Comparing Medicare Advantage And Traditional Medicare: A Systematic Review.

Medicare Advantage enrollment has almost doubled since 2010 and now accounts for more than a third of all Medicare beneficiaries. We performed a systematic review to compare Medicare Advantage and traditional Medicare on key metrics. Evidence from forty-eight studies showed that in most or all comparisons, Medicare Advantage was associated with more preventive care visits, fewer hospital admissions and emergency department visits, shorter hospital and skilled nursing facility lengths-of-stay, and lower health care spending. Medicare Advantage outperformed traditional Medicare in most studies comparing quality-of-care metrics. However, the evidence on patient experience, readmission rates, mortality, and racial/ethnic disparities did not show a trend of better performance in Medicare Advantage. Evidence to date might not fully account for selection bias, unobserved differences in social determinants of health, or risk adjustment challenges, in part because of differences in data quality that limit the comparability of outcomes between Medicare Advantage and traditional Medicare. With Medicare Advantage plans expected to grow in popularity, policy makers should support policies to improve data completeness and comparability, and health plans should focus on improving patient experience.

The Impact Of Bundled Payment On Health Care Spending, Utilization, And Quality: A Systematic Review.

The Centers for Medicare and Medicaid Services (CMS) has promoted bundled payment programs nationwide as one of its flagship value-based payment reforms. Under bundled payment, providers assume accountability for the quality and costs of care delivered during an episode of care. We performed a systematic review of the impact of three CMS bundled payment programs on spending, utilization, and quality outcomes. The three programs were the Acute Care Episode Demonstration, the voluntary Bundled Payments for Care Improvement initiative, and the mandatory Comprehensive Care for Joint Replacement model. Twenty studies that we identified through search and screening processes showed that bundled payment maintains or improves quality while lowering costs for lower extremity joint replacement, but not for other conditions or procedures. Our review also suggests that policy makers should account for patient-level heterogeneity and include risk stratification for specific conditions in emerging bundled payment programs.

The impact of tort reform on defensive medicine, quality of care, and physician supply: A systematic review.

OBJECTIVE: To evaluate the impact of tort reform on defensive medicine, quality of care, and physician supply. DATA SOURCES: Empirical, peer-reviewed English-language studies in the MEDLINE and HeinOnline databases that evaluated the association between tort reform and our study outcomes. STUDY DESIGN: We performed a systematic review in accordance with the PRISMA guidelines. DATA COLLECTION/EXTRACTION METHODS: Title and abstract screening was followed by full-text screening of relevant citations. We created evidence tables, grouped studies by outcome, and qualitatively compared the findings of included studies. We assigned a higher rating to study designs that controlled for unobservable sources of confounding. PRINCIPAL FINDINGS: Thirty-seven studies met screening criteria. Caps on damages, collateral-source rule reform, and joint-and-several liability reform were the most common types of tort reform evaluated in the included studies. We found that caps on noneconomic damages were associated with a decrease in defensive medicine, increase in physician supply, and decrease in health care spending, but had no effect on quality of care. Other reform approaches did not have a clear or consistent impact on study outcomes. CONCLUSIONS: We conclude that traditional tort reform methods may not be sufficient for health reform and policy makers should evaluate and incorporate newer approaches.

Value-Based Insurance Design Improves Medication Adherence Without An Increase In Total Health Care Spending.

Value-based insurance design (VBID) is a strategy that reduces cost sharing for high-value services and increases consumers' out-of-pocket spending for low-value care. VBID has increasingly been implemented by private and public payers and has inspired demonstration programs in Medicare Advantage and TRICARE. Given the recent publication of several studies, we performed an updated systematic review that evaluated the effects of reducing consumer cost sharing on medication adherence and other relevant outcomes. Searches were conducted in key online databases, and the screening of citations yielded twenty-one unique studies, of which eight had not been included in previous reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system, we found moderate-quality evidence showing improvement (range: 0.1-14.3 percent) in medication adherence with VBID. This increase in adherence was associated with no effect on total health care spending, which suggests that the incremental drug spending was offset by decreases in spending for other health care services.

The Effects Of Medicaid Expansion Under The ACA: A Systematic Review.

