Health-related risk behaviors among U.S. childhood cancer survivors: a nationwide estimate

BACKGROUND

Childhood cancer survivors (CCS) are subject to a substantial burden of treatment-related morbidity. Engaging in health protective behaviors and eliminating risk behaviors are critical to preventing chronic diseases and premature deaths. This study is aimed to provide updated information on currently smoking, physical inactivity, binge drinking patterns and associated factors among CCS using a nationwide dataset.

METHODS

We constructed a sample of CCS (cancer diagnosis at ages < 21y) and healthy controls (matched on age, sex, residency, race/ethnicity) using 2020 Behavioral Risk Factor Surveillance System. We used Chi-square tests and Wilcoxon rank-sum test to examine differences in sociodemographics and clinical characteristics between two groups. Logistic, ordinal regression and multivariable models (conditional models for matching) were used to determine factors associated with risk behaviors.

RESULTS

The final sample (18-80y) included 372 CCS and 1107 controls. Compared to controls, CCS had a similar proportion of binge drinking (~ 18%) but higher prevalence of currently smoking (26.6% vs. 14.4%, p < 0.001), physical inactivity (23.7% vs. 17.7%, p = 0.012), and of having 2-or-3 risk behaviors (17.2% vs. 8.1%, p < 0.001). Younger age, lower educational attainment, and having multiple chronic health conditions were associated with engaging in more risk behaviors among CCS. Females, compared to male counterparts, had lower odds of binge drinking (adjusted odds ratio (aOR) = 0.30, 95% confidence interval (CI): 0.16-0.57) among CCS but not in all sample. Having multiple chronic health conditions increased odds of both currently smoking (aOR = 3.52 95%CI: 1.76-7.02) and binge drinking (aOR = 2.13 95%CI: 1.11-4.08) among CCS while it only increased odds of currently smoking in all sample.

DISCUSSION

Our study provided risk behavior information for wide age-range CCS, which is currently lacking. Every one in four CCS was currently smoking. Interventions targeting risk behavior reduction should focus on CCS with multiple chronic health conditions.

Healthcare utilization and cost barriers among U.S. childhood cancer survivors

BACKGROUND

To evaluate healthcare utilization and cost barrier patterns among childhood cancer survivors (CCS) compared with noncancer controls.

PROCEDURE

Using the 2014-2019 Behavioral Risk Factor Surveillance System, we identified CCS < 50 years and matched controls. We used chi-squared tests to compare characteristics between the two groups. Logistic regression analyses were used to assess the likelihood of having a checkup, receiving influenza vaccine, and experiencing healthcare cost barriers (being unable to see the doctor due to cost) during the past 12 months. Conditional models accounted for the matching.

RESULTS

We included 231 CCS and 692 controls. CCS had lower household income (p < 0.001), lower educational attainment (p = 0.021), more chronic health conditions (p < 0.001), and a higher proportion of being current smokers (p = 0.005) than controls. Both groups had similar rates of having a checkup and influenza vaccine; however, a quarter of CCS experienced healthcare cost barriers compared with 13.9% in controls (p = 0.001; regression findings: adjusted odds ratio (aOR) = 1.72, 95% confidence interval (CI): 1.11-2.65). Compared with the youngest CCS group (18-24 years), CCS ages 25-29 years were five times more likely to experience healthcare cost barriers (aOR = 4.79; 95% CI, 1.39-16.54). Among CCS, current smokers were less likely to have a checkup (aOR = 0.46; 95% CI, 0.23-0.94). Uninsured CCS were less likely to have a checkup (aOR = 0.33; 95% CI, 0.14-0.75) and ∼8 times more likely to experience healthcare cost barriers (aOR = 8.28; 95% CI, 3.45-19.88).

CONCLUSION

CCS being 25-29 years, uninsured, or current smokers encounter inferior outcomes in healthcare utilization and cost barriers. We suggest emphasis on programs on care transition and smoking cessation for CCS.

Cost Utility of Schlemm's Canal Microstent Injection With Cataract Surgery for Open-angle Glaucoma in the US Medicare System

PRCIS

Hydrus microstent (HMS) implantation at the time of cataract surgery appears to be cost-effective in mild-to-moderate glaucoma. However, long-term follow-up is essential for a full assessment of device performance, safety and cost-effectiveness.

PURPOSE

The aim was to assess the societal cost-utility to the US Medicare system of implanting HMS with cataract surgery versus cataract surgery alone in patients with open-angle glaucoma.

PATIENTS

Markov model cohort of patients with mild-to-moderate open-angle glaucoma and visually significant cataract.

METHODS

Patients received HMS during cataract surgery versus cataract surgery alone, in a deterministic model over a 2-year horizon using TreeAge software. Both arms received additional ocular hypotensive agents to control intraocular pressure. Treatment effect of HMS was measured as mean number of ocular hypotensive medications and intraocular pressure, which directly impacted transition probabilities. Health states included the Hodapp-Parrish-Anderson glaucoma stages (mild, moderate, advanced, blind) and death. One-way sensitivity and probabilistic sensitivity analyses were conducted on device efficacy and longer time horizons.

RESULTS

At 2 years, HMS with cataract surgery in mild glaucoma had an incremental cost-utility ratio of USD 38,346.43 per utility gained, compared with cataract surgery alone. Probabilistic sensitivity analysis was cost-effective in 61.4% of iterations for HMS+cataract surgery. The probability of side-effects with eye drops, utility decrement with side-effects, cost of the HMS and real-world efficacy rate had the greatest impact on model outcomes. HMS must be 85.60% as effective as published data to maintain cost-effectiveness at a willingness-to-pay threshold of USD 50,000. The incremental cost-utility ratio of HMS with cataract surgery in moderate glaucoma was USD 42,895.38.

