National Health Expenditure Projections, 2017–26: Despite Uncertainty, Fundamentals Primarily Drive Spending Growth

Dermatology medications with the highest cost burden on Medicare Part D: Potential implications of the Inflation Reduction Act

Signed into law in August 2022, the Inflation Reduction Act includes provisions requiring the federal government to negotiate prices for medications covered under Medicare Part D. Initial negotiations will target drugs with the highest total spending and price increases relative to inflation. In this study, we identify dermatology prescriptions with the highest cost burden on Medicare Part D and analyze recent trends in total spending and unit costs.

Effects of participation in an eight-week, online video body-weight resistance training on cognitive function and physical fitness in older adults: A randomized control trial

The purpose of this study was to investigate the effects of an eight-week online video bodyweight resistance training on cognitive function and physical fitness in older adults. A total of 30 older adults was randomly assigned into either an exercise group or a control group. The exercise group participated in the exercise and the control group was required to maintain daily living. Mini mental status examination (MMSE) and senior fit-ness tests (SFT) were measured pre- and post-eight weeks of intervention. Participating in the exercise experienced increases in cognitive functions of attention (p < 0.05) and calculation (p < 0.05), recall (p < 0.05), and repetition (p < 0.05) from the MMSE. Also, older adults in the exercise group demonstrated improved two-minute walk (p < 0.05), chair sit tests (p < 0.05), and results of the SFT. The online video resistance training may help to increase cognitive function and fitness in older adults.

Disparities in Successful Discharge to the Community Following Use of Medicare Home Health by Level of Neighborhood Socioeconomic Disadvantage

Considering the importance of social and structural support and resources in recovering health, where people reside could lead to differences in health outcome in Medicare home health care. We used the 2019 Outcome and Assessment Information Set and Area Deprivation Index to examine the association between neighborhood context and successful discharge to community among older Medicare home health care users. Based on the multivariable logistic regression (OR: 0.84; 95% CI, 0.83-0.85) and conditional logistic regression models stratified by home health agency (OR: 0.95; 95% CI, 0.94-0.95), patients living in the most disadvantaged neighborhoods were less likely to experience successful discharge to community than others. Furthermore, the predicted probability of successful discharge to community decreased as the percentage of patients from the most disadvantaged neighborhoods within a home health agency increased. Policymakers should consider using area-level interventions and supports to reduce disparities in Medicare home health care.

Comparative cost-effectiveness of neoadjuvant chemotherapy regimens for muscle-invasive bladder cancer: Results according to VESPER data

BACKGROUND

The VESPER trial demonstrated improved progression-free (PFS) and (preliminarily) overall survival (OS) with six cycles of neoadjuvant dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin (ddMVACx6) versus four cycles of gemcitabine and cisplatin (GCx4) before radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC), but with increased toxicity. This study compares the cost-effectiveness of these regimens.

METHODS

A cost-effectiveness analysis of neoadjuvant ddMVACx6 and GCx4 was performed using a decision-analytic Markov model with 5-year, 10-year, and lifetime horizons. Probabilities were derived from reported VESPER data. Utility values were obtained from the literature. Primary outcomes were effectiveness measured in quality-adjusted life years (QALY) and incremental cost-effectiveness ratio (ICER) with a willingness to pay threshold of $100,000 per QALY. One-way and probabilistic sensitivity analyses were performed to evaluate the robustness of the model.

RESULTS

At 5 years, ddMVACx6 improved QALYs by 0.30 at an additional cost of $16,100, rendering it cost-effective relative to GCx4 (ICER: $53,284/QALY). Additionally, probabilistic sensitivity analysis found ddMVACx6 to be cost-effective in 79% and 81% of microsimulations at10-year and lifetime horizons, respectively. One-way sensitivity analysis demonstrated a minimum difference in 5-year progression of 0.9% and progression mortality of 0.7% between ddMVACx6 and GCx4 was necessary for ddMVACx6 to remain cost-effective.

CONCLUSIONS

Neoadjuvant ddMVACx6 was more cost-effective than GCx4 for MIBC. These data, together with the improved PFS and (albeit preliminary) OS noted in VESPER, support use of this regimen in appropriate candidates for neoadjuvant chemotherapy before RC.

LAY SUMMARY

We performed a benefit-to-cost analysis using evidence from a randomized controlled trial that compared two different chemotherapy treatments before bladder removal for bladder cancer that had invaded into the bladder muscle. Despite being more expensive and having a greater likelihood of toxicity, six cycles of dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin was more cost-effective (or had higher value) than four cycles of gemcitabine and cisplatin.

The Projection of Iran's Healthcare Expenditures By 2030: Evidence of a Time-Series Analysis

BACKGROUND

The projection of levels and composition of financial resources for the healthcare expenditure (HCE) and relevant trends can provide a basis for future health financing reforms. This study aimed to project Iran's HCEs by the sources of funds until 2030.

METHODS

The structural macro-econometric modeling in the EViews 9 software was employed to simulate and project Iran's HCE by the sources of funds (government health expenditure [GHCE], social security organization health expenditure [SOHCE], out-of-pocket [OOP] payments, and prepaid private health expenditure [PPHCE]). The behavioral equations were estimated by autoregressive distributed lag (ARDL) approach.

RESULTS

If there is a 5%-increase in Iran's oil revenues, the mean growth rate of gross domestic product (GDP) is about 2% until 2030. By this scenario, the total HCE (THCE), GHCE, SOHCE, OOP, and PPHCE increases about 30.5%, 25.9%, 34.4%, 31.2%, and 33.9%, respectively. Therefore, the THCE as a percentage of the GDP will increase from 9.6% in 2016 to 10.7% in 2030. It is predicted that Iran's THCE will cover 22.2%, 23.3%, 40%, and 14.5% by the government, social security organization (SSO), households OOP, and other private sources, respectively, in 2030.

CONCLUSION

Until 2030, Iran's health expenditures will grow faster than the GDP, government revenues, and non-health spending. Despite the increase in GHCE and total government expenditure, the share of the GHCE from THCE has a decreasing trend. OOP payments remain among the major sources of financing for Iran's HCE.

Contemporary national trends and disparities for head CT use in emergency department settings: Insights from National Hospital Ambulatory Medical Care Survey (NHAMCS) 2007-2017

BACKGROUND

The exponential growth in CT utilization in emergency department (ED) until 2008 raised concerns regarding cost and radiation exposure. Head CT was one of the commonest studies. This led to mitigating efforts such as appropriate use guidelines, policy and payment reforms. The impact of these efforts is not fully understood. In addition, disparities in outcomes of acute conditions presenting to the ED is well known however recent trends in imaging utilization patterns and disparities are not well understood. In this study, we describe nationwide trends and disparities associated with head CT in ED settings between 2007 and 2014.

METHODS

We analyzed 2007-2017 National Hospital Ambulatory Medical Care Survey (NHAMCS) with the primary goal to assess the rate and patterns of head CT imaging in ED.

RESULTS

There were an estimated 117 million in 2007 and 139 million ED visits in 2017. There was a 4% increase in the any CT use in 2017 compared to 2007. No significant change in head CT utilization rate was seen. The 2007 head CT rate was 6.7% (95% CI: 6.1-7.3) compared to 7.7% (95% CI: 6.8-8.6) in 2017. Trauma, Headache and Dizziness are the top three indications for head CT use in the ED respectively. On adjusted analyses, significantly higher head CT utilization was seen in elderly, (age>65 yrs) and significantly lower utilization rate was seen in Non-Hispanic Black and Medicaid patients, and patients in rural locations.

CONCLUSIONS

Previously reported exponential growth of CT use in ED is no longer seen. In particular, there was no significant change in ED head CT use between 2007 and 2017. Headache and Dizziness remain commonly used indications despite limited utility in most clinical scenarios, indicating continued need for appropriate use of imaging. There is significantly lower CT utilization in Non-Hispanic Black, Medicaid patients and those in rural locations, suggesting disparities in diagnostic work-up in marginalized and rural populations. This underscores the need for standardizing care regardless of race, insurance status and location.

