Paying Attention or Paying Too Much in Medicare Part D.

We study whether people became less likely to switch Medicare prescription drug plans (PDPs) due to more options and more time in Part D. Panel data for a random 20 percent sample of enrollees from 2006--2010 show that 50 percent were not in their original PDPs by 2010. Individuals switched PDPs in response to higher costs of their status quo plans, saving them money. Contrary to choice overload, larger choice sets increased switching unless the additional plans were relatively expensive. Neither switching overall nor responsiveness to costs declined over time, and above-minimum spending in 2010 remained below the 2006 and 2007 levels.

Sinking, Swimming, or Learning to Swim in Medicare Part D.

Under Medicare Part D, senior citizens choose prescription drug insurance offered by numerous private insurers. We examine nonpoor enrollees' actions in 2006 and 2007 using panel data. Our sample reduced overspending by $298 on average, with gains by 81 percent of them. The greatest improvements were by those who overspent most in 2006 and by those who switched plans. Decisions to switch depended on individuals' overspending in 2006 and on individual-specific effects of changes in their current plans. The oldest consumers and those initiating medications for Alzheimer's disease improved by more than average, suggesting that real-world institutions help overcome cognitive limitations.

Price Indices and the Value of Innovation with Heterogenous Patients.

Many countries use uniform cost-effectiveness criteria to determine whether to adopt a new medical technology for the entire population. This approach assumes homogeneous preferences for expected health benefits and side effects. We examine whether new prescription drugs generate welfare gains when accounting for heterogeneous preferences by constructing quality-adjusted price indices in the market for colorectal cancer drug treatments. We find that while the efficacy gains from newer drugs do not justify high prices for the population as a whole, innovation improves the welfare of sicker, late-stage cancer patients. A uniform evaluation criterion would not permit these innovations despite welfare gains to a subpopulation.

Can amputation save the hospital? The impact of the Medicare Rural Flexibility Program on demand and welfare.

This paper seeks to understand the impact of the Medicare Rural Hospital Flexibility (Flex) Program on hospital choice and consumer welfare for rural residents. The Flex Program created a new class of hospital, the Critical Access Hospital (CAH), which receives more generous Medicare reimbursements in return for limits on capacity and length of stay. We find that conversion to CAH status resulted in a 4.7 percent drop in inpatient admissions to participating hospitals, almost all of which was driven by factors other than capacity constraints. The Flex Program increased consumer welfare if it prevented the exit of at least 6.5 percent of randomly selected converting hospitals.

Quality-adjusted cost of care: a meaningful way to measure growth in innovation cost versus the value of health gains.

Technology drives both health care spending and health improvement. Yet policy makers rarely see measures of cost growth that account for both effects. To fill this gap, we present the quality-adjusted cost of care, which illustrates cost growth net of growth in the value of health improvements, measured as survival gains multiplied by the value of survival. We applied the quality-adjusted cost of care to two cases. For colorectal cancer, drug cost per patient increased by $34,493 between 1998 and 2005 as a result of new drug launches, but value from offsetting health improvements netted a modest $1,377 increase in quality-adjusted cost of care. For multiple myeloma, new therapies increased treatment cost by $72,937 between 2004 and 2009, but offsetting health benefits lowered overall quality-adjusted cost of care by $67,863. However, patients with multiple myeloma on established first-line therapies saw costs rise without corresponding benefits. All three examples document rapid cost growth, but they provide starkly different answers to the question of whether society got what it paid for.

Mediastinite aguda: aspectos de imagem pós-cirurgias cardíacas na tomografia computadorizada de multidetectores / Acute mediastinitis: multidetector computed tomography findings following cardiac surgery

Mediastinite pós-cirurgias torácicas é definida como a infecção dos órgãos e tecidos do espaço mediastinal, ocorrendo em 0,4 por cento a 5 por cento dos casos. A gravidade da infecção pós-operatória varia desde infecção de tecidos superficiais da parede torácica até mediastinite fulminante com envolvimento esternal. O critério diagnóstico da tomografia computadorizada para mediastinite aguda pós-cirúrgica é a presença de coleção mediastinal, podendo estar associada ou não a anormalidades periesternais como edema/borramento de partes moles, separação dos segmentos esternais com reabsorção óssea marginal, esclerose e osteomielite. Achados associados incluem linfonodomegalias, consolidações pulmonares e derrame pleural e pericárdico. Pequenas coleções e gás mediastinais podem ser usualmente encontradas em pós-operatório recente de cirurgias torácicas sem a presença de infecções, limitando a eficácia da tomografia computadorizada nas duas primeiras semanas. Após esse período, a tomografia alcança quase 100 por cento de sensibilidade e especificidade. Pacientes com suspeita clínica de mediastinite devem ser submetidos a exame de tomografia para pesquisa de coleções, identificando a extensão da doença e sua natureza. A versão de multidetectores propicia recursos de reconstruções em diversos planos e janelas, contribuindo especialmente para o estudo do esterno.

Postoperative mediastinitis is defined as an infection of the organs and tissues in the mediastinal space, with an incidence ranging between 0.4 percent and 5 percent of cases. This disease severity varies from infection of superficial tissues in the chest wall to fulminant mediastinitis with sternal involvement. Diagnostic criterion for postoperative detection of acute mediastinitis at computed tomography is the presence of fluid collections and gas in the mediastinal space, which might or might not be associated with peristernal abnormalities such as edema of soft tissues, separation of sternal segments with marginal bone resorption, sclerosis and osteomyelitis. Other associated findings include lymphadenomegaly, pulmonary consolidation and pleural/pericardial effusion. Some of these findings, such as mediastinal gas and small fluid collections can be typically found in the absence of infection, early in the period following thoracic surgery where the effectiveness of computed tomography is limited. After approximately two weeks, computed tomography achieves almost 100 percent sensitivity and specificity. Patients with clinical suspicion of mediastinitis should be submitted to computed tomography for investigating the presence of fluid collections to identify the extent and nature of the disease. Multidetector computed tomography allows 3D images reconstruction, contributing particularly to the evaluation of the sternum.

Avaliacao dos diametros normais da aorta toracica e abdominal pela tomografia computadorizada / Evaluation of normalthoracic and abdominal aortic diameters through computorized tomography

Medimos o diametro antero-posterior da aorta toracica ascendente e descendente e da aorta abdominal, de 350 pacientes, sem doencas cardiovasculares e/ou hipertensao arterial sistemica, que se submetem a tomografia computadorizada de torax e/ou abdomen. Classificados por sexo e faixa etaria (20 a 40 anos, 41 a 60 e mais de 60 anos), calculamos as medias e desvios padrao dos diametros, determinamos os valores maximos e minimos, verificamos a influencia da idade, do sexo e da superficie corporea e determinamos as relacoes entre as medidas dos diametros da aorta toracica ascendente e descendente e da aorta abdominal, concluindo que: tanto a aorta toracica quanto a aorta abdominal reduzem de calibre craniocaudalmente; a superficie corporea tem influencia no tamanho da aorta; seu calibre aumenta com a idade; os diametros sao maiores em homens; as relacoes entre diametros da aorta ascendente e aorta descendente variam conforme sexo e faixa etaria; na aorta abdominal as razoes entre os diametros medidos ao nivel hilos renais e junto a bifurcacao independem de sexo e idade;...

Radiologia convencional / Radiology conventional

O desenvolvimento de novos métodos de diagnóstico, em geral, e de métodos de imagem, em especial o cocardiograma com Doppler, permitiu maior precisão para diagnóstico e acompanhamento de doenças valvares. As radiografias simples de tórax...