Health Policy

The effect of changes in Medicare reimbursement on the practice of office and hospital-based endoscopic surgery for bladder cancer

The effect of changes in Medicare reimbursement on the practice of office and hospital-based endoscopic surgery for bladder cancer
Cancer, Vol. 116, no. 5, pp. 1264-1271. DOI: 10.1002/cncr.24875

Hemani, M.L., D.V. Makarov, W.C. Huang, and S.S. Taneja
03/01/2010

Background: Procedures performed in the office offer potential cost savings. Recent analyses suggest, however, that a fee-for-service system may incentivize subscale operations and, thus, contribute to excessive spending. The authors of this report sought to characterize changes in the practice of office-based and hospital-based endoscopic bladder surgery after 2005 increases in Medicare reimbursement.

Methods: All office and hospital-based endoscopic surgeries that were performed in a faculty practice from 2002 through 2007 were identified using billing codes for procedures, diagnoses, and procedure locations and then analyzed using the chi-square test and logistic regression. Costs were estimated based on published Medicare reimbursements for office and hospital-based surgeries.

Results: In total, 1341 endoscopic bladder surgeries were performed, including 764 in the office and 577 in the hospital. After 2005, the odds ratio (OR) for office surgery occurring among all cystoscopies and for surgery occurring in the office versus the hospital was 2.01 (95% confidence interval [CI], 1.71-2.37) and 2.29 (95% CI, 1.83-2.87), respectively. Among all treated lesions that were associated with a diagnosis of bladder cancer and nonbladder cancer, the OR for a procedure occurring in the office versus the hospital was 1.36 (95% CI, 1.07-1.73) and 1.99 (95% CI, 1.52-2.60), respectively. The likelihood of repeat surgery on the same lesion increased after 2005 (OR, 2.86; 95% CI, 1.46-5.62), and the likelihood of an office surgery leading to a bladder cancer diagnosis at the next visit declined (OR, 0.29; 95% CI, 0.16-0.51). The overall estimated expenditure increased by 50%.

Conclusions: After 2005, more bladder lesions were identified and treated in the office. In a single group practice, office treatment of bladder cancer did not fully explain this new practice pattern, suggesting a lowered threshold for office intervention. 

A qualitative analysis of environmental policy and children's health in Mexico

A qualitative analysis of environmental policy and children's health in Mexico
Environ Health. 2010 Mar 23;9:14

Cifuentes E, Trasande L, Ramirez M, Landrigan PJ.
03/01/2010

BACKGROUND:

Since Mexico's joining the North American Free Trade Agreement (NAFTA) and the Organization for Economic Cooperation and Development (OECD) in 1994, it has witnessed rapid industrialization. A byproduct of this industrialization is increasing population exposure to environmental pollutants, of which some have been associated with childhood disease. We therefore identified and assessed the adequacy of existing international and Mexican governance instruments and policy tools to protect children from environmental hazards.

METHODS:

We first systematically reviewed PubMed, the Mexican legal code and the websites of the United Nations, World Health Organization, NAFTA and OECD as of July 2007 to identify the relevant governance instruments, and analyzed the approach these instruments took to preventing childhood diseases of environmental origin. Secondly, we interviewed a purposive sample of high-level government officials, researchers and non-governmental organization representatives, to identify their opinions and attitudes towards children's environmental health and potential barriers to child-specific protective legislation and implementation.

RESULTS:

We identified only one policy tool describing specific measures to reduce developmental neurotoxicity and other children's health effects from lead. Other governance instruments mention children's unique vulnerability to ozone, particulate matter and carbon monoxide, but do not provide further details. Most interviewees were aware of Mexican environmental policy tools addressing children's health needs, but agreed that, with few exceptions, environmental policies do not address the specific health needs of children and pregnant women. Interviewees also cited state centralization of power, communication barriers and political resistance as reasons for the absence of a strong regulatory platform.

CONCLUSIONS:

The Mexican government has not sufficiently accounted for children's unique vulnerability to environmental contaminants. If regulation and legislation are not updated and implemented to protect children, increases in preventable exposures to toxic chemicals in the environment may ensue.

