Search

In a group of 11 sport horses, the effect of the traianig process, inclunding training and resting periods, on the metabolic profile. Training proces was divided into four part: I. End of the sport season, II. End of the resting period, III. End of the quantitative training charged and IV. End of the qualitative training charged. The level glucose in the blood serum of the observed horses was stated within the reference limits, with the tendency towards the inncreased values in the 2-st and 4-st period (4,34 – 5,03 mmol.l-1). The average values global lipid and cholesterol was stated whitin the reference limits.

Etological and physiological tests were realized on 48 horses. There were observed following activities: spontaneous kinetic activity, voice display; the elimination behavior (excretion and urination) and motionless standing. The horses were observed in 40 minute periods during the morning hours. The horses were classed into the following groups: EHB+ - crossing more than 220 sq. per 40 min. (high sensitiveness to stress), EHB+/- - crossing 131 - 220 sq. per 40 min. (mean sensitiveness to stress), EHB- - crossing 130 and less sq. per 40 min. (low sensitiveness to stress). After the evaluating of mineral, energetic, lipid, nitrogen, and enzymatic profile of sport horses there were not observed significant differences from the reference values.

The aim of this study was to perform an analysis of genetic diversity in four endangered horse populations bred in Slovakia, describing parameters on the probability of identity by descent and gene origin. The analysed populations consisted of (reference populations in brackets) 656 (158) Hucul horses, 2052 (162) Lipizzan horses, 1951 (171) Shagya Arabian horses, and 220 (42) Slovak Sport Ponies. The equivalent complete generations ranged from 4.93 for the Slovak Sport Pony to 10.25 for the Lipizzan horses. The average value of inbreeding ranged from 2.67% for the Slovak Sport Pony to 6.26% for the Hucul. The mean average relationship coefficients varied from 3.08% for the Shagya Arabian to 9.34% for the Hucul. Individual increases in inbreeding ranged from 0.43% for the Lipizzan to 1.06% for the Hucul, while the realized effective sizes were from 117.14 to 47.67 animals. The evaluated populations were derived from 80 to 499 founders. The effective number of founders ranged from 26 to 160, while the effective number of ancestors from 7 to 32.

Introduction: Unexpected out-of-pocket (OOP) costs for preventive care reduce future uptake. Because adherence to service guidelines differs by patient populations, understanding the role of patient demographics and social determinants of health (SDOH) in the incidence and size of unexpected cost-sharing is necessary to address these disparities. This study examined the associations between patient demographics and cost-sharing for common preventive services., Methods: This cross-sectional study used a national sample of insurance claims for recommended preventive services provided to privately insured adult patients between 2017 and 2020. The relationships between patient demographics and OOP costs were adjusted for service type, insurance type, geographic location, and time trends using regression analysis. Analyses were conducted in 2024., Results: The sample included 1,736,063 unique preventive care encounters of 1,078,010 individuals. Among preventive encounters, 40.3% resulted in OOP costs. Lower-educated patients had 9.4% (OR=1.094; 95% CI=1.082, 1.106) higher odds of incurring OOP costs than patients with college degrees. Low-income patients (annual household income of $49,999 or less) had 10.7% (OR=0.893; 95% CI=0.880, 0.906) lower odds of incurring OOP costs than high-income patients. Conditional on incurring costs, lower educated patients paid $15.07 (95% CI= -$15.24, -$14.91) less than higher educated patients, and low-income patients paid $11.76 (95% CI=$11.58, $11.95) more than high-income patients. Significant differences across racial and ethnic groups were observed., Conclusions: The likelihood and size of OOP costs for preventive care varied considerably by patient demographics; this may contribute to inequitable access to high-value care., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Importance: The Patient Protection and Affordable Care Act (ACA) eliminated out-of-pocket cost-sharing for recommended preventive care for most privately insured patients. However, patients seeking preventive care continue to face cost-sharing and administrative hurdles, including claim denials, which may exacerbate inequitable access to care., Objective: To determine whether patient demographics and social determinants of health are associated with denials of insurance claims for preventive care., Design, Setting, and Participants: This cohort study of patients insured through their employers or the ACA Marketplaces used claims and remittance data from Symphony Health Solutions' Integrated DataVerse from 2017 to 2020; analysis was completed from January to July 2024., Exposure: Seeking preventive care., Main Outcomes and Measures: The primary outcome was the frequency of insurer denials for preventive services across 5 categories: specific benefit denials, billing errors, coverage lapses, inadequate coverage, and other. Subgroup analysis was performed across patient household income, education, and race and ethnicity. Secondary outcomes included charges for denied claims, approximating patients' remaining financial responsibility for care., Results: A total of 1 535 181 patients received 4 218 512 preventive services in 2 507 943 unique visits (mean [SD] age at visits, 54.02 [13.19] years; 1 804 637 visits for female patients [71.96%]); 585 299 patients (23.30%) had an annual household income $100 000 or higher, and 824 540 patients had some college education (32.88%). A total of 20 658 individuals (0.82%) were Asian, 139 950 (5.58%) were Hispanic, 219 646 (8.76%) were non-Hispanic Black, 1 372 223 (54.72%) were non-Hispanic White, and 25 412 (1.0%1) were other races and ethnicities not included in the other 4 groups. Of preventive claims, 1.34% (95% CI, 1.32%-1.36%) were denied, consisting mainly of specific benefit denials (0.67%; 95% CI, 0.66%-0.68%) and billing errors (0.51%; 95% CI, 0.50%-0.52%). The lowest-income patients had 43.0% higher odds of experiencing a denial than the highest-income patients (odds ratio, 1.43; 95% CI, 1.37-1.50; P < .001). The least educated enrollees had a denial rate of 1.79% (95% CI, 1.76%-1.82%) compared with 1.14% (95% CI, 1.12%-1.16%) for enrollees with college degrees. Denial rates for Asian (2.72%; 95% CI, 2.55%-2.90%), Hispanic (2.44%; 95% CI, 2.38%-2.50%), and non-Hispanic Black (2.04%; 95% CI, 1.99%-2.08%) patients were significantly higher than those for non-Hispanic White patients (1.13%; 95% CI, 1.12%-1.15%)., Conclusions and Relevance: In this cohort study of 1 535 181 patients seeking preventive care, denials of insurance claims for preventive care were disproportionately more common among at-risk patient populations. This administrative burden potentially perpetuates inequitable access to high-value health care.

Medical imaging, identified as a potential driver of unsustainable US health care spending growth, was subject to policies to reduce prices and use in low-value settings. Meanwhile, the Affordable Care Act increased access to preventive services-many involving imaging-for employer-sponsored insurance (ESI) beneficiaries. We used a large insurance claims database to examine imaging spending trends in the ESI population between 2010 and 2021-a period of considerable policy and benefits changes. Nominal spending on imaging increased 35.9% between 2010 and 2021, but as a share of total health care spending fell from 10.5% to 8.9%. The 22.5% growth of nominal imaging prices was below inflation, 24.3%, as measured by the Consumer Price Index. Other key contributors to imaging spending growth were increased use (7.4 percentage points [pp]), shifts toward advanced modalities (4.0 pp), and demographic changes (3.5 pp). Shifts in care settings and provider network participation resulted in 2.5-pp and 0.3-pp imaging spending decreases, respectively. In sum, imaging spending decreased as a share of all health care spending and relative to inflation, as intended by concurrent cost-containment policies., Competing Interests: Conflicts of interest Please see ICMJE form(s) for author conflicts of interest. These have been provided as supplementary materials., (© The Author(s) 2024. Published by Oxford University Press on behalf of Project HOPE - The People-To-People Health Foundation, Inc.)

