Cancer-Related Financial Hardship Screening as Part of Practice Transformation.

BACKGROUND: Data on financial hardship, an "adverse event" in individuals with cancer, are needed to inform policy and supportive care interventions and reduce adverse economic outcomes. METHODS: Lay navigator-led financial hardship screening was piloted among University of Alabama at Birmingham oncology patients initiating treatment in October 2020. Financial hardship screening, including reported financial distress and difficulty, was added to a standard-of-care treatment planning survey. Screening feasibility and completion and proportions of reported financial distress and difficulty were calculated overall and by patient race and rurality. The risk of financial distress by patient sociodemographics was estimated. RESULTS: Patients who completed a treatment planning survey (N=2741) were 18% Black, Indigenous, or persons of color (BIPOC) and 16% rural dwelling. The majority of patients completed financial hardship screening (90%), surpassing the target feasibility completion rate of 75%. The screening revealed 34% of patients were experiencing financial distress, including 49% of BIPOC and 30% of White patients. Adjusted models revealed BIPOC patients had a 48% higher risk of financial distress compared with those who were White (risk ratio 1.48, 95% CI, 1.31-1.66). Large differences in reported financial difficulties were seen comparing patients who were BIPOC and White (utilities: 33% vs. 10%, upfront medical payments: 44% vs. 23%, transportation: 28% vs. 12%, respectively). CONCLUSIONS: The collection of patient-reported financial hardship data via routine clinical care was feasible and identified racial inequities at treatment initiation. Efforts to collect patient economic data should support the design, implementation, and evaluation of patient-centered interventions to improve equity and reduce the impact of financial hardship.

Changes in US Hospital Financial Performance During the COVID-19 Public Health Emergency.

Importance: The COVID-19 public health emergency (PHE) caused substantial changes in hospital operations. The net effect of these changes on hospital financial performance is unclear. Objective: To evaluate changes in hospital financial performance before and during the COVID-19 PHE. Design, Setting, and Participants: This longitudinal within-hospital cohort analysis from 2017 to 2021 used national RAND hospital data merged with American Community Survey data. A total of 4223 short-term acute care or critical access hospitals in the US with financial data spanning 2017 to 2021 were evaluated. Exposure: Financial performance during the first 2 years of the PHE. Main Outcomes and Measures: The main outcome was PHE financial distress calculated based on net operating income (operating revenue minus operating expenses). Within-hospital changes in net operating income over time were evaluated with and without COVID-19 relief funding. From henceforth, 2020/2021 means the weighted average financial performance for both calendar year 2020 and 2021. Hospitals were characterized as having new financial distress if (1) their average 2020/2021 net operating income was negative and (2) the average 2020/2021 net operating income was less than that hospital's pre-2020 net operating income. Predictors of new financial distress were evaluated using logistic regression and predictors of COVID-19 relief using 2-part models. Results: In this sample of 4423 hospitals, 3529 (80.0%) received PHE funds during 2020/2021. A total of 846 (19.1%) were located in a census tract with more than 20% Hispanic residents. Of the total number of hospitals, 720 (16.3%) of hospitals had PHE financial distress, whereas 2047 (46.3%) had PHE financial distress after excluding COVID-19 relief funding from net operating income. The majority of hospitals (n = 3337; 74.8%) had a positive net operating income across 2020/2021, with 785 (17.8%) hospitals moving from a negative pre-2020 to a positive 2020/2021 net operating income. In adjusted analyses, hospitals treating a higher proportion of Hispanic populations were more likely to have PHE distress (adjusted odds ratio, 1.3; 95% CI, 1.1-1.6; P = .02). Median (IQR) operating margins from 2020/2021 were at an all-time high of 6.5% (0.2%-13.3%) compared with pre-2020 operating margins of 2.8% (-2.8% to 9.3%). Conclusions and Relevance: In this cohort study of US hospitals, the large majority had positive financial performance during 2020/2021, partly due to COVID-19 relief funds. However, hospitals serving Hispanic populations had substantially worsened financial performance during 2020/2021, even after accounting for COVID-19 relief. That COVID-19 relief funding aided in operating margins reaching all-time highs indicates funding amounts may have been larger than was necessary for many hospitals. With COVID-19 relief funding ending yet COVID-19 related continuing to affect hospital expenses, ongoing monitoring of hospital financial performance is vital to ensure patients retain access to care.

