Overview of screening eligibility in patients undergoing ruptured AAA repair from 2003 to 2019 in the Vascular Quality Initiative

OBJECTIVE

Although efforts such as the Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act have improved access to abdominal aortic aneurysm (AAA) screening, certain high-risk populations are currently excluded from the guidelines yet may benefit from screening. We therefore examined all patients who underwent repair of ruptured AAA (rAAA) to characterize those who are ineligible for screening under current guidelines and evaluate the potential impact of these restrictions on their disease.

METHODS

We identified patients undergoing rAAA repair in the Vascular Quality Initiative (VQI) database between 2003 and 2019. These patients were stratified by AAA screening eligibility according to the Centers for Medicare and Medicaid reimbursement guidelines. We then described baseline characteristics to identify high-risk features of these cohorts. Groups with disproportionate representation in the screening-ineligible cohort were identified as potential targets of screening expansion. Trends over time in screening eligibility and the proportion of AAA repairs performed for rAAA were also analyzed.

RESULTS

A total of 5340 patients underwent rAAA repair. The majority (66%) were screening-ineligible. When characterizing the screening-ineligible group by sex and risk factors (smoking history or family history of AAA), the largest contributors to screening ineligibility were males less than 65 years of age with a smoking history or family history of AAA (25%), males greater than 75 years of age with a smoking history (25%), and females older than 65 years of age with a smoking history (19%). In comparison with rAAAs prior to implementation of the SAAAVE act, the proportion of AAA repair performed for rupture among males undergoing AAA repair in the VQI decreased from 12% to 8% (P < .001), whereas in females, there was no change (P = .990). There was no statically significant difference in screening eligibility for either males (P = .762) or females (P = .335).

CONCLUSIONS

Most patients who underwent rAAA repair were ineligible for initial AAA screening or aged out of the screening window. Furthermore, rAAA rates and screening ineligibility have not improved as much as expected since the passage of the SAAAVE Act. Our data suggest that three high-risk populations may benefit from expansion of AAA screening guidelines: males with a smoking history or family history of AAA between ages 55 and 64 years, female smokers older than 65 years, and male smokers older than 75 years who are otherwise in good health. Increased efforts to screen these high-risk populations may increase elective AAA repair and minimize the morbidity and mortality associated with rAAAs.

Towards Endovascular Treatment of Type A Aortic Dissection with Smaller Landing Zones and More Patient Eligibility

OBJECTIVE

Type A or ascending aortic dissection is an acute life-threatening condition with high morbidity and mortality. Open surgery remains standard-of-care. Development of minimally invasive endografts for Type A aortic dissection (TAAD) will require detailed understanding of dissection and aortic root anatomy to determine patient eligibility and optimal device specifications.

METHODS

Computed tomography images of TAAD cases at our institution from 2012-2019 were identified and three-dimensional reconstructions were performed using OsiriX 10.0 (Bernex, Switzerland). Analysis of key anatomic structures including centerline length measurements, ascending aorta/aortic root dimensions, as well as location and extent of dissection were determined in relation to coronary ostia.

RESULTS

A total of 53 patients were identified (mean±SD age 60.4±17.1 years; 36 male, 17 female), 46 of whom underwent surgery for TAAD. Four patients died within 30 days of surgery. In 47 patients (88.7%), the entry tear was distal to the highest coronary ostium. These cases were retrospectively considered for endovascular intervention with a non-branched, single endograft stent. Proximal landing zone (LZ) was defined as distance from the highest coronary ostium to entry tear: 35/53 (66.0%) had a proximal LZ length ≥2.0cm, 38/53 (71.7%) had proximal LZ length ≥1.5cm, and 42/53 (79.2%) had proximal LZ length ≥1.0cm. Proximal and distal LZ diameters of the sinotubular junction (STJ) and distal ascending aorta regions were (median [1^st quartile-3^rd quartile]) 3.29cm [2.73-4.10cm] and 3.49cm [3.09-3.87cm], respectively, with length from STJ to innominate takeoff 8.08cm [6.96-9.40cm]. Ascending aorta radius of curvature was 6.48cm [5.27-8.00cm]. 47.2% (25/53) of patients could be treated with a straight tube graft with ≤20% diameter mismatch between the proximal and distal LZ.

CONCLUSIONS

Almost 80% of patients with TAAD had a proximal LZ ≥1.0cm, and of these, 47.2% had anatomy amenable to endovascular therapy with a non-tapered straight tube graft commercially available devices. To increase patient eligibility for TAAD endovascular intervention, enhanced precision deployment with adequate seal in shorter LZs will be required. Our results serve as a guide for endovascular device specifications designed to treat this devastating condition.

Association of the Comprehensive Care for Joint Replacement Model With Disparities in the Use of Total Hip and Total Knee Replacement

IMPORTANCE

The Comprehensive Care for Joint Replacement (CJR) model is Medicare's mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and income. Results of this study could be the basis for a Medicare payment reform that addresses inequities in joint replacement care.

OBJECTIVE

To examine the association of the CJR model with racial/ethnic and socioeconomic disparities in the use of elective THR and TKR among older Medicare beneficiaries after accounting for the population of patients who were at risk or eligible for these surgical procedures.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used the 2013 to 2017 national Medicare data and multivariable logistic regressions with triple-differences estimation. Medicare beneficiaries who were aged 65 to 99 years, entitled to Medicare, alive at the end of the calendar year, and residing either in the 67 metropolitan statistical areas (MSAs) mandated to participate in the CJR model or in the 104 control MSAs were identified. A subset of Medicare beneficiaries with a diagnosis of arthritis underwent THR or TKR. Data were analyzed from March to December 2020.

