Health Policy

Radical Prostatectomy Improves and Prevents Age Dependent Progression of Lower Urinary Tract Symptoms

Radical Prostatectomy Improves and Prevents Age Dependent Progression of Lower Urinary Tract Symptoms
Journal of Urology. Vol. 191, no. 2, pp. 412-417. DOI: 10.1016/j.juro.2013.08.010

Prabhu, V., G.B. Taksler, G. Sivarajan, J. Laze, D.V. Makarov, and H. Lepor
02/01/2014

Purpose: The prevalence of lower urinary tract symptoms increases with age and impairs quality of life. Radical prostatectomy has been shown to relieve lower urinary tract symptoms at short-term followup but the long-term effect of radical prostatectomy on lower urinary tract symptoms is unclear.

Materials and Methods: We performed a prospective cohort study of 1,788 men undergoing radical prostatectomy. The progression of scores from the self-administered AUASS (American Urological Association symptom score) preoperatively, and at 3, 6, 12, 24, 48, 60, 84, 96 and 120 months was analyzed using models controlling for preoperative AUASS, age, prostate specific antigen, pathological Gleason score and stage, nerve sparing, race and marital status. This model was also applied to patients stratified by baseline clinically significant (AUASS greater than 7) and insignificant (AUASS 7 or less) lower urinary tract symptoms.

Results: Men exhibited an immediate worsening of lower urinary tract symptoms that improved between 3 months and 2 years after radical prostatectomy. Overall the difference between mean AUASS at baseline and at 10 years was not statistically or clinically significant. Men with baseline clinically significant lower urinary tract symptoms experienced immediate improvements in lower urinary tract symptoms that lasted until 10 years after radical prostatectomy (13.5 vs 8.81, p <0.001). Men with baseline clinically insignificant lower urinary tract symptoms experienced a statistically significant but clinically insignificant increase in mean AUASS after 10 years (3.09 to 4.94, p <0.001). The percentage of men with clinically significant lower urinary tract symptoms decreased from baseline to 10 years after radical prostatectomy (p = 0.02).

Conclusions​: Radical prostatectomy is the only treatment for prostate cancer shown to improve and prevent the development of lower urinary tract symptoms at long-term followup. This previously unrecognized long-term benefit argues in favor of the prostate as the primary contributor to male lower urinary tract symptoms.

The Contribution of Health Care and Other Interventions to Black-White Disparities in Life Expectancy, 1980-2007

The Contribution of Health Care and Other Interventions to Black-White Disparities in Life Expectancy, 1980-2007
Population Research and Policy Review, Vol. 33, no. 1 (Feb 2014), pp. 97-126. doi: 10.1007/s11113-013-9309-2

Elo, I.T., H. Beltran-Sanchez, and J. Macinko
02/01/2014

Black–white mortality disparities remain sizable in the United States. In this study, we use the concept of avoidable/amenable mortality to estimate cause-of-death contributions to the difference in life expectancy between whites and blacks by gender in the United States in 1980, 1993, and 2007. We begin with a review of the concept of “avoidable mortality” and results of prior studies using this cause-of-death classification. We then present the results of our empirical analyses. We classified causes of death as amenable to medical care, sensitive to public health policies and health behaviors, ischemic heart disease, suicide, HIV/AIDS, and all other causes combined. We used vital statistics data on deaths and Census Bureau population estimates and standard demographic decomposition techniques. In 2007, causes of death amenable to medical care continued to account for close to 2 years of the racial difference in life expectancy among men (2.08) and women (1.85). Causes amenable to public health interventions made a larger contribution to the racial difference in life expectancy among men (1.17 years) than women (0.08 years). The contribution of HIV/AIDS substantially widened the racial difference among both men (1.08 years) and women (0.42 years) in 1993, but its contribution declined over time. Despite progress observed over the time period studied, a substantial portion of black–white disparities in mortality could be reduced given more equitable access to medical care and health interventions.

The Cost Implications of Prostate Cancer Screening in the Medicare Population

The Cost Implications of Prostate Cancer Screening in the Medicare Population
Cancer, Vol. 120, no. 1, pp. 96-102. DOI: 10.1002/cncr.28373

Ma, X., R. Wang, J.B. Long, J.S. Ross, P.R. Soulos, J.B. Yu, D.V. Makarov, H.T. Gold, and C.P. Gross
01/01/2014

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.

