Caught Between a ROCR and a Hard Place: Improving Proposed Radiation Oncology Alternative Payment Models.

PURPOSE: The Radiation Oncology Case Rate (ROCR) aims to shift radiation reimbursement from fee-for-service (FFS) to bundled payments, which would decouple fractionation from reimbursement in the United States. This study compares historical reimbursement rates from three large centers and a national Medicare sample with proposed base rates from ROCR. It also tests the impact of methodological inclusion of treatment and disease characteristics to determine if any variables are associated with greater rate differences that may lead to inequitable reimbursement. METHODS: Using XXXX electronic medical record data from 2017-2020 and Part B claims from the Medicare 5% research identifiable files (RIF), episodic 90-day historical reimbursement rates for 15 cancer types were calculated per the ROCR payment methodology. XXXX reimbursement rates were stratified by disease and treatment characteristics and multiple linear regression was performed to assess the association of these variables on historical episode reimbursement rates. RESULTS: From XXXX, 3,498 patient episodes were included and 480,526 from the RIF. From both datasets, 25% of brain metastases and 13% of bone metastases episodes included ≥2 treatment courses with an average of 51 days between courses. Accounting for all 15 cancer types, ROCR base rates resulted in an average -2.4% and -2.9% reduction in rates for XXXX and the RIF respectively compared to historical reimbursement. On multivariate analysis of XXXX data, treatment intent (curative vs. palliative) was associated with higher historical reimbursement (+$477 to +$7,417; p ≤ 0.05) for 12 out of 12 applicable cancer types. Stage (3-4 vs. 1-2) was associated with higher historical reimbursement (+$1,169 to +$3,917; p ≤ 0.05) for 8 out of 12 applicable cancer types. CONCLUSION: Our data suggest ROCR base rates introduce an average ≤3% reimbursement rate decrease compared to historical FFS reimbursement per cancer type, which could produce the Medicare savings required for congressional approval of ROCR. Estimating comparisons with future FFS reimbursement would require consideration of additional factors such as the increased utilization of hypofractionation, proposed FFS rate cuts, and inflationary updates. A distinct rate and shortened episode duration (≤ 30 days) should be considered for palliative episodes. Applying a base rate modifier per cancer stage may mitigate disproportionate reductions in reimbursement for facilities with a higher volume of curative advanced stage patients such as freestanding centers in rural settings.

Radiologists' 2021 Quality Reporting and Performance in Medicare's Merit-Based Incentive Payment System: Analysis by Practice Type.

This study of national CMS data shows differences in quality reporting and performance of Merit-Based Incentive Payment System (MIPS)-participating radiologists by practice specialty mix. For certain practice types, radiologist-reported quality measures were commonly not radiology measures. The results support a need to expand radiology measures and to better align measure reporting with clinician specialty.

Heart health for South Asians: improved cardiovascular risk factors with a culturally tailored health education program.

BACKGROUND/AIM: The Kaiser Permanente (KP) Northern California Heart Health for South Asians (HHSA) Program is a two-hour educational class that provides culturally relevant lifestyle and dietary recommendations to South Asian (SA) patients, in an effort to reduce their known disproportionate burden of cardiovascular (CV) disease. We evaluated the impact of the HHSA Program on CV risk factors and major adverse CV events (MACE). METHODS: A retrospective cohort study identified 1517 participants of SA descent, ≥ 18 years old from 2006 to 2019. We evaluated the change in risk factors with program attendance (median follow up of 6.9 years) for systolic blood pressure (SBP), diastolic blood pressure (DBP), triglycerides (TG), LDL, HDL, BMI, and HbA1c. We also performed a propensity matched analysis to evaluate differences in MACE including stroke, myocardial infarction (MI), coronary revascularization, and all-cause mortality. RESULTS: There were significant improvements in DBP, TG, LDL-c, HDL-c, BMI, and HbA1c at one year follow up and sustained improvements in DBP (-1.01mmHg, p = 0.01), TG (-13.74 mg/dL, p = 0.0001), LDL-c (-8.43 mg/dL, p = < 0.0001), and HDL-c (3.16 mg/dL, p = < 0.0001) levels at the end of follow up. In the propensity matched analysis, there was a significant reduction in revascularization (OR 0.33, 95% CI 0.14-0.78, p = 0.011) and mortality (OR 0.41, 95% CI 0.22-0.79, p = 0.008), and a trend towards reduction in stroke. CONCLUSIONS: Our study demonstrates the efficacy of a culturally tailored SA health education program in improving CV risk factors and reducing MACE. The program highlights the importance and value of providing culturally tailored health education in primary CV disease prevention.

