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A model evidencing the advantages, in terms of health, life and costs, of early detection of asymptomatic diseases, is presented. The model also assesses the cost benefits of such detection based on age variation.

Forty five percent of livers are rejected by the first surgeon to whom they are offered, despite the scarcity of transferable organs. This is because the surgeons use data on transplanted patients to find a solution, hence they reject the low quality organ for relatively healthy patient in the hope that they will receive a better organ future.

An accounting and analytical framework was developed to examine the history of the external debt positions of Argentina, Brazil, Chile, Mexico, Peru, Venezuela, Korea and the Philippines. Projections of the debt-export ratios for the 1990s in the eight countries using the analytical framework and a simulation model with moderate baseline assumptions showed an increase in the debt-export ratios in five out of eight countries. The need for external adjustments are discussed,3 and alternatives to the baseline assumptions are suggested.

Objective: To examine how Medicare reimbursement for prostate biopsies was allocated to physicians, ambulatory surgery centers (ASCs), and hospitals from 2012 to 2015.Materials and Methods: Using Medicare Provider Utilization and Payment Data (2012-2015), we assessed provider payments to physicians and ASCs for transrectal ultrasound-guided prostate biopsies (Current Procedural Terminology 55700, 76842, 76972) for fee-for-service Medicare beneficiaries. Data were aggregated at provider-level for those reporting >10 biopsies per year. Hospital payments were estimated based on Outpatient Prospective Payment System. We report average and total payments for physicians, hospitals, and ASCs.Results: We identified 534,807 prostate biopsies, of which 13.3% and 14.8% were associated with an ASC and hospital, respectively. Payments for all biopsies totaled $276.7 million ($152.7 million to physicians; $35.1 million to ASCs, $88.9 million to hospitals). From 2012 through 2015, physician payments for biopsies declined by $19 million (Δ=-43.2%, P = .06 for trend). Payments to ASCs (+$3.2 million, Δ = 38.8%, P = .29) and hospitals (+$11.1 million, Δ = 58.6%, P = .16) both increased. The decline in physician payments was due to a 13.7% decline in volume and lower median reimbursement for office-based procedures ($415 to $277, P = .04). The share of biopsies performed at facilities increased from 26.5% to 30.0%, and the proportion of payments associated with those settings also increased from 42.7% to 65.3%.Conclusion: Over time, a greater share of Medicare payments for biopsies has been directed toward facilities instead of physicians. Understanding the relationship between these trends and cancer screening and Medicare payment policies will be crucial in the future. [ABSTRACT FROM AUTHOR]

Background Recent studies have suggested that vaccination of nursing home staff members may reduce the incidence of influenza among nursing home residents. Current national estimates of employee vaccination rates (around 50%) indicate that residents may be at an unnecessarily high risk of contracting influenza. This article reports on the influenza vaccination rates and attitudes toward the vaccine among employees in 37 nursing homes in 3 states. Methods Nursing home employees were surveyed at nursing homes in Florida, Georgia, and Wisconsin in 2011-2012. Completed surveys were received from a total of 1,965 employees. Results Approximately 54% of the employees surveyed received the vaccination during the 2010-2011 and 2011-2012 influenza seasons. Nursing home–level staff vaccination rates varied widely, from 15%-97%. Black and younger employees were less likely to receive the vaccine. Employee vaccination rates in nursing homes that used incentives were 12 percentage points higher than those that did not use incentives ( P = .08). Conclusion Low vaccination rates among nursing home workers may put residents at increased risk for influenza-related morbidity and mortality. The Centers for Medicare and Medicaid Services may consider employee vaccination rates as a quality indicator in addition to resident vaccination rates. Our findings support the use of a trial to test the use of incentives to increase employee vaccination rates. [ABSTRACT FROM AUTHOR]