Voluntary Separations and Workforce Planning: How Intent to Leave Public Health Agencies Manifests in Actual Departure in the United States

OBJECTIVES

To ascertain levels of turnover in public health staff between 2014 and 2017 due to retirement or quitting and to project levels of turnover for the whole of the state and local governmental public health in the United States nationally.

DESIGN

Turnover outcomes were analyzed for 15 128 staff from public health agencies between 2014 and 2017. Determinants of turnover were assessed using a logit model, associated with actually leaving one's organization. A microsimulation model was used to project expected turnover onto the broader workforce.

RESULTS

Between 2014 and 2017, 33% of staff left their agency. Half of the staff who indicated they were considering leaving in 2014 had done so by 2017, as did a quarter of the staff who had said they were not considering leaving. Staff younger than 30 years constituted 6% of the workforce but 13% of those who left (P < .001).

CONCLUSIONS

Public health agencies are expected to experience turnover in 60 000 of 200 000 staff positions between 2017 and 2020.

IMPLICATIONS

As much as one-third of the US public health workforce is expected to leave in the coming years. Retention efforts, especially around younger staff, must be a priority. Succession planning for those retiring is also a significant concern.

The Cost of Providing the Foundational Public Health Services in Ohio

OBJECTIVES

To examine levels of expenditure and needed investment in public health at the local level in the state of Ohio pre-COVID-19.

DESIGN

Using detailed financial reporting from fiscal year (FY) 2018 from Ohio's local health departments (LHDs), we characterize spending by Foundational Public Health Services (FPHS). We also constructed estimates of the gap in public health spending in the state using self-reported gaps in service provision and a microsimulation approach. Data were collected between January and June 2019 and analyzed between June and September 2019.

PARTICIPANTS

Eighty-four of the 113 LHDs in the state of Ohio covering a population of almost 9 million Ohioans.

RESULTS

In FY2018, Ohio LHDs spent an average of $37 per capita on protecting and promoting the public's health. Approximately one-third of this investment supported the Foundational Areas (communicable disease control; chronic disease and injury prevention; environmental public health; maternal, child, and family health; and access to and linkages with health care). Another third supported the Foundational Capabilities, that is, the crosscutting skills and capacities needed to support all LHD activities. The remaining third supported programs and activities that are responsive to local needs and vary from community to community. To fully meet identified LHD needs in the state pre-COVID-19, Ohio would require an additional annual investment of $20 per capita on top of the current $37 spent per capita, or approximately $240 million for the state.

CONCLUSIONS

A better understanding of the cost and value of public health services can educate policy makers so that they can make informed trade-offs when balancing health care, public health, and social services investments. The current environment of COVID-19 may dramatically increase need, making understanding and growing public health investment critical.

Understanding value and patient complexity among common inpatient vascular surgery procedures

OBJECTIVE

Vascular surgery patients are highly complex, second only to patients undergoing cardiac procedures. However, unlike cardiac surgery, work relative value units (wRVU) for vascular surgery were undervalued based on an overall patient complexity score. This study assesses the correlation of patient complexity with wRVUs for the most commonly performed inpatient vascular surgery procedures.

METHODS

The 2014 to 2017 National Surgical Quality Improvement Program Participant Use Data Files were queried for inpatient cases performed by vascular surgeons. A previously developed patient complexity score using perioperative domains was calculated based on patient age, American Society of Anesthesiologists class of ≥4, major comorbidities, emergent status, concurrent procedures, additional procedures, hospital length of stay, nonhome discharge, and 30-day major complications, readmissions, and mortality. Procedures were assigned points based on their relative rank and then an overall score was created by summing the total points. An observed to expected ratio (O/E) was calculated using open ruptured abdominal aortic aneurysm repair (rOAAA) as the referent and then applied to an adjusted median wRVU per operative minute.

RESULTS

Among 164,370 cases, patient complexity was greatest for rOAAA (complexity score = 128) and the least for carotid endarterectomy (CEA) (complexity score = 29). Patients undergoing rOAAA repair had the greatest proportion of American Society of Anesthesiologists class of ≥IV (84.8%; 95% confidence interval [CI], 82.6%-86.8%), highest mortality (35.5%; 95% CI, 32.8%-38.3%), and major complication rate (87.1%; 95% CI, 85.1%-89.0%). Patients undergoing CEA had the lowest mortality (0.7%; 95% CI, 0.7%-0.8%), major complication rate (8.2%; 95% 95% CI, 8.0%-8.5%), and shortest length of stay (2.7 days; 95% CI, 2.7-2.7). The median wRVU ranged from 10.0 to 42.1 and only weakly correlated with overall complexity (Spearman's ρ = 0.11; P < .01). The median wRVU per operative minute was greatest for thoracic endovascular aortic repair (0.25) and lowest for both axillary-femoral artery bypass (0.12) and open femoral endarterectomy, thromboembolectomy, or reconstruction (0.12). After adjusting for patient complexity, CEA (O/E = 3.8) and transcarotid artery revascularization (O/E = 2.8) had greater than expected O/E. In contrast, lower extremity bypass (O/E = 0.77), lower extremity embolectomy (O/E = 0.79), and open abdominal aortic repair (O/E = 0.80) had a lower than expected O/E.

CONCLUSIONS

Patient complexity varies substantially across vascular procedures and is not captured effectively by wRVUs. Increased operative time for open procedures is not adequately accounted for by wRVUs, which may unfairly penalize surgeons who perform complex open operations.

Price Transparency in Radiology-A Model for the Future

Medicine is the only business transaction in which consumers make important purchase decisions without knowing how much they have to pay. Lack of price transparency in health care imposes financial burden and anxiety among patients as the cost of health care has been shifting from employers to patients through high-deductible health plans (HDHPs). Health economists and policymakers anticipated that HDHPs with price transparency would be a catalyst for patients to "shop" for low-price providers, thus reducing overall health care spending. For patients to shop health care services, price transparency is a requisite. The Department of Health and Human Services mandate of publicly disclosing the hospital chargemaster and state legislatures demanding greater health care price transparency are just two examples of external forces challenging the long history of price opacity in health care. Imaging, pharmacy, laboratory tests, and ambulatory surgeries are considered potentially shoppable health care services. This article examines the intended motivation of price transparency, the limitations of current price transparency tools, and what impact price transparency may have on radiology. We share our experience in developing and implementing University of Utah's online interactive price transparency tool to estimate patients' out-of-pocket expenses.

An assessment of prevalence and expenditure associated with discharge brain MRI in preterm infants

To assess national expenditure associated with preterm-infant brain MRI and potential impact of reduction per Choosing Wisely campaign 2015 recommendation to “avoid routine screening term-equivalent or discharge brain MRIs in preterm-infants”. Cross-sectional U.S. trend data from the Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP) Kids’ Inpatient Database (KID) database (2006, 2009, 2012, 2016) was used to estimate overall national expenditure associated with brain MRI among infants with gestational age (GA) ≤36 weeks, and also when classified as ‘not indicated’ (NI-MRI) i.e., equivalent to routine use without clinical indications and regarded as low-value service (LVS). Associated cost was determined by querying CMS-database for physician-fee-schedules to find the highest global procedure-cost per cycle, then adjusting for inflation. Sensitivity-analyses were conducted to account for additional clinical charges associated with NI-MRI. 3,768 (0.26%) of 1,472,236 preterm-infants had brain MRI across all cycles (inflation-adjusted total $3,690,088). Overall proportion of brain MRIs increased across 2006–2012 from 0.25%-0.33% but decreased in 2016 to 0.16% (P<0.001). Inflation-adjusted overall expenditure by cycle was: 2006, $1,299,130 (95% CI: $987,505, $1,610,755); 2009, $1,194,208 (95% CI: $873,487, $1,516,154); 2012, $931,836 (95% CI: $666,114, $1,197,156); and 2016, $264,648 (95% CI: $172,061, $357,280). Prevalence for NI-MRI in 2006, 2009, 2012 and 2016 was 86% (n = 809), 88% (n = 940), 89% (n = 1028) and 50% (n = 299), respectively; and 70% were in infants 35–36 weeks GA. NI-MRI prevalence was not different over time by payer-type (Medicaid, private), sex or race/ethnicity (white, black, Hispanic); larger hospital size was significantly associated across 2006–2012 but this declined for all sizes in 2016, with most decline in larger hospitals (P for interaction <0.05). NI-MRI expenditure sensitivity-analysis with addition of cycle median total-admission-charge to inflation-adjusted CMS-fee was $1,190,919/$518,343, for 2012/2016 cycles respectively. National MRI prevalence in preterm infants (both overall and LVS) and associated expenditure decreased substantially post recommendation; however, annual savings are modest and unlikely to be >$1.2 million.