CONCLUSIONS

HMS implantation during cataract surgery appears to be cost-effective for patients with mild-to-moderate glaucoma. Nevertheless, more long-term safety and efficacy data are required.

RAPIDIRON: Reducing Anaemia in Pregnancy in India-a 3-arm, randomized-controlled trial comparing the effectiveness of oral iron with single-dose intravenous iron in the treatment of iron deficiency anaemia in pregnant women and reducing low birth weight deliveries

Background

Anaemia is a worldwide problem and iron deficiency is the most common cause. In pregnancy, anaemia increases the risk of adverse maternal, foetal and neonatal outcomes.

India’s anaemia rate is among the highest in the world with India’s National Family Health Survey indicating over 50% of pregnant women were affected by anaemia.

India’s Anaemia Mukt Bharat-Intensified National Iron Plus Initiative aims to reduce the prevalence of anaemia among reproductive-age women, adolescents and children by 3% per year and facilitate the achievement of a Global World Health Assembly 2025 objective to achieve a 50% reduction of anaemia among women of reproductive age.

However, preliminary results of the NFHS-5 survey completed in 2020 indicate that anaemia rates are increasing in some states and these targets are unlikely to be achieved. With oral iron being the first-line treatment for iron deficiency anaemia (IDA) in pregnancy, these results are likely to be impacted by the side effects, poor adherence to tablet ingestion and low therapeutic impact of oral iron. These reports suggest a new approach to treating IDA, specifically the importance of single-dose intravenous iron infusions, may be the key to India effectively reaching its targets for anaemia reduction.

Methods

This 3-arm, randomized controlled trial is powered to report two primary outcomes. The first is to assess whether a single dose of two different intravenous formulations administered early in the second trimester of pregnancy to women with moderate IDA will result in a higher percentage of participants achieving a normal for pregnancy Hb concentration at 30–34 weeks’ gestation or just prior to delivery when compared to participants taking standard doses of oral iron. The second is a clinical outcome of low birth weight (LBW) (< 2500 g), with a hypothesis that the risk of LBW delivery will be lower in the intravenous iron arms when compared to the oral iron arm.

Discussion

The RAPIDIRON trial will provide evidence to determine if a single-dose intravenous iron infusion is more effective and economically feasible in reducing IDA in pregnancy than the current standard of care.

Trial registration

Clinical Trials Registry – India CTRI/2020/09/027730. Registered on 10 September 2020, http://ctri.nic.in/Clinicaltrials/showallp.php?mid1=46801&EncHid=&userName=anemia%20in%20pregnancy

Health care-related time costs in patients with metastatic breast cancer

BACKGROUND

Burdens related to time spent receiving cancer care may be substantial for patients with incurable, life-limiting cancers such as metastatic breast cancer (MBC). Estimates of time spent on health care are needed to inform treatment-related decision-making.

METHODS

Estimates of time spent receiving cancer-related health care in the initial 3 months of treatment for patients with MBC were calculated using the following data sources: (a) direct observations from a time-in-motion quality improvement evaluation (process mapping); (b) cross-sectional patient surveys; and (c) administrative claims. Average ambulatory, inpatient, and total health care time were calculated for specific treatments which differed by antineoplastic type and administration method, including fulvestrant (injection, hormonal), letrozole (oral, hormonal), capecitabine (oral, chemotherapy), and paclitaxel (infusion, chemotherapy).

RESULTS

Average total time spent on health care ranged from 7% to 10% of all days included within the initial 3 months of treatment, depending on treatment. The greatest time contributions were time spent traveling for care and on inpatient services. Time with providers contributed modestly to total care time. Patients receiving infusion/injection treatments, compared with those receiving oral therapy, spent more time in ambulatory care. Health care time was higher for patients receiving chemotherapeutic agents compared to those receiving hormonal agents.

CONCLUSION

Time spent traveling and receiving inpatient care represented a substantial burden to patients with MBC, with variation in time by treatment type and administration method.

Health Insurance Literacy and Financial Hardship in Women Living With Metastatic Breast Cancer

PURPOSE:

In patients with metastatic breast cancer (MBC), low health insurance literacy may be associated with adverse material conditions, psychological response, and coping behaviors because of financial hardship (FH). This study explored the relationship between health insurance literacy and FH in women with MBC.

METHODS:

This cross-sectional study used data collected from 84 women receiving MBC treatment at 2 southeastern cancer centers. Low health insurance literacy was defined as not knowing premium or deductible costs. FH was defined by lifestyle changes as a result of medical expenses, financial toxicity, and medical care modifications attributable to cost. Mean differences were calculated using Cramer’s V. Associations between health insurance literacy and FH were estimated with adjusted linear models.

RESULTS:

Half of the surveyed patients had low health insurance literacy, 26% were underinsured, 45% had private insurance, 39% had Medicare, and 15% had Medicaid. Patients with low health insurance literacy more often reported borrowing money (19% v 4%; V = 0.35); an inability to pay for basic necessities like food, heat, or rent (10% v 4%; V = 0.18); and skipping a procedure (8% v 1%; V = 0.21), medical test (7% v 0%; V = 0.30), or treatment (4% v 0%; V = 0.20) compared with patients with high health insurance literacy. Median Comprehensive Score for Financial Toxicity was 23 (interquartile range, 17-29). In adjusted models, health insurance literacy was not associated with financial toxicity.

CONCLUSION:

Low health insurance literacy was common in women receiving MBC treatment. Additional research to increase health insurance literacy could lessen undesirable material FH and unnecessary behavioral FH associated with cancer-related care.