Background: Few studies have comprehensively compared health-related quality of life (HRQoL) between metastatic prostate cancer survivors, survivors with non-metastatic disease, and men without a cancer history., Methods: We used the Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey (SEER-MHOS) data linkage to identify men aged ≥ 65 years enrolled in Medicare Advantage (MA) plans. Prostate cancer survivors were diagnosed between 1988 and 2017 and completed MHOS surveys between 1998 and 2019. We analyzed data from 752 metastatic prostate cancer survivors (1040 survey records), 19,583 localized or regional prostate cancer survivors (non-metastatic; 30,121 survey records), and 784,305 men aged ≥ 65 years without a cancer history in the same SEER regions (1.15 million survey records). We used clustered linear regressions to compare HRQoL measures at the person-level using the Veterans RAND 12 Item Health Survey (VR-12) T-scores for general health and physical and mental component summaries., Results: Compared to men without a cancer history, prostate cancer survivors were older, more likely to be married, and had higher socioeconomic status. Compared to men without a cancer history, metastatic prostate cancer survivors reported lower general health (T-score differences [95% confidence interval]: - 6.26, [- 7.14, - 5.38], p < .001), physical health (- 4.33, [- 5.18, - 3.48], p < .001), and mental health (- 2.64, [- 3.40, - 1.88], p < .001) component summaries. Results were similar for other VR-12 T-scores. In contrast, non-metastatic prostate cancer survivors reported similar VR-12 T-scores as men without a cancer history. Further analyses comparing metastatic and non-metastatic prostate cancer survivors support these findings., Conclusion: Interventions to improve health-related quality of life for men diagnosed with metastatic prostate cancer merit additional investigation., Implications for Cancer Survivors: Interventions to improve health-related quality of life for metastatic prostate cancer survivors merit additional investigation., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Healthcare price transparency is an effort to inform patient decision-making, but also to decrease prices and their variation across healthcare systems for equivalent medical services. The initiative is meaningful only for medical services that are shoppable-such as imaging examinations-for which patients incur out-of-pocket costs. Therefore, several countries in which patients commonly share a portion of their healthcare costs have been implementing mandates to improve healthcare price transparency. However, the provisional implementation has many issues, especially in the United States, including provider non-compliance and limited accessibility of price transparency tools by the general public. Many of the existing tools are not user-friendly, are difficult to navigate, focus on charges and health plan negotiated rates rather than patients' out-of-pocket costs, and disclose prices on the service level instead of per episode of care. As such, the disclosed amounts are often not reliable. Many price transparency tools also lack valid and measurable quality metrics, which can result in a selection of high-cost care as a proxy for high-value care, as well as an increase in healthcare prices when providers want to imply they offer high-quality care. Nevertheless, the impact of the initiatives on patients' decision-making and healthcare costs remains unclear. While transparency initiatives are patient-centric, efforts should be made to increase patient engagement, provide accurate patient-specific out-of-pocket cost information, compare available treatment and provider alternatives, and couple price information with quality metrics to enable making fully informed decisions., Competing Interests: Competing interestsGS receives honorarium from the Journal of the American College of Radiology in her role as Associate Editor. G Sadigh receives research support from NIH/NCI. MH receives research support from the NIH/NCATS. HA, JT and JJ have no conflicts of interest.

Background: Recent advancements in the clinical management of metastatic prostate cancer include several costly therapies and diagnostic tests. The objective of this study was to provide updated information on the cost to payers attributable to metastatic prostate cancer among men aged 18 to 64 years with employer-sponsored health plans and men aged 18 years or older covered by employer-sponsored Medicare supplement insurance., Methods: By using Merative MarketScan commercial and Medicare supplemental data for 2009-2019, the authors calculated differences in spending between men with metastatic prostate cancer and their matched, prostate cancer-free controls, adjusting for age, enrollment length, comorbidities, and inflation to 2019 US dollars., Results: The authors compared 9011 patients who had metastatic prostate cancer and were covered by commercial insurance plans with a group of 44,934 matched controls and also compared 17,899 patients who had metastatic prostate cancer and were covered by employer-sponsored Medicare supplement plans with a group of 87,884 matched controls. The mean age of patients with metastatic prostate cancer was 58.5 years in the commercial samples and 77.8 years in the Medicare supplement samples. Annual spending attributable to metastatic prostate cancer was $55,949 per person-year (95% confidence interval [CI], $54,074-$57,825 per person-year) in the commercial population and $43,682 per person-year (95% CI, $42,022-$45,342 per person-year) in the population covered by Medicare supplement plans, both in 2019 US dollars., Conclusions: The cost burden attributable to metastatic prostate cancer exceeds $55,000 per person-year among men with employer-sponsored health insurance and $43,000 among those covered by employer-sponsored Medicare supplement plans. These estimates can improve the precision of value assessments of clinical and policy approaches to the prevention, screening, and treatment of prostate cancer in the United States., (© 2023 American Cancer Society.)

