Disparities in eye clinic patient encounters among patients requiring language interpreter services.

BACKGROUND: Communication barriers are a major cause of health disparities for patients with limited English proficiency (LEP). Medical interpreters play an important role in bridging this gap, however the impact of interpreters on outpatient eye center visits has not been studied. We aimed to evaluate the differences in length of eyecare visits between LEP patients self-identifying as requiring a medical interpreter and English speakers at a tertiary, safety-net hospital in the United States. METHODS: A retrospective review of patient encounter metrics collected by our electronic medical record was conducted for all visits between January 1, 2016 and March 13, 2020. Patient demographics, primary language spoken, self-identified need for interpreter and encounter characteristics including new patient status, patient time waiting for providers and time in room were collected. We compared visit times by patient's self-identification of need for an interpreter, with our main outcomes being time spent with ophthalmic technician, time spent with eyecare provider, and time waiting for eyecare provider. Interpreter services at our hospital are typically remote (via phone or video). RESULTS: A total of 87,157 patient encounters were analyzed, of which 26,443 (30.3%) involved LEP patients identifying as requiring an interpreter. After adjusting for patient age at visit, new patient status, physician status (attending or resident), and repeated patient visits, there was no difference in the length of time spent with technician or physician, or time spent waiting for physician, between English speakers and patients identifying as needing an interpreter. Patients who self-identified as requiring an interpreter were more likely to have an after-visit summary printed for them, and were also more likely to keep their appointment once it was made when compared to English speakers. CONCLUSIONS: Encounters with LEP patients who identify as requiring an interpreter were expected to be longer than those who did not indicate need for an interpreter, however we found that there was no difference in the length of time spent with technician or physician. This suggests providers may adjust their communication strategy during encounters with LEP patients identifying as needing an interpreter. Eyecare providers must be aware of this to prevent negative impacts on patient care. Equally important, healthcare systems should consider ways to prevent unreimbursed extra time from being a financial disincentive for seeing patients who request interpreter services.

Impact of the National Centralized Drug Procurement Policy (4 + 7 policy) on the drug expenditures of patients treated in outpatient and emergency departments in a large tertiary level-A hospital in China: A single centre, interrupted time series.

WHAT IS KNOWN AND OBJECTIVE: Like many countries in the world, China is also facing growing drug expenditures year by year. In particular, the rising cost of prescription drugs has been one of the critical factors leading to the serious burden on health insurance programs. The high cost of prescription drugs not only threatens the health budget but also limits the nation's investment in other public sectors. China implemented the National Centralized Drug Procurement (NCDP) policy, also known as the "4 + 7" policy, in tertiary hospitals in various provinces and cities across the country on 18 December 2019, aiming to lessen personal and national health insurance burdens by reducing drug procurement prices. The aim of this study is to explore the impact of the implementation of the NCDP policy on the drug expenditures of patients treated in outpatient and emergency departments and on national health insurance expenditures. METHODS: This study adopts interrupted time series (ITS) to evaluate the impact of China's implementation of the NCDP policy on the drug expenditures of patients treated in outpatient and emergency departments in a tertiary hospital. The NCDP policy was officially implemented on 18 December 2019. A segmented regression model is utilized to analyse the average monthly drug expenditures of patients treated in outpatient and emergency departments from January 2018 to June 2021, including the average monthly per-visit drug expenditures of all patients and the average monthly per-visit drug expenditures of patients who paid for drugs with health insurance and those who did not use health insurance. RESULTS: After the implementation of the NCDP policy, the overall average monthly per-visit drug expenditures of patients treated in outpatient and emergency departments were immediately reduced by 233.954 CNY (p < 0.01). Compared with the continued downward trend for drug expenditures before the implementation of the NCDP policy, the long-term trend after policy implementation was not obvious (p = 0.051973>0.05). Similarly, the average monthly per-visit drug expenditures of patients treated in outpatient and emergency departments who use health insurance to procure drugs also immediately decreased by 505.287 CNY (p < 0.01), but the long-term trends before (p = 0.469>0.05) and after policy implementation (p = 0.51>0.05) did not exhibit obvious change. For the average monthly per-visit drug expenditures of patients treated in outpatient and emergency departments who did not use health insurance, the implementation of the NCDP policy did not produce an immediate reduction in drug expenditures (p = 0.3603>0.05). Although the average monthly per-visit drug expenditures decreased by 9.078 CNY (p < 0.01) before policy implementation, this trend ended after the policy was implemented (p = 0.0735>0.05), and no other changes were triggered. WHAT IS NEW AND CONCLUSION: This study reviews the data for a period of time before and after the implementation of the NCDP policy. The policy is shown to significantly decrease the average monthly per-visit drug expenditures of patients treated in outpatient and emergency departments.

