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To evaluate the diagnostic value of single photon emission computed tomography/computed tomography (SPECT/CT) in patients with avascular necrosis (AVN) of the femoral head.A search of the databases PubMed, ScienceDirect, and Google Scholar was undertaken using targeted index word. Studies satisfying inclusions and exclusions criteria were identified and additional related literature sources were considered. Analysis included pooled sensitivity and specificity, odds ratio (OR), and receiver operating characteristic (ROC) analysis.Seven studies were identified that specifically related to the diagnostic accuracy of SPECT/CT in the detection or characterisation of AVN of the femoral head. These were included in the meta-analysis. The pooled sensitivity and specificity were 94% (95% confidence interval of 87-97%) and 75% (95% confidence interval of 68-81%) respectively, the OR was 44.5 (with a 95% confidence interval of 18.2-108.6), and the area under the SROC was 93.73% (with a 95% confidence interval of 89.2%-98.3%).This meta-analysis provides strong evidence of the high diagnostic efficacy of SPECT/CT in the evaluation of AVN of the femoral head.In the absence of or contraindication to MRI, SPECT/CT is able to provide a suitable alternative for diagnosis of AVN of the head of femur.

Background Our previous work with 123iodine meta-iodobenzylguanidine (123I-mIBG) radionuclide imaging among patients with cardiomyopathy reported limitations associated with the prognostic power of global parameters derived from planar imaging [1]. Employing multivariate analysis, we further showed the regional washout associated with territories adjacent to infarcted myocardium obtained from single-photon emission computed tomography imaging (SPECT) yielded superior prognostic power over the other planar and SPECT indices in predicting future cardiac events [1]. The aim of this study was to apply an artificial neural network (Neural Analyser version 2.9.5) to the original data from the same patient cohort to evaluate the most potent prognostic index for future cardiac events among patient with cardiomyopathy. Methods The original data were reevaluated using an artificial neural network (Neural Analyser version 2.9.5). There were 84 input variables in the original 22 patients from clinical data, electrocardiogram (rest, stress, and continuous ambulatory electrocardiogram recording), transthoracic echocardiography, coronary angiogram, sestamibi myocardial perfusion SPECT, planar and SPECT 123I-mIBG, and genetic and biomarkers, detailed in the previous work. A single binary output was a cardiac event or no cardiac event in the follow-up period. Results Following training and validation phases, the optimal number of inputs was determined to be two with a training loss of 0.025 and selection loss −10%) and 123I-mIBG planar global washout (>30%), two hidden layers of 6 and 1 node, respectively, and a binary output. Using receiver operator characteristics analysis demonstrated an area under the curve of 0.75 correlating to a sensitivity of 100% and specificity of 50%. Conclusion The premise that regional washout of 123I-mIBG SPECT from noninfarcted tissue is the best predictor of cardiac events was built on has a sound and logical foundation. By artificial neural network analysis; however, 123I-mIBG planar global washout of >30% was shown to be the best indicator for risk of cardiac event when accompanied by a decline in left ventricular ejection fraction of >10%. Further investigation should be undertaken assessing assimilation into big data and the potential for automated feature extraction from raw image datasets with convolutional neural networks.

Due to the long underwater propagation delays, the underwater sink node may not receive all of the requests to send RTS and DATA frames from the various underwater sensor nodes, resulting in massive collisions. We proposed an underwater Medium Access Control (MAC) protocol that takes into account the long propagation delay to evaluate the performance of the carrier sense multiple access collision avoidance (CSMA/CA) protocol utilizing a loop-based single hope underwater sensor network. The proposed protocol is designed to restore multiple RTS control packets from n underwater sensor nodes to the underwater sink node in a single slot time. The sink node received multiple RTS frames without overlapping because the n underwater sensor nodes transmitted the RTS frames at the same time, but they were received at different times at the receiver end due to differences in propagation delays that depend on the distances between the n sensor nodes and the sink node. In this paper, by altering the number of underwater sensor nodes and the size of the contention window, the proposed MAC protocol throughput is evaluated by using the underwater propagation delay.

PurposeAn important Islamic imperative is prevention of concentration of wealth among a few so that wealth circulates widely to enhance shared prosperity. In contemporary economic discourse, inequality and concentration of wealth have emerged as among key causes of instability and crisis. Unfortunately, although Islamic finance has emerged as a Shari’ah-compliant industry, it does not seem to be connected with the Islamic concern about inequality and concentration of wealth. This paper aims to explore the issues of inequality and concentration of wealth in the context of Islamic finance.Design/methodology/approachThis paper addresses a number of queries: Are Islamic banks, as the dominant component of the industry, helping to improve inequality and concentration of wealth and thus offer a better framework to deal with instability and crisis? Is the ownership structure of Islamic banks conducive to meeting the Islamic imperative regarding inequality and concentration of wealth? Using secondary data, this research illuminates the pertinent issues in light of the experience of Bahrain as one of the hubs of Islamic banking and finance.FindingsThe paper finds that the ownership pattern of Islamic banks in Bahrain lends credence to the entrenched, not-so-unexpected concentration of wealth.Research limitations/implicationsThis study is based on data of one country. Further studies on other countries will help illuminate the relevant patterns and issues.Practical implicationsInequality and concentration of wealth are among central economic issues in contemporary economic discourse. Because of the significant impact of such inequality and concentration, societies need to be more aware of these impacts and devise ways to address it.Social implicationsInequality and concentration of wealth have fundamental social implications, as the issues of poverty, deprivation, exploitation, etc. are inseparable from concentration of wealth (accompanied by concentration of power), and widening wealth gap can cause or induce major socio-political upheaval.Originality/valueAlthough inequality and concentration of wealth are robust fields of inquiry, this might be the first work addressing the issue of concentration of wealth in the context of Islamic finance in general and Islamic banking in particular.

