Project ACTIVE: a Randomized Controlled Trial of Personalized and Patient-Centered Preventive Care in an Urban Safety-Net Setting.

BACKGROUND: Evidence-based preventive care in the USA is underutilized, diminishing population health and worsening health disparities. We developed Project ACTIVE, a program to improve adherence with preventive care goals through personalized and patient-centered care. OBJECTIVE: To determine whether Project ACTIVE improved utilization of preventive care and/or estimated life expectancy compared to usual care. DESIGN: Single-site randomized controlled trial. PARTICIPANTS: Cluster-randomized 140 English or Spanish speaking adult patients in primary care with at least one of twelve unfulfilled preventive care goals based on USPSTF grade A and B recommendations. INTERVENTION: Project ACTIVE employs a validated mathematical model to predict and rank individualized estimates of health benefit that would arise from improved adherence to different preventive care guidelines. Clinical staff engaged the participant in a shared medical decision-making (SMD) process to identify highest priority unfulfilled clinical goals, and health coaching staff engaged the participant to develop and monitor action steps to reach those goals. MAIN MEASURES: Change in number of unfulfilled preventive care goals from USPSTF grade A and B recommendations and change in overall gain in estimated life expectancy. KEY RESULTS: In an intent-to-treat analysis, Project ACTIVE increased the average number of fulfilled preventive care goals out of 12 by 0.68 in the intervention arm compared with 0.15 in the control arm (mean difference [95% CI] 0.53 [0.19-0.86]), yielding a gain in estimated life expectancy of 8.8 months (3.8, 14.2). In a per-protocol analysis, Project ACTIVE increased fulfilled preventive care goals by 0.80 in the intervention arm compared with 0.16 in the control arm (mean difference [95% CI], 0.65 [0.25-1.04]), yielding a gain in estimated life expectancy of 13.7 months (6.2, 21.2). Among the 12 preventive care goals, more improvement occurred for alcohol use, hypertension, hyperlipidemia, depression, and smoking. CONCLUSIONS: Project ACTIVE improved unfulfilled preventive care goals and improved estimated life expectancy. CLINICAL TRIAL REGISTRATION NUMBER: NCT04211883.

Implications of false-positive results for future cancer screenings.

BACKGROUND: False-positive cancer screening results may affect a patient's willingness to obtain future screening. METHODS: The authors conducted logistic regression analysis of 450,484 person-years of electronic medical records (2006-2015) in 92,405 individuals aged 50 to 75 years. Exposures were false-positive breast, prostate, or colorectal cancer screening test results (repeat breast imaging or negative breast biopsy ≤3 months after screening mammography, repeat prostate-specific antigen [PSA] test ≤3 months after PSA test result ≥4.0 ng/mL or negative prostate biopsy ≤3 months after any PSA result, or negative colonoscopy [without biopsy/polypectomy] ≤6 months after a positive fecal occult blood test). Outcomes were up-to-date status with breast or colorectal cancer screening. Covariates included prior screening history, clinical information (eg, family history, obesity, and smoking status), comorbidity, and demographics. RESULTS: Women were more likely to be up to date with breast cancer screening if they previously had false-positive mammography findings (adjusted odds ratio [AOR], 1.43 [95% confidence interval, 1.34-1.51] without breast biopsy and AOR, 2.02 [95% confidence interval, 1.56-2.62] with breast biopsy; both P<.001). The same women were more likely to be up to date with colorectal cancer screening (AOR range, 1.25-1.47 depending on breast biopsy; both P<.001). Men who previously had false-positive PSA testing were more likely to be up to date with colorectal cancer screening (AOR, 1.22 [P = .039] without prostate imaging/biopsy and AOR, 1.60 [P = .028] with imaging/biopsy). Results were stronger for individuals with more false-positive results (all P≤.005). However, women with previous false-positive colorectal cancer fecal occult blood test screening results were found to be less likely to be up to date with breast cancer screening (AOR, 0.73; P<.001). CONCLUSIONS: Patients who previously had a false-positive breast or prostate cancer screening test were more likely to engage in future screening. Cancer 2018;124:2390-8. © 2018 American Cancer Society.