EXPOSURES

Implementation of the CJR model in 2016.

MAIN OUTCOMES AND MEASURES

Outcomes were separate binary indicators for whether a beneficiary underwent THR or TKR. Key independent variables were MSA treatment status, pre- or post-CJR model implementation phase, combination of race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic beneficiaries) and dual eligibility, and their interactions. Logistic regression models were used to control for patient characteristics, MSA fixed effects, and time trends.

RESULTS

The 2013 cohort included 4 447 205 Medicare beneficiaries, of which 2 025 357 (45.5%) resided in MSAs with the CJR model. The cohort's mean (SD) age was 77.18 (7.95) years, and it was composed of 2 951 140 female (66.4%), 3 928 432 non-Hispanic White (88.3%), and 657 073 dually eligible (14.8%) beneficiaries. Before the CJR model implementation, rates were highest among non-Hispanic White non-dual-eligible beneficiaries at 1.25% (95% CI, 1.24%-1.26%) for THR use and 2.28% (95% CI, 2.26%-2.29%) for TKR use in MSAs with CJR model. Compared with MSAs without the CJR model and the analogous race/ethnicity and dual-eligibility group, the CJR model was associated with a 0.10 (95% CI, 0.05-0.15; P < .001) percentage-point increase in TKR use for non-Hispanic White non-dual-eligible beneficiaries, a 0.11 (95% CI, 0.004-0.21; P = .04) percentage-point increase for non-Hispanic White dual-eligible beneficiaries, a 0.15 (95% CI, -0.29 to -0.01; P = .04) percentage-point decrease for non-Hispanic Black non-dual-eligible beneficiaries, and a 0.18 (95% CI, -0.34 to -0.01; P = .03) percentage-point decrease for non-Hispanic Black dual-eligible beneficiaries. These CJR model-associated changes in TKR use were 0.25 (95% CI, -0.40 to -0.10; P = .001) percentage points lower for non-Hispanic Black non-dual-eligible beneficiaries and 0.27 (95% CI, -0.45 to -0.10; P = .002) percentage points lower for non-Hispanic Black dual-eligible beneficiaries compared with the model-associated changes for non-Hispanic White non-dual-eligible beneficiaries. No association was found between the CJR model and a widening of the THR use gap among race/ethnicity and dual eligibility groups.

CONCLUSIONS AND RELEVANCE

Results of this study indicate that the CJR model was associated with a modest increase in the already substantial difference in TKR use among non-Hispanic Black vs non-Hispanic White beneficiaries; no difference was found for THR. These findings support the widespread concern that payment reform has the potential to exacerbate disparities in access to joint replacement care.

Quality improvement for reducing utilization drift in hypoxic-ischemic encephalopathy management

OBJECTIVES

Therapeutic hypothermia is an effective neuroprotective intervention for infants with moderate or severe hypoxic-ischemic encephalopathy (HIE). With the introduction of new medical therapy comes a learning curve with regards to its proper implementation and understanding of eligibility guidelines. We hypothesized that variation in patient selection and lack of adherence to established protocols contributed to the utilization drift away from the original eligibility guidelines.

METHODS

A retrospective cohort study was conducted including infants who received therapeutic hypothermia in the neonatal intensive care unit (NICU) for HIE to determine utilization drift. We then used QI methodology to address gaps in medical documentation that may lead to the conclusion that therapeutic hypothermia was inappropriately applied.

RESULTS

We identified 54% of infants who received therapeutic hypothermia who did not meet the clinical, physiologic, and neurologic examination criteria for this intervention based on provider admission and discharge documentation within the electronic medical record (EMR). Review of the charts identified incomplete documentation in 71% of cases and led to the following interventions: 1) implementation of EMR smartphrases; 2) engagement of key stakeholders and education of faculty, residents, and neonatal nurse practitioners; and 3) performance measurement and sharing of data. We were able to improve both adherence to the therapeutic hypothermia guidelines and achieve 100% documentation of the modified Sarnat score.

CONCLUSIONS

Incomplete documentation can lead to the assumption that therapeutic hypothermia was inappropriately applied when reviewing a patient's EMR. However, in actual clinical practice physicians follow the clinical guidelines but are not documenting their medical decision making completely. QI methodology addresses this gap in documentation, which will help determine the true utilization drift of therapeutic hypothermia in future studies.

Struggle for the Soul of Medicaid

Medicaid is uniquely equipped to serve low-income populations. We identify four features that form the "soul" of Medicaid, explain how the administration is testing them, and explore challenges in accountability contributing to this struggle. We highlight the work of watchdogs acting to protect Medicaid and conclude with considerations for future health reform.

Eligibility Criteria and Endpoints in Metastatic Renal Cell Carcinoma Trials

OBJECTIVES

Treatments for metastatic renal cell carcinoma (mRCC) are often compared across trials, but trial eligibility criteria and endpoints differ. In an effort to better align trials, the Definition for the Assessment of Time to event Endpoints in CANcer trials (DATECAN) project published recommendations in 2015 to be used in mRCC clinical trial design. We analyzed mRCC trial criteria to determine if DATECAN's recommendations were followed.

MATERIALS AND METHODS

We compared eligibility criteria across 29 phase 3 mRCC trials conducted between 2003 and 2019. We then evaluated endpoints used in 10 phase 3 trials activated between 2015 and 2019 to determine their compliance with DATECAN's recommendations.