Expanding eligibility for Medicaid was a central goal of the Affordable Care Act (ACA), which continues to be debated and discussed at the state and federal levels as further reforms are considered. In an effort to provide a synthesis of the available research, we systematically reviewed the peer-reviewed scientific literature on the effects of Medicaid expansion on the original goals of the ACA. After analyzing seventy-seven published studies, we found that expansion was associated with increases in coverage, service use, quality of care, and Medicaid spending. Furthermore, very few studies reported that Medicaid expansion was associated with negative consequences, such as increased wait times for appointments-and those studies tended to use study designs not suited for determining cause and effect. Thus, there is evidence to document improvements in several areas of health care delivery following the ACA Medicaid expansion. We outline areas for future research that can further reduce current knowledge gaps.

"Weekend Effect" in Patients With Upper Gastrointestinal Hemorrhage: A Systematic Review and Meta-analysis.

OBJECTIVES: "Weekend effect" refers to worse outcomes among patients presenting to the hospital on weekends or holidays. We performed a systematic review and meta-analysis of observational studies assessing the impact of the "weekend effect" in patients with upper gastrointestinal hemorrhage (UGIH). METHODS: We searched key bibliographic databases using keywords and MeSH terms related to gastrointestinal hemorrhage and "weekend effect". Our primary analysis evaluated mortality in patients with UGIH who were hospitalized on the weekend or after-hours compared with a weekday. Secondary outcomes included need for definitive therapy and length of hospital stay. Relevant data were extracted and meta-analyses were performed using random effects model. Subgroup sensitivity analyses were also performed to assess the effects of key variables. RESULTS: A total of 21 of 224 identified studies met inclusion criteria. Overall, there was no association between weekend admission and mortality among patients with UGIH (Odds Ratio (OR): 1.06; 95% confidence interval (CI): 0.99-1.14). However, meta-analysis using only the nine studies that did not report having a weekend rounder showed a significant increase in mortality (OR: 1.12; 95% CI: 1.07-1.17). There was no effect of weekend admission on any of our secondary outcomes. CONCLUSIONS: Current evidence suggests that weekend admission is associated with significant increase in mortality in patients with non-variceal UGIH but no difference in mortality was noted in patients with variceal UGIH. Our findings are relevant to policymakers, practitioners and providers who should ensure the creation of consistent quality and access to care throughout the week.

High-Deductible Health Plans Reduce Health Care Cost And Utilization, Including Use Of Needed Preventive Services.

Enrollment in high-deductible health plans (HDHPs) has greatly increased in recent years. Policy makers and other stakeholders need the best available evidence about how these plans may affect health care cost and utilization, but the literature has not been comprehensively synthesized. We performed a systematic review of methodologically rigorous studies that examined the impact of HDHPs on health care utilization and costs. The plans were associated with a significant reduction in preventive care in seven of twelve studies and a significant reduction in office visits in six of eleven studies-which in turn led to a reduction in both appropriate and inappropriate care. Furthermore, bivariate analyses of data extracted from the included studies suggested that the plans may be associated with a reduction in appropriate preventive care and medication adherence. Current evidence suggests that HDHPs are associated with lower health care costs as a result of a reduction in the use of health services, including appropriate services.

Utility of confocal laser endomicroscopy in identifying high-grade dysplasia and adenocarcinoma in Barrett's esophagus: a systematic review and meta-analysis.