e18836 Background: Oncology biosimilars may play an important role in managing risk for providers participating in value-based payment (VBP) models. The impact of biosimilar substitution on risk to providers remains unclear, as prior researchers have adopted a generic budget impact approach. Methods: We estimated the impact of biosimilar substitution on financial risk to providers in oncology VBPs by applying simulation approaches to model the quantitative methodology (e.g. episode framing, pricing, risk adjustment) of Medicare’s Oncology Care Model (OCM). Patient demographic and utilization data to fit the models were drawn from the Medicare Limited Data Set (LDS). Risk was defined as total cost of care (TCOC) relative to target price for an episode per the OCM methodology. Target prices were estimated using the most recently available OCM risk adjustment coefficients (2020). Biosimilars for six oncology agents were examined: bevacizumab, rituximab, trastuzumab, epoetin alfa, filgrastim, and pegfilgrastim (hereafter biosimilar investigation agents – BIAs). Episode TCOC was computed under the assumption of the use of reference BIAs and was then recomputed after biosimilar substitution. The study population consisted of 1620 episodes framed per the OCM methodology using the most recently available LDS data (2019-2020) that had use of a BIA. The impact to provider groups was estimated by computing the change in OCM risk bands (incentive payment earned/ neutral/ payment owed back to Medicare) associated with biosimilar substitution in panels of 100 randomly selected episodes from the study population over 10000 simulation runs. In our base model, we assumed that substitution for antineoplastics would occur only in treatment naïve patients and that substitution for supportive therapies would occur for all eligible patients. Treatment naïve status was assessed by examining longitudinal LDS data from 2016-2020 for beneficiaries from the study population. Results: Biosimilar substitution resulted in a mean reduction in cost relative to target of approximately $1,200 per eligible episode and reduced the proportion of practices that were above benchmark for eligible episodes by 33% and increased the number of practices below target for eligible episodes by 42%. Additional scenario analyses suggested that adoption strategy was a major determinant of potential impact. If assumptions of antineoplastic substitution requiring treatment naïve status were relaxed, costs savings relative to target would go from $1200 per eligible episode to $2700. Conclusions: Biosimilar substitution significantly reduces aggregate provider risk in OCM, representing a significant potential intervention for providers to mitigate risk in oncology VBPs both in terms of absolute costs saved relative to target and reduction in risk band relative to payer projections.

Background Heart failure (HF) involves both mechanical and autonomic nervous system dysfunction that can lead to sudden cardiac death. In the failing human heart, there is increased release of norepinephrine from neurons and reduced uptake. Iodine-123–labeled metaiodobenzylguanidine (123I-mIBG) demonstrates reduced global uptake and increased washout associated with increased mortality in HF. This research examined the potential benefits of single-photon emission computed tomography (SPECT) regional quantitation in risk stratification of HF patients and its role in prediction of cardiac morbidity and mortality. Methods Twenty-two clinically diagnosed HF patients were recruited into this study. The subjects underwent myocardial perfusion SPECT and cardiac sympathetic imaging with 123I-mIBG. Early (at 15 min after injection) and delayed (four hours after injection) planar and SPECT were performed. Visual and semiquantitative analysis was conducted, and global (from planar imaging) and regional (from SPECT imaging) uptake and washout indices determined. The patients were clinically followed for up to two years, and the cardiac events (CEs) in these patients were recorded and correlated with the various parameters. Results The occurrence of a CE in HF was independent of the patients' demographics or the cause of HF. Genetic biomarkers were unable to reliably predict CEs. Global or regional uptake had limited ability to predict a CE, whereas regional washout from the inferior wall (P = .005) was a statistically significant predictor of CEs. Similarly, a high washout of 40% or more from the peri-infarcted and noninfarcted segments on myocardial perfusion scintigraphy was also a significant predictor of CEs (P = .035). Conclusion HF is a complex, multifactorial, progressive disease that appears to begin regionally. 123I-mIBG provides a valuable tool in imaging the global and regional sympathetic nervous system innervation of the heart. This may allow early identification and stratification of patients at risk of sudden cardiac death.