A risk prediction model to allow personalized screening for cervical cancer.

IMPORTANCE: Cervical cancer screening guidelines are in evolution. Current guidelines do not differentiate recommendations based on individual patient risk. OBJECTIVE: To derive and validate a tool for predicting individualized probability of cervical intraepithelial neoplasia grade 2 or higher (CIN2+) at a single time point, based on demographic factors and medical history. DESIGN: The study design consisted of an observational cohort with hierarchical generalized linear regression modeling. SETTING: The study was conducted in a setting of 33 primary care practices from 2004 to 2010. PARTICIPANTS: The participants of the study were women aged ≥ 30 years. MAIN OUTCOME AND MEASURES: CIN2+ was the main outcome on biopsy, and the following predictors were included: age, race, marital status, insurance type, smoking history, median income based on zip code, prior human papilloma virus (HPV) results. RESULTS: The final dataset included 99,319 women. Of these, 745 (0.75%) had CIN2+. The multivariable model had a C-statistic of 0.81. All factors but race were independently associated with CIN2+. The model categorized women as having below-average CIN2+ risk (0.15% predicted vs. 0.12% observed risk), average CIN2+ risk (0.42% predicted vs. 0.36% observed), and above-average CIN2+ risk (1.76% predicted vs. 1.85% observed). Before screening, women at below-average risk had a risk of CIN2+ well below that of women with ASCUS and HPV negative (0.12 vs. 0.20%). CONCLUSIONS AND RELEVANCE: A multivariable model using data from the electronic health record was able to stratify women across a 50-fold gradient of risk for CIN2+. After further validation, use of a similar model could enable more targeted cervical cancer screening.

Long-Term Continence Outcomes in Men Undergoing Radical Prostatectomy: A Prospective 15-Year Longitudinal Study.

PURPOSE: We examined the time dependent rates of urinary continence following open retropubic radical prostatectomy. MATERIALS AND METHODS: A total of 1,995 men treated with radical prostatectomy were enrolled in a prospective longitudinal outcomes study. The UCLA-PCI-UFS (UCLA-Prostate Cancer Index-Urinary Function Index) was administered at baseline, and 3, 6, 12, 24, 96, 120 and 180 months after open retropubic radical prostatectomy. Urinary continence was defined by 1 pad or less in 24 hours. Two multiple regression models were constructed to evaluate the association of time since open retropubic radical prostatectomy with the UCLA-PCI-UFI score and urinary continence. RESULTS: The decrease in urinary continence rates between baseline and 15 years (99.6% vs 87.2%, p <0.001), and 2 and 15 years (95.3% vs 87.2%, p = 0.021) were statistically significant. Urinary continence rates were consistently higher in the younger group at all time points. CONCLUSIONS: A significant decrease in urinary continence rates was observed between baseline and 2 years, and between 2 and 15 years in the entire cohort. Urinary continence rates in age matched men in the general population who were followed longitudinally for 15 years were comparable to those in our study population. This suggests that while open retropubic radical prostatectomy causes primarily sphincteric urinary incontinence, it may be protective for subsequent benign prostatic hyperplasia mediated urinary incontinence.

Prevalence of Elevated Cardiovascular Risks in Young Adults: A Cross-sectional Analysis of National Health and Nutrition Examination Surveys.

