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Carlucci PM, Preisinger K, Deonaraine KK, Zaminski D, Dall'Era M, Gold HT, Kalunian K, Fava A, Belmont HM, Wu M, Putterman C, Anolik J, Barnas JL, Furie R, Diamond B, Davidson A, Wofsy D, Kamen D, James JA, Guthridge JM, Apruzzese W, Rao D, Weisman MH, Izmirly PM, Buyon J, Petri M. Extrarenal symptoms associate with worse quality of life in patients enrolled in the AMP RA/SLE Lupus Nephritis Network. Rheumatology (Oxford) 2024:keae189. [PMID: 38530774 DOI: 10.1093/rheumatology/keae189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/24/2024] [Accepted: 02/07/2024] [Indexed: 03/28/2024] Open
Abstract
OBJECTIVE Lupus nephritis (LN) can occur as an isolated component of disease activity or be accompanied by diverse extrarenal manifestations. Whether isolated renal disease is sufficient to decrease health related quality of life (HRQOL) remains unknown. This study compared Patient-Reported Outcomes Measurement Information System 29-Item (PROMIS-29) scores in LN patients with isolated renal disease to those with extrarenal symptoms to evaluate the burden of LN on HRQOL and inform future LN clinical trials incorporating HRQOL outcomes. METHODS A total of 181 LN patients consecutively enrolled in the multicentre multi-ethnic/racial Accelerating Medicines Partnership completed PROMIS-29 questionnaires at the time of a clinically indicated renal biopsy. Raw PROMIS-29 scores were converted to standardized T scores. RESULTS Seventy-five (41%) patients had extrarenal disease (mean age 34, 85% female) and 106 (59%) had isolated renal (mean age 36, 82% female). Rash (45%), arthritis (40%) and alopecia (40%) were the most common extrarenal manifestations. Compared with isolated renal, patients with extrarenal disease reported significantly worse pain interference, ability to participate in social roles, physical function, and fatigue. Patients with extrarenal disease had PROMIS-29 scores that significantly differed from the general population by > 0.5 SD of the reference mean in pain interference, physical function, and fatigue. Arthritis was most strongly associated with worse scores in these three domains. CONCLUSION Most patients had isolated renal disease and extrarenal manifestations associated with worse HRQOL. These data highlight the importance of comprehensive disease management strategies that address both renal and extrarenal manifestations to improve overall patient outcomes.
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Affiliation(s)
- Philip M Carlucci
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Katherine Preisinger
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | | | - Devyn Zaminski
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Maria Dall'Era
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Heather T Gold
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Kenneth Kalunian
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Andrea Fava
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - H Michael Belmont
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Ming Wu
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | | | - Jennifer Anolik
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Jennifer L Barnas
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Richard Furie
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Betty Diamond
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Anne Davidson
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - David Wofsy
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Diane Kamen
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Judith A James
- Department of Medicine, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Joel M Guthridge
- Department of Medicine, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | | | - Deepak Rao
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Peter M Izmirly
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Jill Buyon
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Michelle Petri
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Denvir B, Carlucci PM, Corbitt K, Buyon JP, Belmont HM, Gold HT, Salmon JE, Askanase A, Bathon JM, Geraldino-Pardilla L, Ali Y, Ginzler EM, Putterman C, Gordon C, Barbour KE, Helmick CG, Parton H, Izmirly PM. Prevalence of concomitant rheumatologic diseases and autoantibody specificities among racial and ethnic groups in SLE patients. Front Epidemiol 2024; 4:1334859. [PMID: 38516120 PMCID: PMC10956350 DOI: 10.3389/fepid.2024.1334859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/15/2024] [Indexed: 03/23/2024]
Abstract
Objective Leveraging the Manhattan Lupus Surveillance Program (MLSP), a population-based registry of cases of systemic lupus erythematosus (SLE) and related diseases, we investigated the proportion of SLE with concomitant rheumatic diseases, including Sjögren's disease (SjD), antiphospholipid syndrome (APLS), and fibromyalgia (FM), as well as the prevalence of autoantibodies in SLE by sex and race/ethnicity. Methods Prevalent SLE cases fulfilled one of three sets of classification criteria. Additional rheumatic diseases were defined using modified criteria based on data available in the MLSP: SjD (anti-SSA/Ro positive and evidence of keratoconjunctivitis sicca and/or xerostomia), APLS (antiphospholipid antibody positive and evidence of a blood clot), and FM (diagnosis in the chart). Results 1,342 patients fulfilled SLE classification criteria. Of these, SjD was identified in 147 (11.0%, 95% CI 9.2-12.7%) patients with women and non-Latino Asian patients being the most highly represented. APLS was diagnosed in 119 (8.9%, 95% CI 7.3-10.5%) patients with the highest frequency in Latino patients. FM was present in 120 (8.9%, 95% CI 7.3-10.5) patients with non-Latino White and Latino patients having the highest frequency. Anti-dsDNA antibodies were most prevalent in non-Latino Asian, Black, and Latino patients while anti-Sm antibodies showed the highest proportion in non-Latino Black and Asian patients. Anti-SSA/Ro and anti-SSB/La antibodies were most prevalent in non-Latino Asian patients and least prevalent in non-Latino White patients. Men were more likely to be anti-Sm positive. Conclusion Data from the MLSP revealed differences among patients classified as SLE in the prevalence of concomitant rheumatic diseases and autoantibody profiles by sex and race/ethnicity underscoring comorbidities associated with SLE.
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Affiliation(s)
- Brendan Denvir
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - Philip M. Carlucci
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - Kelly Corbitt
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - Jill P. Buyon
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - H. Michael Belmont
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - Heather T. Gold
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
| | - Jane E. Salmon
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, United States
| | - Anca Askanase
- Division of Rheumatology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY, United States
| | - Joan M. Bathon
- Division of Rheumatology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY, United States
| | - Laura Geraldino-Pardilla
- Division of Rheumatology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY, United States
| | - Yousaf Ali
- Division of Rheumatology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Ellen M. Ginzler
- Division of Rheumatology, Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, United States
| | | | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Kamil E. Barbour
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Charles G. Helmick
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Hilary Parton
- Division of Disease Control, Bureau of Communicable Disease, New York City Department of Health and Mental Hygiene, Long Island City, NY, United States
| | - Peter M. Izmirly
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
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Lee SS, Gold HT, Kwon SC, Pothuri B, Lightfoot MDS. Guideline concordant care for patients with locally advanced cervical cancer by disaggregated Asian American and Native Hawaiian/Pacific Islander groups: A National Cancer Database Analysis. Gynecol Oncol 2024; 182:132-140. [PMID: 38262236 DOI: 10.1016/j.ygyno.2023.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/22/2023] [Accepted: 12/25/2023] [Indexed: 01/25/2024]
Abstract
OBJECTIVE Despite the within-group heterogeneity, Asian American (AA) and Native Hawaiian and Pacific Islander (NH/PI) patients are often grouped together. We compared the patterns of guideline-concordant care for locally advanced cervical cancer for disaggregated AA and NH/PI patients. METHODS Patients with stage II-IVA cervical cancer between 2004 and 2020 were identified from the National Cancer Database. AA patients were disaggregated as East Asian (EA), South Asian (SA), and Southeast Asian (SEA). NH/PI patients were classified as a distinct racial subgroup. The primary outcome was the proportion undergoing guideline-concordant care, defined by radiation therapy with concurrent chemotherapy, brachytherapy, and completion of treatment within eight weeks. RESULTS Of 48,116 patients, 2107 (4%) were AA and 171 (<1%) were NH/PI. Of the AA patients, 36% were SEA, 31% were EA, 12% were SA, and 21% could not be further disaggregated due to missing or unknown data. NH/PI patients were more likely to be diagnosed at an early age (53% NH/PI vs. 30% AA, p < 0.001) and have higher rates of comorbidities (18% NH/PI vs. 14% AA, p < 0.001). Within the AA subgroups, only 82% of SEA patients received concurrent chemotherapy compared to 91% of SA patients (p = 0.026). SA patients had the longest median OS (158 months) within the AA subgroups compared to SEA patients (113 months, p < 0.001). CONCLUSION Disparities exist in the receipt of standard of care treatment for cervical cancer by racial and ethnic subgroups. It is imperative to disaggregate race and ethnicity data to understand potential differences in care and tailor interventions to achieve health equity.
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Affiliation(s)
- Sarah S Lee
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, New York University Langone Health, New York, NY, United States of America
| | - Heather T Gold
- Department of Population Health, New York University Langone Health, New York, NY, United States of America
| | - Simona C Kwon
- Department of Population Health, New York University Langone Health, New York, NY, United States of America
| | - Bhavana Pothuri
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, New York University Langone Health, New York, NY, United States of America
| | - Michelle D S Lightfoot
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, New York University Langone Health, New York, NY, United States of America.
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Burns LE, Gencerliler N, Terlizzi K, Solis-Roman C, Sigurdsson A, Gold HT. Apexification Outcomes in the United States: A Retrospective Cohort Study. J Endod 2023; 49:1269-1275. [PMID: 37517583 PMCID: PMC10543604 DOI: 10.1016/j.joen.2023.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/20/2023] [Accepted: 07/21/2023] [Indexed: 08/01/2023]
Abstract
INTRODUCTION This epidemiological analysis used procedure codes from dental insurance claims data to identify apexification cases and evaluate survival at the tooth-level. METHODS Dental insurance claims data from New York State (2006-2019) and Massachusetts (2013-2018) were used in an observational, retrospective cohort study to evaluate the provision and treatment outcomes of apexification. Statistical analyses included Kaplan-Meier survival estimates and Cox proportional hazards regression. Cox proportional hazard regression was used to evaluate the hazard of adverse event occurrence by age, gender, tooth type, placement of permanent restoration, and dental provider type. A sensitivity analysis evaluated potential bias in the survival estimates and adjusted hazard ratios (aHRs) due to differential loss to follow-up. Robust standard errors were used to account for potential dependence between teeth within an individual. RESULTS The analytic cohort of 575 individuals included 632 teeth, with an average follow-up time of 64 months. The survival rates of apexification procedures were 95% at 1 year; 93% at 2 years; 90% at 3 years; and 86% at 5 years. Tooth retention following apexification was 98% at 1 year; 96% at 2 years; 95% at 3 years; and 90% at 5 years. Tooth type and subsequent placement of a permanent restoration were significant predictors of survival after apexification. CONCLUSIONS The procedural and tooth survival outcomes of apexification were high and comparable to studies that analyzed clinical data on tooth survival following apexification.
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Affiliation(s)
- Lorel E Burns
- New York University College of Dentistry, Department of Endodontics, New York, New York.
| | - Nihan Gencerliler
- New York University College of Dentistry, Department of Endodontics, New York, New York
| | - Kelly Terlizzi
- New York University Health Evaluation and Analytics Lab, New York, New York
| | | | - Asgeir Sigurdsson
- New York University College of Dentistry, Department of Endodontics, New York, New York
| | - Heather T Gold
- New York University Langone Health, Department of Population Health, New York, New York
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Hiatt RA, Clayton MF, Collins KK, Gold HT, Laiyemo AO, Truesdale KP, Ritzwoller DP. The Pathways to Prevention program: nutrition as prevention for improved cancer outcomes. J Natl Cancer Inst 2023; 115:886-895. [PMID: 37212639 PMCID: PMC10407697 DOI: 10.1093/jnci/djad079] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 04/14/2023] [Accepted: 05/08/2023] [Indexed: 05/23/2023] Open
Abstract
Adequate nutrition is central to well-being and health and can enhance recovery during illness. Although it is well known that malnutrition, both undernutrition and overnutrition, poses an added challenge for patients with cancer diagnoses, it remains unclear when and how to intervene and if such nutritional interventions improve clinical outcomes. In July 2022, the National Institutes of Health convened a workshop to examine key questions, identify related knowledge gaps, and provide recommendations to advance understanding about the effects of nutritional interventions. Evidence presented at the workshop found substantial heterogeneity among published randomized clinical trials, with a majority rated as low quality and yielding mostly inconsistent results. Other research cited trials in limited populations that showed potential for nutritional interventions to reduce the adverse effects associated with malnutrition in people with cancer. After review of the relevant literature and expert presentations, an independent expert panel recommends baseline screening for malnutrition risk using a validated instrument following cancer diagnosis and repeated screening during and after treatment to monitor nutritional well-being. Those at risk of malnutrition should be referred to registered dietitians for more in-depth nutritional assessment and intervention. The panel emphasizes the need for further rigorous, well-defined nutritional intervention studies to evaluate the effects on symptoms and cancer-specific outcomes as well as effects of intentional weight loss before or during treatment in people with overweight or obesity. Finally, although data on intervention effectiveness are needed first, robust data collection during trials is recommended to assess cost-effectiveness and inform coverage and implementation decisions.
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Affiliation(s)
- Robert A Hiatt
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | | | | | - Heather T Gold
- New York University (NYU) Langone Health/NYU Grossman School of Medicine, New York, NY, USA
| | | | | | - Debra P Ritzwoller
- Kaiser Permanente Colorado Institute for Health Research, Aurora, CO, USA
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Kang SK, Gold HT. How to Perform Economic Evaluation in Implementation Studies: Imaging-Specific Considerations and Comparison of Financial Models. J Am Coll Radiol 2023; 20:292-298. [PMID: 36922103 PMCID: PMC10112005 DOI: 10.1016/j.jacr.2022.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 11/11/2022] [Accepted: 11/16/2022] [Indexed: 03/14/2023]
Abstract
Economic evaluation for implementation science merits unique considerations for a local context, including the main audience of local decision makers. This local context is in contrast with traditional methods for developing coverage policy for medical tests and interventions, which typically emphasize benefits and costs more broadly, for society. Regardless of the strength of evidence backing the efficacy or effectiveness of a clinical intervention, local context is paramount when implementing evidence-based practices. Understanding the costs throughout the processes of implementing a program will inform the decision of whether to plan for and adopt the program, how to sustain the program, and whether to scale up widely. To guide economic evaluation for implementation of evidence-based imaging practices, we describe approaches that consider local stakeholders' needs and connect these with outcomes of cost and clinical utility. Illustrative examples of implementation strategies and economic evaluation are explored in areas of cancer screening and care delivery.
