Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 44
Filtrar
Mais filtros










Base de dados
Intervalo de ano de publicação
1.
Urol Oncol ; 38(2): 39.e21-39.e27, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31711836

RESUMO

OBJECTIVES: To externally validate the European Organization for the Research and Treatment of Cancer (EORTC) risk calculator and National Comprehensive Cancer Network (NCCN) guidelines in a contemporary population of U.S. non-muscle-invasive bladder cancer (NMIBC) patients treated in a community-based setting and compare our findings to those from another U.S. health system. MATERIALS AND METHODS: We identified 1,491 NMIBC patients with a median follow-up of 2.1 years (recurrence) and 4.1 years (progression). We calculated NCCN risk groupings and EORTC prognostic index for recurrence and progression. We followed Royston and Altman's guidelines for the external validation of prognostic calculators. RESULTS: For predicting recurrence using the EORTC framework, Harrell's C (a measure of discrimination) was smaller in our sample (0.66) than in the European Association of Urology sample (0.61), whereas for progression, Harrell's C was larger in our sample (0.78 vs. 0.75). The EORTC calculator overestimated progression risk in the highest stratum for our sample; calibration and discrimination were adequate for all groups except the highest risk group. For NCCN risk groupings, Harrell's C was 0.54 for recurrence and 0.62 for progression, suggesting poor to fair discrimination in our sample. The NCCN framework had slightly better performance for predicting progression vs. recurrence. CONCLUSIONS: Existing NMIBC risk-stratification frameworks have acceptable accuracy to predict outcomes. However, further innovation in NMIBC care will require predictive tools with more granularity to reflect the differential risks of subgroups of NMIBC recurrence, prior treatment histories, and other prognostic variables.

2.
Qual Life Res ; 2019 Dec 06.
Artigo em Inglês | MEDLINE | ID: mdl-31811594

RESUMO

PURPOSE: The Bladder Cancer Quality of Life Study collected detailed and sensitive patient-reported outcomes from bladder cancer survivors in the period after bladder removal surgery, when participation in survey research may present a burden. This paper describes the study recruitment methods and examines the response rates and patterns of missing data. METHODS: Detailed surveys focusing on quality of life, healthcare decision-making, and healthcare expenses were mailed to patients 5-7 months after cystectomy. We conducted up to 10 follow-up recruitment calls. We analyzed survey completion rates following each contact in relation to demographic and clinical characteristics, and patterns of missing data across survey content areas. RESULTS: The overall response rate was 71% (n = 269/379). This was consistent across patient clinical characteristics; response rates were significantly higher among patients over age 70 and significantly lower among racial and ethnic minority patients compared to non-Hispanic white patients. Each follow-up contact resulted in marginal survey completion rates of at least 10%. Rates of missing data were low across most content areas, even for potentially sensitive questions. Rates of missing data differed significantly by sex, age, and race/ethnicity. CONCLUSIONS: Despite the effort required to participate in research, this population of cancer survivors showed willingness to share detailed information about quality of life, health care decision-making, and expenses, soon after major cancer surgery. Additional contacts were effective at increasing participation. Response patterns differed by race/ethnicity and other demographic factors. Our data collection methods show that it is feasible to gather detailed patient-reported outcomes during this challenging period.

3.
J Natl Compr Canc Netw ; 17(10): 1166-1172, 2019 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-31590146

RESUMO

BACKGROUND: Oral tyrosine kinase inhibitors (TKIs) have been the standard of care for chronic myeloid leukemia (CML) since 2001. However, few studies have evaluated changes in the treatment landscape of CML over time. This study assessed the long-term treatment patterns of oral anticancer therapies among patients with CML. METHODS: This retrospective cohort study included patients newly diagnosed with CML between January 1, 2000, and December 31, 2016, from 10 integrated healthcare systems. The proportion of patients treated with 5 FDA-approved oral TKI agents-bosutinib, dasatinib, imatinib, nilotinib, and ponatinib-in the 12 months after diagnosis were measured, overall and by year, between 2000 and 2017. We assessed the use of each oral agent through the fourth-line setting. Multivariable logistic regression estimated the odds of receiving any oral agent, adjusting for sociodemographic and clinical characteristics. RESULTS: Among 853 patients with CML, 81% received an oral agent between 2000 and 2017. Use of non-oral therapies decreased from 100% in 2000 to 5% in 2005, coinciding with imatinib uptake from 65% in 2001 to 98% in 2005. Approximately 28% of patients switched to a second-line agent, 9% switched to a third-line agent, and 2% switched to a fourth-line agent. Adjusted analysis showed that age at diagnosis, year of diagnosis, and comorbidity burden were statistically significantly associated with odds of receiving an oral agent. CONCLUSIONS: A dramatic shift was seen in CML treatments away from traditional, nonoral chemotherapy toward use of novel oral TKIs between 2000 and 2017. As the costs of oral anticancer agents reach new highs, studies assessing the long-term health and financial outcomes among patients with CML are warranted.