BACKGROUND: The 2013 cholesterol management guidelines from the American College of Cardiology and American Heart Association (ACC/AHA) recommend lipid screening in all adults older than 20 years to identify those at increased risk for atherosclerotic cardiovascular disease (ASCVD). Statins may be considered for patients with elevated 10-year risk (>5%) or a low-density lipoprotein cholesterol (LDL-C) level of 4.92 mmol/L (190 mg/dL) or greater. OBJECTIVE: To describe the prevalence of elevated ASCVD risk among nondiabetic adults younger than 50 years. DESIGN: Cross-sectional. SETTING: NHANES (National Health and Nutrition Examination Survey), 1999 to 2000 through 2011 to 2012. PARTICIPANTS: Adults aged 30 to 49 years without known ASCVD or diabetes. MEASUREMENTS: 10-year ASCVD risk was estimated by using the 2013 ACC/AHA ASCVD risk calculator. Participants were subdivided by age, sex, and history of smoking and hypertension. The percentages of adults in each subgroup with a 10-year ASCVD risk greater than 5% and of those with an LDL-C level of 4.92 mmol/L (190 mg/dL) or greater were estimated. Low-prevalence subgroups were defined as those in which a greater than 1% prevalence of elevated cardiovascular risk could be ruled out (that is, the upper 95% confidence bound for prevalence was ≤1%). RESULTS: Overall, 9608 NHANES participants representing 67.9 million adults were included, with approximately half (47.12%, representing 32 million adults) in low-prevalence subgroups. In the absence of smoking or hypertension, 0.09% (95% CI, 0.02% to 0.35%) of adult men younger than 40 years and 0.04% (CI, 0.0% to 0.26%) of adult women younger than 50 years had an elevated risk. Among other subgroups, 0% to 75.9% of participants had an increased risk. Overall, 2.9% (CI, 2.3% to 3.5%) had an LDL-C level of 4.92 mmol/L (190 mg/dL) or greater. LIMITATION: No information was available regarding cardiovascular outcomes. CONCLUSION: In the absence of risk factors, the prevalence of increased ASCVD risk is low among women younger than 50 and men younger than 40 years. PRIMARY FUNDING SOURCE: None.

Provider Variation in Antibiotic Prescribing and Outcomes of Respiratory Tract Infections.

OBJECTIVES: Inappropriate antibiotic use for respiratory tract infection (RTI) is an ongoing problem linked to the emergence of drug resistance and other adverse effects. Less is known about the prescribing practices of individual physicians or the impact of physician prescribing habits on patient outcomes. We studied the prescribing practices of providers for acute RTIs in an integrated health system, identified patient factors associated with receipt of an antibiotic and assessed the relation between providers' adjusted prescribing rates and a number of patient outcomes. METHODS: This was a retrospective analysis of adults with an RTI visit to any primary care providers across the Cleveland Clinic Health System in 2011-2012. Patients with a history of chronic obstructive pulmonary disease or immunocompromised status were excluded. Logistic regression was used to examine patient factors associated with receipt of an antibiotic. RESULTS: Of 31,416 patients with an RTI, 54.8% received an antibiotic. Patient factors associated with antibiotic prescribing included white race (odds ratio [OR] 1.35, P < 0.001), presence of fever (OR 1.66, P < 0.001), and a diagnosis of bronchitis (OR 10.98, P < 0.001) or sinusitis (OR 33.85, P < 0.001). Among 290 providers with ≥10 RTI visits, adjusted antibiotic prescribing rates ranged from 0% to 100% (mean 49%). Antibiotics were prescribed more often for sinusitis (OR 33.85, P < 0.001), bronchitis (OR 10.98, P < 0.001), or pharyngitis (OR 1.76, P < 0.001) compared with upper respiratory tract infection. Patients who were prescribed antibiotics at the index visit were more likely to return for RTI within 1 year (adjusted OR 1.26, P < 0.001). Emergency department visits for respiratory complications were rare and not associated with antibiotic receipt. CONCLUSIONS: Antibiotic prescribing for RTI varies widely among physicians and cannot be explained by patient factors. Patients prescribed antibiotics for RTI were more likely to return for RTI.

High-Cost Patients: Hot-Spotters Don't Explain the Half of It.