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Affiliation(s)
- Stella K Kang
- Associate Chair and Associate Professor, Department of Radiology, NYU Grossman School of Medicine, New York, New York; Chair, ACR Steering Committee on Incidental Findings; and Specialty Chair, Appropriateness Criteria Expert Panel on Gynecologic and Obstetrical Imaging.
| | - Heather T Gold
- Professor, Department of Population Health and Chief, Section on Value and Effectiveness Research, Department of Population Health, NYU Grossman School of Medicine, New York, New York
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Wilker OG, Stevens ER, Gold HT, Haber Y, Slover JD, Sherman SE. Implementation of a relapse prevention program among smokers undergoing arthroplasty: lessons learned. ANZ J Surg 2023; 93:1001-1007. [PMID: 36852876 DOI: 10.1111/ans.18354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 01/27/2023] [Accepted: 02/15/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Surgery is a potent motivator to help people quit smoking to reduce the risk of complications. Many patients who smoke receive tobacco cessation counseling prior to surgery and are able to quit, but do not receive the same resources after surgery and often resume smoking. METHODS We present a case study describing the recruitment process, study components, and lessons learned from StayQuit, a comprehensive relapse prevention program designed to prevent relapse after arthroplasty. Lessons learned were examined post hoc to determine challenges related to program implementation, using existing study procedures and information collected. RESULTS While a comprehensive postoperative relapse prevention program may be beneficial to patients, implementation of StayQuit is unlikely to be feasible under current circumstances. The primary challenges to successful implementation of StayQuit focused on themes of lack of engagement in the preoperative Orthopedic Surgery Quit Smoking Program (OSQSP) and an environment unfavorable to in-person enrollment on the day of surgery. CONCLUSIONS Postoperative relapse prevention programs may be beneficial for patients who quit smoking prior to elective surgery. To help guide implementation, it is important to consider surgeon behavior, the collaboration of clinical and non-clinical teams, and best practices for study enrollment in surgical settings.
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Affiliation(s)
- Olivia G Wilker
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Elizabeth R Stevens
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Heather T Gold
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA.,Department of Orthopedic Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Yaa Haber
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - James D Slover
- Department of Orthopedic Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Scott E Sherman
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA.,Department of Medicine, VA New York Harbor Healthcare System, New York, New York, USA
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Burns LE, Gencerliler N, Gold HT. A comparative analysis of public and private dental benefit payer types for the provision and outcomes of root canal therapy on permanent teeth of children and adolescents in Massachusetts. J Am Dent Assoc 2023; 154:151-158. [PMID: 36528395 PMCID: PMC10026184 DOI: 10.1016/j.adaj.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/13/2022] [Accepted: 10/27/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Despite substantial increases in dental benefits and improvements in the use of dental services among children and adolescents in the United States, oral health disparities according to dental insurance payer type persist. METHODS The authors used an all-payer claims (2013-2017) database to perform a comparative analysis of the provision and treatment outcomes of an endodontic procedure (root canal therapy) in the permanent teeth of a pediatric population aged 6 through 18 years, according to dental insurance payer type. Statistical analyses, including logistic regression, Cox proportional hazards regression, and the Kaplan-Meier method, were performed at person and tooth levels. RESULTS Compared with privately insured children and adolescents, public-payer children and adolescent beneficiaries were more likely to have had root canal therapy (adjusted odds ratio, 1.91; 95% CI, 1.73 to 2.11) and had poorer treatment outcomes associated with the procedure (adjusted hazard ratio, 2.19; 95% CI, 1.53 to 3.14; P < .0001) during the study period. Those enrolled in private insurance were more likely to receive treatment from an endodontist (specialist in providing root canal therapy) (P < .0001). Amounts allowed and paid by the insurer were significantly higher for private payers (P < .001). CONCLUSIONS There were significant differences in the provision and outcomes of endodontic treatment between privately and publicly insured children and adolescents. PRACTICAL IMPLICATIONS Despite ostensibly equal access to care, differences in the provision of oral health care exist between privately and publicly insured patients. These differences may be contributing to persisting oral health disparities.
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Burns LE, Gencerliler N, Terlizzi K, Wu Y, Solis-Roman C, Gold HT. A comparative analysis of outcomes of root canal therapy for pediatric medicaid beneficiaries from New York State. Front Oral Health 2022; 3:1031443. [PMID: 36479449 PMCID: PMC9720667 DOI: 10.3389/froh.2022.1031443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/28/2022] [Indexed: 08/03/2023] Open
Abstract
Objectives This study investigated differences in the provision of root canal therapy and outcomes in a publicly insured cohort of children and adolescents. Methods New York State Medicaid administrative claims from 2006 to 2018 were analyzed. Enrollees aged 6-18 were included in the study if they had initial non-surgical root canal therapy (NSRCT), in the permanent dentition, that allowed for at least 1 year of post-treatment follow-up. Descriptive analyses, multivariable logistic regression, and multivariable Cox proportional hazard models were used to examine the association between demographic variables (gender, age, race/ethnicity, and area-based factors) and dental treatment provision and outcomes. Results Male gender was associated with having more than one initial NSRCT (adjusted odds ratio (aOR) = 1.06; 95% confidence interval (CI) = 1.02-1.10), as was rurality (aOR = 1.15; 95% CI = 1.06-1.24). Black/African American (AA) and Hispanic children were less likely than non-Hispanic white children to have multiple NSRCTs (aOR = 0.88; 95% CI = 0.83-0.93 and aOR = 0.78; 95% CI = 0.74-0.83). Being older or female conferred a lower hazard of an untoward event (aHR = 0.93; 95% CI = 0.92-0.94 and aHR = 0.86; 95% CI = 0.81-0.91). Compared to non-Hispanic white children, Hispanic and Black/AA children had a higher risk of untoward event (aHR = 1.31; 95% CI = 1.21-1.41 and aHR = 1.55; 95% CI = 1.43-1.67) while children of Asian descent had a lower incidence after initial NSRCT (aHR = 0.79; 95% CI = 0.71-0.88). Conclusion Race/ethnicity was the strongest demographic predictor of provision of initial non-surgical root canal therapy, subsequent placement of a permanent restoration and the occurrence of an untoward event after NSRCT in this cohort.
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Affiliation(s)
- Lorel E. Burns
- Department of Endodontics, New York University College of Dentistry, New York, NY, United States
| | - Nihan Gencerliler
- Department of Endodontics, New York University College of Dentistry, New York, NY, United States
| | - Kelly Terlizzi
- Health Evaluation and Analytics Lab, New York University, New York, NY, United States
| | - Yinxiang Wu
- Department of Population Health, New York University Langone Health, New York, NY, United States
| | - Claudia Solis-Roman
- Health Evaluation and Analytics Lab, New York University, New York, NY, United States
| | - Heather T. Gold
- Department of Population Health, New York University Langone Health, New York, NY, United States
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Burns LE, Terlizzi K, Solis‐Roman C, Wu Y, Sigurdsson A, Gold HT. Epidemiological evaluation of the outcomes of initial root canal therapy in permanent teeth of a publicly insured paediatric population. Int J Paediatr Dent 2022; 32:745-755. [PMID: 35000244 PMCID: PMC9272438 DOI: 10.1111/ipd.12953] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/18/2021] [Accepted: 12/30/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Previously published epidemiological outcome studies of nonsurgical root canal therapy (NSRCT) in the United States utilize data only from a single, private dental insurer for adult populations. AIM This study aimed to investigate the outcomes of initial NSRCT, performed on permanent teeth, in a publicly insured paediatric population. DESIGN New York State Medicaid administrative claims were used to follow 77 741 endodontic procedures in 51 545 patients aged 6-18, from the time of initial NSRCT until the occurrence of an untoward event (retreatment, apicoectomy, and extraction). The initial treatment and untoward events were identified by Current Dental Terminology codes. The Kaplan-Meier survival estimates were calculated at 1, 3, and 5 years. Hazard ratios for time to permanent restoration and restoration type were calculated using the Cox proportional hazards model. RESULTS The median follow-up time was 44 months [range: 12-158 months]. Procedural, NSRCT, survival was 98% at 1 year, 93% at 3 years, and 88% at 5 years. Extraction was the most common untoward event. Teeth permanently restored with cuspal coverage had the most favorable treatment outcomes. CONCLUSIONS Overall, 89% of teeth were retained and remained functional over a minimum follow-up time of 5 years. These results elucidate the expected outcomes of NSRCT in permanent teeth for paediatric patients with public-payer dental benefits.
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Affiliation(s)
- Lorel E. Burns
- Department of EndodonticsNew York University College of DentistryNew YorkNYUSA
| | - Kelly Terlizzi
- New York University Health Evaluation and Analytics LabNew YorkNYUSA
| | | | - Yinxiang Wu
- Department of Population HealthNew York University Langone HealthNew YorkNYUSA
| | - Asgeir Sigurdsson
- Department of EndodonticsNew York University College of DentistryNew YorkNYUSA
| | - Heather T. Gold
- Department of Population HealthNew York University Langone HealthNew YorkNYUSA
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Haber Y, Fu SS, Rogers E, Richter K, Tenner C, Dognin J, Goldfeld K, Gold HT, Sherman SE. A novel opt-in vs opt-out approach to referral-based treatment of tobacco use in Veterans Affairs (VA) primary care clinics: A provider-level randomized controlled trial protocol. Contemp Clin Trials 2022; 116:106716. [PMID: 35276337 DOI: 10.1016/j.cct.2022.106716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/17/2022] [Accepted: 02/23/2022] [Indexed: 11/18/2022]
Abstract
To determine whether an opt-out approach is effective for referral to treatment for tobacco use, we designed a clinical reminder for nurses in a primary care setting that provides a referral for patients who smoke cigarettes. We will use a two-arm, cluster-randomized design to assign nurses at the VA New York Harbor Healthcare System to test which mode of referral (opt-in vs opt-out) is more effective. All patients will be referred to evidence-based treatment for tobacco cessation including counseling from the New York State Quitline, and VetsQuit, a text messaging-based system for tobacco cessation counseling. We will measure patient engagement with the referral both in the short and long term to determine if referral modality had an impact on tobacco cessation treatment. We will also measure nurse engagement with the referral before, during, and after the implementation of the reminder to determine whether an opt-out approach is cost effective at the health system level. At the conclusion of this project, we expect to have developed and tested an opt-out system for increasing tobacco cessation treatment for Veterans in VA primary care and to have a thorough understanding of factors associated with implementation. Trial Registration:Clinicaltrials.govIdentifierNCT03477435.
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Affiliation(s)
- Yaa Haber
- VA New York Harbor Healthcare System, New York, NY, USA; Department of Medicine, VA New York Harbor Healthcare System, New York, NY, USA; NYU Grossman School of Medicine, Department of Population Health, New York, NY, USA.
| | - Steven S Fu
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Erin Rogers
- VA New York Harbor Healthcare System, New York, NY, USA; NYU Grossman School of Medicine, Department of Population Health, New York, NY, USA
| | - Kim Richter
- Department of Preventive Medicine and Public Health, University of Kansas Medical Center, Kansas City, KS, USA
| | - Craig Tenner
- VA New York Harbor Healthcare System, New York, NY, USA; NYU Grossman School of Medicine, Department of Medicine, New York, NY, USA
| | - Joanna Dognin
- VA New York Harbor Healthcare System, New York, NY, USA; NYU Grossman School of Medicine, Department of Medicine, New York, NY, USA; Department of Psychology, VA New York Harbor Healthcare System, New York, NY, USA
| | - Keith Goldfeld
- VA New York Harbor Healthcare System, New York, NY, USA; NYU Grossman School of Medicine, Department of Population Health, New York, NY, USA
| | - Heather T Gold
- VA New York Harbor Healthcare System, New York, NY, USA; NYU Grossman School of Medicine, Department of Population Health, New York, NY, USA
| | - Scott E Sherman
- VA New York Harbor Healthcare System, New York, NY, USA; NYU Grossman School of Medicine, Department of Population Health, New York, NY, USA; NYU Grossman School of Medicine, Department of Medicine, New York, NY, USA
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12
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Gold HT, McDermott C, Hoomans T, Wagner TH. Cost data in implementation science: categories and approaches to costing. Implement Sci 2022; 17:11. [PMID: 35090508 PMCID: PMC8796347 DOI: 10.1186/s13012-021-01172-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 11/03/2021] [Indexed: 12/14/2022] Open
Abstract
A lack of cost information has been cited as a barrier to implementation and a limitation of implementation research. This paper explains how implementation researchers might optimize their measurement and inclusion of costs, building on traditional economic evaluations comparing costs and effectiveness of health interventions. The objective of all economic evaluation is to inform decision-making for resource allocation and to measure costs that reflect opportunity costs—the value of resource inputs in their next best alternative use, which generally vary by decision-maker perspective(s) and time horizon(s). Analyses that examine different perspectives or time horizons must consider cost estimation accuracy, because over longer time horizons, all costs are variable; however, with shorter time horizons and narrower perspectives, one must differentiate the fixed and variable costs, with fixed costs generally excluded from the evaluation. This paper defines relevant costs, identifies sources of cost data, and discusses cost relevance to potential decision-makers contemplating or implementing evidence-based interventions. Costs may come from the healthcare sector, informal healthcare sector, patient, participant or caregiver, and other sectors such as housing, criminal justice, social services, and education. Finally, we define and consider the relevance of costs by phase of implementation and time horizon, including pre-implementation and planning, implementation, intervention, downstream, and adaptation, and through replication, sustainment, de-implementation, or spread.
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13
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Lim S, Wyatt LC, Mammen S, Zanowiak JM, Mohaimin S, Troxel AB, Lindau ST, Gold HT, Shelley D, Trinh-Shevrin C, Islam NS. Implementation of a multi-level community-clinical linkage intervention to improve glycemic control among south Asian patients with uncontrolled diabetes: study protocol of the DREAM initiative. BMC Endocr Disord 2021; 21:233. [PMID: 34814899 PMCID: PMC8609264 DOI: 10.1186/s12902-021-00885-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 10/22/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND A number of studies have identified patient-, provider-, and community-level barriers to effective diabetes management among South Asian Americans, who have a high prevalence of type 2 diabetes. However, no multi-level, integrated community health worker (CHW) models leveraging health information technology (HIT) have been developed to mitigate disease among this population. This paper describes the protocol for a multi-level, community-clinical linkage intervention to improve glycemic control among South Asians with uncontrolled diabetes. METHODS The study includes three components: 1) building the capacity of primary care practices (PCPs) to utilize electronic health record (EHR) registries to identify patients with uncontrolled diabetes; 2) delivery of a culturally- and linguistically-adapted CHW intervention to improve diabetes self-management; and 3) HIT-enabled linkage to culturally-relevant community resources. The CHW intervention component includes a randomized controlled trial consisting of group education sessions on diabetes management, physical activity, and diet/nutrition. South Asian individuals with type 2 diabetes are recruited from 20 PCPs throughout NYC and randomized at the individual level within each PCP site. A total of 886 individuals will be randomized into treatment or control groups; EHR data collection occurs at screening, 6-, 12-, and 18-month. We hypothesize that individuals receiving the multi-level diabetes management intervention will be 15% more likely than the control group to achieve ≥0.5% point reduction in hemoglobin A1c (HbA1c) at 6-months. Secondary outcomes include change in weight, body mass index, and LDL cholesterol; the increased use of community and social services; and increased health self-efficacy. Additionally, a cost-effectiveness analysis will focus on implementation and healthcare utilization costs to determine the incremental cost per person achieving an HbA1c change of ≥0.5%. DISCUSSION Final outcomes will provide evidence regarding the effectiveness of a multi-level, integrated EHR-CHW intervention, implemented in small PCP settings to promote diabetes control among an underserved South Asian population. The study leverages multisectoral partnerships, including the local health department, a healthcare payer, and EHR vendors. Study findings will have important implications for the translation of integrated evidence-based strategies to other minority communities and in under-resourced primary care settings. TRIAL REGISTRATION This study was registered with clinicaltrials.gov: NCT03333044 on November 6, 2017.