Differences in telehealth during COVID-19 between commercial and Medicaid enrollees.

OBJECTIVES: To compare how in-person evaluation and management (E&M) visits and telehealth use differed during the COVID-19 pandemic between commercially insured and Medicaid enrollees, and to assess how insurance plan type-fee-for-service (FFS) vs managed care (MC)-and enrollee characteristics contributed to these differences. STUDY DESIGN: Retrospective cohort analysis of 2019 and 2020 data from the commercially insured California Public Employees' Retirement System (CalPERS) and the California Medicaid program (Medi-Cal). METHODS: We conducted unadjusted comparisons of per capita E&M visits and the share of visits conducted via telehealth by payer (CalPERS vs Medi-Cal) and plan type (FFS vs MC). We estimated linear regressions of telehealth use that adjusted for patient demographics, rurality, and internet access. Among Medi-Cal enrollees, we examined telehealth use differences based on race, language, and citizenship status. RESULTS: Regression-adjusted share of telehealth visits as a proportion of all E&M visits was 22.6% for CalPERS FFS patients (the reference group), 38.2% for Medi-Cal FFS patients, 46.0% for Medi-Cal MC patients, and 53.5% for CalPERS MC patients. Among Medi-Cal enrollees, telehealth use as a share of all E&M visits was higher among Spanish speakers, female enrollees, and rural enrollees. Across most demographic characteristics, Medi-Cal patients enrolled in FFS were less likely to receive telehealth compared with those enrolled in MC. CONCLUSIONS: During the first year of the COVID-19 pandemic, California MC enrollees had higher rates of telehealth use compared with FFS enrollees, regardless of insurer. Among FFS enrollees, those enrolled in Medicaid had higher rates of telehealth use compared with those insured by CalPERS. Telehealth policies should be aware of this heterogeneity, as well as its implications for equity of telehealth access.

Vaccine Hesitancy versus Vaccine Behavior in Patients with Chronic Illness.

While vaccine hesitancy has been described for the general population, vaccine hesitancy among the chronically ill has not been well explored. This study assesses COVID­19 vaccine hesitancy and uptake among individuals with chronic illness using nationwide survey data. We analyzed vaccine hesitancy prior to and after approval of the vaccines using multinomial logistic regression and binomial logistic regression, respectively. In the first survey, 39% reported they were unlikely or unsure about receiving the vaccine. In adjusted analyses, female sex, Black race, anti­vaccination attitudes, media mistrust, and not following the media were associated with vaccine hesitancy. Despite this hesitance, in the follow­up survey, 89% reported vaccine receipt, with those more fearful of COVID­19, with more trust in the media, and closely following the development of the vaccine were most likely to move from hesitance to acceptance. Vaccine hesitancy is a mutable characteristic, underscoring the need for high-quality public health messaging.

Health insurance and financial hardship in cancer survivors during the COVID-19 pandemic.