BACKGROUND: Understanding resource utilization patterns among high-cost patients may inform cost reduction strategies. OBJECTIVE: To identify patterns of high-cost healthcare utilization and associated clinical diagnoses and to quantify the significance of hot-spotters among high-cost users. DESIGN: Retrospective analysis of high-cost patients in 2012 using data from electronic medical records, internal cost accounting, and the Centers for Medicare and Medicaid Services. K-medoids cluster analysis was performed on utilization measures of the highest-cost decile of patients. Clusters were compared using clinical diagnoses. We defined "hot-spotters" as those in the highest-cost decile with ≥4 hospitalizations or ED visits during the study period. PARTICIPANTS AND EXPOSURE: A total of 14,855 Medicare Fee-for-service beneficiaries identified by the Medicare Quality Resource and Use Report as having received 100 % of inpatient care and ≥90 % of primary care services at Cleveland Clinic Health System (CCHS) in Northeast Ohio. The highest-cost decile was selected from this population. MAIN MEASURES: Healthcare utilization and diagnoses. KEY RESULTS: The highest-cost decile of patients (n = 1486) accounted for 60 % of total costs. We identified five patient clusters: "Ambulatory," with 0 admissions; "Surgical," with a median of 2 surgeries; "Critically Ill," with a median of 4 ICU days; "Frequent Care," with a median of 2 admissions, 3 ED visits, and 29 outpatient visits; and "Mixed Utilization," with 1 median admission and 1 ED visit. Cancer diagnoses were prevalent in the Ambulatory group, care complications in the Surgical group, cardiac diseases in the Critically Ill group, and psychiatric disorders in the Frequent Care group. Most hot-spotters (55 %) were in the "frequent care" cluster. Overall, hot-spotters represented 9 % of the high-cost population and accounted for 19 % of their overall costs. CONCLUSIONS: High-cost patients are heterogeneous; most are not so-called "hot-spotters" with frequent admissions. Effective interventions to reduce costs will require a more multi-faceted approach to the high-cost population.

Prostate cancer screening practices in a large, integrated health system: 2007-2014.

OBJECTIVES: To assess prostate cancer screening practices in primary care since the initial United States Preventive Services Task Force (USPSTF) recommendation against prostate-specific antigen (PSA) testing for older men, and to assess primary provider variation associated with prostate cancer screening. PATIENTS AND METHODS: Our study population included 160 211 men aged ≥40 years with at least one visit to a primary care clinic in any of the study years in a large, integrated health system. We conducted a retrospective cohort study using electronic medical record data from January 2007 to December 2014. Yearly rates of screening PSA testing by primary care providers (PCPs), rates of re-screening, and rates of prostate biopsies were assessed. RESULTS: Annual PSA-screening testing declined from 2007 to 2014 in all age groups, as did biennial and quadrennial screening. Yearly rates declined for men aged ≥70 years, from 22.8% to 8.9%; ages 50-69 years, from 39.2% to 20%; and ages 40-49 years, from 11% to 4.6%. Overall rates were lower for African-American (A-A) men vs non-A-A men; for men with a family history of prostate cancer, rates were similar or slightly higher than for those without a family history. PCP variation associated with ordering of PSA testing did not substantially change after the USPSTF recommendations. While the number of men screened and rates of follow-up prostate cancer screening declined in 2011-2014 compared to 2007-2010, similar re-screening rates were noted for men aged 45-75 years with initial PSA levels of <1 ng/mL or 1-3 ng/mL in both the earlier and later cohorts. For men aged >75 years with initial PSA levels of <3 ng/mL screened in both cohorts, follow-up screening rates were similar. Rates of prostate biopsy declined for men aged ≥70 years in 2014 compared to 2007. For men who had PSA screening, rates of first prostate biopsy increased in later years for A-A men and men with a family history of prostate cancer. CONCLUSIONS: Prostate cancer screening declined from 2007 to 2014 even in higher-risk groups and follow-up screening rates were not related to previous PSA level. However, rates of first prostate biopsy in men who were screened with a PSA test were higher for men with an increased risk of prostate cancer in later years. Variation in PSA testing was noted among PCPs. Future work should further explore sources of variation in screening practices and implementation of risk-based strategies for prostate cancer screening in primary care.

Assessing Years of Life Lost Versus Number of Deaths in the United States, 1995-2015.

OBJECTIVES: To assess years of life lost to each cause of death in the United States between 1995 and 2015, and compare it with the number of deaths. METHODS: We used Vital Statistics mortality data and defined "life-years lost" as remaining life expectancy for each decedent's age, sex, and race. We calculated the share of life-years lost to each cause of death in each year, and examined reasons for changes. RESULTS: In 2015, heart disease caused the most deaths, but cancer caused 23% more life-years lost. Life-years lost to heart disease declined 6% since 1995, whereas life-years lost to cancer increased 16%. The increase for cancer was entirely attributable to population growth and longer life expectancy; had these factors remained constant, life-years lost to heart disease and cancer would have fallen 56% and 38%, respectively. Accidents (including overdoses), suicides, and homicides each caused twice the share of life-years lost as deaths. Measuring life-years lost highlighted racial disparities in heart disease, homicides, and perinatal conditions. CONCLUSIONS: Life-years lost may provide additional context for understanding long-term mortality trends.