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Affiliation(s)
- Sahnah Lim
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, New York, NY, 10016, USA.
| | - Laura C Wyatt
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, New York, NY, 10016, USA
| | - Shinu Mammen
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, New York, NY, 10016, USA
| | - Jennifer M Zanowiak
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, New York, NY, 10016, USA
| | - Sadia Mohaimin
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, New York, NY, 10016, USA
| | - Andrea B Troxel
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, New York, NY, 10016, USA
| | - Stacy Tessler Lindau
- Departments of Obstetrics and Gynecology and Medicine-Geriatrics, The University of Chicago, 5841 Maryland Avenue MC 2050, Chicago, IL, 60637, USA
| | - Heather T Gold
- Department of Population Health, NYU Grossman School of Medicine, 550 First Ave, VZ30, 6th floor, New York, NY, 10016, USA
| | - Donna Shelley
- Department of Public Health Policy and Management Department, NYU Global School of Public Health, 665 Broadway, 11th Floor, New York, NY, 10012, USA
| | - Chau Trinh-Shevrin
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, New York, NY, 10016, USA
| | - Nadia S Islam
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, New York, NY, 10016, USA
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14
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Makarov DV, Ciprut S, Kelly M, Walter D, Shedlin MG, Braithwaite RS, Tenner CT, Gold HT, Zeliadt S, Sherman SE. Protocol: A multi-modal, physician-centered intervention to improve guideline-concordant prostate cancer imaging. Trials 2021; 22:711. [PMID: 34663435 PMCID: PMC8522153 DOI: 10.1186/s13063-021-05645-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/19/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Almost half of Veterans with localized prostate cancer receive inappropriate, wasteful staging imaging. Our team has explored the barriers and facilitators of guideline-concordant prostate cancer imaging and found that (1) patients with newly diagnosed prostate cancer have little concern for radiographic staging but rather focus on treatment and (2) physicians trust imaging guidelines but are apt to follow their own intuition, fear medico-legal consequences, and succumb to influence from imaging-avid colleagues. We used a theory-based approach to design a multi-level intervention strategy to promote guideline-concordant imaging to stage incident prostate cancer. METHODS We designed the Prostate Cancer Imaging Stewardship (PCIS) intervention: a multi-site, stepped wedge, cluster-randomized trial to determine the effect of a physician-focused behavioral intervention on Veterans Health Administration (VHA) prostate cancer imaging use. The multi-level intervention, developed according to the Theoretical Domains Framework (TDF) and Behavior Change Wheel, combines traditional physician behavior change methods with novel methods of communication and data collection. The intervention consists of three components: (1) a system of audit and feedback to clinicians informing individual clinicians and their sites about how their behavior compares to their peers' and to published guidelines, (2) a program of academic detailing with the goal to educate providers about prostate cancer imaging, and (3) a CPRS Clinical Order Check for potentially guideline-discordant imaging orders. The intervention will be introduced to 10 participating geographically distributed study sites. DISCUSSION This study is a significant contribution to implementation science, providing VHA an opportunity to ensure delivery of high-quality care at the lowest cost using a theory-based approach. The study is ongoing. Preliminary data collection and recruitment have started; analysis has yet to be performed. TRIAL REGISTRATION CliniclTrials.gov NCT03445559. Prospectively registered on February 26, 2018.
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Affiliation(s)
- Danil V Makarov
- Department of Urology, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA
- Department of Population Health, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA
- VA New York Harbor Healthcare System, New York, USA
- Robert F. Wagner Graduate School of Public Service, New York University, New York, USA
- Perlmutter Cancer Center, New York University School of Medicine, New York, USA
| | - Shannon Ciprut
- Department of Urology, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA
- Department of Population Health, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA
- VA New York Harbor Healthcare System, New York, USA
| | - Matthew Kelly
- Department of Urology, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA.
- Department of Population Health, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA.
- VA New York Harbor Healthcare System, New York, USA.
| | - Dawn Walter
- Department of Urology, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA
- Department of Population Health, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA
| | | | - Ronald Scott Braithwaite
- Department of Population Health, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA
| | - Craig T Tenner
- VA New York Harbor Healthcare System, New York, USA
- Department of Medicine - General Internal Medicine, New York University, New York, NY, USA
| | - Heather T Gold
- Department of Population Health, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA
- VA New York Harbor Healthcare System, New York, USA
- Robert F. Wagner Graduate School of Public Service, New York University, New York, USA
| | - Steven Zeliadt
- Health Services Research and Development, Department of Veterans Affairs Medical Center, Seattle, WA, USA
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Scott E Sherman
- Department of Urology, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA
- VA New York Harbor Healthcare System, New York, USA
- Perlmutter Cancer Center, New York University School of Medicine, New York, USA
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15
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Makarov DV, Ciprut S, Martinez-Lopez N, Fagerlin A, Thomas J, Shedlin M, Gold HT, Li H, Bhat S, Warren R, Ubel P, Ravenell JE. Clinical Trial Protocol for a Randomized Trial of Community Health Worker-led Decision Coaching to Promote Shared Decision-making on Prostate Cancer Screening Among Black Male Patients and Their Providers. Eur Urol Focus 2021; 7:909-912. [PMID: 34426097 DOI: 10.1016/j.euf.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 08/05/2021] [Indexed: 10/20/2022]
Abstract
We propose a randomized controlled trial to evaluate the effectiveness of a community health worker-led decision-coaching program to facilitate shared decision-making for prostate cancer screening decisions by Black men at a primary care federally qualified health center.
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Affiliation(s)
- Danil V Makarov
- VA New York Harbor Healthcare System, New York, NY, USA; Department of Urology, NYU Langone Health, New York, NY, USA; Department of Population Health, NYU Langone Health, New York, NY, USA.
| | - Shannon Ciprut
- VA New York Harbor Healthcare System, New York, NY, USA; Department of Urology, NYU Langone Health, New York, NY, USA; Department of Population Health, NYU Langone Health, New York, NY, USA
| | | | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jerry Thomas
- Department of Population Health, NYU Langone Health, New York, NY, USA
| | | | - Heather T Gold
- Department of Population Health, NYU Langone Health, New York, NY, USA
| | - Huilin Li
- Department of Population Health, NYU Langone Health, New York, NY, USA
| | - Sandeep Bhat
- Sunset Park Health Council, Brooklyn, New York, NY, USA
| | - Rueben Warren
- National Center for Bioethics in Research and Health Care, Tuskegee University, Tuskegee, AL, USA
| | - Peter Ubel
- The Fuqua School of Business, Duke University, Durham, NC, USA
| | - Joseph E Ravenell
- Department of Population Health, NYU Langone Health, New York, NY, USA
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16
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Gold HT, Pirraglia E, Huang ES, Wan W, Pascual AB, Jensen RJ, Gonzalez AG. Cost and healthcare utilization analysis of culturally sensitive, shared medical appointment model for Latino children with type 1 diabetes. Pediatr Diabetes 2021; 22:816-822. [PMID: 33909322 PMCID: PMC8627428 DOI: 10.1111/pedi.13218] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 03/08/2021] [Accepted: 04/06/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE This study evaluated costs and healthcare utilization associated with a culturally-sensitive, medical and education program for pediatric Latino patients with type 1 diabetes. RESEARCH DESIGN AND METHODS Program participants included Latino children ages 1-20 years old diagnosed with type 1 diabetes (n = 57). Control subjects with type 1 diabetes were matched by age, sex, and zip code to intervention participants from the Colorado All Payer Claims Database. Data included emergency department (ED) visits, hospitalizations, demographic information, and health insurance claims data 180 days prior to program start/index date through 1 year after program start/index date. We tracked program staff time and estimated costs for healthcare utilization using data from the scientific literature. Generalized Estimating Equation (GEE) models with logit link were used to estimate group differences in probabilities of ED visits and hospitalizations over 6-month periods pre/post-study, accounting for correlation of within-subject data across time points. Sensitivity analyses modeled longer-term cost differences under different assumptions. RESULTS The intervention group had fewer hospitalizations, 2% versus 12% of controls (p = 0.047,OR = 0.13;95%CI: 0.02-0.97) for 6 months following start date. The intervention group had fewer ED visits, 19% versus 32% in controls (n.s.; p = 0.079,OR = 0.52;95%CI:0.25-1.08) and significantly fewer hospitalizations, 4% versus 15% of controls (p = 0.039,OR = 0.21;95%CI: 0.05-0.93) 6-12 months post-start date. One-year per-patient program costs of $633 and healthcare cost savings of $2710 yielded total per-patient savings of $2077, or a 5-year cost savings of $14,106. CONCLUSION This unique type 1 diabetes management program altered health service utilization of program participants, reducing major healthcare cost drivers, ED visits, and hospitalizations.
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Affiliation(s)
| | | | - Elbert S. Huang
- University of Chicago School of Medicine, 5841 S Maryland AveChicago, Illinois, USA
| | - Wen Wan
- University of Chicago School of Medicine, 5841 S Maryland AveChicago, Illinois, USA
| | - Andrea B. Pascual
- Barbara Davis Center, University of Colorado Denver, Aurora, Colorado, USA
| | - Ryan James Jensen
- Barbara Davis Center, University of Colorado Denver, Aurora, Colorado, USA
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17
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Winn AN, Kelly M, Ciprut S, Walter D, Gold HT, Zeliadt SB, Sherman SE, Makarov DV. The cost, survival, and quality-of-life implications of guideline-discordant imaging for prostate cancer. Cancer Rep (Hoboken) 2021; 5:e1468. [PMID: 34137520 PMCID: PMC8842701 DOI: 10.1002/cnr2.1468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 11/16/2022] Open
Abstract
Background National Comprehensive Cancer Network (NCCN) guidelines for incident prostate cancer staging imaging have been widely circulated and accepted as best practice since 1996. Despite these clear guidelines, wasteful and potentially harmful inappropriate imaging of men with prostate cancer remains prevalent. Aim To understand changing population‐level patterns of imaging among men with incident prostate cancer, we created a state‐transition microsimulation model based on existing literature and incident prostate cancer cases. Methods To create a cohort of patients, we identified incident prostate cancer cases from 2004 to 2009 that were diagnosed in men ages 65 and older from SEER. A microsimulation model allowed us to explore how this cohort's survival, quality of life, and Medicare costs would be impacted by making imaging consistent with guidelines. We conducted a probabilistic analysis as well as one‐way sensitivity analysis. Results When only imaging high‐risk men compared to the status quo, we found that the population rate of imaging dropped from 53 to 38% and average per‐person spending on imaging dropped from $236 to $157. The discounted and undiscounted incremental cost‐effectiveness ratios indicated that ideal upfront imaging reduced costs and slightly improved health outcomes compared with current practice patterns, that is, guideline‐concordant imaging was less costly and slightly more effective. Conclusion This study demonstrates the potential reduction in cost through the correction of inappropriate imaging practices. These findings highlight an opportunity within the healthcare system to reduce unnecessary costs and overtreatment through guideline adherence.
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Affiliation(s)
- Aaron N Winn
- School of Pharmacy, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Cancer Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Matthew Kelly
- Department of Urology, New York University School of Medicine, New York, USA.,Department of Population Health, New York University School of Medicine, New York, USA.,VA New York Harbor Healthcare System, New York, USA
| | - Shannon Ciprut
- Department of Urology, New York University School of Medicine, New York, USA.,Department of Population Health, New York University School of Medicine, New York, USA.,VA New York Harbor Healthcare System, New York, USA
| | - Dawn Walter
- Department of Urology, New York University School of Medicine, New York, USA.,Department of Population Health, New York University School of Medicine, New York, USA.,VA New York Harbor Healthcare System, New York, USA
| | - Heather T Gold
- Department of Population Health, New York University School of Medicine, New York, USA.,VA New York Harbor Healthcare System, New York, USA.,Robert F. Wagner Graduate School of Public Service, New York University, New York, USA
| | - Steven B Zeliadt
- Health Services Research and Development, Department of Veterans Affairs Medical Center, Seattle, Washington, USA.,Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Scott E Sherman
- Department of Population Health, New York University School of Medicine, New York, USA.,VA New York Harbor Healthcare System, New York, USA.,Perlmutter Cancer Center, New York University School of Medicine, New York, USA
| | - Danil V Makarov
- Department of Urology, New York University School of Medicine, New York, USA.,Department of Population Health, New York University School of Medicine, New York, USA.,VA New York Harbor Healthcare System, New York, USA.,Robert F. Wagner Graduate School of Public Service, New York University, New York, USA.,Perlmutter Cancer Center, New York University School of Medicine, New York, USA
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18
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Gerber NK, Shao H, Chadha M, Deb P, Gold HT. Radiation Without Endocrine Therapy in Older Women With Stage I Estrogen-Receptor-Positive Breast Cancer Is Not Associated With a Higher Risk of Second Breast Cancer Events. Int J Radiat Oncol Biol Phys 2021; 112:40-51. [PMID: 33974886 DOI: 10.1016/j.ijrobp.2021.04.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/20/2021] [Accepted: 04/23/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE The omission of radiation therapy (RT) in older women with stage 1 estrogen-receptor-positive (ER+) breast cancer receiving endocrine therapy (ET) is an acceptable strategy based on randomized trial data. Less is known about the omission of ET with or without RT. METHODS AND MATERIALS We analyzed surveillance, epidemiology, and end results (SEER)-Medicare data for 13,321 women age 66 years or older with stage I ER+ breast cancer from 2007 to 2012 who underwent breast-conserving surgery. Patients were classified into 4 groups: (1) ET + RT (reference); (2) ET alone; (3) RT alone; and (4) neither RT nor ET (NT). Second breast cancer events (SBCEs) were captured using the Chubak high-specificity algorithm. We used χ2 tests for descriptive statistics, multivariable multinomial logistic regression to estimate relative risk of undergoing a treatment, and multivariable, propensity-weighted competing-risks survival regression to estimate standardized hazard ratio (SHR) of SBCE. We set significance at P ≤ .01. RESULTS Most women underwent both treatments, with 44% undergoing ET + RT, 41% RT alone, 6.6% ET alone, and 8.6% NT, but practice patterns varied over time. From 2007 to 2012, RT decreased from 49% to 30%, whereas ET alone and ET + RT increased (ET alone, 5.4%-9.6%; ET + RT, 38%-51%). Compared with patients age 66 to 69 years, patients age 80 to 85 years were more likely to receive NT (odds ratio [OR], 8.9), RT (OR, 1.9), or ET (OR, 8.8) versus ET + RT (P < .01). Three percent of subjects had an SBCE (2.2% ET + RT, 3.0% RT alone, 3.2% ET alone, 7.0% NT). Relative to ET + RT, NT and ET alone were associated with higher SBCE (NT: SHR, 3.7, P < .001; ET alone: SHR, 2.2, P = .008), whereas RT was not associated with a higher SBCE (SHR 1.21; P = .137). Clinical factors associated with higher SBCE were HER2 positivity and pT1c (SHR, 1.7; P = .006). CONCLUSIONS Treatment with RT alone in older women with stage I ER+ disease is decreasing. RT alone is not associated with an increased risk for SBCE. By contrast, NT and ET are both associated with higher SBCE in multivariable analysis with propensity weighting. Further study of the omission of endocrine therapy in this patient population is warranted.