Underwater Optical Communication (UWOC) systems are attractive to researchers due to their ability of low power consumption, less complexity, high data rates, and covert communication. Various half-duplex (HD) UWOC systems has been proposed in this regard, but due to half-duplex characteristics, these systems have failed to improve the high throughput gain, high power efficiency and high data rates etc. Hence, we provided a review of different Full-Duplex UWOC systems using different light sources, with respect to transmission range, operational power, data rate, wavelength, and different underwater communication mediums. We observed that these FD systems have improved the communication range as well as data transfer rates, while implementing different light sources (i.e. lasers, avalanche photo diodes (APD), green and blue LEDs and lasers) in their transceivers. However, we pointed out that power inefficiency is a major issue faced by FD-UWOC systems. We also presented BER comparison of different FD-UWOC systems, implementing different modulations schemes, and pointed out that FD UWOC systems implementing un-coded 8PPM and BPSK outperformed. Finally, we concluded the paper and also highlighted some future directions for the FD-UWOC systems, and hope that our review can provide a platform for future research in the targeted area.

The existing half-duplex medium access control protocols take longer time to transmit and receive successful data packets, due to longer propagation delays. Therefore, we proposed an Enhanced Full-Duplex Medium Access Control protocol for the underwater acoustic network. The proposed protocol increases throughputs by decreasing the time for successful data transmission. The proposed protocol sets a backoff timer to access the transmission opportunity by transmitting the ID based RTS control packet to the target destination node. The target destination sends back the CTS control packet containing the data transmission and ID information, then both immediately exchange the data with each other, consuming less transmission time while performing FD communication. We evaluate the performance of the proposed protocol with respect to increase in number of underwater sensor nodes and payload size. Simulation results proved that the proposed protocol significantly increased the throughputs, compared to the existing convention medium access control protocols.

ObjectiveThere is very little research regarding quantification of family history as a risk factor for ischaemic heart disease. This is especially so in the South Asian population, which tends to suffer from ischaemic heart disease at a much younger age, even after environmental and dietary factors are accounted for. This indicates a likely genetic basis. The aim of this study was to quantify family history as a risk factor.MethodsIt is a retrospective, cross-sectional study. Patients with family history and hypertension as the only cardiac risk factors were recruited in the study along with control subjects. Myocardial perfusion scintigraphy was used for the detection of myocardial ischemia.Results114 patients had hypertension and family history as the only risk factors. 64 of these patients had myocardial ischemia. 102 control patients were also recruited, of whom only 26 suffered from myocardial ischemia. The odds-ratio was thus calculated to be 3.69 (95% CI: 1.54-9.28, p=0.001).ConclusionsThese findings suggest a strong genetic basis for ischemic heart disease in the South Asian population. This needs to be taken into consideration when such patients present with non-specific cardiac symptoms.

e18852 Background: Transferring financial risk from payers to providers to align incentives is central to value-based payment (VBP) reform, including Medicare’s Oncology Care Model (OCM). We simulated the impact of selected cancer- and patient-level factors on providers’ risk in OCM for multiple myeloma (MM), due to its clinical complexity. We hypothesize that risk exposure is sensitive to factors extrinsic to the OCM methodology, including clinical phenotype, disease state and progression rate. Methods: Simulation was used to address omitted variable bias in payer data. We developed 9 key clinical MM scenarios to examine provider risk, based on conceptual frameworks that included patient- and cancer-level factors. The model was parameterized using the Medicare limited data set, research literature and domain knowledge. Twenty factors were varied for each model, e.g. age, autologous stem cell transplant (ASCT). Results: Simulations results showed MM risk for providers depended highly on cancer and patient level factors (see table). For example, high-risk patients were on average $21.5K over target while undergoing ASCT (despite risk adjustment for ASCT) and $18-28K under target for follow on maintenance (maint.) episodes. Conclusions: Provider exposure to risk in OCM is highly sensitive to factors at the cancer and patient level. The distribution of clinical phenotypes, state of disease, and rate of disease progression can significantly impact risk exposure for providers in OCM. New methodologies that model risk in more clinically granular ways are needed to improve VBP in oncology. [Table: see text]

e18853 Background: Analyzing cost growth in oncology often faces significant challenges, including fragmentation of data for infused vs. oral agents and ascertaining the cost of inpatient care. How differential cost growth at the individual cancer level contributes to aggregate cost growth in oncology is often opaque. We leverage the integrated claims data provided by Medicare for its Oncology Care Model (OCM) pilot to analyze variations across individual cancers with respect to cost growth. Methods: OCM’s innovative methodology creates a natural experiment where costs are compared against a counterfactual comprised of Medicare patients seen in non-OCM practices. Leveraging this differential counterfactual provides an opportunity to gain insight into cost growth for individual cancers compared to oncology as a whole. Specifically, cost growth is measured each Performance Period (PP) with respect to the Baseline Period, from 2012 to 2015. We analytically decomposed and remodeled key quantitative factors in OCM associated with cost dynamics in oncology, including the Trend Factor (TF), which represents non-OCM cost growth. From 124,896 episodes, we sampled with replacement 19,191 episodes from 17 practices between PP1 and PP6 using empirical data distributions. We assumed neutral novel therapy and experience adjustments and then compared the overall TF to the remodeled cancer-level TF, reaggregated from the individual episodes. Results: Reallocating the TF reveals that cost growth among cancer types is highly variable in the broader Medicare population. Cost growth at the individual cancer level varied from +99.3% to -14.3%. Of the 21 OCM cancers, 18 have TFs greater than zero, indicating cost growth in the non-OCM Medicare population since the Baseline Period. Four have a TF greater than 50%. Three cancer types show decreasing costs relative to the baseline period: intestinal cancer, MDS, and CNS tumor. Conclusions: Significant variation exists across individual cancer subtypes in terms of cost growth. Aggregate analyses of cancer at large have insufficient specificity to rationalize payment mechanisms. Payment reform efforts within cancer care should directly address dynamics at the individual cancer or cancer subtype level in order to provide more valid considerations for expected resource utilization, including in future payment policies. [Table: see text]

