Healthcare Costs for Medicare Patients With Hepatocellular Carcinoma in the United States.

BACKGROUND & AIMS: Hepatocellular carcinoma (HCC) has an increasing mortality in the United States and is a leading cause of morbidity and mortality in patients with cirrhosis. We aimed to estimate the financial burden related to HCC in a large nationally representative United States cohort. METHODS: We used the Surveillance, Epidemiology, and End Results program (SEER)-Medicare database to identify 4525 adult patients who were diagnosed with HCC between 2011 and 2015. We generated a 1:1 propensity score-matched cohort of patients with cirrhosis but no HCC as a comparator group to define incremental HCC-specific costs beyond costs related to underlying cirrhosis. Our main outcomes were patient liabilities and Medicare payments in the first year after HCC diagnosis. RESULTS: Compared with patients with cirrhosis, those with HCC had higher incremental patient liabilities (median +$7166; interquartile range, $2401-$16,099) and Medicare payments (+$50,110; interquartile range, $142,42-$136,239; P < .001 for both) in the first year after diagnosis. Patients with HCC had significantly higher inpatient, outpatient, and physician service costs compared with the matched cohort with cirrhosis (P < .001 for all). Patients with early-stage HCC had lower incremental patient liabilities (median, $4195 vs $8238; P < .001) and Medicare payments (median, $28,207 vs $59,509; P < .001) than those with larger tumor burden. In multivariable median regression analysis, incremental patient liabilities and Medicare payments were significantly associated with the National Cancer Institute comorbidity index, nonalcoholic fatty liver disease etiology, presence of ascites, and presence of hepatic encephalopathy. CONCLUSIONS: Patients with HCC suffer from cancer-related financial burden, highlighting a need for policy interventions and financial support systems.

Variation in Bariatric Surgery Costs and Complication Rates in the Military Health System.

INTRODUCTION: Within the Military Health System (MHS), facilities have struggled to meet minimum recommended volume thresholds for certain procedures. Understanding variations in complication rates and cost can help policymakers tailor policy to target improvement. Our objective was to quantify the variation in bariatric surgery complication rates and costs across a sample of military hospitals. MATERIALS AND METHODS: We study a retrospective cohort of 38 military surgeons practicing in 21 military treatment facilities from 2007 to 2014 who performed 1,277 bariatric surgeries. Data from the Centralized Credentials and Quality Assurance System, which provides education and training characteristics of physicians, were linked to patient encounter data from the MHS Data Repository. Physicians were included if they performed at least five bariatric surgeries over the study period. Patients were included if they had a diagnosis of obesity (body mass index > 30) and underwent a bariatric weight loss surgery. We calculated and summarized inpatient costs and complication rates across both surgeons and facilities using multivariable mixed-effects linear or logistic models. We used these models to calculate adjusted complication rates and average costs across both providers and hospitals to characterize variation in bariatric outcomes within the MHS. This study was considered exempt by the Uniformed Services University Institutional Review Board. RESULTS: We find evidence of large variations in both complication rates and costs per admission. Overall, we found a 15.5% complication rate across the sample. When comparing averages across facilities, we find large variation in complications (49.4% coefficient of variation [CV]) and procedure costs (25.9% CV). Controlling for patient comorbidities, BMI, and year attenuates much of the variation (12.6% CV complications, 4.4% CV cost), but cannot completely explain differences across facilities. Our model suggests that complications cost 32% more than complication-free surgeries on average suggesting that quality improvement efforts could potentially yield large savings. CONCLUSIONS: We find large variations in complication rates even after controlling for patient health. Furthermore, surgical complications are a significant determinant of cost. Policymakers should target efforts to improve surgical quality across facilities and physicians. Surgical quality improvement initiatives could produce savings to the MHS through reduced complications and improved surgical readiness.

To tweet or not to tweet, that is the question: A randomized trial of Twitter effects in medical education.

