by 40% ( P  = 0.26) and 8.1% ( P  = 0.28) in the liver and lungs. The median dose (mGy/MBq) of tumours determined in IART was found to be increased by 62.2% ( P  = 0.04). CONCLUSION: IART with 177 Lu-DOTATATE significantly increases tumour dose while reducing overall systemic toxicity in comparison to SRT treatment. After considering the maximum tolerance limit of kidneys in peptide receptor radionuclide therapy, the number of treatment cycles and injected activity can be optimized further with IART for better response and survival.

Serum Gamma-Glutamyl Transpeptidase-to-Platelet Ratio as a Noninvasive Marker of Liver Fibrosis in Chronic Hepatitis B.

Background The gamma-glutamyl transpeptidase (GGT)-to-platelet ratio (GPR) is identified as a new model for the assessment of liver fibrosis in patients with chronic hepatitis B (CHB). We aimed to determine the diagnostic performance of GPR for the prediction of liver fibrosis in patients with CHB. Methods In an observational cohort study, patients with CHB were enrolled. The diagnostic performance of GPR was compared with transient elastography (TE), aspartate aminotransferase-to-platelet ratio index (APRI), and fibrosis-4 (FIB-4) scores for the prediction of liver fibrosis using liver histology as a gold standard. Results Forty-eight patients with CHB with a mean age of 33.42 ± 15.72 years were enrolled. Liver histology showed meta-analysis of histological data in viral hepatitis (METAVIR) stage F0, F1, F2, F3, and F4 fibrosis in 11, 12, 11, seven, and seven patients, respectively. The Spearman correlation of METAVIR fibrosis stage with APRI, FIB-4, GPR, and TE were 0.354, 0.402, 0.551, and 0.726, respectively (P value < 0.05). TE had the highest sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) (80%, 83%, 83%, and 79%, respectively), followed by GPR (76%, 65%, 70%, and 71%, respectively) for predicting significant fibrosis (≥F2). However, TE had comparable sensitivity, specificity, PPV, and NPV with GPR (86%, 82%, 42%, and 93%, and 86%, 71%, 42%, and 92%, respectively) for predicting extensive fibrosis (≥F3). Conclusion The performance of GPR is comparable to TE in predicting significant and extensive liver fibrosis. GPR may be an acceptable, low-cost alternative for predicting compensated advanced chronic liver disease (cACLD) (F3-F4) in CHB patients.

Dosimetry in Lu-177-PSMA-617 prostate-specific membrane antigen targeted radioligand therapy: a systematic review.

BACKGROUND: 177Lu-prostate-specific membrane antigen (PSMA) gained popularity as a choice of agent in the treatment of patients with advanced prostate cancer or metastatic castration-resistant stage of prostate carcinoma (mCRPC) diseases. However, this treatment may cause fatal effects, probably due to unintended irradiation of normal organs. We performed an extensive systematic review to assess the organs at risk and the absorbed dose received by tumor lesions in 177Lu-PSMA therapy. DESIGN: In this review, published peer-reviewed articles that cover clinical dosimetry in patients following peptide radionuclide ligand therapy using 177Lu-PSMA have been included. Two senior researchers independently checked the articles for inclusion. A systematic search in the database was made using PubMed, Publons and DOAJ. All selected articles were categorized into three groups: (1) clinical studies with the technical description of dosimetry in 177Lu-PSMA therapy (2) organ dosimetry in 177Lu-PSMA therapy or (3) tumor dosimetry in 177Lu-PSMA therapy. RESULT: In total, 182 citations were identified on PSMA therapy and 17 original articles on 177Lu-PSMA dosimetry were recognized as eligible for review. The median absorbed dose per unit of administered activity for kidneys, salivary, liver, spleen, lacrimal and bone marrow was 0.55, 0.81, 0.1, 0.1, 2.26 and 0.03 Gy/GBq, respectively. The median absorbed dose per unit of activity for tumor lesions was found in a range of 2.71-10.94 Gy/GBq. CONCLUSION: 177Lu-PSMA systemic radiation therapy (SRT) is a well-tolerated and reliable treatment option against the management of the mCRPC stage of prostate carcinoma. Lacrimal glands and salivary glands are the major critical organs in 177Lu-PSMA SRT. Besides, tumors receive 3-6 times higher absorbed doses compared to organs at risk.

