Cost Of Workup Research Articles

Incidental Findings on MRIs for Asymmetric Sensorineural Hearing Loss: A Clinical and Economic Analysis.

The gold-standard assessment of asymmetric sensorineural hearing loss (ASNHL) is contrast-enhanced MRI. Although rates of identifying a vestibular schwannoma are low (<5%), it is generally accepted as cost-effective. Yet, the impact of incidentalomas is rarely considered. This study aims to characterize the incidence of incidentalomas in the workup of ASNHL and quantify the associated socioeconomic burden. Retrospective cohort study. Single academic institution in a midsized city in the United States. Radiology records were queried for MRI's ordered for ASNHL between January 2012 and November 2022. Results were characterized as "group 1: normal," "group 2: abnormal read/normal variant," "group 3: abnormal-likely cause of ASNHL," or "group 4: abnormal-follow-up needed." Subsequent costs of workup for group 4 were estimated using Medicare Physician Fee Schedule for Medicare costs, US Congressional Budgeting Office data for private insurer costs, and USC-Brookings Schaeffer Initiative for Health Policy estimates for uninsured individuals. Six hundred patients met the inclusion criteria. Eighteen (3.0%) were categorized in group 3, whereas 40 (6.7%) were categorized in group 4. Of these patients, 7.5% (n = 3) had interventions to manage their incidental findings. Estimated per patient cost for further workup of incidental findings amounted to approximately $744, $1,534, and $2,260 for Medicare, private insurance, and uninsured costs, respectively. Incidentalomas occur over twice as often as retrocochlear pathologies responsible for ASNHL. Although the number of patients requiring treatment for incidentaloma is low, the economic impact is not insubstantial and should be considered for both individual patients and health system payers.

Disparities in infertility workup costs across the United States

Disparities in infertility workup costs across the United States

Modeling the population health impact of incorporating a multi-cancer early detection (MCED) test to existing cancer screening among immunocompromised individuals

Objective To assess the screening efficiency of an multi-cancer early detection (MCED) test added to standard of care (SoC) screening, compared to SoC screening alone, among immunocompromised individuals, and to estimate the diagnostic workup costs associated with positive screening results. Methods We estimated the potential impact of cancer screening among immunocompromised individuals aged 50–79 years within the University of Utah Health system who underwent a stem cell/solid organ transplant or were diagnosed with a primary or secondary immunodeficiency disorder between January 2000 and February 2018. We derived cancer incidence rates from the Huntsman Cancer Institute Tumor Registry, and screening performance of SoC screening and an MCED test from published literature. Outcomes of screening efficiency included the true-positive to false-positive (TP:FP) ratio, diagnostic yield (DY), and cancer detection rate (CDR) for SoC screening alone and an incremental MCED test. Scenario and probabilistic sensitivity analyses were conducted. Results Among 4932 immunocompromised individuals aged 50–79 years, we estimated that 2595 tests would be done under SoC screening and assumed that all individuals received an additional MCED test. Adding an MCED test to SoC screening substantially improved screening efficiency (TP:FP = 1:1, DY = 5.15/1000 tests, CDR = 42.0%), compared to SoC screening alone (TP:FP = 1:99, DY = 1.23/1000 tests, CDR = 5.3%), assuming an MCED test with 100% uptake. Our findings were also robust to parameter uncertainty. Conclusion Adding an MCED test to complement existing screening may be a highly efficient strategy to increase the detection of cancers among immunocompromised individuals. These results could help to improve cancer prevention and detection efforts among individuals with multiple cancer risk factors.

The clinical and financial burden of nonhepatocellular carcinoma focal lesions detected during the surveillance of patients with cirrhosis.