Complex Inferior Vena Cava Filter Retrievals: Success Rate and Predictors of Adverse Events at a Large Specialized Referral Center.

BACKGROUND. Specialized inferior vena cava (IVC) filter referral centers can achieve improved retrieval outcomes, potentially facilitating complex retrievals after long filter dwell times. OBJECTIVE. The purpose of this study was to determine the success rate of complex IVC filter retrievals at a large specialized IVC filter referral center and to identify predictors of adverse events during complex retrievals. METHODS. This retrospective study included patients who underwent complex IVC filter retrieval from March 2014 to June 2018 at a large regional health system with specialized complex retrieval referral centers and interventional radiologists with expertise in such procedures. Complex retrievals methods included a range of loop snare, coaxial sheath, forceps, and snare techniques. Data were collected from the electronic medical record. The success rate of complex retrieval was determined. Factors associated with adverse events during retrieval procedures were explored. RESULTS. The study included 125 patients (51 women, 74 men; mean age, 60 years). The mean filter dwell time at retrieval was 47.5 months (median, 21.8 months). The complex retrieval success rate was 99.2% on the first attempt and 100.0% overall. A total of 11.2% (14/125) of patients experienced an adverse event during retrieval, including 10.4% (13/125) with minor and 0.8% (1/125) with major events. Prolonged dwell time was the only indication for complex retrieval that was significantly associated with adverse events (adverse event rate, 16.7% for patients with this indication vs 5.1% for patients without this indication; p = .04). In multiple regression analysis, the only significant independent predictor of adverse events was a filter dwell time of 5 years or longer (odds ratio, 6.98 [95% CI, 1.64-29.81]; p = .009). CONCLUSION. In a specialized referral system with expertise in complex retrieval methods, high retrieval success rates can be achieved in patients who have filters with long dwell times. Nonetheless, longer dwell times are associated with adverse events during retrieval procedures. CLINICAL IMPACT. The observations support performing early filter retrieval and referring patients who have filters with prolonged dwell times to specialized centers.

Association of State Share of Nonphysician Practitioners With Diagnostic Imaging Ordering Among Emergency Department Visits for Medicare Beneficiaries.

Importance: The use of nonphysician practitioners (NPPs) in the emergency department (ED) continues to expand, yet little is known about associations between NPPs and ED imaging use. Objective: To investigate whether the state share of ED visits for which an NPP was the clinician of record is associated with imaging studies ordered, given that state NPP share is associated with state-level NPP scopes of practice. Design, Setting, and Participants: This cross-sectional study compared diagnostic imaging ordering patterns associated with ED visits based on 2005-2020 Medicare claims for a nationally representative 5% sample of fee-for-service beneficiaries. For all 50 states and the District of Columbia, the state NPP share of ED visits by year was used to represent state-specific practice patterns for NPPs and physicians and how those patterns have evolved over time. The analysis controlled for patient demographic characteristics, Charlson Comorbidity Index scores, ED visit severity, year, and principal diagnosis. Exposures: The share of ED visits in each state in each year (state share) for which an NPP was the evaluation and management clinician. Main Outcomes and Measures: The main outcomes were the number and modality of imaging studies associated with ED visits. Analyses were by logistic regression and generalized linear model with γ-distribution and log-link function. Results: Among 16 922 274 ED visits, 60.0% involved women, and patients' mean (SD) age was 70.3 (16.1) years. The share of all ED visits with an NPP as the clinician increased from 6.1% in 2005 to 16.6% in 2020. Compared with no NPPs, the presence of NPPs in the ED was associated with 5.3% (95% CI, 5.1%-5.5%) more imaging studies per ED visit, including a 3.4% (95% CI, 3.2%-3.5%) greater likelihood of any imaging order per ED visit and 2.2% (95% CI, 2.0%-2.3%) more imaging studies ordered per visit involving imaging. Conclusions and Relevance: In this study, use of NPPs in the ED was associated with higher imaging use compared with the use of only physicians in the ED. Although expanded use of NPPs in the ED may improve patient access, the costs and radiation exposure associated with more imaging warrants additional study.