ACO Spending and Utilization Among Medicare Patients at the End of Life: an Observational Study.

BACKGROUND: End-of-life (EOL) costs constitute a substantial portion of healthcare spending in the USA and have been increasing. ACOs may offer an opportunity to improve quality and curtail EOL spending. OBJECTIVE: To examine whether practices that became ACOs altered spending and utilization at the EOL. DESIGN: Retrospective analysis of Medicare claims. PATIENTS: We assigned patients who died in 2012 and 2015 to an ACO or non-ACO practice. Practices that converted to ACOs in 2013 or 2014 were matched to non-ACOs in the same region. A total of 23,643 ACO patients were matched to 23,643 non-ACO patients. MAIN MEASURES: Using a difference-in-differences model, we examined changes in EOL spending and care utilization after ACO implementation. KEY RESULTS: The introduction of ACOs did not significantly impact overall spending for patients in the last 6 months of life (difference-in-difference (DID) = $192, 95%CI -$841 to $1125, P = 0.72). Changes in spending did not differ between ACO and non-ACO patients across spending categories (inpatient, outpatient, physician services, skilled nursing, home health, hospice). No differences were seen between ACO and non-ACO patients in rates of ED visits, inpatient admissions, ICU admission, mean healthy days at home, and mean hospice days at 180 and 30 days prior to death. However, non-ACO patients had a significantly greater increase in hospice utilization compared to ACO patients at 180 days (DID P-value = 0.02) and 30 days (DID P-value = 0.01) prior to death. CONCLUSIONS: With the exception of hospice care utilization, spending and utilization were not different between ACOs and non-ACO patients at the EOL. Longer follow-up may be necessary to evaluate the impact of ACOs on EOL spending and care.

Spending outcomes among patients with cancer in accountable care organizations 4 years after implementation.

BACKGROUND: The long-term impact of affordable care organizations (ACOs) on cancer spending remains unknown. The authors examined whether practices that became ACOs altered their spending for patients with cancer in the first 4 years after ACO implementation. METHODS: By using national Medicare data from 2011 to 2017, a random sample of 20% of fee-for-service Medicare beneficiaries aged 65 years and older with cancer was obtained (n = 866,532), and each patient was assigned to a practice. Practices that became ACOs in the Medicare Shared Savings Program were matched to non-ACO practices. Total, cancer-specific, and service category-specific yearly spending per patient was calculated. A difference-in-differences model was used to determine spending changes associated with ACO status for patients with cancer in the 4 years after ACO implementation. RESULTS: The introduction of ACOs did not have a significant impact on overall spending for patients with cancer in the 2 years after ACO implementation (difference, -$38; 95% CI, -$268, $191; P = .74). Changes in spending also did not differ between ACO and non-ACO patients within service categories or among the 11 cancer types examined. The lack of difference in spending for patients with cancer in ACO and non-ACO practices persisted in the third and fourth years after ACO implementation (difference, -$120; 95% CI, -$284, $525; P = .56). CONCLUSIONS: ACOs did not significantly change spending for patients with cancer in the first 4 years after their implementation compared with non-ACOs. This prompts a reevaluation of the current efficacy of ACOs in reducing spending for cancer care and may encourage policymakers to reconsider the incentive structures of ACOs. LAY SUMMARY: Accountable care organizations (ACOs) were developed to curtail health care spending and improve quality, but their effects on cancer spending in their first 2 years have been minimal. The long-term impact of ACOs on cancer spending remains unknown. By using data from 866,532 Medicare beneficiaries with cancer, the authors observed that the association of a practice with an ACO did not significantly change total yearly spending per patient in the first 4 years after ACO implementation. This finding prompts a reevaluation of the current efficacy of ACOs in reducing spending for cancer care.

Association of Teaching Status and Mortality After Cancer Surgery.