Abstract: Background:: There is little published research addressing how the 2003 Infectious Diseases Society of America (IDSA) guidelines for empiric therapy of community-acquired pneumonia (CAP) are implemented in clinical practice. Objective:: This study was designed to describe antibiotic treatment patterns among patients with CAP treated in ambulatory settings in light of the IDSA guidelines. Methods:: Health insurance claims data from a large managed care organization with −30 million enrollees located in geographically diverse regions of the United States were analyzed. Patients ≥18 years of age with CAP who received a prescription for any antibiotic in an ambulatory setting during 2004 were identified via International Classification of Diseases, Ninth Revision, Clinical Modification codes for diagnosis (481–486). Recent antibiotic use was defined as receipt of any antibiotics <90 days before the date of diagnosis. Antibiotics were identified through National Drug Codes and from outpatient medical claims data with the use of J codes. Individuals were classified, per IDSA guidelines, as previously healthy without recent antibiotic use (group 1); previously healthy with recent antibiotic use (group 2); with comorbidities and without recent antibiotic use (group 3); and with comorbidities and recent antibiotic use (group 4). The guideline adherence was calculated using the number of patients receiving recommended treatment divided by the total number of patients in each group. Results:: Of 34,342 patients identified, 76.5% had no reported comorbidities. Among group-1 patients, 52.0% received the recommended empiric therapy (macrolide or doxycycline). In group-2 patients, 42.5% received the recommended therapy (respiratory quinolone alone or advanced-generation macrolide plus amoxicillin or amoxicillin-clavulanate). A high rate of compliance with recommended empiric therapy (advanced-generation macrolides or respiratory quinolones) was observed in group-3 patients (81.5%). In group-4 patients, 43.4% received the recommended therapy (respiratory quinolone or advanced-generation macrolide plus ß-lactam). Patients whose therapy was adherent with the guidelines had fewer respiratory-infection-related hospital admissions within 30 days after initiation of antibiotic treatment (overall, relative risk = 0.81 [95% CI, 0.71–0.94]). Conclusion:: Although these data reflect a period shortly after the 2003 IDSA guidelines were published, they suggest that there is room for improvement with regard to choice of empiric antibiotic therapy among these patients with CAP treated in ambulatory settings. [Copyright &y& Elsevier]

Abstract: Background:: Macrolide antibiotics are used as firt-line therapy for the treatment of respiratory tract infections. The recent emergence of macrolide-resistant pathogens is a major concern. Objective:: This study quantifies the frequency of macrolide treatment failure in respiratory infections and examines its impact on health care use. Methods:: Patients with respiratory infections treated with macrolides in outpatient clinics from January to December 2002 were identified from a health insurance claims database. Macrolide treatment failure was defined as the receipt of a second antibiotic, different from the first, within 4 weeks after the initial macrolide. The end points were numbers of hospitalizations and emergency department and office visits within 1 month after the initial macrolide. We examined diagnostic codes on claim forms for posttreatment hospitalizations and visits to identify those most likely to be related to treatment failure as opposed to other causes. Utilization data were analyzed by Poisson regression to control for confounding variables. Results:: The patients were divided into acute sinusitis (n = 111,135), acute bronchitis (n = 157,360), and community-acquired pneumonia (n = 36,212). Of these respective groups, 11,285 (10.2%), 15,498 (9.9%), and 4144 (11.4%) received a second antibiotic within 4 weeks. This subgroup with macrolide treatment failure was older, included more women, and had used more medical care before the index visit compared with patients with treatment success. After adjustment for age, sex, and previous health care use, patients experiencing treatment failure were more likely to be admitted to the hospital or to use emergency department or outpatient care after the index visit. This association was strongest for admissions and visits pertaining to the care of respiratory infections. Conclusions:: By our definition, about 10% of patients with respiratory infections who were treated with macrolide antibiotics experienced treatment failure within 4 weeks. Macrolide treatment failure was associated with increased health care utilization. [Copyright &y& Elsevier]

Objective: To assess adoption of prebiopsy prostate magnetic resonance imaging (MRI) in the United States and to evaluate factors associated with magnetic resonance imaging-guided prostate biopsy (MRI-Bx) use. Prior reports have shown improved cancer detection with MRI-Bx vs transrectal ultrasound-guided methods (transrectal ultrasound-guided biopsy [TRUS-Bx]). Population-based trends of their use and outcomes have not been previously characterized.Materials and Methods: Using private insurance claims (2009-2015), we identified men who underwent prostate biopsy. Exposures were biopsy year and geographic region defined by metropolitan statistical area. Outcomes included biopsy type (MRI-Bx, TRUS-Bx, or transperineal biopsy) based on procedure codes and cancer detection based on a new diagnosis for prostate cancer (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] 185). Hierarchical mixed-effects multivariable regression estimated odds of undergoing MRI-Bx.Results: We identified 241,681 men (mean age 57.5 ± 5.4 years) who underwent biopsy. The use of MRI-Bx rose rapidly (0.2% in 2009 to 6.5% in 2015, P <.001). Overall, 3429 men underwent MRI before biopsy, more commonly in metropolitan statistical areas (odds ratio 1.90, 95% confidence interval 1.66-2.19). In 2015, nearly 18% of men with prior negative biopsy underwent a prebiopsy MRI. Patients with prior negative biopsies were over 4 times more likely to use MRI guidance (vs no prior biopsies, odds ratio 4.63, 95% confidence interval 4.27-5.02) and had a greater chance of cancer detection with MRI-Bx (25.2%) vs TRUS-Bx (19.7%, P = .010).Conclusion: Among men undergoing prostate biopsy, prebiopsy prostate MRI utilization was concentrated within urban areas and among patients with prior negative biopsies, where its use was associated with superior cancer detection compared with traditional TRUS-Bx. [ABSTRACT FROM AUTHOR]