Objective: To determine the healthcare costs and use burden of pediatric feeding disorder after congenital heart surgery., Study Design: A retrospective, population-based cohort study using claims data (2009-2018) was performed. Participants include patients aged 0-18 years who had undergone congenital heart surgery and were included in the insurance database ≥1 year after surgery. The main exposure variable was the presence of a pediatric feeding disorder, defined as a need for a feeding tube at discharge or diagnosis of dysphagia or feeding-related difficulty within the study timeframe. Main outcomes include overall and feeding-related medical care use, defined as readmissions and outpatient use, and feeding-related cost of care within 1 year of surgery., Results: A total of 10 849 pediatric patients were identified, with 3347 (30.9%) presenting with pediatric feeding disorder within 1 year of surgery. Patients with pediatric feeding disorder spent a median of 12 days (IQR, 6-33 days) in the hospital, compared with 5 days (IQR, 3-8 days) in patients without (P < .001). Rate ratios for overall readmissions, feeding-related readmissions, feeding-related outpatient use, and cost of care over the first year after surgery were significantly increased at 2.9 (95% CI, 2.5-3.4), 5.1 (95% CI, 4.6-5.7), 7.7 (95% CI, 6.5-9.1), and 2.2 (95% CI, 2.0-2.3) among patients with pediatric feeding disorder as compared with those without., Conclusions: Pediatric feeding disorder after congenital heart surgery is associated with a significant healthcare burden. Multidisciplinary care for and research on this health condition is needed to identify optimal management strategies to reduce this burden and improve outcomes., Competing Interests: Declaration of Competing Interest This research was supported by a science infrastructure grant provided by the Marcus Foundation. M.H. receives research support from the Harvey L. Neiman Health Policy Institute for unrelated work. N.R. receives salary support from the Marcus Foundation. There was no direct support of data analysis, study design, or publication. The authors declare no conflicts of interests., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Shared decision-making is mandated for patients receiving primary prevention implantable cardioverter defibrillators (ICDs). Less attention has been paid to generator exchange decisions, although at the time of generator exchange, patients' risk of sudden cardiac death, risk of procedural complications, quality of life, or prognosis may have changed. This study was designed to explore how patients make ICD generator exchange decisions., Methods: Emory Healthcare patients with primary prevention ICDs implanted from 2013 to 2021 were recruited to complete in-depth interviews exploring perspectives regarding generator exchanges. Interviews were conducted in 2021. Transcribed interviews were qualitatively coded using multilevel template analytic methods. To investigate benefit thresholds for pursuing generator exchanges, patients were presented standard-gamble type hypothetical scenarios where their ICD battery was depleted but their 5-year risk of sudden cardiac death at that time varied (10%, 5%, and 1%)., Results: Fifty patients were interviewed; 18 had a prior generator exchange, 16 had received ICD therapy, and 17 had improved left ventricular ejection fraction. As sudden cardiac death risk decreased from 10% to 5% to 1%, the number of participants willing to undergo a generator exchange decreased from 48 to 42 to 33, respectively. Responses suggest that doctor's recommendations are likely to substantially impact patients' decision-making. Other drivers of decision-making included past experiences with ICD therapy and device implantation, as well as risk aversion. Therapeutic inertia and misconceptions about ICD therapy were common and represent substantive barriers to effective shared decision-making in this context., Conclusions: Strong defaults may exist to continue therapy and exchange ICD generators. Updated risk stratification may facilitate shared decision-making and reduce generator exchanges in very low-risk patients, especially if these interventions are directed toward clinicians. Interventions targeting phenomena such as therapeutic inertia may be more impactful and warrant exploration in randomized trials., Competing Interests: Disclosures Dr Rao reports receiving research funding from National Institutes of Health grant UL1TR002378, TL1TR002382, and from the Agency for Healthcare Research and Quality grant 1F32HS028558. Dr Dickert reports receiving research funding from the Agency for Healthcare Research and Quality, National Institutes of Health and Patient-Centered Outcomes Research Institute, and the Greenwall Foundation and consulting fees from Abiomed. Dr Kramer reports support from National Institutes of Health grants R01AG068141 and R01HL161697. Dr Horný reports receiving research funding from the National Institutes of Health, Centers for Disease Control and Prevention and Harvey L. Neiman Health Policy Institute. The other authors report no conflicts.

BACKGROUND. Increases in the use of CT to evaluate patients presenting with trauma have raised concern about inappropriate imaging. The evolving utilization of CT for trauma evaluation may be impacted by injury severity. OBJECTIVE. The purpose of this study was to explore patterns in utilization of chest and abdominopelvic CT among trauma-related emergency department (ED) visits across the United States. METHODS. This retrospective study was conducted with national commercial claims information extracted from the MarketScan Commercial Database. Trauma-related ED encounters were identified from the 2011-2018 MarketScan database files and classified by injury severity score (minor, intermediate, and major injuries) on the basis of International Classification of Diseases codes. ED encounters were also assessed for chest CT, abdominopelvic CT, and single-encounter chest and abdominopelvic CT examinations. Utilization per 1000 trauma-related ED encounters was determined. Multivariable Poisson regression models were used to determine incidence rate ratios (IRRs) as a measure of temporal changes in utilization. RESULTS. From 2011 to 2018, 8,369,092 trauma-related ED encounters were identified (5,685,295 for minor, 2,624,944 for intermediate, and 58,853 for major injuries). Utilization of chest CT per 1000 trauma-related ED encounters increased from 4.9 to 13.5 examinations (adjusted IRR, 1.15 per year; minor injuries, from 2.2 to 7.7 [adjusted IRR, 1.17]; intermediate injuries, from 8.5 to 21.5 [adjusted IRR, 1.16]; major injuries, from 117.8 to 200.1 [adjusted IRR, 1.08]). Utilization of abdominopelvic CT per 1000 trauma-related ED encounters increased from 7.5 to 16.4 (adjusted IRR, 1.12; minor injuries, 4.8 to 12.2 [adjusted IRR, 1.13]; intermediate injuries, 10.6 to 21.7 [adjusted IRR, 1.13]; major injuries, 134.8 to 192.6 [adjusted IRR, 1.07]). Utilization of single-encounter chest and abdominopelvic CT per 1000 trauma-related ED encounters increased from 3.4 to 8.9 [adjusted IRR, 1.16; minor injuries, 1.1 to 4.6 [adjusted IRR, 1.18]; intermediate injuries, 6.4 to 16.4 [adjusted IRR, 1.16]; major injuries, 99.6 to 179.9 [adjusted IRR, 1.08]). CONCLUSION. National utilization of chest and abdominopelvic CT for trauma-related ED encounters increased among commercially insured patients from 2011 to 2018, particularly for single-encounter chest and abdominopelvic CT examinations and for minor injuries. CLINICAL IMPACT. Given concerns about increased cost and detection of incidental findings, further investigation is warranted to explore the potential benefit of single-encounter chest and abdominopelvic CT examinations of patients with minor injuries and to develop strategies for optimizing appropriateness of imaging orders.

Purpose: Recent price transparency initiatives have considerable limitations, notably due to the complexity of health care products. A single care encounter often consists of several services that may be performed by numerous clinicians and health care facilities that bill independently. The objective of this study was to describe the complexity in billing for nonemergency, noninvasive outpatient imaging and its variation across care delivery settings and imaging modalities., Methods: Using billing records from the 2019 IBM MarketScan Commercial Database, the authors examined the number of billing entities involved in outpatient imaging encounters and the sets of relevant items and services for which patients were billed., Results: In total, 5,210,129 imaging encounters were analyzed. Patients received bills from multiple billing entities for 70.9% of hospital-based encounters, 4.5% of office-based encounters, and 7.6% of encounters at imaging centers. Contrast agent was billed separately from the imaging procedures in 55.9%, 71.5%, and 55.3% of encounters for contrast imaging at hospitals, offices, and imaging centers, respectively. Billing for other ancillary items and services (facility fees, 3-D reconstruction, anesthesia and sedation) was relatively rare., Conclusions: Two key aspects of billing complexity may make obtaining complete and reliable price estimates before receiving outpatient imaging difficult for patients: the number of billing entities involved in care delivery and billing for fees and ancillary services beyond the primary imaging procedure. Given that price transparency initiatives are aimed primarily at helping patients anticipate the total cost of their care, policymakers, payers, and providers should take additional steps to provide patients with reliable information on the prices of entire care experiences., (Copyright © 2022 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Demographic changes in the population are an under-studied driving force of imaging utilization and associated spending. This study used national databases to characterize variations in spending on medical imaging among individuals with primary or secondary employer-sponsored insurance. Spending on imaging generally increased with age until individuals were approximately 80-85 years old, and among those who were 14-70 years old, spending was higher among women than men. The findings provide insight into how demographic changes could impact future spending on medical imaging.

Given the integral role of CT in patient care, the current global contrast media shortage creates profound and manifold patient care implications. We used a large insurance dataset to highlight examinations (abdominopelvic and chest CT), delivery settings (emergency department and outpatient hospital), and clinical indications (acute abdominopelvic and chest disease and cancer surveillance) for which contrast-enhanced CT is most commonly used. Such information may help inform emerging national guidelines and institutional policies.

