Impact of extended release naltrexone on health-related quality of life in individuals with legal involvement and opioid use disorders.

Background: Understanding the impact of medications for opioid use disorder on health related quality of life (QOL) may help to explain why few individuals with legal involvement remain in treatment, specifically those receiving opioid antagonists. QOL is an established predictor of treatment retention and has been shown to improve with some treatment for opioid use disorder. Yet limited research has examined QOL with opioid antagonists. We examined the impact of extended release naltrexone (XR-NTX) on QOL and retention in treatment in a randomized, multi-site trial of individuals with legal involvement. Methods: The participants were 308 community-dwelling adults with current or recent legal involvement with opioid dependence at five site across United States. They were randomized to receive XR-NTX or treatment as usual for 6 months. QOL was measured every 2 weeks using Euro QOL individual items, summary index score, and health state today metric. Results: No significant difference in QOL scores were observed between the two groups at the completion of active treatment or on follow up at 52 and 78 weeks. There were no time effects of treatment on scores. Contrary to expectation, baseline and average QOL did not predict retention in treatment. Conclusion: In contrast to prior research, our findings did not demonstrate significant changes (improvements or decreases) in QOL associated with XR-NTX treatment. Clinicians may consider that individuals receiving XR-NTX may not experience changes in perceived well-being in response to treatment and consider discussing with patients that they may not necessarily perceive improvement in their QOL. This may help to ground patient's expectations about the effects of treatment and potentially reduce attrition from treatment with opioid antagonists.

Depression symptoms and cognitive impairment in older nursing home residents in the USA: A latent class analysis.

OBJECTIVES: To identify subgroups of nursing home (NH) residents in the USA experiencing homogenous depression symptoms and evaluate if subgroups vary by cognitive impairment. METHODS: We identified 104 465 newly admitted, long-stay residents with depression diagnosis at NH admission in 2014 using the Minimum Data Set 3.0. The Patient Health Questionnaire-9 was used to measure depression symptoms and the Brief Interview of Mental Status for cognitive impairment (intact; moderately impaired; severely impaired). Latent class analysis (LCA) with logistic regression was used to: (a) construct the depression subgroups and (b) estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) of the associations between the subgroups and cognitive impairment level, adjusting for demographic and clinical characteristics. RESULTS: The best-fitted LCA model suggested four subgroups of depression: minimal symptoms (latent class prevalence: 42.4%), fatigue (32.0%), depressed mood (14.5%), and multiple symptoms (11.2%). Odds of subgroup membership varied by cognitive impairment. Compared to residents with intact cognition, those with moderate or severe cognitive impairment were less likely to belong to the fatigue subgroup [aOR(95% CI): moderate: 0.75 (0.71-0.80); severe: 0.26 (0.23-0.29)] and more likely to belong to the depressed mood subgroup [aOR (95% CI): moderate: 4.54 (3.55-5.81); severe: 6.41 (4.86-8.44)]. Residents with moderate cognitive impairment had increased odds [aOR (95% CI): 1.19 (1.12-1.27)] while those with severe impairment had reduced odds of being in the multiple symptoms subgroup [aOR (95% CI): 0.63 (0.58-0.68)]. CONCLUSIONS: Findings provide a basis for improving depression management with consideration of both subgroups of depression symptoms and levels of cognitive function.

Inaugural Readmission Penalties for Total Hip and Total Knee Arthroplasty Procedures Under the Hospital Readmissions Reduction Program.