Financial Incentives and Diabetes Disease Control in Employees: A Retrospective Cohort Analysis.

BACKGROUND: Many employers offer worksite wellness programs, including financial incentives to achieve goals. Evidence supporting such programs is sparse. OBJECTIVE: To assess whether diabetes and cardiovascular risk factor control in employees improved with financial incentives for participation in disease management and for attaining goals. DESIGN: Retrospective cohort study using insurance claims linked with electronic medical record data from January 2008-December 2012. PARTICIPANTS: Employee patients with diabetes covered by the organization's self-funded insurance and propensity-matched non-employee patient comparison group with diabetes and commercial insurance. INTERVENTION: Financial incentives for employer-sponsored disease management program participation and achieving goals. MAIN MEASURES: Change in glycosylated hemoglobin (HbA1c), low-density lipoprotein (LDL), systolic blood pressure (SBP), and weight. RESULTS: A total of 1092 employees with diabetes were matched to non-employee patients. With increasing incentives, employee program participation increased (7 % in 2009 to 50 % in 2012, p < 0.001). Longitudinal mixed modeling demonstrated improved diabetes and cardiovascular risk factor control in employees vs. non-employees [HbA1c yearly change -0.05 employees vs. 0.00 non-employees, difference in change (DIC) p <0.001]. In their first participation year, employees had larger declines in HbA1c and weight vs. non-employees (0.33 vs. 0.14, DIC p = 0.04) and (2.3 kg vs. 0.1 kg, DIC p < 0.001), respectively. Analysis of employee cohorts corresponding with incentive offerings showed that fixed incentives (years 1 and 2) or incentives tied to goals (years 3 and 4) were not significantly associated with HbA1c reductions compared to non-employees. For each employee cohort offered incentives, SBP and LDL also did not significantly differ in employees compared with non-employees (DIC p > 0.05). CONCLUSIONS: Financial incentives were associated with employee participation in disease management and improved cardiovascular risk factors over 5 years. Improvements occurred primarily in the first year of participation. The relative impact of specific incentives could not be discerned.

Association of Influenza Vaccination Coverage in Younger Adults With Influenza-Related Illness in the Elderly.

BACKGROUND: Older adults have the highest influenza-related morbidity and mortality risk, but the influenza vaccine is less effective in the elderly. It is unknown whether influenza vaccination of nonelderly adults confers additional disease protection on the elderly population. METHODS: We examined the association between county-wide influenza vaccination coverage among 520 229 younger adults (aged 18-64 years) in the Behavioral Risk Factors Surveillance System Survey and illnesses related to influenza in 3 317 709 elderly Medicare beneficiaries aged ≥65 years, between 2002 and 2010 (13 267 786 person-years). Results were stratified by documented receipt of a seasonal influenza vaccine in each Medicare beneficiary. RESULTS: Increases in county-wide vaccine coverage among younger adults were associated with lower adjusted odds of illnesses related to influenza in the elderly. Compared with elderly residents of counties with ≤15% of younger adults vaccinated, the adjusted odds ratio for a principal diagnosis of influenza among elderly residents was 0.91 (95% confidence interval, .88-.94) for counties with 16%-20% of younger adults vaccinated, 0.87 (.84-.90) for counties with 21%-25% vaccinated, 0.80 (.77-.83) for counties with 26%-30% vaccinated, and 0.79 (.76-.83) for counties with ≥31% vaccinated (P for trend <.001). Stronger associations were observed among vaccinated elderly adults, in peak months of influenza season, in more severe influenza seasons, in influenza seasons with greater antigenic match to influenza vaccine, and for more specific definitions of influenza-related illness. CONCLUSIONS: In a large, nationwide sample of Medicare beneficiaries, influenza vaccination among adults aged 18-64 years was inversely associated with illnesses related to influenza in the elderly.