Confocal laser endomicroscopy (CLE) is a novel endoscopic technique that has emerged as an important tool in the in-vivo visualization and detailed assessment of the mucosal layer and subcellular structures in Barrett's esophagus. Current guidelines recommend four-quadrant random biopsies for identification of high-grade dysplasia (HGD) in Barrett's esophagus. However, random biopsies are associated with sampling error and inconsistent histopathologic interpretation. CLE, by providing targeted biopsies, could decrease the sampling error and increase the yield of detection of HGD/adenocarcinoma [esophageal adenocarcinoma (EAC)]. We carried out a meta-analysis to evaluate the diagnostic accuracy of the CLE-based targeted biopsies in detecting HGD/adenocarcinoma compared with four-quadrant random biopsies. A search using medical subject headings (MeSH) terms and keywords was performed in the MEDLINE and Cochrane review databases and relevant studies were identified. All the studies that compared the diagnostic yield from CLE-based targeted biopsies to detect HGD/adenocarcinoma with a gold standard of histopathology were included and a meta-analysis was carried out to estimate the pooled sensitivity, specificity, and positive and negative likelihood ratios using Meta-Disc software. There were a total of seven studies with 345 patients and 3080 lesions that were finally included in the meta-analysis. All the studies had reported per-lesion analyses; however, only four of the seven studies had data reported on per-patient analyses. 'Per-lesion' analysis for the diagnosis of HGD/adenocarcinoma yielded a pooled sensitivity and specificity of 68% [95% confidence interval (CI) of 64-73%] and 88% (95% CI of 87-89%), respectively. The pooled positive and negative likelihood ratios were 6.56 (95% CI of 3.61-11.90) and 0.24 (95% CI of 0.09-0.63), respectively. Similar numbers were calculated on the basis of 'per-patient' basis, which showed a pooled sensitivity and specificity of 86% (95% CI of 74-96%) and 83% (95% CI of 77-88%), respectively. The pooled positive and negative likelihood ratios were 5.61 (95% CI of 2.00-15.69) and 0.21 (95% CI of 0.08-0.59), respectively. CLE, by providing targeted biopsies, has a good diagnostic accuracy in identifying HGD/EAC; however, the overall prevalence of HGD/EAC in the studies included was much higher than what would be seen in clinical practice and these results should be interpreted with caution. Because of its relatively low sensitivity and negative predictive value, CLE may currently not replace standard biopsy techniques for the diagnosis of HGD/EAC in Barrett's esophagus.

Should bowel preparation, antifoaming agents, or prokinetics be used before video capsule endoscopy? A systematic review and meta-analysis.

OBJECTIVES: The ideal bowel preparation regime before small bowel video capsule endoscopy (VCE) is not known. We carried out a systematic review and meta-analysis to study the effect of purgatives, antifoaming agents, and prokinetics on the outcomes associated with VCE. MATERIALS AND METHODS: We performed literature searches in MEDLINE and Cochrane Library and included randomized-controlled trials studying the effect of purgatives, antifoaming agents, and prokinetics in patients undergoing VCE. Our outcomes of interest were visualization quality, diagnostic yield, and completion rate. Meta-analyses were carried out using the RevMan software and heterogeneity was assessed using the I statistic. RESULTS: Fifteen studies fulfilled the inclusion criteria. As compared with no bowel preparation, bowel preparation with polyethylene glycol (PEG) led to adequate visualization in a significantly higher number of patients undergoing VCE [odds ratio (OR) 3.13; 95% confidence interval (CI) 1.70-5.75]. Both PEG and sodium phosphate significantly improved the diagnostic yield (OR 1.68; 95% CI 1.16-2.42 and OR 1.77; 95% CI 1.18-2.64, respectively) but did not affect the completion rate. All studies with simethicone showed significantly improved visualization quality with its use as compared with overnight fasting or purgatives alone. Prokinetics did not significantly improve the completion rate of VCE. CONCLUSION: On the basis of the data available, a combination of PEG and simethicone appears to be the best approach for small bowel preparation before VCE. However, large multicenter randomized-controlled trials are needed to validate this recommendation and to evaluate the ideal dose of PEG and timing of bowel preparation before VCE. Prokinetics administered before VCE do not improve the completion rate and should not be used.

Quick diagnosis units--an effective alternative to hospitalization for diagnostic workup: a systematic review.