Importance: The Hospital Readmissions Reduction Program (HRRP) is a Centers for Medicare and Medicaid Services policy that levies hospital reimbursement penalties based on excess readmissions of patients with 4 medical conditions and 3 surgical procedures. A greater understanding of factors associated with the 3 surgical reimbursement penalties is needed for clinicians in surgical practice. Objective: To investigate the first year of HRRP readmission penalties applied to 2 surgical procedures-elective total hip arthroplasty (THA) and total knee arthroplasty (TKA)-in the context of hospital and patient characteristics. Design, Setting, and Participants: Fiscal year 2015 HRRP penalization data from Hospital Compare were linked with the American Hospital Association Annual Survey and with the Healthcare Cost and Utilization Project State Inpatient Database for hospitals in the state of Florida. By using a case-control framework, those hospitals were separated based on HRRP penalty severity, as measured with the HRRP THA and TKA excess readmission ratio, and compared according to orthopedic volume as well as hospital-level and patient-level characteristics. The first year of HRRP readmission penalties applied to surgery in Florida Medicare subsection (d) hospitals was examined, identifying 60 663 Medicare patients who underwent elective THA or TKA in 143 Florida hospitals. The data analysis was conducted from February 2016 to January 2017. Exposures: Annual hospital THA and TKA volume, other hospital-level characteristics, and patient factors used in HRRP risk adjustment. Main Outcomes and Measures: The HRRP penalties with HRRP excess readmission ratios were measured, and their association with annual THA and TKA volume, a common measure of surgical quality, was evaluated. The HRRP penalties for surgical care according to hospital and readmitted patient characteristics were then examined. Results: Among 143 Florida hospitals, 2991 of 60 663 Medicare patients (4.9%) who underwent THA or TKA were readmitted within 30 days. Annual hospital arthroplasty volume seemed to follow an inverse association with both unadjusted readmission rates (r = -0.16, P = .06) and HRRP risk-adjusted readmission penalties (r = -0.12, P = .14), but these associations were not statistically significant. Other hospital characteristics and readmitted patient characteristics were similar across HRRP orthopedic penalty severity. Conclusions and Relevance: This study's findings suggest that higher-volume hospitals had less severe, but not significantly different, rates of readmission and HRRP penalties, without systematic differences across readmitted patients.

Costs of Cancer Care Across the Disease Continuum.

PURPOSE: The aim of this study was to estimate Medicare payments for cancer care during the initial, continuing, and end-of-life phases of care for 10 malignancies and to examine variation in expenditures according to patient characteristics and cancer severity. MATERIALS AND METHODS: We used linked Surveillance, Epidemiology and End Results-Medicare data to identify patients aged 66-99 years who were diagnosed with one of the following 10 cancers: prostate, bladder, esophageal, pancreatic, lung, liver, kidney, colorectal, breast, or ovarian, from 2007 through 2012. We attributed payments for each patient to a phase of care (i.e., initial, continuing, or end of life), based on time from diagnosis until death or end of study interval. We summed payments for all claims attributable to the primary cancer diagnosis and analyzed the overall and phase-based costs and then by differing demographics, cancer stage, geographic region, and year of diagnosis. RESULTS: We identified 428,300 patients diagnosed with one of the 10 malignancies. Annual payments were generally highest during the initial phase. Mean expenditures across cancers were $14,381 during the initial phase, $2,471 for continuing, and $13,458 at end of life. Payments decreased with increasing age. Black patients had higher payments for four of five cancers with statistically significant differences. Stage III cancers posed the greatest annual cost burden for four cancer types. Overall payments were stable across geographic region and year. CONCLUSION: Considerable differences exist in expenditures across phases of cancer care. By understanding the drivers of such payment variations across patient and tumor characteristics, we can inform efforts to decrease payments and increase quality, thereby reducing the burden of cancer care. IMPLICATIONS FOR PRACTICE: Considerable differences exist in expenditures across phases of cancer care. There are further differences by varying patient characteristics. Understanding the drivers of such payment variations across patient and tumor characteristics can inform efforts to decrease costs and increase quality, thereby reducing the burden of cancer care.

System-Level Health-Care Integration and the Costs of Cancer Care Across the Disease Continuum.