BACKGROUND. The volume of emergency department (ED) visits and the number of neuroimaging examinations have increased since the start of the century. Little is known about this growth in the commercially insured and Medicare Advantage populations. OBJECTIVE. The purpose of our study was to evaluate changing ED utilization of neuroimaging from 2007 through 2017 in both commercially insured and Medicare Advantage enrollees. METHODS. Using patient-level claims from Optum's deidentified Clinformatics Data Mart database, which annually includes approximately 12-14 million commercial and Medicare Advantage health plan enrollees, annual ED utilization rates of head CT, head MRI, head CTA, neck CTA, head MRA, neck MRA, and carotid duplex ultrasound (US) were assessed from 2007 through 2017. To account for an aging sample population, utilization rates were adjusted using annual relative proportions of age groups and stratified by patient demographics, payer type, and provider state. RESULTS. Between 2007 and 2017, age-adjusted ED neuroimaging utilization rates per 1000 ED visits increased 72% overall (compound annual growth rate [CAGR], 5%). This overall increase corresponded to an increase of 69% for head CT (CAGR, 5%), 67% for head MRI (CAGR, 5%), 1100% for head CTA (CAGR, 25%), 1300% for neck CTA (CAGR, 27%), 36% for head MRA (CAGR, 3%), and 52% for neck MRA (CAGR, 4%) and to a decrease of 8% for carotid duplex US (CAGR, -1%). The utilization of head CT and CTA of the head and neck per 1000 ED visits increased in enrollees 65 years old or older by 48% (CAGR, 4%) and 1011% (CAGR, 24%). CONCLUSION. Neuroimaging utilization in the ED grew considerably between 2007 and 2017, with growth of head and neck CTA far outpacing the growth of other modalities. Unenhanced head CT remains by far the dominant ED neuroimaging examination. CLINICAL IMPACT. The rapid growth of head and neck CTA observed in the fee-for-service Medicare population is also observed in the commercially insured and Medicare Advantage populations. The appropriateness of this growth should be monitored as the indications for CTA expand.

Importance: To improve health care price transparency and promote cost-conscious selection of health care organizations and practitioners, the Centers for Medicare & Medicaid Services (CMS) required that hospitals share payer-specific negotiated prices for selected shoppable health services by January 2021. While this regulation improves price transparency, it is unclear whether disclosed prices reflect total costs of care, since many hospital-based services are delivered and billed separately by independent practitioners or other health care entities., Objective: To assess the extent to which prices disclosed under the new hospital price transparency regulation are correlated with total costs of care among commercially insured individuals., Design, Setting, and Participants: This cross-sectional study used a large database of commercial claims from 2018 to analyze encounters at US hospitals for shoppable health care services for which price disclosure is required by CMS. Data were analyzed from November 2020 to February 2021., Exposures: Whether the service was billed by the hospital or another entity., Main Outcomes and Measures: Outcomes of interest were the percentage of encounters with at least 1 service billed by an entity other than the hospital providing care, number of billing entities, amounts billed by nonhospital entities, and the correlation between hospital and nonhospital reimbursements., Results: The study analyzed 4 545 809 encounters for shoppable care. Independent health care entities were involved in 7.6% (95% CI, 6.7% to 8.4%) to 42.4% (95% CI, 39.1% to 45.6%) of evaluation and management encounters, 15.9% (95% CI, 15.8% to 16%) to 22.2% (95% CI, 22% to 22.4%) of laboratory and pathology services, 64.9% (95% CI, 64.2% to 65.7%) to 87.2% (95% CI, 87.1% to 87.3%) of radiology services, and more than 80% of most medicine and surgery services. The median (IQR) reimbursement of independent practitioners ranged from $61 ($52-$102) to $412 ($331-$466) for evaluation and management, $5 ($4-$6) to $7 ($4-$12) for laboratory and pathology, $26 ($20-$32) to $210 ($170-$268) for radiology, and $47 ($21-$103) to $9545 ($7750-$18 277) for medicine and surgery. The reimbursement for services billed by the hospital was not strongly correlated with the reimbursement of independent clinicians, ranging from r = -0.11 (95% CI, -0.69 to 0.56) to r = 0.53 (95% CI, 0.13 to 0.78)., Conclusions and Relevance: This cross-sectional study found that independent practitioners were frequently involved in the delivery of shoppable hospital-based care, and their reimbursement may have represented a substantial portion of total costs of care. These findings suggest that disclosed hospital reimbursement was usually not correlated with total cost of care, limiting the potential benefits of the hospital price transparency rule for improving consumer decision-making.