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Affiliation(s)
- Naamit K Gerber
- Department of Radiation Oncology, NYU School of Medicine, New York, New York.
| | - Huibo Shao
- Baptist Clinical Research Institute, Memphis, Tennessee
| | - Manjeet Chadha
- Department of Radiation Oncology, Mount Sinai School of Medicine, New York, New York
| | - Partha Deb
- Department of Economics, Hunter College, CUNY, New York, New York
| | - Heather T Gold
- Department of Population Health, NYU School of Medicine, New York, New York
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19
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Makarov DV, Feuer Z, Ciprut S, Lopez NM, Fagerlin A, Shedlin M, Gold HT, Li H, Lynch G, Warren R, Ubel P, Ravenell JE. Randomized trial of community health worker-led decision coaching to promote shared decision-making for prostate cancer screening among Black male patients and their providers. Trials 2021; 22:128. [PMID: 33568208 PMCID: PMC7876807 DOI: 10.1186/s13063-021-05064-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 01/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Black men are disproportionately affected by prostate cancer, the most common non-cutaneous malignancy among men in the USA. The United States Preventive Services Task Force (USPSTF) encourages prostate-specific antigen (PSA) testing decisions to be based on shared decision-making (SDM) clinician professional judgment, and patient preferences. However, evidence suggests that SDM is underutilized in clinical practice, especially among the most vulnerable patients. The purpose of this study is to evaluate the efficacy of a community health worker (CHW)-led decision-coaching program to facilitate SDM for prostate cancer screening among Black men in the primary care setting, with the ultimate aim of improving/optimizing decision quality. METHODS We proposed a CHW-led decision-coaching program to facilitate SDM for prostate cancer screening discussions in Black men at a primary care FQHC. This study enrolled Black men who were patients at the participating clinical site and up to 15 providers who cared for them. We estimated to recruit 228 participants, ages 40-69 to be randomized to either (1) a decision aid along with decision coaching on PSA screening from a CHW or (2) receiving a decision aid along with CHW-led interaction on modifying dietary and lifestyle to serve as an attention control. The independent randomization process was implemented within each provider and we controlled for age by dividing patients into two strata: 40-54 years and 55-69 years. This sample size sufficiently powered the detection differences in the primary study outcomes: knowledge, indicative of decision quality, and differences in PSA screening rates. Primary outcome measures for patients will be decision quality and decision regarding whether to undergo PSA screening. Primary outcome measures for providers will be acceptability and feasibility of the intervention. We will examine how decision coaching about prostate cancer screening impact patient-provider communication. These outcomes will be analyzed quantitatively through objective, validated scales and qualitatively through semi-structured, in-depth interviews, and thematic analysis of clinical encounters. Through a conceptual model combining elements of the Preventative Health Care Model (PHM) and Informed Decision-Making Model, we hypothesize that the prostate cancer screening decision coaching intervention will result in a preference-congruent decision and decisional satisfaction. We also hypothesize that this intervention will improve physician satisfaction with counseling patients about prostate cancer screening. DISCUSSION Decision coaching is an evidence-based approach to improve decision quality in many clinical contexts, but its efficacy is incompletely explored for PSA screening among Black men in primary care. Our proposal to evaluate a CHW-led decision-coaching program for PSA screening has high potential for scalability and public health impact. Our results will determine the efficacy, cost-effectiveness, and sustainability of a CHW intervention in a community clinic setting in order to inform subsequent widespread dissemination, a critical research area highlighted by USPSTF. TRIAL REGISTRATION The trial was registered prospectively with the National Institute of Health registry ( www.clinicaltrials.gov ), registration number NCT03726320 , on October 31, 2018.
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Affiliation(s)
- Danil V Makarov
- VA New York Harbor Healthcare System, 423 E 23rd St, New York, NY, USA.
- Departments of Urology, NYU Langone Health, 227 E 30th St, New York, NY, USA.
- Population Health, NYU Langone Health, 227 E 30th St, New York, NY, USA.
| | - Zachary Feuer
- VA New York Harbor Healthcare System, 423 E 23rd St, New York, NY, USA
- Departments of Urology, NYU Langone Health, 227 E 30th St, New York, NY, USA
| | - Shannon Ciprut
- VA New York Harbor Healthcare System, 423 E 23rd St, New York, NY, USA
- Departments of Urology, NYU Langone Health, 227 E 30th St, New York, NY, USA
- Population Health, NYU Langone Health, 227 E 30th St, New York, NY, USA
| | | | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | - Heather T Gold
- Population Health, NYU Langone Health, 227 E 30th St, New York, NY, USA
| | - Huilin Li
- Population Health, NYU Langone Health, 227 E 30th St, New York, NY, USA
| | - Gina Lynch
- Sunset Park Health Council, Brooklyn, NY, USA
| | - Rueben Warren
- National Center for Bioethics in Research and Health Care, Tuskegee University, Tuskegee, USA
| | - Peter Ubel
- The Fuqua School of Business, Duke University, Durham, NC, USA
| | - Joseph E Ravenell
- Population Health, NYU Langone Health, 227 E 30th St, New York, NY, USA
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20
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Gold HT, Siman N, Cuthel AM, Nguyen AM, Pham-Singer H, Berry CA, Shelley DR. A practice facilitation-guided intervention in primary care settings to reduce cardiovascular disease risk: a cost analysis. Implement Sci Commun 2021; 2:15. [PMID: 33549152 PMCID: PMC7868016 DOI: 10.1186/s43058-021-00116-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 01/28/2021] [Indexed: 11/23/2022] Open
Abstract
Background A stepped-wedge, cluster randomized controlled trial assessed the effectiveness of practice facilitation (PF) for adoption of guidelines for prevention and treatment of cardiovascular disease risk factors. This study estimated the associated cost of PF for guideline adoption in small, private primary care practices. Methods The cost analysis included categories for start-up costs, intervention costs, and practice staff costs for the implemented PF-guided intervention. We estimated the total 1-year costs to operate the program and calculated the mean and range of the cost-per-practice by quarter of the intervention. We estimated the lower and upper bounds for all salary expenses, rounding to the nearest $100. Results Total 1-year intervention costs for all 261 practices ranged from $7,900,000 to $10,200,000, with program and practice salaries comprising $6,600,000–$8,400,000 of the total. Start-up costs were a small proportion (3%) of the total 1-year costs. Excluding start-up costs, quarter 1 cost-per-practice was the most expensive at $20,400–$26,700, and quarter 4 was the least expensive at about $10,000. Practice staff time (compared with program staff time) was the majority of the staffing costs at 75–84%. Conclusions The PF strategy costs approximately $10,000 per practice per quarter for program and practice costs, once implemented and running at highest efficiency. Whether this program is “worth it” to the decision-maker depends on the relative costs and effectiveness of their other options for improving cardiovascular risk reduction. Trial registration This study is retrospectively registered on January 5, 2016, at www.clinicaltrials.gov as NCT02646488.
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Affiliation(s)
- Heather T Gold
- Department of Population Health, NYU Langone Health, New York, NY, USA.
| | - Nina Siman
- Department of Population Health, NYU Langone Health, New York, NY, USA
| | - Allison M Cuthel
- Ronald O. Perelman Department of Emergency Medicine, NYU Langone Health, New York, NY, USA
| | - Ann M Nguyen
- Rutgers Center for State Health Policy, Rutgers University, New Brunswick, NJ, USA
| | - Hang Pham-Singer
- New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - Carolyn A Berry
- Department of Population Health, NYU Langone Health, New York, NY, USA
| | - Donna R Shelley
- Department of Policy and Public Health Management, School of Global Public Health, New York University, New York, NY, USA
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21
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Becker DJ, Iyengar AD, Punekar SR, Kaakour D, Griffin M, Nicholson J, Gold HT. Diabetes mellitus and colorectal carcinoma outcomes: a meta-analysis. Int J Colorectal Dis 2020; 35:1989-1999. [PMID: 32564124 DOI: 10.1007/s00384-020-03666-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The impact of diabetes mellitus (DM) on colorectal cancer (CRC) outcomes remains unknown. We studied this by conducting a meta-analysis to evaluate (1) CRC outcomes with and without DM and (2) treatment patterns. METHODS We searched PubMed, EMBASE, Google Scholar, and CINAHL for full-text English studies from 1970 to 12/31/2017. We searched keywords, subject headings, and MESH terms to locate studies of CRC outcomes/treatment and DM. Studies were evaluated by two oncologists. Of 14,332, 48 met inclusion criteria. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method, we extracted study location, design, DM definition, covariates, comparison groups, outcomes, and relative risks and/or hazard ratios. We utilized a random-effects model to pool adjusted risk estimates. Primary outcomes were all-cause mortality (ACM), disease-free survival (DFS), relapse-free survival (RFS), and cancer-specific survival (CSS). The secondary outcome was treatment patterns. RESULTS Forty-eight studies were included, 42 in the meta-analysis, and 6 in the descriptive analysis, totaling > 240,000 patients. ACM was 21% worse (OR 1.21, 95% CI 1.15-1.28) and DFS was 75% worse (OR 1.75, 95% CI: 1.33-2.31) in patients with DM. No differences were detected in CSS (OR 1.10, 95% CI 0.98-1.23) or RFS (OR 1.12, 95% CI 0.91-1.38). Descriptive analysis of treatment patterns in CRC and DM suggested potentially less adjuvant therapy use in cases with DM and CRC. CONCLUSIONS Our meta-analysis suggests that patients with CRC and DM have worse ACM and DFS than patients without DM, suggesting that non-cancer causes of death in may account for worse outcomes.
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Affiliation(s)
- Daniel J Becker
- Grossman School of Medicine, New York University, New York, NY, 10016, USA
| | - Arjun D Iyengar
- Grossman School of Medicine, New York University, New York, NY, 10016, USA
| | - Salman R Punekar
- Grossman School of Medicine, New York University, New York, NY, 10016, USA.
| | - Dalia Kaakour
- Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Megan Griffin
- Grossman School of Medicine, New York University, New York, NY, 10016, USA
| | - Joseph Nicholson
- Grossman School of Medicine, New York University, New York, NY, 10016, USA
| | - Heather T Gold
- Grossman School of Medicine, New York University, New York, NY, 10016, USA
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22
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Abstract
Health care decision makers often request information showing how a new treatment or intervention will affect their budget (i.e., a budget impact analysis; BIA). In this article, we present key topics for considering how to measure downstream health care costs, a key component of the BIA, when implementing an evidence-based program designed to reduce a quality gap. Tracking health care utilization can be done with administrative or self-reported data, but estimating costs for these utilization data raises 2 issues that are often overlooked in implementation science. The first issue has to do with applicability: are the cost estimates applicable to the health care system that is implementing the quality improvement program? We often use national cost estimates or average payments, without considering whether these cost estimates are appropriate. Second, we need to determine the decision maker's time horizon to identify the costs that vary in that time horizon. If the BIA takes a short-term time horizon, then we should focus on costs that vary in the short run and exclude costs that are fixed over this time. BIA is an increasingly popular tool for health care decision makers interested in understanding the financial effect of implementing an evidence-based program. Without careful consideration of some key conceptual issues, we run the risk of misleading decision makers when presenting results from implementation studies.
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Affiliation(s)
- Todd H Wagner
- Health Economics Resource Center, US Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, CA, USA.,Department of Surgery, Stanford University, Stanford, CA
| | | | - Heather T Gold
- Departments of Population Health and Orthopedic Surgery, New York University (NYU) Langone Health, NY, USA
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23
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Schwarzkopf R, Kaplan DJ, Friedlander S, Gold HT. Outcomes of a First Total Knee Arthroplasty Are Associated With Outcomes of the Subsequent Contralateral Total Knee Arthroplasty. J Arthroplasty 2020; 35:1534-1539. [PMID: 32061478 DOI: 10.1016/j.arth.2020.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/06/2020] [Accepted: 01/14/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND To determine if preoperative characteristics and postoperative outcomes of a first total knee arthroplasty (TKA) were predictive of characteristics and outcomes of the subsequent contralateral TKA in the same patient. METHODS Retrospective administrative claims data from (SPARCS) database were analyzed for patients who underwent sequential TKAs from September 2015 to September 2017 (n = 5,331). Hierarchical multivariable Poisson regression (length of stay [LOS]) and multivariable logistic regression (all other outcomes), controlling for sex, age, and Elixhauser comorbidity scores were performed. RESULTS The cohort comprised 65% women, with an average age of 66 years and an average duration of 7.3 months between surgeries (SD: 4.7 months). LOS was significantly shorter for the second TKA (2.6 days) than for the first TKA (2.8 days; P < .001). Patients discharged to a facility after their first TKA had a probability of 76% of discharge to facility after the second TKA and were significantly more likely to be discharged to a facility compared with those discharged home after the first TKA (odds ratio [OR]: 63.7; 95% confidence interval [CI]: 52.1-77.8). The probability of a readmission at 30 and 90 days for the second TKA if the patient was readmitted for the first TKA was 1.0% (OR: 3.70; 95% CI: 0.98-14.0) and 6.4% (OR: 9; 95% CI: 5.1-16.0), respectively. Patients with complications after their first TKA had a 27% probability of a complication after the second TKA compared with a 1.6% probability if there was no complication during the first TKA (OR: 14.6; 95% CI: 7.8.1-27.2). CONCLUSION The LOS, discharge disposition, 90-day readmission rate, and complication rate for a second contralateral TKA are strongly associated with the patient's first TKA experience. The second surgery was found to be associated with an overall shorter LOS, fewer readmissions, and higher likelihood of home discharge. LEVEL OF EVIDENCE Level 3-retrospective cohort study.