4.
J Oncol Pract ; 15(7): e616-e627, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31107629

RESUMO

PURPOSE: Spending for patients with advanced cancer is substantial. Past efforts to characterize this spending usually have not included patients with recurrence (who may differ from those with de novo stage IV disease) or described which services drive spending. METHODS: Using SEER-Medicare data from 2008 to 2013, we identified patients with breast, colorectal, and lung cancer with either de novo stage IV or recurrent advanced cancer. Mean spending/patient/month (2012 US dollars) was estimated from 12 months before to 11 months after diagnosis for all services and by the type of service. We describe the absolute difference in mean monthly spending for de novo versus recurrent patients, and we estimate differences after controlling for type of advanced cancer, year of diagnosis, age, sex, comorbidity, and other factors. RESULTS: We identified 54,982 patients with advanced cancer. Before diagnosis, mean monthly spending was higher for recurrent patients (absolute difference: breast, $1,412; colorectal, $3,002; lung, $2,805; all P < .001), whereas after the diagnosis, it was higher for de novo patients (absolute difference: breast, $2,443; colorectal, $4,844; lung, $2,356; all P < .001). Spending differences were driven by inpatient, physician, and hospice services. Across the 2-year period around the advanced cancer diagnosis, adjusted mean monthly spending was higher for de novo versus recurrent patients (spending ratio: breast, 2.39 [95% CI, 2.05 to 2.77]; colorectal, 2.64 [95% CI, 2.31 to 3.01]; lung, 1.46 [95% CI, 1.30 to 1.65]). CONCLUSION: Spending for de novo cancer was greater than spending for recurrent advanced cancer. Understanding the patterns and drivers of spending is necessary to design alternative payment models and to improve value.

5.
JCO Clin Cancer Inform ; 3: 1-10, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30995122

RESUMO

PURPOSE: Hospitalizations are a common occurrence during chemotherapy for advanced cancer. Validated risk stratification tools could facilitate proactive approaches for reducing hospitalizations by identifying at-risk patients. PATIENTS AND METHODS: We assembled two retrospective cohorts of patients receiving chemotherapy for advanced nonhematologic cancer; cohorts were drawn from three integrated health plans of the Cancer Research Network. We used these cohorts to develop and validate logistic regression models estimating 30-day hospitalization risk after chemotherapy initiation. The development cohort included patients in two health plans from 2005 to 2013. The validation cohort included patients in a third health plan from 2007 to 2016. Candidate predictor variables were derived from clinical data in institutional data warehouses. Models were validated based on the C-statistic, positive predictive value, and negative predictive value. Positive predictive value and negative predictive value were calculated in reference to a prespecified risk threshold (hospitalization risk ≥ 18.0%). RESULTS: There were 3,606 patients in the development cohort (median age, 63 years) and 634 evaluable patients in the validation cohort (median age, 64 years). Lung cancer was the most common diagnosis in both cohorts (26% and 31%, respectively). The selected risk stratification model included two variables: albumin and sodium. The model C-statistic in the validation cohort was 0.69 (95% CI, 0.62 to 0.75); 39% of patients were classified as high risk according to the prespecified threshold; 30-day hospitalization risk was 24.2% (95% CI, 19.9% to 32.0%) in the high-risk group and 8.7% (95% CI, 6.1% to 12.0%) in the low-risk group. CONCLUSION: A model based on data elements routinely collected during cancer treatment can reliably identify patients at high risk for hospitalization after chemotherapy initiation. Additional research is necessary to determine whether this model can be deployed to prevent chemotherapy-related hospitalizations.