Purpose: Clinical practice guidelines intended to reduce unnecessary cervical spine imaging have yielded mixed results. We aimed to assess evolving emergency department (ED) cervical spine imaging utilization in patients with trauma by injury severity., Methods: Using 2009 to 2018 IBM MarketScan Commercial Databases, we identified ED trauma encounters, associated cervical spine imaging, and related diagnosis codes. We classified encounters by injury severity (minor, intermediate, major) using an International Classification of Disease code-derived Injury Severity Score algorithm and studied evolving imaging utilization using multivariable Poisson regression models., Results: Of all 11,346,684 ED visits for trauma, 7,753,914 (68.3%), 3,524,250 (31.1%), and 68,520 (0.6%) involved minor, intermediate, and major injuries, respectively. Overall cervical spine imaging increased 5.7% annually (incidence rate ratio [IRR] 1.057, P < .001) with radiography decreasing 2.7% annually (IRR 0.973, P < .001) and CT increasing 10.5% annually (IRR 1.105, P < .001). Radiography utilization remained unchanged for minor injuries (IRR 0.994, P = .14) but decreased for intermediate (IRR 0.928 versus minor, P < .001) and major (IRR 0.931 versus minor, P < .001) injuries. Increases in CT utilization were greatest for minor injuries (IRR 1.109, P < .001) with smaller increases in intermediate (IRR 0.960 versus minor, P < .001) and major (IRR 0.987 versus minor, P = .022) injuries., Conclusions: Recent increases in cervical spine imaging in commercially insured patients with trauma seen in the ED have been largely related to increases in CT for patients with only minor injuries, in whom imaging utilization has been historically low. Further study is necessary to assess appropriateness, implications on costs and population radiation dose, and factors influencing ordering decision making., (Copyright © 2021 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Introduction: The Affordable Care Act of 2010 mandated private health plans to fully cover the services recommended by the U.S. Preventive Services Task Force. In June 2016, the Task Force added computed tomography colonography to its list of recommended tests for colorectal cancer screening. This study evaluates the association among the updated recommendation, patient cost-sharing obligations, and the uptake of colorectal cancer screening through computed tomography colonography in the privately insured population., Methods: Using individual claims from the 2010-2018 IBM MarketScan Commercial Database, monthly screening computed tomography colonography utilization rates per 100,000 privately insured beneficiaries aged 50-64 years and the monthly proportions of these services delivered by in-network providers for which patients had to bear a portion of the procedure costs were calculated, and an interrupted time series analysis was performed. The study was conducted between January and May 2020., Results: Although the proportion of in-network procedures subject to patient cost sharing declined from 38.2% in 2010 to 10.2% in early 2016, the monthly utilization remained nearly constant. The announcement of the updated recommendation was associated with an immediate increase in the monthly screening computed tomography colonography utilization rate from 0.4 to 0.6 procedures per 100,000 individuals but with no change in the proportion of in-network procedures subject to patient cost sharing., Conclusions: In an environment of already largely eliminated patient cost sharing, the release of supportive evidence-based recommendations by a recognized credible body was associated with an immediate increase in computed tomography colonography use for colorectal cancer screening in the privately insured population., (Copyright © 2021 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Importance: The risk of hematoma formation after rhytidectomy is gender associated and can lead to postoperative complications. The literature to help explain and elucidate the mechanism behind this gender-associated risk is poorly developed and requires further investigation. Objective: The objective of this study was to compare facial skin micro-vessel density of female and male-to-female (MTF) transgender patients undergoing rhytidectomy to better understand the mechanism of gender-correlated hematoma risk factors. The authors hypothesized that transgender patients would have higher micro-vessel density compared with female patients. Design, Setting, and Participants: This was a prospective histopathological analysis of pre- and post-auricular facial skin samples from patients undergoing primary rhytidectomy. Patient clinical data and skin samples were collected. Histopathological slides were prepared and stained with CD-31, a marker of vessel endothelium, followed by image analysis allowing for micro-vessel stained pixel counts and calculated pixel density comparisons at a single academic hospital. Female, MTF transgender, and male patients >18 years of age were studied. Exposure: Patients undergoing primary rhytidectomy between 2015 and 2018. Main Outcomes: Gender-associated pre- and post-auricular micro-vessel pixel density. Results: Forty-one patients contributed skin samples for analysis. Post-auricular micro-vessel pixel density was greater than pre-auricular density (mean difference post-pre 0.359 percentage points [p.p.], standard error [SE] = 0.135, p  = 0.009). The mean post-auricular micro-vessel pixel density was 1.60% (SE = 0.13 p.p.), 2.16% (SE = 0.19 p.p.), and 2.77% (SE = 0.34 p.p.) for female, transgender, and male patients, respectively ( p  = 0.016). Pre-auricular micro-vessel pixel density showed no difference among females, males, and transgender patients ( p  = 0.30). Gender was a strong predictor of increased post-auricular micro-vessel pixel density on stepwise linear regression, but it did not predict pre-auricular micro-vessel density. Both preoperative hair removal and a history of hypertension were associated with increased pre-auricular micro-vessel density. Conclusions and Relevance: Facial skin micro-vessel density differs by gender, in addition to pre- and post-auricular locations in patients undergoing rhytidectomy.

The distribution of out-of-pocket spending throughout the year is an important determinant of health care affordability that has received little attention. We used 2017 data from a large database of US commercial insurance claims to study the distribution of patient-level out-of-pocket spending throughout the year, highlighting potential hardship due to temporal clustering of spending. We found that although most commercially insured people had several health care encounters throughout the year, their out-of-pocket spending was mostly concentrated within short time intervals. Nearly one-third of people with above-the-median total annual health care spending (plan plus out-of-pocket spending) incurred half of their annual out-of-pocket spending in just one day. Policy makers working to improve the affordability of care should focus on innovative approaches to cost sharing that prevent dramatic financial shocks to household budgets due to medical bills.

Purpose: The aim of this study was to explore state-level relationships between the incidence and payout amounts for medical malpractice claims and Medicare imaging utilization and spending across the United States., Methods: Using claims data from a 5% sample of Medicare beneficiaries for 2004 to 2016, annual state population-adjusted rates of imaging utilization and spending were calculated. Using National Practitioner Data Bank files, all paid physician malpractice claims were identified, and lagged state population-adjusted rolling averages of paid claim frequencies and payout amounts were calculated. Controlling for secular trends and state fixed effects with robust standard errors clustered at the state level to account for serial autocorrelation, associations between imaging utilization and lagged paid malpractice claims were assessed using multivariate regression models. Log-log model specification was used to obtain elasticity measures., Results: Between 2004 and 2016, national Medicare diagnostic imaging utilization and spending declined by 31.4% and 47.2%, respectively (from 355,057 to 243,517 examinations and from $28,591,146 to $15,099,291 per 100,000 beneficiaries). Overall national paid malpractice claims and payout amounts declined by 46.4% and 39.6%, respectively (from 4.83 to 2.59 claims and from $1,803,565 to $1,089,112 per 100,000 population). After controlling for secular trends and state fixed effects, advanced imaging utilization was positively associated with the lagged number of per capita paid malpractice claims. Each 1% increase in average paid malpractice claims was associated with a subsequent 0.20% increase in advanced imaging utilization (P = .001)., Conclusions: Positive associations between paid malpractice claims and advanced Medicare imaging utilization support the contention that US physicians use medical imaging as a defensive medicine strategy., (Copyright © 2020 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Objective: The primary objectives of this investigation were to evaluate the use of screening CT colonography (CTC) examinations by age comparing individuals of Medicare-eligible age to younger cohorts and to determine if the association between use of CTC and Medicare-eligible age varies by race. Although the Affordable Care Act requires commercial insurance coverage of screening CTC, Medicare does not cover screening CTC., Materials and Methods: Using the ACR's CTC registry, the distribution of procedures by age was evaluated using a negative binomial model with patient age (to capture overall trend), indicator of Medicare-eligible age (to capture immediate changes in trend at age 65), and their interaction (to capture gradual changes after age 65) as independent variables. The association between the number of screening CTCs and age was compared by racial identity., Results: The CTC registry contained data on 12,648 screening examinations. Between ages 52 and 64, the number of screening examinations increased; each additional age year was associated with a 5.3% (P < .001) increase in the number of screenings. However, after age 65, the number of screening examinations decreased by -6.9% per additional year of age above 65 compared with the trend between ages 52 and 64 (P < .001). The modal age group for CTC use was 65 to 69 years in white and 55 to 59 in black individuals., Conclusion: After age 65, the number of screening CTC examinations decreased, likely due, at least in part, to lack of Medicare coverage. Medicare noncoverage may have a disproportionate impact on black patients and other racial minorities., (Copyright © 2020 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to evaluate the contemporary use of procedural interventions to treat symptomatic uterine fibroids and assess associated health care system costs., Methods: Using the IBM Watson MarketScan Commercial Claims and Encounters database for 2009 to 2015 and relevant International Classification of Diseases diagnosis codes, women aged 18 to 55 years with clinically significant uterine fibroids were identified. Using Current Procedural Terminology codes, relevant procedural interventions were identified (hysterectomy, endometrial ablation, myomectomy, and uterine fibroid embolization [UFE]). Costs were defined as total actual payments by insurers and patients (per procedure and per episode of care) and were adjusted and compared using generalized linear models., Results: Of 241,757 invasive procedures for fibroids, hysterectomy was most common (76.5%), followed by endometrial ablation (14.5%), myomectomy (4.7%), and UFE (4.3%). Hysterectomy was more common in older women and those in rural areas (65.2% of patients <40 years of age, 77.6% of those 40-49 years of age, and 83.6% of those 50-55 years of age; 83.9% of patients outside versus 75.3% within metropolitan statistical areas). Per procedure, adjusted mean costs were $3,188 (95% confidence interval [CI], $3,114-$3,264) for hysterectomy, $2,781 (95% CI, $2,695-$2,870) for ablation, $4,436 (95% CI, $4,256-$4,623) for myomectomy, and $6,161 (95% CI, $5,736-$6,617) for UFE. Adjusted mean costs for entire episodes of care were $14,676 (95% CI, $14,496-$14,858) for hysterectomy, $6,702 (95% CI, $6,534-$6,875) for endometrial ablation, $14,791 (95% CI, $14,465-$15,125) for myomectomy, and $13,873 (95% CI, $13,182-$14,599) for UFE., Conclusions: Of invasive procedures for symptomatic uterine fibroids, hysterectomy was used more frequently than endometrial ablation, myomectomy, and UFE combined. Per procedure and per episode, ablation was least costly. Costs per episode were similar for hysterectomy, myomectomy, and UFE., (Copyright © 2020 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Rationale and Objectives: To evaluate the clinical yield of routine chest radiography in identifying pneumothorax warranting chest tube decompression in patients undergoing ultrasound-guided thoracentesis., Materials and Methods: All adult patients without pre-existing pneumothorax who underwent ultrasound-guided thoracentesis by a radiologist within a four-hospital large metropolitan academic health system over a 10-year period were identified. Demographic, clinical, and radiographic report information were obtained. Chest radiographic reports were assessed for the presence of pneumothorax and, if positive, manual image and chart review were performed., Results: Of 2541 consecutive ultrasound-guided thoracentesis procedures, 12 were excluded due to pre-existing pneumothorax, yielding 2529 cases. Mean patient age was 67.7 years; 54.5% were male. Overall, 89 procedures (3.5%) resulted in a postprocedural pneumothorax. Of those, only six (6.7%) had documented changes in patient symptoms. Chest tubes were placed in 15, representing 16.9% (15/89) of cases with postprocedural pneumothoraces and 0.59% (15/2,529) of all procedures. Of these 15, 5 (33.3%) had symptomatic pneumothoraces, most commonly shortness of breath., Conclusion: Following ultrasound-guided thoracentesis, the incidence of pneumothorax requiring chest tube decompression is only 1 in 170. Of the 1 in 30 patients who develop a pneumothorax, only 1 in 6 require a chest tube. This information can inform procedural consent discussions as well as future guidelines about the necessity of routine postprocedural chest radiography., (Copyright © 2019 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