INTRODUCTION: This era of healthcare reform emphasizes improving value of care. Inpatient admissions for diagnostic evaluation put economic pressure on an already strained healthcare system. We conducted a systematic review of effectiveness of quick diagnosis units (QDUs), an established outpatient model for early diagnostic workups in Europe. METHODS: We searched MEDLINE and Embase for studies that focused on implementation of quick/rapid diagnosis units, with relevant Medical Subject Headings terms and keywords. Of 2047 studies, we selected 13 for full-text screening and bibliography review. Of these, 5 studies included at least 2 primary outcomes of interest and were included in our review. These units functioned as outpatient clinics, staffed by internists, nurses, and clerical staff, with expedited scheduling of outpatient diagnostic tests. Our primary outcome measures were final diagnosis, the mean time to final diagnosis, inpatient bed-days saved per patient, and costs saved per patient. We also studied discharge disposition, care preferences, and safety data. RESULTS: About 18% to 30% of patients were diagnosed with malignancy, with an average time to diagnosis of 6 to 11 days. Inpatient bed-days saved per patient ranged from 4.5 to 7. Savings from fixed costs of hospitalization ranged from $2336(€1764) to $3304(€2514) for each patient enrolled in the protocol. The QDU model was preferred by 88% of patients, and patient satisfaction rates were 95% to 97%. CONCLUSIONS: QDUs seem an effective and cost-saving alternative to inpatient hospitalization, and appear to be a safe approach for diagnostic workup of potentially severe diseases in select patient populations, although there are limited safety data available.

Renal sympathetic denervation for treatment of resistant hypertension: a systematic review.

Catheter-based renal sympathetic denervation (RSD) is a novel technique that is being investigated as treatment for resistant hypertension. To systematically evaluate the existing literature on the safety and efficacy of RSD in persons with resistant hypertension, online searches of Medline and the Cochrane Library Database (up to June 2012) were performed. Randomized controlled trials, observational studies, and conference proceedings published in English language were included. Nineteen studies (N=683 persons) were included. Follow-up duration ranged from 1 to 24 months. All studies reported significant reductions in systolic and diastolic pressures. Maximal reduction of blood pressure ranged from 18 mm Hg to 36 mm Hg (systolic) and 9 mm Hg to 15 mm Hg (diastolic). Sustained benefit of blood pressure reduction at 12 months was seen in 5 studies. No worsening of renal function was reported and there were few procedure-related adverse events such as pseudoaneurysm formation, hypotension, and bradycardia. Data from short-term studies suggest that RSD is a safe and effective therapeutic option in carefully selected patients with resistant hypertension. Long-term studies with large patient populations are needed to study whether this benefit is sustained with a demonstrable difference in cardiovascular disease event rates.

Nonpharmacologic interventions for prevention of catheter-related thrombosis: a systematic review.

PURPOSE: The aim of this study was to summarize randomized controlled trials (RCTs) of nonpharmacologic interventions for prevention of catheter-related thromboses (CRTs). METHODS: MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials were systematically searched for RCTs examining any nonpharmacologic intervention to prevent symptomatic or asymptomatic CRT. Titles and abstracts were screened by a single reviewer, followed by full-text screening by 2 independent reviewers. Data were extracted and quality assessed by a single analyst and audited by a second analyst. Strength of the evidence for each intervention was assessed using the Grading of Recommendations Assessment, Development and Evaluation. RESULTS: Ten RCTs enrolling 1,378 patients were included. Moderate- to high-quality evidence suggested peripherally inserted central catheters and insertion of central venous catheters (CVCs) at the femoral site increased CRT when compared with other catheter types or insertion sites, respectively. Evidence comparing CRT in CVCs inserted at the jugular vs the subclavian site as well as the placement of the CVC tip was of low quality and inconclusive. Low-quality evidence suggested that valved ports and silver-coated catheters had no effect on CRT. No RCT evidence was identified for other interventions. CONCLUSIONS: Peripherally inserted central catheters and femoral insertion of CVCs should be avoided if possible. Randomized controlled trials are needed to ascertain the effects of other nonpharmacologic interventions to prevent CRT.

Tissue Doppler imaging for diagnosis of coronary artery disease: a systematic review and meta-analysis.