OBJECTIVE: To examine patient outcomes for nine cancer-specific procedures performed in teaching versus non-teaching hospitals. SUMMARY BACKGROUND DATA: Few contemporary studies have evaluated patient outcomes in teaching versus non-teaching hospitals across a comprehensive set of cancer-specific procedures. METHODS: Use of national Medicare data to compare 30-, 60-, and 90-day mortality rates in teaching and non-teaching hospitals for cancer-specific procedures. Risk-adjusted 30-day, all-cause, postoperative mortality overall and for each specific surgery, as well as overall 60- and 90-day mortality rates, were assessed. RESULTS: The sample consisted of 159,421 total cancer surgeries at 3,151 hospitals. Overall thirty-day mortality rates, adjusted for procedure type, state, and invasiveness of procedure were 1.3% lower at major teaching hospitals (95%CI=-1.6% to -1.1%; p<0.001) relative to non-teaching hospitals. After accounting for patient characteristics, major teaching hospitals continued to demonstrate lower mortality rates compared with non-teaching hospitals (-1.0% difference [95%CI -1.2% to -0.7%]; p<0.001). Further adjustment for surgical volume as a mediator reduced the difference to -0.7% (95%CI -0.9% to -0.4%, p<0.001). Cancer surgeries for four of the nine disease sites (bladder, lung, colorectal and ovarian) followed this overall trend. Sixty- and ninety-day overall mortality rates, adjusted for procedure type, state, and invasiveness of procedure showed that major teaching hospitals had a 1.7% (95%CI -2.1% to -1.4%; p<0.001) and 2.0% (95%CI -2.4 to -1.6%, p<0.001) lower mortality relative to non-teaching hospitals. These trends persisted after adjusting for patient characteristics. CONCLUSIONS: Among cancer-specific procedures for Medicare beneficiaries, major teaching hospital status was associated with lower 30-, 60-, and 90-day mortality rates overall and across four of the nine cancer types.

Analysis of absorbed dose in radioimmunotherapy with 177Lu-trastuzumab using two different imaging scenarios: a pilot study.

OBJECTIVES: Internal organ dosimetry is an important procedure to demonstrate the reliable application of 177Lu-trastuzumab radioimmunotherapy for human epidermal growth factor receptor-positive metastatic breast cancers. We are reporting the first human dosimetry study for 177Lu-trastuzumab. Another objective of our study was to calculate and compare the absorbed doses for normal organs and tumor lesions in patients before radioimmunotherapy with 177Lu-trastuzumab using two different imaging scenarios. METHODS: Eleven patients (48.27 ± 8.95 years) with a history of metastatic breast cancer were included in the study. Postadministration of 177Lu-trastuzumab (351.09 ± 23.89 MBq/2 mg), acquisition was performed using planar and hybrid imaging scenarios at 4, 24, 72 and 168 h. Single-photon emission computed tomography/computed tomography imaging was performed at 72 h postinjection. Acquired images were processed using Dosimetry Toolkit software for the estimation of normalized cumulated activity in organs and tumor lesions. OLINDA/EXM 2.0 software was used for absorbed dose calculation in both scenarios. RESULTS: Significant difference in normalized cumulated activity and the absorbed dose is noted between two imaging scenarios for the organs and tumor lesions (P < 0.05). Mean absorbed dose (mGy/MBq) estimated from heart, lungs, liver, spleen, kidney, adrenal, pancreas and colon using planar and hybrid scenarios were 0.81 ± 0.19 and 0.63 ± 0.17; 0.75 ± 0.13 and 0.32 ± 0.06; 1.26 ± 0.25 and 1.01 ± 0.17; 0.68 ± 0.22 and 0.53 ± 0.16; 0.91 ± 0.3 and 0.69 ± 0.24; 0.18 ± 0.04 and 0.11 ± 0.02; 0.25 ± 0.22 and 0.09 ± 0.02 and 0.75 ± 0.61 and 0.44 ± 0.28, respectively. CONCLUSIONS: On the basis of our dosimetric evaluation, we concluded that radioimmunotherapy with 177Lu-trastuzumab is well tolerated to be implemented in routine clinical practice against HER2 positive metastatic breast cancer. Liver is the main critical organ at risk. Hybrid scenario demonstrated significantly lower absorbed doses in organs and tumors compared to the multiplanar method.

Differences in health outcomes for high-need high-cost patients across high-income countries.