6.
JCO Clin Cancer Inform ; 3: 1-9, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30869998

RESUMO

PURPOSE: We previously developed and validated informatic algorithms that used International Classification of Diseases 9th revision (ICD9)-based diagnostic and procedure codes to detect the presence and timing of cancer recurrence (the RECUR Algorithms). In 2015, ICD10 replaced ICD9 as the worldwide coding standard. To understand the impact of this transition, we evaluated the performance of the RECUR Algorithms after incorporating ICD10 codes. METHODS: Using publicly available translation tables along with clinician and other expertise, we updated the algorithms to include ICD10 codes as additional input variables. We evaluated the performance of the algorithms using gold standard recurrence measures associated with a contemporary cohort of patients with stage I to III breast, colorectal, and lung (excluding IIIB) cancer and derived performance measures, including the area under the receiver operating curve, average absolute prediction error, and correct classification rate. These values were compared with the performance measures derived from the validation of the original algorithms. RESULTS: A total of 659 colorectal, 280 lung, and 2,053 breast cancer cases were identified. Area under the receiver operating curve derived from the updated algorithms was 89.0% (95% CI, 82.3% to 95.7%), 88.9% (95% CI, 79.3% to 98.2%), and 80.5% (95% CI, 72.8% to 88.2%) for the colorectal, lung, and breast cancer algorithms, respectively. Average absolute prediction errors for recurrence timing were 2.7 (SE, 11.3%), 2.4 (SE, 10.4%), and 5.6 months (SE, 21.8%), respectively, and timing estimates were within 6 months of actual recurrence for more than 80% of colorectal, more than 90% of lung, and more than 50% of breast cancer cases using the updated algorithm. CONCLUSION: Performance measures derived from the updated and original algorithms had overlapping confidence intervals, suggesting that the ICD9 to ICD10 transition did not affect the RECUR Algorithm performance.

7.
Popul Health Manag ; 22(1): 83-89, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-29927702

RESUMO

Colorectal cancer (CRC) causes more than 50,000 deaths each year in the United States but early detection through screening yields survival gains; those diagnosed with early stage disease have a 5-year survival greater than 90%, compared to 12% for those diagnosed with late stage disease. Using data from a large integrated health system, this study evaluates the cost-effectiveness of fecal immunochemical testing (FIT), a common CRC screening tool. A probabilistic decision-analytic model was used to examine the costs and outcomes of positive test results from a 1-FIT regimen compared with a 2-FIT regimen. The authors compared 5 diagnostic cutoffs of hemoglobin concentration for each test (for a total of 10 screening options). The principal outcome from the analysis was the cost per additional advanced neoplasia (AN) detected. The authors also estimated the number of cancers detected and life-years gained from detecting AN. The following costs were included: program management of the screening program, patient identification, FIT kits and their processing, and diagnostic colonoscopy following a positive FIT. Per-person costs ranged from $33 (1-FIT at 150ng/ml) to $92 (2-FIT at 50ng/ml) across screening options. Depending on willingness to pay, the 1-FIT 50 ng/ml and the 2-FIT 50 ng/ml are the dominant strategies with cost-effectiveness of $11,198 and $28,389, respectively, for an additional AN detected. The estimates of cancers avoided per 1000 screens ranged from 1.46 to 4.86, depending on the strategy and the assumptions of AN to cancer progression.


Assuntos
Neoplasias Colorretais/diagnóstico , Detecção Precoce de Câncer , Imuno-Histoquímica , Sangue Oculto , Análise Custo-Benefício , Detecção Precoce de Câncer/economia , Detecção Precoce de Câncer/estatística & dados numéricos , Fezes/química , Feminino , Humanos , Imuno-Histoquímica/economia , Imuno-Histoquímica/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade
9.
Cancer ; 124(23): 4477-4485, 2018 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-30289971

RESUMO

BACKGROUND: Multiple chronic conditions (MCC) are common among older patients with cancer; however, the exclusion of these patients from clinical trials has resulted in scarce knowledge concerning outcomes, resulting in variations in treatment. Superficial bladder cancer (SBC) disproportionately affects older adults, yet to the authors' knowledge few studies to date have examined whether treatment improves long-term survival. In the current study, the authors evaluated the association between treatment of SBC and 10-year mortality in medically complex older adults. METHODS: The authors identified 1800 older (aged ≥60 years) patients with SBC (American Joint Committee on Cancer stage ≤I) from 2 community-based health systems who received treatment (bladder instillation and/or transurethral resection) or observation. Cox proportional hazards regression was performed adjusting for age, sex, race, health system, stage of disease/grade, and MCC (≥2 baseline chronic conditions). Propensity score analysis using stabilized inverse probability of treatment weights was used to compare 10-year mortality in the 2 treatment groups with adjustment for covariates. RESULTS: Overall, 1485 patients (82.5%) and 315 patients (17.5%) received treatment and observation, respectively. In unweighted multivariable analysis, treatment was associated with a 30% reduction in death (adjusted hazard ratio [HR], 0.70; 95% confidence interval [95% CI], 0.58-0.85 [P<.01]) and MCC with a 72% increase in death (adjusted HR, 1.72; 95% CI, 1.44-2.05 [P<.01]). Weighted analysis with adjustment (doubly robust) also demonstrated a survival benefit for treatment (adjusted HR, 0.66; 95% CI, 0.52-0.84 [P<.01]). CONCLUSIONS: The results of the current study demonstrated a clinically meaningful association between cancer treatment and survival benefit in older, medically complex patients with SBC, even after adjustment for medical complexity. These data provide a foundation for future work aimed at personalizing the treatment guidance of older patients with cancer with MCC.


