Complex implementation factors demonstrated when evaluating cost-effectiveness and monitoring racial disparities associated with [18F]DCFPyL PET/CT in prostate cancer men.

Prostate cancer (PC) staging with conventional imaging often includes multiparametric magnetic resonance (MR) of the prostate, computed tomography (CT) of the chest, abdomen, and pelvis, and whole-body bone scintigraphy. The recent development of highly sensitive and specific prostate specific membrane antigen (PSMA) positron emission tomography (PET) has suggested that prior imaging techniques may be insufficiently sensitive or specific, particularly when evaluating small pathologic lesions. As PSMA PET/CT is considered to be superior for multiple clinical indications, it is being deployed as the new multidisciplinary standard-of-care. Given this, we performed a cost-effectiveness analysis of [18F]DCFPyL PSMA PET/CT imaging in the evaluation of PC relative to conventional imaging and anti-3-[18F]FACBC (18F-Fluciclovine) PET/CT. We also conducted a single institution review of PSMA PET/CT scans performed primarily for research indications from January 2018 to October 2021. Our snapshot of this period of time in our catchment demonstrated that PSMA PET/CT imaging was disproportionately accessed by men of European ancestry (EA) and those residing in zip codes associated with a higher median household income. The cost-effectiveness analysis demonstrated that [18F]DCFPyL PET/CT should be considered as an alternative to anti-3-[18F]FACBC PET/CT and standard of care imaging for prostate cancer staging. [18F]DCFPyL PET/CT is a new imaging modality to evaluate PC patients with higher sensitivity and specificity in detecting disease than other prostate specific imaging studies. Despite this, access may be inequitable. This discrepancy will need to be addressed proactively as the distribution network of the radiotracer includes both academic and non-academic sites nationwide.

Elevated end-of-life spending: A new measure of potentially wasteful health care spending at the end of life.

OBJECTIVE: To construct a new measure of end-of-life (EoL) spending-the elevated EoL spending-and examine its associations with measures of quality of care and patient and physician preferences in comparison with the commonly used total Medicare EoL spending measures. DATA SOURCES AND STUDY SETTING: Medicare claims data for a 20% random sample of Medicare fee-for-service (FFS) patients, from the health care quality data for 2015-2016, from the Hospital Compare and the Medicare Geographic Variation public use file, and survey data about patient and physician preferences. STUDY DESIGN: We constructed the elevated EoL spending measure as the differential monthly spending between decedents and survivors with the same one-year mortality risk, where the risk was predicted using machine learning models. We then examined the associations of the hospital referral region (HRR)-level elevated EoL spending with various health care quality measures and with the survey-elicited patient and provider preferences. We also examined analogous associations for monthly total EoL spending on decedents. DATA EXTRACTION METHODS: Medicare FFS patients who were continuously enrolled in Medicare Parts A & B in 2015 and were alive as of January 1, 2016. PRINCIPAL FINDINGS: We found a large variation in the elevated EoL spending across HRRs in the United States. There was no evidence of an association between HRR-level elevated EoL spending and established health care quality measures, including those specific to EoL care, whereas total EoL spending was positively associated with certain quality of care measures. We also found no evidence that elevated EoL spending was associated with patient preferences for EoL care. However, elevated EoL spending was positively and significantly associated with physician preferences for treatment intensity. CONCLUSIONS: Our findings suggested that elevated EoL spending captures different resource use from conventional measures of EoL spending and may be more valuable in identifying potentially wasteful spending.

Access to cardiac PET/CT by sarcoidosis patients and cost-effectiveness analysis of cardiac PET/MR compared to the standard of care.