RESULTS

Among the 29 trials, performance status, renal function, and disease characteristics differed in terms of requirements and measures used. In terms of endpoints, the 10 trials did not entirely follow DATECAN's recommendations. In total, 7/10 trials' primary endpoint was progression-free survival (PFS) as recommended; 4/9 trials used PFS as an endpoint but did not publish their definition of PFS, and the 5 that did, included "death from any cause" instead of DATECAN's recommendation of "death from kidney cancer."

CONCLUSIONS

Key eligibility criteria were somewhat inconsistent across the phase 3 mRCC trials studied. Endpoints in the newer trials did not align with DATECAN's recommendations. Not only is greater standardization needed to facilitate meta-analyses and cross-trial comparisons, but as evident from lack of adherence to DATECAN's recommendations, greater promotion and adoption of recommendations are needed to better harmonize trial design.

Exclusion of Pregnant Women from Clinical Trials during the Coronavirus Disease 2019 Pandemic: A Review of International Registries

OBJECTIVE

Pregnant women have been historically excluded from clinical trials for nonobstetric conditions, even during prior epidemics. The objective of this review is to describe the current state of research for pregnant women during the coronavirus disease 2019 (COVID-19) pandemic.

STUDY DESIGN

We conducted a search of international trial registries for trials relating to the novel coronavirus. The eligibility criteria for each trial were reviewed for inclusion/exclusion of pregnant women. Relevant data were extracted and descriptive statistics were calculated for individual and combined data. The total number of trials from each registry were compared, as well as the proportions of pregnancy-related trials within each.

RESULTS

Among 621,370 trials in the World Health Organization International Clinical Trials Registry, 927 (0.15%) were COVID-19 related. Of those, the majority (52%) explicitly excluded pregnancy or failed to address pregnancy at all (46%) and only 16 (1.7%) were pregnancy specific. When categorized by region, 688 (74.2%) of COVID-19 trials were in Asia, followed by 128 (13.8%) in Europe, and 66 (7.2%) in North America. Of the COVID-19 trials which included pregnant women, only three were randomized-controlled drug trials.

CONCLUSION

Approximately 1.7% of current COVID-19 research is pregnancy related and the majority of trials either explicitly exclude or fail to address pregnancy. Only three interventional trials worldwide involved pregnant women. The knowledge gap concerning the safety and efficacy of interventions for COVID-19 created by the exclusion of pregnant women may ultimately harm them. While "ethical" concerns about fetal exposure are often cited, it is in fact unethical to habitually exclude pregnant women from research.

KEY POINTS

· Pregnancy was excluded from past pandemic research.. · Pregnancy is being excluded from COVID-19 research.. · Exclusion of pregnant women is potentially harmful..

Few eligible for the newly recommended short course MDR-TB regimen at a large Mumbai private clinic

BACKGROUND

India has the world's highest tuberculosis burden, and Mumbai is particularly affected by multidrug resistant tuberculosis (MDR-TB). WHO recommends short, intensive treatment ("Short Course") for previously untreated pulmonary MDR-TB patients but does not require universal drug susceptibility testing (DST) before Short Course. DST would likely screen out many MDR-TB patients in places like Mumbai with significant drug resistance.

METHODS

MDR-TB patients at a private clinic were recruited for a prospective observational cohort. Short Course eligibility was evaluated by clinical criteria and DST results. Eligibility by DST was classified as rifampin monoresistance (as tested by Xpert MTB/RIF), rifampin, fluoroquinolones, and 2nd-line injectable drugs resistance (as tested by line probe assays) and resistance to other drugs.

RESULTS

Of 559 participants with MDR-TB, 33% met clinical eligibility for Short Course. DST for rifampin, fluoroquinolones, and 2nd-line injectable drugs excluded 74.7% of participants. Complete phenotypic DST excluded 96.6% of participants. Prior treatment with either 1st or 2nd-line drugs did not significantly affect eligibility.

CONCLUSIONS

In a global MDR-TB hotspot, < 5% of participants with MDR-TB were appropriate for Short Course by clinical characteristics and DST results. Rapid molecular testing would not sufficiently identify drug resistance in this population. Eligibility rates were not significantly reduced by prior TB treatment.

Cardiovascular Risk and Statin Eligibility of Young Adults After an MI: Partners YOUNG-MI Registry

BACKGROUND

Despite significant progress in primary prevention, the rate of MI has not declined in young adults.

OBJECTIVES

The purpose of this study was to evaluate statin eligibility based on the 2013 American College of Cardiology/American Heart Association guidelines for treatment of blood cholesterol and 2016 U.S. Preventive Services Task Force recommendations for statin use in primary prevention in a cohort of adults who experienced a first-time myocardial infarction (MI) at a young age.

METHODS

The YOUNG-MI registry is a retrospective cohort from 2 large academic centers, which includes patients who experienced an MI at age ≤50 years. Diagnosis of type 1 MI was adjudicated by study physicians. Pooled cohort risk equations were used to estimate atherosclerotic cardiovascular disease risk score based on data available prior to MI or at the time of presentation.

RESULTS

Of 1,685 patients meeting inclusion criteria, 210 (12.5%) were on statin therapy prior to MI and were excluded. Among the remaining 1,475 individuals, the median age was 45 years, there were 294 (20%) women, and 846 (57%) had ST-segment elevation MI. At least 1 cardiovascular risk factor was present in 1,225 (83%) patients. The median 10-year atherosclerotic cardiovascular disease risk score of the cohort was 4.8% (interquartile range: 2.8% to 8.0%). Only 724 (49%) and 430 (29%) would have met criteria for statin eligibility per the 2013 American College of Cardiology/American Heart Association guidelines and 2016 U.S. Preventive Services Task Force recommendations, respectively. This finding was even more pronounced in women, in whom 184 (63%) were not eligible for statins by either guideline, compared with 549 (46%) men (p < 0.001).

