Long-term economic outcomes of ureteral injury in the United States.

OBJECTIVES: Ureteral injuries (UIs) during surgical procedures can have serious consequences for patients. Although UIs can result in substantial clinical burden, few studies report the impact of these injuries on payer reimbursement and patient cost-sharing. This retrospective study evaluated 30-day, 90-day, and 1-year healthcare resource utilization for patients with UIs and estimated patient and payer costs. METHODS: Patients aged ≥ 12 years who underwent abdominopelvic surgery from January 2016 to December 2018 were identified in a United States claims database. Patients were followed for 1 year to estimate all-cause healthcare visits and costs for patients and payers. Surgeries resulting in UIs within 30 days from the surgery date were matched to surgeries without UIs to estimate UI-attributable visits and costs. RESULTS: Five hundred and twenty-two patients with UIs were included. Almost a third (29.9%) of patients with UIs had outpatient surgery. Patients with UIs had slightly more healthcare visits and a 15.3% higher 30-day hospital readmission rate than patients without UIs. Patient costs due to UIs were not statistically significant, but annual payer costs attributable to UIs were $38,859 (95% CI = 28,142-49,576), largely driven by inpatient costs. CONCLUSIONS: UIs add substantial cost for payers and result in more healthcare visits for patients. These findings highlight the importance of including inpatient and outpatient settings for UI prevention. Although UIs are rare, the associated patient and payer burdens are high; thus, protocols or techniques are needed to recognize and avert UIs as current guideline recommendations are lacking.

Though not common, injuries to the ureters, which carry urine from the kidneys to the bladder, can occur during surgeries on the abdomen. Ureter injuries can lead to discomfort, pain, infection, and death. Patients with ureter injuries can also require additional care from doctors, leading to increased costs for both patients and insurance companies. The researchers in this study calculated the costs of ureter injuries at 30-days, 90-days, and 1-year after surgery using anonymous information from insurance claims from patients who received abdominal surgery.Compared with patients who did not have a ureter injury from surgery, a higher percentage of those with ureter injuries had healthcare visits in the year following surgery and a greater chance of being readmitted to the hospital in the 30 days after surgery. Costs for both patients and insurance companies increased in the year after surgery. Insurance companies paid almost $39,000 more on average per patient with ureter injury in the year after surgery compared with costs for patients who did not have ureter injuries. Patients with ureter injuries paid approximately $1,000 more out-of-pocket in the year after surgery compared with patients without ureter injuries.This study showed that ureter injuries increased costs for both patients and insurance companies. Patients with ureter injuries needed more healthcare and the insurance companies for those patients had higher financial costs. Though ureter injuries are uncommon, this study supports efforts to minimize their occurrence to prevent these impacts on patients and the healthcare system.

Effectiveness and Cost of Stenting in Ureteral Injury in Colorectal Surgeries in the US: 2015 - 2019.

Background: Intraoperative ureteral injury (IUI) during colorectal surgery can have devastating consequences. This study aimed to assess the clinical and economic impact of pre-operative ureteral stenting in colorectal surgeries. Methods: A retrospective cohort study was conducted using United States hospital data (October 2015 - December 2019). IUI incidence was examined across selected inpatient surgery types (elective colectomy, enterectomy, proctectomy, enterostomy, other colorectal procedures; emergency colectomy). Stenting effectiveness was evaluated as the difference in IUI and intraoperative detection rates between propensity score-matched groups. The additional hospital cost for stenting was also estimated considering the savings from IUIs that were potentially avoidable or detected by stenting. Results: In total, 283,549 colorectal surgeries were analyzed. Across surgery types, stent use and IUI incidence ranged from 1.47% - 8.86% and from 0.91% - 2.90%, respectively. Stents were used in 6.75% of elective colectomy cases, where they were associated with an absolute reduction of 1.14 percentage points (95% CI: -1.85 to -1.03) in IUI rate and a 21.6 percentage point reduction in the intraoperative detection rate. Additional hospital costs for stenting ranged from $1,464 - $4,436 across surgery types. Additional results varied by case but were consistent with the colectomy example. Conclusions: While effective in limited settings, the IUI reduction attributed to stenting and ability to shift IUI detection to the intraoperative setting could not offset the hospital cost of stent placement during colectomy (and colorectal surgery, in general). There thus remains an ongoing need in colorectal surgery for a universal, cost-effective solution to prevent IUI.