How much should we invest in preventing childhood obesity?

How much should we invest in preventing childhood obesity?
Health Aff (Millwood). 2010 Mar-Apr;29(3):372-8.

Trasande L
03/01/2010

Policy makers generally agree that childhood obesity is a national problem. However, it is not always clear whether enough is being spent to combat it. This paper presents nine scenarios that assume three different degrees of reduction in obesity/overweight rates among children in three age groups. A mathematical model was then used to project lifetime health and economic gains. Spending $2 billion a year would be cost-effective if it reduced obesity among twelve-year-olds by one percentage point. The analysis also found that childhood obesity has more profound economic consequences than previously documented. Large investments to reduce this major contributor to adult disability may thus be cost-effective by widely accepted criteria.

Medicare Payments, Health Care Services Use, and Telemedicine Implementation Cost in Randomized Trial Comparing Telemedicine Case Management With Usual Care in Medically Underserved Patients With Diabetes Mellitus

Medicare Payments, Health Care Services Use, and Telemedicine Implementation Cost in Randomized Trial Comparing Telemedicine Case Management With Usual Care in Medically Underserved Patients With Diabetes Mellitus
Journal of the American Medical Informatics Association

Palmas, W., Shea, S., Starren, J., Teresi, J.E., Ganz, M.L., Burton, T.M., Pashos, C.L., Blustein, J., Field, L., Morin, P.C., Izquierdo, R.E., Silver, S., Eimicke, J.P., Langiua, R.A. & Weinstock, S.
03/01/2010

Objective
To determine whether a diabetes case management telemedicine intervention reduced healthcare expenditures, as measured by Medicare claims, and to assess the costs of developing and implementing the telemedicine intervention.
Design
We studied 1665 participants in the Informatics for Diabetes Education and Telemedicine (IDEATel), a randomized controlled trial comparing telemedicine case management of diabetes to usual care. Participants were aged 55 years or older, and resided in federally designated medically underserved areas of New York State.
Measurements
We analyzed Medicare claims payments for each participant for up to 60 study months from date of randomization, until their death, or until December 31, 2006 (whichever happened first). We also analyzed study expenditures for the telemedicine intervention over six budget years (February 28, 2000- February 27, 2006).
Results
Mean annual Medicare payments (SE) were similar in the usual care and telemedicine groups, $9040 ($386) and $9669 ($443) per participant, respectively (p>0.05). Sensitivity analyses, including stratification by censored status, adjustment by enrollment site, and semi-parametric weighting by probability of dropping-out, rendered similar results. Over six budget years 28 821 participant/months of telemedicine intervention were delivered, at an estimated cost of $622 per participant/month.
Conclusion
Telemedicine case management was not associated with a reduction in Medicare claims in this medically underserved population. The cost of implementing the telemedicine intervention was high, largely representing special purpose hardware and software costs required at the time. Lower implementation costs will need to be achieved using lower cost technology in order for telemedicine case management to be more widely used.

DNA content in the diagnostic biopsy for benign-adjacent and cancer-tissue areas predicts the need for treatment in men with T1c prostate cancer undergoing surveillance in an expectant management programme

DNA content in the diagnostic biopsy for benign-adjacent and cancer-tissue areas predicts the need for treatment in men with T1c prostate cancer undergoing surveillance in an expectant management programme
BJU International, Vol. 105, no. 3, pp. 329-333. DOI: 10.1111/j.1464-410X.2009.08791.x

Isharwal, S., D.V. Makarov, H.B. Carter,J.I. Epstein, A.W. Partin, P. Landis, C. Marlow, and R.W. Veltri
02/01/2010

Objective: To assess the DNA content in benign-adjacent and cancer-tissue areas of a diagnostic biopsy, to predict which patients would subsequently develop an unfavourable biopsy necessitating treatment for prostate cancer in the expectant management (EM) programme.

