The Effects of Isocaloric Intermittent Fasting vs Daily Caloric Restriction on Weight Loss and Metabolic Risk Factors for Noncommunicable Chronic Diseases: A Systematic Review of Randomized Controlled or Comparative Trials.

BACKGROUND: Intermittent fasting (IF) has gained favor as an alternative regimen to daily caloric restriction (DCR). Therefore, there is a need for systematic reviews of randomized controlled/comparison trials examining the effects of isocaloric IF vs DCR on metabolic risk factors for noncommunicable chronic diseases. OBJECTIVE: To systematically investigate the effects of isocaloric IF vs DCR on metabolic risk factors for noncommunicable chronic diseases in adults with overweight and obesity. METHODS: Five online databases (PubMed, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar) were searched for articles published from January 2000 through April 2022. The updated Cochrane Risk of Bias Assessment tool for randomized controlled/comparison trials was used to assess risk of bias in the included studies. This review includes randomized controlled/comparison trials with matched energy intakes (isocaloric) between IF and DCR among adults with overweight and obesity with ≥8-week durations, that assessed risk factors related to obesity and for diabetes, cardiovascular diseases, and cancers. RESULTS: Thirteen randomized controlled/comparison trials with matched energy intakes (isocaloric) between IF and DCR were identified. The effects of IF on weight loss and metabolic risk markers of diabetes, cardiovascular diseases, and cancers were varied but generally comparable with DCR. IF (4:3 and 5:2 diets) was superior to DCR for improving insulin sensitivity in two studies. Reductions in body fat were significantly greater with IF (5:2 diet and time-restricted eating) than DCR in two studies of isocaloric diets. CONCLUSIONS: With matched energy intakes, IF interventions produced similar beneficial effects for weight loss and chronic disease risk factors compared with DCR. Very limited evidence suggests that IF may be more effective vs DCR for fat loss and insulin sensitivity, but conclusions cannot be drawn based on the current evidence. Future clinical studies with larger populations and longer durations are needed for further elucidation of any potential effects of IF regimens for prevention of noncommunicable chronic diseases.

The Effects of Adding Semaglutide to High Daily Dose Insulin Regimens in Patients With Type 2 Diabetes.

BACKGROUND: Escalating doses of insulin required with progression of type 2 diabetes may lead to weight gain. Weight loss associated with semaglutide may be beneficial. However, data on the use of semaglutide in patients requiring high daily doses of insulin are currently lacking. OBJECTIVE: The purpose of this project was to evaluate the impact of semaglutide on total daily dose (TDD) of insulin when initiated in patients with type 2 diabetes mellitus (T2DM) on high daily doses of insulin. Secondary objectives assessed included changes in weight, body mass index (BMI), blood pressure, heart rate, and diabetes and blood pressure medications. METHODS: This IRB exempt retrospective medical record review included patients with T2DM prescribed semaglutide and at least 100 units TDD of insulin between January 1, 2019, and December 31, 2019. RESULTS: Of the 72 patients included, the TDD of insulin decreased from baseline to 6 months (183 ± 98 units and 143 ± 99 units, P < 0.001). Average A1c and body weight also decreased from baseline to 6 months (8.9% ± 1.3% and 7.6% ± 1.5%, P < 0.001 and 123.9 ± 23.5 kg and 118.9 ± 22.9 kg, P < 0.001, respectively). Limitations included a homogenous patient population and inability to control confounding factors. CONCLUSION AND RELEVANCE: Improvement in glycemic control occurred despite reductions in TDD of insulin. Improvements in A1c and body weight were clinically significant. This analysis adds to existing literature supporting the use of GLP-1 RAs in patients on high daily doses of insulin.

ACO Participation Associated With Decreased Spending For Medicare Beneficiaries With Serious Mental Illness.

Serious mental illness (SMI) is a major source of suffering among Medicare beneficiaries. To date, limited evidence exists evaluating whether Medicare accountable care organizations (ACOs) are associated with decreased spending among people with SMI. Using national Medicare data from the period 2009-17, we performed difference-in-differences analyses evaluating changes in spending and use associated with enrollment in the Medicare Shared Savings Program (MSSP) among beneficiaries with SMI. After five years, participation in MSSP ACOs was associated with small savings for beneficiaries with SMI (-$233 per person per year) in total health care spending, primarily related to savings from chronic medical conditions (excluding mental health; -$227 per person per year) and not from savings related to mental health services (-$6 per person per year). Savings were driven by reductions in acute and postacute care for medical conditions. Further work is needed to ensure that Medicare ACOs invest in strategies to reduce potentially unnecessary care related to mental health disorders and to improve health outcomes.

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.

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.