CONCLUSIONS

The vast majority of adults who present with an MI at a young age would not have met current guideline-based treatment thresholds for statin therapy prior to their MI. These findings highlight the need for better risk assessment tools among young adults.

Medicaid, family spending, and the financial implications of crowd-out

A primary purpose of health insurance is to protect families from medical expenditure risk. Despite this goal and despite the fact that research has found that Medicaid can crowd out private coverage, little is known about the effect of Medicaid on families' spending patterns. This paper implements a simulated instrumental variables strategy with data from the Consumer Expenditure Survey to estimate the effect of an additional family member becoming eligible for Medicaid on family-level health insurance coverage and spending. The results indicate that an additional family member becoming eligible for Medicaid increases the number of people in the family with Medicaid coverage by about 0.135-0.142 and decreases the likelihood that a family has any medical spending in a quarter by 2.7 percentage points. As previous research often finds with different data sets, I find evidence that Medicaid expansions crowd out some private coverage. Unlike most other data sets, the Consumer Expenditure Survey allows for considering the financial implications of crowd-out. The results indicate that families that transition from private coverage to Medicaid are able to spend significantly less on health insurance expenses, meaning Medicaid expansions can be welfare improving for families even when crowd-out occurs.

Considering Eligibility for Studies of Deep Brain Stimulation for Treatment-Resistant Depression: Insights From a Clinical Trial in Unipolar and Bipolar Depression

BACKGROUND

While electroconvulsive therapy (ECT) is the most effective treatment for major depression (major depressive disorder [MDD]), deep brain stimulation (DBS) has shown efficacy in patients who have not received benefit from ECT. Studies of DBS are small, and a better understanding of which eligibility criteria lead to exclusion may help achieve a more appropriate balance between scientific rigor and generalizability in future trials. We assessed the rate and reasons for exclusion from a study of DBS for treatment-resistant MDD and bipolar type II (BPII) depression.

METHODS

One thousand ninety-eight adults were screened for a study of DBS for MDD or BPII. Reasons for exclusion were documented. Descriptive statistics were calculated for each reason for exclusion for the entire sample as well as the self-reported MDD and BPII subgroups.

RESULTS

Ninety-eight percent (98%) of patients screened were excluded. Exclusion due to lack of interest or inability to relocate to the study site was high (41%). Following this, primary reasons for exclusion were lack of prior ECT and presence of psychiatric/general medical comorbidity. Patients with MDD were more likely to be excluded because of inadequate ECT, whereas patients with BPII depression were more likely to be excluded for comorbid psychiatric diagnoses and not meeting minimum severity criteria.

CONCLUSIONS

A surprisingly high number of potential participants were excluded because of lack of adequate ECT. This suggests that many patients self-identifying as "treatment resistant" have not truly exhausted available, evidence-based treatments. Overall exclusion rate was high, with key differences in exclusion reasons between the MDD and BPII subgroups. These findings can inform design of future clinical trials for treatment-resistant unipolar and bipolar depression.Clinicaltrials.gov Identifier: NCT00367003.

[Update assessment of mental health diseases for sick pay--experience of the AWMF guideline]

In August 2012, we reported (VersMed 1/2014, S. 9) the results for the first 12 months following implementation of AWMF guideline 051-029 in the medical assessment of mental health diseases with a view to sick pay and supplementary disability insurance (BU). Today we provide an update of the experience gained in the last three years. We are glad to report that the results have remained stable.

EFSUMB COMPASS for Rheumatologists dissemination and implementation--an international survey

AIM

The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) competency assessment (COMPASS) for rheumatologists performing musculoskeletal ultrasound (MSUS) was developed and published 2 years ago. It consists of a 3 level competency system. The objective of this study was to evaluate how the EFSUMB COMPASS has been disseminated and implemented and to assess the potential obstacles encountered.

MATERIALS AND METHODS

A questionnaire was developed and distributed by e-mail to all rheumatologists certified as EFSUMB level 3.

RESULTS

Seventeen (85%) rheumatologists considered that the EFSUMB COMPASS is useful for training MSUS. The majority of them (17; 85%) had informed their colleagues or national rheumatology societies about the EFSUMB COMPASS. The most common obstacle encountered for the implementation of the COMPASS was the lack of time for supervision of the trainees (9; 45%). A total of 83 rheumatologists had been trained and assessed for competency in the three EFSUMB levels.

CONCLUSION

This survey highlights the current status of EFSUMB COMPASS implementation in European countries with an expected increased number of rheumatologists being able to train and assess new trainees. Still, more efforts should be done for a higher implementation of EFSUMB COMPASS across European countries.

Accuracy of Assessment of Eligibility for Early Medical Abortion by Community Health Workers in Ethiopia, India and South Africa

OBJECTIVE

To assess the accuracy of assessment of eligibility for early medical abortion by community health workers using a simple checklist toolkit.

DESIGN

Diagnostic accuracy study.

SETTING

Ethiopia, India and South Africa.

METHODS

Two hundred seventeen women in Ethiopia, 258 in India and 236 in South Africa were enrolled into the study. A checklist toolkit to determine eligibility for early medical abortion was validated by comparing results of clinician and community health worker assessment of eligibility using the checklist toolkit with the reference standard exam.

