Healthcare utilization and clinical outcomes after ablation of atrial fibrillation in patients with and without insertable cardiac monitoring.

BACKGROUND: Compared with short-term electrocardiogram (ECG) monitors, insertable cardiac monitors (ICMs) have been shown to increase atrial fibrillation (AF) detection rates and the opportunity to treat recurrent AF in patients postablation. OBJECTIVE: To examine healthcare utilization and clinical outcomes following AF ablation, in patients with vs without ICM. METHODS: Retrospective analysis pooling Optum Clinformatics and Medicare Fee-for-service 5% Sample claims databases. Patients with an AF ablation between January 1, 2011, and March 31, 2018 who received an ICM implant within 1 year pre-/postablation were propensity score matched 1:3 to patients without ICM. Outcomes included AF-related healthcare utilization, medication use, and occurrence of composite severe cardiovascular events (stroke / transient ischemic attack, major bleeds, systemic embolism, AF- or heart failure-related hospitalization, or death). RESULTS: A total of 1000 ICM patients and 2998 non-ICM patients were included. During mean follow-up of 33 ± 16 months postablation, ICM patients experienced significantly fewer severe cardiovascular events (1.09 ± 2.22 vs 1.37 ± 4.19, P = .008) and associated costs ($20,757 vs $29,106, P = .0005). ICM patients had a greater number of AF-related clinic visits (16.8 vs 11.6 visits, P < .0001) and were more likely to receive a repeat ablation (38.7% vs 32.4%, P = .0003). Total all-cause costs during follow-up were not statistically different. Discontinuation of oral anticoagulation was higher in ICM patients at 1 year (44% vs 31%, P < .0001) and 2 years (73% vs 64%, P = .0012). CONCLUSION: A shift from acute, reactive care to routine outpatient management was observed in patients with long-term ECG monitoring. Results suggest closer patient management in patients with long-term monitoring after an AF ablation and an improvement in outcomes, at similar overall cost.

Regional variation in colorectal cancer testing and geographic availability of care in a publicly insured population.

Despite its demonstrated effectiveness, colorectal cancer (CRC) testing is suboptimal, particularly in vulnerable populations such as those who are publicly insured. Prior studies provide an incomplete picture of the importance of the intersection of multilevel factors affecting CRC testing across heterogeneous geographic regions where vulnerable populations live. We examined CRC testing across regions of North Carolina by using population-based Medicare and Medicaid claims data from disabled individuals who turned 50 years of age during 2003-2008. We estimated multilevel models to examine predictors of CRC testing, including distance to the nearest endoscopy facility, county-level endoscopy procedural rates, and demographic and community contextual factors. Less than 50% of eligible individuals had evidence of CRC testing; men, African-Americans, Medicaid beneficiaries, and those living furthest away from endoscopy facilities had significantly lower odds of CRC testing, with significant regional variation. These results can help prioritize intervention strategies to improve CRC testing among publicly insured, disabled populations.

Social ecology of asthma: engaging stakeholders in integrating health behavior theories and practice-based evidence through systems mapping.

This article describes a process for integrating health behavior and social science theories with practice-based insights using participatory systems thinking and diagramming methods largely inspired by system dynamics methods. This integration can help close the gap between research and practice in health education and health behavior by offering a systematic approach to bring together stakeholders across multiple domains. In this process we create a diagram using constructs from multiple health behavior theories at all levels of the social ecological framework as variables in causal loop diagrams. The goal of this process is to elucidate the reciprocal relationships between explanatory factors at various levels of the social ecological framework that render so many public health problems intractable. To illustrate, we detail a theory-based, replicable process for creating a qualitative diagram to enrich understanding of caregiver and provider behavior around adherence to pediatric asthma action plans. We describe how such diagramming can serve as the foundation for translating evidence into practice to address real-world challenges. Key insights gained include recognition of the complex, multilevel factors affecting whether, and how effectively, parents/caregivers and medical providers co-create an asthma action plan, and important "feedback" dynamics at play that can support or derail ongoing collaboration. Although this article applies this method to asthma action plan adherence in children, the method and resulting diagrams are applicable and adaptable to other health behaviors requiring continuous, daily action.

The Development and Application of the RAND Program Classification Tool.

As a result of extended military engagements in Iraq and Afghanistan during the past decade, the U.S. Department of Defense (DoD) has implemented numerous programs to support servicemembers and family members who experience difficulty handling stress, face mental health challenges, or are affected by a traumatic brain injury (TBI). As these efforts have proliferated, it has become more challenging to monitor these programs and to avoid duplication. To support DoD in this area, RAND compiled a comprehensive catalog of DoD-funded programs that address psychological health and TBI. In creating the catalog of programs, RAND recognized the need to consistently describe and compare multiple programs according to a set of core program characteristics, driven largely by the lack of a single, clear, widely accepted operational definition of what constitutes a program. To do this, RAND developed the RAND Program Classification Tool (R-PCT) to allow users to describe and compare programs, particularly those related to psychological health and TBI, along eight key dimensions that that define a program. The tool consists of a set of questions and responses for consistently describing various aspects of programs, along with detailed guidance regarding how to select the appropriate responses. The purpose of this article is to describe the R-PCT, to help potential users understand how it was developed, and to explain how the tool can be used.

The RAND Online Measure Repository for Evaluating Psychological Health and Traumatic Brain Injury Programs.