Health insurance literacy, status, and financial toxicity in women receiving treatment for metastatic breast cancer

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Background: Though uninsurance rates declined after the Affordable Care Act, the number of underinsured, or individuals who spend > 10% of their income on out-of-pocket (OOP) medical costs, continues to rise. In patients with metastatic breast cancer (MBC), underinsurance may lead to financial toxicity (FT), or patient-level financial burden and distress, since diagnosis and treatment is extremely costly. This study explores health insurance literacy and the association between FT and health insurance status in women receiving treatment for MBC. Methods: This cross-sectional study utilized survey data collected from 2017-2019 in women age ≥18 receiving treatment for MBC at two academic medical centers in Alabama. FT was measured by the Comprehensive Score for Financial Toxicity (COST) tool (11-item scale from 0-44, with lower scores indicating worse FT). Health insurance status and OOP costs were self-reported. Effect sizes were calculated using Cohen’s d or Cramer’s V. Mixed and generalized linear models clustered by site and treating medical oncologist estimated the association between FT and health insurance status. Results: In 81 women with MBC, median COST score was 24 (interquartile range [IQR] 17-30), 44% had private insurance, 40% Medicare, and 16% Medicaid. Though 25% and 33% of surveyed patients did not know their health insurance premium or deductible cost, respectively, privately insured patients more often knew the cost of their premiums (97%; V = 0.58) and deductibles (81%; V = 0.33) compared to publicly insured patients. In adjusted models, FT levels did not differ significantly based on health insurance type (private insurance COST 21, 95% confidence interval [CI] 18-25; Medicaid COST 23, 95% CI 17-29; Medicare COST 24, 95% CI 20-27). However, risk of severe FT (COST ≤13) was 147% higher for privately insured patients versus Medicare beneficiaries (risk ratio 2.47, 95% CI 1.44-4.21). Conclusions: Despite higher levels of health insurance literacy, privately insured patients receiving treatment for MBC may be at increased risk of severe FT. Further research is needed to understand causes of underinsurance in patients with MBC, which could lead to cancer-related FT.

Tracking the clinical experience of women with metastatic breast cancer at an academic cancer center

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Background: Time-driven activity-based costing (TDABC) can be used by health systems to identify inefficiencies and improve the patient experience in clinical encounters. This quality improvement project utilized a Plan, Do, Study, Act (PDSA) cycle to evaluate routine clinic-based care for women with metastatic breast cancer (MBC). Methods: A project plan was developed to directly observe the time spent by MBC patients in clinic (Plan). Patient clinical encounters could include a physician visit along with scans, infusion, and/or labs. We then created process maps of typical patient clinical experiences (Do). Next, we tabulated times (mean, standard deviation [SD]) that patients spent in waiting areas and with each clinical team member (physician, fellow, nurse practitioner, registered nurse, medical assistant, chaplain, social worker, pharmacist, navigator) to identify care inefficiencies (Study). Lastly, we discussed results with providers and identified and implemented strategies for improving efficiency (Act). Results: We directly observed clinic visits (n = 33) for MBC patients from November 2016 to June 2017. On average, patients spent 219 minutes (SD 108) at clinic visits including 71 minutes (SD 45) spent with clinical team members and 85 minutes (SD 43) spent in waiting areas. We identified several opportunities for efficiency improvement, including the delay prior to rooming by medical assistants (n = 31; mean 22, SD 20 minutes), delays with port lab draws in infusion (n = 5; mean 22, SD 13 minutes), and delays awaiting drug from pharmacy (n = 22; mean 15, SD 29 minutes). To improve efficiency, we implemented strategies including having a dedicated infusion nurse assigned to draw labs from patient ports and modifications to medical assistants’ workflow. Conclusions: In this PDSA cycle, we found that patients spend a substantial amount of time at clinic visits, and the majority of this time is spent in waiting areas. Our use of process mapping and evaluation of time spent receiving care identified important opportunities for improving care delivery and efficiency for patients with MBC.

Costs and Effectiveness of Treating Homeless Persons with Cocaine Addiction with Alternative Contingency Management Strategies

BACKGROUND

Between 1990 and 2006 in Birmingham, Alabama USA, 4 separate randomized controlled studies, called "Homeless 1" through "Homeless 4", treated cocaine substance abuse among chronically homeless adults, largely black men, many with non-psychotic mental health problems. The 4 studies had 9 treatment arms that used various counseling methods plus, in some arms, the provision of housing and work therapy usually with a contingent requirement of urine-test verified abstinence from substances. Participants in the abstinent-contingent arms who lapsed on abstinence were removed from housing and sent to an evening public shelter from which they were daily transported to day treatment until they returned to abstinence.

AIMS OF THE STUDY

This paper compares the cost effectiveness of the treatment arms.

METHODS

Societal cost per participant (in 2014 dollars) for each arm is defined as direct treatment cost plus cost of jail or hospital plus societal expense of public shelter use by lapsed participants. An untreated Base Case is defined as 5 percent abstinence with 95 percent usage of a public shelter. Incremental Cost Effectiveness Ratios (ICERs) for paired arms are defined as the change in cost per participant divided by the change in abstinence. Bootstrapping estimates confidence intervals.

RESULTS

Average cost per participant at the end of 6 months of active treatment in 7 arms with comparable data ranged from USD 10,447 to USD 36,194 with corresponding average weeks abstinent ranging from 6.1 to 15.3 out of a possible 26 weeks. In contrast, the Base Case would cost USD 6,123 for 1.3 weeks of abstinence. Compared to the Base Case, the least expensive "DT2" treatment has an ICER of USD 901 (95% CI = USD 571 to USD 1,681) per additional week of abstinence and the most expensive "CMP4" has an ICER of USD 2,147 (95% CI = USD 1,701 to USD 2,848). Additionally, the Homeless 3 study found that the abstinent contingent housing (ACH3) treatment compared to the Non Abstinent Contingent Housing (NAC3), analogous to "Housing First", achieved better abstinence (12.1 v. 10 weeks) at higher average cost (USD 22,512 v. USD 17,541) yielding an ICER for this comparison of (USD 2,367, 95% CI=USD -10,587 to USD 12,467). Similar results are found at 12 months (6 months after active treatment).