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Affiliation(s)
- Ran Schwarzkopf
- Departments of Population Health and Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Daniel J Kaplan
- Departments of Population Health and Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Scott Friedlander
- Departments of Population Health and Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Heather T Gold
- Departments of Population Health and Orthopedic Surgery, NYU Langone Health, New York, NY
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24
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Klifto CS, Lavery JA, Gold HT, Milone MT, Karia R, Palusci V, Chu A. Pediatric Fingertip Injuries: Association With Child Abuse. Journal of Hand Surgery Global Online 2020; 2:31-34. [PMID: 35415471 PMCID: PMC8991547 DOI: 10.1016/j.jhsg.2019.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 09/06/2019] [Indexed: 10/31/2022] Open
Abstract
Purpose Methods Results Conclusions Type of study/level of evidence
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25
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Lim S, Wyatt LC, Mammen S, Zanowiak JM, Mohaimin S, Goldfeld KS, Shelley D, Gold HT, Islam NS. The DREAM Initiative: study protocol for a randomized controlled trial testing an integrated electronic health record and community health worker intervention to promote weight loss among South Asian patients at risk for diabetes. Trials 2019; 20:635. [PMID: 31752964 PMCID: PMC6868710 DOI: 10.1186/s13063-019-3711-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 09/09/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Electronic health record (EHR)-based interventions that use registries and alerts can improve chronic disease care in primary care settings. Community health worker (CHW) interventions also have been shown to improve chronic disease outcomes, especially in minority communities. Despite their potential, these two approaches have not been tested together, including in small primary care practice (PCP) settings. This paper presents the protocol of Diabetes Research, Education, and Action for Minorities (DREAM) Initiative, a 5-year randomized controlled trial integrating both EHR and CHW approaches into a network of PCPs in New York City (NYC) in order to support weight loss efforts among South Asian patients at risk for diabetes. METHODS/DESIGN The DREAM Initiative was funded by the National Institute of Diabetes and Digestive and Kidney Diseases (National Institutes of Health). A total of 480 individuals at risk for type 2 diabetes will be enrolled into the intervention group, and an equal number will be included in a matched control group. The EHR intervention components include the provision of technical assistance to participating PCPs regarding prediabetes-related registry reports, alerts, and order sets. The CHW intervention components entail group education sessions on diabetes prevention, including weight loss and nutrition. A mixed-methods approach will be used to evaluate the feasibility, adoption, and impact (≥ 5% weight loss) of the integrated study components. Additionally, a cost effectiveness analysis will be conducted using outcomes, implementation costs, and healthcare claims data to determine the incremental cost per person achieving 5% weight loss. DISCUSSION This study will be the first to test the efficacy of an integrated EHR-CHW intervention within an underserved, minority population and in a practical setting via a network of small PCPs in NYC. The study's implementation is enhanced through cross-sector partnerships, including the local health department, a healthcare payer, and EHR vendors. Through use of a software platform, the study will also systematically track and monitor CHW referrals to social service organizations. Study findings, including those resulting from cost-effectiveness analyses, will have important implications for translating similar strategies to other minority communities in sustainable ways. TRIAL REGISTRATION This study protocol has been approved and is made available on ClinicalTrials.gov by NCT03188094 as of 15 June 2017.
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Affiliation(s)
- Sahnah Lim
- Department of Population Health, NYU School of Medicine, 180 Madison Avenue, New York, NY 10016 USA
| | - Laura C. Wyatt
- Department of Population Health, NYU School of Medicine, 180 Madison Avenue, New York, NY 10016 USA
| | - Shinu Mammen
- Department of Population Health, NYU School of Medicine, 180 Madison Avenue, New York, NY 10016 USA
| | - Jennifer M. Zanowiak
- Department of Population Health, NYU School of Medicine, 180 Madison Avenue, New York, NY 10016 USA
| | - Sadia Mohaimin
- Department of Population Health, NYU School of Medicine, 180 Madison Avenue, New York, NY 10016 USA
| | - Keith S. Goldfeld
- Department of Population Health, NYU School of Medicine, 180 Madison Avenue, New York, NY 10016 USA
| | - Donna Shelley
- Department of Population Health, NYU School of Medicine, 180 Madison Avenue, New York, NY 10016 USA
| | - Heather T. Gold
- Department of Population Health, NYU School of Medicine, 550 First Avenue, New York, NY 10016 USA
| | - Nadia S. Islam
- Department of Population Health, NYU School of Medicine, 180 Madison Avenue, New York, NY 10016 USA
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26
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Slover J, Lavery JA, Toombs C, Bosco JA, Gold HT. Factors Associated with Utilizing the Same Hospital for Subsequent Total Hip or Knee Arthroplasty in Osteoarthritis Patients. Bull Hosp Jt Dis (2013) 2019; 77:164-170. [PMID: 31487480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Little is known about the factors that drive hospital-switching behavior of patients when they seek a second total joint arthroplasty (TJA) surgery. METHODS We analyzed the population-based, all-payer California Healthcare Cost and Utilization Project (HCUP) data for a cohort undergoing sequential TJAs for osteoarthritis (N = 48,800) from 2006 to 2011, excluding TJA for fracture. We used multivariable logistic regression analysis to identify factors associated with returning to the same hospital for each surgery, including rural or urban, surgery sequence and timing, Deyo-Charlson comorbidity index, age, sex, race and ethnicity, and insurance. RESULTS Overall, 15.1% of subjects (7,364/48,000) utilized a different hospital for their second surgery. Increasing years between TJAs was associated with decreasing odds of going to the same hospital for the second TJA (p < 0.05). Subjects switching from private insurance to Medicare between surgeries were much less likely to return to same hospital (OR: 0.53; 95% CI: 0.47-0.59), as were those with alternate-joint sequencing (e.g., hip-knee). Those with Medicaid were somewhat less likely to return for the second surgery (OR: 0.87; 95% CI: 0.75-1.01). Urban and rural residents were equally likely to return to the same hospital (p > 0.05). Increasing age was associated with increasing likelihood of returning to the same hospital [e.g., ages 75- 79, OR: 1.36 (95% CI: 1.19-1.56) and ages 80+, OR: 1.41 (95% CI: 1.22-1.63)]. CONCLUSION Fifteen percent of patients switched hospitals for their second TJA within the 6-year study period. Those with Medicare or who had surgery on the alternate joint for second surgery were more likely to switch hospitals as were those who waited longer between surgeries and those living in a rural environment.
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MESH Headings
- Age Factors
- Aged
- Arthroplasty, Replacement, Hip/methods
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Arthroplasty, Replacement, Knee/methods
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Female
- Hospitalization/statistics & numerical data
- Humans
- Male
- Medicare/statistics & numerical data
- Middle Aged
- Osteoarthritis, Hip/surgery
- Osteoarthritis, Knee/surgery
- Patient Acceptance of Health Care/statistics & numerical data
- Patient Preference/statistics & numerical data
- Patient Readmission/statistics & numerical data
- Residence Characteristics
- Sex Factors
- United States
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27
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Walter WR, Bearison C, Slover JD, Gold HT, Gyftopoulos S. Clinical and patient-reported outcomes after image-guided intra-articular therapeutic hip injections for osteoarthritis-related hip pain: a retrospective study. Skeletal Radiol 2019; 48:713-719. [PMID: 30415421 DOI: 10.1007/s00256-018-3113-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/29/2018] [Accepted: 11/02/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate change in patient-reported outcomes following image-guided intra-articular therapeutic steroid hip injections for pain and assess correlations of outcomes with patient- and injection-specific factors. MATERIALS AND METHODS We retrospectively reviewed consecutive patients treated for hip pain who completed outcomes assessments from October 2011 to September 2017 at an outpatient orthopedic surgery clinic. Only patients with radiographic hip osteoarthritis (Tönnis grade ≥ 1) who underwent steroid hip injections were included. Outcomes assessments included EuroQol-5 domain (EQ5D), EQ5D-visual analog scale (VAS), and hip disability and osteoarthritis outcome score (HOOS), obtained before and within 1-6 months post-injection. Among 113 patients who completed surveys, the mean age was 59 years (±13.7 years), including 77 women (68%) and 36 men (32%). Time to repeat injection or arthroplasty was recorded. Exact Wilcoxon signed rank test assessed score differences and Spearman correlation, Kruskal-Wallis, and Mann-Whitney tests assessed correlations. RESULTS Of 113 patients, 34 had outcomes measured at <8 weeks and 79 at ≥8 weeks. There was no significant change among any of the patients, short- or long-term follow-up subgroups in EQ5D (p = 0.450, 0.770, 0.493 respectively), EQ5D-VAS (p = 0.581, 0.915, 0.455), average-HOOS (p = 0.478, 0.696, 0.443) or total-HOOS (p = 0.380, 0.517, 0.423) scores. Forty-nine patients underwent hip arthroplasty within 1 year. Positive correlation was found between days from injection to surgery and change in EQ5D (r = 0.29, p = 0.025), average-HOOS (r = 0.33, p = 0.019), and total-HOOS (r = 0.37, p = 0.008). CONCLUSION We demonstrated no significant change in patient-reported outcomes measured at short- and long-term intervals up to 6 months after therapeutic steroid hip injections.
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Affiliation(s)
- William R Walter
- Department of Radiology, Musculoskeletal Division, NYU Langone Health, 301 E. 17th Street, 6th Floor, New York, NY, 10003, USA.
| | - Craig Bearison
- Mount Sinai Beth Israel Medical Center, New York, NY, USA
| | - James D Slover
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Heather T Gold
- Department of Orthopedic Surgery and Department of Population Health, NYU Langone Health, New York, NY, USA
| | - Soterios Gyftopoulos
- Department of Radiology, Musculoskeletal Division, NYU Langone Health, New York, NY, USA
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28
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Calip GS, Yu O, Boudreau DM, Shao H, Oratz R, Richardson SB, Gold HT. Diabetes and differences in detection of incident invasive breast cancer. Cancer Causes Control 2019; 30:435-441. [PMID: 30949885 DOI: 10.1007/s10552-019-01166-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 03/30/2019] [Indexed: 01/03/2023]
Abstract
Many women diagnosed with breast cancer have chronic conditions such as diabetes that may impact other health behaviors. Our purpose was to determine if breast cancer screening and detection differs among women with and without diabetes. We conducted a cross-sectional analysis of a retrospective cohort of women aged 52-74 years diagnosed with incident stages I-III breast cancer enrolled in an integrated health plan between 1999 and 2014 with linkage to the Surveillance, Epidemiology and End Results registry (n = 2040). Screening data were taken from electronic health records. We used multivariable modified Poisson regression models with robust standard errors to estimate relative risks (RR) and 95% confidence intervals (CI) for outcomes of (i) receipt of screening in the 2 years prior to diagnosis; (ii) symptom-detected breast cancer; and (iii) diagnosis of locally advanced stage III breast cancer. Compared to women without diabetes, women with diabetes were similar with respect to receipt of screening mammography (78% and 77%), symptom-detected breast cancer (46% and 49%), and stage III diagnosis (7% and 7%). In multivariable models adjusting for age and year of diagnosis, race, BMI, Charlson comorbidity score and depression diagnosis no differences were observed in the outcomes by presence of diabetes. Further investigation is warranted to determine how diabetes acts as a mediating factor in adverse breast cancer outcomes.
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Affiliation(s)
- Gregory S Calip
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, 833 South Wood Street MC 871, Chicago, IL, 60612, USA.
| | - Onchee Yu
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.,Departments of Epidemiology and Pharmacy, University of Washington, Seattle, WA, USA
| | - Huibo Shao
- Baptist Memorial Health Care, Germantown, TN, USA
| | - Ruth Oratz
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Stephen B Richardson
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Heather T Gold
- Department of Population Health, New York University School of Medicine, New York, NY, USA
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29
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Jazrawi L, Gold HT, Zuckerman JD. Physical Therapy or Arthroscopic Surgery for Treatment of Meniscal Tears: Is Noninferiority Enough? JAMA 2018; 320:1326-1327. [PMID: 30285160 DOI: 10.1001/jama.2018.13181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Laith Jazrawi
- Department of Orthopedic Surgery, New York University School of Medicine, New York
| | - Heather T Gold
- Department of Orthopedic Surgery, New York University School of Medicine, New York
- Department of Population Health, New York University School of Medicine, New York
| | - Joseph D Zuckerman
- Department of Orthopedic Surgery, New York University School of Medicine, New York
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Gyftopoulos S, Guja KE, Subhas N, Virk MS, Gold HT. Response to Nazarian et al regarding: "Cost-effectiveness of magnetic resonance imaging versus ultrasound for the detection of symptomatic full-thickness supraspinatus tendon tears". J Shoulder Elbow Surg 2018; 27:e320-e321. [PMID: 30093231 DOI: 10.1016/j.jse.2018.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 03/11/2018] [Indexed: 02/01/2023]
Affiliation(s)
- Soterios Gyftopoulos
- Department of Radiology; NYU Langone Medical Center; 660 First Ave; New York, NY 10016, USA.
| | - Kip E Guja
- Department of Pharmacology; Stony Brook University Medical Center; Stony Brook, NY, USA
| | - Naveen Subhas
- Department of Radiology; Cleveland Clinic; Cleveland, OH, USA
| | - Mandeep S Virk
- Department of Orthopaedic Surgery; NYU Hospital for Joint Diseases; New York, NY, USA
| | - Heather T Gold
- Department of Population Health; NYU School of Medicine; New York, NY, USA
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Makarov DV, Ciprut S, Walter D, Kelly M, Gold HT, Zhou XH, Sherman SE, Braithwaite RS, Gross C, Zeliadt S. Association Between Guideline-Discordant Prostate Cancer Imaging Rates and Health Care Service Among Veterans and Medicare Recipients. JAMA Netw Open 2018; 1:e181172. [PMID: 30646111 PMCID: PMC6324262 DOI: 10.1001/jamanetworkopen.2018.1172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 05/12/2018] [Indexed: 12/21/2022] Open
Abstract
Importance Prostate cancer imaging rates appear to vary by health care setting. With the recent extension of the Veterans Access, Choice, and Accountability Act, the government has provided funds for veterans to seek care outside the Veterans Health Administration (VA). It is important to understand the difference in imaging rates and subsequent differences in patterns of care in the VA vs a traditional fee-for-service setting such as Medicare. Objective To assess the association between prostate cancer imaging rates and a VA vs fee-for-service health care setting. Design, Setting, and Participants This cohort study included data for men who received a diagnosis of prostate cancer from January 1, 2004, through March 31, 2008, that were collected from the VA Central Cancer Registry, linked to administrate claims and Medicare utilization records, and the Surveillance, Epidemiology, and End Results Program database. Three distinct nationally representative cohorts were constructed (use of VA only, use of Medicare only, and dual use of VA and Medicare). Men older than 85 years at diagnosis and men without high-risk features but missing any tumor risk characteristic (prostate-specific antigen, Gleason grade, or clinical stage) were excluded. Analysis of the data was completed from March 2016 to February 2018. Exposures Patient utilization of different health care delivery systems. Main Outcomes and Measures Rates of prostate cancer imaging were analyzed by health care setting (Medicare only, VA and Medicare, and VA only) among patients with low-risk prostate cancer and patients with high-risk prostate cancer. Results Of 98 867 men with prostate cancer (77.4% white; mean [SD] age, 70.26 [7.48] years) in the study cohort, 57.3% were in the Medicare-only group, 14.5% in the VA and Medicare group, and 28.1% in the VA-only group. Among men with low-risk prostate cancer, the Medicare-only group had the highest rate of guideline-discordant imaging (52.5%), followed by the VA and Medicare group (50.9%) and the VA-only group (45.9%) (P < .001). Imaging rates for men with high-risk prostate cancer were not significantly different among the 3 groups. Multivariable analysis showed that individuals in the VA and Medicare group (risk ratio [RR], 0.87; 95% CI, 0.76-0.98) and VA-only group (RR, 0.79; 95% CI, 0.67-0.92) were less likely to receive guideline-discordant imaging than those in the Medicare-only group. Conclusions and Relevance The results of this study suggest that patients with prostate cancer who use Medicare rather than the VA for health care could experience more utilization of health care services without an improvement in the quality of care.