Patients and Methods: Of 71 patients who had benign-adjacent and cancer-tissue areas of diagnostic biopsies available, 39 developed unfavourable biopsies (Gleason score ≥7, Gleason pattern 4/5, three or more cores positive for cancer, >50% of any core involved with cancer), while 32 maintained favourable biopsies on annual surveillance examination (median follow-up 3.7 years). DNA content was measured on Feulgen-stained biopsy sections using an automatic imaging system (AutoCyteTM, TriPath Imaging Inc, Burlington, NC, USA). Cox proportional-hazard regression and Kaplan-Meier plots were used to identify significant predictors for unfavourable biopsy conversion.

Results: Univariately, DNA content measurements i.e. an excess of optical density (OD) in the benign-adjacent tissuer area, and the sd of the OD in the cancer tissue were significant, with a hazard ratio and 95% confidence interval of 2.58 (1.17–5.68; P = 0.019) and 5.36 (1.89–15.24; P = 0.002), respectively, for predicting unfavourable biopsy conversion that required intervention. Also, several other DNA content measurements in benign-adjacent and cancer-tissue areas showed a trend to statistical significance. Further, benign-adjacent excess of OD (3.12, 1.4–6.95; P = 0.005) and cancer sd of OD (5.88, 2.06–16.82; P = 0.001) remained significant in the multivariate model to predict unfavourable biopsy conversion. Patients with benign-adjacent excess of OD > 25.0 and cancer sd of OD of >4.0 had the highest risk for unfavourable biopsy conversion (P < 0.001).

Conclusions: DNA content measurements in the benign-adjacent and cancer-tissue areas appear to be useful for predicting unfavourable biopsy conversion (a recommendation for intervention) on annual surveillance examinations in the EM programme.

Review: The Net Benefits of Depression Management in Primary Care

Review: The Net Benefits of Depression Management in Primary Care
Medical Care Research and Review, 2010. Volume 67 / Issue 03 / January 2010, pp 251-274, Published online

Sherry Glied, Karin Herzog and Richard Frank
01/21/2010

Depression is often diagnosed and treated in primary care settings. Organizational and systems interventions that restructure primary care practices and train staff have been shown to be cost-effective strategies for treating depression. Funders are increasingly calling for a cost–benefit assessment of such programs. In this study, the authors review existing cost-effectiveness studies of primary care depression treatments, classify them into categories, translate the results into net benefit terms, and assess whether more costly programs generate greater net benefit. The authors find that interventions that provide training to primary care teams in how to manage depression most consistently produce net benefits, with more costly interventions of this type generating larger net benefits than less costly interventions. Collaborative care interventions, which add specialized staff to primary care practices, and therapy interventions, in which clinicians are trained to provide therapy, also generate net social benefits at conventional valuations of quality-adjusted life years.

Validation of the Partin Nomogram for Prostate Cancer in a National Sample

Validation of the Partin Nomogram for Prostate Cancer in a National Sample
Journal of Urology, Vol. 183, no. 1, pp. 105-111. DOI: 10.1016/j.juro.2009.08.143

Yu, J.B., D.V. Makarov, R. Sharma, R.E. Peschel, A.W. Partin, and C.P. Gross
01/01/2010

Purpose: The Partin tables are a nomogram that is widely used to discriminate prostate cancer pathological stages, given common preoperative clinical characteristics. The nomogram is based on patients undergoing radical prostatectomy at The Johns Hopkins Medical Institutions. We validated the Partin tables in a large, population based sample.

Materials and Methods: The National Cancer Institute Surveillance, Epidemiology and End Results database was used to identify patients treated from 2004 to 2005 who underwent radical prostatectomy. The 2007 Partin tables were used to estimate the prevalence of positive lymph nodes, seminal vesicle invasion, extraprostatic extension and organ confined disease in men with prostate cancer in the database using clinical stage, preoperative prostate specific antigen and Gleason score. The discriminative ability of the tables was explored by constructing ROC curves.