OBJECTIVE: This study explores variations in outcomes of care for two types of patient personas-an older frail person recovering from a hip fracture and a multimorbid older patient with congestive heart failure (CHF) and diabetes. DATA SOURCES: We used individual-level patient data from 11 health systems. STUDY DESIGN: We compared inpatient mortality, mortality, and readmission rates at 30, 90, and 365 days. For the hip fracture persona, we also calculated time to surgery. Outcomes were standardized by age and sex. DATA COLLECTION/EXTRACTION METHODS: Data was compiled by the International Collaborative on Costs, Outcomes and Needs in Care across 11 countries for the years 2016-2017 (or nearest): Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States. PRINCIPAL FINDINGS: The hip sample across ranged from 1859 patients in Aragon, Spain, to 42,849 in France. Mean age ranged from 81.2 in Switzerland to 84.7 in Australia, and the majority of hip patients across countries were female. The congestive heart failure (CHF) sample ranged from 742 patients in England to 21,803 in the United States. Mean age ranged from 77.2 in the United States to 80.3 in Sweden, and the majority of CHF patients were males. Average in-hospital mortality across countries was 4.1%. for the hip persona and 6.3% for the CHF persona. At the year mark, the mean mortality across all countries was 25.3% for the hip persona and 32.7% for CHF persona. Across both patient types, England reported the highest mortality at 1 year followed by the United States. Readmission rates for all periods were higher for the CHF persona than the hip persona. At 30 days, the average readmission rate for the hip persona was 13.8% and 27.6% for the CHF persona. CONCLUSION: Across 11 countries, there are meaningful differences in health system outcomes for two types of patients.

Healthy days at home: A population-based quality measure for cancer patients at the end of life.

BACKGROUND: Healthy Days at Home (HDAH) is a novel population-based outcome measure. In this study, its use as a potential measure for cancer patients at the end of life (EOL) was explored. METHODS: Patient demographics and health care use among Medicare beneficiaries with cancer who died over the years 2014 to 2017 were identified. The HDAH was calculated by subtracting the following components from 180 days: number of days spent in inpatient and outpatient hospital observation, the emergency room, skilled nursing facilities (SNF), inpatient psychiatry, inpatient rehabilitation, long-term hospitals, and inpatient hospice. How HDAH and its components varied by beneficiary demographics and health care market were evaluated. A patient-level linear regression model with HDAH as the outcome, hospital referral region (HRR) random effects, and market fixed effects were specified, as well as beneficiary age, sex, and comorbidities as covariates. RESULTS: The 294,751 beneficiaries at the EOL showed a mean number of 154.0 HDAH (out of 180 days). Inpatient (10.7 days) and SNF (9.7 days) resulted in the most substantial reductions in HDAH. Males had fewer adjusted HDAH (153.1 vs 155.7, P < .001) than females; Medicaid-eligible patients had fewer HDAH compared with non-Medicaid-eligible patients (152.0 vs 154.9; P < .001). Those with hematologic malignancies had the fewest number of HDAH (148.9). Across HRRs, HDAH ranged from 10.8 fewer to 10.9 more days than the national mean. At the HRR-level, home hospice was associated with greater HDAH, whereas home health was associated with fewer HDAH. CONCLUSIONS: HDAH may be a useful measure to understand, quantify, and improve patient-centered outcomes for cancer patients at EOL.

Comparison of Patient Outcomes of Surgeons Who Are US Versus International Medical Graduates.

OBJECTIVE: The aim of this study was to compare patient outcomes between International Medical Graduate (IMG) versus US medical graduate (USMG) surgeons. SUMMARY BACKGROUND DATA: One in 7 surgeons practicing in the US graduated from a foreign medical school. However, it remains unknown whether patient outcomes differ between IMG versus USMG surgeons. METHODS: Using 20% random sample of Medicare fee-for-service beneficiaries aged 65 to 99 years who underwent 1 of 13 common nonelective surgical procedures (as a "natural experiment" as surgeons are less likely to select patients in this context) in 2011 to 2014 (638,973 patients treated by 37,221 surgeons for the mortality analysis), we compared operative mortality, complications, and length of stay (LOS) between IMG and USMG surgeons, adjusting for patient and surgeon characteristics and hospital-specific fixed effects (effectively comparing IMG and USMG surgeons within the same hospital). We also conducted stratified analyses by patients' severity of illness and procedure type. RESULTS: We found no evidence that patient outcomes differ between IMG and USMG surgeons for operative mortality [adjusted mortality, 7.3% for IMGs vs 7.3% for USMGs; adjusted odds ratio (aOR), 1.01; 95% confidence interval (CI), 0.96-1.05; P = 0.79], complication rate (adjusted complication rate, 0.6% vs 0.6%; aOR, 0.95; 95% CI, 0.85-1.06; P = 0.43), and LOS (adjusted LOS, 6.6 days vs 6.6 days; adjusted difference, +0.02 days; 95% CI, -0.05 to +0.08; P = 0.54). We also found no difference when we stratified by severity of illness and procedures. CONCLUSION: Using national data of Medicare beneficiaries who underwent common surgical procedures, we found no evidence that outcomes differ between IMG and USMG surgeons.