Uninsured or underinsured individuals with cancer are likely to experience financial hardship, including forgoing healthcare or non-healthcare needs such as food, housing, or utilities. This study evaluates the association between health insurance coverage and financial hardship among cancer survivors during the COVID-19 pandemic. This cross-sectional analysis used Patient Advocate Foundation (PAF) survey data from May to July 2020. Cancer survivors who previously received case management or financial aid from PAF self-reported challenges paying for healthcare and non-healthcare needs during the COVID-19 pandemic. Associations between insurance coverage and payment challenges were estimated using Poisson regression with robust standard errors, which allowed for estimation of adjusted relative risks (aRR). Of 1,437 respondents, 74% had annual household incomes <$48,000. Most respondents were enrolled in Medicare (48%), 22% in employer-sponsored insurance, 13% in Medicaid, 6% in an Affordable Care Act (ACA) plan, and 3% were uninsured. Approximately 31% of respondents reported trouble paying for healthcare during the COVID-19 pandemic. Respondents who were uninsured (aRR 2.58, 95% confidence interval [CI] 1.83-3.64), enrolled in an ACA plan (aRR 1.86, 95% CI 1.28-2.72), employer-sponsored insurance (aRR 1.70, 95% CI 1.23-2.34), or Medicare (aRR 1.49, 95% CI 1.09-2.03) had higher risk of trouble paying for healthcare compared to Medicaid enrollees. Challenges paying for non-healthcare needs were reported by 57% of respondents, with 40% reporting trouble paying for food, 31% housing, 28% transportation, and 20% internet. In adjusted models, Medicare and employer-sponsored insurance enrollees were less likely to have difficulties paying for non-healthcare needs compared to Medicaid beneficiaries. Despite 97% of our cancer survivor sample being insured, 31% and 57% reported trouble paying for healthcare and non-healthcare needs during the COVID-19 pandemic, respectively. Greater attention to both medical and non-medical financial burden is needed given the economic pressures of the COVID-19 pandemic.

Effect Of Nonpharmaceutical Interventions On COVID-19 Cases And Deaths In Brazil.

Lacking national direction, in 2020 Brazilian states adopted a variety of nonpharmaceutical interventions to combat COVID-19, adjusting their stringency over time. We took advantage of this variation across states and over time to estimate the independent effect of seven interventions on the growth rate ratios of COVID-19 cases and deaths. Panel regressions using daily data from March to December 2020 for twelve states show that two interventions, suspension of public events and masking mandates, significantly reduced the spread of the disease. Partial and full suspension of public events were equally effective. Full masking mandates were more effective than partial ones. Together, suspension of public events and full masking mandates reduced the growth rate ratios of both cases and deaths almost to 1, the point at which cases and deaths are no longer increasing. Policy makers may find this analysis useful as they aim to choose the most effective nonpharmaceutical interventions to reduce COVID-19's social and economic burdens.

Survival in the Real World: A National Analysis of Patients Treated for Early-Stage Breast Cancer.

PURPOSE: Many patient population groups are not proportionally represented in clinical trials, including patients of color, at age extremes, or with comorbidities. It is therefore unclear how treatment outcomes may differ for these patients compared with those who are well-represented in trials. METHODS: This retrospective cohort study included women diagnosed with stage I-III breast cancer between 2005 and 2015 in the national CancerLinQ Discovery electronic medical record-based data set. Patients with comorbidities or concurrent cancer were considered unrepresented in clinical trials. Non-White patients and/or those age < 45 or ≥ 70 years were considered under-represented. Patients who were White, age 45-69 years, and without comorbidities were considered well-represented. Cox proportional hazards models were used to evaluate 5-year mortality by representation group and patient characteristics, adjusting for cancer stage, subtype, chemotherapy, and diagnosis year. RESULTS: Of 11,770 included patients, 48% were considered well-represented in trials, 45% under-represented, and 7% unrepresented. Compared with well-represented patients, unrepresented patients had almost three times the hazard of 5-year mortality (adjusted hazard ratio [aHR], 2.71; 95% CI, 2.08 to 3.52). There were no significant differences in the hazard of 5-year mortality for under-represented patients compared with well-represented patients (aHR, 1.19; 95% CI, 0.98 to 1.45). However, among under-represented patients, those age < 45 years had a lower hazard of 5-year mortality (aHR, 0.63; 95% CI, 0.48 to 0.84) and those age ≥ 70 years had a higher hazard of 5-year mortality (aHR, 2.21; 95% CI, 1.76 to 2.77) compared with those age 45-69 years. CONCLUSION: More than half of the patients were under-represented or unrepresented in clinical trials, because of age, comorbidity, or race. Some of these groups experienced poorer survival compared with those well-represented in trials. Trialists should ensure that study participants reflect the disease population to support evidence-based decision making for all individuals with cancer.