Efficacy of a pediatric headache infusion center: A single-center experience.

OBJECTIVE: To evaluate the efficacy of a pediatric headache infusion center (HIC) in alleviating the symptoms and preventing future visits to the emergency department (ED). BACKGROUND: Headache is a common reason for visits to the pediatric ED. ED visits are associated with inordinate costs of care and are conceived by parents to be avoidable if adequate alternatives are available. An infusion center for acute treatment of intractable headache in children with chronic migraine may be an effective alternative to an ED visit. METHODS: This was a retrospective analysis of data from a single-center cohort of patients with a known history of chronic migraine, presenting to Dayton Children's HIC with an acute migraine from June 1, 2017 to June 1, 2020. Patients were treated according to established protocols divided into two pathways. Patient demographics, clinical characteristics, pre- and postinfusion pain scores, ED visits and inpatient admissions within 2 weeks of HIC visit, and ED visits 1 year prior and 1 year after the HIC visit were noted. RESULTS: A total of 297 HIC visits were analyzed from 201 patients. The HIC was effective in controlling symptoms with a significant reduction in pain score (median [interquartile range; IQR] 7.0 [2.0] preinfusion vs. 1.0 [2.0] postinfusion, p < 0.001). Only 25/297 (8.4%) patients came to the ED within 2 weeks of the HIC visit, and an even smaller number of patients (20/297, 6.7%) were admitted as inpatients within 2 weeks of the HIC visit. The number of ED visits was significantly reduced in the year after the HIC visit compared with the year prior (median [IQR] 1.0 [2.0] before vs. 0.0 [1.0] after, p < 0.001). CONCLUSION: A pediatric HIC is effective in alleviating the symptoms and preventing ED visits. These centers should be considered as standard of care at children's hospitals.

Disparities in utilization of outpatient surgical care among children.

BACKGROUND: The purpose of this study was to quantify disparities in the utilization of outpatient pediatric surgical care and to examine the extent to which neighborhood-level socioeconomic disadvantage is associated with access to care among children. METHODS: Clinic "no-shows" were examined among children scheduled from 2017 to 2019 at seven pediatric surgery clinics associated with a tertiary care children's hospital. The association between Area Deprivation Index, a neighborhood-level measure of socioeconomic disadvantage, and other patient factors with clinic no-shows was examined using multivariable logistic regression models. Difficulties in accessing postoperative care in particular were explored in a subgroup analysis of postoperative (within 90 days) clinic visits after appendectomy or inguinal/umbilical hernia repairs. RESULTS: Among 10,162 patients, 16% had at least 1 no-show for a clinic appointment. Area Deprivation Index (most deprived decile adjusted odds ratio 3.17, 95% confidence interval 2.20-4.58, P < .001), Black race (adjusted odds ratio 3.30, 95% confidence interval 2.70-4.00, P < .001), and public insurance (adjusted odds ratio 2.75, 95% confidence interval 2.38-3.31, P < .001) were associated with having at least 1 no-show. Similar associations were identified among 2,399 children scheduled for postoperative clinic visits after undergoing appendectomy or inguinal/umbilical hernia repair, among whom 20% were a no-show. CONCLUSION: Race, insurance type, and neighborhood-level socioeconomic disadvantage are associated with disparities in utilization of outpatient pediatric surgical care. Challenges accessing routine outpatient care among disadvantaged children may be one mechanism through which disparate outcomes result among children requiring surgical care.

A retrospective study comparing interventions by oncology and non-oncology pharmacists in outpatient chemotherapy.