INTRODUCTION: Many medical education journals use Twitter to garner attention for their articles. The purpose of this study was to test the effects of tweeting on article page views and downloads. METHODS: The authors conducted a randomized trial using Academic Medicine articles published in 2015. Beginning in February through May 2018, one article per day was randomly assigned to a Twitter (case) or control group. Daily, an individual tweet was generated for each article in the Twitter group that included the title, #MedEd, and a link to the article. The link delivered users to the article's landing page, which included immediate access to the HTML full text and a PDF link. The authors extracted HTML page views and PDF downloads from the publisher. To assess differences in page views and downloads between cases and controls, a time-centered approach was used, with outcomes measured at 1, 7, and 30 days. RESULTS: In total, 189 articles (94 cases, 95 controls) were analyzed. After days 1 and 7, there were no statistically significant differences between cases and controls on any metric. On day 30, HTML page views exhibited a 63% increase for cases (M = 14.72, SD = 63.68) when compared to controls (M = 9.01, SD = 14.34; incident rate ratio = 1.63, p = 0.01). There were no differences between cases and controls for PDF downloads on day 30. DISCUSSION: Contrary to the authors' hypothesis, only one statistically significant difference in page views between the Twitter and control groups was found. These findings provide preliminary evidence that after 30 days a tweet can have a small positive effect on article page views.

Assessing practice pattern differences in the treatment of acute low back pain in the United States Military Health System.

BACKGROUND: Acute low back pain is one of the most common reasons for individuals to seek medical care in the United States. The US Military Health System provides medical care to approximately 9.4 million beneficiaries annually. These patients also routinely suffer from acute low back pain. Within this health system, patients can receive care and treatment from physicians, or physician extenders including physician assistants and nurse practitioners. Given the diversity of provider types and their respective training programs, it would be informative to evaluate variation in care delivery, adherence to clinical guidelines, and differences within the MHS among a complex mix of provider types. METHODS: This study was a retrospective, cross-sectional quantitative analysis that examined variations in treatment between provider types within the Military Health System in 2015 for treatment of acute low back pain using administrative data. In addition to descriptive and summary statistics, binomial logistic regression models were used to assess variation in practice patterns among physicians and mid-level practitioners for prescribing of non-steroidal anti-inflammatory, opioids, plain radiography, computed tomography, and magnetic resonance imaging. RESULTS: With regard to prescribing practices, results indicated that the odds of receiving non-steroidal anti-inflammatory prescriptions increased significantly for both physician assistants and nurse practitioners when compared to physicians. For basic radiological referrals, odds increased significantly for ordering plain radiography for physician assistants and nurse practitioners when compared to physicians. For more advanced imaging, odds significantly decreased for ordering computed tomography (CT) and slightly decreased for magnetic resonance for physician assistants, nurse practitioners and physician residents compared to the physician group. Additionally this study discovered differences in the prescribing patterns between provider categories. Both contractors and civilians had higher odds of prescribing opioids compared to active duty providers. CONCLUSIONS: As physician assistants and nurse practitioners continue to gain popularity as physician extenders in the US and in addressing provider shortages for the Military Health System, further research should be conducted to determine what impact, if any, the differences found in this study have on patient outcomes. In addition, provider type warrants further investigation to determine if labor mix and outsourcing decisions within a single payer system impacts health delivery and value based care.

#MedEd: exploring the relationship between altmetrics and traditional measures of dissemination in health professions education.

INTRODUCTION: Researchers, funders, and institutions are interested in understanding and quantifying research dissemination and impact, particularly related to communicating with the public. Traditionally, citations have been a primary impact measure; however, citations can be slow to accrue and focus on academic use. Recently altmetrics, which track alternate dissemination forms (e. g., social media), have been suggested as a complement to citation-based metrics. This study examines the relationship between altmetrics and traditional measures: journal article citations and access counts. METHODS: The researchers queried Web of Science and Altmetric Explorer for articles published in HPE journals between 2013-2015. They identified 2,486 articles with altmetrics. Data were analyzed using negative binomial and linear regression models. RESULTS: Blogging was associated with the greatest increase in citations (13% increase), whereas Tweets (1.2%) and Mendeley (1%) were associated with smaller increases. Journal impact factor (JIF) was associated with a 21% increase in citations. Publicly accessible articles were associated with a 19% decrease, but the interactive effect between accessible articles and JIF was associated with a 12% increase. When examining access counts, publicly accessible articles had an increase of 170 access counts whereas blogging was associated with a decrease of 87 accesses. DISCUSSION: This study suggests that several altmetrics outlets are positively associated with citations, and that public accessibility, holding all other independent variables constant, is positively related to article access. Given the scientific community's evolving focus on dissemination these findings have implications for stakeholders, providing insight into the factors that may improve citations and access of articles.

