ABSTRACT
BACKGROUND CONTEXT: While some studies have demonstrated that ambulatory surgery centers (ASCs) are associated with reduced costs of orthopedic procedures, there is no consensus in the current literature as to the impact of ASCs versus hospital-based outpatient departments (HOPDs) on anterior cervical discectomies and fusions (ACDFs). PURPOSE: This study sought to 1) compare immediate procedure reimbursements, patient out-of-pocket expenditures, and surgeon reimbursements for ACDFs performed at ASCs versus HOPDs and 2) identify factors predicting facility utilization. STUDY DESIGN: Retrospective cross-sectional study. PATIENT SAMPLE: We identified ACDF procedures performed at an ASC or HOPD in commercially-insured patients aged 18-64. OUTCOME MEASURES: Payment variables were calculated from claims within 3 days preoperatively and postoperatively. METHODS: Multivariable regression models assessed a) associations between the surgery setting and payment variables and b) factors associated with the surgery setting. RESULTS: We included 18,191 ACDFs (14.8% ASC, 85.2% HOPD). In multivariable analyses, ACDFs performed in an ASC (versus HOPD) were associated with 9.8% higher immediate procedure reimbursements (95% CI:7.5-12.2%), 17.2% higher patient out-of-pocket expenditures (95% CI:11.8-22.8), and 11.7% higher surgeon reimbursements (95% CI:9.18-14.2; all P<0.01) (all P<0.001). Surgery setting utilization varied by region, insurance-related factors, comorbidities, and procedural complexity. CONCLUSIONS: We found that ASCs had significantly higher reimbursements compared to HOPDs. Regional variations in ASC utilization imply there are opportunities for standardization of care.
ABSTRACT
Although somatic mutations influence the pathogenesis, phenotype, and outcome of myeloproliferative neoplasms (MPNs), little is known about their impact on molecular response to cytoreductive treatment. We performed targeted next-generation sequencing (NGS) on 202 pretreatment samples obtained from patients with MPN enrolled in the DALIAH trial (A Study of Low Dose Interferon Alpha Versus Hydroxyurea in Treatment of Chronic Myeloid Neoplasms; #NCT01387763), a randomized controlled phase 3 clinical trial, and 135 samples obtained after 24 months of therapy with recombinant interferon-alpha (IFNα) or hydroxyurea. The primary aim was to evaluate the association between complete clinicohematologic response (CHR) at 24 months and molecular response through sequential assessment of 120 genes using NGS. Among JAK2-mutated patients treated with IFNα, those with CHR had a greater reduction in the JAK2 variant allele frequency (median, 0.29 to 0.07; P < .0001) compared with those not achieving CHR (median, 0.27 to 0.14; P < .0001). In contrast, the CALR variant allele frequency did not significantly decline in those achieving CHR or in those not achieving CHR. Treatment-emergent mutations in DNMT3A were observed more commonly in patients treated with IFNα compared with hydroxyurea (P = .04). Furthermore, treatment-emergent DNMT3A mutations were significantly enriched in IFNα-treated patients not attaining CHR (P = .02). A mutation in TET2, DNMT3A, or ASXL1 was significantly associated with prior stroke (age-adjusted odds ratio, 5.29; 95% confidence interval, 1.59-17.54; P = .007), as was a mutation in TET2 alone (age-adjusted odds ratio, 3.03; 95% confidence interval, 1.03-9.01; P = .044). At 24 months, we found mutation-specific response patterns to IFNα: (1) JAK2- and CALR-mutated MPN exhibited distinct molecular responses; and (2) DNMT3A-mutated clones/subclones emerged on treatment.