Skull Base Chordoma: Long-Term Observation and Evaluation of Prognostic Factors after Surgical Resection.

BACKGROUND: Skull base chordoma (SBC) is relatively rare and data on its clinical outcome after surgical resection and adjuvant radiotherapy are still limited. OBJECTIVE: Analyzing the clinical postoperative outcome of SBC patients and defining prognostic factors regarding current treatment modalities. METHODS AND MATERIAL: In this study, 41 SBC patients from 2001 to 2017 were retrospectively analyzed in this single-center study. RESULTS: The most common clinical symptoms were headache (63%) and problems concerning vision (54%) like diplopia. The follow-up controls took place from 1 to 192 months. The mean survival time for the patients was 123.37 months (95% CI 90.89-155.86). The 5- and 10-year survival rates were 73.3 and 49%, respectively. Regarding the Karnofsky-Performance Scale (KPS), Cox regression showed a significant relationship between the survival rates in the overall study population and pre-surgery KPS (P = 0.004). This was further supported with a positive significant correlation between the pre-surgery KPS and the KPS at the last follow-up (P = 0.039). CONCLUSION: Statistical analysis showed that repeat surgical resection and radiotherapy could be prognostic factors. Furthermore, we were able to show that mortality decreased by 4.5% with each 10 points increase of pre-surgery KPS. This could be a major prognostic factor when deciding treatment modalities. Nevertheless, further standardized clinical studies with a larger patient population should be carried out to extrapolate prognostic factors and improve treatment modalities.

Changes in Racial Disparities in Mortality After Cancer Surgery in the US, 2007-2016.

Importance: Racial disparities are well documented in cancer care. Overall, in the US, Black patients historically have higher rates of mortality after surgery than White patients. However, it is unknown whether racial disparities in mortality after cancer surgery have changed over time. Objective: To examine whether and how disparities in mortality after cancer surgery have changed over 10 years for Black and White patients overall and for 9 specific cancers. Design, Setting, and Participants: In this cross-sectional study, national Medicare data were used to examine the 10-year (January 1, 2007, to November 30, 2016) changes in postoperative mortality rates in Black and White patients. Data analysis was performed from August 6 to December 31, 2019. Participants included fee-for-service beneficiaries enrolled in Medicare Part A who had a major surgical resection for 9 common types of cancer surgery: colorectal, bladder, esophageal, kidney, liver, ovarian, pancreatic, lung, or prostate cancer. Exposures: Cancer surgery among Black and White patients. Main Outcomes and Measures: Risk-adjusted 30-day, all-cause, postoperative mortality overall and for 9 specific types of cancer surgery. Results: A total of 870 929 cancer operations were performed during the 10-year study period. In the baseline year, a total of 103 446 patients had cancer operations (96 210 White patients and 7236 Black patients). Black patients were slightly younger (mean [SD] age, 73.0 [6.4] vs 74.5 [6.8] years), and there were fewer Black vs White men (3986 [55.1%] vs 55 527 [57.7%]). Overall national mortality rates following cancer surgery were lower for both Black (-0.12%; 95% CI, -0.17% to -0.06% per year) and White (-0.14%; 95% CI, -0.16% to -0.13% per year) patients. These reductions were predominantly attributable to within-hospital mortality improvements (Black patients: 0.10% annually; 95% CI, -0.15% to -0.05%; P < .001; White patients: 0.13%; 95% CI, -0.14% to -0.11%; P < .001) vs between-hospital mortality improvements. Across the 9 different cancer surgery procedures, there was no significant difference in mortality changes between Black and White patients during the period under study (eg, prostate cancer: 0.35; 95% CI, 0.02-0.68; lung cancer: 0.61; 95% CI, -0.21 to 1.44). Conclusions and Relevance: These findings offer mixed news for policy makers regarding possible reductions in racial disparities following cancer surgery. Although postoperative cancer surgery mortality rates improved for both Black and White patients, there did not appear to be any narrowing of the mortality gap between Black and White patients overall or across individual cancer surgery procedures.