HCC surveillance is challenged by the detection of hepatic focal lesions (HFLs) of other types. This study aimed to describe the incidence, characteristics, outcomes, and costs of non-HCC HFL detected during surveillance. We retrospectively analyzed nonstandardized workup performed in French patients included in HCC surveillance programs recruited in 57 French tertiary centers (ANRS CirVir and CIRRAL cohorts, HCC 2000 trial). The overall cost of workup was evaluated, with an estimation of an average cost per patient for the entire population and per lesion detected. A total of 3295 patients were followed up for 59.8 months, 391 (11.9%) patients developed HCCs (5-year incidence: 12.1%), and 633 (19.2%) developed non-HCC HFLs (5-year incidence: 21.8%). Characterization of non-HCC HFL required a median additional of 0.7 exams per year. A total of 11.8% of non-HCC HFLs were not confirmed on recall procedures, and 19.6% of non-HCC HFLs remained undetermined. A definite diagnosis of benign liver lesions was made in 65.1%, and malignant tumors were diagnosed in 3.5%. The survival of patients with benign or undetermined non-HCC HFL was similar to that of patients who never developed any HFL (5-year survival 92% vs. 88%, p = 0.07). The average cost of the diagnostic workup was 1087€ for non-HCC HFL and €1572 for HCC. Non-HCC HFLs are frequently detected in patients with cirrhosis, and do not impact prognosis, but trigger substantial costs. This burden must be considered in cost-effectiveness analyses of future personalized surveillance strategies.

Abstract 942: Real-world demographics, baseline characteristics, healthcare resource utilization and costs amongst non-small cell lung cancer (NSCLC) patients tested with a Host Immune Classifier (HIC)

Abstract Background: The Host Immune Classifier is a proteomic test that identifies a chronic inflammatory disease state for patients diagnosed with NSCLC. The test stratifies patients into two groups, HIC-H and HIC-C and helps evaluate patient prognosis and response to treatment. While much work has been done to evaluate the clinical validity of the HIC test, to date, no recent real-world studies have described healthcare resource utilization (HCRU) and costs amongst patients utilizing the test. This subset analysis of HIC claims examined demographic and baseline clinical characteristics among patients with lung cancer using the HIC proteomic test as well as HCRU and costs prior to test use. Methods: This retrospective claims analysis utilized MarketScan® Commercial and Medicare Supplemental Databases using data from January 1, 2016 to June 30, 2021 linked to Biodesix data files of HIC test results. Patients were age 18 or older on index date (date of HIC testing), underwent a HIC proteomic test, were continuously enrolled in the MarketScan database for the 6-months before index (pre-index period), and had at least one non-diagnostic medical claim of lung cancer during the pre-index period. Clinical characteristics and HCRU and costs were measured per patient per month (PPPM) during the pre-index period and compared between HIC-H and HIC-C cohorts. Results: Of the 328 included patients, 260 patients were HIC-H and 68 were HIC-C. On index, 178 patients had non-metastatic lung cancer and 150 patients had metastatic lung cancer. When assessing lung cancer related comorbid conditions, significantly more HIC-C patients had empyema (3% vs 0%, P&amp;lt;0.05) and pneumonia (34% vs 19%, P&amp;lt;0.05). When examining HCRU in patients prior to the HIC test, significantly more HIC-C patients had an outpatient visit with an oncologist (40% vs 27%, P&amp;lt;0.05) or a primary care physician (71% vs 56%, P&amp;lt;0.05). Total costs and inpatient costs were higher amongst HIC-C patients ($10,299 vs $9,689 and $4,032 vs $3,218, respectively) although not significant. While fewer HIC-C patients underwent lung biopsy (41% vs 53%), HIC-C patients had significantly higher biopsy costs than HIC-H patients ($1,285 vs $400, P&amp;lt;0.05). Although not statistically significant, more HIC-C patients had an inpatient admission (47% vs 38%) and longer average length of stay (5.3 vs 4.2 days). Conclusion: Patients with NSCLC who are identified as HIC-C have higher HCRU and costs, including lung cancer workup costs, prior to HIC testing. Further analyses are planned to determine long-term clinical outcomes, HCRU, and costs amongst patients post-testing. Citation Format: Wade Iams, Kimberly Le, Nicole Princic, Isabelle Winer, Taylor Marlin. Real-world demographics, baseline characteristics, healthcare resource utilization and costs amongst non-small cell lung cancer (NSCLC) patients tested with a Host Immune Classifier (HIC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 942.