Clinical trial representativeness and treatment intensity in a real-world sample of women with early stage breast cancer.

PURPOSE: The extent to which evidence-based treatments are applied to populations not well represented in early stage breast cancer (EBC) trials remains unknown. This study evaluated treatment intensity for patients traditionally well represented, underrepresented, and unrepresented in clinical trials. METHODS: This retrospective cohort study used real-world data to evaluate the intensity (high or low) of EBC chemotherapy by patient characteristics (age, race and ethnicity, presence of comorbidity) denoting clinical trial representation status (well represented, underrepresented, unrepresented) for patients diagnosed from 2011 to 2020. Odds ratios (OR) from a logistic regression model was used to evaluate the association between receipt of high-intensity chemotherapy and clinical trial representation status characteristics adjusting for cancer stage and subtype. RESULTS: Of 970 patients with EBC, 41% were characterized as well represented, 45% as underrepresented, and 13% as unrepresented in clinical trials. In adjusted models, patients aged ≥ 70 versus 45-69 had lower odds of receiving a high-intensity treatment (OR 0.40, 95% CI 0.26-0.60), while those aged < 45 versus 45-69 had higher odds of receiving high-intensity treatment (OR 1.82, 95% CI 1.10-3.01). In predicted estimates, the proportion of patients receiving a high-intensity treatment was 87% for patients aged < 45, 79% for patients aged 45-69, and 60% for patients aged ≥ 70. CONCLUSION: 59% of the EBC population is not well represented in clinical trials. Age was associated with differential treatment intensity. Widening clinical trial eligibility criteria should be considered to better understand survival outcomes, toxicity effects, and ultimately make evidence-based treatment decisions using a more diverse sample.

End-of-Life Cost Trajectories in Cancer Patients Treated by Medicare versus the Veterans Health Administration.

BACKGROUND/OBJECTIVES: To evaluate differences in end-of-life cost trajectories for cancer patients treated through Medicare versus by the Veterans Health Administration (VA). DESIGN: A retrospective analysis of VA and Medicare administrative data from FY 2010 to 2014. We employed three-level generalized estimating equations to evaluate monthly cost trajectories experienced by patients in their last year of life, with patients nested within hospital referral region. SETTING: Care received at VA facilities or by Medicare-reimbursed providers nationwide. PARTICIPANTS: A total of 36,401 patients dying from cancer and dually enrolled in VA and Medicare. MEASUREMENTS: We evaluated trajectories for total, inpatient, outpatient, and drug costs, using the last 12 months of life. Cost trajectories were prioritized as costs are not directly comparable across Medicare and VA. Patients were assigned to be VA-reliant, Medicare-reliant or Mixed-reliant based on their healthcare utilization in the last year of life. RESULTS: All three groups experienced significantly different cost trajectories for total costs in the last year of life. Inpatient cost trajectories were significantly different between Medicare-reliant and VA-reliant patients, but did not differ between VA-reliant and Mixed-reliant patients. Outpatient and drug cost trajectories exhibited the inverse pattern: they were significantly different between VA-reliant and Mixed-reliant patients, but not between VA-reliant and Medicare-reliant patients. However, visual examination of cost trajectories revealed similar cost patterns in the last year of life among all three groups; there was a sharp rise in costs as patients approach death, largely due to inpatient care. CONCLUSION: Despite substantially different financial incentives and organization, VA- and Medicare-treated patients exhibit similar patterns of increasing end-of-life costs, largely driven by inpatient costs. Both systems require improvement to ensure quality of end-of-life care is aligned with recommended practice.

Correction to: Estimating Transition Probabilities from Published Evidence: A Tutorial for Decision Modelers.

In the original version of this article a number of equations were incorrectly represented.

Estimating Transition Probabilities from Published Evidence: A Tutorial for Decision Modelers.