Thrombotic Risk Associated with Inferior Vena Cava Filter Placement in Patients with Heparin-Induced Thrombocytopenia.

PURPOSE: This study sought to define thromboembolic risk and mortality in patients with heparin-induced thrombocytopenia (HIT) undergoing inferior vena cava filter (IVCF) placement, in light of the American Society of Hematology's 2018 guidelines against routine use of IVCFs in this population. METHODS: A total of 26 patients with HIT who received IVCFs were retrospectively reviewed, and the outcomes of this group were compared with those of 4,707 controls with either HIT or IVCFs alone and with reported outcomes in prior studies. RESULTS: The patient group demonstrated 6- and 12-month mortality rates of 26.9% and 30.8%, respectively, which did not differ significantly from those of the control groups and were in line with published mortality rates in the literature. The measured thromboembolic risk of 19.2% in the patient group was also within the range of published rates for patients with HIT or IVCF alone. CONCLUSIONS: IVCF placement did not significantly increase the risk of thromboembolism or death in patients with HIT and may be a viable option in the subset of these patients who are not candidates for anticoagulation.

Real-World Experiences with Pazopanib in Patients with Advanced Soft Tissue and Bone Sarcoma in Northern California.

Background: Pazopanib was approved for advanced soft tissue sarcoma as a second- or third-line therapy based on the clinical trial "Pazopanib for metastatic soft-tissue sarcoma" (PALETTE). We hypothesized that the real-world experiences may be significantly different from the clinical trial results. Methods: We analyzed the response pattern of patients with advanced soft tissue and bone sarcoma who received pazopanib treatment between 1 January 2011 and 31 October 2018 in Kaiser Permanente Northern California. Results: A total of 123 patients with 23 different histologic subtypes were assessable. One patient with low-grade fibromyxoid sarcoma obtained complete response (CR) after 2 months of treatment with pazopanib, 12 patients (9.7%) obtained partial response (PR), 34 patients (27.6%) had stable disease (SD), while 76 patients (61.8%) developed progressive disease (PD). The disease control rate (DCR) was 46.3% (CR + PR + SD). Among the 12 patients with PR, 3 had undifferentiated pleomorphic sarcoma (UPS), 4 had leiomyosarcoma (LMS), 2 had pleomorphic rhabdomyosarcoma, 1 had pleomorphic liposarcoma, 1 had dedifferentiated liposarcoma, and 1 had angiosarcoma. The median duration of response was 9 months. Two patients with Ewing's sarcoma had SD for 6 and 13 months, and two patients with osteosarcoma had SD for 6 and 9 months. Among 65 patients assessed at 8 weeks, 9 had a response, and 10 had SD. Among 104 patients assessed at 12 weeks, 12 had a response, and 26 had SD. The median progression-free survival (PFS) was approximately 3 months for all 123 cases and for patients with UPS and LMS. Conclusions: Our cohort of patients with advanced soft tissue and bone sarcoma in Northern California treated with pazopanib had diverse histologic subtypes. The response rate (CR + PR) was higher than that of the PALETTE trial, while the DCR and the median PFS were significantly lower. The observation of PR in two patients with liposarcoma and durable SD in several patients with bone sarcoma indicates that pazopanib has activity in liposarcoma and bone sarcoma.

Heart Transplant Recipients Prefer a Telemental Health Cognitive-Behavioral Therapy Intervention Delivered by Telephone.