RESULTS

Accuracy was over 90% and the negative likelihood ratio <0.1 at all three sites when used by clinician assessors. Positive likelihood ratios were 4.3 in Ethiopia, 5.8 in India and 6.3 in South Africa. When used by community health workers the overall accuracy of the toolkit was 92% in Ethiopia, 80% in India and 77% in South Africa negative likelihood ratios were 0.08 in Ethiopia, 0.25 in India and 0.22 in South Africa and positive likelihood ratios were 5.9 in Ethiopia and 2.0 in India and South Africa.

CONCLUSION

The checklist toolkit, as used by clinicians, was excellent at ruling out participants who were not eligible, and moderately effective at ruling in participants who were eligible for medical abortion. Results were promising when used by community health workers particularly in Ethiopia where they had more prior experience with use of diagnostic aids and longer professional training. The checklist toolkit assessments resulted in some participants being wrongly assessed as eligible for medical abortion which is an area of concern. Further research is needed to streamline the components of the tool, explore optimal duration and content of training for community health workers, and test feasibility and acceptability.

Contemporary Strategies for Rapid Recovery Total Hip Arthroplasty

Over the past several years, rapid recovery protocols for total hip arthroplasty have evolved in parallel with advancements in pain management, regional anesthesia, focused rehabilitation, and the patient selection process. As fiscal pressures from payers of health care increase, surgical outcomes and complications are being scrutinized, which evokes a sense of urgency for arthroplasty surgeons as well as hospitals. The implementation of successful accelerated recovery pathways for total hip arthroplasty requires the coordinated efforts of surgeons, practice administrators, anesthesiologists, nurses, physical and occupational therapists, case managers, and postacute care providers. To optimize performance outcomes, it is important for surgeons to select patients who are eligible for rapid recovery. The fundamental tenets of multimodal pain control, regional anesthesia, prudent perioperative blood management, venous thromboembolic prophylaxis, and early ambulation and mobility should be collectively addressed for all patients who undergo primary total hip replacement.

2013 ACC/AHA versus 2004 NECP ATP III Guidelines in the Assignment of Statin Treatment in a Korean Population with Subclinical Coronary Atherosclerosis

Background

The usefulness of the 2013 ACC/AHA guidelines for the management of blood cholesterol in the Asian population remains controversial. In this study, we investigated whether eligibility for statin therapy determined by the 2013 ACC/AHA guidelines is better aligned with the presence of subclinical coronary atherosclerosis detected by CCTA (coronary computed tomography angiography) compared to the previously recommended 2004 NCEP ATP III guidelines.

Methods

We collected the data from 5,837 asymptomatic subjects who underwent CCTA using MDCT during routine health examinations. Based on risk factor assessment and lipid data, we determined guideline-based eligibility for statin therapy according to the 2013 ACC/AHA and 2004 NCEP ATP III guidelines. We defined the presence and severity of subclinical coronary atherosclerosis detected in CCTA according to the presence of significant coronary artery stenosis (defined as >50% stenosis), plaques, and the degree of coronary calcification.

Results

As compared to the 2004 ATP III guidelines, a significantly higher proportion of subjects with significant coronary stenosis (61.8% vs. 33.8%), plaques (52.3% vs. 24.7%), and higher CACS (CACS >100, 63.6% vs. 26.5%) was assigned to statin therapy using the 2013 ACC/AHA guidelines (P < .001 for all variables). The area under the curves of the pooled cohort equation of the new guidelines in detecting significant stenosis, plaques, and higher CACS were significantly higher than those of the Framingham risk calculator.

Conclusions

Compared to the previous ATP III guidelines, the 2013 ACC/AHA guidelines were more sensitive in identifying subjects with subclinical coronary atherosclerosis detected by CCTA in an Asian population.

Requirements for blood and blood components intended for transfusion or for further manufacturing use. Final rule

The Food and Drug Administration (FDA) is amending the regulations applicable to blood and blood components, including Source Plasma, to make the donor eligibility and testing requirements more consistent with current practices in the blood industry, to more closely align the regulations with current FDA recommendations, and to provide flexibility to accommodate advancing technology. In order to better assure the safety of the nation's blood supply and to help protect donor health, FDA is revising the requirements for blood establishments to test donors for infectious disease, and to determine that donors are eligible to donate and that donations are suitable for transfusion or further manufacture. FDA is also requiring establishments to evaluate donors for factors that may adversely affect the safety, purity, and potency of blood and blood components or the health of a donor during the donation process. Accordingly, these regulations establish requirements for donor education, donor history, and donor testing. These regulations also implement a flexible framework to help both FDA and industry to more effectively respond to new or emerging infectious agents that may affect blood product safety.

Comparative analysis of specialization in palliative medicine processes within the World Health Organization European region

CONTEXT

Palliative medicine (PM), still in the development phase, is a new, growing specialty aimed at caring for both oncology and non-oncology patients. There is still confusion about the training offered in the various European PM certification programs.

OBJECTIVES

To provide a detailed, comparative update and analysis of the PM certification process in Europe, including the different training approaches and their main features.

METHODS

Experts from each country completed an online survey addressing historical background, program name, training requirements, length of time in training, characteristic and content, official certifying institution, effectiveness of accreditation, and 2013 workforce capacity. We prepared a comparative analysis of the data provided.

RESULTS

In 2014, 18 of 53 European countries had official programs on specialization in PM (POSPM): Czech Republic, Denmark, Finland, France, Georgia, Germany, Hungary, Ireland, Israel, Italy, Latvia, Malta, Norway, Poland, Portugal, Romania, Slovakia, and the U.K. Ten of these programs were begun in the last five years. The PM is recognized as a "specialty," "subspecialty," or "special area of competence," with no substantial differences between the last two designations. The certification contains the term "palliative medicine" in most countries. Clinical training varies, with one to two years being the most frequent duration. There is a clear trend toward establishing the POSPM as a mandatory condition for obtaining a clinical PM position in countries' respective health systems.