e18850 Background: Value based models (VBMs) in which cancers are bundled are a growing alternative to fee for service, as in the Oncology Care Model (OCM). However, bundles in OCM may not capture the clinical granularity needed to predict resource utilization for cancer subtypes. One such bundle is lymphoma, which groups highly heterogeneous diseases with distinct treatments and differing intensity of care. Here, we compare OCM predicted episode costs (targets) to actual episode costs by lymphoma subtype. Methods: Our cohort study used OCM data from a large academic medical center (AMC) and large community oncology practice (COP). Six-month episodes of lymphoma beginning between July 2016 and June 2019 were categorized based on ICD-10 diagnoses on antineoplastic infusions and E&M visits, as well as disease and data modeling. Episodes were subdivided into follicular (FL), diffuse large B (DLBCL), small B (SBCL), mantle (MCL), Hodgkin (HL), Waldenstrom macroglobulinemia (WM), mature T/NK (T/NK), and Other. The distributional consistency of episode costs and targets for each subtype relative to the rest of the episodes was evaluated by Kolmogorov-Smirnov tests. We also compared the proportion of subtypes contributing to episodes in the AMC vs. COP. Results: A total of 1801 lymphoma episodes were identified (44% in AMC, 56% in COP). The most common subtypes (DLBCL and FL) contributed a larger proportion of episodes in the COP, while less frequent subtypes (T/NK, WM) were more prevalent at the AMC. Further, episode costs are significantly different across individual subtypes. Target variance was significantly lower than cost variance across subtypes. For example, the average target for WM was $50.4K, average costs were $40.2K, with 26% of episodes over target. In contrast, the average target for T/NK was $55.9K, average costs were $72.7K, with 64% of episodes over target. Conclusions: VBMs such as OCM currently aggregate cancer types and lack clinical granularity. Our evaluation of OCM episodes at an AMC and COP found considerable differences in lymphoma populations and in costs by subtype. Failure to account for clinical features (i.e. lymphoma history) could lead to inappropriate shifts of risk from payers to providers in VBMs.[Table: see text]

e13515 Background: Reducing avoidable hospital and emergency department (ED) use are national priorities in cancer care. Acute care centers (ACCs) that expand access for patients with oncologic emergencies are increasingly implemented as alternatives to inpatient and ED care. The impact of these ACCs is uncertain. Additionally, how to rigorously evaluate these interventions and to iteratively improve their effectiveness remains unclear as infrastructure interventions such as ACCs are not amenable to experimental manipulation. Methods: We are developing a novel quasi-experimental framework for evaluating and improving the effectiveness of an ACC intervention at the Simmons Comprehensive Cancer Center (SCCC) of the University of Texas Southwestern. SCCC covers one of the largest geographic regions of any academic medical center in the country, creating challenges addressing access to care. Drawing on the Andersen model for healthcare utilization we hypothesize that ACC effectiveness is mediated through enabling factors, particularly distance. Our initial evaluation framework draws on an untreated control group design with multiple pretest and post-test samples. The control group is comprised of patients living in zip codes farther away from the ACC. Additional analytic work will assess the feasibility of adding a matching cohort group structure based on factors such as onset of illness and matching individual patient episodes based on risk adjustment parameters. If the ACC is later expanded to other sites, the design can be further developed by adding a switching replications methodology to augment the quasi-experiment. Data collection draws on claims data provided through SCCC’s participation in Medicare’s Oncology Care Model (OCM). Results: Over OCM’s initial four performance periods (each six months long), all-cause risk adjusted hospitalization rates for SCCC patients ranged from 25.2% to 27.2%. All-cause risk adjusted OCM ED use ranged from 28.1 to 29.9%. Seeking to improve performance for both, SCCC leadership initially implemented a temporary urgent care clinic in August 2018. This initial prototype clinic was formalized into an operational ACC in August 2020. Evaluation of the impact of this ACC intervention is ongoing. Conclusions: ACCs represent potentially important means to reduce avoidable hospital and ED use. However, complex infrastructure interventions are not amenable to experimental evaluations assessing their impact, and it remains difficult to gain insights into how to tailor services through these interventions to support patients with oncologic urgencies and emergencies. Quasi-experimental approaches when integrated alongside ACC interventions represent promising mechanisms of evaluation and continuous quality improvement.