Assuntos
Antineoplásicos/administração & dosagem , Múltiplas Afecções Crônicas/epidemiologia , Neoplasias da Bexiga Urinária/terapia , Procedimentos Cirúrgicos Urológicos/métodos , Administração Intravesical , Idoso , Idoso de 80 Anos ou mais , Antineoplásicos/uso terapêutico , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise de Sobrevida , Resultado do Tratamento
10.
Am J Cardiol ; 122(7): 1128-1132, 2018 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-30086877

RESUMO

High triglyceride (TG) levels are associated with higher medical costs, but the long-term impact of high TG on costs among patients with statin-controlled low-density lipoprotein cholesterol (LDL-C) is unclear. We compared medical utilization and costs over 6.5years between patients with high (200 to 400 mg/dl) versus normal (<150 mg/dl) TG levels, all of whom had established atherosclerotic cardiovascular disease (ASCVD). This was an observational cohort study of 17,183 patients with TG measured in 2010 and followed until death, disenrollment or the end of 2016. All patients had LDL-C levels between 40 and 100 mg/dl and were receiving statin therapy at the time of their TG measurement. We compared annualized medical utilization adjusted for differences between group in age, sex, race, and study site. We also compared annualized medical costs, further adjusting for baseline costs as a proxy for resource-intensive comorbidities. After multivariable adjustment, patients with high TG levels (n=2,702) had a mean of 13% more inpatient admissions per year (p <0.001). Despite adjustment for comorbidities such as diabetes and chronic kidney disease, total outpatient costs were 5% greater (p = 0.035) among those with high TG, including emergency care costs (6% greater) and hospital ambulatory costs (25% greater). The overall difference in annual costs of $964 per patient in the high TG cohort totaled over $2.6million per year in excess annual costs and more than $13.5million over the mean follow-up of 5.2years.


Assuntos
LDL-Colesterol/efeitos dos fármacos , Doença da Artéria Coronariana/tratamento farmacológico , Custos de Cuidados de Saúde , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Hipertrigliceridemia/tratamento farmacológico , Revisão da Utilização de Recursos de Saúde , Idoso , California , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade
11.
Health Serv Res ; 53(6): 5106-5128, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30043542

RESUMO

OBJECTIVE: To address the knowledge gap regarding medical care costs for advanced cancer patients, we compared costs for recurrent versus de novo stage IV breast, colorectal, and lung cancer patients. DATA SOURCES/STUDY SETTING: Virtual Data Warehouse (VDW) information from three Kaiser Permanente regions: Colorado, Northwest, and Washington. STUDY DESIGN: We identified patients aged ≥21 with de novo or recurrent breast (nde novo  = 352; nrecurrent  = 765), colorectal (nde novo  = 1,072; nrecurrent  = 542), and lung (nde novo  = 4,041; nrecurrent  = 340) cancers diagnosed 2000-2012. We estimated average total monthly and annual costs in the 12 months preceding, month of, and 12 months following the index de novo/recurrence date, stratified by age at diagnosis (<65, ≥65). Generalized linear repeated-measures models controlled for demographics and comorbidity. PRINCIPAL FINDINGS: In the pre-index period, monthly costs were higher for recurrent than for de novo breast (<65: +$2,431; ≥65: +$1,360), colorectal (<65: +$3,219; ≥65: +$2,247), and lung cancer (<65: +$3,086; ≥65: +$2,260) patients. Conversely, during the index and post-index periods, costs were higher for de novo patients. Average total annual pre-index costs were five- to ninefold higher for recurrent versus de novo patients <65. CONCLUSIONS: Cost differences by type of advanced cancer and by age suggest heterogeneous patterns of care that merit further investigation.