CONCLUSION

PM is growing as a specialization field in Europe. Processes leading to certification are generally long and require substantial clinical training. The POSPM education plans are heterogeneous. The European Association for Palliative Care should commit to establishing common learning standards, leading to additional European-based recognition of expertise in PM.

Optimal methods for measuring eligibility for liver transplant in hepatocellular carcinoma patients undergoing transarterial chemoembolization

BACKGROUND & AIMS

We investigated the optimal radiologic method for measuring hepatocellular carcinoma (HCC) treated by transarterial chemoembolization (TACE) in order to assess suitability for liver transplantation (LT).

METHODS

271 HCC patients undergoing TACE prior to LT were classified according to both Milan and up-to-seven criteria after TACE by using the enhancement or size method on computed tomography images. The cumulative incidence function curves with competing risks regression was used in post-LT time-to-recurrence analysis. The predictive accuracy for recurrence was compared using area under the time-dependent receiver operating characteristic curves (AUC) estimation.

RESULTS

Of the 271 patients, 246 (90.8%) and 164 (60.5%) fell within Milan and 252 (93.0%) and 210 (77.5%) fell within up-to-seven criteria, when assessed by enhancement and size methods, respectively. Competing risks regression analyses adjusting for covariates indicated that meeting the criteria by enhancement and by size methods was independently related to post-LT time-to-recurrence in the Milan or up-to-seven model. Higher AUC values were observed with the size method only in the up-to-seven model (p<0.05). Mean differences in the sum of tumor diameter and number of tumors between pathologic and radiologic findings were significantly less by the enhancement method (p<0.05). Cumulative incidence curves showed similar recurrence results between patients with and without prior TACE within the criteria based on either method, except for the within up-to-seven by the enhancement method (p=0.017).

CONCLUSIONS

The enhancement method is a reliable tool for assessing the control or downstaging of HCC within Milan after TACE, although the size method may be preferable when applying the up-to-seven criterion.

An approach for utilizing clinical statements in HL7 RIM to evaluate eligibility criteria

The HL7 RIM (Reference Information Model) is a commonly used standard for the exchange of clinical data and can be employed for integrating the patient care and clinical research domains. Yet it is not sufficiently well specified to ensure a canonical representation of structured clinical data when used for the automated evaluation of eligibility criteria from a clinical trial protocol. We present an approach to further constrain the RIM to create a common information model to hold clinical data. In order to demonstrate our approach, we identified 132 distinct data elements from 10 rich clinical trails. We then defined a taxonomy to (i) identify the types of data elements that would need to be stored and (ii) define the types of predicate that would be used to evaluate them. This informed the definition of a pattern used to represent the data, which was shown to be sufficient for storing and evaluating the clinical statements required by the trials.

Evaluating predictive modeling algorithms to assess patient eligibility for clinical trials from routine data

BACKGROUND

The necessity to translate eligibility criteria from free text into decision rules that are compatible with data from the electronic health record (EHR) constitutes the main challenge when developing and deploying clinical trial recruitment support systems. Recruitment decisions based on case-based reasoning, i.e. using past cases rather than explicit rules, could dispense with the need for translating eligibility criteria and could also be implemented largely independently from the terminology of the EHR's database. We evaluated the feasibility of predictive modeling to assess the eligibility of patients for clinical trials and report on a prototype's performance for different system configurations.

METHODS

The prototype worked by using existing basic patient data of manually assessed eligible and ineligible patients to induce prediction models. Performance was measured retrospectively for three clinical trials by plotting receiver operating characteristic curves and comparing the area under the curve (ROC-AUC) for different prediction algorithms, different sizes of the learning set and different numbers and aggregation levels of the patient attributes.

RESULTS

Random forests were generally among the best performing models with a maximum ROC-AUC of 0.81 (CI: 0.72-0.88) for trial A, 0.96 (CI: 0.95-0.97) for trial B and 0.99 (CI: 0.98-0.99) for trial C. The full potential of this algorithm was reached after learning from approximately 200 manually screened patients (eligible and ineligible). Neither block- nor category-level aggregation of diagnosis and procedure codes influenced the algorithms' performance substantially.

CONCLUSIONS

Our results indicate that predictive modeling is a feasible approach to support patient recruitment into clinical trials. Its major advantages over the commonly applied rule-based systems are its independency from the concrete representation of eligibility criteria and EHR data and its potential for automation.

[Trial helplessness of defendant healthcare facilities in cases concerning nosocomial infections]

The number of pecuniary cases involving patient claims due to nosocomial infections has been increasing for many years, and with it, the amount of adjudged compensations has also been increasing. In this situation, it is important for defendant healthcare facilities to implement a proper policy, both before the trial and during the court proceedings. Unfortunately, as a rule, defendant facilities commit a variety of errors, such as: wrong strategy, inability to cooperate on the part of those involved in the matter and improper preparation and usage of evidence. The result is that the risk of unfavorable assessment of the case increases significantly.

Choosing the right strategy for point-of-service collections

Healthcare organizations should keep three key considerations in mind when selecting and implementing a pricing transparency tool: The approach that the tool will take (e.g., claims-based or contract-based). The training required of staff. The benchmarks that will be used to measure performance, ROI, and satisfaction of patients and staff.