The Effect of the Diffusion of the Surgical Robot on the Hospital-level Utilization of Partial Nephrectomy.

INTRODUCTION: The rapid diffusion of the surgical robot has been controversial because of the technology's high costs and its disputed marginal benefit. Some, however, have suggested that adoption of the robot may have improved care for patients with renal malignancy by facilitating partial nephrectomy, an underutilized, technically challenging procedure believed to be less morbid than radical nephrectomy. We sought to determine whether institutional acquisition of the robot was associated with increased utilization of partial nephrectomy. METHODS: We used all payer data from 7 states to identify 21,569 nephrectomies. These patient-level records were aggregated to the hospital-level then merged with the American Hospital Association Annual Survey and publicly available data on timing of robot acquisition. We used a multivariable difference-in-difference model to assess at the hospital-level whether robot acquisition was associated with an increase in the proportion of partial nephrectomy, adjusting for hospital nephrectomy volume, year of surgery, and several additional hospital-level factors. RESULTS: In the multivariable-adjusted differences-in-differences model, hospitals acquiring a robot between 2001 and 2004 performed a greater proportion of partial nephrectomy in both 2005 (29.9% increase) and 2008 (34.9% increase). Hospitals acquiring a robot between 2005 and 2008 also demonstrated a greater proportion of partial nephrectomy in 2008 (15.5% increase). In addition, hospital nephrectomy volume and urban location were also significantly associated with increased proportion of partial nephrectomy. CONCLUSIONS: Hospital acquisition of the surgical robot is associated with greater proportion of partial nephrectomy, an underutilized, guideline-encouraged procedure. This is one of the few studies to suggest robot acquisition is associated with improvement in quality of patient care.

Vitamin D deficiency in minority populations.

OBJECTIVE: Black and Hispanic individuals synthesize less vitamin D per unit of sun exposure than white individuals. The relationship between UV radiation and vitamin D insufficiency in minorities has not been well explored. DESIGN: Prospective cohort study. SETTING: Using the National Health and Nutrition Examination Survey, we obtained serum vitamin D levels for non-Hispanic Whites, Hispanics and non-Hispanic Blacks aged ≥18 years from 2000-2006. We linked these data with the average monthly solar UV index by census tract and data on sun exposure, vitamin D supplementation, health and demographics. We used multivariable regression analyses to assess vitamin D deficiency (<15 ng/ml) and insufficiency (<20 ng/ml) in January (when the UV index was lowest) by race/ethnicity and geography. SUBJECTS: Adults (n 14,319) aged ≥18 years. RESULTS: A 1-point increase in the UV index was associated with a 0·51 ng/ml increase in vitamin D (95% CI 0·35, 0·67 ng/ml; P<0·001). Non-Hispanic Black race and Hispanic ethnicity were associated with a 7·47 and 3·41 ng/ml decrease in vitamin D, respectively (both P<0·001). In January, an estimated 65·4% of non-Hispanic Blacks were deficient in vitamin D, compared with 28·9% of Hispanics and 14·0% of non-Hispanic Whites. An estimated 84·2% of non-Hispanic Blacks were insufficient in vitamin D v. 56·3% of Hispanics and 34·8% of non-Hispanic Whites. More non-Hispanic Blacks were estimated to be deficient in vitamin D in January in the highest UV index quartile than were non-Hispanic Whites in the lowest UV index quartile (60·2% v. 25·7%). CONCLUSIONS: Wintertime vitamin D insufficiency is pervasive among minority populations, and not uncommon among non-Hispanic Whites.

Impact of Video Education on Influenza Vaccination in Pregnancy.