This tutorial presents practical guidance on transforming various types of information published in journals, or available online from government and other sources, into transition probabilities for use in state-transition models, including cost-effectiveness models. Much, but not all, of the guidance has been previously published in peer-reviewed journals. Our purpose is to collect it in one location to serve as a stand-alone resource for decision modelers who draw most or all of their information from the published literature. Our focus is on the technical aspects of manipulating data to derive transition probabilities. We explain how to derive model transition probabilities from the following types of statistics: relative risks, odds, odds ratios, and rates. We then review the well-known approach for converting probabilities to match the model's cycle length when there are two health-state transitions and how to handle the case of three or more health-state transitions, for which the two-state approach is not appropriate. Other topics discussed include transition probabilities for population subgroups, issues to keep in mind when using data from different sources in the derivation process, and sensitivity analyses, including the use of sensitivity analysis to allocate analyst effort in refining transition probabilities and ways to handle sources of uncertainty that are not routinely formalized in models. The paper concludes with recommendations to help modelers make the best use of the published literature.

Impact of Scribes on Physician Satisfaction, Patient Satisfaction, and Charting Efficiency: A Randomized Controlled Trial.

PURPOSE: Scribes are increasingly being used in clinical practice despite a lack of high-quality evidence regarding their effects. Our objective was to evaluate the effect of medical scribes on physician satisfaction, patient satisfaction, and charting efficiency. METHODS: We conducted a randomized controlled trial in which physicians in an academic family medicine clinic were randomized to 1 week with a scribe then 1 week without a scribe for the course of 1 year. Scribes drafted all relevant documentation, which was reviewed by the physician before attestation and signing. In encounters without a scribe, the physician performed all charting duties. Our outcomes were physician satisfaction, measured by a 5-item instrument that included physicians' perceptions of chart quality and chart accuracy; patient satisfaction, measured by a 6-item instrument; and charting efficiency, measured by time to chart close. RESULTS: Scribes improved all aspects of physician satisfaction, including overall satisfaction with clinic (OR = 10.75), having enough face time with patients (OR = 3.71), time spent charting (OR = 86.09), chart quality (OR = 7.25), and chart accuracy (OR = 4.61) (all P values <.001). Scribes had no effect on patient satisfaction. Scribes increased the proportion of charts that were closed within 48 hours (OR =1.18, P =.028). CONCLUSIONS: To our knowledge, we have conducted the first randomized controlled trial of scribes. We found that scribes produced significant improvements in overall physician satisfaction, satisfaction with chart quality and accuracy, and charting efficiency without detracting from patient satisfaction. Scribes appear to be a promising strategy to improve health care efficiency and reduce physician burnout.

Association between aggressive care and bereaved families' evaluation of end-of-life care for veterans with non-small cell lung cancer who died in Veterans Affairs facilities.

BACKGROUND: To the authors' knowledge, little is known regarding the relationship between patients' and families' satisfaction with aggressive end-of-life care. Herein, the authors examined the associations between episodes of aggressive care (ie, chemotherapy, mechanical ventilation, acute hospitalizations, and intensive care unit admissions) within the last 30 days of life and families' evaluations of end-of-life care among patients with non-small cell lung cancer (NSCLC). METHODS: A total of 847 patients with NSCLC (34% of whom were aged <65 years) who died in a nursing home or intensive care, acute care, or hospice/palliative care (HPC) unit at 1 of 128 Veterans Affairs Medical Centers between 2010 and 2012 were examined. Data sources included Veterans Affairs administrative and clinical data, Medicare claims, and the Bereaved Family Survey. The response rate for the Bereaved Family Survey was 62%. RESULTS: Greater than 72% of veterans with advanced lung cancer who died in an inpatient setting had at least 1 episode of aggressive care and 31% received chemotherapy within the last 30 days of life. For all units except for HPC, when patients experienced at least 1 episode of aggressive care, bereaved families rated care lower compared with when patients did not receive any aggressive care. For patients dying in an HPC unit, the associations between overall ratings of care and ≥2 inpatient admissions or any episode of aggressive care were not found to be statistically significant. Rates of aggressive care were not associated with age, and family ratings of care were similar for younger and older patients. CONCLUSIONS: Aggressive care within the last month of life is common among patients with NSCLC and is associated with lower family evaluations of end-of-life care. Specialized care provided within an HPC unit may mitigate the negative effects of aggressive care on these outcomes. Cancer 2017;123:3186-94. © 2017 American Cancer Society.