Incidence of Typical Neutrophil Count with Fy(a-b-) Status Among Hematology Referrals for Neutropenia at an Urban Safety-Net Hospital

Typical neutrophil count with Fy(a-b-) status, known variously as Duffy null phenotype or Benign Ethnic Neutropenia, causes asymptomatic neutropenia without clinical sequelae.[i][ii] Fy(a-b-) phenotype is correlated to homozygosity of a single nucleotide polymorphism in the promoter region of atypical chemokine receptor 1 (ACKR1; formerly known as DARC), a decoy chemokine receptor, and may protect against malaria infection.[iii][iv] This genotype is enriched in malaria-endemic regions.[v] 25% to 50% of people of African ancestry in the United States are thought to have Fy(a-b-) status and are often erroneously identified as having pathologically low neutrophil counts. We performed a retrospective chart review of new neutropenia referrals to Hematology Clinic at Boston Medical Center (BMC) to evaluate diagnostic patterns for typical neutrophil count with Fy(a-b-) status. Overall, 103 new referrals for evaluation of neutropenia were made to BMC Hematology Clinic from 1/2020 to 2/2022, of which 78 were included for further analysis. Demographic and laboratory data are summarized in the accompanying Table. Typical neutrophil count with Fy(a-b-) status was identified as the primary etiology for neutropenia in 64.1% (50 of 78 referrals), of which 41 (82%) identified as African American or Black or were born in an African or Caribbean country. Of patients suspected of having Duffy null phenotype, 66% (33 of 50 patients) underwent confirmatory blood bank testing, and 97% (32 of 33) of these patients were found to have Fy(a-b-) status. Average cost of laboratory visit was calculated for each new referral using the Outpatient Price Transparency Tool from BMC Billing Department, which is based on chargemaster prices for the hospital. Patients with typical neutrophil count with Fy(a-b-) status on average had lower, but not negligible, cost of workup ($363.82 vs $689.46; p<.005 by unpaired student's T test assuming unequal variance) and were statistically less likely to have a follow up appointment (p=0.039 by unpaired student's T test assuming unequal variance) compared to those without. Though this phenotype reflects normal variation of white cell count in non-White populations, it is a "...label that illustrates how common phenotypes seen in non-White individuals continue to be considered nonstandard in the medical community." Workup of referrals that have typical neutrophil count with Fy(a-b-) status is not currently recommended, unless they have a change in their baseline white cell count or new, atypical features concerning for a secondary etiology.[vi] In our study, asymptomatic referrals were the majority and represent an unnecessary cost burden on an overtaxed healthcare system. Fy(a,b) antigen testing provides a low-cost alternative to hematology referral for confirmation of Fy(a-b-) status for patients or providers who require reassurance. Expanded use of serological Fy(a,b) antigen testing by primary care providers for patients with ancestry from malaria-endemic regions and chronic, asymptomatic neutropenia could reduce cost of care and referrals to Hematology clinic. [i] Ortiz MV, Meier ER, Hsieh MM. Identification and Clinical Characterization of Children With Benign Ethnic Neutropenia. J Pediatr Hematol Oncol. 2016 Apr;38(3):e140-3. doi: 10.1097/MPH.0000000000000528. PMID: 26925714; PMCID: PMC5102334. [ii] Merz LE, Achebe M. When non-Whiteness becomes a condition. Blood. 2021 Jan 7;137(1):13-15. doi: 10.1182/blood.2020008600. PMID: 33181819. [iii] Reich D et al. Reduced neutrophil count in people of African descent is due to a regulatory variant in the Duffy antigen receptor for chemokines gene. PLoS Genet. 2009 Jan;5(1):e1000360. doi: 10.1371/journal.pgen.1000360. Epub 2009 Jan 30. PMID: 19180233; PMCID: PMC2628742. [iv] Miller LH, Mason SJ, Clyde DF, McGinniss MH. The resistance factor to Plasmodium vivax in blacks. The Duffy-blood-group genotype, FyFy. N Engl J Med. 1976 Aug 5;295(6):302-4. doi: 10.1056/NEJM197608052950602. PMID: 778616. [v] Haddy TB, Rana SR, Castro O. Benign ethnic neutropenia: what is a normal absolute neutrophil count? J Lab Clin Med. 1999 Jan;133(1):15-22. doi: 10.1053/lc.1999.v133.a94931. PMID: 10385477. [vi] Gibson C, Berliner N. How we evaluate and treat neutropenia in adults. Blood (2014) 124 (8): 1251-1258. https://doi.org/10.1182/blood-2014-02-482612 Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

MP40-01 COST AND DIAGNOSTIC YIELD OF UPPER TRACT IMAGING IN HIGH RISK MICROHEMATURIA; ARE WE STILL DOING TOO MUCH?