OBJECTIVE: Despite influenza vaccination being an integral part of prenatal care, vaccination rates remain low. To evaluate the impact of pre-visit video education on patients' vaccination health beliefs and vaccination rate. STUDY DESIGN: From November 2013-January 2014 unvaccinated patients seen for routine prenatal carewere randomized into 2 study groups: pre-visit vaccination video education or control. Pre- and post-video health beliefs were assessed on a 5-point scale, and unvaccinated participants were subsequently interviewed by phone. RESULTS: In 105 randomized participants, intervention positively influenced health beliefs, as demonstrated by differences in mean pre- versus post-video scores for intervention versus control: vaccination may harm mother (difference = -0.05, p = 0.009) and baby (difference = -0.44, p = 0.015), and vaccination can protect mother (difference = 0.49, p = 0.003) and baby (difference = 0.59, p = 0.001). Vaccination rates were 28% intervention and 25% control (p = 0.70). Provider recommendation was associated with vaccination (47% if recommended vs. 12% if not, p < 0.001). Phone interviews revealed susceptibility, to influenza and vaccine safety as primary reasons for remaining unvaccinated. CONCLUSION: Video education positively influenced vaccination health beliefs without impacting vaccination rates. Physician's recommendation was strongly associated with participant's decision to become vaccinated and may be most effective when emphasizing influenza vaccination's protective impact on the newborn,.

Clinical and economic outcomes of patients with brain metastases based on symptoms: an argument for routine brain screening of those treated with upfront radiosurgery.

BACKGROUND: Insurers have started to deny reimbursement for routine brain surveillance with magnetic resonance imaging (MRI) after stereotactic radiosurgery (SRS) for brain metastases in favor of symptom-prompted imaging. The authors investigated the clinical and economic impact of symptomatic versus asymptomatic metastases and related these findings to the use of routine brain surveillance. METHODS: Between January 2000 and December 2010, 442 patients underwent upfront SRS for brain metastases. In total, 127 asymptomatic patients and 315 symptomatic patients were included. Medical records were used to determine the presenting symptoms, distant and local brain failure, retreatment, and need for hospital and rehabilitative care. Cost-of-care estimates were based on Medicare payment rates as of January 2013. RESULTS: Symptomatic patients had an increased hazard for all-cause mortality (hazard ratio, 1.448) and were more likely to experience neurologic death (42% vs 20%; P < .0001). Relative to asymptomatic patients, symptomatic patients required more craniotomies (43% vs 5%; P < .0001), had more prolonged hospitalization (2 vs 0 days; P < .0001), were more likely to have Radiation Therapy Oncology Group grade 3 and 4 post-treatment symptoms (24% vs 5%; P < .0001), and required $11,957 more on average to manage per patient. Accounting for all-cause mortality rates and the probability of diagnosis at each follow-up period, the authors estimated that insurers would save an average $1326 per patient by covering routine surveillance MRI after SRS to detect asymptomatic metastases. CONCLUSIONS: Patients who presented with symptomatic brain metastases had worse clinical outcomes and cost more to manage than asymptomatic patients. The current findings argue that routine brain surveillance after radiosurgery has clinical benefits and reduces the cost of care.

Radical prostatectomy improves and prevents age dependent progression of lower urinary tract symptoms.

PURPOSE: The prevalence of lower urinary tract symptoms increases with age and impairs quality of life. Radical prostatectomy has been shown to relieve lower urinary tract symptoms at short-term followup but the long-term effect of radical prostatectomy on lower urinary tract symptoms is unclear. MATERIALS AND METHODS: We performed a prospective cohort study of 1,788 men undergoing radical prostatectomy. The progression of scores from the self-administered AUASS (American Urological Association symptom score) preoperatively, and at 3, 6, 12, 24, 48, 60, 84, 96 and 120 months was analyzed using models controlling for preoperative AUASS, age, prostate specific antigen, pathological Gleason score and stage, nerve sparing, race and marital status. This model was also applied to patients stratified by baseline clinically significant (AUASS greater than 7) and insignificant (AUASS 7 or less) lower urinary tract symptoms. RESULTS: Men exhibited an immediate worsening of lower urinary tract symptoms that improved between 3 months and 2 years after radical prostatectomy. Overall the difference between mean AUASS at baseline and at 10 years was not statistically or clinically significant. Men with baseline clinically significant lower urinary tract symptoms experienced immediate improvements in lower urinary tract symptoms that lasted until 10 years after radical prostatectomy (13.5 vs 8.81, p <0.001). Men with baseline clinically insignificant lower urinary tract symptoms experienced a statistically significant but clinically insignificant increase in mean AUASS after 10 years (3.09 to 4.94, p <0.001). The percentage of men with clinically significant lower urinary tract symptoms decreased from baseline to 10 years after radical prostatectomy (p = 0.02). CONCLUSIONS: Radical prostatectomy is the only treatment for prostate cancer shown to improve and prevent the development of lower urinary tract symptoms at long-term followup. This previously unrecognized long-term benefit argues in favor of the prostate as the primary contributor to male lower urinary tract symptoms.