Results: We identified 11,185 men who underwent radical prostatectomy for prostate cancer in 2004 to 2005. The Partin tables discriminated well between patient groups at risk for positive lymph nodes and seminal vesicle invasion (AUC 0.77 and 0.74, respectively). The discrimination of extraprostatic extension and organ confined disease was more limited (AUC 0.62 and 0.68, respectively). The AUC for positive lymph nodes was 0.78 in white men, 0.73 in black men and 0.83 in Asian/Pacific Islander men (p = 0.17). The AUC for positive lymph nodes in men 61 years old or younger was 0.80 vs 0.74 in men older than 61 years (p = 0.03).

Conclusions: The Partin tables showed excellent discrimination for seminal vesicle invasion and positive lymph nodes. Discrimination of extraprostatic extension and organ confined disease was more limited. The Partin tables performed best in young men.

Substance Use Treatment Barriers for Patients with Frequent Hospital Admissions

Substance Use Treatment Barriers for Patients with Frequent Hospital Admissions
Journal of Substance Abuse Treatment

Billings, J., Raven, M., Carrier, E. et al.
01/01/2010

Substance use (SU) disorders adversely impact health status and contribute to inappropriate health services use. This qualitative study sought to determine SU-related factors contributing to repeated hospitalizations and to identify opportunities for preventive interventions. Fifty Medicaid-insured inpatients identified by a validated statistical algorithm as being at high-risk for frequent hospitalizations were interviewed at an urban public hospital. Patient drug/alcohol history, experiences with medical, psychiatric and addiction treatment, and social factors contributing to readmission were evaluated. Three themes related to SU and frequent hospitalizations emerged: (a) barriers during hospitalization to planning long-term treatment and follow-up, (b) use of the hospital as a temporary solution to housing/family problems, and (c) unsuccessful SU aftercare following discharge. These data indicate that homelessness, brief lengths of stay complicating discharge planning, patient ambivalence regarding long-term treatment, and inadequate detox-to-rehab transfer resources compromise substance-using patients' likelihood of avoiding repeat hospitalization. Intervention targets included supportive housing, detox-to-rehab transportation, and postdischarge patient support.

Transportation to Clinic: Findings from a Pilot Clinic-Based Survey of Low-Income Suburbanites

Transportation to Clinic: Findings from a Pilot Clinic-Based Survey of Low-Income Suburbanites
Journal of Immigrant and Minority Health 2010.  DOI: 10.1007/s10903-010-9410-0

Silver D, J Blustein, BC Weitzman.
01/01/2010

Health care policymakers have cited transportation barriers as key obstacles to providing health care to low-income suburbanites, particularly because suburbs have become home to a growing number of recent immigrants who are less likely to own cars than their neighbors. In a suburb of New York City, we conducted a pilot survey of low income, largely immigrant clients in four public clinics, to find out how much transportation difficulties limit their access to primary care. Clients were receptive to the opportunity to participate in the survey (response rate = 94%). Nearly one-quarter reported having transportation problems that had caused them to miss or reschedule a clinic appointment in the past. Difficulties included limited and unreliable local bus service, and a tenuous connection to a car. Our pilot work suggests that this population is willing to participate in a survey on this topic. Further, since even among those attending clinic there was significant evidence of past transportation problems, it suggests that a population based survey would yield information about substantial transportation barriers to health care.

Tous les systèmes de santé coûtent de plus en plus cher

Tous les systèmes de santé coûtent de plus en plus cher
Propos recueillis par Marc Rambuzet le 10 décembre 2009, Objectif méditerranée, n'lOB, Décembre-Janvier 2010, pg 4.

Rambuzet, M. & Rodwin, V.G.
12/10/2009

Victor G. Rodwin, qui tiendra une conférence à Marseille le 22 janvier prochain, explique en quoi la réforme
du système de santé est si difficile à mettre en oeuvre aux États-Unis. Si le Président Obama a surmonté
les premières difficultés, la course d'obstacles n'est pas pour autant terminée. Rodwin reconnaît l'excellence
du système médical français tout en contestant la première place attribuée par l'OMS à notre pays.

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