BACKGROUND: The differences in the clinical pharmacy services (CPS) provided by oncology and non-oncology pharmacists have not been sufficiently explained. AIM: This study aimed to demonstrate the differences in direct CPS provided by oncology and non-oncology pharmacists for patients and physicians, and to assess the potential impact of these services on medical costs. METHODS: We retrospectively examined CPS provided by oncology and non-oncology pharmacists for outpatients who underwent chemotherapy between January and December 2016. RESULTS: In total, 1177 and 1050 CPS provided by oncology and non-oncology pharmacists, respectively, were investigated. The rates of interventions performed by oncology and non-oncology pharmacists for physicians-determined treatment were 18.5% and 11.3%, respectively (p < .001). The rates of oncology and non-oncology pharmacist interventions accepted by physicians were 84.6 and 78.8%, respectively (p = .12). Level 4 and Level 5 interventions accounted for 64.6% of all oncology pharmacist interventions and 53.0% of all non-oncology pharmacist interventions (p = .03). The rates of improvement in symptoms from adverse drug reactions among patients resulting from interventions by oncology and non-oncology pharmacists were 89.4 and 72.1%, respectively (p = .02). Conservative assessments of medical cost impact showed that a single intervention by an oncology and by a non-oncology pharmacist saved ¥6355 and ¥3604, respectively. CONCLUSION: The results of the present study suggested that CPS by oncology pharmacists enable safer and more effective therapy for patients with cancer and indirectly contribute to reducing health care fees.

Association of Race, Health Insurance Status, and Household Income With Location and Outcomes of Ambulatory Surgery Among Adult Patients in 2 US States.

Importance: The receipt of surgery in freestanding ambulatory surgery centers (ASCs) is often less costly compared with surgery in hospital-based outpatient departments. Although increasing numbers of surgical procedures are now being performed in freestanding ASCs, questions remain regarding the existence of disparities among patients receiving care at ASCs. Objective: To examine the association of patient race, health insurance status, and household income with the location (ASC vs hospital-based outpatient department) of ambulatory surgery. Design, Setting, and Participants: This cohort study used data from the State Ambulatory Surgery and Services Databases of the Healthcare Cost and Utilization Project to perform a secondary analysis of patients who received ambulatory surgery in New York and Florida between 2011 and 2013. Patients aged 18 to 89 years who underwent 12 different types of ambulatory surgical procedures were included. Data were analyzed from December 2018 to June 2019. Main Outcomes and Measures: Receipt of surgery at a freestanding ASC and 30-day unplanned hospital visits after ambulatory surgery. Results: A total of 5.6 million patients in New York (57.4% female; 68.9% aged ≥50 years; and 62.5% White) and 7.5 million patients in Florida (57.3% female; 77.4% aged ≥50 years; 74.3% White) who received ambulatory surgery were included in the analysis. After adjusting for age, comorbidities, health insurance status, household income, location of surgery, and type of surgical procedure, the likelihood of receiving ambulatory surgery at a freestanding ASC was significantly lower among Black patients (adjusted odds ratio [aOR], 0.82; 95% CI, 0.81-0.83; P < .001) and Hispanic patients (aOR, 0.78; 95% CI, 0.77-0.79; P < .001) compared with White patients in New York. This likelihood was also lower among Black patients (aOR, 0.65; 95% CI, 0.65-0.66; P < .001) compared with White patients in Florida. Public health insurance coverage was associated with a significantly lower likelihood of receiving ambulatory surgery at freestanding ASCs in both New York and Florida, particularly among patients with Medicaid (in New York, aOR, 0.22; 95% CI, 0.22-0.22; P < .001; in Florida, aOR, 0.40; 95% CI, 0.40-0.41; P < .001) and Medicare (in New York, aOR, 0.46; 95% CI, 0.46-0.46; P < .001; in Florida, aOR, 0.67; 95% CI, 0.66-0.67; P < .001). Conclusions and Relevance: Differences in the use of freestanding ASCs were found among Black patients and patients with public health insurance. Further exploration of the factors underlying these differences will be important to ensure that all populations have access to the increasing number of freestanding ASCs.

Quick diagnosis units: predictors of time to diagnosis and costs.