Assuntos
Neoplasias da Mama/terapia , Neoplasias Colorretais/terapia , Custos de Cuidados de Saúde/estatística & dados numéricos , Neoplasias Pulmonares/terapia , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Adulto , Fatores Etários , Idoso , Neoplasias da Mama/patologia , Neoplasias Colorretais/patologia , Bases de Dados Factuais , Feminino , Humanos , Neoplasias Pulmonares/patologia , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Estudos Retrospectivos , Estados Unidos
12.
J Natl Compr Canc Netw ; 16(4): 402-410, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29632060

RESUMO

Background: The high economic burden of cancer is projected to continue growing. Cost-of-care estimates are key inputs for comparative effectiveness and economic analyses that aim to inform policies associated with cancer care. Existing estimates are based largely on SEER-Medicare data in the elderly, leaving a knowledge gap regarding costs for patients aged <65 years. Methods: We estimated total and net medical care costs using data on individuals diagnosed with breast, colorectal, lung, or prostate cancer (n=45,522) and noncancer controls (n=314,887) enrolled in 1 of 4 participating health plans. Net costs were defined as the difference in mean total costs between patients with cancer and controls. The phase-of-care approach and Kaplan-Meier Sample Average method were used to estimate mean total and net 1- and 5-year costs (in 2015 US dollars) by cancer site, stage at diagnosis, and age group (<65 and ≥65 years). Results: Total and net costs were consistently highest for lung cancer and lowest for prostate cancer. Net costs were higher across all cancer sites for patients aged <65 years than those aged ≥65 years. Medical care costs for all cancers increased with advanced stage at diagnosis. Conclusions: This study improves understanding of medical care costs for the 4 most common invasive cancers in the United States. Higher costs among patients aged <65 years highlight limitations of relying on SEER-Medicare data alone to understand the national burden of cancer, whereas higher costs for patients with advanced-stage cancer underscore the importance of early detection to curtail high long-term costs. These cost estimates can be used in the development and evaluation of interventions and policies across the cancer care continuum.


Assuntos
Prestação Integrada de Cuidados de Saúde/economia , Custos de Cuidados de Saúde , Neoplasias/epidemiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Efeitos Psicossociais da Doença , Custos e Análise de Custo , Prestação Integrada de Cuidados de Saúde/métodos , Humanos , Medicare , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Neoplasias/diagnóstico , Neoplasias/terapia , Programa de SEER , Estados Unidos/epidemiologia
13.
Dig Dis Sci ; 63(1): 270, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29181742

RESUMO

The article Early Colorectal Cancer Detected by Machine Learning Model Using Gender, Age, and Complete Blood Count Data, written by Mark C. Hornbrook, Ran Goshen, Eran Choman, Maureen O'Keeffe-Rosetti, Yaron Kinar, Elizabeth G. Liles, and Kristal C. Rust, was originally published Online First without open access.

14.
Dig Dis Sci ; 62(10): 2719-2727, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28836087

RESUMO

BACKGROUND: Machine learning tools identify patients with blood counts indicating greater likelihood of colorectal cancer and warranting colonoscopy referral. AIMS: To validate a machine learning colorectal cancer detection model on a US community-based insured adult population. METHODS: Eligible colorectal cancer cases (439 females, 461 males) with complete blood counts before diagnosis were identified from Kaiser Permanente Northwest Region's Tumor Registry. Control patients (n = 9108) were randomly selected from KPNW's population who had no cancers, received at ≥1 blood count, had continuous enrollment from 180 days prior to the blood count through 24 months after the count, and were aged 40-89. For each control, one blood count was randomly selected as the pseudo-colorectal cancer diagnosis date for matching to cases, and assigned a "calendar year" based on the count date. For each calendar year, 18 controls were randomly selected to match the general enrollment's 10-year age groups and lengths of continuous enrollment. Prediction performance was evaluated by area under the curve, specificity, and odds ratios. RESULTS: Area under the receiver operating characteristics curve for detecting colorectal cancer was 0.80 ± 0.01. At 99% specificity, the odds ratio for association of a high-risk detection score with colorectal cancer was 34.7 (95% CI 28.9-40.4). The detection model had the highest accuracy in identifying right-sided colorectal cancers. CONCLUSIONS: ColonFlag® identifies individuals with tenfold higher risk of undiagnosed colorectal cancer at curable stages (0/I/II), flags colorectal tumors 180-360 days prior to usual clinical diagnosis, and is more accurate at identifying right-sided (compared to left-sided) colorectal cancers.