6513 Background: Clinical trials are critical for improving outcomes for patients with cancer. However, there is some concern from health insurers that clinical trial participation can increase total cost of care for cancer patients. We investigated the impact of clinical trial participation on total costs paid by Medicare during the OCM program in a large community-based practice. Methods: Tennessee Oncology (TO) is a community oncology practice comprising over 90 oncologists across 30 sites of care. We linked TO trial data and electronic medical record data with OCM data for episodes of care from 2016-2018. To assess the impact of trial participation on total cost relative to routine care, we created matched comparator groups for each OCM episode based on cancer type, metastatic status, number of comorbidities, performance status, and age. Patients with breast cancer receiving hormone therapy only were excluded. Absolute and percent cost differences between groups were calculated for episodes that had a comparator group size of five or greater. Differences in total cost for trial episodes were compared to non-trial episodes, and significance was assessed using the Mann–Whitney U test. We also studied the impact of trial participation on receipt of active treatment in the last 14 days of life (TxEOL), hospice use, and hospitalizations. Results: During the study period, 8,026 completed OCM episodes met study criteria. Patients were enrolled in a clinical trial for 459 of these episodes. On average, episodes during which patients were on trial cost $5,973 less than matched non-trial episodes (Table), independent of early versus late-phase trial. Most savings resulted from decreased drug costs. There were no differences in rates of TxEOL (15% vs. 14% p=1.0), rates of hospitalizations (31% vs. 30% p=0.54), or hospice use (52% vs. 62% p=0.08) between trial and non-trial episodes. Median difference from comparator group average cost was significantly lower for clinical trial episodes (-18% vs. -6%, p

e13525 Background: The Oncology Care Model (OCM) is an oncology-specific value-based care model that holds participating practices accountable for all costs of care. Medicare implements quantitative adjustments to model target costs in OCM, including a trend factor to reflect aggregate cost growth and a novel therapy adjustment for new indications. However, it is unclear how well these adjustments account for the emergence of new therapies that are evidence based and influence standard of care for an individual cancer type. We sought to investigate this by studying the impact that FDA approval for brentuximab vedotin (BV) in the first line setting in March 2018 had on OCM practice performance in Hodgkin’s Lymphoma (HL). Methods: We identified all HL OCM episodes attributed to Tennessee Oncology (TO), a large community oncology network of over 90 oncologists, during performance periods (PP) 3 through 6. HL episodes within the lymphoma bundle were identified through the use of individual ICD-10 coded diagnoses on claims for antineoplastic infusions and E&M visits. Using OCM performance data, our electronic health record, and claims data analytics software, we calculated average episode target costs, drug spending by drug type, and hospitalization costs to determine key determinants of OCM performance. Results: During the study period, there were 577 episodes of lymphoma attributed to TO, of which 28 were for patients with HL. TO’s OCM performance in HL was significantly under target in PP4 (under target by $13.5K) and significantly over target in PP5 (over target by $32.1K) after the updated BV FDA approval. Average episode spending on BV increased by over $45K during this timeframe, while OCM target cost increased only by approximately $19K. Despite the change in OCM performance, hospitalization costs and hospice utilization remained relatively stable. Conclusions: In the OCM, despite quantitative payment factors that in principle are intended to adjust target prices to reflect changing cost dynamics, significant gaps exist. These gaps can inappropriately shift risk to providers for the appropriate use of new indications, including those that change standard of care. The example of brentuximab vedotin in HL illustrates the difficulty in reaching performance benchmarks due to dynamics associated with the rising cost of drugs. Further methodological changes are needed in future oncology value-based care models to ensure accurate prediction of rapidly changing treatment costs for appropriate therapies. Hodgkin’s lymphoma OCM payment period cost and utilization comparison data.[Table: see text]

e18854 Background: Aggregating different subtypes of cancers into bundles is an important methodology in oncology payment reform as an alternative to fee for service. However, expected resource utilization can vary significantly across cancer subtypes. We evaluated the impact that modeling Chronic Leukemia into a more clinically granular two part framework of chronic myelogenous leukemia (CML) and chronic lymphocytic leukemia would have on OCM results and the risk that the distribution of clinical subtypes at a practice would influence overall performance in the bundle. Methods: OCM episodes of chronic leukemia initiating between July 2016 and June 2019 were subdivided on the basis of individual ICD-10 coded diagnoses on cancer-related E&M visits. From a total of 4,658 episodes, we randomly sampled with replacement 3,500 episodes from 16 practices using empirical data distributions. Data models and mappings were developed based on clinical knowledge and exploratory data analyses to subdivide the OCM bundle of Chronic Leukemias into CLL and CML. Total cost of care and episode target prices were calculated through implementation of the OCM methodology. The distributional consistencies of episode target, cost, cost above target, and percent above target for the two diseases were evaluated by two-sample Kolmogorov-Smirnov (KS) tests. Results: The CML and CLL subtypes modeled from the aggregate OCM bundle demonstrated significantly different cost distributions relative to each other. As anticipated, treatments used in each subtype varied significantly marking different patterns of expected resource utilization. In our model, CLL episodes were on average 13.7% over target. Average CLL episode costs were $52.2K vs. an average target of $47.6K with 54% of episodes running over target. In contrast, CML episodes were 6.1% under target. Average CML episode costs were $45.2K vs. an average target of $50.3K with 43% of episodes running over target. Conclusions: Value based payment models in oncology such as OCM can be improved by modeling cancer bundles in more clinically granular ways that better reflect expected resource utilization for appropriate, standard of care. Insufficient clinical granularity in bundle construction can lead to provider performance being influenced by the distribution of patient subtypes at the practice. This can lead to inappropriate shifts of risk from payers to providers in value based models. Aggregate vs. subtype episode costs (mean, 5th, and 95th percentiles).[Table: see text]