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Affiliation(s)
- Danil V. Makarov
- Department of Urology, New York University School of Medicine, New York
- Department of Population Health, New York University School of Medicine, New York
- VA New York Harbor Healthcare System, New York University School of Medicine, New York
- Robert F. Wagner Graduate School of Public Service, New York University, New York
- Cancer Institute, New York University School of Medicine, New York
| | - Shannon Ciprut
- Department of Urology, New York University School of Medicine, New York
- Department of Population Health, New York University School of Medicine, New York
- VA New York Harbor Healthcare System, New York University School of Medicine, New York
| | - Dawn Walter
- Department of Urology, New York University School of Medicine, New York
- Department of Population Health, New York University School of Medicine, New York
| | - Matthew Kelly
- Department of Urology, New York University School of Medicine, New York
- Department of Population Health, New York University School of Medicine, New York
- VA New York Harbor Healthcare System, New York University School of Medicine, New York
| | - Heather T. Gold
- Department of Population Health, New York University School of Medicine, New York
- Robert F. Wagner Graduate School of Public Service, New York University, New York
- Cancer Institute, New York University School of Medicine, New York
| | - Xiao-Hua Zhou
- Department of Biostatistics, University of Washington, Seattle
- Health Services Research and Development, Department of Veterans Affairs Medical Center, Seattle, Washington
| | - Scott E. Sherman
- Department of Population Health, New York University School of Medicine, New York
- VA New York Harbor Healthcare System, New York University School of Medicine, New York
- Cancer Institute, New York University School of Medicine, New York
| | | | - Cary Gross
- Cancer Outcomes Policy and Effectiveness Research Center, Yale University School of Medicine, New Haven, Connecticut
| | - Steven Zeliadt
- Health Services Research and Development, Department of Veterans Affairs Medical Center, Seattle, Washington
- Fred Hutchinson Cancer Research Center, Seattle, Washington
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Oh C, Slover JD, Bosco JA, Iorio R, Gold HT. Time Trends in Characteristics of Patients Undergoing Primary Total Hip and Knee Arthroplasty in California, 2007-2010. J Arthroplasty 2018; 33:2376-2380. [PMID: 29605148 DOI: 10.1016/j.arth.2018.02.079] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 02/19/2018] [Accepted: 02/20/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND As the number of total hip and knee arthroplasty cases increases, it is important to understand the burden of factors that impact patient outcomes of these procedures. This article examined the time trends in key demographics, clinical characteristics, comorbidity burden (Deyo-Charlson Comorbidity Index [CCI]), and presence of depression in patients undergoing primary total hip arthroplasty and total knee arthroplasty using population-based, all-payer inpatient database, California Healthcare Cost and Utilization Project, from 2007 to 2010. METHODS Chi-square tests and analysis of variance were used. Multivariate logistic regression analyses were also performed to compare the prevalence of depression in 2007 to later years. RESULTS In the primary total hip arthroplasty cohort, the prevalence of depression significantly increased by 20%, mean age decreased by 0.4 years, mean length of stay (LOS) decreased by 0.5 days, and having a CCI score of ≥3 increased by 30% (P value < .001 for all) over the study period. Similarly, in the primary total knee arthroplasty cohort, the prevalence of depression increased by 23%, the mean age decreased by 0.4 years, mean LOS decreased by 0.4 days, and the prevalence of CCI score of ≥3 increased by 35% (P value < .001 for all). CONCLUSION Despite the younger age of the joint arthroplasty population over time, we found increased prevalence of depression and comorbidity scores but shorter LOS. Further study is needed to determine the impact of the changing demographics of the total joint population and the best strategies to optimize their outcome with these procedures.
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Affiliation(s)
- Cheongeun Oh
- Department of Population Health, NYU School of Medicine, New York, New York
| | - James D Slover
- Department of Orthopaedic Surgery, NYU School of Medicine, New York, New York
| | - Joseph A Bosco
- Department of Orthopaedic Surgery, NYU School of Medicine, New York, New York
| | - Richard Iorio
- Department of Orthopaedic Surgery, NYU School of Medicine, New York, New York
| | - Heather T Gold
- Department of Population Health, NYU School of Medicine, New York, New York; Department of Orthopaedic Surgery, NYU School of Medicine, New York, New York
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Abstract
BACKGROUND Although outcomes for patients with squamous cell carcinoma of the anus (SCCA) have improved, the gains in benefit may not be shared uniformly among patients of disparate socioeconomic status. In the current study, the authors investigated whether area-based median household income (MHI) is predictive of survival among patients with SCCA. METHODS Patients diagnosed with SCCA from 2004 through 2013 in the Surveillance, Epidemiology, and End Results registry were included. Socioeconomic status was defined by census-tract MHI level and divided into quintiles. Multivariable Cox proportional hazards models and logistic regression were used to study predictors of survival and radiotherapy receipt. RESULTS A total of 9550 cases of SCCA were included. The median age of the patients was 58 years, 63% were female, 85% were white, and 38% were married. In multivariable analyses, patients living in areas with lower MHI were found to have worse overall survival and cancer-specific survival (CSS) compared with those in the highest income areas. Mortality hazard ratios for lowest to highest income were 1.32 (95% confidence interval [95% CI], 1.18-1.49), 1.31 (95% CI, 1.16-1.48), 1.19 (95% CI, 1.06-1.34), and 1.16 (95% CI, 1.03-1.30). The hazard ratios for CSS similarly ranged from 1.34 to 1.22 for lowest to highest income. Older age, black race, male sex, unmarried marital status, an earlier year of diagnosis, higher tumor grade, and later American Joint Committee on Cancer stage of disease also were associated with worse CSS. Income was not found to be associated with the odds of initiating radiotherapy in multivariable analysis (odds ratio of 0.87 for lowest to highest income level; 95% CI, 0.63-1.20). CONCLUSIONS MHI appears to independently predict CSS and overall survival in patients with SCCA. Black race was found to remain a predictor of SCCA survival despite controlling for income. Further study is needed to understand the mechanisms by which socioeconomic inequalities affect cancer care and outcomes. Cancer 2018;124:1791-7. © 2018 American Cancer Society.
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Affiliation(s)
- Daniel Lin
- Perlmutter Cancer Center, NYU Langone Medical Center, New York, New York
| | - Heather T Gold
- Perlmutter Cancer Center, NYU Langone Medical Center, New York, New York.,Department of Population Health, New York University School of Medicine, New York, New York
| | - David Schreiber
- Department of Radiation Oncology, State University of New York Downstate Medical Center, Brooklyn, New York
| | - Lawrence P Leichman
- Moores Cancer Center, University of California at San Diego, San Diego, California
| | - Scott E Sherman
- Department of Medicine, Veterans Affairs New York Harbor Healthcare System, New York, New York
| | - Daniel J Becker
- Perlmutter Cancer Center, NYU Langone Medical Center, New York, New York.,Department of Medicine, Veterans Affairs New York Harbor Healthcare System, New York, New York
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Gold HT, Walter D, Tousimis E, Hayes MK. New Breast Cancer Radiotherapy Technology Confers Higher Complications and Costs Before Effectiveness Proven: A Medicare Data Analysis. Inquiry 2018; 55:46958018759115. [PMID: 29502466 PMCID: PMC5846914 DOI: 10.1177/0046958018759115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A new breast cancer treatment, brachytherapy-based accelerated partial breast radiotherapy (RT), was adopted before long-term effectiveness evidence, potentially increasing morbidity and costs compared with whole breast RT. The aim of this study was to estimate complication rates and RT-specific and 1-year costs for a cohort of female Medicare beneficiaries diagnosed with breast cancer (N = 47 969). We analyzed 2005-2007 Medicare claims using multivariable logistic regression for complications and generalized linear models (log link, gamma distribution) for costs. Overall, 11% (n = 5296) underwent brachytherapy-based RT; 9.4% had complications. Odds of any complication were higher (odds ratio [OR]: 1.62; 95% confidence interval [CI]: 1.49-1.76) for brachytherapy versus whole breast RT, similarly to seroma (OR: 2.85; 95% CI: 1.97-4.13), wound complication/infection (OR: 1.72; 95% CI: 1.52-1.95), cellulitis (OR: 1.48; 95% CI: 1.27-1.73), and necrosis (OR: 2.07; 95% CI: 1.55-2.75). Mean RT-specific and 1-year total costs for whole breast RT were $6375, and $19 917, $4886, and $4803 lower than brachytherapy ( P < .0001). Multivariable analyses indicated brachytherapy yielded 76% higher RT costs (risk ratio: 1.76; 95% CI: 1.74-1.78, P < .0001) compared with whole breast RT. Brachytherapy had higher complications and costs before long-term evidence proved its effectiveness. Policies should require treatment registries with reimbursement incentives to capture surveillance data for new technologies.
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Affiliation(s)
| | | | - Eleni Tousimis
- 2 MedStar Georgetown University Hospital, Washington, DC, USA
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Becker DJ, Lin D, Lee S, Levy BP, Makarov DV, Gold HT, Sherman S. Exploration of the ASCO and ESMO Value Frameworks for Antineoplastic Drugs. J Oncol Pract 2017; 13:e653-e665. [DOI: 10.1200/jop.2016.020339] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose: In 2015, both ASCO and the European Society for Medical Oncology (ESMO) proposed frameworks to quantify the benefit of antineoplastic drugs in the face of rising costs. We applied these frameworks to drugs approved by the US Food and Drug Administration over the past 12 years and examined relationships between costs and benefits. Methods: We searched FDA.gov for drugs that received initial approval for solid tumors from 2004 to 2015 and calculated the ASCO Net Health Benefit version 2016 (NHB16) and 2015 (NHB15) and the ESMO Magnitude of Clinical Benefit Scale scores for each drug. We calculated descriptive statistics and explored correlations and associations among benefit scores, cost, and independent variables. Results: We identified 55 drug approvals supported by phase II (18.2%) and III (81.8%) trials, with primary outcomes of overall survival (36.4%), progression-free survival (43.6%), or response rate (20.0%). No significant association was found between NHB16 and year of approval ( P = .81), organ system ( P = .20), or trial comparator arm ( P = .17), but trials with progression-free survival outcomes were associated with higher scores ( P = .007). Both NHB15 and Magnitude of Clinical Benefit Scale scores were approximately normally distributed, but only a moderate correlation existed between them ( r = 0.40, P = .006). No correlation between benefit score and cost (NHB16, r = 0.19; ESMO, r = −0.07) was found. Before 2010, two (15.3%) of 13 approved drugs exceeded $500/NHB point × month compared with 10 (25.0%) of 40 drugs subsequently approved. Conclusion: Our analysis of the ASCO and ESMO value frameworks illuminates the heterogeneous benefit of new medications and highlights challenges in constructing a unified concept of drug value. Drug benefit does not correlate with cost, and the number of high cost/benefit outliers has increased.
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Affiliation(s)
- Daniel J. Becker
- New York University School of Medicine; Veterans Affairs–New York Harbor Healthcare System; and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Daniel Lin
- New York University School of Medicine; Veterans Affairs–New York Harbor Healthcare System; and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steve Lee
- New York University School of Medicine; Veterans Affairs–New York Harbor Healthcare System; and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Benjamin P. Levy
- New York University School of Medicine; Veterans Affairs–New York Harbor Healthcare System; and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Danil V. Makarov
- New York University School of Medicine; Veterans Affairs–New York Harbor Healthcare System; and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Heather T. Gold
- New York University School of Medicine; Veterans Affairs–New York Harbor Healthcare System; and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Scott Sherman
- New York University School of Medicine; Veterans Affairs–New York Harbor Healthcare System; and Icahn School of Medicine at Mount Sinai, New York, NY
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Lin D, Levinson B, Goldberg JD, Hochman T, Leichman LP, Gold HT. Abstract 5282: Comparison of a public versus private hospital in New York City in delivering timely adjuvant chemotherapy among stage III colon cancer patients. Cancer Res 2017. [DOI: 10.1158/1538-7445.am2017-5282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Although the optimal timing of adjuvant chemotherapy (AC) for stage III colon cancer patients has been debated, most studies recommend initiating AC within approximately 60 days of surgery. Significant disparities in timeliness of AC initiation in colon cancer have been reported in public versus private hospitals, with longer time to AC at public hospitals. We evaluated whether timeliness of AC differed between a public and a private hospital, both affiliated with the same major academic institution in New York City.
Methods: We conducted a retrospective cohort study of Stage III colon cancer patients who underwent surgery and received AC at the same institution from 2008-2015 at NYU Langone Medical Center’s affiliated public hospital (Bellevue) or its private hospital (Tisch). Patient data were obtained through review of hospital tumor registry and electronic medical records. Patient characteristics were compared by hospital. We defined timeliness as receipt of AC within 60 days postoperatively. Univariate and stepwise multivariable logistic regressions were used to identify factors associated with timely AC.
Results: Forty three patients at Bellevue Hospital and 79 patients at Tisch Hospital who underwent surgery and received AC at the same institution were included. Median number of days to AC was significantly greater among patients receiving care at Bellevue (53, range 31-231) compared to Tisch (43, range 25-105; p=0.002). However, the percentage of patients who received timely AC did not differ substantially at Bellevue and Tisch (74% vs 81%, p=0.40). Individual characteristics significantly associated with timely initiation of AC were non-Hispanic ethnicity (OR: 2.71, 95% CI: 1.06-6.95), married (OR: 2.89, 95%CI: 1.15-7.30), and laparoscopic (vs open) surgery (OR: 4.30, 95%CI: 1.64-11.25). The odds of receiving timely AC at Bellevue compared to Tisch was not significant (OR: 0.68, 95% CI: 0.28-1.65). When hospital and other factors were examined jointly, only age (OR: 0.95/year, 95% CI: 0.91-0.99) and laparoscopic (vs open) surgery (OR: 5.65, 95% CI: 1.92-16.62) remained as important factors associated with receiving timely AC (Likelihood Ratio Chi-Square=14.95, p=0.0019). When hospital was omitted from multivariable analysis, age and surgery type still remained the only significant factors associated with timely AC (OR’s unchanged, Likelihood Ratio Chi-Square=14.81, p-value=0.0006).
Conclusions: The proportion of patients receiving timely AC within 60 days of surgery was similar at both an affiliated public and private hospital at NYU Langone Medical Center. Age and type of surgery were significant predictors of timeliness in our population. Further research should be conducted to understand how system-level factors may promote timely receipt of care.