Proactive approach identifies benefits

The University of Iowa Hospitals and Clinics in Iowa City, has developed strategies to identify uninsured patients early in the stay, and help them access ongoing care in the community. Twelve healthcare benefit assistance program social workers educate patients and families about financial options and help them apply for government-sponsored programs. Through a Revolving Fund agreement, the hospital pays the Medicaid rate to post-acute facilities while patients' Social Security Disability is pending and is paid back when the disability coverage is approved. Dedicated social workers help patients who need brand name medications and can't afford them sign up for national pharmaceutical assistance programs.

Think like a payer when patients are uninsured

Hospitals need to develop a detailed policy of when and how they'll provide post-acute financial assistance for uninsured or under-insured patients. The policy should allow staff to get real time decisions about what will be covered. Staff should apply the policy consistently to all patients in all situations. A policy frees up case managers to coordinate care for all their patients rather than spending hours at a time trying to line up post-acute care for unfunded patients.

Eligibility, compliance and persistence of extended adjuvant endocrine therapy for breast cancer

BACKGROUND

Extended therapy (ET) beyond the standard five years of tamoxifen-containing treatment is a widely discussed therapy option in adjuvant endocrine breast cancer (BC) therapy which might offer an opportunity for further protection against late relapses. In this study we evaluated eligibility, compliance and persistence of extended adjuvant endocrine BC therapy.

PATIENTS AND METHODS

Data concerning all BC patients (≤75 years) who initiated endocrine adjuvant therapy between 1999 and 2005 (n = 286) was analyzed.

RESULTS

One hundred and thirty-eight patients were valid candidates for an ET according current guidelines; this represents 48.3% of the individuals who started endocrine therapy five years ago. Of these, 89 (64.5%) received a corresponding offer/recommendation by their treating physicians. Advanced age (p = 0.002), favorable disease stage (p = 0.011), and follow-up at a general practitioner (p < 0.001) were significant factors where a recommendation for an ET was not made. Of the 89 patients who were offered an ET, 64 followed this proposal (compliance: 84.7%). Eighteen patients (28.1%) were non-persistent to the ET; therapy-related adverse effects were the main reason for discontinuation. Sixteen patients received an ET beyond current guidelines (tamoxifen or an aromatase inhibitor alone was given longer than five years); this represents 11.0% of all patients who completed five years of endocrine therapy.

CONCLUSIONS

Only a minority of the patients who started an endocrine therapy were actually eligible for an ET. Patients who were offered/recommended an ET had a high rate of compliance and persistence. Efforts should be made to make sure that all physicians, above all general practitioners, who are involved in the treatment of BC patients, are provided with current therapy guidelines as to guarantee an optimal patient management.

Longitudinal patterns of Medicaid and Medicare coverage among disability cash benefit awardees

This article explores the role of the Social Security Disability Insurance (DI) and Supplemental Security Income (SSI) cash benefit programs in providing access to public health insurance coverage among working-aged people with disabilities, using a sample of administrative records spanning 84 months. We find that complex longitudinal interactions between DI and SSI eligibility determine access to and timing of Medicare and Medicaid coverage. SSI plays an important role in providing a pathway to Medicaid coverage for many low-income individuals during the 29-month combined DI and Medicare waiting periods, when Medicare coverage is not available. After Medicare eligibility kicks in, public health insurance coverage is virtually complete among awardees with some DI involvement. Medicaid coverage continues at or above 90 percent after 2 years for SSI-only awardees. Many people who exit SSI retain their Medicaid coverage, but the gap in coverage between stayers and those who leave SSI increases over time.

[Analysis of the explicit guarantees of health inclusion criteria for elderly burned patients]

BACKGROUND

The guidelines for the treatment of severely burned patients, included in the explicit guarantees in health care (GES), accept having a Garces' index over 70, among others, as an inclusion criterion. This criterion allows elderly patients with small total burn surface area (TBSA) to have access to GES.

AIM

To analyze if a universal access to GES for this group of patients is justified.

MATERIAL AND METHODS

Revision of medical records of adult patients admitted to a burn service. Causative agent, TBSA, associated illnesses and outcome were compared between 218 subjects aged 65 years or more and 720 subjects aged less than 65 years.

RESULTS

Older subjects had smaller TBSA, a lower prevalence of inhalation injury and more associated diseases. Their lethality was three times greater than that of younger subjects and their risk of dying. When adjusting for TBSA, presence of inhalation injury and associated diseases was 11 times greater.

CONCLUSIONS

The inclusion of older people with lower TBSA in the explicit guarantees in health is fully justified, considering the lethality of burns in this age group.

Administrative simplification: adoption of operating rules for eligibility for a health plan and health care claim status transactions. Interim final rule with comment period

Section 1104 of the Administrative Simplification provisions of the Patient Protection and Affordable Care Act (hereafter referred to as the Affordable Care Act) establishes new requirements for administrative transactions that will improve the utility of the existing HIPAA transactions and reduce administrative costs. Specifically, in section 1104(b)(2) of the Affordable Care Act, Congress required the adoption of operating rules for the health care industry and directed the Secretary of Health and Human Services to "adopt a single set of operating rules for each transaction * * * with the goal of creating as much uniformity in the implementation of the electronic standards as possible." This interim final rule with comment period adopts operating rules for two Health Insurance Portability and Accountability Act of 1996 (HIPAA) transactions: eligibility for a health plan and health care claim status. This rule also defines the term "operating rules" and explains the role of operating rules in relation to the adopted transaction standards. In general, transaction standards adopted under HIPAA enable electronic data interchange through a common interchange structure, thus minimizing the industry's reliance on multiple formats. Operating rules, in turn, attempt to define the rights and responsibilities of all parties, security requirements, transmission formats, response times, liabilities, exception processing, error resolution and more, in order to facilitate successful interoperability between data systems of different entities.