Assuntos
Contagem de Células Sanguíneas , Neoplasias Colorretais/diagnóstico , Mineração de Dados/métodos , Diagnóstico por Computador/métodos , Detecção Precoce de Câncer/métodos , Aprendizado de Máquina , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Área Sob a Curva , Colonoscopia , Neoplasias Colorretais/sangue , Neoplasias Colorretais/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Valor Preditivo dos Testes , Curva ROC , Encaminhamento e Consulta , Sistema de Registros , Reprodutibilidade dos Testes , Fatores de Risco , Fatores Sexuais
15.
J Oncol Pract ; 13(5): e441-e450, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28221895

RESUMO

PURPOSE: The overuse of imaging, particularly for staging of low-risk prostate cancer, is well documented and widespread. The existing literature, which focuses on the elderly in fee-for-service settings, points to financial incentives as a driver of overuse and may not identify factors relevant to policy solutions within integrated health care systems, where physicians are salaried. METHODS: Imaging rates were analyzed among men with incident prostate cancer diagnosed between 2004 and 2011 within the Colorado and Northwest regions of Kaiser Permanente. The sample was stratified according to indication for imaging, ie, high risk for whom imaging was necessary versus low risk for whom imaging was discouraged. Logistic regression was used to model the association between imaging receipt and clinical/demographic patient characteristics by risk strata. RESULTS: Of the men with low-risk prostate cancer, 35% received nonindicated imaging at diagnosis, whereas 42% of men with high-risk prostate cancer did not receive indicated imaging. Compared with men diagnosed in 2004, those diagnosed in subsequent years were less likely to receive imaging across both risk groups. Men with high-risk cancer diagnosed at ≥ 65 years of age and those with clinical stage ≥ T2 were more likely to receive indicated imaging. Men with comorbidities were more likely to receive imaging across both risk groups. Men with low-risk prostate cancer who had higher median household incomes were less likely to receive nonindicated imaging. CONCLUSION: Nonindicated imaging for diagnostic staging of patients with low-risk prostate cancer was common, but has decreased over the past decade. These findings suggest that factors other than financial incentives may be driving overuse of imaging.


Assuntos
Prestação Integrada de Cuidados de Saúde/organização & administração , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Diagnóstico por Imagem/estatística & dados numéricos , Prática Clínica Baseada em Evidências/estatística & dados numéricos , Neoplasias da Próstata/epidemiologia , Idoso , Colorado/epidemiologia , Prestação Integrada de Cuidados de Saúde/métodos , Prática Clínica Baseada em Evidências/métodos , Humanos , Modelos Logísticos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Estadiamento de Neoplasias , Razão de Chances , Oregon/epidemiologia , Vigilância da População , Neoplasias da Próstata/diagnóstico por imagem , Risco , Tomografia Computadorizada por Raios X
16.
Am J Cardiol ; 119(3): 410-415, 2017 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-27890243

RESUMO

High triglyceride (TG) levels among patients with type 2 diabetes mellitus (DM) are associated with higher medical costs. We analyzed the economic impact of TG-lowering therapies and whether the association between medical costs and therapy differed according to TG reduction. We conducted an observational cohort study of 184,932 patients with diabetes mellitus who had a TG measurement between January 2012 and June 2013 and a second TG measurement 3 to 15 months later. We identified 4 therapy groups (statin monotherapy, TG-specific monotherapy, statin/TG-specific combination therapy, or no therapy) and stratified those groups by percent change in TG (increased ≥5%, change of ≤4.9%, decreased 5% to 29%, decreased ≥30%). We compared change in medical costs between the year before and after therapy, adjusted for demographic and clinical characteristics. Of the 184,932 total patients, 143,549 (77.6%) received statin monotherapy, 900 (0.5%) received TG-specific monotherapy, 1,956 (1.1%) received statin and TG-specific combination therapy, and 38,527 (20.8%) received no prescription lipid agents. After covariate adjustment, statin/TG-specific agent recipients had a mean 1-year total cost reduction of $1,110. The greatest cost reduction was seen among statin/TG-specific combination therapy patients who reduced TG levels by ≥30% (-$2,859). Statin monotherapy patients who reduced TG by ≥30% also had a large reduction in adjusted costs (-$1,079). In conclusion, we found a substantial economic benefit to treating diabetic patients with statin/TG-specific combination lipid therapy compared with monotherapy of either type or no lipid pharmacotherapy. A TG reduction of ≥30% produced a particularly large reduction in 1-year medical costs.