Financial crisis has forced health systems to seek alternatives to hospitalization-based healthcare. Quick diagnosis units (QDUs) are cost-effective compared to hospitalization, but the determinants of QDU costs have not been studied.We aimed at assessing the predictors of costs of a district hospital QDU (Hospital Plató, Barcelona) between 2009 and 2016.This study was a retrospective longitudinal single center study of 404 consecutive outpatients referred to the QDU of Hospital Plató. The referral reason was dichotomized into suggestive of malignancy vs other. The final diagnosis was dichotomized into organic vs nonorganic and malignancy vs nonmalignancy. All individual resource costs were obtained from the finance department to conduct a micro-costing analysis of the study period.Mean age was 62 ±â€Š20 years (women = 56%), and median time-to-diagnosis, 12 days. Total and partial costs were greater in cases with final diagnosis of organic vs nonorganic disorder, as it was in those with symptoms suggestive or a final diagnosis of cancer vs noncancer. Of all subcosts, imaging showed the stronger correlation with total cost. Time-to-diagnosis and imaging costs were significant predictors of total cost above the median in binary logistic regression, with imaging costs also being a significant predictor in multiple linear regression (with total cost as quantitative outcome).Predictors of QDU costs are partly nonmodifiable (i.e., cancer suspicion, actually one of the goals of QDUs). Yet, improved primary-care-to-hospital referral circuits reducing time to diagnosis as well as optimized imaging protocols might further increase the QDU cost-effectiveness process. Prospective studies (ideally with direct comparison to conventional hospitalization costs) are needed to explore this possibility.

Opioids or Steroids for Pneumonia or Sinusitis.

OBJECTIVES: To compare the frequency of opioid and corticosteroid prescriptions dispensed for children with pneumonia or sinusitis visits on the basis of location of care. METHODS: We evaluated 2016 South Carolina Medicaid claims data for 5 to 18 years olds with pneumonia or sinusitis. Visits were associated with 1 of 3 locations: the emergency department (ED), urgent care, or the ambulatory setting. RESULTS: Inclusion criteria were met by 31 838 children. Pneumonia visits were more often linked to an opioid prescription in the ED (34 of 542 [6.3%]) than in ambulatory settings (24 of 1590 [1.5%]; P ≤ .0001) and were more frequently linked to a steroid prescription in the ED (106 of 542 [19.6%]) than in ambulatory settings (196 of 1590 [12.3%]; P ≤ .0001). Sinusitis visits were more often linked to an opioid prescription in the ED (202 of 2705 [7.5%]) than in ambulatory settings (568 of 26 866 [2.1%]; P ≤ .0001) and were more frequently linked to a steroid prescription in the ED (510 of 2705 [18.9%]) than in ambulatory settings (1922 of 26 866 [7.2%]; P ≤ .0001). In logistic regression for children with pneumonia, the ED setting was associated with increased odds of receiving an opioid (adjusted odds ratio [aOR] 4.69) or steroid (aOR 1.67). Similarly, patients with sinusitis were more likely to be prescribed opioids (aOR 4.02) or steroids (aOR 3.05) in the ED than in ambulatory sites. CONCLUSIONS: School-aged children received opioid and steroid prescriptions for pneumonia or sinusitis at a higher frequency in the ED versus the ambulatory setting.

COVID-19 strategy in organizing and planning orthopedic surgery in a major orthopedic referral center in an area of Italy severely affected by the pandemic: experience of the Department of Orthopedics, University of Padova.

BACKGROUND: According to the required reorganization of all hospital activities, the recent COVID-19 pandemic had dramatic consequences on the orthopedic world. We think that informing the orthopedic community about the strategy that we adopted both in our hospital and in our Department of Orthopedics could be useful, particularly for those who are facing the pandemic later than Italy. METHODS: Changes were done in our hospital by medical direction to reallocate resources to COVID-19 patients. In the Orthopedic Department, a decrease in the number of beds and surgical activity was stabilized. Since March 13, it has been avoided to perform elective surgery, and since March 16, non-urgent outpatient consultations were abolished. This activity reduction was associated with careful evaluation of staff and patients: extensive periodical swab testing of all healthcare staff and swab testing of all surgical patients were applied. RESULTS: These restrictions determined an overall reduction of all our surgical activities of 30% compared to 2019. We also had a reduction in outpatient clinic activities and admissions to the orthopedic emergency unit. Extensive swab testing has proven successful: of more than 160 people tested in our building, only three COVID-19 positives were found, and of over more than 200 surgical procedures, only two positive patients were found. CONCLUSIONS: Extensive swab test of all people (even if asymptomatic) and proactive tracing and quarantining of potential COVID-19 positive patients may diminish the virus spread.