e18667 Background: How oncology providers should implement practice transformation for value-based care is unclear, particularly at scale. Organizational size enables efficient “top down” approaches, but also presents challenges such as physician engagement. Dis-economies of scale can be acute in oncology due to physician autonomy and coordination costs. We hypothesized that organizational change based in sense-making models that enhance physician engagement and use a decentralized, iterative microsystems approach will enable practice transformation to scale. Methods: Florida Cancer Specialists & Research Institute (FCS) is a physician led 250-oncologist statewide practice, with regional variation in disease state/mix, patient cohort, etc., making a purely top-down approach to organizational change infeasible. FCS prototyped a transformation strategy starting in June 2017 based on sharing interpreted data with physician and executive leadership. Later implementation directly engaged physicians in a microsystems quality QI strategy focused on regional performance. Interventions targeted disease, health service utilization, location, and individual physicians. Performance was evaluated using data from Medicare’s Oncology Care Model (OCM) and assessed using the one-sided risk target (4% below benchmark). We analyzed 70,239 performance period (PP) episodes at FCS across 35,116 patients. Results: In the pre- intervention period (90% of PP1 episodes, completed by June 2017), FCS was 5.8% above target. Performance was 10.9% above target for the remainder of PP1 (10% of PP1 episodes), then improved to 0.3% above target in PP2 and PP3, and below target by 0.9%, 0.8%, and 0.75% in PP4, PP5, and PP6. Early QI efforts focused on performance in lung cancer, which was 2.5% over target in PP1; it improved to 2.1% under target in PP6. Later regional QI sessions targeted cancer, utilization and providers. Pre-intervention, all 18 regions were above target; by PP6, 11 out of 19 regions were below target. Relative to the pre-intervention period, per-episode inpatient costs increased by 12.1% for the remainder of PP1 and increased by 4.3% and 1.3% in PP2 and PP6; inpatient costs decreased in PP3, PP4, and PP5 by 3.8%, 2.4% and 4.8%. Conclusions: Practice transformation in oncology can achieve scale through models of organizational change that foster physician engagement. Data, when clinically contextualized, is a foundational tool in the sense-making process. Scale can develop through an additive microsystems approach in which QI units are de-centralized, accountability is defined, and iteration becomes part of organizational culture. [Table: see text]

Underwater wireless communication has gained a great deal of attention in the last couple of decades because of its applications in the military, industrial, and monitoring sectors. Despite the extreme physical and MAC layer difficulties, acoustics are used for various applications among the various modes of underwater communication technologies used. While significant research efforts have been made to address these issues, the bottleneck remains in achieving high bandwidth, high throughputs, and data rate. Researchers have begun to look into full duplex (FD) implementation to improve bandwidth efficiency and increase data rate and throughput. Users can send and receive data simultaneously over the FD links, maximizing bandwidth utilization and increasing throughput. As a result, we thoroughly reviewed various FD physical layered UWAC systems and MAC layered protocols for underwater communication. The various problems that the aforementioned systems and protocols have faced, as well as the solutions suggested in previous works to solve each problem, are also highlighted. Various metrics are used to compare the performance of various physical layered FD systems and FD MAC protocols. We also explore some of the open research questions in these FD-physical layered and MAC layered protocols, as well as future research directions. Based on ample information, we suggest a cross-layered architecture based on various IBFD-SI cancellations, DA-CSMA, and FD-MAC protocols. This review provides a broad view of the current FD physical and MAC layered protocols based on acoustic communication, as well as recommendations.