Assuntos
Diabetes Mellitus Tipo 2/complicações , Custos de Cuidados de Saúde , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Hipercolesterolemia/tratamento farmacológico , Hipertrigliceridemia/tratamento farmacológico , Hipolipemiantes/uso terapêutico , Idoso , HDL-Colesterol/sangue , LDL-Colesterol/sangue , Estudos de Coortes , Análise Custo-Benefício , Diabetes Mellitus Tipo 2/economia , Quimioterapia Combinada , Ácidos Graxos Ômega-3/uso terapêutico , Feminino , Ácidos Fíbricos/uso terapêutico , Humanos , Hipercolesterolemia/complicações , Hipercolesterolemia/economia , Hipertrigliceridemia/complicações , Hipertrigliceridemia/economia , Masculino , Pessoa de Meia-Idade , Niacina/uso terapêutico , Estudos Retrospectivos , Triglicerídeos/sangue
17.
Med Care ; 54(11): 984-991, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27547943

RESUMO

BACKGROUND: Although past research demonstrated that Medicaid expansions were associated with increased emergency department (ED) and primary care (PC) utilization, little is known about how long this increased utilization persists or whether postcoverage utilization is affected by prior insurance status. OBJECTIVES: (1) To assess changes in ED, PC, mental and behavioral health care, and specialist care visit rates among individuals gaining Medicaid over 24 months postinsurance gain; and (2) to evaluate the association of previous insurance with utilization. METHODS: Using claims data, we conducted a retrospective cohort analysis of adults insured for 24 months following Oregon's 2008 Medicaid expansion. Utilization rates among 1124 new and 1587 returning enrollees were compared with those among 5126 enrollees with continuous Medicaid coverage (≥1 y preexpansion). Visit rates were adjusted for propensity score classes and geographic region. RESULTS: PC visit rates in both newly and returning insured individuals significantly exceeded those in the continuously insured in months 4 through 12, but were not significantly elevated in the second year. In contrast, ED utilization rates were significantly higher in returning insured compared with newly or continuously insured individuals and remained elevated over time. New visits to PC and specialist care were higher among those who gained Medicaid compared with the continuously insured throughout the study period. CONCLUSIONS: Predicting the effect of insurance expansion on health care utilization should account for the prior coverage history of new enrollees. In addition, utilization of outpatient services changes with time after insurance, so expansion evaluations should allow for rate stabilization.


Assuntos
Assistência à Saúde/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Adolescente , Adulto , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Seguro Saúde/estatística & dados numéricos , Masculino , Serviços de Saúde Mental/estatística & dados numéricos , Pessoa de Meia-Idade , Oregon , Patient Protection and Affordable Care Act , Atenção Primária à Saúde/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos , Adulto Jovem
18.
Diabetes Care ; 39(11): 1981-1986, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27561921

RESUMO

OBJECTIVE: Weight loss is recommended for overweight patients with diabetes but avoidance of weight gain may be a more realistic goal. We calculated the 4-year economic impact of maintaining body weight versus gaining weight. RESEARCH DESIGN AND METHODS: Among 8,154 patients with type 2 diabetes, we calculated weight change as the difference between the first body weight measure in 2010 and the last measure in 2013 and calculated mean glycated hemoglobin (A1C) from all measurements from 2010 to 2013. We created four analysis groups: weight change <5% and A1C <7%; weight gain ≥5% and A1C <7%; weight change <5% and A1C ≥7%; and weight gain ≥5% and A1C ≥7%. We compared change in medical costs between 2010 and 2013, adjusted for demographic and clinical characteristics. RESULTS: Patients who maintained weight within 5% of baseline experienced a reduction in costs of about $400 regardless of A1C. In contrast, patients who gained ≥5% of baseline weight and had mean A1C ≥7% had an increase in costs of $1,473 (P < 0.001). Those who gained >5% of their baseline weight with mean A1C <7% had a modest increase in costs ($387, NS). CONCLUSIONS: Patients who gained at least 5% of their baseline body weight and did not maintain A1C <7% over 4 years experienced a 14% increase in medical costs, whereas those who maintained good glycemic control had a mean cost increase of 3.3%. However, patients who maintained weight within 5% of baseline had costs that were ∼5% lower than baseline. Avoidance of weight gain may reduce costs in the long-term.


Assuntos
Manutenção do Peso Corporal , Diabetes Mellitus Tipo 2/economia , Diabetes Mellitus Tipo 2/terapia , Custos de Cuidados de Saúde , Ganho de Peso , Adulto , Idoso , Custos e Análise de Custo , Feminino , Hemoglobina A Glicada/metabolismo , Humanos , Masculino , Pessoa de Meia-Idade , Tamanho da Amostra , Perda de Peso
19.
Value Health ; 19(2): 176-84, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27021751