The year 2019 featured extensive debates on transforming the United States multipayer health care system into a single-payer system. At a time when reimbursement structures are in flux and potential changes in government may affect health care, it is important for neuroradiologists to remain informed on how emerging policies may impact their practices. The purpose of this article is to examine potential ramifications for neuroradiologist reimbursement with the Medicare for All legislative proposals. An institution-specific analysis is presented to illustrate general Medicare for All principles in discussing issues applicable to practices nationwide., (© 2020 by American Journal of Neuroradiology.)

Dense breast tissue is a common finding that decreases the sensitivity of mammography in detecting cancer. Many states have recently enacted dense breast notification (DBN) laws to provide patients with information to help them make better-informed decisions about their health. To test whether DBN legislation affected the probability of screening mammography follow-up by ultrasound and magnetic resonance imaging (MRI), we examined the proportion of times screening mammography was followed by ultrasound or MRI for a series of months pre- and post-legislation. The subjects were women aged 40 to 64 years, covered by private health insurance, undergoing screening mammography from 2007 to 2014. Except for Hawaii, Maryland, and New York, DBN legislation significantly increased the probability of ultrasound follow-up in all states that implemented DBN legislation before December 2014. It also increased the probability of MRI follow-up in California, North Carolina, Pennsylvania, and Texas. The financial and access consequences merit further study.

Objective: The objective was to develop a novel metric for quantifying patient-level utilization of emergency department (ED) imaging., Methods: Using 2009 to 2015 Truven Health MarketScan commercial claims and encounters database, all ED visits and associated imaging services were identified. To measure imaging resource intensity, total imaging relative value units (RVUs) were calculated for each patient per ED visit. An individual's annual imaging h-index is defined as the largest number, h, such that h ED visits by that individual in a given year is associated with total medical imaging RVUs of a value of at least h., Results: Over 7 years, in a sample of 86,506,362 privately insured individuals (232,919,808 person-years) in all 50 states and the District of Columbia, 38,973,716 ED visits were identified. A total of 9.5% of person-years had one ED visit and 2.7% had two or more (the remainder had none). From 2009 to 2015, the percentage of ED patients undergoing imaging increased from 25.1% to 34.6%. Individuals with two or more ED visits each associated with two or more imaging RVUs (ED imaging h-index ≥ 2) comprised 0.2% of the sample and 1.4% of ED visitors; however, they accounted for 4.0% of ED visits and the use of 18.6% of imaging resources. From 2009 to 2015, imaging resource allocation for such patients increased from 16.5% to 21.0%., Conclusions: The ED imaging h-index allows identification of patients who undergo significant ED imaging, based on a single-digit patient-specific metric that incorporates both annual ED visit number and medical imaging resource intensity per visit. While ED patients with an ED imaging h-index ≥ 2 represented a minuscule fraction of privately insured individuals, they were associated with one-fifth of all ED imaging resources., (© 2019 by the Society for Academic Emergency Medicine.)

OBJECTIVE. Recent research on inferior vena cava (IVC) filter utilization in the United States has largely focused on national aggregate Medicare datasets, showing recent declines. Whether these national Medicare trends are generalizable across regions and payer populations is unknown. We studied recent state-level variation in IVC filter utilization across both Medicare and private insurance populations. MATERIALS AND METHODS. Using large individual beneficiary claims-level Medicare research identifiable files and a proprietary U.S. research database of the commercially insured population, we identified all billed IVC filter placement procedures performed between 2009 and 2015. We compared population-adjusted utilization rates by state and payer type. RESULTS. Between 2009 and 2015, IVC filter utilization across the United States declined by 36.3% (from 177.9 to 113.3 procedures per 100,000 beneficiaries) in the Medicare population and by 26.6% (from 32.7 to 24.0 procedures per 100,000 beneficiaries) in the privately insured population. For the Medicare population, state-level utilization rates varied 5.2-fold, from 48.4 to 251.3 procedures per 100,000 beneficiaries in Alaska and New Jersey, respectively. For the private insurance population, rates varied 5.5-fold, from 10.8 to 59.5 procedures per 100,000 beneficiaries in Oregon and Michigan, respectively. Nationally, utilization in the Medicare population was 5.0 times higher than that in the private insurance population (range by state, from 2.0 times higher in Hawaii to 11.1 times higher in Utah). Despite the national decline, utilization in Medicare and private insurance populations increased in five and seven states, respectively. State-level IVC filter utilization rates for the Medicare population correlated strongly with those for the privately insured population ( r = 0.74; p < 0.001). In both the Medicare and privately insured populations, utilization rates correlated moderately with beneficiary age ( r = 0.44 and r = 0.50, respectively; p < 0.001 for both). CONCLUSION. IVC filter utilization rates vary dramatically by state and payer population, and they likely depend in part on the age of the covered population. To better identify demographic and socioeconomic drivers of utilization, future research should prioritize nonaggregate multipayer claims-level approaches.