You have accessJournal of UrologyCME1 May 2022MP40-01 COST AND DIAGNOSTIC YIELD OF UPPER TRACT IMAGING IN HIGH RISK MICROHEMATURIA; ARE WE STILL DOING TOO MUCH? Clay Martin, Eric Macdonald, Ella Taubenfeld, and Simon Hall Clay MartinClay Martin More articles by this author , Eric MacdonaldEric Macdonald More articles by this author , Ella TaubenfeldElla Taubenfeld More articles by this author , and Simon HallSimon Hall More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002600.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The 2020 AUA guidelines have brought some cost and potentially morbidity-saving changes to the workup and treatment of microhematuria (MH). With these changes comes a call for validating evidence. Herein the new guidelines have been applied to 1,906 patients. METHODS: All patients diagnosed with MH (RBC ≥3/hpf) at a single institution between 2010 and 2019 were retrospectively analyzed. Those with a complete workup including cystoscopy and upper tract imaging within 1 year of diagnosis were included. The new 2020 risk stratification was applied and cancer detection rates by risk group were assessed. A basic cost analysis was performed using the Centers for Medicare & Medicaid Services Physician and Clinical Laboratory Fee Schedule for 2021. RESULTS: Of the total MH cohort (n=1906), 1010 patients were stratified as high risk according to the 2020 guidelines. 770 of the 1010 (76.3%) had cross sectional imaging as part of their workup. Overall, 28 neoplasms were diagnosed in this patient group which corresponds to a detection rate of 2.77%. Of the 28 neoplasms identified, 18 were bladder tumors, 2 were upper tract urothelial malignancies and 8 were solid renal neoplasms. Cross-sectional imaging identified a total of 10 upper tract neoplasms (urothelial and renal) which corresponds to a 1.30% (10/770) detection rate. Furthermore, of the 8 solid renal masses, only 3 were of sufficient radiologic concern to warrant upfront surgical treatment. Additionally, 3 of these 8 patients had renal US in addition to their CT, 2 out of these 3 identified the solid renal mass. Cost analysis suggests that replacement of CT urography with renal US could decrease cost of workup by 38% ($433.04 vs $703.43). CONCLUSIONS: Cross sectional imaging in 770 patients with High-risk MH by the 2020 AUA guidelines yielded a detection rate of only 1.30% for upper tract neoplasms. Only 2 of these were urothelial malignancies that may not have been picked up via renal ultrasonography. Assuming most significant solid renal lesions could be identified by renal US, the utility of cross-sectional imaging is a positive finding in less than 1% of CT scans in this population. These data suggest that cross-sectional imaging may be unnecessary in the workup of MH, even in high-risk patients. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e674 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Clay Martin More articles by this author Eric Macdonald More articles by this author Ella Taubenfeld More articles by this author Simon Hall More articles by this author Expand All Advertisement PDF DownloadLoading ...

192 An Early Innovation Report of an Epidermal Ventriculoperitoneal (VP) Shunt Pressure Sensor

Abstract Introduction Ventriculoperitoneal shunt insertion, a common procedure for hydrocephalus, has a revision rate of approximately 20–30% within the first year, and continues to increase with each consecutive year. In Leeds, the average work-up cost for suspected shunt malfunctions was £765/patient. Additionally, patients with malfunctioning shunts present with vague symptoms potentially contributing to delayed presentation, especially important in Low-Middle Income Countries (LMICs) where neurosurgical expertise is less accessible. To reduce investigative costs and delayed presentations, we sought to design an epidermal shunt reservoir sensor to detect shunt malfunction by measuring the reservoir pressure. Method Literature searches were conducted to identify a proof of concept and suitable materials to engineer a concept device based on a Failure Modes and Effects Analysis (FMEA) table with design specifications to assess relative clinical risks. Using the IDEAL-D Framework, we designed our low-fidelity prototype using Solidworks® software. Results Literature revealed several devices aimed to detect shunt malfunctions. For our concept device, our focus was an accurate sensor and reliable connectivity. Our prototype uses gold nanowires to achieve high sensitivity to pressure change, as small as 15mPa. Near-field communication (NFC) for connectivity has less power requirement and has rapid connectivity compared to Bluetooth. Estimated cost of the device is £500. Conclusions Our device, in Stage 0 of the IDEAL-D Framework, identified potential sensors and connectivity methods. We could utilise magnets to adhere to the reservoir with overlying hair. However, magnetic fields and atmospheric pressure could cause interference. Power source options still require exploring before benchtop testing for accuracy, interference, and feasibility.