Abdominopelvic Surgery: Intraoperative Ureteral Injury and Prophylaxis in the United States, 2015-2019.

INTRODUCTION: Preoperative ureteral catheterization/stenting (stenting) and intraoperative diagnostic cystoscopy (cystoscopy) may help prevent or identify intraoperative ureteral injuries (IUIs) during abdominopelvic surgery. In order to provide a comprehensive, single source of data for health care decision makers, this study aimed to catalog the incidence of IUI and rates of stenting and cystoscopy across a wide spectrum of abdominopelvic surgeries. METHODS: We conducted a retrospective cohort analysis of United States (US) hospital data (October 2015-December 2019). IUI rates and stenting/cystoscopy use were investigated for gastrointestinal, gynecological, and other abdominopelvic surgeries. IUI risk factors were identified using multivariable logistic regression. RESULTS: Among approximately 2.5 million included surgeries, IUIs occurred in 0.88% of gastrointestinal, 0.29% of gynecological, and 1.17% of other abdominopelvic surgeries. Aggregate rates varied by setting and for some surgery types were higher than previously reported, especially in certain higher-risk colorectal procedures. Prophylactic measures were generally employed at a relatively low frequency, with cystoscopy used in 1.8% of gynecological procedures and stenting used in 5.3% of gastrointestinal and 2.3% of other abdominopelvic surgeries. In multivariate analyses, stenting and cystoscopy use, but not surgical approach, were associated with a higher risk of IUI. Risk factors associated with stenting or cystoscopy, as well as those for IUI, largely mirrored the variables reported in the literature, including patient demographics (older age, non-White race, male sex, higher comorbidity), practice settings, and established IUI risk factors (diverticulitis, endometriosis). CONCLUSION: Use of stenting and cystoscopy largely varied by surgery type, as did rates of IUI. The relatively low use of prophylactic measures suggests there may be an unmet need for a safe, convenient method of injury prophylaxis in abdominopelvic surgeries. Development of new tools, technology, and/or techniques is needed to help surgeons identify the ureter and avoid IUI and the resulting complications.

Secondary invasive fungal infection in hospitalised patients with COVID-19 in the United States.

BACKGROUND: Invasive fungal infections (IFIs) have been identified as a complication in patients with Coronavirus disease 2019 (COVID-19). To date, there are few US studies examining the excess humanistic and economic burden of IFIs on hospitalised COVID-19 patients. OBJECTIVES: This study investigated the incidence, risk factors, clinical and economic burden of IFIs in patients hospitalised with COVID-19 in the United States. PATIENTS/METHODS: Data from adult patients hospitalised with COVID-19 during 01 April 2020-31 March 2021 were extracted retrospectively from the Premier Healthcare Database. IFI was defined either by diagnosis or microbiology findings plus systemic antifungal use. Disease burden attributable to IFI was estimated using time-dependent propensity score matching. RESULTS: Overall, 515,391 COVID-19 patients were included (male 51.7%, median age: 66 years); IFI incidence was 0.35/1000 patient-days. Most patients did not have traditional host factors for IFI such as hematologic malignancies; COVID-19 treatments including mechanical ventilation and systemic corticosteroid use were identified as risk factors. Excess mortality attributable to IFI was estimated at 18.4%, and attributable excess hospital costs were $16,100. CONCLUSIONS: Invasive fungal infection incidence was lower than previously reported, possibly due to a conservative definition of IFI. Typical COVID-19 treatments were among the risk factors identified. Furthermore, diagnosis of IFIs in COVID-19 patients may be complicated because of the several non-specific shared symptoms, leading to underestimation of the true incidence rate. The healthcare burden of IFIs was significant among COVID-19 patients, including higher mortality and greater cost.

Effectiveness of the GoCheck Kids Vision Screener in Detecting Amblyopia Risk Factors.