IMPORTANCE: Cardiac sarcoidosis is associated with a high mortality rate. Given multiple barriers to obtaining cardiac PET imaging, we suspect individuals with access to this imaging modality are not representative of the Sarcoid patient population, which in the United States are predominantly Black females. OBJECTIVE: To evaluate the demographics of patients with cardiac PET access and the cost-effectiveness of cardiac PET/MR imaging relative to standard of care. DESIGN: This is a retrospective, observational study. The demographic information of patients with suspected cardiac sarcoidosis and cardiac PET/CT imaging within a national registry of sarcoidosis were reviewed (n = 4561). An individual-level, continuous, time-state transition model was used for the evaluation of long-term cost-effectiveness for the combined cardiac PET/MR compared to standard of care cardiac MR followed by cardiac PET/CT. RESULTS: Patients who underwent cardiac PET in the national registry had 88.35% higher odds of being male (p < 0.001) and 43.82% higher odds of being White (p = 0.003) than their counterparts who did not have cardiac PET imaging. Combined cardiac PET/MR had overall lower total lifetime costs ($8761 vs $10,777) and overall improved expected quality of life-years compared to the standard of care (0.77 vs 0.69). CONCLUSION AND RELEVANCE: The findings suggest that patients with access to cardiac PET/CT are not representative of the patient population most likely to have cardiac sarcoidosis in this limited study evaluation. Universal insurance coverage should be considered for Cardiac PET imaging as same day cardiac PET and MR imaging has potential long-term cost and quality of life benefit.

Price Indices and the Value of Innovation with Heterogenous Patients.

Many countries use uniform cost-effectiveness criteria to determine whether to adopt a new medical technology for the entire population. This approach assumes homogeneous preferences for expected health benefits and side effects. We examine whether new prescription drugs generate welfare gains when accounting for heterogeneous preferences by constructing quality-adjusted price indices in the market for colorectal cancer drug treatments. We find that while the efficacy gains from newer drugs do not justify high prices for the population as a whole, innovation improves the welfare of sicker, late-stage cancer patients. A uniform evaluation criterion would not permit these innovations despite welfare gains to a subpopulation.

Robust Prescription Monitoring Programs and Abrupt Discontinuation of Long-term Opioid Use.

INTRODUCTION: This study assesses the associations between the recent implementation of robust features of state Prescription Drug Monitoring Programs and the abrupt discontinuation of long-term opioid therapies. METHODS: Data were from a national commercial insurance database and included privately insured adults aged 18-64 years and Medicare Advantage enrollees aged ≥65 years who initiated a long-term opioid therapy episode between Quarter 2 of 2011 and Quarter 2 of 2017. State Prescription Drug Monitoring Programs were characterized as nonrobust, robust, and strongly robust. Abrupt discontinuation was measured on the basis of high daily morphine milligram equivalents over the last 30 days of a long-term opioid therapy episode or no sign of tapering before discontinuation. Difference-in-differences models were estimated in 2019‒2020 to assess the association between robust Prescription Drug Monitoring Programs and abrupt discontinuation. RESULTS: Among nonelderly privately insured adults, robust Prescription Drug Monitoring Programs were associated with an increase from 14.8% to 15.4% (4% relative increase, p=0.02) in the rate of ending long-term opioid therapy with ≥60 daily morphine milligram equivalents. For older Medicare Advantage enrollees, strongly robust Prescription Drug Monitoring Programs were associated with a reduction from 4.8% to 4.3% (10.4%, p=0.01) and from 3.0% to 2.4% (17.3%, p=0.001) in the rate of ending long-term opioid therapy with ≥90 and 120 daily morphine milligram equivalents, respectively. Prescription Drug Monitoring Programs robustness was not associated with clinically meaningful changes in the rate of discontinuing long-term opioid therapy without tapering. CONCLUSIONS: Discontinuation without tapering was the norm for long-term opioid therapies in the samples throughout the study years. Findings do not support the notion that policies aimed at enhancing Prescription Drug Monitoring Program use were associated with substantial increases in abrupt long-term opioid therapy discontinuation.

The Secret Menu in Health Care: A Cash Market for Imaging in California.