Measuring the Degree of Integrated Tuberculosis and HIV Service Delivery in Cape Town, South Africa

Measuring the Degree of Integrated Tuberculosis and HIV Service Delivery in Cape Town, South Africa
Health Policy and Planning, Vol. 29, no. 1 (Jan 2014), pp. 42-55. doi: 10.1093/heapol/czs131

Uyei, J., D. Coetzee, J. Macinko, S.L. Weinberg, and S. Guttmacher
01/01/2014

To address the considerable tuberculosis (TB)/HIV co-infected population in Cape Town, a number of clinics have made an effort of varying degrees to integrate TB and HIV services. This article describes the development of a theory-based survey instrument designed to quantify the extent to which services were integrated in 33 clinics and presents the results of the survey. Using principal factor analysis, eight factors were extracted and used to make comparisons across three types of clinics: co-located TB and antiretroviral therapy (ART) services, clinics with TB services only and clinics with ART only. Clinics with co-located services scored highest on measures related to integrated TB/ART service delivery compared to clinics with single services, but within group variability was high indicating that co-location of TB and ART services is a necessary but insufficient condition for integrated service delivery. In addition, we found almost all clinics with only TB services in our sample had highly integrated pre-ART services, suggesting that integration of these services across a large number of clinics is feasible and acceptable to clinic staff. TB clinics with highly integrated pre-ART services appear to be efficient sites for introducing ART given that co-infected patients are already engaged in care, and may potentially facilitate earlier access to treatment and minimize loss to follow-up.

How States Stand to Gain or Lose Federal Funds by Opting In or Out of the Medicaid Expansion

How States Stand to Gain or Lose Federal Funds by Opting In or Out of the Medicaid Expansion
The Commonwealth Fund Vol 32, December 2013

Sherry Glied and Stephanie Ma
12/05/2013

Following the Supreme Court's decision in 2012, state officials are now deciding whether to expand their Medicaid programs under the Affordable Care Act. While the states' costs of participating in the Medicaid expansion have been at the forefront of this discussion, the expansion has much larger implications for the flow of federal funds going to the states. This issue brief examines how participating in the Medicaid expansion will affect the movement of federal funds to each state. States that choose to participate in the expansion will experience a more positive net flow of federal funds than will states that choose not to participate. In addition to providing valuable health insurance benefits to low-income state residents, and steady sources of financing to state health care providers, the Medicaid expansion will be an important source of new federal funds for states.

Dispelling An Urban Legend: Frequent Emergency Department Users Have Substantial Burden Of Disease

Dispelling An Urban Legend: Frequent Emergency Department Users Have Substantial Burden Of Disease
Health Affairs, 32, no.12 (2013):2099-2108

Billings, John and Maria C. Raven
12/01/2013

Urban legend has often characterized frequent emergency department (ED) patients as mentally ill substance users who are a costly drain on the health care system and who contribute to ED overcrowding because of unnecessary visits for conditions that could be treated more efficiently elsewhere. This study of Medicaid ED users in New York City shows that behavioral health conditions are responsible for a small share of ED visits by frequent users, and that ED use accounts for a small portion of these patients’ total Medicaid costs. Frequent ED users have a substantial burden of disease, and they have high rates of primary and specialty care use. They also have linkages to outpatient care that are comparable to those of other ED patients. It is possible to use predictive modeling to identify who will become a repeat ED user and thus to help target interventions. However, policy makers should view reducing frequent ED use as only one element of more-comprehensive intervention strategies for frequent health system users.

National Trends in the Utilization of Partial Nephrectomy Before and After the Establishment of AUA Guidelines for the Management of Renal Masses

National Trends in the Utilization of Partial Nephrectomy Before and After the Establishment of AUA Guidelines for the Management of Renal Masses
Urology, Vol. 82, no. 6, pp. 1283-1290. DOI: 10.1016/j.urology.2013.07.068

Bjurlin, M.A. D. Walter, G.B. Taksler, W.C. Huang, J.S. Wysock, G. Sivarajan, S. Loeb, S.S. Taneja, and D.V. Makarov
12/01/2013

Objective To assess the impact of the American Urological Association (AUA) guidelines advocating partial nephrectomy for T1 tumors guidelines on the likelihood of undergoing partial nephrectomy.