Purpose: To identify and characterize the most frequent users of emergency department (ED) imaging., Materials and Methods: All patients with at least one ED visit in 2016 across a four-hospital healthcare system were retrospectively identified and their ED imaging utilization characterized., Results: Overall, 126,940 unique patients underwent 187,603 ED visits (mean 1.5 ± 1.7) and a total of 192,142 imaging examinations (mean 1.7 ± 2.7). Fifty-eight percent of patients were imaged (73,672) and underwent a mean 2.6 ± 2.7 exams. When ranked by ED visits, 1.6% (2007) of patients had ≥ 4 ED visits (mean 6.1 ± 5.4). These ED "clinical superusers" accounted for 7.7% (14,409) of total ED visits and underwent 6.8 ± 5.4 imaging examinations, while non-superusers underwent 1.5 ± 2.2 (p < 0.01). When ranked by ED imaging utilization, 12.3% (15,575) of patients underwent ≥ 4 ED imaging examinations and consumed 49.5% (95,053) of all imaging services. A subset of just 1.3% (1608) of ED patients underwent > 10 annual ED examinations (ED "imaging superusers") and accounted for 12.4% (23,787) of all ED imaging services. Only 0.4% (n = 472) of patients were both clinical and imaging superusers. Despite similar ED visits to clinical superusers (6.0 ± 5.6 vs. 6.1 ± 5.4, p = 0.92), imaging superusers underwent significantly more imaging (14.8 ± 4.8 vs. 6.8 ± 5.4 examinations, p < 0.01)., Conclusion: Just 12% of ED patients consume 50% of all ED imaging services, and 1.3% consume 12.4%. These ED imaging superusers represent a distinct group from clinical superusers. Prospective identification of this newly described subgroup might permit targeted interventions to control ED imaging volume, restrain costs, and minimize per-patient radiation exposure.

The field of radiology has witnessed a burst of technological advances that improve diagnostic quality, reduce harm to patients, support clinical needs, and better serve larger more diverse patient populations. One of the critical challenges with these advances is proving that value outweighs the cost. The use of cutting-edge technology is often expensive, and the reality is that our society cannot afford all the screening and diagnostic tests that are being developed. At the societal level, we need tools to help us decide which health programs should be funded. Therefore, decision makers are increasingly looking toward scientific methods to compare health technologies in order to improve allocation of resources. One of such methods is cost-effectiveness analysis. In this article, we review key features of cost-effectiveness analysis and its specific issues as they relate to radiology., (Copyright © 2018 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Objective: Otolaryngology residents face time-management challenges between clinical duties and self-directed learning. Mobile devices provide a new medium for education that could aid with educational efficiency. The objective of this study was to investigate whether spaced repetition mobile app use of an otolaryngology question bank was associated with improving factual knowledge as measured by in-service exam performance., Methods: For approximately 6 months prior to the 2016 in-service examination, 12 otolaryngology residents at a single institution were provided access to a spaced-repetition app with a preloaded licensed otolaryngology review question bank. The number of questions answered, as well as the time spent on the app, were electronically tracked. The associations of app usage on in-service results were analyzed using an autoregressive model adjusted for prior historical Otolaryngology Trainee Examination performance and postgraduate year., Results: Eleven residents used the mobile app and were included in the analysis for an average of 304 minutes (range: 3 to 1,020) and reviewed on average 679 questions (range: 6 to 1,934). Controlling for residency year and prior performance, app usage was associated with an improvement by 2.92 percentage points (pp) (95% confidence interval [CI]: 0.14, 5.70) on overall in-service score. Allergy and pediatric subsection scores improved by 11.3 pp (95% CI: 3.8, 18.8) and 15.2 pp. (95% CI: 8.9, 21.5), respectively. Increased app use was associated with a score improvement by 0.008 pp per minute of use (95% CI: 0.004, 0.012)., Conclusion: Use of mobile spaced-repetition technology can aid resident factual knowledge retention measured by improved in-service exam performance., Level of Evidence: 4 Laryngoscope, 129:E15-E20, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: The aim of this study was to investigate the value of coformulated Tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) for preexposure prophylaxis (PrEP) for conception in the U.S. and to identify scenarios in which 'Undetectable = Untransmittable' (U = U) may not be adequate, and rather, PrEP or assisted reproduction would improve outcomes., Design: We developed a Markov cohort simulation model to estimate the incremental benefits and cost-effectiveness of PrEP compared with alternative safer conception strategies, including combination antiretroviral therapy (cART) alone for the HIV-infected partner and assisted reproductive technologies. We modelled various scenarios in which HIV RNA suppression in the male partner was less than perfect., Setting: U.S. healthcare sector perspective., Participants: Serodiscordant couples in the U.S. was composed of an HIV-infected male and HIV-uninfected female seeking conception., Intervention: Economic analysis., Main Outcome Measure(s): Cumulative risks of HIV transmission to women and babies, maternal life expectancy, discounted quality-adjusted life years (QALY), discounted lifetime medical costs and incremental cost-effectiveness ratios., Results: cART with condomless intercourse limited to ovulation was the preferred HIV prevention strategy among women seeking to conceive with an HIV-infected partner who is HIV-suppressed. PrEP was not cost-effective for women who had partners who were virologically suppressed. When the probability of male partner HIV suppression was low and we assumed generic pricing of PrEP, PrEP was cost-effective, and sometimes even cost-saving compared with cART alone., Conclusion: From a U.S. healthcare sector perspective, when the male partner was not reliably suppressed, PrEP became economically attractive, and in some cases, cost-saving.

Background: Increased breast tissue density may mask cancer and thus decrease the diagnostic sensitivity of mammography. A patient group advocacy led to the implementation of laws to increase the awareness of breast tissue density and to improve access to supplemental imaging in many states. Given limited evidence about best practices, variation exists in several characteristics of adopted policies., Objective: To identify which characteristics of state-level policies with regard to dense breast tissue were associated with increased use of downstream breast ultrasound., Research Design: This was a retrospective series of monthly cross-sections of screening mammography procedures before and after implementation of laws., Subjects: A sample of 13,481,554 screening mammography procedures extracted from the MarketScan Research database performed between 2007 and 2014 on privately insured women aged 40-64 years that resided in a state that had implemented relevant legislation during that period., Measures: The outcome was an indicator of whether breast ultrasound imaging followed a screening mammography procedure within 30 days. The main independent variables were policy characteristics indicators., Results: Notification of patients about issues surrounding increased breast density was associated with increased follow-up by ultrasound by 1.02 percentage points (P=0.016). Some policy characteristics such as the explicit suggestion of supplemental imaging or mandated coverage of supplemental imaging by health insurance augmented that effect. Other policy characteristics moderated the effect., Conclusions: The heterogeneous effect of state legislation with regard to dense breast tissue on screening mammography follow-up by ultrasound may be explained by specific and unique characteristics of the approaches taken by a variety of states.