DISCUSSION

More intensive methods of counseling improved abstinence but 4 of the 7 treatments were inefficient ("dominated"). Bootstrapping shows that results are sensitive to which individuals were randomly assigned to each arm. A limitation of the analysis is that it does not consider the full societal cost of lost wages, crime costs beyond jail expenses and deterioration of neighborhood quality of life. Additionally, populations treated by Housing First programs may differ from the Birmingham Homeless studies in the severity of addiction or co-occuring psychological problems.

IMPLICATIONS FOR TREATMENT

The Homeless studies show that abstinent contingent safe housing with counseling can substantially improve abstinence for homeless cocaine abusers. Incremental costs rise sharply with more intensive counseling; modest programs of counseling may be more cost effective in a stepped treatment strategy.

Eye Care Quality and Accessibility Improvement in the Community (EQUALITY): impact of an eye health education program on patient knowledge about glaucoma and attitudes about eye care

Purpose

To assess the impact of the education program of the Eye Care Quality and Accessibility Improvement in the Community (EQUALITY) telemedicine program on at-risk patients’ knowledge about glaucoma and attitudes about eye care as well as to assess patient satisfaction with EQUALITY.

Patients and methods

New or existing patients presenting for a comprehensive eye exam (CEE) at one of two retail-based primary eye clinics were enrolled based on ≥1 of the following at-risk criteria for glaucoma: African Americans ≥40 years of age, Whites ≥50 years of age, diabetes, family history of glaucoma, and/or preexisting diagnosis of glaucoma. A total of 651 patients were enrolled. A questionnaire was administered prior to the patients’ CEE and prior to the patients receiving any of the evidence-based eye health education program; a follow-up questionnaire was administered 2–4 weeks later by phone. Baseline and follow-up patient responses regarding knowledge about glaucoma and attitudes about eye care were compared using McNemar’s test. Logistic regression models were used to assess the association of patient-level characteristics with improvement in knowledge and attitudes. Overall patient satisfaction was summarized.

Results

At follow-up, all patient responses in the knowledge and attitude domains significantly improved from baseline (P≤0.01 for all questions). Those who were unemployed (odds ratio =0.63, 95% confidence interval =0.42–0.95, P=0.026) or had lower education (odds ratio =0.55, 95% confidence interval =0.29–1.02, P=0.058) were less likely to improve their knowledge after adjusting for age, sex, race, and prior glaucoma diagnosis. This association was attenuated after further adjustment for other patient-level characteristics. Ninety-eight percent (n=501) of patients reported being likely to have a CEE within the next 2 years, whereas 63% (n=326) had a CEE in the previous 2 years. Patient satisfaction with EQUALITY was high (99%).

Conclusion

Improved knowledge about glaucoma and a high intent to pursue eye care may lead to improved detection of early disease, thus lowering the risk of blindness.

Anniston community health survey: Follow-up and dioxin analyses (ACHS-II)--methods

High serum concentrations of polychlorinated biphenyls (PCBs) have been reported previously among residents of Anniston, Alabama, where a PCB production facility was located in the past. As the second of two cross-sectional studies of these Anniston residents, the Anniston Community Health Survey: Follow-Up and Dioxin Analyses (ACHS-II) will yield repeated measurements to be used to evaluate changes over time in ortho-PCB concentrations and selected health indicators in study participants. Dioxins, non-ortho PCBs, other chemicals, heavy metals, and a variety of additional clinical tests not previously measured in the original ACHS cohort will be examined in ACHS-II. The follow-up study also incorporates a questionnaire with extended sections on diet and occupational history for a more comprehensive assessment of possible exposure sources. Data collection for ACHS-II from 359 eligible participants took place in 2014, 7 to 9 years after ACHS.

Eye Care Quality and Accessibility Improvement in the Community (EQUALITY) for adults at risk for glaucoma: study rationale and design

Background

Primary open angle glaucoma is a chronic, progressive eye disease that is the leading cause of blindness among African Americans. Glaucoma progresses more rapidly and appears about 10 years earlier in African Americans as compared to whites. African Americans are also less likely to receive comprehensive eye care when glaucoma could be detected before irreversible blindness. Screening and follow-up protocols for managing glaucoma recommended by eye-care professional organizations are often not followed by primary eye-care providers, both ophthalmologists and optometrists. There is a pressing need to improve both the accessibility and quality of glaucoma care for African Americans. Telemedicine may be an effective solution for improving management and diagnosis of glaucoma because it depends on ocular imaging and tests that can be electronically transmitted to remote reading centers where tertiary care specialists can examine the results. We describe the Eye Care Quality and Accessibility Improvement in the Community project (EQUALITY), set to evaluate a teleglaucoma program deployed in retail-based primary eye care practices serving communities with a large percentage of African Americans.

Methods/Design

We conducted an observational, 1-year prospective study based in two Walmart Vision Centers in Alabama staffed by primary care optometrists. EQUALITY focuses on new or existing adult patients who are at-risk for glaucoma or already diagnosed with glaucoma. Patients receive dilated comprehensive examinations and diagnostic testing for glaucoma, followed by the optometrist’s diagnosis and a preliminary management plan. Results are transmitted to a glaucoma reading center where ophthalmologists who completed fellowship training in glaucoma review results and provide feedback to the optometrist, who manages the care of the patient. Patients also receive eye health education about glaucoma and comprehensive eye care. Research questions include diagnostic and management agreement between providers, the impact of eye health education on patients’ knowledge and adherence to follow-up and medication, patient satisfaction, program cost-effectiveness, and EQUALITY’s impact on Walmart pharmacy prescription rates.