PURPOSE: The GoCheck Kids smartphone photoscreening app (Gobiquity Mobile Health, Scottsdale, Arizona, USA), introduced in 2014, is marketed to pediatricians with little published validation. We wished to evaluate the GoCheck Kids Screener for accuracy in detecting amblyopia risk factors (ARF) using 2013 American Association for Pediatric Ophthalmology and Strabismus guidelines. DESIGN: Validity assessment. METHODS: Children 6 months to 6 years of age presenting from October 2016 to August 2017 were included. Children were screened with the GoCheck preloaded Nokia Lumia 1020, software version 4.6 with image processing version R4d, prior to undergoing a comprehensive eye examination by a pediatric ophthalmologist masked to the screener results. Determination of the presence of age-specific ARF was made based upon the examination and compared with the GoCheck recommendation. RESULTS: A total of 206 children were included (average age 43 months). When compared to examination, GoCheck had a sensitivity of 76.0% and specificity of 67.2% in detecting ARF. Positive predictive value was 57.0% and negative predictive value 83.0%. The screener results of 13 children were changed from "no risk factors" to "risk factors identified" based on the GoCheck remote review process. Four images remained "not gradable" and screening was unsuccessful in 3 children. CONCLUSION: In our high-risk population, this version of the Gocheck Kids smartphone app was useful in identifying ARF in children who are often not able to cooperate with visual acuity testing. This study informs pediatricians about the efficacy of this new screener as they make decisions about how to best detect vision problems in young children.

Adherence and Persistence Patterns in Medication Use Among Men With Lower Urinary Tract Symptoms/Benign Prostatic Hyperplasia.

Medication adherence and persistence patterns among patients with lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH) were analyzed. Electronic medical records of patients from the Reliant Medical Group were examined to evaluate adherence and persistence patterns. A total of 1,807 patients with LUTS/BPH were included in the study, and the number of patients at least 50 years of age was 1,748/1,807 (97%). Overall, 15.77% of patients were prescribed index prescription once, and no patients on combination alpha-blocker and 5-alpha reductase inhibitor therapies were prescribed their index prescriptions once. For all patients with LUTS/BPH, the mean number of prescriptions filled was 6.26, and the percentage of men persisting on index therapy for ≥4 years was 48%. Patients with LUTS/BPH showed a high proportion of both adherent and persistent treatment patterns, especially among patients taking combination therapy. The long follow-up time in our study provides evidence that patients are experiencing sufficient symptom relief to tolerate the challenges of remaining adherent and persistent.

Predictors of self-reported benign prostatic hyperplasia in European men: analysis of the European National Health and Wellness Survey.

PURPOSE: This study aimed to identify predictors of European men who self-reported being diagnosed with benign prostatic hyperplasia (DxBPH) compared to men with moderate-to-severe lower urinary tract symptoms [American Urological Association Symptom Index (AUA-SI) score ≥8] who did not self-report a BPH diagnosis (non-DxBPH). METHODS: Data were taken from the 2010 European National Health and Wellness Survey; a cross-sectional, self-administered, Internet-based questionnaire. This analysis included males ≥40 years with DxBPH or without DxBPH, but with AUA-SI ≥8. Chi-square tests were used for categorical variables and independent samples t tests were used for continuous variables. Logistic regressions were conducted among all men ≥40 years to predict being DxBPH. RESULTS: About 1,638 DxBPH and 3,676 non-DxBPH men were included. The estimated prevalence of DxBPH and non-DxBPH was 8.53 and 19.13 %. Men with DxBPH were older than non-DxBPH males (mean age 66.1 and 58.3, P < 0.001). The mean AUA-SI score was 11.3 for DxBPH and 13.2 for non-DxBPH. Being older (OR = 1.077), having a university education (OR = 1.252), having private health insurance (OR = 1.186), and specific health behaviors/attitudes [regular exercise (OR = 1.191), visiting a doctor within the previous 6 months (OR = 2.398), consulting with a medical professional when not feeling well (OR = 1.097), reporting having an attentive doctor (OR = 1.112)], and higher voiding symptoms (OR = 1.032) were significant predictors of DxBPH. CONCLUSIONS: Older men with higher education and access to care and more engagement in their healthcare were more likely to self-report being diagnosed.