In addition to the prices they negotiate with private health insurers, most providers also have a cash price schedule for patients who have the wherewithal to ask and are willing to pay in full when they receive a service. This is the first study that estimates the potential cost saving of allowing privately-insured consumers to observe both in-network negotiated prices and cash prices, which is of particular interest given the growing importance of high-deductible health plans and a recent executive order mandating greater price transparency. Using data from five private health insurers and 142 imaging facilities in the San Francisco Bay Area, we estimate that patients could save between 10% and 22% of their insurer's in-network price by paying cash. Potential savings are much larger (between 45% and 64% of their insurer's in-network price) if consumers observe both cash and in-network prices and select the facility in the region offering the lowest price for a particular service.

The effect of assigning dedicated general practitioners to nursing homes.

OBJECTIVE: To determine whether assigning a dedicated general practitioner (GP) to a nursing home reduces hospitalizations and readmissions. DATA SOURCES/STUDY SETTING: Secondary data on hospitalizations and deaths by month for the universe of nursing home residents in Denmark from January 2011 through February 2014. STUDY DESIGN: In 2012, Denmark initiated a program in seven nursing homes that volunteered to participate. We used a difference-in-differences model to estimate the effect of assigning a dedicated GP to a nursing home on the likelihood that a nursing home resident will be hospitalized, will experience a preventable hospitalization, and will be readmitted. The unit of observation is a resident-month. DATA COLLECTION/EXTRACTION METHODS: Data were extracted from the Danish public administrative register dataset. PRINCIPAL FINDINGS: We found that assigning a GP to a nursing home was associated with a 0.55 [95 percent CI, 0.08 to 1.02] percentage point reduction in the monthly probability of a preventable hospitalization, which was a 26 percent reduction from the preintervention level of 2.13 percentage points. The associated reduction in the monthly probability of a readmission was 0.68 [95 percent CI, -0.01 to 1.37] percentage points, which was a 25 percent reduction from the baseline level of 2.68 percentage points. Survey results indicated that the likely mechanism for the effect was more efficient and consistent communication between GPs and nursing home personnel. CONCLUSIONS: Assigning a dedicated physician in a nursing home can reduce medical spending and improve patients' health.

The effect of education debt on dentists' career decisions.

BACKGROUND: The purpose of the study was to determine whether there is an association between the amount of education debt on completing dental school (initial debt) and certain career decisions. METHODS: The authors surveyed 1,842 practicing dentists who completed dental school between 1996 and 2011 to ascertain their initial education debt, the balance on their debt in 2013, and a variety of specialization and practice decisions made during their careers. Data also included demographic characteristics and parental income and education levels. RESULTS: Dentists with higher initial debt were less likely to specialize and more likely to enter private practice, accept high-paying jobs on graduation, and work longer hours. Choice of employment setting, practice ownership, and whether to provide Medicaid and charity care were associated with dentists' sexes and races but not debt. CONCLUSIONS: High debt levels influenced some career decisions, but the magnitude of these effects was small compared with the effects of demographic characteristics, including race and sex, on career choices. PRACTICAL IMPLICATIONS: Policy makers concerned about the influence of student debt on the professional decisions of dental school graduates should recognize that students' demographic characteristics may be more powerful in driving career choices.

Quality-adjusted cost of care: a meaningful way to measure growth in innovation cost versus the value of health gains.

Technology drives both health care spending and health improvement. Yet policy makers rarely see measures of cost growth that account for both effects. To fill this gap, we present the quality-adjusted cost of care, which illustrates cost growth net of growth in the value of health improvements, measured as survival gains multiplied by the value of survival. We applied the quality-adjusted cost of care to two cases. For colorectal cancer, drug cost per patient increased by $34,493 between 1998 and 2005 as a result of new drug launches, but value from offsetting health improvements netted a modest $1,377 increase in quality-adjusted cost of care. For multiple myeloma, new therapies increased treatment cost by $72,937 between 2004 and 2009, but offsetting health benefits lowered overall quality-adjusted cost of care by $67,863. However, patients with multiple myeloma on established first-line therapies saw costs rise without corresponding benefits. All three examples document rapid cost growth, but they provide starkly different answers to the question of whether society got what it paid for.