Discussion

As eye-care delivery systems in the US strive to improve quality while reducing costs, telemedicine programs including teleglaucoma initiatives such as EQUALITY could contribute toward reaching this goal, particularly among underserved populations at-risk for chronic blinding diseases.

Impact of the HITECH Act on physicians' adoption of electronic health records

BACKGROUND AND OBJECTIVE

The Health Information Technology for Economic and Clinical Health (HITECH) Act has distributed billions of dollars to physicians as incentives for adopting certified electronic health records (EHRs) through the meaningful use (MU) program ultimately aimed at improving healthcare outcomes. The authors examine the extent to which the MU program impacted the EHR adoption curve that existed prior to the Act.

METHODS

Bass and Gamma Shifted Gompertz (G/SG) diffusion models of the adoption of "Any" and "Basic" EHR systems in physicians' offices using consistent data series covering 2001-2013 and 2006-2013, respectively, are estimated to determine if adoption was stimulated during either a PrePay (2009-2010) period of subsidy anticipation or a PostPay (2011-2013) period when payments were actually made.

RESULTS

Adoption of Any EHR system may have increased by as much as 7 percentage points above the level predicted in the absence of the MU subsidies. This estimate, however, lacks statistical significance and becomes smaller or negative under alternative model specifications. No substantial effects are found for Basic systems. The models suggest that adoption was largely driven by "imitation" effects (q-coefficient) as physicians mimic their peers' technology use or respond to mandates. Small and often insignificant "innovation" effects (p-coefficient) are found suggesting little enthusiasm by physicians who are leaders in technology adoption.

CONCLUSION

The authors find weak evidence of the impact of the MU program on EHR uptake. This is consistent with reports that many current EHR systems reduce physician productivity, lack data sharing capabilities, and need to incorporate other key interoperability features (e.g., application program interfaces).

Reducing older driver motor vehicle collisions via earlier cataract surgery

Older adults who undergo cataract extraction have roughly half the rate of motor vehicle collision (MVC) involvement per mile driven compared to cataract patients who do not elect cataract surgery. Currently in the U.S., most insurers do not allow payment for cataract surgery based upon the findings of a vision exam unless accompanied by an individual's complaint of visual difficulties that seriously interfere with driving or other daily activities and individuals themselves may be slow or reluctant to complain and seek relief. As a consequence, surgery tends to occur after significant vision problems have emerged. We hypothesize that a proactive policy encouraging cataract surgery earlier for a lesser level of complaint would significantly reduce MVCs among older drivers. We used a Monte Carlo model to simulate the MVC experience of the U.S. population from age 60 to 89 under alternative protocols for the timing of cataract surgery which we call "Current Practice" (CP) and "Earlier Surgery" (ES). Our base model finds, from a societal perspective with undiscounted 2010 dollars, that switching to ES from CP reduces by about 21% the average number of MVCs, fatalities, and MVC cost per person. The net effect on total cost - all MVC costs plus cataract surgery expenditures - is a reduction of about 16%. Quality Adjusted Life Years would increase by about 5%. From the perspective of payers for healthcare, the switch would increase cataract surgery expenditure for ages 65+ by about 8% and for ages 60-64 by about 47% but these expenditures are substantially offset after age 65 by reductions in the medical and emergency services component of MVC cost. Similar results occur with discounting at 3% and with various sensitivity analyses. We conclude that a policy of ES would significantly reduce MVCs and their associated consequences.

Effects of sustained abstinence among treated substance-abusing homeless persons on housing and employment

OBJECTIVES

We examined whether cocaine-dependent homeless persons had stable housing and were employed 6, 12, and 18 months after they entered a randomized controlled trial comparing 2 treatments.

METHODS

One group (n = 103) received abstinence-contingent housing, vocational training, and work; another group (n = 103) received the same intervention plus cognitive behavioral day treatment. We examined baseline and early treatment variables for association with long-term housing and employment.

RESULTS

Although the enhanced-treatment group achieved better abstinence rates, the groups did not differ in long-term housing and employment stability. However, consecutive weeks of abstinence during treatment (and to a lesser extent, older age and male gender) predicted long-term housing and employment stability after adjustment for baseline differences in employment, housing, and treatment.

CONCLUSIONS

Our data showed a relationship of abstinence with housing stability. Contrasting these results with the increasingly popular Housing First interventions reveals important gaps in our knowledge to be addressed in future research.

Randomized comparison of ultrasound surveillance and clinical monitoring on arteriovenous graft outcomes

Arteriovenous graft thrombosis is a frequent event in hemodialysis patients, and usually occurs in grafts with significant underlying stenosis. Regular surveillance for graft stenosis, with pre-emptive angioplasty of significant lesions, may improve graft outcomes. This prospective, randomized, clinical trial allocated 126 hemodialysis patients with grafts to either clinical monitoring alone (control group) or to regular ultrasound surveillance for graft stenosis every 4 months in addition to clinical monitoring (ultrasound group). The two randomized groups were closely matched with respect to demographic, clinical, and graft characteristics, with the exception of a lower frequency of diabetes in the ultrasound group. The primary outcome was graft survival, and the secondary outcome was thrombosis-free graft survival. The frequency of pre-emptive graft angioplasty was 64% higher in the ultrasound group than in the control group (1.05 vs 0.64 events per patient-year, P<0.001), whereas the frequency of thrombosis was not different (0.67 vs 0.78 per patient-year, P=0.37). The median time to permanent graft failure was similar between the two groups (38 vs 37 months, P=0.93). Likewise, the median time to graft thrombosis or failure did not differ (22 vs 25 months, P=0.33). There was no significant association between diabetes and time to graft failure (P=0.93) or time to graft thrombosis or failure (P=0.88). In conclusion, the addition of regular ultrasound surveillance for graft stenosis to clinical monitoring increases the frequency of pre-emptive angioplasty, but may not decrease the likelihood of graft failure or thrombosis.