Materials and Methods We analyzed the Nationwide Inpatient Sample (NIS), a dataset encompassing 20% of all United States inpatient hospitalizations, from 2007 through 2010. Our dependent variable was receipt of radical vs partial nephrectomy (55.50, 55.51, 55.52, and 55.54 vs 55.4) for a renal mass (International Classification of Disease, 9th Revision [ICD-9] code 189.0). The independent variable of interest was time of surgery (before or after the establishment of AUA guidelines); covariates included a diagnosis of chronic kidney disease (CKD), overall comorbidity, age, race, gender, geographic region, income, and hospital characteristics. Bivariate and multivariable adjusted logistic regression was used to determine the association between receipt of partial nephrectomy and time of guideline establishment.

Results We identified 26,165 patients with renal tumors who underwent surgery. Before the guidelines, 4031 patients (27%) underwent partial nephrectomy compared to 3559 (32%) after. On multivariable analysis, undergoing surgery after the establishment of guidelines (odds ratio [OR] 1.20, 95% confidence interval [CI] 1.08-1.32, P <.01) was an independent predictor of partial nephrectomy. Other factors associated with partial nephrectomy were urban location, surgery at a teaching hospital, large hospital bed size, Northeast location, and Black race. Female gender and CKD were not associated with partial nephrectomy.

Conclusion Although adoption of partial nephrectomy increased after establishment of new guidelines on renal masses, partial nephrectomy remains an underutilized procedure. Future research must focus on barriers to adoption of partial nephrectomy and how to overcome them.

Calorie Labeling, Fast Food Purchasing and Restaurant Visits

Calorie Labeling, Fast Food Purchasing and Restaurant Visits
Obesity, 21: 2172–2179. doi: 10.1002/oby.20550

Elbel, B., Mijanovich, T., Dixon, L. B., Abrams, C., Weitzman, B., Kersh, R., Auchincloss, A. H. and Ogedegbe, G.
10/17/2013

Objective
Obesity is a pressing public health problem without proven population-wide solutions. Researchers sought to determine whether a city-mandated policy requiring calorie labeling at fast food restaurants was associated with consumer awareness of labels, calories purchased and fast food restaurant visits.

Design and Methods
Difference-in-differences design, with data collected from consumers outside fast food restaurants and via a random digit dial telephone survey, before (December 2009) and after (June 2010) labeling in Philadelphia (which implemented mandatory labeling) and Baltimore (matched comparison city). Measures included: self-reported use of calorie information, calories purchased determined via fast food receipts, and self-reported weekly fast-food visits.

Results
The consumer sample was predominantly Black (71%), and high school educated (62%). Postlabeling, 38% of Philadelphia consumers noticed the calorie labels for a 33% point (P < 0.001) increase relative to Baltimore. Calories purchased and number of fast food visits did not change in either city over time.

Conclusions
While some consumers report noticing and using calorie information, no population level changes were noted in calories purchased or fast food visits. Other controlled studies are needed to examine the longer term impact of labeling as it becomes national law.

Potentially avoidable hospitalizations: how to estimate the costs?

Potentially avoidable hospitalizations: how to estimate the costs?
Gestion Hospitalière (529) October, 2013

Rodwin, V., A. Sommer, and D. Weisz
10/01/2013

Based on the number of hospitalizations for ambulatory-care sensitive conditions in the Paris region (Ile-de-France), and the DRG-based rates for these hospital stays, we estimate the hospital expenditures that could be avoided if patients had access to primary care services that successfully manage their chronic conditions and avoid exacerbations that lead to necessary hospitalizations when they occur. In addition, we caution policymakers about what inferences can legitimately be drawn from such estimates for the expenditures averted on hospital care do not represent a net gain as there would likely be additional expenditures needed to upgrade ambulatory care to manage a host of complex chronic diseases.

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