PURPOSE: Policy reforms in the Affordable Care Act encourage health care integration to improve quality and lower costs. We examined the association between system-level integration and longitudinal costs of cancer care. METHODS: We used linked SEER-Medicare data to identify patients age 66 to 99 years diagnosed with prostate, bladder, esophageal, pancreatic, lung, liver, kidney, colorectal, breast, or ovarian cancer from 2007 to 2012. We attributed each patient to one or more phases of care (ie, initial, continuing, and end of life) according to time from diagnosis until death or end of study interval. For each phase, we aggregated all claims with the primary cancer diagnosis and identified patients treated in an integrated delivery network (IDN), as defined by the Becker Hospital Review list of the top 100 most integrated health delivery systems. We then determined if care provided in an IDN was associated with decreased payments across cancers and for each individual cancer by phase and across phases. RESULTS: We identified 428,300 patients diagnosed with one of 10 common cancers. Overall, there were no differences in phase-based payments between IDNs and non-IDNs. Average adjusted annual payments by phase for IDN versus non-IDNs were as follows: initial, $14,194 versus $14,421, respectively ( P = .672); continuing, $2,051 versus $2,099 ( P = .566); and end of life, $16,257 versus $16,232 ( P = .948). However, in select cancers, we observed lower payments in IDNs. For bladder cancer, payments at the end of life were lower for IDNs ($11,041 v $12,331; P = .008). Of the four cancers with the lowest 5-year survival rates (ie, pancreatic, lung, esophageal, and liver), average expenditures during the initial and continuing-care phases were lower for patients with liver cancer treated in IDNs. CONCLUSION: For patients with one of 10 common malignancies, treatment in an IDN generally is not associated with lower costs during any phase of cancer care.

Association of Delivery System Integration and Outcomes for Major Cancer Surgery.

BACKGROUND: Integrated delivery systems (IDSs) are postulated to reduce spending and improve outcomes through successful coordination of care across multiple providers. Nonetheless, the actual impact of IDSs on outcomes for complex multidisciplinary care such as major cancer surgery is largely unknown. METHODS: Using 2011-2013 Medicare data, this study identified patients who underwent surgical resection for prostate, bladder, esophageal, pancreatic, lung, liver, kidney, colorectal, or ovarian cancer. Rates of readmission, 30-day mortality, surgical complications, failure to rescue, and prolonged hospital stay for cancer surgery were compared between patients receiving care at IDS hospitals and those receiving care at non-IDS hospitals. Generalized estimating equations were used to adjust results by cancer type and patient- and hospital-level characteristics while accounting for clustering of patients within hospitals. RESULTS: The study identified 380,053 patients who underwent major resection of cancer, with 38% receiving care at an IDS. Outcomes did not differ between IDS and non-IDS hospitals regarding readmission and surgical complication rates, whereas only minor differences were observed for 30-day mortality (3.5% vs 3.2% for IDS; p < 0.001) and prolonged hospital stay (9.9% vs 9.2% for IDS; p < 0.001). However, after adjustment for patient and hospital characteristics, the frequencies of adverse perioperative outcomes were not significantly associated with IDS status. CONCLUSIONS: The collective findings suggest that local delivery system integration alone does not necessarily have an impact on perioperative outcomes in surgical oncology. Moving forward, stakeholders may need to focus on surgical and oncology-specific methods of care coordination and quality improvement initiatives to improve outcomes for patients undergoing cancer surgery.

Episode-based Payment Variation for Urologic Cancer Surgery.

OBJECTIVE: To investigate payment variation for 3 common urologic cancer surgeries and evaluate the potential for applying bundled payment programs to these procedures. METHODS: Using 2008-2011 Surveillance, Epidemiology, and End Results-Medicare linked data, we identified all beneficiaries aged greater than 65 years who underwent cystectomy, prostatectomy, or nephrectomy for cancer. Total episode payments were determined by aggregating hospital, professional, and post-acute care claims from the index surgical hospitalization through 90 days post discharge. Total episode payments were then compared to examine hospital level-variation within each procedure type and the specific payment components (ie, index hospitalization, professional, readmission, and post-acute care) driving spending variation. RESULTS: Ninety-day episodes of care were identified for 1849 cystectomies, 8770 prostatectomies, and 4304 nephrectomies. We observed wide variation in mean episode payments for all 3 conditions (cystectomy mean $35,102: range $24,112-$57,238, prostatectomy mean $10,803: range $8,816-$17,877, nephrectomy mean $17,475: range $11,681-$26,711). Majority of payment variation was attributable to index hospitalization and post-acute care for cystectomy and nephrectomy and professional payments for prostatectomy. The most expensive hospitals by procedure each demonstrated a unique opportunity for spending reduction due to individual differences in component payment patterns between hospitals. CONCLUSION: Ninety-day episode payments for urologic cancer surgery vary widely across hospitals in the United States. The key drivers of this payment variation differ for individual procedures and hospitals. Accordingly, hospitals will need individualized data and clinical re-design strategies to succeed with implementation of episode-based payment models for urologic cancer care.