Employment in households with stroke after Constraint-Induced Movement therapy

Randomized controlled clinical studies show that Constraint-Induced Movement therapy (CI therapy) improves impaired arm function in patients with stroke. Little is known about how this therapy affects employment of patients or their caregivers. Individuals more than 1-year post-stroke (N=121) were retrospectively surveyed about their activities and employment prior to stroke, after stroke but before CI therapy and after CI therapy. They were also asked if someone had stopped working to be a caregiver and if that person had resumed employment. Before stroke, 48% of patients had been employed; this fell to 22% after stroke and did not significantly rise after CI therapy with most of the newly unemployed moving into a permanent retirement status before starting CI therapy. Among the CI therapy patients, one-quarter (29/121) reported that someone had limited their employment to take care of them following their stroke. After CI therapy, more than 60% (18/29) of caregivers returned to employment. Our preliminary finding regarding return to work by caregivers of stroke patients post-CI therapy warrants further study using prospective methods and randomized, controlled designs.

Costs and effectiveness of substance abuse treatments for homeless persons

BACKGROUND

Several reviews of the effectiveness of drug abuse treatment have concluded that treatment works. However, studies analyzing cost-effectiveness or cost-benefits of drug treatment have been limited. Consequently, policy decisions regarding substance abuse treatment have utilized educated guesses or consensus of experts in the absence of controlled and scientifically rigorous studies of the benefits and costs of treatment.

AIMS OF THE STUDY

This study presents a cost analysis of two randomized controlled studies comparing four drug addiction interventions for homeless persons. The studies controlled for some limitations of previous research in this area including random assignment. Findings are based on treatment costs obtained from actual expenditures and treatment outcomes of drug abstinence from toxicology tests. Cost-effectiveness is considered from the viewpoint of the treatment program. Cost-effectiveness from a societal viewpoint is discussed, but not calculated.

METHODS

This is a retrospective analysis of treatment and treatment outcome costs from two randomized controlled drug addiction treatment outcome studies: Homeless 1 and Homeless 2. Both studies were two-group-usual versus enhanced-care designs with similar treatment components, outcome variables and assessment points, but different research questions. Both studies investigated the efficacy of a contingency management intervention specifically designed for persons who are homeless. This costs analysis reports direct costs of treatment by service category and costs of abstinence at 2-, 6-, and 12-month points by study and study treatment group. Treatment costs and costs per week abstinent are reported for four substance abuse treatments across two studies for persons homeless and addicted primarily to crack cocaine. Treatment components for each program included counseling, housing, work, administrative, and other expenses.

RESULTS

Drug abstinence rates by treatment program for each study revealed superior outcomes for the enhanced interventions with the greatest abstinence found at the earlier time points (up to 6 months) as established by previous research. Abstinence rates at 12 months failed to differentiate treatment groups. Average costs per abstinent week were generally greater for the enhanced programs compared to usual care, except early in treatment where these were similar. The incremental direct cost ratios (in year 2000 dollars) for these enhanced programs to increase abstinence by one average week were similar ($1,244 and $1,007) for the Homeless 1 and 2 projects at 12-months. These figures are compared to figures of other life saving events.

DISCUSSION

When only the direct costs of programs and their abstinence rates are considered, treatments that involve abstinent contingent work and housing have incremental cost ratios that are within the range of many other common social and medical interventions. These enhanced programs are more cost effective earlier in treatment than at 12-month follow-up due to relapse common among existing drug treatment. A methodological limitation of this study is that direct program costs do not measure the societal value of reducing homelessness itself.

IMPLICATIONS FOR HEALTH POLICIES

Usual and improved treatment methods offer a cost-effective approach to improving abstinence among addicted homeless persons. Policy makers might reasonably choose to implement enhanced treatment programs that also reduce homelessness because the incremental cost of these programs is within a reasonable range compared to other common societal interventions.

IMPLICATIONS FOR FURTHER RESEARCH

Methods and data need to be developed to better measure the societal benefit to communities of reducing the numbers of homeless persons with addictive drug problems.

Reducing the cost of diagnosis of breast carcinoma: impact of ultrasound and imaging-guided biopsies on a clinical breast practice

BACKGROUND

The objective of this study was to determine whether the use of ultrasound and percutaneous breast biopsies in patients with screen-detected nonpalpable abnormalities can reduce benign open surgical biopsies of the breast without increasing cost or sacrificing detection of potentially curable breast carcinomas.

METHOD

Using a computerized mammography database and consecutive logs of needle localization procedures and fine- and large core needle biopsies of a single university-based breast imaging practice, the authors determined the breast carcinoma yield and cost of diagnosis over a 14-year period and the changes that occurred over time with the sequential introduction of ultrasound, ultrasound-guided biopsies, and stereotactic biopsies.

RESULTS

The overall breast carcinoma yield for needle localization biopsies of nonpalpable lesions increased from 21% in 1984 to 68% in 1998 (P < 0.0001). The yield for nonpalpable masses increased from 21% to 87% (P < 0.0001) over the same period. The selective use of ultrasound alone and percutaneous fine- and large core needle biopsy resulted in a substantial reduction in benign open surgical biopsies. A cost analysis showed a 50% reduction in the average expense of discovering breast carcinoma. The breast carcinomas detected after introduction of these methods were prognostically favorable with 88% measuring 1.5 cm or less in size and 66% measuring less than 1 cm.