Medicaid Expansion and Mortality Among Patients With Breast, Lung, and Colorectal Cancer.

Importance: Medicaid expansion under the Patient Protection and Affordable Care Act may be associated with increased screening and may improve access to earlier treatment for cancer, but its association with mortality for patients with cancer is uncertain. Objective: To determine whether Medicaid expansion is associated with improved mortality among patients with cancer. Design, Setting, and Participants: This is a quasi-experimental, difference-in-difference (DID), cross-sectional, population-based study. Patients in the National Cancer Database with breast, lung, or colorectal cancer newly diagnosed from January 1, 2012, to December 31, 2015, were included. Data analysis was performed from January to May 2020. Exposure: Living in a state where Medicaid was expanded vs a nonexpansion state. Main Outcomes and Measures: The main outcome was mortality rate according to whether the patient lived in a state where Medicaid was expanded. Results: A total of 523 802 patients (385 739 women [73.6%]; mean [SD] age, 54.8 [6.5] years) had a new diagnosis of invasive breast (273 272 patients [52.2%]), colorectal (111 720 patients [21.3%]), or lung (138 810 patients [26.5%]) cancer; 289 330 patients (55.2%) lived in Medicaid expansion states, and 234 472 patients (44.8%) lived in nonexpansion states. After Medicaid expansion, mortality significantly decreased in expansion states (hazard ratio [HR], 0.98; 95% CI, 0.97-0.99; P = .008) but not in nonexpansion states (HR, 1.01; 95% CI, 0.99-1.02; P = .43), resulting in a significant DID (HR, 1.03; 95% CI, 1.01-1.05; P = .01). This difference was seen primarily in patients with nonmetastatic cancer (stages I-III). After adjusting for cancer stage, the mortality improvement in expansion states from the periods before and after expansion was no longer evident (HR, 1.00; 95% CI, 0.98-1.02; P = .94), nor was the difference between expansion vs nonexpansion states (DID HR, 1.00; 95% CI, 0.98-1.02; P = .84). Conclusions and Relevance: Among patients with newly diagnosed breast, colorectal, and lung cancer, Medicaid expansion was associated with a decreased hazard of mortality in the postexpansion period, which was mediated by earlier stage of diagnosis.

Evaluation of factors associated with complications in amoebic liver abscess in a predominantly toddy-drinking population: A retrospective study of 198 cases.

BACKGROUND AND AIM: Although the mortality rate has declined in recent years, amoebic liver abscesses (ALAs) still carry a substantial risk of morbidity. Studies regarding the indicators of severity, complication, or prognosis of ALA are limited in number and heterogeneous in methodology and results. METHODS: Clinicodemographic profile, therapeutic modalities, and outcomes of indoor ALA patients admitted between January 2016 and October 2017 were analyzed. An analysis of possible prognostic factors associated with complications and interventional therapy in patients with ALA was performed retrospectively. RESULTS: Data of 198 patients with ALA (mean age: 45 ± 12.1; M:F ratio: 193:5) were analyzed. The volume of abscess (503.1 ± 391.2: 300.2 ± 305.8 mL), elevated liver enzymes, and duration of hospital stay (11.98 ± 5.75): 10.23 ± 4.1 days) were significantly (P < 0.05) higher in alcoholic, compared to nonalcoholic, individuals. On univariate analysis, older age, duration of alcohol consumption, smoking, leukocytosis, hyperbilirubinemia, hypoalbuminemia, hyponatremia, and a larger volume of abscess were found to be significantly (P < 0.05) associated with complications. On multivariate analysis, older age, duration of alcohol consumption, smoking, leukocytosis, hyperbilirubinemia, hypoalbuminemia, and hyponatremia were found to be significantly (P < 0.05) associated with complications. Male gender, hypoalbuminemia, and larger volume of abscess were significantly (P < 0.05) associated with interventional treatment. CONCLUSION: Older age, leukocytosis, hyperbilirubinemia, hypoalbuminemia, hyponatremia, chronic alcoholism, and smoking are independent factors significantly associated with complications in patients with ALA. Hypoalbuminemia, larger volume of abscess, and male gender are independent variables associated with the requirement of interventional therapy.