Citation Format: Daniel Lin, Benjamin Levinson, Judith D. Goldberg, Tsivia Hochman, Lawrence P. Leichman, Heather T. Gold. Comparison of a public versus private hospital in New York City in delivering timely adjuvant chemotherapy among stage III colon cancer patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 5282. doi:10.1158/1538-7445.AM2017-5282
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Affiliation(s)
- Daniel Lin
- 1New York University Langone Medical Center, New York, NY
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Loeb S, Stork B, Gold HT, Stout NK, Makarov DV, Weight CJ, Borgmann H. Tweet this: how advocacy for breast and prostate cancers stacks up on social media. BJU Int 2017; 120:461-463. [DOI: 10.1111/bju.13908] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Stacy Loeb
- Department of Urology; New York University; New York NY USA
- Department of Population Health; New York University; New York NY USA
- VA New York Harbor Healthcare System; New York NY USA
| | | | - Heather T. Gold
- Department of Population Health; New York University; New York NY USA
| | - Natasha K. Stout
- Department of Population Medicine; Harvard Medical School and Harvard Pilgrim Health Care Institute; Boston MA USA
| | - Danil V. Makarov
- Department of Urology; New York University; New York NY USA
- Department of Population Health; New York University; New York NY USA
- VA New York Harbor Healthcare System; New York NY USA
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Abstract
OBJECTIVE A discoid meniscus is more prone to tears than a normal meniscus. Patients with a torn discoid lateral meniscus are at increased risk for early onset osteoarthritis requiring total knee arthroplasty (TKA). Optimal management for this condition is controversial given the up-front cost difference between the two treatment options: the more expensive meniscal allograft transplantation compared with standard partial meniscectomy. We hypothesize that meniscal allograft transplantation following excision of a torn discoid lateral meniscus is more cost-effective compared with partial meniscectomy alone because allografts will extend the time to TKA. METHODS A decision analytic Markov model was created to compare the cost effectiveness of two treatments for symptomatic, torn discoid lateral meniscus: meniscal allograft and partial meniscectomy. Probability estimates and event rates were derived from the scientific literature, and costs and benefits were discounted by 3%. One-way sensitivity analyses were performed to test model robustness. RESULTS Over 25 years, the partial meniscectomy strategy cost $10,430, whereas meniscal allograft cost on average $4040 more, at $14,470. Partial meniscectomy postponed TKA an average of 12.5 years, compared with 17.30 years for meniscal allograft, an increase of 4.8 years. Allograft cost $842 per-year-gained in time to TKA. CONCLUSION Meniscal allografts have been shown to reduce pain and improve function in patients with discoid lateral meniscus tears. Though more costly, meniscal allografts may be more effective than partial meniscectomy in delaying TKA in this model. Additional future long term clinical studies will provide more insight into optimal surgical options.
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Affiliation(s)
- Austin J Ramme
- a Department of Orthopaedic Surgery , New York University Hospital for Joint Diseases , New York , NY , USA
| | - Eric J Strauss
- a Department of Orthopaedic Surgery , New York University Hospital for Joint Diseases , New York , NY , USA
| | - Laith Jazrawi
- a Department of Orthopaedic Surgery , New York University Hospital for Joint Diseases , New York , NY , USA
| | - Heather T Gold
- a Department of Orthopaedic Surgery , New York University Hospital for Joint Diseases , New York , NY , USA.,b Department of Population Health , New York University School of Medicine , New York , NY , USA
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Makarov DV, Hu EYC, Walter D, Braithwaite RS, Sherman S, Gold HT, Zhou XA, Gross CP, Zeliadt SB. Appropriateness of Prostate Cancer Imaging among Veterans in a Delivery System without Incentives for Overutilization. Health Serv Res 2016; 51:1021-51. [PMID: 26423687 PMCID: PMC4874832 DOI: 10.1111/1475-6773.12395] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To determine the frequency of appropriate and inappropriate prostate cancer imaging in an integrated health care system. DATA SOURCES/STUDY SETTING Veterans Health Administration Central Cancer Registry linked to VA electronic medical records and Medicare claims (2004-2008). STUDY DESIGN We performed a retrospective cohort study of VA patients diagnosed with prostate cancer (N = 45,084). Imaging (CT, MRI, bone scan, PET) use was assessed among patients with low-risk disease, for whom guidelines recommend against advanced imaging, and among high-risk patients for whom guidelines recommend it. PRINCIPAL FINDINGS We found high rates of inappropriate imaging among men with low-risk prostate cancer (41 percent) and suboptimal rates of appropriate imaging among men with high-risk disease (70 percent). Veterans utilizing Medicare-reimbursed care had higher rates of inappropriate imaging [OR: 1.09 (1.03-1.16)] but not higher rates of appropriate imaging. Veterans treated in middle [OR: 0.51 (0.47-0.56)] and higher [OR: 0.50 (0.46-0.55)] volume medical centers were less likely to undergo inappropriate imaging without compromising appropriate imaging. CONCLUSIONS Our results highlight the overutilization of imaging, even in an integrated health care system without financial incentives encouraging provision of health care services. Paradoxically, imaging remains underutilized among high-risk patients who could potentially benefit from it most.
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Affiliation(s)
- Danil V. Makarov
- VA New York Harbor Healthcare SystemNew York UniversityNew YorkNY
- Department of UrologyNew York UniversityNew YorkNY
- Department of Population HealthNew York UniversityNew YorkNY
- Cancer InstituteNew York UniversityNew YorkNY
- Robert F. Wagner Graduate School of Public ServiceNew York UniversityNew YorkNY
| | - Elaine Y. C. Hu
- VA Puget Sound Healthcare System and University of WashingtonSeattleWA
| | - Dawn Walter
- VA New York Harbor Healthcare SystemNew York UniversityNew YorkNY
- Department of UrologyNew York UniversityNew YorkNY
- Department of Population HealthNew York UniversityNew YorkNY
- Cancer InstituteNew York UniversityNew YorkNY
| | - R. Scott Braithwaite
- Department of Population HealthNew York UniversityNew YorkNY
- Cancer InstituteNew York UniversityNew YorkNY
| | - Scott Sherman
- VA New York Harbor Healthcare SystemNew York UniversityNew YorkNY
- Department of Population HealthNew York UniversityNew YorkNY
- Cancer InstituteNew York UniversityNew YorkNY
| | - Heather T. Gold
- Department of Population HealthNew York UniversityNew YorkNY
- Cancer InstituteNew York UniversityNew YorkNY
| | | | - Cary P. Gross
- Robert Wood Johnson Clinical Scholars Program and Department of Internal MedicineYale University School of MedicineNew HavenCT
| | - Steven B. Zeliadt
- VA Puget Sound Healthcare System and University of WashingtonSeattleWA
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Bitterman DS, Grew D, Gu P, Cohen RF, Sanfilippo NJ, Leichman CG, Leichman LP, Moore HG, Gold HT, Du KL. Comparison of anal cancer outcomes in public and private hospital patients treated at a single radiation oncology center. J Gastrointest Oncol 2015; 6:524-33. [PMID: 26487947 DOI: 10.3978/j.issn.2078-6891.2015.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To compare clinical and treatment characteristics and outcomes in locally advanced anal cancer, a potentially curable disease, in patients referred from a public or private hospital. METHODS We retrospectively reviewed 112 anal cancer patients from a public and a private hospital who received definitive chemoradiotherapy at the same cancer center between 2004 and 2013. Tumor stage, radiotherapy delay, radiotherapy duration, and unplanned treatment breaks ≥10 days were compared using t-test and χ(2) test. Overall survival (OS), disease free survival (DFS), and colostomy free survival (CFS) were examined using the Kaplan-Meier method and compared with the log-rank test. Cox proportional hazard models for OS and DFS were developed. RESULTS The follow-up was 14.9 months (range, 0.7-94.8 months). Public hospital patients presented with significantly higher clinical T stage (P<0.05) and clinical stage group (P<0.05), had significantly longer radiotherapy delays (P<0.05) and radiotherapy duration (P<0.05), and had more frequent radiation therapy (RT) breaks ≥10 days (P<0.05). Three-year OS showed a marked trend in favor of private hospital patients for 3-year OS (72.8% vs. 48.9%; P=0.171), 3-year DFS (66.3% vs. 42.7%, P=0.352), and 3-year CFS (86.4% vs. 68.9%, P=0.299). Referral hospital was not predictive of OS or DFS on multivariate analysis. CONCLUSIONS Public hospital patients presented at later stage and experienced more delays in initiating and completing radiotherapy, which may contribute to the trend in poorer DFS and OS. These findings emphasize the need for identifying clinical and treatment factors that contribute to decreased survival in low socioeconomic status (SES) populations.
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Affiliation(s)
- Danielle S Bitterman
- 1 Department of Radiation Oncology, 2 Division of Hematology and Medical Oncology, Department of Medicine, 3 Division of Colon and Rectal Surgery, Department of Surgery, 4 Department of Population Health, New York University Langone Medical Center, New York, NY 10016, USA
| | - David Grew
- 1 Department of Radiation Oncology, 2 Division of Hematology and Medical Oncology, Department of Medicine, 3 Division of Colon and Rectal Surgery, Department of Surgery, 4 Department of Population Health, New York University Langone Medical Center, New York, NY 10016, USA
| | - Ping Gu
- 1 Department of Radiation Oncology, 2 Division of Hematology and Medical Oncology, Department of Medicine, 3 Division of Colon and Rectal Surgery, Department of Surgery, 4 Department of Population Health, New York University Langone Medical Center, New York, NY 10016, USA
| | - Richard F Cohen
- 1 Department of Radiation Oncology, 2 Division of Hematology and Medical Oncology, Department of Medicine, 3 Division of Colon and Rectal Surgery, Department of Surgery, 4 Department of Population Health, New York University Langone Medical Center, New York, NY 10016, USA
| | - Nicholas J Sanfilippo
- 1 Department of Radiation Oncology, 2 Division of Hematology and Medical Oncology, Department of Medicine, 3 Division of Colon and Rectal Surgery, Department of Surgery, 4 Department of Population Health, New York University Langone Medical Center, New York, NY 10016, USA
| | - Cynthia G Leichman
- 1 Department of Radiation Oncology, 2 Division of Hematology and Medical Oncology, Department of Medicine, 3 Division of Colon and Rectal Surgery, Department of Surgery, 4 Department of Population Health, New York University Langone Medical Center, New York, NY 10016, USA
| | - Lawrence P Leichman
- 1 Department of Radiation Oncology, 2 Division of Hematology and Medical Oncology, Department of Medicine, 3 Division of Colon and Rectal Surgery, Department of Surgery, 4 Department of Population Health, New York University Langone Medical Center, New York, NY 10016, USA
| | - Harvey G Moore
- 1 Department of Radiation Oncology, 2 Division of Hematology and Medical Oncology, Department of Medicine, 3 Division of Colon and Rectal Surgery, Department of Surgery, 4 Department of Population Health, New York University Langone Medical Center, New York, NY 10016, USA
| | - Heather T Gold
- 1 Department of Radiation Oncology, 2 Division of Hematology and Medical Oncology, Department of Medicine, 3 Division of Colon and Rectal Surgery, Department of Surgery, 4 Department of Population Health, New York University Langone Medical Center, New York, NY 10016, USA
| | - Kevin L Du
- 1 Department of Radiation Oncology, 2 Division of Hematology and Medical Oncology, Department of Medicine, 3 Division of Colon and Rectal Surgery, Department of Surgery, 4 Department of Population Health, New York University Langone Medical Center, New York, NY 10016, USA
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Makarov DV, Soulos PR, Gold HT, Yu JB, Sen S, Ross JS, Gross CP. Regional-Level Correlations in Inappropriate Imaging Rates for Prostate and Breast Cancers: Potential Implications for the Choosing Wisely Campaign. JAMA Oncol 2015; 1:185-94. [PMID: 26181021 PMCID: PMC4707944 DOI: 10.1001/jamaoncol.2015.37] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The association between regional norms of clinical practice and appropriateness of care is incompletely understood. Understanding regional patterns of care across diseases might optimize implementation of programs like Choosing Wisely, an ongoing campaign to decrease wasteful medical expenditures. OBJECTIVE To determine whether regional rates of inappropriate prostate and breast cancer imaging were associated. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study using the the Surveillance, Epidemiology, and End Results-Medicare linked database. We identified patients diagnosed from 2004 to 2007 with low-risk prostate (clinical stage T1c/T2a; Gleason score, ≤6; and prostate-specific antigen level, <10 ng/mL) or breast cancer (in situ, stage I, or stage II disease), based on Choosing Wisely definitions. MAIN OUTCOMES AND MEASURES In a hospital referral region (HRR)-level analysis, our dependent variable was HRR-level imaging rate among patients with low-risk prostate cancer. Our independent variable was HRR-level imaging rate among patients with low-risk breast cancer. In a subsequent patient-level analysis we used multivariable logistic regression to model prostate cancer imaging as a function of regional breast cancer imaging and vice versa. RESULTS We identified 9219 men with prostate cancer and 30,398 women with breast cancer residing in 84 HRRs. We found high rates of inappropriate imaging for both prostate cancer (44.4%) and breast cancer (41.8%). In the first, second, third, and fourth quartiles of breast cancer imaging, inappropriate prostate cancer imaging was 34.2%, 44.6%, 41.1%, and 56.4%, respectively. In the first, second, third, and fourth quartiles of prostate cancer imaging, inappropriate breast cancer imaging was 38.1%, 38.4%, 43.8%, and 45.7%, respectively. At the HRR level, inappropriate prostate cancer imaging rates were associated with inappropriate breast cancer imaging rates (ρ = 0.35; P < .01). At the patient level, a man with low-risk prostate cancer had odds ratios (95% CIs) of 1.72 (1.12-2.65), 1.19 (0.78-1.81), or 1.76 (1.15-2.70) for undergoing inappropriate prostate imaging if he lived in an HRR in the fourth, third, or second quartiles, respectively, of inappropriate breast cancer imaging, compared with the lowest quartile. CONCLUSIONS AND RELEVANCE At a regional level, there is an association between inappropriate prostate and breast cancer imaging rates. This finding suggests the existence of a regional-level propensity for inappropriate imaging utilization, which may be considered by policymakers seeking to improve quality of care and reduce health care spending in high-utilization areas.