How might immunization rates change if cost sharing is eliminated?

OBJECTIVES: There is a debate regarding the effect of cost sharing on immunization, particularly as the Affordable Care Act will eliminate cost sharing for recommended vaccines. This study estimates changes in immunization rates and spending associated with extending first-dollar coverage to privately insured children for four childhood vaccines. METHODS: We used the 2008 National Immunization Survey and peer-reviewed literature to generate estimates of immunization status for each vaccine by age group and insurance type. We used the Truven Health Analytics 2006 MarketScan Commercial Claims and Encounters Database of line-item medical claims to estimate changes in immunization rates that would result from eliminating cost sharing, and we used the Kaiser Family Foundation/Health Research and Educational Trust Employer Health Benefits Survey to determine the prevalence of coverage for patients with first-dollar coverage, patients who face office visit cost sharing, and patients who face cost sharing for all vaccine cost components. We assumed that once cost sharing is removed, coverage rates in plans that impose cost sharing will rise to the level of plans that do not. RESULTS: We estimate that immunization rates would increase modestly and result in additional direct spending of $26.0 million to insurers/employers. Further, these payers would have an additional $11.0 million in spending associated with eliminating cost sharing for children already receiving immunizations. CONCLUSIONS: The effects of eliminating cost sharing for vaccines vary by vaccine. Overall, immunization rates will rise modestly given high insurance coverage for vaccinations, and these increases would be more substantial for those currently facing cost sharing. However, in addition to the removal of cost sharing for immunizations, these findings suggest other strategies to consider to further increase immunization rates.

Treatment patterns in alpha-blocker therapy for benign prostatic hyperplasia.

This study examined treatment patterns and patient characteristics of men initiating alpha adrenergic blocker therapy (alpha-blocker) for benign prostatic hyperplasia (BPH). The 2009 Thomson Reuters MarketScan® Database was used to identify the newly initiated alpha-blocker: men ≥40 years old with continuous medical and pharmacy coverage for 12 months before and after alpha-blocker initiation, with no alpha-blocker or 5-alpha-reductase inhibitors in the previous year, and with ≥1 BPH diagnosis within 1 month before and 6 months after alpha-blocker initiation. This study analyzed patient demographics, clinical characteristics, adherence (percentage of men achieving medication possession ratio [MPR] ≥ 0.8), restarting the same alpha-blocker after discontinuation, switching to another BPH medication, and type of alpha-blocker (alpha 1 type selective or alpha 1 subtype selective agents). T tests and chi-square tests compared differences at the .05 significance level. A total of 13,474 men met the study criteria (mean age of 63.1 years). Two thirds of the men discontinued alpha-blocker in the 12-month period, among which restarts or switches were statistically different (p = .036) but numerically similar across cohorts. Adherence for alpha 1 type selective agents versus alpha 1 subtype selective agents at 6 months was 43.3% versus 38.1% (p < .01); at 12 months, 34.4% versus 30.5% (p < .01). Alpha-blocker discontinuation rates were high, which confirms low medication adherence reported among medications for several other chronic conditions; therefore, it is necessary to understand the reasons for alpha-blocker discontinuation.

Erectile dysfunction with or without coexisting benign prostatic hyperplasia in the general US population: analysis of US National Health and Wellness Survey.