[Neurosis as a mental disease--controversies surrounding insurance certification]

In the years 2008-2009, experts from the Department of Forensic Medicine in Katowice issued a dozen of expert opinions on the nature of the neurosis, addressing the question whether neurosis is a mental disease as understood under the general insurance conditions or whether neurosis is a mental disease as such. All the submitted cases involved policemen who had been diagnosed as neurotic and were refused insurance payments since the insurance company claimed payments could not have been effected due to the diagnosis of mental disease, meaning neurosis in the discussed cases. The plaintiffs invoked the fact that medical terminology describes such states as "mental disorders". In the article, the authors present the adopted model of opinionating, make an attempt at explaining the controversy and discuss the subtleties of medical terminology and the core differences between the terms "mental disorder" and "mental disease" as employed in medico-legal opinionating in such cases.

Bariatric surgery: a primer

OBJECTIVE

To review the management of bariatric surgical patients.

QUALITY OF EVIDENCE

MEDLINE, EMBASE, and Cochrane Library databases were searched, as well as PubMed US National Library, from January 1950 to December 2009. Evidence was levels I, II, and III.

MAIN MESSAGE

Bariatric surgery should be considered for obese patients at high risk of morbidity and mortality who have not achieved adequate weight loss with lifestyle and medical management and who are suffering from the complications of obesity. Bariatric surgery can result in substantial weight loss, resolution of comorbid conditions, and improved quality of life. The patient's weight-loss history; his or her personal accountability, responsibility, and comprehension; and the acceptable level of risk must be taken into account. Complications include technical failure, bleeding, abdominal pain, nausea or vomiting, excess loose skin, bowel obstruction, ulcers, and anastomotic stricture. Lifelong monitoring by a multidisciplinary team is essential.

CONCLUSION

Limited long-term success of behavioural and pharmacologic therapies in severe obesity has led to renewed interest in bariatric surgery. Success with bariatric surgery is more likely when multidisciplinary care providers, in conjunction with primary care providers, assess, treat, monitor, and evaluate patients before and after surgery. Family physicians will play a critical role in counseling patients about bariatric surgery and will need to develop skills in managing these patients in the long-term.

How effective is your organization's financial assistance eligibility program?

Steps to take in determining whether your organization's financial assistance eligibility program should be revamped include the following: Conduct a "gap analysis" to evaluate your organization's specific needs. Communicate with other facilities that have faced similar problems to uncover what solutions worked--or didn't work--for them. Recognize that identifying coverage for the underinsured and uninsured requires a special skill set.

Influence of subject eligibility criteria on compliance with National Institutes of Health guidelines for inclusion of women, minorities, and children in treatment research

BACKGROUND

Many alcohol treatment outcome studies exclude some patients with particular problems, such as psychiatric disorders, noncompliance, and homelessness. Such criteria may increase the likelihood of a study being successfully conducted, but may also have the unintended consequence of reducing a study's ability to comply with National Institutes of Health guidelines for inclusion of racial minorities, women, and children in treatment research.

METHODS AND RESULTS

This paper examined this issue empirically using 5 prior studies of treatment systems enrolling over 100,000 alcohol patients. Widely used eligibility criteria in the alcohol treatment field typically exclude between one-fifth to one-third of patients from enrolling in research. Under several eligibility criteria, most notably those for drug use and social/residential instability, women and African-American patients are substantially more likely to be excluded than are men and non-African-American patients, respectively.

CONCLUSIONS

In designing treatment studies with many eligibility criteria, researchers may therefore inadvertently be thwarting their own good faith efforts to ensure that a range of vulnerable populations are able to participate in research. We analyze the implications of this dilemma for the generalizability of treatment results and for research design, and provide data that may help researchers working in different treatment systems estimate the impact of various eligibility criteria.

Medication therapy management survey of the prescription drug plans

OBJECTIVE

To evaluate the preliminary development and implementation plans for medication therapy management (MTM) services across plan sponsors for the Medicare Part D Prescription Drug Plans (PDPs) and provide pharmacists with insights for MTM development.

DESIGN

Cross-sectional survey.

SETTING

United States.

PARTICIPANTS

307 individual contacts from Medicare Advantage or stand-alone PDPs.

INTERVENTION

A survey comprising questions about the PDP demographics, plans and implementation, beneficiary eligibility criteria, scope of services, providers of services, and payment structure for MTM services was e-mailed and mailed in November 2005.

MAIN OUTCOME MEASURES

Descriptive and bivariate analysis of survey items.

RESULTS

A total of 97 usable surveys were completed, a 31.5% response rate. Almost all respondents had a plan in place for MTM services. The majority of PDPs perceived that MTM would have a moderate benefit to their organization. Most PDPs planned to focus efforts on diabetes, heart failure, and other forms of cardiovascular disease. Overwhelmingly, PDPs planned to follow the Centers for Medicare & Medicaid Services (CMS) mandate for criteria regarding beneficiary eligibility. Only 8.2% of respondents planned to use a "traditional" pharmacist, such as a community, long-term care, hospital, or clinic pharmacist. The majority of PDPs (53.6%) planned to employ managed care pharmacists to administer MTM services.

CONCLUSION

Pharmacists are eager to implement MTM services and are looking for PDPs to provide a path of implementation and reimbursement. Many PDPs were planning to deliver MTM services internally using health professional staff, thereby limiting the extent of participation of community, long-term care, hospital and health-system, and clinic-based pharmacists. Further research and advocacy are required to ensure that MTM services accomplish the true intent of the congressional and CMS mandates.