Educational debt and intended employment choice among dental school seniors.

BACKGROUND: The authors examined the association between educational debt and dental school seniors' intended activity after graduation. METHODS: The authors used multinomial logit regression analysis to estimate the relationship between dental educational debt and intended activity after graduation, controlling for potentially confounding variables. They used data from the 2004 through 2011 ADEA (American Dental Education Association) Survey of Dental School Seniors. RESULTS: Fourth-year dental school students with high levels of educational debt were more likely to express an interest in choosing to go into private practice, although the magnitude of this effect was relatively small. For each $10,000 increase in debt, the likelihood of choosing advanced education relative to private practice was 1.5 percent lower (relative risk ratio [RRR], 0.985 [95 percent confidence interval {CI}, 0.978-0.991]). For the same $10,000 increase in debt, the probability of choosing teaching, research and administration was 3.1 percent lower than that for choosing private practice (RRR, 0.969 [95 percent CI, 0.954-0.986]) and was 8.4 percent lower than that for choosing a government service position (RRR, 0.916 [95 percent CI, 0.908-0.924]). CONCLUSIONS: Although educational debt was statistically significant for predicting intended activity after graduation, the magnitude of influence of other variables such as sex, race and whether a parent is a dentist was substantially larger. Practical Implications Concerns regarding rising educational debt and its effect on the dental labor market may be misplaced. The characteristics of the dental school student body may be a more accurate predictor of employment choices that dental school seniors are making than are total educational debt levels.

Economic burden of urgency urinary incontinence in the United States: a systematic review.

BACKGROUND: The International Continence Society (ICS) identifies several urinary incontinence (UI) subtypes: urgency urinary incontinence (UUI), stress UI (SUI), and mixed UI (MUI). UUI is a common symptom of overactive bladder (OAB) syndrome. Based on the current ICS definition of OAB, all patients with UUI have OAB, whereas not all patients with OAB have UUI. Because UUI is a chronic condition that is expected to increase in prevalence as the population of elderly individuals grows, it is important to understand its economic burden on society and patients and its cost components.  OBJECTIVE: To summarize the published English language medical literature on estimates of the economic burden of UUI in the United States from a societal and patient perspective, including direct costs (diagnosis, treatment, routine care [including incontinence pads], and UUI-associated comorbidities/complications); indirect costs (lost wages by patients and caregivers and lost work productivity due to absenteeism and presenteeism); and intangible costs (pain, suffering, and decreased health-related quality of life).  METHODS: A PubMed search of the literature for articles on the economic burden of UUI in the United States was conducted using the search terms (urgency urinary incontinence OR urge incontinence OR mixed incontinence OR overactive bladder) AND (burden OR cost OR economic) AND (United States), with limits for English language, publication from 1991 to 2011, humans, and adults (19+ years). Only primary articles of non-neurogenic UUI in the United States were retained.  RESULTS: Seven studies were identified that included data on the economic burden of UUI in the United States from a societal and patient perspective. Although estimates of the total economic burden of UUI include direct, indirect, and intangible costs, none of the 7 U.S. studies included all of these cost components. Furthermore, the costs of UUI often could not be fully extracted from the costs of OAB, which include patients with and without UUI, or the costs of other types of UI. The most recent cost analysis incorporated OAB with UUI prevalence rates and data on use of each cost component to calculate the total annual direct costs in 2007 for adults aged ≥ 25 years. The estimated total national cost of OAB with UUI in 2007 was $65.9 billion, with projected costs of $76.2 billion in 2015 and $82.6 billion in 2020. This 2007 estimate was markedly higher than those reported in older studies. Direct costs are the main driver of the overall cost of UUI in the United States. Studies that assessed patient costs indicated that the personal costs of routine care items for UUI and MUI represent a meaningful contribution to the overall economic burden of these conditions. These substantial personal expenditures may explain why patients reported that they were willing to pay considerable amounts for a treatment that would reduce the frequency of their UUI episodes.  CONCLUSIONS: UUI in the United States is associated with a substantial economic burden from both a societal and patient perspective. Studies evaluating the impact of interventions that reduce the frequency of UUI episodes on the overall economic burden of UUI are warranted. 

