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Fujimoto S, Nozaki YO, Sakamoto T, Nakanishi R, Asano T, Kadota K, Komiyama K, Taguchi E, Okubo R, Saito A, Ikuta A, Nojiri S, Tanabe K. Clinical impacts of CT-derived fractional flow reserve under insurance reimbursement: Results from multicenter, prospective registry. J Cardiol 2023:S0914-5087(23)00273-3. [PMID: 37949315 DOI: 10.1016/j.jjcc.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Although computed tomography-derived fractional flow reserve (FFRCT) has been reimbursed in a few countries, its impacts on daily practice of coronary artery diseases are not fully elucidated. We evaluated the clinical impacts of FFRCT under the real Japanese insurance reimbursement. METHODS In the multicenter prospective registry: DYNAMIC-FFRCT study, a total of 410 patients who underwent FFRCT analysis under reimbursement were prospectively enrolled at 6 Japanese sites from October 2019 to November 2021. Coronary CT angiography and FFRCT findings, treatment plans, and 90-day outcomes were recorded. The primary endpoint was the redirection rate from the tests that might be expected without FFRCT [invasive coronary angiography (ICA)-selected group, myocardial perfusion single photon emission CT (MPS)-selected group, optimal medical therapy (OMT)-selected group, and others-selected group] to those that were actually performed based on FFRCT. RESULTS ICA could be avoided in 39.5 % in the ICA-selected group (N = 233). In particular, in 94.3 % of patients with an FFRCT value of >0.80, additional examinations, such as ICA, were avoided. In addition, in the MPS-selected group (N = 133), 92.6 % had no additional tests with FFRCT > 0.80, while only 2 cases with FFRCT ≤ 0.80 underwent additional MPS examination. On the contrary, 33.3 % of the OMT-selected group (N = 33) had FFRCT ≤ 0.80. Approximately, 35 % medical cost reduction was also finally expected. CONCLUSION Introduction of FFRCT could not only reduce unnecessary ICA and be a test that replaces the conventional non-invasive functional assessment modality but also result in medical cost reduction even when used under real Japanese insurance reimbursement.
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Affiliation(s)
- Shinichiro Fujimoto
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Yui O Nozaki
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Tomohiro Sakamoto
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Rine Nakanishi
- Department of Cardiovascular Medicine, Toho University Graduate School of Medicine, Tokyo, Japan; Department of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Taku Asano
- Department of Cardiovascular Medicine, St. Luke's International Hospital, St. Luke's International University, Tokyo, Japan
| | - Kazushige Kadota
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kota Komiyama
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Eiji Taguchi
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Ryo Okubo
- Department of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Akira Saito
- Department of Cardiovascular Medicine, St. Luke's International Hospital, St. Luke's International University, Tokyo, Japan
| | - Akihiro Ikuta
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Shuko Nojiri
- Medical Technology Innovation Center, Juntendo University, Tokyo, Japan
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
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Affiliation(s)
- Glyn Elwyn
- The Dartmouth Institute for Health Policy & Clinical Practice, Level 5, WTRB, 1 Medical Center Drive, Lebanon, NH 03766, USA.
| | - Ailyn Sierpe
- The Dartmouth Institute for Health Policy & Clinical Practice, Level 5, WTRB, 1 Medical Center Drive, Lebanon, NH 03766, USA
| | - Rachel Forcino
- The Dartmouth Institute for Health Policy & Clinical Practice, Level 5, WTRB, 1 Medical Center Drive, Lebanon, NH 03766, USA
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Watanabe T, Honda T, Totsuka H, Yoshida M, Tanioka M, Shiraishi K, Shimada Y, Arai E, Ushiama M, Tamura K, Yoshida T, Kanai Y, Kohno T. Simple prediction model for homologous recombination deficiency in breast cancers in adolescents and young adults. Breast Cancer Res Treat 2020; 182:491-502. [PMID: 32488393 DOI: 10.1007/s10549-020-05716-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/18/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Homologous recombination deficiency (HRD), which influences the efficacy of PARP inhibitor- and platinum agent-based therapies, is a prevalent phenotype of breast cancer in adolescents and young adults (AYAs; 15-39 years old). However, HRD score, indicating HRD status, is not routinely assessed in the breast oncology clinic, particularly in patients without germline BRCA1/2 mutations. Hence, we sought to develop a model for determining HRD status based on genetic and clinicopathological factors. METHODS Subjects were our own cohort of 46 Japanese AYA breast cancer patients and two existing breast cancer cohorts of US and European patients. Models for prediction of the HRD-high phenotype, defined as HRD score ≥ 42, were constructed by logistic regression analysis, using as explanatory variables genetic and clinicopathological factors assessable in the clinical setting. RESULTS In all three cohorts, the HRD-high phenotype was associated with germline BRCA1/2 mutation, somatic TP53 mutation, triple-negative subtype, and higher tumor grade. A model based on these four factors, developed using the US cohort, was validated in the Japanese and European AYA cases: area under the receiver operating characteristic curve [AUC] was 0.90 and 0.96, respectively. A model based on three factors excluding germline BRCA1/2 mutation also yielded high-predictive power in cases from these two cohorts without germline BRCA1/2 mutations: AUC was 0.92 and 0.90, respectively. CONCLUSIONS The HRD-high phenotype of AYA breast cancer patients can be deduced from genomic and pathological factors that are routinely examined in the oncology clinic, irrespective of germline BRCA1/2 mutations.