POSA134 Evaluating the Economic Effects of Flexible Radionuclide Delivery Timing and Same-Day Work-up and Radioembolization in Patients with Unresectable Liver Tumors Undergoing Selective Internal Radiation Therapy

The nature of radioactive decay means that the administration of medical interventions that utilize radionuclides is time sensitive and requires careful planning. For techniques such as selective internal radiation therapy (SIRT), pre-treatment work-up procedures are also required to assess the vascular anatomy of the liver, potentially occlude certain hepatic blood vessels, and establish the hepatopulmonary shunt fraction. The aim of the present study was to evaluate the effect of the SIR-Spheres Y-90 resin microspheres FLEXdose and Order-Map-Treat radionuclide delivery and procedure planning programs on the cost of performing SIRT. The effects of the FLEXdose and Order-Map-Treat programs on costs were evaluated from the perspective of the UK Department of Health (DoH). The FLEXdose program allows for delivery of SIR-Spheres Y-90 resin microspheres at multiple timepoints prior to the planned treatment, while the complementary Order-Map-Treat program enables both the work-up and procedure to be performed on the same day. Costs of work-up and treatment were calculated based on 2018-19 NHS Reference Costs, and the cost reduction was assumed to arise from the avoidance of one day case admission per patient treated with SIRT. Assuming the complementary FLEXdose and Order-Map-Treat programs would together enable work-up and treatment to be performed in a single day, the anticipated cost savings relative to administering SIR-Spheres Y-90 resin microspheres without the two programs would be GBP 2,619 per patient, corresponding to a cost reduction of 19.8% from GBP 13,237 to GBP 10,619 per patient treated. The present analysis showed that the FLEXdose and Order-Map-Treat programs would result in cost savings from the UK DoH perspective versus performing SIRT without either of the programs. The additional flexibility afforded by the FLEXdose and Order-Map-Treat programs may also increase flexibility of interventional radiology suite scheduling, which may in turn bring about benefits beyond cost alone.

Transfusion Preparedness in the Labor and Delivery Unit: An Initiative to Improve Safety and Cost.

To evaluate patient safety, resource utilization, and transfusion-related cost after a policy change from universal type and screen to selective type and screen on admission to labor and delivery. Between October 2017 and September 2019, we performed a single-center implementation study focusing on risk-based type and screen instead of universal type and screen. Implementation of our policy was October 2018 and compared 1 year preimplementation with 1 year postimplementation. Patients were risk-stratified in alignment with California Maternal Quality Care Collaborative recommendations. Under the new policy, the blood bank holds a blood sample for processing (hold clot) on patients at low- and medium-risk of hemorrhage. Type and screen and crossmatch are obtained on high-risk patients or with a prior positive antibody screen. We collected patient outcomes, safety and cost data, and compliance and resource utilization metrics. Cost included direct costs of transfusion-related testing in the labor and delivery unit during the study period, from a health system perspective. In 1 year postimplementation, there were no differences in emergency-release transfusion events (4 vs 3, P>.99). There were fewer emergency-release red blood cell (RBC) units transfused (9 vs 24, P=.002) and O-negative RBC units transfused (8 vs 18, P=.016) postimplementation compared with preimplementation. Hysterectomies (0.05% vs 0.1%, P=.44) and intensive care unit admissions (0.45% vs 0.51%, P=.43) were not different postimplementation compared with preimplementation. Postimplementation, mean monthly type and screen-related costs (ABO typing, antibody screen, and antibody workup costs) were lower, $9,753 compared with $20,676 in the preimplementation year, P<.001. Implementation of selective type and screen policy in the labor and delivery unit was associated with projected annual savings of $181,000 in an institution with 4,000 deliveries per year, without evidence of increased maternal morbidity.