Background/objective: The etiology and risk factors for angioedema remain poorly understood with causative triggers often going undiagnosed despite repeated reactions. The purpose of this study was to determine the relationship between inhalant allergen sensitization and angioedema., Methods: A retrospective review of patients who had in vitro inhalant allergy testing from 2006 to 2010 was performed. Patients with a diagnosis of angioedema who underwent inhalant allergy testing were identified. Analyses for co-morbidities, class of sensitization, seasonal timing of angioedema, and concurrent use of known hypertensive medications that can cause angioedema were performed., Results: There were 1000 patients who underwent inhalant allergy testing and qualified for the study. 37/1000 had at least one episode of angioedema and of these patients, 34 had positive inhalant sensitization testing results. Multivariate regression models showed overall sensitization status, seasonal allergen and epidermal/mite sensitization as independent risk factors (p<0.001, p=0.005, p=0.025 respectively) when controlling for ACE inhibitor use and other covariates. Tree, and epidermal/mite sensitizations were independent risk factors for angioedema in mono-sensitized subject analysis (p=0.028, p=0.029, respectively)., Conclusion: Both seasonal and perennial allergen sensitizations are independent risk factors for the development of angioedema. In patients with angioedema and an unknown trigger, inhalant allergen sensitization should be considered as a potential contributing factor to the development of angioedema., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Recent emphasis on value based care and population management, such as Accountable Care Organizations in the United States, promote patient navigation to improve the quality of care and reduce costs. Evidence supporting the efficacy of patient navigation for chronic disease care is limited. The objective of this study was to evaluate the effect of a patient navigation program on medical and administrative outcomes among patients with diabetes in an urban, safety-net hospital clinic setting., Methods: A retrospective cohort study with pre- and post-intervention periods was conducted. Eligible patients were those with A1C ≥ 8.5% and at least one appointment no-show in the previous 12 months. The intervention and reference groups were balanced on observed characteristics and baseline outcome levels using propensity score matching. The effect of patient navigation was isolated using the difference-in-differences approach. Primary outcomes were A1C, low-density lipoprotein cholesterol, triglycerides, random urine microalbumin, the number of scheduled appointments, clinic visits, emergency visits, and inpatient stays, and the percentage of arrivals, cancellations, and no-shows to scheduled appointments., Results: Of 797 eligible patients, 328 entered the navigation program. Matching reduced the sample size to 392 individuals (196 in each group). Patient navigation resulted in improved A1C (-1.1 percentage points; p < .001), more scheduled appointments (+ 5.3 per year; p < .001), more clinic visits (+6.4 per year; p < .001), more arrivals to scheduled appointments (+7.4 percentage points; p = .009) and fewer no-shows (-9.8 percentage points; p < .001)., Conclusions: Navigation was associated with improved glycemic control and better clinic engagement among patients with diabetes. Further research is important to identify what features of navigation in diabetes care are critical to achieving success and to understand navigators' role in other settings.

Although the value of interprofessional collaborative education has been promoted, it is unclear how teams of clinical and nonclinical learners perceive this experience. The authors studied an interprofessional quality improvement (QI) curriculum implemented in 2013 integrating internal medicine residents (n = 90) and Master of Public Health (MPH) students (n = 33) at an urban safety net academic medical center. Pre and post curriculum surveys assessed attitudes toward QI and interprofessional education and team performance. Resident attitudes toward learning and engaging in QI work improved at the end of the curriculum. Overall, MPH students demonstrated significantly more positive attitudes about interprofessional learning and work than residents. They also agreed more strongly than residents that patients would benefit if residents and public health students worked together. As health care organizations evolve to become more integrated, it is crucial that interprofessional educational opportunities be developed and evaluated to help encourage a culture of collaboration among health care providers., (© The Author(s) 2015.)

Objective: To quantify changes in private insurance payments for and utilization of abdominal/pelvic computed tomography scans (CTs) after 2011 changes in CPT coding and Medicare reimbursement rates, which were designed to reduce costs stemming from misvalued procedures., Data Sources: TruvenHealth Analytics MarketScan Commercial Claims and Encounters database., Study Design: We used difference-in-differences models to compare combined CTs of the abdomen/pelvis to CTs of the abdomen or pelvis only. Our main outcomes were inflation-adjusted log payments per procedure, daily utilization rates, and total annual payments., Data Extraction Methods: Claims data were extracted for all abdominal/pelvic CTs performed in 2009-2011 within noncapitated, employer-sponsored private plans., Principal Findings: Adjusted payments per combined CTs of the abdomen/pelvis dropped by 23.8 percent (p < .0001), and their adjusted daily utilization rate accelerated by 0.36 percent (p = .034) per month after January 2011. Utilization rate of abdominal-only or pelvic-only CTs dropped by 5.0 percent (p < .0001). Total annual payments for combined CTs of the abdomen/pelvis decreased in 2011 despite the increased utilization., Conclusions: Private insurance payments for combined CTs of the abdomen/pelvis declined and utilization accelerated significantly after 2011 policy changes. While growth in total annual payments was contained in 2011, it may not be sustained if 2011 utilization trends persist., (© Health Research and Educational Trust.)

Objective: The aim of the study was to investigate whether the increase in utilization of advanced diagnostic imaging for privately insured patients in 2011 was the beginning of a new trend in imaging utilization growth, or an isolated deviation from the declining trend that began in 2008., Methods: We extracted outpatient and inpatient CT, diagnostic ultrasound, MRI, and PET procedures from databases, for the years 2007 to 2013. This study extended previous work, covering 2012 to 2013, using the same methodology. For every year of the study period, we calculated the following: number of procedures per person-year covered by private health insurance; proportion of office and emergency visits that resulted in an imaging session; average payments per procedure; and total payments per person-year covered by private health insurance., Results: Outpatient utilization of CT and PET decreased in both 2012 and 2013; outpatient utilization of MRI mildly increased in 2012, but then decreased in 2013. Outpatient utilization of diagnostic ultrasound showed a very different pattern, increasing throughout the study period. Inpatient utilization of all imaging modalities except PET decreased in both 2012 and 2013. Adjusted payments for all imaging modalities increased in 2012, and then dropped substantially in 2013, except the adjusted payments for diagnostic ultrasound that increased in 2013 again., Conclusions: The trend of increasing utilization of advanced diagnostic imaging seems to be over for some, but not all, imaging modalities. A combination of policy (eg, breast density notification laws), technologic advancement, and wider access seems to be responsible for at least part of an increasing utilization of diagnostic ultrasound., (Copyright © 2015 American College of Radiology. All rights reserved.)

Recent studies have reported that the rate of growth in utilization of noninvasive diagnostic imaging has slowed, with a concomitant reduction in total payments to providers in the Medicare Part B fee-for-service population. Utilization and payment growth trends in commercially insured populations, however, are not as well understood. We used the Truven Health Analytics MarketScan® Commercial Claims and Encounters database containing more than 29 million individuals to investigate commercially insured population trends in utilization of and payments for CT, MRI, PET, and ultrasound procedures in the years 2007-2011. We found that imaging use--after a brief downturn in 2010--rose again in 2011, coupled with substantial increases in adjusted payments for all four imaging modalities, raising concerns about future efforts to stem growth in imaging use and associated spending., (Copyright © 2014 American College of Radiology. All rights reserved.)