The Potential Role of Creatine in Vascular Health

Creatine is an organic compound, consumed exogenously in the diet and synthesized endogenously via an intricate inter-organ process. Functioning in conjunction with creatine kinase, creatine has long been known for its pivotal role in cellular energy provision and energy shuttling. In addition to the abundance of evidence supporting the ergogenic benefits of creatine supplementation, recent evidence suggests a far broader application for creatine within various myopathies, neurodegenerative diseases, and other pathologies. Furthermore, creatine has been found to exhibit non-energy related properties, contributing as a possible direct and in-direct antioxidant and eliciting anti-inflammatory effects. In spite of the new clinical success of supplemental creatine, there is little scientific insight into the potential effects of creatine on cardiovascular disease (CVD), the leading cause of mortality. Taking into consideration the non-energy related actions of creatine, highlighted in this review, it can be speculated that creatine supplementation may serve as an adjuvant therapy for the management of vascular health in at-risk populations. This review, therefore, not only aims to summarize the current literature surrounding creatine and vascular health, but to also shed light onto the potential mechanisms in which creatine may be able to serve as a beneficial supplement capable of imparting vascular-protective properties and promoting vascular health.

Exploring the relation between modelled and perceived workload of nurses and related job demands, job resources and personal resources; a longitudinal study

Aim

Calculating a modelled workload based on objective measures. Exploring the relation between this modelled workload and workload as perceived by nurses, including the effects of specific job demands, job resources and personal resources on the relation.

Design

Academic hospital in the Netherlands. Six surgical wards, capacity 15–30 beds. Data collected over 15 consecutive day shifts.

Methods

Modelled workload is calculated as a ratio of required care time, based on patient characteristics, baseline care time and time for non-patient related activities, and allocated care time, based on the amount of available nurses. Both required and allocated care time are corrected for nurse proficiency. Five dimensions of perceived workload were determined by questionnaires. Both the modelled and the perceived workloads were measured on a daily basis. Linear mixed effects models study the longitudinal relation between this modelled and workload as perceived by nurses and the effects of personal resources, job resources and job demands. ANOVA and post-hoc tests were used to identify differences in modelled workload between wards.

Results

Modelled workload varies roughly between 70 and 170%. Significant differences in modelled workload between wards were found but confidence intervals were wide. Modelled workload is positively associated with all five perceived workload measures (work pace, amount of work, mental load, emotional load, physical load). In addition to modelled workload, the job resource support of colleagues and job demands time spent on direct patient care and time spent on registration had the biggest significant effects on perceived workload.

Conclusions

The modelled workload does not exactly predict perceived workload, however there is a correlation between the two. The modelled workload can be used to detect differences in workload between wards, which may be useful in distributing workload more evenly in order prevent issues of over- and understaffing and organizational justice. Extra effort to promote team work is likely to have a positive effect on perceived workload. Nurse management can stimulate team cohesion, especially when workload is high. Registered nurses perceive a higher workload than other nurses. When the proportion of direct patient care in a workday is higher, the perceived workload is also higher. Further research is recommended. The findings of this research can help nursing management in allocating resources and directing their attention to the most relevant factors for balancing workload.

Medicaid and Medicare Part B spending on immunomodulators and biosimilars

INTRODUCTION

Prices for immunomodulators used in dermatological conditions are rising in the United States. While Medicare Part-D solely covers medication costs, Medicare Part-B covers outpatient infusion and injection costs given by medical professionals. We aim to analyze recent trends in Medicare Part-B spending on immunomodulators and their biosimilars used in the treatment of common chronic inflammatory dermatoses.

METHODS

The 2012-2018 Medicare Part-B spending data on immunomodulators commonly used for dermatologic conditions were extracted from the Centers for Medicare and Medicaid Services database. Inflation was adjusted to reflect 2012-dollar amounts using the Consumer Price Index.

RESULTS

Medicare Part-B spending has increased by 27.5% from 2012 to 2018 ($2.5B, $3.2B). Average annual total spending (AATS) is greatest for rituximab ($1,522,757,520), and average annual spending per maintenance dose (AASPMD) is greatest for ustekinumab-90 mg ($12,976). The percent change in AASPMD increased for all immunomodulators with Etanercept-50 mg having the greatest percent change (+64.6%, +$285.70). Infliximab had a greater AATS and AASPMD than its biosimilars.

DISCUSSION

Medicare Part-B spending is often overlooked but plays a big role in federal healthcare spending. Exploring the strategic use of less expensive biosimilars could help mitigate spending.

Laparoscopic partial hepatectomy is cost-effective when performed in high volume centers: A five state analysis

BACKGROUND

Prior studies comparing the efficacy of laparoscopic (LHR) and open hepatic resection (OHR) have not evaluated inpatient costs.

METHODS

We conducted a retrospective cohort study using the Healthcare Cost and Utilization Project State Inpatient Databases to identify patients undergoing hepatic resection between 2010 and 2014.

RESULTS

10,239 patients underwent hepatic resection. 865 (8%) underwent LHR and 9374 (92%) underwent OHR. On adjusting for hospital volume, patients undergoing LHR had a lower risk of respiratory (OR 0.64, 95% CI [0.52, 0.78]), wound (OR 0.48; 95% CI [0.29, 0.79]) and hematologic (OR 0.57; 95% CI [0.44, 0.73]) complication as well as a lower risk of being in the highest quartile of cost (0.58; 95% CI [0.43, 0.77]) than those undergoing OHR. Patients undergoing LHR in very high volume (>314 hepatectomies/year) centers had lower risk-adjusted 90-day aggregate costs of care than those undergoing OHR (-$8022; 95% CI [-$11,732, -$4311).

DISCUSSION

Laparoscopic partial hepatectomy is associated with lower risk of postoperative complication than OHR. This translates to lower aggregate costs in very high-volume centers.

Utilization fraction of rhinoplasty instrument sets: Model for efficient use of surgical instruments

OBJECTIVES

Recognize the avoidable costs incurred due to overpacking of rhinoplasty instrument trays. Reduce rhinoplasty instrument trays by including only instruments used frequently. Establish methods to reduce trays prepared for other otolaryngologic procedures.

METHODS

This is a prospective study. The study evaluates the specific use of instruments opened for rhinoplasty procedures at the New York Eye & Ear Infirmary of Mount Sinai. Instruments were counted in 10 rhinoplasty cases. Usage rate was calculated for each instrument. Additionally, all instruments used in at least 20% of cases were noted. This "20%" threshold was used to create new rhinoplasty tray inventories more reflective of actual instrument usage. Some instruments above the 20% threshold were included in multiples (i.e. two Adson Brown forceps vs. one curved iris scissor).

RESULTS

189 instruments were opened, and 32 instruments were used on average in each rhinoplasty. 55 instruments were used in at least 20% of cases. The 55 "high usage" instruments were used to create new, reduced rhinoplasty tray inventory lists. Based on our analysis, a new rhinoplasty tray inventory was created comprised of 68 instruments, a 64% reduction from 189.