Global and regional left ventricular (LV) systolic dysfunction is a marker of coronary artery disease (CAD), which is conventionally assessed using two-dimensional echocardiography. Tissue Doppler imaging (TDI) has emerged as an adjunct tool in the diagnosis of regional wall motion abnormalities from CAD. We performed a systematic review and meta-analysis to assess the efficacy of TDI indices in the diagnosis of CAD. We searched MEDLINE and the Cochrane Library for controlled studies comparing TDI measurements in those with and without CAD as confirmed by coronary angiography. Meta-analyses of mean differences in TDI velocities between these populations were performed. Screening of titles and abstracts followed by full-text screening identified 8 studies. At rest, TDI was associated with a significant decrease in the pooled maximum systolic velocity among CAD patients compared to those without CAD [mean difference (MD): -0.66; 95% confidence interval (CI): -0.98 to -0.34]. There were no significant differences in maximum early and late diastolic velocities. Post-stress, TDI was associated with a significant decrease in maximum early diastolic velocity (MD: -1.91; 95% CI: -2.74 to -1.09) and maximum late diastolic velocity (MD: -1.57; 95% CI: -2.95 to -0.18) among CAD patients compared to those without CAD. There was no significant difference in maximum systolic velocity post-stress. Our results suggest that TDI may have a role in the evaluation of CAD. Future studies should evaluate the incremental value of TDI velocities over LV ejection fraction and two dimensional wall motion analysis in the detection of CAD and assessment of its severity. (Word Count: 249).

Magnetocardiography for the diagnosis of coronary artery disease: a systematic review and meta-analysis.

BACKGROUND: Coronary artery disease (CAD) has a significant disease burden making early diagnosis and management imperative. Magnetocardiography (MCG) is a relatively new noninvasive technique that allows diagnosis of CAD by recording the magnetic fields generated by the electrical activity of the heart. METHODS: We searched MEDLINE and the Cochrane Central Register of Controlled Trials for prospective studies that evaluated the test characteristics (e.g., sensitivity, specificity, likelihood ratios) of MCG for detection of CAD. Studies were included if they evaluated either patients with stable CAD documented by angiogram or patients presenting initially with acute coronary syndrome and subsequently diagnosed with CAD. The quality of included studies was assessed using an adaptation of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. We performed meta-analyses of sensitivity, specificity and positive and negative likelihood ratios using Meta-DiSc software. RESULTS: Screening of titles and abstracts followed by full-text review yielded seven studies that met our inclusion criteria. Meta-analyses yielded a pooled sensitivity of 83% (95% confidence interval [CI] 80% to 86%) and a specificity of 77% (95% CI 73% to 81%). The pooled positive likelihood ratio was 3.92 (95% CI 2.30 to 6.66) and negative likelihood ratio was 0.20 (95% CI 0.12 to 0.35). Significant heterogeneity was present in all meta-analyses. CONCLUSIONS: The pooled test characteristics for MCG are similar to those of existing noninvasive modalities for diagnosing CAD. Our results suggest that MCG is a potential complementary or alternative tool for noninvasive detection of CAD.

Safety of endoscopic procedures after acute myocardial infarction: a systematic review.

BACKGROUND: The management of patients who develop gastrointestinal (GI) bleeding after acute myocardial infarction (MI) is difficult due to concerns about possible cardiovascular complications. Gastroenterologists are often reluctant to perform endoscopic procedures despite urgent indications. We performed a systematic review of the literature to determine the safety of endoscopic procedures after MI. METHODS: We searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled trials for controlled clinical trials or case series examining the diagnostic efficacy and complications of esophagogastroduodenoscopy (EGD), colonoscopy and flexible sigmoidoscopy after MI. Title and abstract screening was followed by full-text review with subsequent data extraction of included studies. RESULTS: A total of seven studies met inclusion criteria. Four studies evaluated safety and efficacy of EGD after MI. The reported complication rate ranged between 1-8%, with a large predominance of minor complications. We found one study addressing safety of flexible sigmoidoscopy that reported minor complications in two patients. We also identified one study addressing the safety of colonoscopy after MI, which showed a complication rate of 9%. Most of these complications were minor. A decision analysis was also included in this review. CONCLUSIONS: Our review demonstrated that endoscopic procedures are safe and beneficial in stable patients with GI bleeding after recent MI and should be performed without a requisite delay. Unstable patients should undergo endoscopic procedures only in the intensive care setting, after stabilization and with close monitoring.

Platelet count/spleen diameter ratio to predict the presence of esophageal varices in patients with cirrhosis: a systematic review.