Since 2001, U.S. military forces have been engaged in extended conflicts in Iraq and Afghanistan. While most military personnel cope well across the deployment cycle, the operational tempo may raise the risk of mental health problems, such as post-traumatic stress disorder (PTSD) and major depression, and consequences from traumatic brain injury (TBI). To support servicemembers and their families as they cope with these challenges, the U.S. Department of Defense has implemented numerous programs addressing biological, social, spiritual, and holistic influences on psychological health along the resilience, prevention, and treatment continuum that focus on a variety of clinical and nonclinical concerns. As these efforts have proliferated, evaluating their effectiveness has become increasingly important. To support the design and implementation of program evaluation, RAND developed the RAND Online Measure Repository (ROMR) which indexes and describes measures related to psychological health and TBI. The ROMR is a publicly accessible, online, searchable database containing 171 measures related to psychological health and TBI. This article describes the rationale for developing the ROMR, the content included in the ROMR, and its potential in both civilian and military populations. The ROMR includes information about measure domains, psychometrics, number of items, and costs, which can inform the selection of measures for program evaluations. Included measures address domains of primary importance to psychological health (PTSD, depression, anxiety, suicidal ideation, and resiliency) and TBI (cognition, executive functioning, and memory). Also identified are measures relevant to military units, such as unit cohesion and force readiness.

Programs Addressing Psychological Health and Traumatic Brain Injury Among U.S. Military Servicemembers and Their Families.

Over the last decade, U.S. military forces have been engaged in extended conflicts that are characterized by increased operational tempo, most notably in Iraq and Afghanistan. While most military personnel cope well across the deployment cycle, many will experience difficulties handling stress at some point; will face psychological health challenges, such as post-traumatic stress disorder or major depression; or will be affected by the short- and long-term psychological and cognitive consequences of a traumatic brain injury (TBI). Over the past several years, the Department of Defense (DoD) has implemented numerous programs that address various components of psychological health along the resilience, prevention, and treatment continuum and focus on a variety of clinical and nonclinical concerns. This article provides detail from an evaluation of 211 programs currently sponsored or funded by DoD to address psychological health and TBI, along with descriptions of how programs relate to other available resources and care settings. It also provides recommendations for clarifying the role of programs, examining gaps in routine service delivery that could be filled by programs, and reducing implementation barriers. Barriers include inadequate funding and resources, concerns about the stigma associated with receiving psychological health services, and inability to have servicemembers spend adequate time in programs. The authors found that there is significant duplication of effort, both within and across branches of service. As each program develops its methods independently, it is difficult to determine which approaches work and which are ineffective. Recommendations include strategic planning, centralized coordination, and information-sharing across branches of service, combined with rigorous evaluation. Programs should be evaluated and tracked in a database, and evidence-based interventions should be used to support program efforts.

Feasibility and Design Options for a Potential Entity to Research the Comparative Effectiveness of Medical Treatments.

In 2008, the Massachusetts state legislature mandated an examination of the feasibility of the state's participation in establishing a comparative effectiveness center (CEC) and requested recommendations for the entity's design. "Comparative effectiveness" research involves the direct comparative assessment of the efficacy and cost-effectiveness of health care interventions and strategies. The center's findings would guide purchasing and payment decisions related to medical procedures, devices, drugs, and biologics by public- and private-sector organizations. The state has several options in terms of its approach to comparative effectiveness research. It could establish an interstate CEC that synthesizes existing findings for regional decisionmakers, it could establish an interstate CEC that supports new research, it could join an existing CEC, it could join the Drug Effectiveness Review Project and the Medicare Evidence-Based Decisions Project and also establish a regional center, or it could elect not to establish a CEC at all. An exploration of the options and the types of research that could be sponsored reveals that all of the options are potentially feasible, but the legislature's decision with regard to design must consider the level of prioritization of comparative effectiveness research relative to other approaches to improving health care quality and reducing spending growth.

Improving Access to Medicines for Non-Communicable Diseases in the Developing World.

Non-communicable diseases (NCDs) now account for the majority of global morbidity and mortality and are increasingly affecting developing countries whose under-resourced health care systems also have to handle a high burden of infectious disease. To counter the global devastation caused by NCDs, the United Nations General Assembly decided to "set a new global agenda" and convened a high-level meeting on NCDs in September 2011. In connection with this meeting, the authors of this article took a first step toward developing a policy research agenda for improving access to NCD medicines in developing countries, a step that the research-based pharmaceutical industry, in particular, can carry forward as part of broader global efforts to combat NCD. The authors provide a framework for understanding the obstacles to access for NCD medicines, review specific issues to be confronted within each obstacle in the developing world, identify promising ideas for improving access to NCD medicines, and point to several highly promising areas for the research-based pharmaceutical industry to focus on as it develops its NCD policy research program in close collaboration with other key stakeholders.

Policy Implications of the Use of Retail Clinics.

Retail clinics, located within larger retail stores, treat a limited number of acute conditions and offer a small set of preventive services. Although there are nearly 1,200 such clinics in the United States, a great deal about their utilization, relationships with other parts of the health care system, and quality of care remains unknown. The federal government has taken only limited action regarding retail clinics, and little evidence exists about the potential costs and benefits of integrating retail clinics into federal programs and initiatives. Through a literature review, semistructured interviews, and a panel of experts, the authors show that retail clinics have established a niche in the health care system based on their convenience and customer service. Levels of patient satisfaction and of the quality and appropriateness of care appear comparable to those of other provider types. However, we know little about the effects of retail clinic use on preventive services, care coordination, and care continuity. As clinics begin to expand into other areas of care, including chronic disease management, and as the number of patients with insurance increases and the shortage of primary care physicians continues, answering outstanding questions about retail clinics' role in the health care system will become even more important. These changes will create new opportunities for health policy to influence both how retail clinics function and the ways in which their care is integrated with that of other providers.