The Economic Burden of Out-of-Pocket Expenses for Plastic Surgery Procedures.

BACKGROUND: Health insurance reimbursement structure has evolved, with patients becoming increasingly responsible for their health care costs through rising out-of-pocket expenses. High levels of cost sharing can lead to delays in access to care, influence treatment decisions, and cause financial distress for patients. METHODS: Patients undergoing the most common outpatient reconstructive plastic surgery operations were identified using Truven MarketScan databases from 2009 to 2017. Total cost of the surgery paid to the insurer and out-of-pocket expenses, including deductible, copayment, and coinsurance, were calculated. Multivariable generalized linear modeling with log link and gamma distribution was used to predict adjusted total and out-of-pocket expenses. All costs were inflation-adjusted to 2017 dollars. RESULTS: The authors evaluated 3,165,913 outpatient plastic and reconstructive surgical procedures between 2009 and 2017. From 2009 to 2017, total costs had a significant increase of 25 percent, and out-of-pocket expenses had a significant increase of 54 percent. Using generalized linear modeling, procedures performed in outpatient hospitals conferred an additional $1999 in total costs (95 percent CI, $1978 to $2020) and $259 in out-of-pocket expenses (95 percent CI, $254 to $264) compared with office procedures. Ambulatory surgical center procedures conferred an additional $1698 in total costs (95 percent CI, $1677 to $1718) and $279 in out-of-pocket expenses (95 percent CI, $273 to $285) compared with office procedures. CONCLUSIONS: For outpatient plastic surgery procedures, out-of-pocket expenses are increasing at a faster rate than total costs, which may have implications for access to care and timing of surgery. Providers should realize the increasing burden of out-of-pocket expenses and the effect of surgical location on patients' costs when possible.

Biosimilar Uptake in Medicare Part B Varied Across Hospital Outpatient Departments and Physician Practices: The Case of Filgrastim.

OBJECTIVES: To examine the uptake of filgrastim-sndz (Zarxio), the first biosimilar to launch in the United States, in the Medicare Part B fee-for-service program from its launch in September 2015 to December 2017 and compare characteristics of patients and facilities that used filgrastim-sndz or originator filgrastim (Neupogen). METHODS: The 20% sample of Medicare Part B fee-for-service administrative claims data was used to extract information on claims for any filgrastim product between January 1, 2015 and December 31, 2017. RESULTS: The utilization of filgrastim-sndz in Medicare Part B increased sharply between January and August 2016, surpassing filgrastim by November 2017, contributing to a 30% decrease in overall spending on this drug since 2015. Uptake was faster and larger in physician practices compared with hospital outpatient departments. About 77% of patients receiving filgrastim-sndz were new users. Utilization patterns indicated that product selection occurred at the facility level, rather than being at the discretion of the prescribing physician or driven by patient characteristics. CONCLUSION: Uptake of biosimilar filgrastim in the Medicare Part B program occurred despite multiple challenges to the adoption of biosimilars in the US market, suggesting that substantial potential savings could be generated by improving biosimilar uptake. Our findings indicated that physician practices and hospital outpatient departments have distinctive biosimilar uptake patterns. Thus policy makers aiming to contain Medicare Part B spending might consider focusing on incentivizing biosimilar uptake among hospital outpatient departments.

Sex Differences in Factors Affecting Hospital Outpatient Department Visits: Korea Health Panel Survey Data from 2009 to 2016.