Background:Depression and anxiety are common after heart transplant, and in a regional heart transplant center servicing northern California, willingness to participate in treatment can be a major barrier.Introduction:Our primary aim is to design a remote cognitive-behavioral therapy (CBT) intervention. This study is the first step in the process. Through a survey to the cohort of heart transplant recipients (N = 230), managed within the Kaiser Permanente Northern California's Heart Transplant Service, we aimed to assess symptoms of stress, depression, and anxiety, patient willingness to participate in a CBT intervention, and preference between video and telephone. We proposed to patients a five-visit intervention, with the first and last visits in person and the three middle visits by video.Materials and Methods:One hundred twenty of 230 heart transplant recipients returned the 12-question Likert-like survey. Statistical tests included chi-square, fisher exact test, t-tests, and a logistic regression model.Results:Patients who reported two or more symptoms of stress, depression, and anxiety were 5.67 times more likely to engage in a remote CBT intervention (odds ratio = 5.67; 95% confidence interval 1.63-19.78; p = 0.006). Patients experiencing stress with depression were the most willing group to participate in a CBT intervention. The 12 patients who met the study criteria of 3 years post-transplant and experiencing at least one mental health symptom were invited to participate in the CBT intervention. All patients (12) who met the CBT intervention criteria were not willing to participate in the two in-person visits. All were willing to participate in a telephone-only CBT intervention.Discussion:Among the heart transplant recipients in this cohort, there is more willingness to participate in a CBT intervention when distress is higher and there is a preference for telephone visits as the modality for treatment delivery.Conclusions:Based on the findings, the CBT intervention will be shorter in duration; instead of five visits, there will be four visits; and it will be conducted by telephone only. The new intervention will be tested with 8 to 10 patients, changed, and then it will need to be empirically tested.

Effectiveness of a Retrospective Drug Utilization Review on Potentially Unsafe Opioid and Central Nervous System Combination Therapy.

BACKGROUND: Drug overdose deaths are the leading cause of unintentional death in the United States, and opioid-related mortality is the primary contributor (75.2%). Among opioid-related mortalities, opioids are most commonly taken with benzodiazepines (30.1%) and antidepressants (13.4%). The utility of a retrospective drug utilization review (DUR) program initiated by a commercial health plan for members taking potentially unsafe opioid and central nervous system (CNS) combination therapy is currently unknown. OBJECTIVE: To determine the effectiveness of a retrospective DUR program on potentially unsafe opioid and CNS combination therapy. METHODS: This research is a pre-post study utilizing pharmacy claims data from 2.6 million commercially insured members enrolled in a health plan in the Midwest. Members were required to be at least aged 18 years as of August 30, 2013, and continuously enrolled from May 2, 2013, through February 15, 2014. Members with 1 or more paid claims for an opioid at least 200 morphine equivalent dose (MED) daily and a concur- rent supply of another opioid, benzodiazepine, or antidepressant from May 2, 2013, through August 30, 2013 (120-day preintervention period) were targeted for the retrospective DUR program. These exclusion criteria were applied: members belonging to commercial groups requiring permission on claims data analyses, missing or invalid prescriber information, or presence of pharmacy claims indicating human immunodeficiency virus or acquired immunodeficiency syndrome during the 2 years prior to the pre-intervention period. Prescribers of high-dose opioids received a mailing (intervention) containing a member-specific letter, medication profile, and satisfaction survey to determine the prescriber-perceived clinical value of the program. To assess the effectiveness of the retrospective DUR program, criteria was reapplied to identify members still meeting criteria 120 days postintervention (February 15, 2014). Paired samples t-test was used to compare pre-post results. RESULTS: Of 2,236,243 eligible members aged 18 years and older, 980 met DUR criteria. Prescribers for these members subsequently received a mailing regarding potentially unsafe opioid and CNS combination therapy. A total of 671 prescribers were sent a mailing regarding these 980 members. Among the 980 members meeting DUR criteria, distribution of prescriber specialty was family medicine (25.9%), physical medicine and rehabilitation (14.4%), internal medicine (13.0%), pain (9.2%), anesthesiology (7.0%), other (8.8%), and unknown (21.7%). High-dose opioids most commonly identified by the DUR were oxycodone extended release (27.6%), morphine sulfate extended release (17.7%), and fentanyl patch (13.1%). After reapplying DUR criteria to identify members still meeting criteria 120 days after the DUR, 528 members remained, representing a 28.1% reduction in high-risk opioid use. Survey response rate was 23.6% (231 of 980 surveys returned). The majority (62.3%) of respondents reported that this retrospective DUR program was useful in their daily practice. CONCLUSIONS: A 28.1% reduction in potentially unsafe opioid and CNS combination therapy was observed after implementing a retrospective DUR program targeting high-risk opioid use. Among members remaining high risk after the DUR, the change in total unique opioids and total daily MED was nonsignificant. Members remaining at high risk after the DUR can be targeted for further interventions such as care management and member education regarding fraud, waste, and abuse. A majority of prescribers (90.5%) self-report using their states' prescription monitoring programs when prescribing controlled substances.