CONCLUSION

Instruments are sterilized and packed in gross excess for rhinoplasty procedures. Previously published figures estimate re-sterilization costs of $0.51 to $0.77 per instrument. Reduction in instruments opened from 189 to 68 is expected to lead to cost savings ranging from $62 to $93 per case, yielding a savings between $6200 and $9300 per 100 cases performed.

LEVEL OF EVIDENCE

II-3.

Association of for-profit hospital ownership status with intracranial hemorrhage outcomes and cost of care

OBJECTIVE

Much of the current discourse surrounding healthcare reform in the United States revolves around the role of the profit motive in medical care. However, there currently exists a paucity of literature evaluating the effect of for-profit hospital ownership status on neurological and neurosurgical care. The purpose of this study was to compare inpatient mortality, operation rates, length of stay, and hospital charges between private nonprofit and for-profit hospitals in the treatment of intracranial hemorrhage.

METHODS

This retrospective cohort study utilized data from the National Inpatient Sample (NIS) database. Primary outcomes, including all-cause inpatient mortality, operative status, patient disposition, hospital length of stay, total hospital charges, and per-day hospital charges, were assessed for patients discharged with a primary diagnosis of intracranial (epidural, subdural, subarachnoid, or intraparenchymal) hemorrhage, while controlling for baseline demographics, comorbidities, and interhospital differences via propensity score matching. Subgroup analyses by hemorrhage type were then performed, using the same methodology.

RESULTS

Of 155,977 unique hospital discharges included in this study, 133,518 originated from private nonprofit hospitals while the remaining 22,459 were from for-profit hospitals. After propensity score matching, mortality rates were higher in for-profit centers, at 14.50%, compared with 13.31% at nonprofit hospitals (RR 1.09, 95% CI 1.00-1.18; p = 0.040). Surgical operation rates were also similar (25.38% vs 24.42%; RR 0.96, 95% CI 0.91-1.02; p = 0.181). Of note, nonprofit hospitals appeared to be more intensive, with intracranial pressure monitor placement occurring in 2.13% of patients compared with 1.47% in for-profit centers (RR 0.69, 95% CI 0.54-0.88; p < 0.001). Discharge disposition was also similar, except for higher rates of absconding at for-profit hospitals (RR 1.59, 95% CI 1.12-2.27; p = 0.018). Length of stay was greater among for-profit hospitals (mean ± SD: 7.46 ± 11.91 vs 6.50 ± 8.74 days, p < 0.001), as were total hospital charges ($141,141.40 ± $218,364.40 vs $84,863.54 ± $136,874.71 [USD], p < 0.001). These findings remained similar even after segregating patients by subgroup analysis by hemorrhage type.

CONCLUSIONS

For-profit hospitals are associated with higher inpatient mortality, lengths of stay, and hospital charges compared with their nonprofit counterparts.

Changes in Drug List Prices and Amounts Paid by Patients and Insurers

IMPORTANCE

High out-of-pocket drug costs can cause patients to skip treatment and worsen outcomes, and high insurer drug payments could increase premiums. Drug wholesale list prices have doubled in recent years. However, because of manufacturer discounts and rebates, the extent to which increases in wholesale list prices are associated with amounts paid by patients and insurers is poorly characterized.

OBJECTIVE

To determine whether increases in wholesale list prices are associated with increases in amounts paid by patients and insurers for branded medications.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional retrospective study analyzing pharmacy claims for patients younger than 65 years in the IBM MarketScan Commercial Database and pricing data from SSR Health, LLC, between January 1, 2010, and December 31, 2016. Pharmacy claims analyzed represent claims of employees and dependents participating in employer health benefit programs belonging to large employers. Rebate data were estimated from sales data from publicly traded companies. Analysis focused on the top 5 patent-protected specialty and 9 traditional brand-name medications with the highest total drug expenditures by commercial insurers nationwide in 2014. Data were analyzed from July 2017 to July 2020.

EXPOSURES

Calendar year.

MAIN OUTCOMES AND MEASURES

Changes in inflation-adjusted amounts paid by patients and insurers for branded medications.

RESULTS

In this analysis of 14.4 million pharmacy claims made by 1.8 million patients from 2010-2016, median drug wholesale list price increased by 129% (interquartile range [IQR], 78%-133%), while median insurance payments increased by 64% (IQR, 28%-120%) and out-of-pocket costs increased by 53% (IQR, 42%-82%). The mean percentage of wholesale list price accounted for by discounts increased from 17% in 2010 to 21% in 2016, and the mean percentage of wholesale list price accounted for by rebates increased from 22% in 2010 to 24% in 2016. For specialty medications, median patient out-of-pocket costs increased by 85% (IQR, 73%-88%) from 2010 to 2016 after adjustment for inflation and 42% (IQR, 25%-53%) for nonspecialty medications. During that same period, insurer payments increased by 116% for specialty medications (IQR, 100%-127%) and 28% for nonspecialty medications (IQR, 5%-34%).

CONCLUSIONS AND RELEVANCE

This study's findings suggest that drug list prices more than doubled over a 7-year study period. Despite rising manufacturer discounts and rebates, these price increases were associated with large increases in patient out-of-pocket costs and insurer payments.

Quality of Life and Value Assessment in Health Care

Proposals for health care cost containment emphasize high-value care as a way to control spending without compromising quality. When used in this context, 'value' refers to outcomes in relation to cost. To determine where health spending yields the most value, it is necessary to compare the benefits provided by different treatments. While many studies focus narrowly on health gains in assessing value, the notion of benefit is sometimes broadened to include overall quality of life. This paper explores the implications of using subjective quality of life measures for value assessment. This approach is claimed to be more respectful of patients and better capture the perspectival nature of quality of life. Even if this is correct, though, subjective measurement also raises challenging issues of interpersonal comparability when used to study health outcomes. Because such measures do not readily distinguish benefits due to medical interventions from benefits due to personal or other factors, they are not easily applied to the assessment of treatment value. I argue that when the outcome of interest in value assessment is broadened to include quality of life, the cost side of these measures should also be broadened. I show how one philosophical theory of well-being, Jason Raibley's "agential flourishing" theory, can be adapted for use in quality of life research to better fit the needs and aims of value assessment in health care. Finally, I briefly note some implications of this argument for debates about fairness in health care allocations.

Embedding the Pillars of Quality in Health Information Technology Solutions Using "Integrated Patient Journey Mapping" (IPJM): Case Study

BACKGROUND

Health information technology (HIT) and associated data analytics offer significant opportunities for tackling some of the more complex challenges currently facing the health care sector. However, to deliver robust health care service improvements, it is essential that HIT solutions be designed by parallelly considering the 3 core pillars of health care quality: clinical effectiveness, patient safety, and patient experience. This requires multidisciplinary teams to design interventions that both adhere to medical protocols and achieve the tripartite goals of effectiveness, safety, and experience.

OBJECTIVE

In this paper, we present a design tool called Integrated Patient Journey Mapping (IPJM) that was developed to assist multidisciplinary teams in designing effective HIT solutions to address the 3 core pillars of health care quality. IPJM is intended to support the analysis of requirements as well as to promote empathy and the emergence of shared commitment and understanding among multidisciplinary teams.

METHODS

A 6-month, in-depth case study was conducted to derive findings on the use of IPJM during Learning to Evaluate Blood Pressure at Home (LEANBH), a connected health project that developed an HIT solution for the perinatal health context. Data were collected from over 700 hours of participant observations and 10 semistructured interviews.

RESULTS

The findings indicate that IPJM offered a constructive tool for multidisciplinary teams to work together in designing an HIT solution, through mapping the physical and emotional journey of patients for both the current service and the proposed connected health service. This allowed team members to consider the goals, tasks, constraints, and actors involved in the delivery of this journey and to capture requirements for the digital touchpoints of the connected health service.