Most cancer centers are ill-equipped to pursue value-based payment (VBP) because of limited information on their population’s cost of care. Herein, we outline the stepwise approach used by Smilow Cancer Hospital at Yale-New Haven in our pursuit of better value care. First, we addressed institutional barriers. A move toward value required demonstration to Yale-New Haven Health System leadership that OCM would improve patient care, fund new infrastructure, and provide the opportunity to gain experience with VBP without a major threat to the financial stability of the health system. We evaluated patterns of care and found that of patients presenting to the emergency department (ED), 88% were admitted, 62% arrived during the workday, and 50% could have been stabilized with urgent care services. Within 30 days of death, 27% were admitted to the intensive care unit, 38% presented to the ED, and 52% were admitted. To quantify total cost of care, we accessed the 5% Medicare Limited Data Set to map out total cost of care for patients receiving chemotherapy at Smilow Cancer Hospital. Costs increased as patients moved through 6-month episodes, used the ED (patients with two or more visits were twice as expensive as those with one or fewer), or died during an episode (costs were twice as high as episodes in which the patient lived). To determine strategic interventions to improve value, we targeted investments in urgent care to reduce ED utilization, care management to prevent hospital admissions, and referral to palliative care for clarification of goals of care and avoidance of costly futile treatment. Developing internal metrics to evaluate success will require monitoring our interventions by having utilization measures for each site of care and individual provider.

An important Islamic imperative is prevention of concentration of wealth among a few so that wealth circulates widely to enhance shared prosperity. In contemporary economic discourse inequality and concentration of wealth have emerged as among key causes of instability and crisis. Unfortunately, while Islamic finance has emerged as a Shari’ah-compliant industry, it does not seem to be connected with the Islamic concern about inequality and concentration of wealth. Are Islamic banks, as the dominant component of the industry, helping to improve inequality and concentration of wealth and thus offer a better framework to deal with instability and crisis? Is the ownership structure of Islamic banks conducive to meeting the Islamic imperative regarding inequality and concentration of wealth? The research in this paper illuminates the pertinent issues in light of the experience of Bahrain as one of the hubs of Islamic banking and finance.

The role of a nuclear medicine diagnostic bone scan is well established and the influence of potential artifacts well documented. This case provides an insight into an unusual artifact associated with a tampon in situ and highlights the clinical relevance of single-photon emission computed tomography/computed tomography imaging in differentiating uncommon artifacts from potential pelvic pathology.

2 Background: Value-based payment programs like the Oncology Care Model (OCM) have focused efforts to reduce costly acute care use through improvements in access and coordination rather than targeting the exponential rise in pharmaceutical pricing. We assessed how participation in OCM affected total cost of cancer care at a large academic cancer center. Methods: Using Medicare claims for Yale-Smilow Cancer Hospital, an NCI-designated cancer center with an academic hub and 10 community practices, we identified episodes for chemotherapy initiated during a historical period (pre-OCM, 2012-2015) and performance period (post-OCM, 2016-2017) following OCM criteria to identify total cost of care. We reported frequency of utilization categories, the mean cost per episode, the proportion of total cost attributed to each utilization category and compared pre- and post-participation periods. Results: There were 8,843 episodes during the historical period and 6,679 episodes during the performance period. The mean total cost per episode increased from $28,645 to $32,666, but this was less than the Medicare-defined expected increase (target price). Between the two periods, the percentage of total episodes decreased for emergency department (ED) use from 36% to 33%, inpatient care from 33% to 29%, and post-acute care from 28% to 25% (p < 0.01). Mean costs of drugs per episode increased by 27% between periods, and from 52% to 58% of total cost of care (p < 0.01). While mean cost per episode for ED, inpatient, and post-acute care remained stable, the mean cost per episode for antineoplastics increased 39% from $10,676 to $14,843. Conclusions: After implementing OCM, we beat the Medicare target largely by decreasing acute care use and stabilizing the cost of hospitalizations and ED; however, actual cost increased largely due to pharmaceutical spending. Because drug costs were the largest proportion of overall cost of care, future value-based models must address the rising cost of pharmaceuticals. [Table: see text]

6635 Background: The Oncology Care Model (OCM) is intended to incentivize physicians to improve the quality and reduce the cost of cancer care. In OCM, providers are accountable for all costs during six month episodes of care relative to target costs (TC) derived from a baseline spending period (BSP; 2013-2015). This accountability is intended to foster care coordination to reduce preventable emergency department visits and hospitalizations (EDH). Benefits of reducing EDH may be diluted when new treatment indications for costly immunotherapies (IO) are introduced into clinical practice after BSP. Methods: We identified all non-small cell lung cancer (NSCLC) and bladder cancer (BC) OCM episodes attributed to Tennessee Oncology (TO), a large community oncology network of over 90 oncologists, during performance period 2 (PP2; the most recent PP with available data). We selected NSCLC and BC because both diseases have IO indications that became standard of care after BSP. Using claims data analytics software, we identified all NSCLC and BC episodes with spending above TC, and found a subset of these above target episodes (ATEs) without any EDH that remained above TC due to IO use. Two medical oncologists reviewed these cases in duplicate to assess guideline concordance of IO. Results: During PP2 there were 2,623 OCM episodes attributed to TO, including 240 NSCLC and 31 BC episodes. Spending was above TC in 118 (49%) and 13 (42%) of NSCLC and BC episodes, respectively. For these NSCLC and BC ATEs, EDH was prevented in 62 (53%) and 5 (38%) of cases, respectively. In NSCLC and BC ATEs without EDH, 43 (69%) and 5 (100%) of episodes included IO, respectively. Clinician review in duplicate (S.M.S.; C.A.W.) found that the use of IO was NCCN guideline concordant in 33 (77%) and 4 (80%) of these NSCLC and BC cases, respectively (K = 0.87). Conclusions: Guideline-concordant use of expensive IO as its treatment indications expand poses substantial challenges to meeting cost targets in OCM, even when practices prevent EDH. [Table: see text]