Garcinol inhibits cell growth in hepatocellular carcinoma Hep3B cells through induction of ROS-dependent apoptosis.

Garcinol, derived from Garcinia indica and other related species, has been found to modulate several cell signalling pathways involved in apoptosis and cancer development. Growth arrest and DNA damage-inducible gene 153 (GADD153) is a member of the CCAAT/enhancer-binding protein (C/EBP) family of transcription factors; it is expressed at low levels under normal conditions but strongly induced upon growth arrest, DNA damage, and endoplasmic reticulum (ER) stress. This study investigated the effect of garcinol on Hep3B cells, a human hepatocellular cancer cell line lacking functional p53, with the goal of elucidating the molecular mechanisms of p53-independent apoptosis in hepatocellular cancer. Overall, garcinol activated not only the death receptor and the mitochondrial apoptosis pathways but also the ER stress modulator GADD153. Garcinol treatment led to the accumulation of reactive oxygen species (ROS), increased GADD153 expression, and reduced mitochondrial membrane potential. An increase in the Bax/Bcl-2 ratio resulted in enhanced apoptosis. Caspase-8 and tBid (truncated Bid) expression also increased in a time-dependent manner. The enzymatic activities of caspase-3 and caspase-9 increased approximately 13-fold and 7.8-fold, respectively. In addition, the proteolytic cleavage of poly-(ADP-ribose)-polymerase (PARP) and DNA fragmentation factor-45 (DFF-45) increased in dose- and time-dependent manners. Our data suggest a promising therapeutic application of garcinol in p53-independent apoptosis in cancers.

Threat-responsiveness and the decision to obtain free influenza vaccinations among the older adults in Taiwan.

BACKGROUND: Although older adults are encouraged by government agencies to receive influenza vaccinations, many do not obtain them. In Taiwan, where universal health care coverage has significantly reduced the barriers of access to care, the health care system has provided free influenza vaccinations for people 65 years or older since 2001. Nevertheless, the numbers of people who use this service are much fewer than expected. The aim of this study was to explore major factors that might affect the decision to receive influenza vaccinations among older adults in Taiwan. METHODS: Using national representative health insurance medical claims from the National Health Insurance Research Database between 2002 and 2004, we investigated the role of threat-responsiveness, represented by prior vaccinations and prior physician visits for flu-like respiratory conditions, in the decisions of older adults to obtain vaccinations in Taiwan. RESULTS: Among the sample of 23,023 older adults, the overall yearly vaccination rates in this study were 38.6%, 44.3% and 39.3% for 2002, 2003, and 2004, respectively. Adjusting for covariates of individual and health care facility characteristics, the multivariate logistic regression revealed that older adults who had had prior vaccinations were ten times more likely to be vaccinated during the following influenza season than those who had not (OR=10.22, 95%CI: 9.82-10.64). The greater the frequency of prior physician visits for flu-like respiratory conditions, the greater the likelihood that one would decide to be vaccinated. Visits during prior interim (non-epidemic) season exerted a stronger positive influence than prior influenza season on this likelihood (OR=1.59, 95% CI: 1.46-1.73 vs. OR=1.11 95% CI: 1.01-1.22, respectively). CONCLUSION: Threat-responsiveness, or perceived risk, greatly influences influenza vaccination rates among the older adults in Taiwan. These findings can be used to help design public health campaigns to increase the influenza vaccination rate in this vulnerable group of citizens. Particularly, older adults who never had influenza vaccinations can be identified, educated, and encouraged to participate.