The Appropriate Provision of Primary versus Specialist Palliative Care to Cancer Patients: Oncologists' Perspectives.

BACKGROUND: Many cancer patients do not receive recommended palliative care (PC). Oncologists' perspectives about PC have not been adequately described qualitatively and may explain some of the gaps in the delivery of PC. OBJECTIVE: To characterize U.S. oncologists' perceptions of: primary and specialist PC; experiences interacting with PC specialists; and the optimal interface of PC and oncology in providing PC. DESIGN: In-depth interviews with practicing oncologists. SETTING/SUBJECTS: Oncologists working in: the general community, academic medical centers (AMC), and Veterans Health Administration. MEASUREMENTS: Semistructured telephone interviews with 31 oncologists analyzed using matrix and thematic approaches. RESULTS: Seven major themes emerged: PC was perceived as appropriate throughout the disease trajectory but due to resource constraints was largely provided at end of life; oncologists had three schools of thought on primary versus specialist PC; there was an under-availability of outpatient PC; poor communication about prognosis and care plans created tension between providers; PC was perceived as a "team of outsiders"; PC had too narrow a focus of care; and AMC-based PC evidence did not generalize to community practices. Oncologists noted three ways to improve the interface between oncologists and PC providers: a clear division of responsibility, in-person collaboration, and sharing of nonphysician palliative team members. CONCLUSIONS: Oncologists in our sample were supportive of PC, but they reported obstacles related to care coordination and inpatient PC. Inpatient PC posed some unique challenges with respect to conflicting prognoses and care practices that would be mitigated through the increased availability and use of outpatient PC.

Multifaceted academic detailing program to increase pharmacotherapy for alcohol use disorder: interrupted time series evaluation of effectiveness.

BACKGROUND: Active consideration of effective medications to treat alcohol use disorder (AUD) is a consensus standard of care, yet knowledge and use of these medications are very low across diverse settings. This study evaluated the overall effectiveness a multifaceted academic detailing program to address this persistent quality problem in the US Veterans Health Administration (VHA), as well as the context and process factors that explained variation in effectiveness across sites. METHODS: An interrupted time series design, analyzed with mixed-effects segmented logistic regression, was used to evaluate changes in level and rate of change in the monthly percent of patients with a clinically documented AUD who received naltrexone, acamprosate, disulfiram, or topiramate. Using data from a 20 month post-implementation period, intervention sites (n = 37) were compared to their own 16 month pre-implementation performance and separately to the rest of VHA. RESULTS: From immediately pre-intervention to the end of the observation period, the percent of patients in the intervention sites with AUD who received medication increased over 3.4 % in absolute terms and 68 % in relative terms (i.e., 4.9-8.3 %). This change was significant compared to the pre-implementation period in the intervention sites and secular trends in control sites. Sites with lower pre-implementation adoption, more person hours of detailing, but fewer people detailed, had larger immediate increases in medication receipt after implementation. The average number of detailing encounters per person was associated with steeper increases in slope over time. CONCLUSIONS: This study found empirical support for a multifaceted quality improvement strategy aimed at increasing access to and utilization of pharmacotherapy for AUD. Future studies should focus on determining how to enhance the programs effects, especially in non-responsive locations.

Evaluating Two Measures of Lumbar Spine MRI Overuse: Administrative Data Versus Chart Review.