Purpose: Though superior in clinical trial settings, outcomes following magnetic resonance image (MRI)-guided prostate biopsies have not been reported broadly. We compared prostate cancer detection rates for men who did and did not undergo prebiopsy MRI and evaluated treatment patterns based on biopsy approach, year of biopsy, and proximity to early adopters.Methods: Using private insurance claims (2009-2015), we identified men who underwent prostate biopsy using appropriate procedure codes. Exposure was receipt of prebiopsy MRI within 3 months prior to biopsy. Outcomes included new prostate cancer diagnosis, treatment with prostatectomy/radiation, and receipt of adjunct procedures typically used for higher-risk disease (i.e., lymphadenectomy with prostatectomy, androgen deprivation therapy with radiation). Hierarchical mixed-effects multivariable logistic regression predicted probabilities of each outcome.Results: We identified 77,350 men (mean age 57.5 ± 5.4 years) who underwent biopsy with 12% having had a prior negative biopsy. Use of prebiopsy MRI was more common among men biopsied from 2014 to 2015 (4.4% vs. 1.3% 2012-2013), in metropolitan statistical areas (2.6% vs. 1.1% not), residing close to early adopters (5.5% vs. 1.5% far), and with prior negative biopsy (7.3% vs. 1.7% biopsy-naïve; all P < 0.001). Compared to patients with a prior negative biopsy and no MRI, men were more likely to be diagnosed with prostate cancer if they had a prior negative biopsy and MRI (24.7% vs. 21.4% prior negative without MRI, odds ratio 1.25, 95% confidence interval 1.04-1.51) or an initial biopsy without prior MRI (40.0% vs. 21.4% prior negative without MRI, odds ratio 2.49, 95% confidence interval 2.36-2.64; P < 0.001). Predicted probability of treatment overall and adjunct treatment did not differ based on receipt of pre-biopsy MRI.Conclusions: Among privately insured men in the United States, use of prostate MRI prior to prostate biopsy was associated with increased cancer detection among those with prior negative biopsies, but we did not observe significant changes with downstream treatment patterns. [ABSTRACT FROM AUTHOR]

Background Vertebroplasty and kyphoplasty are procedures for treating vertebral compression fractures (VCFs). In August 2009, 2 randomized trials in the New England Journal of Medicine found that vertebroplasty did not reduce pain or disability relative to a sham procedure among patients with osteoporotic VCFs. Study Design We evaluated quarterly trends in per capita rates of vertebroplasties and kyphoplasties using the Florida hospital inpatient discharge and ambulatory surgery center databases from 2005 to 2012, supplemented with physician specialty and population data. We reported trends by procedure type, patient diagnosis, and physician specialty. We modeled the procedures as interrupted time series with a break when the clinical trials were published, and estimated changes in procedure rates and health expenditures resulting from the trials. Results The trials led to a 51.5% decline in the per capita vertebroplasty rate and a 40.0% decline in the kyphoplasty rate (both results p < 0.010) compared with what procedure rates would have been without the trials. Vertebroplasty rates for interventional radiologists displayed no significant change; rates for surgeons and other specialists declined by 73.1% (p < 0.010). Overall, these changes imply nationwide health expenditure savings of just over $1 billion per year. Conclusions Publication of negative clinical trial results led to moderate reductions in vertebroplasties and kyphoplasties for osteoporotic VCFs. However, vertebroplasty and kyphoplasty continue to be widely used to treat patients with osteoarthritis. Substantial differences in response across physicians suggest an important role for specialty society clinical guidelines in modulating how clinical evidence is incorporated into routine practice. [ABSTRACT FROM AUTHOR]

Background: The treatment for men diagnosed with localized prostate cancer has changed over time given the increased attention to the harms associated with over-diagnosis and the development of protocols for active surveillance.Methods: We examined trends in the treatment of men diagnosed with localized prostate cancer between 2004 and 2015, using the most recently available data from Surveillance, Epidemiology, and End Results Program (SEER)-Medicare. Patients were stratified by Gleason score, age, and race groups.Results: The use of active surveillance increased from 22% in 2004-2005 to 50% in 2014-2015 for patients with a Gleason score of 6 or below and increased from 9% in 2004-2005 to 13% in 2014-2015 for patients with a Gleason score of 7 or above. Patients with a Gleason score of 7 or above had increased use of intensity-modulated radiation therapy and prostatectomy, especially among patients aged 75 years and older. Among patients with a Gleason score of 6 or below non-Hispanic black men were less likely to undergo active surveillance than non-Hispanic white men.Conclusions: There has been a large increase in the use of active surveillance among men with a Gleason score of 6 or below. However, non-Hispanic black men with a Gleason score of 6 or below are less likely to receive active surveillance. [ABSTRACT FROM AUTHOR]