Utilization and prescription patterns of phosphidiesterase-5 inhibitor medications in the United States military health system.

Phosphodiesterase-5 inhibitors (PDE-5Is) are the first-line medical treatments for erectile dysfunction (ED), but are often restricted in public formularies. This study assesses PDE-5I usage among active-duty service members before and after the addition of sildenafil to the formulary of the Military Health System (MHS) in 2012. To assess, a cross-sectional evaluation was conducted, utilizing encounter and pharmaceutical claims data from the Military Health System Data Repository between 2010 and 2014. Separate zero-inflated, negative binomial models were used to assess changes in usage rates by prescription and by number of pills issued, for 37 947 patients. Increased PDE-5I usage was noted with select comorbidities, notably mental health and neurologic conditions. There was significant proportional variation in medication distribution following inclusion of sildenafil within the MHS formulary, with a minimal demographic impact on medication models. The average number of prescriptions decreased, while the quantity of distributed medications increased. A significant portion of PDE-5I recipients were young men, under 25 years old, who received medications on the first visit, which invites speculation about the effectiveness of treatment and appropriateness of use. Future studies aimed at evaluating prevalence in younger population may be of benefit.

Transitioning to Patient-Centered Medical Homes: Associations With Appointment Availability.

INTRODUCTION: Recent implementation of the Patient-Centered Medical Home (PCMH) in military primary care has gained significant traction and attention from leadership and policy makers. The study objective was to measure the rate of change in appointment availability before and after primary care clinics were certified as a medical home. Access to care is one core tenet of the medical home and appointment availability is an important indicator of access. MATERIALS AND METHODS: This was a retrospective, longitudinal observational study involving 21 U.S. Navy primary care clinics from 2011 to 2014. Appointment availability, as measured by third next available appointment, was constructed for 21 primary care clinics over a 29-month time period (14 months precertification, certification month, 14 months postcertification). A mixed-effects model with linear splines was applied where third next available appointment was the dependent variable. Main interest independent variables include time (precertification and postcertification). Remaining independent variables include categories pertaining to clinic characteristics, ancillary services, and nonemergent primary care treatable emergency department visits. RESULTS: Appointment availability improved slightly postcertification. Although there were statistically significant differences in appointment availability pre- and postcertification, the differences were so small that patients may not actually experience noticeable improvements. CONCLUSION: Although slight improvements in appointment availability following medical home certification exist, adoption of the medical home model in the military setting may not have all the potential outcomes expected on the basis of prior findings in civilian settings. This study demonstrated that improvements in appointment availability following medical home certification exist, but are quite small. Patients, as a result, are unlikely to notice any improvements. Additional research should test other expected benefits of PCMH in military settings. At that point, military policy makers can decide which aspects of PCMH practices merit sustaining.

Military Deployments and Mental Health Utilization Among Spouses of Active Duty Service Members.

Since the onset of the wars in Iraq and Afghanistan attention has increased on the importance of mental health with military service members. An integral component, although far less studied, are the ties between mental health and military spouses. Military deployments place considerable stress on military families. This study analyzed the mental health utilization of military spouses of active duty service members assigned to an aircraft carrier between 2011 and 2014. A negative binomial generalized estimating equation was used to examine the rate of change in mental health utilization over time against various deployment phases. Associations emerged between select deployment phases (i.e., deployment 1, between deployments, deployment 2) with increases in mental health utilization ranging between 12% and 20% for military spouses. This study demonstrated, for military spouses, the in between deployment phase has associations with mental health utilization rates similar to actual deployed periods. As a result, military leaders should continue to monitor the well-being of their service members' families throughout all deployment phases.

U.S. Military Discharges and Pre-existing Personality Disorders: A Health Policy Review.

The Department of Defense (DoD) is facing allegations service members were wrongfully discharged for pre-existing personality disorders. From 2001 to 2007, 26,000 enlisted service members were discharged for a pre-existing personality disorder (2.6 % of total discharges). With national media attention of the issue, personality disorder discharges were reduced by 31 % in 2008 with new discharge procedures issued by the DoD. Even with the reduction, a government review found the DoD did not adhere to its discharge protocols. The objective of this paper is to explore personality disorders in the military, analyze various costs to stakeholders, and identify potential policy alternatives.