Early National Dissemination of Abiraterone and Enzalutamide for Advanced Prostate Cancer in Medicare Part D.

INTRODUCTION: Abiraterone and enzalutamide were approved by the Food and Drug Administration in 2011 and 2012 to treat men with metastatic castration-resistant prostate cancer (mCRPC). Most men with mCRPC are > 65 years of age and thus eligible for Medicare Part D. We conducted a study to better understand the early dissemination of these drugs across the United States using national Medicare Part D data. METHODS: We evaluated the number of prescriptions for abiraterone and enzalutamide by provider specialty and hospital referral region (HRR) using Medicare Part D and Dartmouth Atlas data. We categorized HRRs by abiraterone and enzalutamide prescriptions, adjusted for prostate cancer incidence, and examined factors associated with regional variation using multilevel regression models. RESULTS: Among providers who wrote the majority of prescriptions for abiraterone or enzalutamide in 2013 (n = 2,121), 87.5% were medical oncologists, 3.3% were urologists, and 9.2% were other provider specialties. Among prescribers, approximately 30% were responsible for three quarters of the claims for abiraterone and 20% were responsible for more than half the claims for enzalutamide. Some HRRs demonstrated low-prescribing rates despite average medical oncology and urology physician workforce density. Our multilevel model demonstrated that regional factors potentially influenced variation in care. CONCLUSION: The majority of prescriptions written for abiraterone and enzalutamide through Medicare Part D in 2013 were written by a minority of providers, with marked regional variation across the United States. Better understanding of the early national dissemination of these effective but expensive drugs can help inform strategies to optimize introduction of new, evidence-based mCRPC treatments.

No Differences in Population-based Readmissions After Open and Robotic-assisted Radical Cystectomy: Implications for Post-discharge Care.

OBJECTIVE: To inform whether readmission reduction strategies should consider surgical approach, we examined readmission differences between open and robotic-assisted radical cystectomy (RARC) using population-based data. METHODS: We identified patients who underwent cystectomy between January 2010 and September 2013 based on International Classification of Diseases-9th edition codes and administrative claims from a large, national US health insurer (Clinformatics Data Mart Database, OptumInsight, Eden Prairie, MN). We assessed post-discharge health system utilization and tested for differences in readmissions after the 2 surgical approaches. RESULTS: We identified 935 patients treated with cystectomy: open = 785 (84%) and RARC = 150 (16%). Patients undergoing RARC were slightly older, male, had more ileal conduit urinary reconstruction, and less need for intensive care. Index length of stay was shorter for RARC than for open surgery (7 days vs 8 days, P < .001). However, we found no differences in 30-day readmission rates (24% open vs 29% RARC, P = .26) or other readmission parameters, including readmission length of stay (5 days open vs 4 days RARC, P = .32), emergency department use (22% open vs 24% RARC, P = .86), reasons for readmission, or timing of first outpatient visits (11.5 days open vs 9 days RARC, P = .41). For both approaches, the majority of patients were readmitted within 2 weeks. CONCLUSION: The surgical approach to cystectomy does not appear to impact readmissions. Strategies to reduce the readmission burden after cystectomy do not need to consider surgical approach but should focus on timing of medical contacts.