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Goodman RM, Bridges CB, Kim D, Pike J, Rose A, Prosser LA, Hutton DW. Billing and payment of commercial and Medicaid health plan adult vaccination claims in Michigan since the Affordable Care Act. Vaccine 2019; 37:6803-6813. [PMID: 31585724 DOI: 10.1016/j.vaccine.2019.09.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 09/09/2019] [Accepted: 09/10/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Provider concern regarding insurance non-payment for vaccines is a common barrier to provision of adult immunizations. We examined current adult vaccination billing and payment associated with two managed care populations to identify reasons for non-payment of immunization insurance claims. METHODS We assessed administrative data from 2014 to 2015 from Blue Care Network of Michigan, a nonprofit health maintenance organization, and Blue Cross Complete of Michigan, a Medicaid managed care plan, to determine rates of and reasons for non-payment of adult vaccination claims across patient-care settings, insurance plans, and vaccine types. We compared commercial and Medicaid payment rates to Medicare payment rates and examined patient cost sharing. RESULTS Pharmacy-submitted claims for adult vaccine doses were almost always paid (commercial 98.5%; Medicaid 100%). As the physician office accounted for the clear majority (79% commercial; 69% Medicaid) of medical (non-pharmacy) vaccination services, we limited further analyses of both commercial and Medicaid medical claims to the physician office setting. In the physician office setting, rates of payment were high with commercial rates of payment (97.9%) greater than Medicaid rates (91.6%). Reasons for non-payment varied, but generally related to the complexity of adult vaccine recommendations (patient diagnosis does not match recommendations) or insurance coverage (complex contracts, multiple insurance payers). Vaccine administration services were also generally paid. Commercial health plan payments were greater for both vaccine dose and vaccine administration than Medicare payments; Medicaid paid a higher amount for the vaccine dose, but less for vaccine administration than Medicare. Patients generally had very low (commercial) or no (Medicaid) cost-sharing for vaccination. CONCLUSIONS Adult vaccine dose claims were usually paid. Medicaid generally had higher rates of non-payment than commercial insurance.
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Affiliation(s)
- Robert M Goodman
- Blue Care Network/Blue Cross Blue Shield of Michigan, Southfield, MI, United States
| | - Carolyn B Bridges
- Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases, Immunization Services Division, Atlanta, GA, United States; Berry Technology Solutions, Inc., Peachtree City, GA, United States(1)
| | - David Kim
- Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases, Immunization Services Division, Atlanta, GA, United States
| | - Jamison Pike
- Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases, Immunization Services Division, Atlanta, GA, United States
| | - Angela Rose
- University of Michigan, Ann Arbor, MI, United States
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Thiffault I, Farrow E, Zellmer L, Berrios C, Miller N, Gibson M, Caylor R, Jenkins J, Faller D, Soden S, Saunders C. Clinical genome sequencing in an unbiased pediatric cohort. Genet Med 2019; 21:303-10. [PMID: 30008475 DOI: 10.1038/s41436-018-0075-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 05/18/2018] [Indexed: 11/08/2022] Open
Abstract
PURPOSE We report for the first time, the use of clinical genome sequencing (GS) in an unbiased pediatric cohort. We describe the clinical validation, patient metrics, ordering patterns, results, reimbursement, and physician retrieval of results for the first consecutive 80 cases. METHODS Clinical GS was performed for both inpatients and outpatients undergoing etiologic evaluations. Results were reported in the electronic medical record. Evidence of report retrieval by clinicians and whether interpretation was concordant with laboratory report was obtained through retrospective chart review. RESULTS Twenty definitive diagnoses were made in 19 patients (24%; n = 80). Except for two partial gene deletions, all diagnostic variants would have been detectable by our exome methods. Surprisingly, there was no documentation of communication of results to the family in the medical record for 17.5% of patients, and in 7.5%, physician and laboratory interpretations were discordant. Average insurance reimbursement was 30.2%, with yield for commercial payers significantly higher, at 54.1%. CONCLUSIONS The detection rate of GS is equivalent and potentially superior to exome sequencing (ES). Reimbursement rates were variable but overall satisfactory for commercial insurers, and poor for government entities. In addition, we identify opportunities for improvement in the communication of results to families, likely translatable to other tests and other institutions.
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