Calorie labeling and consumer estimation of calories purchased.

BACKGROUND: Studies rarely find fewer calories purchased following calorie labeling implementation. However, few studies consider whether estimates of the number of calories purchased improved following calorie labeling legislation. FINDINGS: Researchers surveyed customers and collected purchase receipts at fast food restaurants in the United States cities of Philadelphia (which implemented calorie labeling policies) and Baltimore (a matched comparison city) in December 2009 (pre-implementation) and June 2010 (post-implementation). A difference-in-difference design was used to examine the difference between estimated and actual calories purchased, and the odds of underestimating calories.Participants in both cities, both pre- and post-calorie labeling, tended to underestimate calories purchased, by an average 216-409 calories. Adjusted difference-in-differences in estimated-actual calories were significant for individuals who ordered small meals and those with some college education (accuracy in Philadelphia improved by 78 and 231 calories, respectively, relative to Baltimore, p = 0.03-0.04). However, categorical accuracy was similar; the adjusted odds ratio [AOR] for underestimation by >100 calories was 0.90 (p = 0.48) in difference-in-difference models. Accuracy was most improved for subjects with a BA or higher education (AOR = 0.25, p < 0.001) and for individuals ordering small meals (AOR = 0.54, p = 0.001). Accuracy worsened for females (AOR = 1.38, p < 0.001) and for individuals ordering large meals (AOR = 1.27, p = 0.028). CONCLUSIONS: We concluded that the odds of underestimating calories varied by subgroup, suggesting that at some level, consumers may incorporate labeling information.

Personalized estimates of benefit from preventive care guidelines: a proof of concept.

BACKGROUND: The U.S. Preventive Services Task Force (USPSTF) makes recommendations for 60 distinct clinical services, but clinicians rarely have time to fully evaluate and implement the recommendations. OBJECTIVE: To complete a proof of concept for prioritization and personalization of USPSTF recommendations, using patient-specific clinical characteristics. DESIGN: Mathematical model. DATA SOURCES: USPSTF recommendations and supporting evidence and National Vital Statistics Reports. TARGET POPULATION: Nonpregnant adults. TIME HORIZON: Lifetime. PERSPECTIVE: Individual. INTERVENTION: USPSTF grade A and B recommendations. OUTCOME MEASURES: Personalized gain in life expectancy associated each recommendation. RESULTS OF BASE-CASE ANALYSIS: Increases in life expectancy varied more than 100-fold across USPSTF recommendations, and the rank order of benefits varied considerably among patients. For an obese man aged 62 years who smoked and had hypercholesterolemia, hypertension, and a family history of colorectal cancer, the model's top 3 recommendations (from most to least gain in life expectancy) were tobacco cessation (adding 2.8 life-years), weight loss (adding 1.6 life-years), and blood pressure control (adding 0.8 life-year). Lower-ranked recommendations were a healthier diet, aspirin use, cholesterol reduction, colonoscopy, screening for abdominal aortic aneurysm, and HIV testing (each adding 0.1 to 0.3 life-years). For a person with the same characteristics plus uncontrolled type 2 diabetes mellitus, the model's top 3 recommendations were diabetes control, tobacco cessation, and weight loss (each adding 1.4 to 1.8 life-years). RESULTS OF SENSITIVITY ANALYSIS: Robust to variation of model inputs and satisfied face validity criteria. LIMITATION: Expected adherence rates and quality of life were not considered. CONCLUSION: Models of personalized preventive care may illustrate how magnitude and rank order of benefit associated with preventive guidelines vary across recommendations and patients. These predictions may help clinicians to prioritize USPSTF recommendations at the patient level.