OBJECTIVE: Erectile dysfunction (ED) and benign prostatic hyperplasia (BPH) commonly affect older men. There is limited epidemiology information on coexisting ED and BPH. This study assessed self-reported prevalence of ED with or without a diagnosis of BPH (ED/DxBPH versus ED only) in US men. METHODS: Men ≥40 years old, who reported experiencing ED in the past 6 months with or without a diagnosis of BPH, were identified from the nationally representative 2011 US National Health and Wellness Survey (NHWS) - a cross-sectional, self-administered online survey. Unpaired t-tests were used to compare characteristics between ED-only and ED/DxBPH populations. RESULTS: The prevalence of ED only and ED/DxBPH was 24.6% and 4.9% (mean ages of 60 and 68 years, respectively). About two-thirds of those with ED only and ED/DxBPH reported speaking to their physician about ED. About 23% of either group reported currently using ED medication and 11.7% of men with ED only were prescribed ED medication by a urologist, compared to 31.1% with ED/DxBPH. Approximately 51.7% of men with ED/DxBPH were taking BPH medication. Overall, 37.3% of men with ED only and 74.6% with ED/DxBPH reported moderate-to-severe urinary symptoms on the American Urological Association-Symptom Index (AUA-SI ≥8). CONCLUSION: While self-reported ED is common, few men with ED in the US population report being diagnosed with BPH. The majority of ED only and ED/DxBPH men reported speaking to a physician about ED; however, few reported currently taking ED medication. A majority of men with ED/DxBPH reported an AUA-SI score ≥8, but only half reported taking BPH medications. Thus, although men are experiencing erectile or urinary symptoms, many remain untreated. A limitation of this study is that symptoms and diagnosis were self-reported and may not reflect how these conditions are diagnosed in a healthcare setting; however, patient self-report provides a unique perspective on the burden associated with these conditions.

Medication adherence and treatment patterns for hypogonadal patients treated with topical testosterone therapy: a retrospective medical claims analysis.

INTRODUCTION: There is limited information on adherence to topical testosterone replacement therapy (TRT) among hypogonadal men. AIM: To determine adherence rates among men treated with topical testosterone gels and to examine factors that may influence adherence, including age, presence of a specific diagnosis, and index dose. METHODS: Included were 15,435 hypogonadal men, from the Thomson Reuters MarketScan Database, who had an initial topical testosterone prescription in 2009 and who were followed for 12 months. MAIN OUTCOME MEASURES: Adherence to testosterone was measured by medication possession ratio (MPR), with high adherence defined as ≥0.8. Persistence was defined as the duration of therapy from the index date to the earliest of the following events: end date of the last prescription, date of the first gap of >30 days between prescriptions, or end of the study period (12 months). RESULTS: Adherence to topical TRT was low. By 6 months, only 34.7% of patients had continued on medication; at 12 months, only 15.4%. Adherence rates were numerically similar among men who received AndroGel or Testim topical gels and did not differ among men of different age groups. Approximately 80% of patients initiated at the recommended dose of 50 mg/day. Over time, an increased proportion of men used a higher dose. This change was the result of dose escalation, rather than of greater adherence among men initiating therapy at a high dose. Dose escalation was seen as early as 1 month into therapy. Approximately 50% of men who discontinued treatment resumed therapy; most men used the same medication and dose. CONCLUSIONS: Discontinuation rates are high among hypogonadal men treated with testosterone gels, irrespective of their age, diagnosis, and index dose. Further study, evaluating other measurable factors associated with low adherence among patients receiving topical TRT, may lead to interventions designed to improve adherence with therapy.

Policy implications of first-dollar coverage: a qualitative examination from the payer perspective.

OBJECTIVES: Immunization against potentially life-threatening illnesses for children and adults has proved to be one of the great public health successes of the 20th century and is extremely cost-effective. The Patient Protection and Affordable Care Act includes a number of provisions to increase coverage and access to immunizations for the consumer, including a provision for health plans to cover all Advisory Committee on Immunization Practices-recommended vaccines at first dollar, or without cost sharing. In this study, we examined payers' perspectives on first-dollar coverage of vaccines and strategies to improve vaccination rates. METHODS: This was a qualitative study, using a literature review and semistructured expert interviews with payers. RESULTS: Four key themes emerged, including (1) the cost implications of the first-dollar change; (2) the importance of examining barriers to children, adolescents, and adults separately to focus interventions more strategically; (3) the importance of provider knowledge and education in increasing immunization; and (4) the effect of first-dollar coverage on those who decline vaccination for personal reasons. CONCLUSIONS: We determined that, while reducing financial barriers through first-dollar coverage is an important first step to increasing immunization rates, there are structural and cultural barriers that also will require collaborative, strategic work among all vaccine stakeholders.