PURPOSE: Lumbar spine (LS) MRI overuse may be identified in administrative data, but these data may lack the detailed clinical information needed to correctly assess overuse. The aim of this study was to compare chart review with analysis of administrative data to determine the appropriateness of LS MRI. METHODS: The sensitivity and specificity of the administrative method were determined, with inappropriateness regarded as the positive result, as if chart review determined the true state. Patients were the first 146 veterans who underwent LS MRI in the outpatient setting in fiscal year 2012 at the Veterans Affairs Palo Alto Health Care System. The InterQual criteria for chart review and the method of evaluating administrative data developed by CMS and endorsed by the National Quality Forum were used. Slight modifications were made to each measure to ensure completeness and comparability. RESULTS: Of the 146 scans reviewed, 23% were considered inappropriate by the administrative measure, whereas 59% were considered inappropriate by chart review. Compared with chart review, the administrative measure had specificity of 82% for identifying inappropriate scans and sensitivity of 27% for identifying appropriate scans. CONCLUSIONS: Compared with chart review, analysis of administrative data identified scans that were appropriate but underestimated inappropriate ordering. Contrary to expectations, chart review resulted in more scans being classified as inappropriate. The administrative method is economically feasible for identifying the overuse of LS MRI, but it underestimates the true extent of inappropriate ordering.

Gap between Recommendations and Practice of Palliative Care and Hospice in Cancer Patients.

BACKGROUND: Specialty societies recommend patients with advanced cancer receive early exposure to palliative care and exposure to hospice care. OBJECTIVE: We sought to understand real-world practice of care, specifically, the timing of palliative care, and how timing and duration of hospice care varied across Medicare, VA, and VA-Purchased care. DESIGN: We conducted a retrospective analysis of administrative data for veterans aged 65 years or older who died with cancer in 2012. Multilevel logistic regression was used to evaluate the likelihood of receiving palliative care, receiving hospice care, and receiving hospice care for at least three days. SETTING: Medicare, VA, and VA-Purchased care environments. MEASUREMENTS: The receipt and timing of palliative care within VA and the receipt and timing of hospice care across three healthcare environments. RESULTS: Most veterans received hospice care (71%), whereas fewer received palliative care (52%). Among all cancer decedents, 59% received hospice care for their last three days of life. Patients who received hospice care did so a median of 20 days before death (interquartile range [IQR]: 7-46). Patients who received palliative care did so a median of 38 days before death (IQR: 13-94). Adjusted analyses revealed significant differences in receipt of palliative care across cancer type, and significant differences in receipt of hospice care across cancer type. After adjusting for age and cancer type, patients who received VA hospice care were significantly less likely to receive it for at least three days compared with patients who received VA-Purchased or Medicare hospice care. CONCLUSIONS: There remains a gap between recommended timing of supportive services and real-world practice of care. Results suggest that difficulties in prognosticating death are not fully responsible for underexposure to hospice.

Inappropriate ordering of lumbar spine magnetic resonance imaging: are providers Choosing Wisely?

OBJECTIVES: To analyze inappropriate use of magnetic resonance imaging (MRI) for patients with low back pain in a healthcare system with no financial incentives for overuse. STUDY DESIGN: We used administrative data to assess the appropriateness of lumbar spine (LS) MRI in the Veterans Health Administration. METHODS: All veterans who received LS MRI in the outpatient setting in fiscal year 2012 were included. We based our assessments of appropriateness on CMS criteria, which have been endorsed by the National Quality Forum. Generalized estimating equations were used to evaluate characteristics of inappropriate scans. RESULTS: Of the 110,661 LS MRIs performed, 31% were classified as inappropriate. Most scans that were considered appropriate were characterized as such because they were preceded by conservative therapy (53%). "Red flag" conditions were responsible for a much smaller percentage of scans being considered appropriate; 13% of scans were preceded by conservative therapy and were performed in patients with a red flag condition, while only 4% of scans were considered appropriate because of red flag conditions only. Scans ordered in the emergency department and in urgent care, primary care, and internal medicine clinics were most likely to be classified as inappropriate. Resident physicians were significantly less likely than other provider types to order inappropriate LS MRIs (odds ratio, 0.80; P < .0001). Approximately 24% of providers ordered 74% of inappropriate scans. CONCLUSIONS: We found that 31% of LS MRIs were inappropriate in a healthcare system largely absent of financial and other incentives for ordering. The problem of inappropriate ordering of LS MRI is concentrated in a small number of providers; any provider-facing interventions to reduce inappropriate order should therefore be targeted, rather than aimed at all providers who order LS MRI.