CONCLUSIONS

Overall, IPJM facilitates the design and implementation of complex HITs that require multidisciplinary participation.

Assessment of Receipt of the First Home Health Care Visit After Hospital Discharge Among Older Adults

Importance

Home health care is one of the fastest growing postacute services in the US and is increasingly important in the era of coronavirus disease 2019 and payment reform, yet it is unknown whether patients who need home health care are receiving it.

Objective

To examine how often patients referred to home health care at hospital discharge receive it and whether there is evidence of disparities.

Design, Setting, and Participants

This cross-sectional study used Medicare data regarding the postacute home health care setting from October 1, 2015, through September 30, 2016. The participants were Medicare fee-for-service and Medicare Advantage beneficiaries who were discharged alive from a hospital with a referral to home health care (2 379 506 discharges). Statistical analysis was performed from July 2019 to June 2020.

Exposures

Hospital referral to home health care.

Main Outcomes and Measures

Primary outcomes included whether discharges received their first home health care visit within 14 days of hospital discharge and the number of days between hospital discharge and the first home health visit. Differences in the likelihood of receiving home health care across patient, zip code, and hospital characteristics were also examined.

Results

Among 2 379 506 discharges from the hospital with a home health care referral, 1 358 697 patients (57.1%) were female, 468 762 (19.7%) were non-White, and 466 383 (19.6%) were dually enrolled in Medicare and Medicaid; patients had a mean (SD) age of 73.9 (11.9) years and 4.1 (2.1) Elixhauser comorbidities. Only 1 284 300 patients (54.0%) discharged from the hospital with a home health referral received home health care services within 14 days of discharge. Of the remaining 1 095 206 patients (46.0%) discharged, 37.7% (896 660 discharges) never received any home health care, while 8.3% (198 546 discharges) were institutionalized or died within 14 days without a preceding home health care visit. Patients who were Black or Hispanic received home health at lower rates than did patients who were White (48.0% [95% CI, 47.8%-48.1%] of Black and 46.1% [95% CI, 45.7%-46.5%] of Hispanic discharges received home health within 14 days compared with 55.3% [95% CI, 55.2%-55.4%] of White discharges). In addition, disadvantaged patients waited longer for their first home health care visit. For example, patients living in high-unemployment zip codes waited a mean of 2.0 days (95% CI, 2.0-2.0 days), whereas those living in low-unemployment zip codes waited 1.8 days (95% CI, 1.8-1.8 days).

Conclusions and Relevance

Disparities in the use of home health care remain an issue in the US. As home health care is increasingly presented as a safer alternative to institutional postacute care during coronavirus disease 2019, and payment reforms continue to pressure hospitals to discharge patients home, ensuring the availability of safe and equitable care will be crucial to maintaining high-quality care.

The Study on Spatial Elements of Health-Supportive Environment in Residential Streets Promoting Residents' Walking Trips

Residents’ walking trips are a kind of natural motion that promotes health and wellbeing by modifying individual behavior. The purpose of this study was to evaluate the major influence of the spatial elements of a health-supportive environment on residents’ walking trips. This study analyzes residents’ walking trips’ elements based on the spatiotemporal characteristics of walking trips, as well as the spatial elements of a health-supportive environment in residential streets based on residential health needs. To obtain the spatial elements that promote residents’ walking trips and to build an ordered logistic regression model, two methods—a correlation analysis and a logistic regression analysis—were applied to analyze the elements of residents’ walking trips as well as the spatial elements of a health-supportive environment in residential streets by means of SPSS software, using on-site survey results of ten residential streets and 2738 pieces of research data. The research showed that the nine kinds of spatial elements that significantly affect residents’ walking trips are density of pedestrian access, density of bus routes, near-line rate of roadside buildings, average pedestrian access distance, square area within a 500 m walking distance, distance to the nearest garden, green shade ratio, density of street intersections, and the mixed proportion of differently aged residential buildings. In order to construct a spatial environment that promotes walking trips, it is necessary to improve the convenience of residents’ walking trips, to increase the safety of roadside buildings and pedestrian access, to expand the comfort of “getting out to the nature”, and to enrich the diversity of different architectural styles and street density.

Supportive Care for Superutilizers of a Managed Care Organization

Background: Ohana Health Plan, Inc., (OHP) is one of the first managed care organizations offering supportive care services targeted to superutilizers. Bristol Hospice Hawaii, LLC, partnered with OHP to provide interdisciplinary supportive care services to home-bound OHP members. Objectives: The purpose of this study was to measure symptom relief, satisfaction, resource utilization, and cost savings associated with supportive care. Design: Prospective study. Setting: Over 12 months, 27 superutilizer members residing in the community were referred by OHP, 21 members were enrolled into supportive care. Measurements: Data were collected upon admission and repeatedly thereafter using the Edmonton Symptom Assessment Scale (ESAS) and the Missoula-Vitas Quality of Life Index (MVQOLI). The Family Satisfaction with Advanced Cancer Care (FAMCARE) Scale was administered at discharge. Emergency department (ED) visits and hospital utilization were tracked. Results: Median age was 63 years; more than half had cardiac diagnoses. Majority of members were Hawaiian and other Pacific Islander. Median length of stay in supportive care was 90 days. Five (23%) members enrolled in hospice following supportive care. Symptom improvement occurred in pain (p < 0.0001), anxiety (p = 0.0052), and shortness of breath (p = 0.0447). This model has shown a 79.5% reduction of ED visits per thousand members and a 75% reduction of hospitalizations per thousand. Overall net savings was 36%. Discussions and documentation of end-of-life wishes increased from 23% to 85%. Conclusion: Supportive care is highly effective in reducing costs associated with superutilizers. Our experience demonstrates the effectiveness of supportive care approaches in this population through improved care and lower health care costs overall.

Impact of Pharmacy Benefit Managers on Oncology Practices and Patients

Pharmacy benefit managers (PBMs) are thoroughly integrated into the drug supply chain as administrators of prescription drug benefits for private insurers, self-insuring business, and government health plans. As the role of PBMs has expanded, their opaque business practices and impact on drug prices have come under increasing scrutiny. PBMs are particularly influential in oncology care because prescription drugs play a major role in the treatment of most cancers and an increasing number of patients with cancer are treated with oral oncology agents managed by PBMs. There is concern that some PBM practices may threaten access to high-quality cancer care and may increase the financial and administrative burden on patients and practices. In this article, we review the role of PBMs in prescription drug coverage and reimbursement, discuss the impact of PBMs on oncology care, and present data from the 2018 ASCO Practice Survey assessing the knowledge and attitude of oncology practices toward PBMs.

Supporting Innovative Person-Centred Care in Financially Constrained Environments: The WE CARE Exploratory Health Laboratory Evaluation Strategy

The COST CARES project aims to support healthcare cost containment and improve healthcare quality across Europe by developing the research and development necessary for person-centred care (PCC) and health promotion. This paper presents an overview evaluation strategy for testing 'Exploratory Health Laboratories' to deliver these aims. Our strategy is theory driven and evidence based, and developed through a multi-disciplinary and European-wide team. Specifically, we define the key approach and essential criteria necessary to evaluate initial testing, and on-going large-scale implementation with a core set of accompanying methods (metrics, models, and measurements). This paper also outlines the enabling mechanisms that support the development of the "Health Labs" towards innovative models of ethically grounded and evidenced-based PCC.

Improving the prognosis of health care in the USA

Although health care expenditure per capita is higher in the USA than in any other country, more than 37 million Americans do not have health insurance, and 41 million more have inadequate access to care. Efforts are ongoing to repeal the Affordable Care Act which would exacerbate health-care inequities. By contrast, a universal system, such as that proposed in the Medicare for All Act, has the potential to transform the availability and efficiency of American health-care services. Taking into account both the costs of coverage expansion and the savings that would be achieved through the Medicare for All Act, we calculate that a single-payer, universal health-care system is likely to lead to a 13% savings in national health-care expenditure, equivalent to more than US$450 billion annually (based on the value of the US$ in 2017). The entire system could be funded with less financial outlay than is incurred by employers and households paying for health-care premiums combined with existing government allocations. This shift to single-payer health care would provide the greatest relief to lower-income households. Furthermore, we estimate that ensuring health-care access for all Americans would save more than 68 000 lives and 1·73 million life-years every year compared with the status quo.