Introduction: The malignant lymphomas are the fifth most common neoplasm in both men and women. Staging, re-staging and treatment response evaluation pose a difficult task in many patients of lymphomas. Histological variants in both Hodgkin's and Non-Hodgkin's types of lymphoma greatly affect the response to treatment and overall prognosis. Objective: This study was conducted to correlate the degree of abnormal Gallium-67 uptake with the histological variants of non-Hodgkin's lymphoma. This project was a part of the study to see the ability of Gallium-67 scintigraphy to predict the response to chemotherapy early in the course of therapy. Material & Methods: 65 patients were included in the study with a mean age of 25 years. All patients had undergone medical imaging, bone marrow biopsy and histopathology. Results: Sixty-five patients were classified according to the REAL classification. 11 patients were of T-cell type, 50 were of B-cell type and 4 were anaplastic. 46 showed gallium-67 uptake in the lesions, whereas 19 (29.2%) had no discernable Gallium-67 uptake.

Heart failure is a progressive, heterogeneous form of cardiovascular disease that requires treatment to be individualized depending on the presenting symptoms. A decision to use an implantable cardioverter‐defibrillator (ICD) is based on chronic heart failure patients presenting with a New York Heart Association classification of II or III and a left ventricular ejection fraction (LVEF) less than or equal to 30%‐35%. A large percentage of ICD devices, however, never deliver therapy during their lifetime, and as many as 33% of patients ineligible for an ICD (LVEF . 35%) die of sudden cardiac death. 123 I-metaiodobenzylguanidine ( 123 I-MIBG) scintigraphy identifies sympathetic nervous system dysfunction and has been shown to lead to better patient stratification. This article reviews the role of planar 123 I-MIBG global quantitation in improving differentiation of heart failure, regardless of the LVEF, to better identify those in whom an ICD is more likely to reap benefits. It goes on to explore the potential incremental benefit of SPECT-based regional quantitation to risk stratification and provides a case example in which 123I-MIBG SPECT was used to inform a deci

Single photon emission computed tomography (SPECT) has been widely used in nuclear medicine for several decades. Since the late 1980s and early 1990s SPECT images have been combined with x-ray computed tomography (CT) to provide complimentary information of anatomy and function for improved diagnostic outcomes. Image registration emerged to bring SPECT and CT into a combined SPECT/CT imaging modality. Despite the success of these approaches, diffi culties exist with the co-registration process; diff ering spatial resolutions, diff ering respiratory state / cardiac cycle and diff ering abdominal contents from examinations being performed at diff erent times of the day. Hardware innovations, hybrid SPECT/CT, were developed to address co-registration soft ware limitations. Acquisition of both SPECT and CT images can be made within a few seconds of one another. Since the fi rst commercial system became available in 1999, which used low x-ray outputs with low quality CT images, SPECT/CT have evolved to utilise higher output diagnostic standard CT scanners such as 64 slice CT systems. Th e improved capability and diagnostic quality CT images has been accompanied by widespread clinical use and demand. Th e ability to accurately locate the functional information seen from SPECT has an incremental benefi t over the SPECT and CT images alone. Clinical examples are provided to highlight these combined strengths. SPECT/CT is one example of the 'blurring' of traditional boundaries between radiology and nuclear medicine. An understanding of the technical and clinical aspects of SPECT/CT can provide improved clinical outcomes for the benefi t of the patient and of the professional development of medical radiation scientists.

Advancements in molecular medicine technology have allowed the development of innovative and better radiopharmaceuticals to augment or replace the existing ones, allowing the acquisition of higher-quality and detailed diagnostic information and accuracy. They build on the strengths of the existing radiotracers or remove their shortcomings, thus bringing them closer to the ideal. Given the discovery of more novel molecules, it is now possible that processes in the human body indicative of predisease stage can be imaged, allowing for appropriate interventions earlier-preventing the development of late stage disease, preventing morbidity and mortality, and reducing the burden on the national health care system. Both positron emission tomography and single-photon emission computed tomography are developing in the fields of perfusion, metabolic, and innervation imaging of the heart. Newer radiotracers can yield higher-quality images with a greater diagnostic potential that are more convenient to use in the daily practice, and at a lower cost. In addition, tracers have been developed for imaging processes like cardiac apoptosis, angiogenesis, and the development of coronary atherosclerosis, enabling physicians to minimize the pathological changes at the reversible stage by promoting appropriate lifestyle changes and pharmaceutical interventions. In this article, we overview the most promising radiotracers that in the future have the potential to become established imaging agents in the field of cardiac nuclear medicine.