This study intends to inspect the sex differences in proportion of hospital outpatient department (OPD) visits in overall outpatient (OP) visits using national panel data and to explore factors that influence the proportions by sex. This study analyzed data of the 2009-2016 Korea Health Panel Survey. Fractional logit regression was applied to analyze factors that affect proportion of hospital visits among outpatient visits. Analysis of related factors was carried out first for all analysis subjects and then by sex. The study data were provided by 7470 women (52.2%) and 6846 men (47.8%). The overall average number of OP visits was 13.0, and women showed a much higher frequency of visits (15.8) than men (9.9). The average proportion of hospital OPD visits among overall OP visits was 21.9%, and men showed a higher rate (25.1%) than women (19.5%). The analysis model including sociodemographic factors, economic factors, and health-related factors confirmed that men showed a higher rate of hospital usage than women. Type of medical security, household income, participation in economic activities, disability, and serious illnesses were significant variables for both sexes. Age, education level, marital status, and subscription to voluntary private health insurance were significant only for women, whereas region of residence was significant only for men. This study confirmed that there is a sex difference in proportion of hospital OPD visits and in the factors that affect the proportion of hospital OPD visits. Universal health coverage is provided through social health insurance, but there is a sex difference in hospital OPD visits, and factors related to socioeconomic status have a significant effect, especially on women's selection of health care institutions. More attention should be given to sex differences in factors affecting health care utilization.

Choice of birth place among antenatal clinic attendees in rural mission hospitals in Ebonyi State, South-East Nigeria.

BACKGROUND: Low utilization of health facilities for delivery by pregnant women poses a public health challenge in Nigeria. AIM: To determine the factors that influence the choice of birth place among antenatal clinic attendees. METHODOLOGY: This was a cross-sectional study of the eligible antenatal clinic attendees recruited at Mater Misericordiae Hospital, Afikpo and Saint Vincent Hospital, Ndubia in Ebonyi State from February 1, 2016 to June 30, 2016. Analysis was done using EPI Info 7.21 software (CDC Atlanta Georgia). RESULTS: A total of 397(99.3%) completely filled questionnaires were collated and analysed. Approximately 71% of the health facilities closest to the respondents had maternity services. It took at least 1 hour for 80.9% of the respondents to access health facilities with maternity services. Most (60.2%) of the respondents had at least one antenatal clinic attendance and majority of them did so at public hospitals. Approximately 43.8% of the respondents were delivered by the skilled birth attendants. The respondents' age and the couple's educational level, history of antenatal clinic attendance, distance of the health facility and availability of transport fare had a significant effect on delivery by skilled birth attendants. The common determinants of birth place were nearness of the health facilities, familiarity of healthcare providers, improved services, sudden labour onset and cost. Also 61.7% of the respondents chose to deliver in public health facilities due to favourable reasons but this could be hampered by the rudeness of some healthcare providers at such facilities. A significant proportion of private health facilities had unskilled manpower and shortage of drugs. CONCLUSION: A greater proportion of women will prefer to deliver in health facilities. However there are barriers to utilization of these facilities hence the need to address such barriers.

Closing the Gap: Identifying Rates and Reasons for Nonadherence in a Specialty Population.

BACKGROUND: Adherence to specialty and nonspecialty medications is often calculated using pharmacy claims data. However, specialty medication regimens are complex and may require periods of intentional gaps in therapy. Common adherence calculations are insufficient in identifying reasons for gaps in therapy. Because adherence reporting is a growing measure of quality care for specialty pharmacy accreditation and payer and manufacturer contracts, a better understanding of the rates and reasons for nonadherence within a specialty population is needed. OBJECTIVE: To identify rates and reasons for misidentified and true nonadherence in patients who are prescribed specialty medications. METHODS: A single center, retrospective cohort study was conducted using pharmacy claims data between March 2017 and February 2018. Medication adherence was calculated using proportion of days covered (PDC). Electronic medical records of a random 10% sample of nonadherent patients (PDC < 80%) were manually reviewed to identify reasons for nonadherence. Patients were then classified as either (a) misidentified as nonadherent (i.e., a provider-directed discontinuation or disruption of treatment that varies from the prescribed administration schedule or transfer of the prescription to an external pharmacy) or (b) truly nonadherent (discontinuation or disruption of treatment that varies from the prescribed administration instruction that is not directed or recommended by the provider or health care team). RESULTS: Of the 7,488 included prescription records from 18 specialty areas, 1,059 met criteria for nonadherence. 105 prescription records (representing 105 unique patients) were manually reviewed; most of these patients (58%) were truly nonadherent, driven by inability to contact patients for refills (59%). However, 40% were misidentified as nonadherent, most due to provider-directed medication holding (69%). Two percent of patients were nonadherent for unknown reasons. CONCLUSIONS: Many patients classified as nonadherent based on pharmacy claims experienced gaps in therapy due to medically appropriate reasons. Methods to better measure and identify true nonadherence are needed to efficiently and adequately affect specialty medication adherence behavior. DISCLOSURES: This study received funding support from CTSA Award No. UL1 TR002243 from the National Center for Advancing Translational Sciences. Study findings and conclusions are solely the responsibility of the authors and do not necessarily represent official views of the National Center for Advancing Translational Sciences or the National Institutes of Health. Zuckerman reports research support from Sanofi and Gilead Sciences, unrelated to this study. The other authors have nothing to disclose. A poster based on the data from this study was presented at AMCP Nexus 2018 on October 24, 2018, in Orlando, FL.