Performance of UK National Health Service compared with other high income countries: observational study.

OBJECTIVE: To determine how the UK National Health Service (NHS) is performing relative to health systems of other high income countries, given that it is facing sustained financial pressure, increasing levels of demand, and cuts to social care. DESIGN: Observational study using secondary data from key international organisations such as Eurostat and the Organization for Economic Cooperation and Development. SETTING: Healthcare systems of the UK and nine high income comparator countries: Australia, Canada, Denmark, France, Germany, the Netherlands, Sweden, Switzerland, and the US. MAIN OUTCOME MEASURES: 79 indicators across seven domains: population and healthcare coverage, healthcare and social spending, structural capacity, utilisation, access to care, quality of care, and population health. RESULTS: The UK spent the least per capita on healthcare in 2017 compared with all other countries studied (UK $3825 (£2972; €3392); mean $5700), and spending was growing at slightly lower levels (0.02% of gross domestic product in the previous four years, compared with a mean of 0.07%). The UK had the lowest rates of unmet need and among the lowest numbers of doctors and nurses per capita, despite having average levels of utilisation (number of hospital admissions). The UK had slightly below average life expectancy (81.3 years compared with a mean of 81.7) and cancer survival, including breast, cervical, colon, and rectal cancer. Although several health service outcomes were poor, such as postoperative sepsis after abdominal surgery (UK 2454 per 100 000 discharges; mean 2058 per 100 000 discharges), 30 day mortality for acute myocardial infarction (UK 7.1%; mean 5.5%), and ischaemic stroke (UK 9.6%; mean 6.6%), the UK achieved lower than average rates of postoperative deep venous thrombosis after joint surgery and fewer healthcare associated infections. CONCLUSIONS: The NHS showed pockets of good performance, including in health service outcomes, but spending, patient safety, and population health were all below average to average at best. Taken together, these results suggest that if the NHS wants to achieve comparable health outcomes at a time of growing demographic pressure, it may need to spend more to increase the supply of labour and long term care and reduce the declining trend in social spending to match levels of comparator countries.

Early Accountable Care Organization Results in End-of-Life Spending Among Cancer Patients.

BACKGROUND: Spending on cancer patients is substantial and has increased in recent years. Accountable care organizations (ACOs) are arguably the most important national experiment to control health-care spending. How ACOs are managing patients with cancer at the end of life (EOL) is largely unknown. We conducted this study with the objective of determining whether becoming an ACO is associated with subsequent changes in EOL spending or utilization among patients with cancer. METHODS: Using national Medicare claims from 2011 to 2015, we identified patients who died in 2012 (pre-ACO, n = 12 248) and 2015 (post-ACO, n = 12 248), assigning each decedent to a practice. ACOs were matched to non-ACOs within the same geographic region. We used a difference-in-difference model to examine changes in EOL spending and utilization associated with becoming an ACO in the Medicare Shared Savings Program for beneficiaries with cancer. RESULTS: We found that the introduction of ACOs had no meaningful impact on overall EOL spending in cancer patients (change in overall spending in ACOs = -$1687 vs -$1434 in non-ACOs, difference = $253, 95% confidence interval = -$1809 to $1304, P= .75). We found no changes in total patient spending by cancer type examined or by spending categories, including cancer-specific categories of radiation, therapy, and hospice services. Finally, emergency department visits, inpatient hospitalization, intensive care unit admissions, radiation therapy, chemotherapy, and hospice use did not meaningfully differ between ACO and non-ACO patients. CONCLUSIONS: The introduction of ACOs does not appear to have had any meaningful effect on EOL spending or utilization for patients with a cancer diagnosis.