CONCLUSIONS

Selective use of ultrasound and imaging-guided percutaneous biopsies can significantly reduce the number of benign open surgical biopsies generated by mammographic screening. This can result in substantial cost savings without decreasing the sensitivity for detecting small potentially curable lesions.

A bootstrap approach to medical decision analysis

In economic evaluations of health treatments, the sensitivity of a cost-benefit (CB), cost-effectiveness (CE) or cost-utility (CU) analysis to changes in modeling assumptions, variation in data, and sampling error is important. The typical approach to this problem is ad hoc experimentation; namely, a few parameters of particular interest are changed, either separately or in combination, over plausible ranges. The impact of random variation in the data is seldom explored beyond parametric tests of the statistical significance of estimated coefficients. This note suggests a systematic approach to sensitivity analysis. Bootstrap sampling is used to determine to what extent the patients' response to treatment and economic consequences might vary due to many replications of a clinical trial.

Antiviral therapy for neonatal herpes simplex virus: a cost-effectiveness analysis

Each year, about 1,600 infants in the United States are infected with neonatal herpes simplex virus. We conducted a cost-effectiveness analysis of antiviral drug therapy (acyclovir) for three forms of herpes simplex virus infection: skin, ear, and mouth (SEM), central nervous system (CNS), and disseminated multiorgan (DIS) disease. Five levels of patient outcomes were examined (normal, mild, moderate, severe, dead). We obtained information on disease occurrence and survival from clinical trials and historical reviews of untreated newborns. We considered approaches for treating all or any of the forms of the disease and compared them with no use of antiviral drugs. The main measure of effectiveness was lives saved, including those of descendants of survivors. Costs were measured from a societal perspective and included direct medical costs, institutional care, and special education. We used a discount rate of 3% and valued dollars at 1995 levels. We also considered the perspective of a managed care organization. From a societal viewpoint relative to no treatment, antiviral therapy for SEM resulted in a gain of 0.8 lives and a cost reduction of $78,601 per case. For the treatment of CNS and DIS disease, antiviral therapy saved more lives but at increased cost, with respective marginal costs per additional life saved of $75,125 and $46,619. From a managed care perspective, antiviral therapy is more cost-effective than from a societal viewpoint because costs of institutional care and special education are not the responsibility of managed care organizations. Development of at-home therapies will further improve the cost-effectiveness of antiviral therapy for neonatal herpes simplex virus infection.

Death and reputation: how consumers acted upon HCFA mortality information

From 1986 through 1992, the Health Care Financing Administration (HCFA) released information comparing patient death rates at individual hospitals. This was viewed widely as an effort to aid consumers in selecting hospitals. This study evaluates how the release of this information affected hospital utilization, as measured by discharges. It finds a very small, but statistically significant effect of the HCFA data release. A hospital with an actual death rate twice that expected by HCFA had fewer than one less discharge per week in the first year. However, press reports of single, unexpected deaths were associated with an average 9% reduction in hospital discharges within one year. HCFA was justified in eliminating its mortality report, not because it was being used by consumers to choose hospitals, but because it was not. Implications for report cards are discussed.

Using patient outcomes to screen for clinical laboratory errors

How to measure the quality of laboratory testing has long been a challenging problem for laboratory managers and accrediting agencies. Traditionally, laboratory quality has been assessed by direct inspection, proficiency testing, and the credentials of staff. None of these methods is entirely satisfactory at answering a fundamental question: does the laboratory give technically accurate and clinically meaningful information for each patient that it tests? This paper discusses how information on patient outcomes can be used to screen for laboratories that may be making frequent random or systematic errors. This approach is called downstream event monitoring (DEM). The basic idea is to look at what happens to a laboratory's patients in a critical window of time after they have been tested. The approach carries out a basic adage of quality management: follow up with your customers to see if your product has met their needs. The main idea of DEM is that if a laboratory has not conveyed accurate information, the clinician may take actions that fail to help, or maybe even harm, the patient. If a laboratory's patients have an unusually high rate of adverse events that happen within a window of time when the laboratory test would have played a critical role, the laboratory should be further examined to see if it is the cause of the problem. Right now, DEM is a technique under development. It needs a clinical logic to relate a patient's outcomes back to a laboratory test, and it needs good data to compare laboratories. This paper discusses how the prothrombin time test and the serum digoxin test have been examined for Medicare patients to see if certain laboratory characteristics are associated with unusually high occurrences of adverse events after testing. The need for future validation studies is also discussed.

Screening for clinical laboratory errors with Medicare claims data: results for digoxin

A statistical model is demonstrated for finding outpatient clinical laboratories having high frequencies of bad patient outcomes, after testing, that may indicate testing errors. A sample of Medicare Part A and Part B claims for 30,685 digoxin tests for 1985 through 1987 was analyzed. Deaths or digoxin-related hospitalizations within 14 days of digoxin testing are defined as "adverse events" potentially influenced by test information. Approximately 3.3% of digoxin tests were followed by adverse events with two-thirds resulting in hospitalization or death. Adverse events were (a) lower in states with stronger laboratory regulations, (b) 15% higher whenever the site of testing switched, (c) unrelated to testing in low volume physician office laboratories, and (d) unrelated to frequency of digoxin testing in previous 6 months. Results a and b are consistent with findings for prothrombin testing but c and d are not. Differences are consistent with technical characteristics of the tests.