Global prevalence and economic burden of urgency urinary incontinence: a systematic review.

CONTEXT: The prevalence and economic burden of urgency urinary incontinence (UUI) are difficult to ascertain because of overlap with data on overactive bladder and other types of incontinence. OBJECTIVE: To summarize the evidence on the global prevalence and economic burden of UUI. EVIDENCE ACQUISITION: A PubMed search was performed used the following terms: (urgency urinary incontinence OR urge incontinence OR mixed incontinence OR overactive bladder) AND (burden OR cost OR economic OR prevalence). A similar search was conducted using Embase. English-language articles published from 1991 through 2013 on non-neurogenic UUI were retained. EVIDENCE SYNTHESIS: We retained 54 articles (50 studies); 22 large-scale, population-based surveys indicated varying UUI prevalence estimates with ranges of 1.8-30.5% in European populations, 1.7-36.4% in US populations, and 1.5-15.2% in Asian populations, with prevalence dependent on age and gender. Nineteen smaller-scale studies supported these findings. Despite varying methods, 11 studies estimating the costs of UUI worldwide consistently concluded that the economic burden is substantial and will increase markedly as the population ages. In a 2005 multinational study, the annual cost-of-illness estimate for UUI in Canada, Germany, Italy, Spain, Sweden, and the United Kingdom was €7 billion. A US cost-of-illness study reported a total cost of $66 billion in 2007 US dollars. The costs of routine care and nursing home admissions for UUI were major contributors to the cost. CONCLUSIONS: UUI affects millions of men and women worldwide. Current evidence demonstrates the substantial economic burden of UUI to patients and society. Worldwide public health and clinical management programs are needed to improve UUI awareness and highlight the need for early diagnosis and management.

How do you deliver a good obstetrician? Outcome-based evaluation of medical education.

The goal of medical education is the production of a workforce capable of improving the health and health care of patients and populations, but it is hard to use a goal that lofty, that broad, and that distant as a standard against which to judge the success of schools or training programs or particular elements within them. For that reason, the evaluation of medical education often focuses on elements of its structure and process, or on the assessment of competencies that could be considered intermediate outcomes. These measures are more practical because they are easier to collect, and they are valuable when they reflect activities in important positions along the pathway to clinical outcomes. But they are all substitutes for measuring whether educational efforts produce doctors who take good care of patients.The authors argue that the evaluation of medical education can become more closely tethered to the clinical outcomes medical education aims to achieve. They focus on a specific clinical outcome-maternal complications of obstetrical delivery-and show how examining various observable elements of physicians' training and experience helps reveal which of those elements lead to better outcomes. Does it matter where obstetricians trained? Does it matter how much experience they have? Does it matter how good they were to start? Each of these questions reflects a component of the production of a good obstetrician and, most important, defines a good obstetrician as one whose patients in the end do well.

Association between physicians' experience after training and maternal obstetrical outcomes: cohort study.