Two-Way Clinical Messaging in a CML Specialty Pharmacy Service Model.

BACKGROUND: Adherence to treatment is correlated with treatment success in chronic myeloid leukemia (CML). CVS Specialty explored novel methods to improve adherence in this population to ensure optimal adherence and lower the risk of unsuccessful treatment. One novel program explored involved an interactive 2-way clinical messaging technology that coaches patients with adherence and knowledge about taking their treatment and managing their conditions. Clinical secure messaging is a 2-way messaging program distinct from the 1-way refill reminders and order status messages that patients were receiving if opted into the messaging program. OBJECTIVE: To assess the effect on adherence of 2-way clinical messaging in a CML population treated with tyrosine kinase inhibitors (TKIs) compared with patients enrolled in 1-way refill reminders. METHODS: A retrospective cohort study was conducted using prescription claims data. Patients new to TKI therapy and enrolled in at least 1-way messaging were identified and divided into control and study cohorts based on clinical messaging enrollment status. Participants were followed for 365 days after their first fill. Adherence outcomes were defined by medication possession ratio (MPR), length of therapy, first fill drop-off rate, and gap days between refills. Optimal adherence was defined as an MPR ≥ 85%. RESULTS: Patients receiving clinical messaging had on average a 7.64% higher MPR score (MPR: 73.94% vs. 66.30%) compared with the control arm (P = 0.0063). This translates to 22% more patients being optimally adherent while exposed to clinical messaging (P = 0.022). Patients in the exposed group had a mean 32-day increase in average length of therapy compared with the control group (243 days vs. 275 days, P = 0.0043), potentially driving an increase in adherence. Additional drivers included a 5.4 percentage point reduction in first fill drop-off rates (4.66% vs. 10.04%, P = 0.0149). Persistency after 12 months was similar between the study arms (41%). CONCLUSIONS: Two-way clinical messaging positively affected adherence outcomes in a CML population. This effect was in addition to 1-way refill reminders and order status messages. The nature of the clinical content encourages further investigation into this novel execution of adherence coaching and counseling through a digital platform. DISCLOSURES: Funding for this research was provided by CVS Health. The sponsor was involved at all stages of the study's conduct and reporting. Sawicki and Friend are employed by CVS Health. The other authors were employed by CVS at the time of this study. The authors have nothing more to disclose. Posters based on this work were presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2016; April 19-22, 2016; San Francisco, CA, and AMCP Nexus 2016; October 3-6, 2016; National Harbor, MD.

A Successful Walk-In Psychiatric Model for Integrated Care.

PURPOSE: Accommodating walk-in psychiatry visits in primary care can improve access to psychiatric care for patients from historically underserved groups. We sought to determine whether a walk-in psychiatry model embedded within an integrated care practice could be sustained over time, and to characterize the patients who accessed care through it. METHODS: We reviewed electronic health records linked to 811 psychiatry encounters in an integrated care practice between October 1, 2015 and September 30, 2017. Primary outcomes were the initial and return psychiatry encounters per month. Secondary outcomes were the demographics and diagnoses of patients who accessed their initial visits through walk-in sessions and scheduled appointments. RESULTS: 490 initial psychiatry evaluations and 321 return encounters took place over the 2-year study period. The volume of initial psychiatry evaluations per month did not significantly change, but the volume of psychiatry follow-up encounters significantly increased after the walk-in session expanded. Medicaid recipients (OR, 1.9; 95% CI, 1.2 to 3.0); individuals without a college degree (OR, 1.7; 95% CI, 1.1 to 2.5); individuals who were single, divorced, or separated (OR, 1.7; 95% CI, 1.1 to 2.5); and individuals who identified as Black or Hispanic (OR, 2.5; 95% CI, 1.7 to 3.6) were more likely to access an initial psychiatry evaluation through a walk-in session as opposed to a scheduled appointment. CONCLUSIONS: Providing psychiatric care on a walk-in basis in integrated care is sustainable. Patients from historically underserved groups may access psychiatric care disproportionately through a walk-in option when it is available.