Bed rest in pregnancy

OBJECTIVE

To summarize existing data about the effectiveness of bed rest when used to improve various pregnancy outcomes and to determine how often bed rest is used and the cost associated with its use.

DATA SOURCES

We used the MEDLINE data base to search for all English language papers evaluating the effectiveness of bed rest in pregnancy. We also reviewed a number of textbooks and the 1988 National Infant Mortality Survey.

METHODS OF STUDY SELECTION

We reviewed these sources for recommendations about using bed rest in various obstetric conditions. We used the 1988 National Infant Mortality Survey to determine how often bed rest was used either to prevent or to treat various obstetric conditions and estimated the costs associated with its use.

DATA EXTRACTION AND SYNTHESIS

Bed rest is used in nearly 20% of all pregnancies to prevent or treat a wide variety of conditions, including spontaneous abortion, preterm labor, fetal growth retardation, edema, chronic hypertension, and preeclampsia. There is little evidence of effectiveness. The estimated costs associated with bed rest, including hospitalization, lost wages, and lost domestic productivity, range from more than $250 million to billions of dollars per year.

CONCLUSIONS

Bed rest is used extensively to treat a wide variety of pregnancy conditions, at substantial cost but with little proof of effectiveness. We recommend that because this intervention has failed the test of effectiveness, its use during pregnancy should be curtailed unless randomized trials demonstrate improvement in a specific outcome.

Strategies for the prevention of early-onset neonatal group B streptococcal sepsis: a decision analysis

OBJECTIVE

To perform a decision analysis to understand better the implications of 19 potential group B streptococcus screening and treatment strategies.

METHODS

We searched the literature to locate appropriate articles from which to derive probability estimates. Using decision analysis, we determined the likely outcomes of 19 group B streptococcus screening and treatment strategies and focused on three main outcomes: 1) number of expected cases of early-onset neonatal group B streptococcal sepsis, 2) percentage of gravidas treated with intrapartum antibiotics, and 3) total costs.

RESULTS

The strategy recently recommended by two committees of the American Academy of Pediatrics (universal 28-week maternal rectovaginal group B streptococcal culture and treatment of culture-positive, high-risk patients in labor) is among the least effective at reducing neonatal sepsis and the most costly. Strategies based on the currently available rapid streptococcus identification tests are ineffective at reducing neonatal sepsis and are costly. Three strategies outperform the rest: 1) Universal intrapartum maternal antibiotic treatment is the most effective strategy in reducing early-onset neonatal group B streptococcal sepsis (6% of expected) and is also the least costly; 2) intrapartum treatment based solely on risk factors (recently endorsed by ACOG) lowers the rate of neonatal sepsis to 31% of expected with an 18% maternal treatment rate and low total costs; and 3) universal 36-week maternal culture, and treatment of all patients experiencing preterm birth and all culture-positive patients results in 14% of expected neonatal sepsis, with a 27% maternal treatment rate and low total costs.

CONCLUSION

Given the present state of knowledge, three strategies emerge from this decision analysis as most optimal for the prevention of early-onset neonatal group B streptococcal sepsis: universal treatment, treatment based on risk factors, and treatment based on preterm delivery and 36-week culture status.

Searching for inaccuracy in clinical laboratory testing using Medicare data. Evidence for prothrombin time

OBJECTIVE

To determine if the occurrence of health outcomes following clinical laboratory testing can be used to identify types of laboratories that may be having higher than expected error rates.

DESIGN

Retrospective analysis of Medicare Part B outpatient claims, Part A hospitalization bills, and death records using a case-control study.

SETTING

Medicare records from six carrier territories were sampled during the period 1985 through 1987.

PATIENTS

A total of 14,755 Medicare patients receiving a prothrombin time test in either a physician office laboratory or a commercial laboratory.

OUTCOME MEASURES

Occurrence of a hospitalization for stroke or acute myocardial infarction, death, or no adverse outcome within 6 days of a prothrombin time.

RESULTS

In physician office laboratories where prothrombin time test volume is below 40 per month, the odds that a tested patient will experience a stroke or an acute myocardial infarction are up to 1.96 and 3.43 times greater, respectively, than for a similar patient tested in a commercial laboratory. Switching from one laboratory to another between successive prothrombin time tests increased the odds of a stroke or an acute myocardial infarction by 1.57 and 1.32, respectively. Patients in two states with strong laboratory regulatory programs had fewer adverse outcomes.

CONCLUSION

Examining patient outcomes subsequent to clinical laboratory testing may be a useful tool for clinical laboratory quality assurance.

Downstream outcomes: using insurance claims data to screen for errors in clinical laboratory testing

A methodology is described by which health insurance claims data might be used to discover the occurrence of systematic errors by clinical laboratories. False-positive results should generate a series of tests or treatments that are eventually abandoned as the false signal of the initial test is discovered while false-negative results may cause necessary tests or treatments to be unduly delayed. False results may also generate adverse outcomes such as an unusually high number of deaths or hospitalizations among persons who have received particular laboratory tests. Health insurance claims data may be used to discover these patterns and how the inclusion of laboratory results on claims would improve the precision of such inferences. Appropriate statistical tests are discussed.

Effects of competition on Medicare administrative costs

This paper examines the effects of introducing competitive contracting into the Medicare: Part B program. The administrative costs of contractors (carriers) who process Medicare claims for medical services are examined to determine relative efficiencies of firms operating under either competitive or non-competitive contracts. Pooled time-series cross-sectional data are used to estimate an average total cost function. Findings are that (1) appreciable cost reductions were obtained by the introduction of competition, (2) economies of scale are present in Medicare claims processing, and (3) carriers who are non-profit organizations (i.e. Blue Shield plans) do not exhibit higher costs than comparable commercial insurance companies.