BACKGROUND: Esophageal variceal bleeding remains the leading cause of acute mortality in patients with cirrhosis. Platelet count to spleen diameter (PC/SD) ratio less than 909 is one of several parameters proposed for the noninvasive prediction of esophageal varices. The aim of this study is to systematically review the evidence on the diagnostic accuracy of the 909 ratio. METHODS: We identified relevant studies from a MEDLINE search and performed a meta-analysis to estimate the pooled sensitivity, specificity, and positive and negative likelihood ratios (LRs) using Meta-Disc software. RESULTS: Eight studies met the inclusion criteria and included a total of 1275 patients. Meta-analysis yielded a pooled sensitivity of 89% [95% confidence interval (CI) 87-92%; I2 statistic 92.9%] and a pooled specificity of 74% (95% CI 70-78%; I2 statistic 94.5%). The pooled positive LR was 3.5 (95% CI 1.92-6.25; I2 statistic 94.0%) and the pooled negative LR was 0.12 (95% CI 0.05-0.32; I2 statistic 90.8%). The quality of the evidence as assessed by the GRADE methodology was low. CONCLUSION: In its present form, the test characteristics of PC/SD ratio of 909 may not be adequate to completely replace esophagogastroduodenoscopy as a noninvasive screening tool for esophageal varices, given the low grade of evidence. However, it may be potentially useful as part of a prediction rule incorporating other clinical characteristics or varying PC/SD cutoffs. When compared with other noninvasive predictor tools, the PC/SD ratio is elegant, simple, and inexpensive. With some minor modifications, it may become a helpful tool to limit the number of endoscopies in primary prophylaxis to be performed in patients with portal hypertension.

Procalcitonin to guide duration of antimicrobial therapy in intensive care units: a systematic review.

Can the use of serum procalcitonin levels safely reduce antimicrobial use in intensive care unit (ICU) patients? We performed a systematic literature review that identified 6 published randomized controlled trials comparing PCT-guided antimicrobial therapy to usual care in ICU patients, extracting data on ICU and patient characteristics, PCT guideline content, intensity of antimicrobial exposure, ICU length of stay, infection relapse, and mortality. Procalcitonin guidance was associated with significantly reduced antimicrobial exposure (effect sizes, 19.5%-38%) in all 5 studies assessing its impact on treatment duration but did not significantly impact antimicrobial exposure in the study assessing treatment initiation only. Length of ICU stay was significantly decreased in 2 studies but was unchanged in the others. Neither infection relapse nor mortality varied significantly in any of the studies. Procalcitonin guidance of antimicrobial duration appears to decrease antimicrobial use in the ICU safely and significantly and may also decrease the length of stay in the ICU.

Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs.

OBJECTIVE: To estimate the proportion of healthcare-associated infections (HAIs) in US hospitals that are "reasonably preventable," along with their related mortality and costs. METHODS: To estimate preventability of catheter-associated bloodstream infections (CABSIs), catheter-associated urinary tract infections (CAUTIs), surgical site infections (SSIs), and ventilator-associated pneumonia (VAP), we used a federally sponsored systematic review of interventions to reduce HAIs. Ranges of preventability included the lowest and highest risk reductions reported by US studies of "moderate" to "good" quality published in the last 10 years. We used the most recently published national data to determine the annual incidence of HAIs and associated mortality. To estimate incremental cost of HAIs, we performed a systematic review, which included costs from studies in general US patient populations. To calculate ranges for the annual number of preventable infections and deaths and annual costs, we multiplied our infection, mortality, and cost figures with our ranges of preventability for each HAI. RESULTS: As many as 65%-70% of cases of CABSI and CAUTI and 55% of cases of VAP and SSI may be preventable with current evidence-based strategies. CAUTI may be the most preventable HAI. CABSI has the highest number of preventable deaths, followed by VAP. CABSI also has the highest cost impact; costs due to preventable cases of VAP, CAUTI, and SSI are likely less. CONCLUSIONS: Our findings suggest that 100% prevention of HAIs may not be attainable with current evidence-based prevention strategies; however, comprehensive implementation of such strategies could prevent hundreds of thousands of HAIs and save tens of thousands of lives and billions of dollars.