Use of emergency departments for conditions related to poor oral healthcare: implications for rural and low-resource urban areas for three states.

Persistent and worsening shortages of oral healthcare providers in rural areas, combined with limited acceptance of Medicaid and State Children's Health Insurance Programs, have left many patients without adequate access to dental care. Evidence suggests that such patients seek treatment in emergency departments (EDs) for problems that might have been prevented given adequate oral healthcare. This finding has public policy questions that are explored by this study. To investigate these questions, the State Emergency Department Databases available as part of the Healthcare Cost and Utilization Project and Area Resource Files were used, along with communication with state Medicaid offices for three diverse states: Utah, Vermont, and Wisconsin. While overall patterns of oral healthcare-seeking among the three states are similar, our research discovered important differences with implications for healthcare policy: In states with less generous Medicaid reimbursements, Medicaid beneficiaries in rural areas have ED care-seeking patterns like those of the uninsured. In more generous states, they seek care more like the privately insured. This suggests that Medicaid policy is one important tool in providing low-income and other vulnerable populations with access to higher-quality dental care.

Gender differences in the relationships of cardiovascular symptoms and somatosensory amplification to mortality.

Symptoms of angina and dyspnea predict coronary artery disease and death less well in women than in men. Greater somatosensory amplification - a psychosocial propensity to report symptoms of physical discomfort - may lead women to report relatively high levels of angina and dyspnea for reasons unrelated to coronary disease, reducing their associations with mortality. We assessed this hypothesis in a nationally representative survey of U.S. adults. When stratified by gender, angina and dyspnea significantly predicted mortality among men, but predicted it less well among women. After adjusting for amplification, cardiovascular symptoms did not predict mortality among women, but amplification was positively associated with mortality among older women.

Contraindications to oral contraceptive use among women in the United States, 1999-2001.

OBJECTIVE: The prescription requirement for oral contraceptives (OCs) is designed to prevent women with contraindications from using OCs, but this system has never been evaluated. This analysis investigates OC use among women who have contraindications. METHODS: We use National Health and Nutrition Examination Survey data to estimate the prevalence of contraindications among OC users and nonusers. We associate OC use with contraindication status, controlling for sociodemographic characteristics and access to health services. RESULTS: Overall, 16% of fecund women aged 20 to 51 years are contraindicated from OC use. The prevalence of contraindications among current OC users is 6%, as compared to 19% among nonusers. Regression results show that OC use is more strongly associated with age, race, marital status and health insurance coverage than with having a contraindication to OCs. CONCLUSION: The results suggest that under the prescription requirement, screening for contraindications to OCs may be working, but not perfectly. More research is needed to identify more effective and convenient screening methods.

Contraceptive counseling in managed care: preventing unintended pregnancy in adults.

This study examines contraceptive counseling received by adult women in their managed care plans and the relationship between counseling and women's contraceptive attitudes and practices. Telephone interviews were conducted with a random sample of 898 women ages 18 to 44 enrolled in a commercial health maintenance organization (HMO) or point-of-service (POS) health plan. Counseling received in the past 2 years was measured on three dimensions: exposure through any communication channel; content of information; and personalization of discussion. Multiple logistic regression analysis was used to examine the determinants of counseling and the relationship between counseling and four outcomes: satisfaction with counseling received, self-efficacy for preventing unintended pregnancy, current use of contraception (if at risk of unintended pregnancy), and intent to contracept in the next year (if at risk). Overall, 60.5% of women were at risk of unintended pregnancy; among those at risk, 69% received any counseling in the past 2 years, compared with 38% among those not at risk. Receiving personalized counseling (as opposed to no counseling or only informational counseling) significantly increases the odds of satisfaction with counseling, current contraceptive use, and intent to contracept. Informational counseling alone (without personalization) significantly increases the odds of contraceptive use. Women ages 40-44 were less likely than younger women to receive counseling and to use contraception if at risk of unintended pregnancy. We conclude that receiving contraceptive counseling in managed care is associated with contraceptive attitudes and practices among adults and that there is substantial room for quality improvement in the provision of contraceptive counseling.