Envisioning a Better U.S. Health Care System for All: Coverage and Cost of Care

This paper is part of the American College of Physicians' policy framework to achieve a vision for a better health care system, where everyone has coverage for and access to the care they need, at a cost they and the country can afford. Currently, the United States is the only wealthy industrialized country that has not achieved universal health coverage. The nation's existing health care system is inefficient, unaffordable, unsustainable, and inaccessible to many. Part 1 of this paper discusses why the United States needs to do better in addressing coverage and cost. Part 2 presents 2 potential approaches, a single-payer model and a public choice model, to achieve universal coverage. Part 3 describes how an emphasis on value-based care can reduce costs.

A systematic review of case-mix models for home health care payment: Making sense of variation

BACKGROUND

Case-mix based payment of health care services offers potential to contain expenditure growth and simultaneously support needs-based care provision. However, limited evidence exists on its application in home health care (HHC). Therefore, this study aimed to synthesize available international literature on existing case-mix models for HHC payment.

METHODS

We performed a systematic review of scientific literature, supplemented with grey literature. We searched for literature using six scientific databases, reference lists, expert consultation, and targeted websites. Data on study design, case-mix model attributes, and conclusions were extracted narratively.

RESULTS

Of 3303 references found, 22 scientific studies and 27 grey documents met eligibility criteria. Eight case-mix models for HHC were identified, from the US, Canada, New Zealand, Australia, and Germany. Three countries have implemented a case-mix model as part of a HHC payment system. Different combinations of in total 127 unique case-mix predictors are included across models to predict HHC use. Case-mix models also differ in targeted services, operationalization, and outcome measures and predictive power.

CONCLUSIONS

Case-mix based payment is not yet widely used within HHC. Multiple varieties were found between HHC case-mix models, and no one best form of a model seems to exist. Even though varieties are partly inevitable due to country-specific contexts, developing a shared vision in case-mix model attributes would be key to achieving efficient, needs-based HHC.

The Impact of Artificial Intelligence on Quality and Safety

As exponential expansion of computing capacity converges with unsustainable health care spending, a hopeful opportunity has emerged: the use of artificial intelligence to enhance health care quality and safety. These computer-based algorithms can perform the intricate and extremely complex mathematical operations of classification or regression on immense amounts of data to detect intricate and potentially previously unknown patterns in that data, with the end result of creating predictive models that can be utilized in clinical practice. Such models are designed to distinguish relevant from irrelevant data regarding a particular patient; choose appropriate perioperative care, intervention or surgery; predict cost of care and reimbursement; and predict future outcomes on a variety of anchored measures. If and when one is brought to fruition, an artificial intelligence platform could serve as the first legitimate clinical decision-making tool in spine care, delivering on the value equation while serving as a source for improving physician performance and promoting appropriate, efficient care in this era of financial uncertainty in health care.

Balancing workload of nurses: Linear mixed effects modelling to estimate required nursing time on surgical wards

Aim

Quantifying the relation between patient characteristics and care time and explaining differences in nursing time between wards.

Design

Academic hospital in the Netherlands. Six surgical wards, capacity 15-30 beds, 2012-2014.

Methods

Linear mixed effects model to study the relation between patient characteristics and care time. Estimated marginal means to estimate baseline care time and differences between wards.

Results

Nine patient characteristics significantly related to care time. Most required between 18 and 35 min extra, except "two or more IV/drip/drain" (8) and "one-on-one care" (156). Care time for minimum patient profile: 44-57 min and for average patient profile: 75-88 min. Sources of variation: nurse proficiency, patients, day-to-day variation within patients. The set of characteristics is short, simple and useful for planning and comparing workload. Explained variance up to 36%. Calculating estimated means per ward has not been done before. Nurse proficiency is an important factor.

Incorporation of Telestroke into Neurology Residency Training: "Time Is Brain and Education"

Background: With increasing demand for neurologists, nontraditional health care delivery mechanisms have been developed to leverage this limited resource. Introduction: Telemedicine has emerged as an effective digital solution. Over the past three decades, telemedicine use has steadily grown; however, neurologists often learn on the job, rather than as part of their medical training. The current literature regarding telestroke training during neurology training is sparse, focusing on cerebrovascular fellowship curricula. We sought to enhance telestroke training in our neurology residency by incorporating real-life application. Materials and Methods: We implemented a formal educational model for neurology residents to use telemedicine for remote acquisition of the National Institutes of Health Stroke Scale (NIHSS) for patients with suspected acute ischemic stroke (AIS) before arrival at our comprehensive stroke center. This three-phase educational model involved multidisciplinary classroom didactics, simulation exercises, and real-world experience. Training and feedback were provided by neurologists experienced in telemedicine. Results: All residents completed formal training in telemedicine prehospital NIHSS acquisition and had the opportunity to participate in additional simulation exercises. Currently, residents are gaining additional experience by performing prehospital NIHSS acquisition for patients in whom AIS is suspected. Our preliminary data indicate that resident video encounters average 10.6 min in duration, thus saving time once patients arrive at our hospital. Discussion: To our knowledge, this is the first report of a telestroke-integrated neurology residency program in a comprehensive stroke center resulting in shortened time to treatment in patients with suspected AIS. Conclusions: We present a model that can be adopted by other neurology residency programs as it provides real-world telemedicine training critical to future neurologists.

Understanding Payer Perspectives on Value in the Use of Pharmaceuticals in the United States

BACKGROUND

In recent years, value assessment frameworks have been introduced to inform discussions about how to define and assess value in the U.S. health care system. However, there is uncertainty as to how value assessment frameworks and other approaches to achieve value such as outcomes-based contracting are perceived and used in coverage decisions.

OBJECTIVE

To understand how U.S. payers determine value in the use of pharmaceuticals and how it differs from payers outside the United States.

METHODS

Qualitative in-depth phone interviews with 13 executive-level public and private U.S. managed care representatives and 6 health technology assessment advisors outside the United States were conducted from September to November 2017.

RESULTS

Despite various mechanisms used by U.S. payers to assess value, no consistent definitions of value were provided, and U.S. payers felt limited in what they can do to achieve value in pharmaceutical decision making. Value assessment frameworks are not formally considered in formulary and reimbursement decisions but are used as a reference as they become available by most or all U.S. health plans. U.S. payers expressed concerns, including limited control over pharmaceutical pricing and budget caps, and limited ability to use incremental cost per quality-adjusted life-year thresholds. Outcomes-based contracting could have some utility in specific cases where the treatment has a particularly high cost and a clear outcomes measure, but payers indicated that outcomes-based contracts can be difficult to operationalize, and determination of savings was uncertain. Payers outside the United States-who are enabled by government health care bodies, policy tools, and analytical frameworks that have no counterpart in the United States-have a wider array of instruments at their disposal. U.S. payers were largely open to learning from other health care systems outside the United States, particularly the German health care system, where patient-relevant benefit compared with a predetermined treatment comparator is the primary determinant for price negotiations.

CONCLUSIONS

Although there is interest in including value assessment frameworks during the decision-making process in the United States, there are significant challenges to operationalizing them. The current environment in the United States restricts payers' ability to make favorable contracts with manufacturers, and changes to the U.S. health system design are needed to facilitate this effort. Adoption of a value assessment framework in Medicare or Medicaid would accelerate adoption of these tools by private payers in the United States.

DISCLOSURES

This study was conducted by RTI Health Solutions under the direction of The Pew Charitable Trusts and was funded by The Pew Charitable Trusts. Vekaria is employed by RTI Health Solutions. Reynolds and Coukell are employed by The Pew Charitable Trusts. Brogan and Hogue have nothing to disclose.