Cancer care spending and use by site of provider-administered chemotherapy in Medicare.

OBJECTIVES: To compare cancer care spending and utilization by site of provider-administered chemotherapy in Medicare. STUDY DESIGN: A retrospective analysis using 2010-2013 Medicare claims. METHODS: The study population was a random sample of Medicare fee-for-service beneficiaries with cancer who initiated provider-administered chemotherapy in a hospital outpatient department (HOPD) or physician office (PO). We assessed the following outcomes during the 6-month follow-up period: (1) spending on cancer-related outpatient services excluding chemotherapy, (2) spending on cancer-related inpatient services, (3) utilization of select cancer-related outpatient services (evaluation and management, commonly used expensive billing codes, and radiation therapy sessions), and (4) the number of cancer-related hospitalizations. We used regression analyses to adjust for patient health risk factors and market characteristics. RESULTS: During the 6-month follow-up period, risk-adjusted spending on nonchemotherapy outpatient services was slightly lower among patients receiving chemotherapy in HOPDs than in POs ($12,183 [95% CI, $12,008-$12,358] vs $12,444 [95% CI, $12,313-$12,575]; P <.05). Risk-adjusted cancer-related inpatient spending was higher in the HOPD group than in the PO group ($3996 [95% CI, $3837-$4156] vs $3168 [95% CI, $3067-$3268]; P <.01). The HOPD group had fewer visits in all select outpatient services but had a higher number of hospitalizations than the PO group. CONCLUSIONS: Differences in cancer care spending by site of chemotherapy (HOPDs vs POs) vary by service type. Those differences are partially driven by utilization differences. As the site of chemotherapy shifts from POs to HOPDs, spending and utilization patterns in both settings need to be monitored.

Reference pricing: The case of screening colonoscopies.

We study the introduction of reference pricing to the California Public Employees' Retirement System. Reference pricing changes the relative price of using a hospital versus an ambulatory surgery center (ASC) for patients receiving a colonoscopy, leading to as good as random variation in patients' use of ASCs. We find a 10 percentage point increase in the share of patients using an ASC, leading to a $2300 to $1700 reduction in prices paid for patients who switch to ASCs. Our results suggest that the use of ASCs has a causal effect on prices paid and has no negative effect on patient health outcomes.

Barriers to Pediatric Surgical Care in Low-Income Countries: The Three Delays' Impact in Uganda.

BACKGROUND: We sought to understand the challenges in accessing pediatric surgical care in the context of the "three delays" model at the Pediatric Surgery Outpatient Clinic (PSOPC) at a tertiary hospital in Kampala, Uganda. MATERIALS AND METHODS: An outpatient database was established at the weekly PSOPC. A survey regarding prior healthcare visits and barriers to care was additionally administered to clinic patients and inpatients. RESULTS: Patients first sought healthcare a median of 56 d before the current visit to the PSOPC. A majority (52%) of patients first sought care at another health facility, and 17% of those surveyed had presented to the PSOPC three or more times for their current medical issue. Of 240 patients with a new issue or due for their next surgery, 10% were admitted to the ward, with only 54% receiving definitive care. Included in the most commonly needed surgeries for PSOPC patients were herniotomy (16% inguinal; 14.9% umbilical), orchiopexy (6.3%), posterior sagittal anorectoplasty (6.3%), and colostomy closure (4.4%), with the range of patient ages at the time of presentation reflecting delays in care. Patient expenditures associated with travel to the hospital showed inpatients coming from significantly further away, with higher costs of travel and need to borrow or sell assets to cover travel costs, when compared with PSOPC patients. CONCLUSIONS: Patients face significant delays in accessing and receiving definitive surgical care. Associated burdens associated with these delays place patients at risk for catastrophic health expenditures. Infrastructure and capacity development are necessary for improvement in pediatric surgical care.