OBJECTIVE: To assess the association between obstetricians' years of experience after training and the maternal complications of their patients during their first 40 years of post-residency practice. DESIGN: Retrospective cohort analysis. SETTING: Obstetrical discharges from acute care hospitals in Florida and New York between academic years 1992 and 2009. POPULATION: 6,704,311 deliveries performed by 5175 obstetricians. MAIN OUTCOME MEASURE: Three composite measures of maternal complication rates per physician year from vaginal and cesarean births separately and combined, adjusted for secular trends. RESULTS: Obstetricians' maternal complication rates declined during the first three decades after completion of residency. The improvement was largest in the first decade and diminished thereafter. For all deliveries, the change was -0.21 (95% confidence interval -0.23 to -0.19) percentage points per year in the first decade, -0.11 (-0.13 to -0.09) percentage points per year in the second decade, and -0.05 (-0.08 to -0.01) percentage points in the third decade (P<0.001 for second to first decade comparison; P=0.001 for third to second decade comparison). The patterns were comparable for cesarean deliveries and vaginal deliveries and across several sensitivity checks. CONCLUSIONS: Among obstetricians practicing in Florida and New York, those with more years of experience had fewer maternal complications. This association persisted over the first three decades of practice but diminished in magnitude.

US physician practices versus Canadians: spending nearly four times as much money interacting with payers.

Physician practices, especially the small practices with just one or two physicians that are common in the United States, incur substantial costs in time and labor interacting with multiple insurance plans about claims, coverage, and billing for patient care and prescription drugs. We surveyed physicians and administrators in the province of Ontario, Canada, about time spent interacting with payers and compared the results with a national companion survey in the United States. We estimated physician practices in Ontario spent $22,205 per physician per year interacting with Canada's single-payer agency--just 27 percent of the $82,975 per physician per year spent in the United States. US nursing staff, including medical assistants, spent 20.6 hours per physician per week interacting with health plans--nearly ten times that of their Ontario counterparts. If US physicians had administrative costs similar to those of Ontario physicians, the total savings would be approximately $27.6 billion per year. The results support the opinion shared by many US health care leaders interviewed for this study that interactions between physician practices and health plans could be performed much more efficiently.

Commentary: improving the supply and distribution of primary care physicians.

The current medical education system and reimbursement policies in the United States have contributed to a maldistribution of physicians by specialty and geography. The causes of this maldistribution include financial barriers that prevent the individuals who would be the most likely to serve in primary care and underserved areas from entering the profession, large taxpayer subsidies to teaching hospitals that provide incentives to act in ways that are not in the best interest of society, and reimbursement policies that discourage physicians from providing primary care. The authors propose that the maldistribution of physicians can be addressed successfully by reducing the financial barriers to becoming a primary care physician, aligning subsidies with societal interests, and providing financial incentives that target primary care. They suggest that the Patient Protection and Affordable Care Act of 2010 takes steps in the right direction but that more financially prudent measures should be taken as politicians revisit health care reform with heightened financial scrutiny.

Improvements in US maternal obstetrical outcomes from 1992 to 2006.

BACKGROUND: Over 4 million women give birth annually in the United States, making delivery one of the most common reasons for hospital care. OBJECTIVE: We examined 15-year trends in risk-adjusted maternal complications following childbirth. RESEARCH DESIGN: We examined maternal obstetrical outcomes from 1992-2006 among women undergoing cesarean delivery (CD) and vaginal delivery (VD). A composite measure of major maternal complications including infection, hemorrhage, laceration, and other major operative and thrombotic complications was evaluated. SUBJECTS: Population-based sample of over 6 million women from Florida and New York hospital discharge data. MEASURES: Obstetric procedures and maternal complications postdelivery. RESULTS: During the 15-year time period, the CD rate decreased from 24.7% in 1992 to 23% in 1996 and increased to 34.7% in 2006. The risk-adjusted rate of any major complication declined from 14.7% in 1992 to 10.7% in 2006 for all deliveries; from 14.4% to 11.6% for VD; and from 15.7% to 8.5% for CD. During 1992 to 2006, the average number of comorbidities increased from 0.65 to 0.93 for patients overall, from 0.43 to 0.58 for VD patients, and 1.34 to 1.59 for CD patients. CONCLUSION: As evidenced by New York and Florida, the US has seen large reductions in major maternal complications over the past 15 years. Concurrently, the average number of comorbidities increased. These results reflect substantial improvements in maternal delivery outcomes.