Association of Echocardiography Before Major Elective Non-Cardiac Surgery With Improved Postoperative Outcomes - Possible Implications for Patient Care

BACKGROUND

Whether preoperative echocardiography improves postoperative outcomes is not well established, so we examined the value of echocardiographic assessment on the onset of postoperative heart failure (HF), and determining which patients benefitted most from undergoing echocardiography prior to major elective non-cardiac surgery.

METHODS AND RESULTS

We identified all patients aged 50 years and older who had major elective non-cardiac surgery, and excluded patients with previously identified severe cardiovascular disease. The primary endpoint was the onset of HF during hospitalization. A total of 806 patients were included in the analysis. During hospitalization, 49 patients (6%) reached the primary endpoint. Within the matched cohort, preoperative echocardiography was associated with a statistically significant decrease in postoperative HF (hazard ratio: 0.46, P=0.01). In subgroup analyses, age, sex, body surface area, hypertension, diabetes mellitus, prior HF, surgical type, chronic kidney disease, pulmonary disease, and malignancy influenced the association of echocardiography with postoperative HF.

CONCLUSIONS

The use of echocardiography in elderly patients with certain risk factors was associated with improved postoperative outcomes. The basis for this finding remains to be determined; particularly whether echocardiography is simply a marker of a population with better outcomes or whether it leads to better management that improves outcomes.

Financial Stress and Risk for Entry into Medicaid Among Older Adults

Background and Objectives

Spending in the Medicaid program is a significant concern to both state and federal policy makers. Medicaid spending is driven by program enrollment and services use. Older adults with high health care needs incur a disproportionate proportion of program spending. This analysis identifies factors that place older Medicare beneficiaries at increased risk for entering into Medicaid.

Research Design and Methods

We use multinomial logistic regression and the 2011–2017 National Health and Aging Trends Study (NHATS) to examine the risks among older Medicare beneficiaries for entering into Medicaid over a 6-year follow-up period. We examine both time-invariant and time-varying factors to measure the impact of social and health and functioning changes at older ages.

Results

The risk of entry into Medicaid was higher for older adults who relocated to a nursing home (relative risk ratio [RRR]: 7.75; 95% confidence interval [CI]: 5.33–11.26) or other residential care setting (RRR: 1.36; 95% CI: 0.96–1.92) compared to those who remained in traditional community settings. Older adults who reported skipping a meal in the last month because there was not enough money to buy food were 2.4 times (95% CI: 1.10–5.21) more likely to enter Medicaid than those who did not. Similarly, older adults who reported not having enough money to pay household utility bills in the last year were 1.89 times (95% CI: 1.08–3.30) more likely to enter Medicaid.

Discussion and Implications

Study findings suggest that trouble paying for basic needs increases the risk of entry into Medicaid. Further research is required to examine whether addressing these needs through improved access to social services that enable older adults to live safely in their home may delay or mitigate entry into Medicaid.

Association of the Functional Medicine Model of Care With Patient-Reported Health-Related Quality-of-Life Outcomes

IMPORTANCE

The incidence of chronic disease is increasing along with health care-related costs. The functional medicine model of care provides a unique operating system to reverse illness, promote health, and optimize function. The association between this model of care and patient's health-related quality of life (HRQoL) is unknown.

OBJECTIVE

To assess the association between functional medicine and patient-reported HRQoL using Patient-Reported Outcome Measurement Information System (PROMIS) global health measures.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was performed to compare 7252 patients aged 18 years or older treated in a functional medicine setting with propensity score (PS)-matched patients in a primary care setting. Sensitivity analyses assessed improvement limited to patients seen at both 6 and 12 months. The study included patients who visited the Cleveland Clinic Center for Functional Medicine or a Cleveland Clinic family health center between April 1, 2015, and March 1, 2017.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in PROMIS Global Physical Health (GPH) at 6 months. Secondary outcomes included PROMIS Global Mental Health (GMH) at 6 months and PROMIS GPH and GMH at 12 months. The PROMIS GPH and GMH scores were transformed to a T-score from 0 to 100 with a mean of 50. Higher scores indicate a better health-related quality of life.

RESULTS

Of the 7252 patients (functional medicine center: 1595; family health center: 5657), 4780 (65.9%) were women; mean (SD) age was 54.1 (16.0) years. At 6 months, functional medicine patients exhibited significantly larger improvements in PROMIS GPH T-score points than were seen in patients treated at a family health center (mean [SD] change, functional medicine center: 1.59 [6.29] vs family health center: 0.33 [6.09], P = .004 in 398 PS-matched pairs). At 12 months, functional medicine patients showed improvement similar to that observed at 6 months; however, comparisons with patients seen at the family health center were not significant. Patients in the functional medicine center with data at both 6 and 12 months demonstrated improvements in PROMIS GPH (mean [SD], 2.61 [6.53]) that were significantly larger compared with patients seen at a family health center (mean [SD], 0.25 [6.54]) (P = .02 in 91 PS-matched pairs).

CONCLUSIONS AND RELEVANCE

In this study, the functional medicine model of care demonstrated beneficial and sustainable associations with patient-reported HRQoL. Prospective studies are warranted to confirm these findings.

Combining a gravitational search algorithm, particle swarm optimization, and fuzzy rules to improve the classification performance of a feed-forward neural network

BACKGROUND AND OBJECTIVE

A feed-forward neural network (FNN) is a type of artificial neural network that has been widely used in medical diagnosis, data mining, stock market analysis, and other fields. Many studies have used FNN to develop medical decision-making systems to assist doctors in clinical diagnosis. The aim of the learning process in FNN is to find the best combination of connection weights and biases to achieve the minimum error. However, in many cases, FNNs converge to the local optimum but not the global optimum. Using open disease datasets, the purpose of this study was to optimize the connection weights and biases of the FNN to minimize the error and improve the accuracy of disease diagnosis.

METHOD

In this study, the chronic kidney disease (CKD) and mesothelioma (MES) disease datasets from the University of California Irvine (UCI) machine learning repository were used as research objects. This study applied the FNN to learn the features of each datum and used particle swarm optimization (PSO) and a gravitational search algorithm (GSA) to optimize the weights and biases of the FNN classifiers based on the algorithms inspired by the observation of natural phenomena. Moreover, fuzzy rules were used to optimize the parameters of the GSA to improve the performance of the algorithm in the classifier.

RESULTS

When applied to the CKD dataset, the accuracies of PSO and GSA were 99%. By using fuzzy rules to optimize the GSA parameter, the accuracy of fuzzy-GSA was 99.25%. The accuracies of the combined algorithms PSO-GSA and fuzzy-PSO-GSA reached 100%. In the MES disease dataset, all methods exhibited good performance with 100% accuracy.

CONCLUSIONS

This study used PSO, GSA, fuzzy-GSA, PSO-GSA, and fuzzy-PSO-GSA on CKD and MES disease datasets to identify the disease, and the performance of different algorithms was explored. Compared with other methods in the literature, our proposed method achieved higher accuracy.

Evaluation of a Novel Financial Navigator Pilot to Address Patient Concerns about Medical Care Costs

CONTEXT

Interventions are required that address patients' medically related financial needs.

OBJECTIVE

To evaluate a Financial Navigator pilot addressing patients' concerns/needs regarding medical care costs in an integrated health care system.

METHODS

Adults (aged ≥ 18 years) enrolled at Kaiser Permanente Northwest, who had a concern/need about medical care costs and received care in 1 of 3 clinical departments at the intervention or comparison clinic were recruited between August 1, 2016, and October 31, 2016. Baseline and 30-day follow-up participant surveys were administered to assess medical and nonmedical socioeconomic needs, satisfaction with medical care, and satisfaction with assistance with cost concerns. Physicians at both clinics were invited to complete a survey on medical care costs. We assessed participant characteristics and survey responses using descriptive statistics and 30-day change in satisfaction measures using multivariable linear regression models.