RESUMO

OBJECTIVE: Preplanned economic analysis of a pragmatic trial using electronic-medical-record-linked interactive voice recognition (IVR) reminders for enhancing adherence to cardiovascular medications (i.e., statins, angiotensin-converting enzyme inhibitors [ACEIs], and angiotensin receptor blockers [ARBs]). METHODS: Three groups, usual care (UC), IVR, and IVR plus educational materials (IVR+), with 21,752 suboptimally adherent patients underwent follow-up for 9.6 months on average. Costs to implement and deliver the intervention (from a payer perspective) were tracked during the trial. Medical care costs and outcomes were ascertained using electronic medical records. RESULTS: Per-patient intervention costs ranged from $9 to $17 for IVR and from $36 to $47 for IVR+. For ACEI/ARB, the incremental cost-effectiveness ratio for each percent adherence increase was about 3 times higher with IVR+ than with IVR ($6 and $16 for IVR and IVR+, respectively). For statins, the incremental cost-effectiveness ratio for each percent adherence increase was about 7 times higher with IVR+ than with IVR ($6 and $43 for IVR and IVR+, respectively). Considering potential cost offsets from reduced cardiovascular events, the probability of breakeven was the highest for UC, but the IVR-based interventions had a higher probability of breakeven for subgroups with a baseline low-density lipoprotein (LDL) level of more than 100 mg/dl and those with two or more calls. CONCLUSIONS: We found that the use of an automated voice messaging system to promote adherence to ACEIs/ARBs and statins may be cost-effective, depending on a decision maker's willingness to pay for unit increase in adherence. When considering changes in LDL level and downstream medical care offsets, UC is the optimal strategy for the general population. However, IVR-based interventions may be the optimal choice for those with elevated LDL values at baseline.


Assuntos
Fármacos Cardiovasculares/economia , Fármacos Cardiovasculares/uso terapêutico , Doenças Cardiovasculares/tratamento farmacológico , Doenças Cardiovasculares/economia , Custos de Medicamentos , Adesão à Medicação , Educação de Pacientes como Assunto/economia , Sistemas de Alerta/economia , Idoso , Bloqueadores do Receptor Tipo 1 de Angiotensina II/economia , Bloqueadores do Receptor Tipo 1 de Angiotensina II/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/economia , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Biomarcadores/sangue , Fármacos Cardiovasculares/efeitos adversos , Doenças Cardiovasculares/sangue , Doenças Cardiovasculares/diagnóstico , Análise Custo-Benefício , Registros Eletrônicos de Saúde/economia , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Recursos em Saúde/economia , Recursos em Saúde/estatística & dados numéricos , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Lipoproteínas LDL/sangue , Masculino , Registro Médico Coordenado , Pessoa de Meia-Idade , Modelos Econômicos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
20.
J Cancer Surviv ; 9(2): 201-7, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25252623

RESUMO

PURPOSE: We compare breast and colorectal cancer survivors' annual receipt of preventive care and office visits to that of age- and gender-matched cancer-free controls. METHODS: Automated data, including tumor registries, were used to identify insured individuals aged 50+ at the time of breast or colorectal cancer diagnosis between 2000 and 2008 as well as cancer-free controls receiving care from four integrated delivery systems. Those with metastatic or un-staged disease, or a prior cancer diagnosis were excluded. Annual visits to primary care, oncology, and surgery as well as receipt of mammography, colorectal cancer, Papanicolaou, bone densitometry, and cholesterol screening were observed for 5 years. We used generalized estimating equations that accounted for repeated observations over time per person to test annual service use differences by cancer survivor/cancer-free control status and whether survivor/cancer-free status associations were moderated by patient age <65 years and calendar year of diagnosis. RESULTS: A total of 3743 breast and 1530 colorectal cancer survivors were identified, representing 12,923 and 5103 patient-years of follow-up, respectively. Compared to cancer-free controls, breast and colorectal cancer survivors were equally or more likely to use all types of office visits and to receive cancer screenings and bone densitometry testing. Both breast and colorectal cancer survivors were less likely than cancer-free controls to receive cholesterol testing, regardless of age, year of diagnosis, or use of primary care. IMPLICATIONS FOR CANCER SURVIVORS: Programs targeting cancer survivors may benefit from addressing a broad range of primary preventive care needs, including recommended cardiovascular disease screening.


Assuntos
Neoplasias da Mama/mortalidade , Neoplasias Colorretais/mortalidade , Visita a Consultório Médico/estatística & dados numéricos , Prevenção Secundária , Sobreviventes , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/reabilitação , Estudos de Casos e Controles , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/reabilitação , Detecção Precoce de Câncer/estatística & dados numéricos , Feminino , Humanos , Masculino , Mamografia , Pessoa de Meia-Idade , Atenção Primária à Saúde/estatística & dados numéricos , Programa de SEER , Fatores Sexuais
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA