jeudi 11 août 2016
By the Numbers: Health Spending and Income
There was no dearth of studies, columns and thinkpieces exploring the slowdown in healthcare costs for the decade starting in 2004.
But the slowdown didn't affect everyone equally, according to a report in the July issue of Health Affairs , and the result is a growing disparity in health expenditures. Samuel L. Dickman and others looked at average annual healthcare costs for each of five income brackets. They found that the top quintile continued to see rapidly rising costs, the middle class held relatively steady and the lower class actually had costs decrease.
Doctors are likely performing more services or more expensive services for the wealthiest clients.
To the authors, the finding illustrates that more medical services are going to the group with the least need.
"The pattern of sharply rising spending for the wealthy and flat or slow growth for others mirrors the widening gap in the consumption of other goods and could represent a shift from need-based to income-based receipt of medical care. We fear that it might presage deepening disparities in health outcomes," they wrote.
Figures are inflation-adjusted in 2012 dollars. They are also adjusted for age and health.
By the Numbers: Health Spending and Incomemercredi 10 août 2016
Difficulties of Big Data: The Anesthesiology News Report
Several experts unravel the challenges of big data.
A recent meta-analysis found that neuraxial anesthesia reduces surgical site infections compared with general anesthesia in patients undergoing total joint arthroplasty.
The risk of being sued for malpractice is significantly greater for physicians who have already been sued, according to a study in The New England Journal of Medicine.
A recent study found that the number of OR personnel involved in the intraoperative period does not increase a patient's risk for surgical site infections.
Respiratory depression occurs more frequently and severely in patients receiving a GI-led colonoscopy than anesthesiology-assisted gastrointestinal endoscopy, according to new research.
The Anesthesiology News Report is brought to MedPage Today readers by our friends at Anesthesiology News, a McMahon Group title. Registration (free) may be required for some content.
Difficulties of Big Data: The Anesthesiology News ReportFeedback on TEE Ordering Cuts Inappropriate Use (CME/CE)
Personal feedback on one's rate of ordering inappropriate transthoracic echocardiography (TTE) -- along with a lecture on which scenarios are rarely appropriate -- improved utilization, a single-center trial suggested.
Rory B. Weiner, MD, of Boston's Massachusetts General Hospital, and colleagues subjected some of their staff cardiologists to an educational intervention: a lecture accompanied by an electronic information card, plus monthly feedback via email that revealed a count of "rarely appropriate" TTEs ordered and an explanation of why they were classified as such according to the 2011 American College of Cardiology appropriate use criteria.
This group showed a reduction in inappropriate outpatient TTEs ordered compared with attending cardiologists who received the lecture but not monthly feedback (10.5% versus 16.5%, OR 0.59, 95% CI 0.39 to 0.88) and a nonsignificant trend towards a higher rate of appropriate TTEs (77.6% versus 72.0%, OR 1.38, 95% CI 0.93 to 2.05), Weiner's group reported online in JAMA Cardiology.
The intervention and the control groups showed similar rates of ordering TTEs that "may be appropriate" as per the appropriate use criteria (11.9% versus 11.5%, OR 0.99, 95% CI 0.59 to 1.67).
"Results from our study indicate that attending academic cardiologists can amend their ordering of outpatient TTEs in response to education and feedback," they wrote.
Moreover, it appeared that experience did not affect the trend, as stratification by academic rank did not produce any outlying groups.
The most common reasons for inappropriate TTE were:
- Routine imaging within 3 years of prosthetic valve insertion (17.1% of cases)
- Routine screening for valvular stenosis less than a year apart between TTEs (15.0%)
- Routine surveillance of cardiomyopathy (10.5%) or ventricular function (8.4%)
Cases involving atrial fibrillation were the most common source of unclassifiable TTEs (3.3%), which appropriate use criteria guidelines did not designate as "appropriate," "may be appropriate," or "rarely appropriate." Other unclassifiable scenarios involved serial follow-up on cardiac resynchronization therapy without worsening heart failure or device dysfunction and left ventricular function assessment after revascularization.
"It is possible that the need for practice improvement in these domains is greater than believed, since the appropriate use criteria do not readily capture clinical practice in these particular settings," Weiner and colleagues suggested.
Their prospective, randomized trial included a staff of 66 attending cardiologists (one of whom retired during the course of the study and was excluded from the analysis) who saw patients from November 2013 to June 2014 .
"There are several limitations of this study," the investigators acknowledged.
"First, the trial was aimed at attending academic cardiologists, and the effect of performing this type of intervention on attending physicians from other disciplines (ie, general internists) is unknown. Noncardiologists (e.g., primary care, family practice, surgeons, neurologists) ordered up to half of the TTEs in a large Medicare database; therefore, any systemic efforts will need to include physicians other than cardiologists," they wrote, adding that future studies should include nurse practitioners who order TTEs.
"Second, this study was performed at an academic center, where several specialized referral cardiac programs (e.g., interventional valvular disease, thoracic aortic disease, and adult congenital heart disease) exist; therefore, our findings may not be generalizable to other practice environments."
They commented that it was impossible to blind their study participants and that "perhaps knowing that they were to receive individual feedback stimulated a change in ordering from the outset in the intervention group." Another caveat to their findings was the possibility that patterns in documentation changed in response to that monthly email, not actual practice.
Finally, "the sustainability of the impact of this type of intervention needs further study since there are discrepant data on the long-lasting effects of these types of interventions," the authors added.
To address some of the study's limitations, Weiner's group pointed to an ongoing, multi-center study on appropriate use criteria-based interventions in TTE ordering.
Weiner disclosed no relevant relationships with industry.
UNOS/OPTN Propose New Liver Allocation Plan
Liver transplantation might become more equitable under an allocation program being considered by the United Network for Organ Sharing (UNOS) and the Organ Procurement and Transplantation Network (OPTN).
The proposed plan, which will be released for public comment on Aug. 17, would change the geographic regions in which livers are allocated throughout the U.S. Under the current system, the country is divided into 11 different regions, and organs are allocated within each region based on how sick the patients on the transplant list are.
However, the regions vary greatly in terms of size and also vary a lot in terms of how many patients are waiting for transplants and how many potential donors there are, explained Ryutaro Hirose, MD, chair of the Liver and Intestinal Committee at OPTN, on a call with reporters.
In addition, the degree of illness that's required to get a transplant -- which is determined based on a 40-point scale known as a MELD score -- varies greatly from region to region. "In some areas of the country, you have to reach MELD score of 35 -- those are patients who are extremely ill and usually will die within a week," explained Hirose, who is also an organ transplant surgeon at the University of California San Francisco.
"Whereas in some areas, you have to have a score of 23, and those folks are sitting at home and we have to call them in for a transplant." As a result, there is as much as a 60% difference by geographic area in the rates of death within 3 months among patients who don't receive a transplant.
From 11 Regions to Eight
Under the proposed changes, the country would be divided up into eight regions. The sickest patients would continue to have the highest priority, Hirose said. "When we re-draw the lines, it actually matches better with organ supply and demand, and encourages better access." UNOS and OPTN employed a firm that used mathematical modeling "to select the best solutions that met the goals of decreasing this inequity within certain boundaries ... and to help with practical issues such as decreasing the amount of transport time to get a liver from one part of a district to another, and to make sure that any solution we came out with did not increase the number of waitlist deaths."
The map was also modified so that in places where a donor hospital is located, transplant candidates who are in a 150-mile "proximity circle" will get more priority on the list, "and that will keep organs from flying long distances for very small differences in the MELD score," Hirose explained.
If no patient in the geographic region needs or wants the liver, then UNOS and OPTN will prioritize the sicker patients nationwide by their MELD score, "from 40 all the way down to 29," to see if any of them could use it, Hirose said. "Then we would go back to more local distribution for less sick patients and then go back to a wider district and national distribution should no one want that liver or [if there were] nobody who could use that liver within the higher categories."
The model found that the variance in median MELD score required for a transplant would be cut in half by the new system, from 6.2 points to 2.9 points. It also found that pre-transplants deaths would not increase, and that 95% of transplants would take place within the assigned geographic area. Researchers did find that there would be an overall 2% decrease in the number of transplants performed, but "[they] have told us this was probably a very low reliability number," Hirose added.
Less Transplant Travel?
Hirose told MedPage Today that the new map could potentially reduce the issue of having some patients get an unfair advantage by moving from one area of the country -- where a higher MELD score is needed for a transplant -- to another area that has a lower required MELD score, something that the late Apple CEO Steve Jobs did.
"There are a fair number of patients who have the resources to move from one area of the country to another," he noted. "In some areas you only have to have a MELD score of 20 or 23, while within others, like where Steve Jobs came from, you have to have a score of 35. It's completely legal and within our policy to have folks multiple list ... [But] that really disadvantages folks without resources that can't travel."
In addition, there is also the insurance issue. "Folks with Medicaid are never going to be covered to have a transplant done somewhere else where the liver supply is much better, so you have an exacerbation of a very two-tiered system," said Hirose. "That's a different disparity -- not just where you live, but how much money you make and how well-insured you are."
The new map would mean that patients in some regions would need higher MELD scores than before in order to receive a transplant, so some people have raised the issue of whether more livers will be wasted on sicker patients who will end up dying even with a transplant. "Right now that hasn't happened in any of the allocation policies that could potentially do that; we haven't seen that yet," he said. Instead, "we've had better and better outcomes since the MELD score was put in place" to determine patient priority.
Other Issues Being Considered
The committee is also looking at several other issues; one involves the review boards in each region that decide whether to grant exceptions to the priority system to allow liver transplants for patients whose severity of illness might not be accurately reflected by their MELD score. The regional boards vary in the number of cases they get, how they review them, and how often they approve exceptions.
"So a related but separate proposal we are putting forth is the creation of a national review board to make more consistent, across the board and across the country, how these practices are done," said Hirose.
Another thing the committee is looking at is adjusting the number of MELD points patients with liver cancer get, he added. "Right now, patients with liver cancer are a little more advantaged than folks that don't have liver cancer, and we want to make sure we're giving everyone a fair opportunity to go ahead and get a liver transplant."
The comment period on the proposals will remain open until Oct. 14; final proposals will then be drafted and another comment period opened in January.
UNOS/OPTN Propose New Liver Allocation PlanIVF With Frozen Embryos May be Better in Women With PCOS (CME/CE)
Infertile women with polycystic ovary syndrome (PCOS) seemed to have a higher rate of live birth after undergoing in vitro fertilization (IVF) with frozen embryos compared with fresh embryos, a small study from China found.
Overall, nearly half (49.3%) the women with frozen embryo transfer had a live birth compared with 42% of women with fresh embryo transfer (relative risk 1.17, 95% CI 1.05 to 1.31, P=0.004). One potential explanation for this could be lower rates of pregnancy loss, as nearly a third of women in the fresh embryo group experienced a pregnancy loss compared to only 22.0% of the frozen-embryo group (RR 0.67, 95% CI 0.54 to 0.83, P<0.001), reported Zi-Jiang Chen, MD, of Shandong University in China, and colleagues.
Not only was the frequency of live birth after the first transfer higher, but frozen embryo transfer was associated with a significantly lower frequency of pregnancy loss and ovarian hyperstimulation syndrome, a potentially life-threatening medical condition affecting women taking fertility medication), they wrote in the New England Journal of Medicine.
However, compared with fresh embryo transfer, frozen embryo transfer was also linked with a higher rate of preeclampsia, they noted.
The frozen embryo versus fresh embryo debate has been long and ongoing among the IVF community, with certain recent evidence in favor of frozen embryo transfer. But this may be especially important for women with PCOS, the authors explained, because this population is particularly at risk for ovarian hyperstimulation syndrome (OHSS) and later pregnancy complications.
In an email to MedPage Today, Kaylen Silverberg, MD, of Ovation Fertility in Los Angeles, a national fertility service provider, said this confirms many of the findings about patients with PCOS that he has observed.
"Patients with PCOS are at high risk of ovarian hyperstimulation syndrome following IVF due, primarily, to their typically vigorous response to gonadotropin induced ovarian stimulation," said Silverberg, who was not involved with the research. "When embryos are frozen and the transfer is delayed until a subsequent cycle, the ovaries have a chance to recover. In addition, as no gonadotropin stimulation is required for frozen embryo transfers, embryos are transferred into a more physiologic uterine environment, there is essentially no risk of OHSS, and higher pregnancy rates result as well."
The researchers examined infertile women with PCOS undergoing their first IVF cycle. All the women were between ages of 20 and 34, and weighed at least 40 kg (about 88 lbs).
They randomized 762 patients to receive fresh embryo transfer and 726 patients to embryo cryopreservation, followed by frozen embryo transfer. Transfers occurred after 3 days of embryo development, and up to two embryos were transferred.
"This protocol potentially offers immediate benefits to women with PCOS, so practitioners should consider freezing all embryos for these patients," said co-author Richard Legro, MD, of Penn State College of Medicine in Hershey, in a statement.
The authors reported that the rates of OHSS were significantly higher among women with PCOS in the fresh group versus the frozen group (1.3% versus 7.1%, RR 0.19, P<0.001).
The preeclampsia rate among the frozen-embryo group was 4.4% compared with only 1.4% in the fresh-embryo group (RR 3.12, 95% CI 1.26 to 7.03, P=0.009). The authors said that this was consistent with prior observational studies, where frozen embryo transfers were associated with a higher risk of hypertensive disorders.
There were no significant differences in other pregnancy rates -- biochemical pregnancy, clinical pregnancy, ongoing pregnancy, ectopic pregnancy -- other pregnancy complications, neonatal complications, or congenital anomalies. The frozen embryo group had two stillbirths and five neonatal deaths, while the fresh embryo group had none.
But just because frozen embryo transfer was associated with positive outcomes when compared with fresh embryos, it does not mean there are no downsides to this procedure, pointed out Christos Coutifaris, MD, of University of Pennsylvania in Philadelphia, in an accompanying editorial. He argued that the many costs of frozen embryo transfer may be potential drawbacks.
"[There are] higher incremental financial costs (by a factor of 5 to 10) ... the emotional costs of deferring by 4 to 8 weeks the programmed frozen-embryo transfer, and the physical costs of additional treatments involving the administration of hormones, multiple injections and office visits," he wrote. "On the basis of current evidence, in women with a sufficient number of good quality embryos who are at low risk for implantation failure ... it may be reasonable to recommend fresh-embryo transfer as available."
Limitations to the study include that 10% of patients in each group may not have received the assigned treatment, which could have attenuated the between-group differences, as well as the fact that these results for women with PCOS may not be generalizable to other women undergoing IVF.
Also, the authors acknowledged that "the potential excess of neonatal death, owing primarily to prematurity, in the frozen-embryo group warrants attention."
They pointed out that the study was not designed to determine the mechanisms underlying their results, but "frozen-embryo transfer allows the ovary to recover from the ovarian stimulation and the exposed endometrial lining to shed, providing a fresh start for both."
The study was supported by the National Basic Research Program of China, the National Natural Science Foundation of China, and the Thousand Talents Program.
DAPT Score: Not the End-All in Decision-Making
The DAPT score does fine as a risk assessment for extended dual antiplatelet therapy (DAPT) -- but like similar tools, the real question is whether it is even used, clinicians said.
"From a methodologic standpoint, the construction of this score represents an elegant solution to a complicated problem: quantifying both benefits and harms from a therapeutic intervention into a singular metric from which clinical decisions can be based," Roxana Mehran, MD, and Usman Baber, MD, both of Mount Sinai Medical Center in New York City, wrote in a commentary online in JAMA Cardiology.
But the score failed to include certain "well-established correlates" like bleeding and body mass index, the duo noted. In addition, the DAPT trial that was the basis for the score did not enroll patients requiring triple therapy. Also, inherent in this tool is the assumption that thrombosis and bleeding are opposite and comparable risks, they added.
"These limitations notwithstanding, the DAPT score provides a timely and intuitive tool to inform a very important clinical decision. Certainly other scores will also be developed, and numerous studies will compare them in an effort to refine the decision-making process."
"However, as clinical investigators, it is critical that we do not lose sight of the forest from the trees and realize that, without implementation, the development of such scores alone will not improve the outcomes of our patients. To this end, it is sobering that only 30% to 40% of physicians use well-validated and long standing risk scores as part of routine clinical care," Mehran and Baber wrote.
"So for now, the clinician's evaluation of the patient remains paramount in the decision-making process, and although the risk scores are a great tool, their application will always be in the context of the clinician's perspective."
Mehran declared receiving research grant support from Eli Lilly/Daiichi Sankyo, Bristol-Myers Squibb, AstraZeneca, The Medicines Company, OrbusNeich, Bayer, and CSL Behring; and has worked as a consultant for Janssen Pharmaceuticals, Osprey Medical, Watermark Research Partners, and Medscape; is on the scientific advisory board of Abbott Laboratories and has given lectures sponsored by PlatformQ and Sanofi; and was also on the committee and data safety monitoring board of Covidien and Forest Laboratories and has stock or stock options in Claret Medical and the Elixir Medical Corporation.
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