RESULTS

Eighty-five intervention and 51 comparison participants completed the baseline survey. At baseline, intervention participants reported transportation (52.9%), housing (38.2%), and social isolation (32.4%) needs; comparison participants identified employment (33.3%), food (33.3%), and housing (33.3%) needs. Intervention participants reported higher satisfaction with care (p = 0.01) and higher satisfaction with cost concerns assistance (p = 0.01) vs comparison participants at 30-day follow-up, controlling for baseline responses. Although most physicians (80%) reported discussing medical care costs with their patients, only 18% reported knowing about their patients' financial well-being.

CONCLUSION

We demonstrated the promise of a novel Financial Navigator pilot intervention to address medical care cost concerns and needs, and underscored the prevalence of nonmedical social needs in an economically vulnerable population.

Competition and price among brand-name drugs in the same class: A systematic review of the evidence

BACKGROUND

Some experts have proposed combating rising drug prices by promoting brand-brand competition, a situation that is supposed to arise when multiple US Food and Drug Administration (FDA)-approved brand-name products in the same class are indicated for the same condition. However, numerous reports exist of price increases following the introduction of brand-name competition, suggesting that it may not be effective. We performed a systematic literature review of the peer-reviewed health policy and economics literature to better understand the interplay between new drug entry and intraclass drug prices.

METHODS AND FINDINGS

We searched PubMed and EconLit for original studies on brand-brand competition in the US market published in English between January 1990 and April 2019. We performed a qualitative synthesis of each study's data, recording its primary objective, methodology, and results. We found 10 empirical investigations, with 1 study each on antihypertensives, anti-infectives, central nervous system stimulants for attention deficit/hyperactivity disorder, disease-modifying therapies for multiple sclerosis, histamine-2 (H2) blockers, and tumor necrosis factor (TNF) inhibitors; 2 studies on cancer medications; and 2 studies on all marketed or new drugs. None of the studies reported that brand-brand competition lowers list prices of existing drugs within a class. The findings of 2 studies suggest that such competition may help restrain how new drug prices are set. Other studies found evidence that brand-brand competition was mediated by the relative quality of competing drugs and the extent to which they are marketed, with safer or more effective new drugs and greater marketing associated with higher intraclass list prices. Our investigation was limited by the studies' use of list rather than net prices and the age of some of the data.

CONCLUSIONS

Our findings suggest that policies to promote brand-brand competition in the US pharmaceutical market, such as accelerating approval of non-first-in-class drugs, will likely not result in lower drug list prices absent additional structural reforms.

Reconciling the Seemingly Irreconcilable: How Much Are We Spending on Drugs?

BACKGROUND

Estimates of drug spending are often central to the public policy debate on how to manage healthcare spending in the United States. Nevertheless, common estimates of prescription drug spending vary substantially by source, which can inhibit productive policy dialogue.

OBJECTIVES

To review publicly reported estimates of drug spending and uncover the underlying methodological inputs that drive the substantial variation in estimates of prescription drug spending.

METHODS

We systematically evaluated 5 estimates of drug spending to identify differences in the underlying methodological inputs and approaches. To uniformly assess and compare estimates, we developed a model to identify the inputs of 3 primary components associated with each estimate: numerator (How is drug cost measured?), denominator (How is healthcare cost measured?), and population (What group of individuals is included in the measurement?). We then applied standardized methodological inputs to each estimate to assess whether variation among estimates could be reconciled. We then conducted a sensitivity analysis to address important limitations.

RESULTS

We found that the 18.8 percentage point range in the publicly reported estimates is predominately attributed to methodological differences. Reconciling estimates using a standardized methodological approach reduces this range to 4.0 percentage points.

CONCLUSIONS

Because variation in estimates of drug spending is primarily driven by methodological differences, stakeholders should seek to establish a mutually agreed upon methodological approach that is appropriate for the policy question at hand to provide a sound basis for health spending policy discussions.

Workflow Requirements for Cost-of-Care Conversations in Outpatient Settings Providing Oncology or Primary Care: A Qualitative, Human-Centered Design Study

BACKGROUND

Patients prefer to discuss costs in the clinical setting, but physicians and teams may be unprepared to incorporate cost discussions into existing workflows.

OBJECTIVE

To understand and improve clinical workflows related to cost-of-care conversations.

DESIGN

Qualitative human-centered design study.

SETTING

2 integrated health systems in the U.S. Pacific Northwest: a system-wide oncology service line and a system-wide primary care service line.

PARTICIPANTS

Clinicians, clinical team members, operations staff, and patients.

MEASUREMENTS

Ethnographic observations were made at the integrated health systems, assessing barriers to and facilitators of discussing costs with patients. Three unique patient experiences of having financial concerns addressed in the clinic were designed. These experiences were refined after in-person interviews with patients (n = 20). Data were synthesized into a set of clinical workflow requirements.

RESULTS

Most patient cost concerns take 1 of 3 pathways: informing clinical care decision making, planning and budgeting concerns, and addressing immediate financial hardship. Workflow requirements include organizational recognition of the need for clinic-based cost-of-care conversations; access to cost and health plan benefit data to support each conversation pathway; clear team member roles and responsibilities for addressing cost-of-care concerns; a patient experience where cost questions are normal and each patient's preferences and privacy are respected; patients know who to go to with cost questions; patients' concerns are documented to minimize repetition to multiple team members; and patients learn their expected out-of-pocket costs before treatment begins.

LIMITATION

Results may have limited generalizability to other health care settings, and the study did not test the effectiveness of the workflows developed.

CONCLUSION

Clinic-based workflows for cost-of-care conversations that optimize patients' care experience require organizational commitment to addressing cost concerns, clear roles and responsibilities, appropriate and complete data access, and a team-based approach.

PRIMARY FUNDING SOURCE

Robert Wood Johnson Foundation.

Development and Implementation of a Person-Centered, Technology-Enhanced Care Model For Managing Chronic Conditions: Cohort Study

Background

Caring for individuals with chronic conditions is labor intensive, requiring ongoing appointments, treatments, and support. The growing number of individuals with chronic conditions makes this support model unsustainably burdensome on health care systems globally. Mobile health technologies are increasingly being used throughout health care to facilitate communication, track disease, and provide educational support to patients. Such technologies show promise, yet they are not being used to their full extent within US health care systems.

Objective

The purpose of this study was to examine the use of staff and costs of a remote monitoring care model in persons with and without a chronic condition.

Methods

At Dartmouth-Hitchcock Health, 2894 employees volunteered to monitor their health, transmit data for analysis, and communicate digitally with a care team. Volunteers received Bluetooth-connected consumer-grade devices that were paired to a mobile phone app that facilitated digital communication with nursing and health behavior change staff. Health data were collected and automatically analyzed, and behavioral support communications were generated based on those analyses. Care support staff were automatically alerted according to purpose-developed algorithms. In a subgroup of participants and matched controls, we used difference-in-difference techniques to examine changes in per capita expenditures.

Results

Participants averaged 41 years of age; 72.70% (2104/2894) were female and 12.99% (376/2894) had at least one chronic condition. On average each month, participants submitted 23 vital sign measurements, engaged in 1.96 conversations, and received 0.25 automated messages. Persons with chronic conditions accounted for 39.74% (8587/21,607) of all staff conversations, with higher per capita conversation rates for all shifts compared to those without chronic conditions (P<.001). Additionally, persons with chronic conditions engaged nursing staff more than those without chronic conditions (1.40 and 0.19 per capita conversations, respectively, P<.001). When compared to the same period in the prior year, per capita health care expenditures for persons with chronic conditions dropped by 15% (P=.06) more than did those for matched controls.

Conclusions

The technology-based chronic condition management care model was frequently used and demonstrated potential for cost savings among participants with chronic conditions. While further studies are necessary, this model appears to be a promising solution to efficiently provide patients with personalized care, when and where they need it.