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Affiliation(s)
- Danil V Makarov
- US Department of Veterans Affairs, Washington, DC2Department of Urology, New York University School of Medicine, New York3Department of Population Health, New York University School of Medicine, New York4New York University Cancer Institute, New York
| | - Pamela R Soulos
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut6Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Heather T Gold
- Department of Population Health, New York University School of Medicine, New York4New York University Cancer Institute, New York7Department of Medicine, New York University School of Medicine, New York
| | - James B Yu
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut8Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Sounok Sen
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut
| | - Joseph S Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut10Section of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut11Department of Health Policy and Managem
| | - Cary P Gross
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut6Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut12Department of Epidemiology and Public Health, Y
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Fenstermaker M, Loeb S, Gold HT, Ravenell J, Makarov D. MP5-12 UNDERSTANDING THE LIMITATIONS OF PROSTATE-SPECIFIC ANTIGEN TESTING DOES NOT DETER MEN FROM UNDERGOING PROSTATE CANCER SCREENING. J Urol 2015. [DOI: 10.1016/j.juro.2015.02.239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Loeb S, Walter D, Dewitt S, Gold HT, Makarov DV. PD34-11 PATTERNS OF CARE FOR MEN WITH PROSTATE CANCER UNDERGOING ACTIVE SURVEILLANCE AS INITIAL MANAGEMENT. J Urol 2015. [DOI: 10.1016/j.juro.2015.02.2247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Prabhu V, Lee T, Loeb S, Holmes JH, Gold HT, Lepor H, Penson DF, Makarov DV. Twitter response to the United States Preventive Services Task Force recommendations against screening with prostate-specific antigen. BJU Int 2015; 116:65-71. [PMID: 24661474 DOI: 10.1111/bju.12748] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To examine public and media response to the draft (October 2011) and finalised (May 2012) recommendations of the United States Preventive Services Task Force (USPSTF) against prostate-specific antigen (PSA) testing via Twitter, a popular social network with over 200 million active users. MATERIALS AND METHODS We used a mixed-methods design to analyse posts on Twitter, known as 'tweets'. Using the search term 'prostate cancer', we archived tweets in the 24-h periods following the release of both the draft and the finalised USPSTF recommendations. We recorded tweet rate per h and developed a coding system to assess the type of user and sentiment expressed in tweets and linked articles. RESULTS After the draft and finalised USPSTF recommendations were released, 2042 and 5357 tweets focused on the USPSTF report, respectively. The tweet rate nearly doubled within 2 h of both announcements. Fewer than 10% of tweets expressed an opinion about screening, and the majority of these were pro-screening during both periods. By contrast, anti-screening articles were tweeted more frequently in both the draft and finalised study periods. Between the draft and the finalised recommendations, the proportion of anti-screening tweets and anti-screening article links increased (P = 0.03 and P < 0.01, respectively). CONCLUSIONS There was increased Twitter activity surrounding the USPSTF draft and finalised recommendations. The percentage of anti-screening tweets and articles appeared to increase, perhaps due to the interval public comment period. Despite this, most tweets did not express an opinion, suggesting a missed opportunity in this important arena for advocacy.
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Affiliation(s)
- Vinay Prabhu
- Department of Urology, New York University School of Medicine, New York, NY, USA
| | - Ted Lee
- Department of Urology, New York University School of Medicine, New York, NY, USA
| | - Stacy Loeb
- Department of Urology, New York University School of Medicine, New York, NY, USA.,Department of Population Health, New York University School of Medicine, New York, NY, USA.,New York University Cancer Institute, New York, NY, USA
| | - John H Holmes
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Heather T Gold
- Department of Population Health, New York University School of Medicine, New York, NY, USA.,New York University Cancer Institute, New York, NY, USA
| | - Herbert Lepor
- Department of Urology, New York University School of Medicine, New York, NY, USA.,New York University Cancer Institute, New York, NY, USA
| | - David F Penson
- Department of Urology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Danil V Makarov
- Department of Urology, New York University School of Medicine, New York, NY, USA.,Department of Population Health, New York University School of Medicine, New York, NY, USA.,Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Veterans Affairs New York Harbor Healthcare System, New York, NY, USA.,New York University Wagner Graduate School of Public Service, New York, NY, USA
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Abstract
BACKGROUND Ethnic/racial minorities encounter disparities in healthcare, which may carry into end-of-life (EOL) care. Advanced cancer, highly prevalent and morbid, presents with worsening symptoms, heightening the need for supportive and EOL care. PURPOSE To conduct a systematic review examining ethnic/racial disparities in EOL care for cancer patients. DESIGN We searched four electronic databases for all original research examining EOL care use, preferences, and beliefs for cancer patients from ethnic/racial minority groups. RESULTS Twenty-five studies were included: 20 quantitative and five qualitative. All had a full-text English language article and focused on the ethnic/racial minority groups of African Americans, Hispanics Americans, or Asian Americans. Key themes included EOL decision making processes, family involvement, provider communication, religion and spirituality, and patient preferences. Hospice was the most studied EOL care, and was most used among Whites, followed by use among Hispanics, and least used by African and Asian Americans. African Americans perceived a greater need for hospice, yet more frequently had inadequate knowledge. African Americans preferred aggressive treatment, yet EOL care provided was often inconsistent with preferences. Hispanics and African Americans less often documented advance care plans, citing religious coping and spirituality as factors. CONCLUSION EOL care differences among ethnic/racial minority cancer patients were found in the processes, preferences, and beliefs regarding their care. Further steps are needed to explore the exact causes of differences, yet possible explanations include religious or cultural differences, caregiver respect for patient autonomy, access barriers, and knowledge of EOL care options.
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Affiliation(s)
- Melissa A LoPresti
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Fritz Dement
- Department of Medical Library, New York University School of Medicine, New York, NY, USA
| | - Heather T Gold
- Department of Population Health, New York University School of Medicine, New York, NY, USA
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Li H, Gail MH, Braithwaite RS, Gold HT, Walter D, Liu M, Gross CP, Makarov DV. Are hospitals "keeping up with the Joneses"?: Assessing the spatial and temporal diffusion of the surgical robot. Healthc (Amst) 2014; 2:152-157. [PMID: 25821720 PMCID: PMC4376012 DOI: 10.1016/j.hjdsi.2013.10.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND The surgical robot has been widely adopted in the United States in spite of its high cost and controversy surrounding its benefit. Some have suggested that a "medical arms race" influences technology adoption. We wanted to determine whether a hospital would acquire a surgical robot if its nearest neighboring hospital already owned one. METHODS We identified 554 hospitals performing radical prostatectomy from the Healthcare Cost and Utilization Project Statewide Inpatient Databases for seven states. We used publicly available data from the website of the surgical robot's sole manufacturer (Intuitive Surgical, Sunnyvale, CA) combined with data collected from the hospitals to ascertain the timing of robot acquisition during year 2001 to 2008. One hundred thirty four hospitals (24%) had acquired a surgical robot by the end of 2008. We geocoded the address of each hospital and determined a hospital's likelihood to acquire a surgical robot based on whether its nearest neighbor owned a surgical robot. We developed a Markov chain method to model the acquisition process spatially and temporally and quantified the "neighborhood effect" on the acquisition of the surgical robot while adjusting simultaneously for known confounders. RESULTS After adjusting for hospital teaching status, surgical volume, urban status and number of hospital beds, the Markov chain analysis demonstrated that a hospital whose nearest neighbor had acquired a surgical robot had a higher likelihood itself acquiring a surgical robot. (OR=1.71, 95% CI: 1.07-2.72, p=0.02). CONCLUSION There is a significant spatial and temporal association for hospitals acquiring surgical robots during the study period. Hospitals were more likely to acquire a surgical robot during the robot's early adoption phase if their nearest neighbor had already done so.
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Affiliation(s)
- Huilin Li
- Department of Population Health, New York University, New York, NY, 10016
- New York University Cancer Institute
| | - Mitchell H. Gail
- Division of Cancer Epidemiology and Genetics, Biostatistics Branch, National Cancer Institute, NIH, Rockville, MD, 20852-7242
| | | | - Heather T. Gold
- Department of Population Health, New York University, New York, NY, 10016
- New York University Cancer Institute
- Robert F. Wagner Graduate School of Public Service
| | - Dawn Walter
- Department of Urology, New York University School of Medicine
| | - Mengling Liu
- Department of Population Health, New York University, New York, NY, 10016
- New York University Cancer Institute
| | - Cary P. Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, and Division of General Internal Medicine, Yale University School of Medicine
- United States Department of Veterans Affairs
| | - Danil V. Makarov
- Department of Population Health, New York University, New York, NY, 10016
- New York University Cancer Institute
- Robert F. Wagner Graduate School of Public Service
- Department of Urology, New York University School of Medicine
- United States Department of Veterans Affairs
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Ma X, Wang R, Long JB, Ross JS, Soulos PR, Yu JB, Makarov DV, Gold HT, Gross CP. The cost implications of prostate cancer screening in the Medicare population. Cancer 2013; 120:96-102. [PMID: 24122801 DOI: 10.1002/cncr.28373] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 08/09/2013] [Accepted: 08/12/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND Recent debate about prostate-specific antigen (PSA)-based testing for prostate cancer screening among older men has rarely considered the cost of screening. METHODS A population-based cohort of male Medicare beneficiaries aged 66 to 99 years, who had never been diagnosed with prostate cancer at the end of 2006 (n = 94,652), was assembled, and they were followed for 3 years to assess the cost of PSA screening and downstream procedures (biopsy, pathologic analysis, and hospitalization due to biopsy complications) at both the national and the hospital referral region (HRR) level. RESULTS Approximately 51.2% of men received PSA screening tests during the 3-year period, with 2.9% undergoing biopsy. The annual expenditures on prostate cancer screening by the national fee-for-service Medicare program were $447 million in 2009 US dollars. The mean annual screening cost at the HRR level ranged from $17 to $62 per beneficiary. Downstream biopsy-related procedures accounted for 72% of the overall screening costs and varied significantly across regions. Compared with men residing in HRRs that were in the lowest quartile for screening expenditures, men living in the highest HRR quartile were significantly more likely to be diagnosed with prostate cancer of any stage (incidence rate ratio [IRR] = 1.20, 95% confidence interval [CI] = 1.07-1.35) and localized cancer (IRR = 1.30, 95% CI = 1.15-1.47). The IRR for regional/metastasized cancer was also elevated, although not statistically significant (IRR = 1.31, 95% CI = 0.81-2.11). CONCLUSIONS Medicare prostate cancer screening-related expenditures are substantial, vary considerably across regions, and are positively associated with rates of cancer diagnosis.
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Affiliation(s)
- Xiaomei Ma
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut; Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale University, New Haven, Connecticut
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Abstract
BACKGROUND Little is known about the cost to Medicare of breast cancer screening or whether regional-level screening expenditures are associated with cancer stage at diagnosis or treatment costs, particularly because newer breast cancer screening technologies, like digital mammography and computer-aided detection (CAD), have diffused into the care of older women. METHODS Using the linked Surveillance, Epidemiology, and End Results-Medicare database, we identified 137 274 women ages 66 to 100 years who had not had breast cancer and assessed the cost to fee-for-service Medicare of breast cancer screening and workup during 2006 to 2007. For women who developed cancer, we calculated initial treatment cost. We then assessed screening-related cost at the Hospital Referral Region (HRR) level and evaluated the association between regional expenditures and workup test utilization, cancer incidence, and treatment costs. RESULTS In the United States, the annual costs to fee-for-service Medicare for breast cancer screening-related procedures (comprising screening plus workup) and treatment expenditures were $1.08 billion and $1.36 billion, respectively. For women 75 years or older, annual screening-related expenditures exceeded $410 million. Age-standardized screening-related cost per beneficiary varied more than 2-fold across regions (from $42 to $107 per beneficiary); digital screening mammography and CAD accounted for 65% of the difference in screening-related cost between HRRs in the highest and lowest quartiles of cost. Women residing in HRRs with high screening costs were more likely to be diagnosed as having early-stage cancer (incidence rate ratio, 1.78 [95% CI, 1.40-2.26]). There was no significant difference in the cost of initial cancer treatment per beneficiary between the highest and lowest screening cost HRRs ($151 vs $115; P = .20). CONCLUSIONS The cost to Medicare of breast cancer screening exceeds $1 billion annually in the fee-for-service program. Regional variation is substantial and driven by the use of newer and more expensive technologies; it is unclear whether higher screening expenditures are achieving better breast cancer outcomes.
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Affiliation(s)
- Cary P Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Comprehensive Cancer Center and Yale University School of Medicine, New Haven, CT 06520, USA.
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Blinder VS, Murphy MM, Vahdat LT, Gold HT, de Melo-Martin I, Hayes MK, Scheff RJ, Chuang E, Moore A, Mazumdar M. Employment after a breast cancer diagnosis: a qualitative study of ethnically diverse urban women. J Community Health 2012; 37:763-72. [PMID: 22109386 DOI: 10.1007/s10900-011-9509-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Employment status is related to treatment recovery and quality of life in breast cancer survivors, yet little is known about return to work in immigrant and minority survivors. We conducted an exploratory qualitative study using ethnically cohesive focus groups of urban breast cancer survivors who were African-American, African-Caribbean, Chinese, Filipina, Latina, or non-Latina white. We audio- and video-recorded, transcribed, and thematically coded the focus group discussions and we analyzed the coded transcripts within and across ethnic groups. Seven major themes emerged related to the participants' work experiences after diagnosis: normalcy, acceptance, identity, appearance, privacy, lack of flexibility at work, and employer support. Maintaining a sense of normalcy was cited as a benefit of working by survivors in each group. Acceptance of the cancer diagnosis was most common in the Chinese group and in participants who had a family history of breast cancer; those who described this attitude were likely to continue working throughout the treatment period. Appearance was important among all but the Chinese group and was related to privacy, which many thought was necessary to derive the benefit of normalcy at work. Employer support included schedule flexibility, medical confidentiality, and help maintaining a normal work environment, which was particularly important to our study sample. Overall, we found few differences between the different ethnic groups in our study. These results have important implications for the provision of support services to and clinical management of employed women with breast cancer, as well as for further large-scale research in disparities and employment outcomes.
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Affiliation(s)
- V S Blinder
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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Field TS, Bosco JLF, Prout MN, Gold HT, Cutrona S, Pawloski PA, Ulcickas Yood M, Quinn VP, Thwin SS, Silliman RA. Age, comorbidity, and breast cancer severity: impact on receipt of definitive local therapy and rate of recurrence among older women with early-stage breast cancer. J Am Coll Surg 2011; 213:757-65. [PMID: 22014658 DOI: 10.1016/j.jamcollsurg.2011.09.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 09/14/2011] [Accepted: 09/14/2011] [Indexed: 01/06/2023]
Abstract
BACKGROUND The definitive local therapy options for early-stage breast cancer are mastectomy and breast-conserving surgery followed by radiation therapy. Older women and those with comorbidities frequently receive breast-conserving surgery alone. The interaction of age and comorbidity with breast cancer severity and their impact on receipt of definitive therapy have not been well-studied. STUDY DESIGN In a cohort of 1,837 women aged 65 years and older receiving treatment for early-stage breast cancer in 6 integrated health care delivery systems in 1990-1994 and followed for 10 years, we examined predictors of receiving nondefinitive local therapy and assessed the impact on breast cancer recurrence within levels of severity, defined as level of risk for recurrence. RESULTS Age and comorbidity were associated with receipt of nondefinitive therapy. Compared with those at low risk, women at the highest risk were less likely to receive nondefinitive therapy (odds ratio = 0.32; 95% CI, 0.22-0.47), and women at moderate risk were about half as likely (odds ratio = 0.54; 95% CI, 0.35-0.84). Nondefinitive local therapy was associated with higher rates of recurrence among women at moderate (hazard ratio = 5.1; 95% CI, 1.9-13.5) and low risk (hazard ratio = 3.2; 95% CI, 1.1-8.9). The association among women at high risk was weak (hazard ratio = 1.3; 95% CI, 0.75-2.1). CONCLUSIONS Among these older women with early-stage breast cancer, decisions about therapy partially balanced breast cancer severity against age and comorbidity. However, even among women at low risk, omitting definitive local therapy was associated with increased recurrence.
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Affiliation(s)
- Terry S Field
- Meyers Primary Care Institute, Worcester, MA 01605, USA.
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