Quantifying diagnostic and etiologic management costs of perimenopausal abnormal uterine bleeding and postmenopausal bleeding

Quantifying diagnostic and etiologic management costs of perimenopausal abnormal uterine bleeding and postmenopausal bleeding

Role of magnetic resonance neurography in intercostal neuralgia; diagnostic utility and efficacy.

To evaluate the utility and efficacy of MR neurography (MRN) in the diagnostic work-up for intercostal neuralgia and to assess the treatment course and outcomes in MRN-imaged clinically suspected intercostal neuropathy cases of chronic chest and abdominal wall pain syndromes. Following a retrospective cross-sectional study, a consecutive series of patients who underwent MRN of torso for suspected intercostal neuralgia were included. Patient demographics, pain location/level/duration, previous work-up for the same indication, MRN imaging results, and MRN cost per patient were recorded. An inter-reader reliability assessment was performed on the MRN findings using Cohen's weighted κ analysis. Post-MRN treatment choice, as well as success rates of MRN directed perineural injections and surgical management were also evaluated. A total of 28 patients (mean ± SD age, 48.3 ± 18.0 years, female/male = 3.0) were included. Pain and/or numbness in the right upper quadrant were the most common complaints. The mean maximum pain level experienced was 7.4 ± 2.5 on a 1 (lowest pain level) - 10 (highest pain level) visual analog scale. The duration of pain before MRN work-up was 36.9 ± 37.9 months. The patients had seen an average of 5 ± 2.8 physicians for such syndromes. 20 (71%) patients had one or multiple other imaging studies for prior work-up. MRN identified positive intercostal nerve abnormality in 19 cases with clinical symptoms of intercostal neuralgia. From the inter-reader reliability assessment, a Cohen's weighted κ value of 0.78 was obtained. The costs of work-up was about one-third with MRN for diagnostic purposes with less financial and psychological harm. Among the MRN-positive cases, 9/19 patients received perineural injections, of which 6 reported improvement after their first round, lasting an average of 41.1 ± 83 days. Among the nine MRN-negative cases, two received perineural injections, of which none reported improvement. Surgical management was mostly successful with a positive outcome in six out of seven operated cases (85.7%). MRN is useful in diagnostic algorithm of intercostal neuralgia and MRN-positive cases demonstrate favorable treatment response to perineural injections and subsequent surgical management. The use of MRN in intercostal neuralgia is an application that has not been previously explored in the literature. This study demonstrates that MRN offers superior visualization of pathology in intercostal neuralgia and confirms that treatment directed at MRN identified neuropathy results in good outcomes while maintaining cost efficiency.

Economic Impact of Diagnostic Imaging in the Workup of Uncomplicated Bell's Palsy.

Objective Our primary objective is to identify the costs associated with imaging in the diagnostic workup of uncomplicated Bell's palsy. Our secondary objective is to identify a dollar amount spent on extraneous diagnostic testing on a state and national level. Design and Setting Retrospective chart analysis was performed at our tertiary care medical center between 2007 and 2018. International Statistical Classification of Diseases-10 code G51.0 was used to identify patients with Bell's palsy seen by the senior author. A total of 163 patients were divided into two groups: those having received imaging and those diagnosed without imaging. The imaging group was then further subdivided by imaging modality: computed tomography (CT) only, magnetic resonance imaging (MRI) only, or both. There was a total of 138 scans in 115 patients. To quantify the amount spent by insurance companies or patients on these scans, net expected pay (NEP) for each modality was used as a representation of cost. The NEP for a CT was $618. The NEP for an MRI was $1,119. The NEP for both scans was $1,737. We extrapolated our results to a state and national level. Main Outcome Measurements Cost of workup; state and national economic burden. Results Extrapolating our data, we forecast that in Illinois and in the United States, over $2 million and $53 million, respectively, are spent on unnecessary imaging. Conclusion By highlighting an unnecessary financial burden, our study provides concrete evidence to support the American Academy of Otolaryngology's recommendation that clinicians should not perform routine imaging studies when diagnosing uncomplicated Bell's palsy.

New Intensification Strategies for the Direct Conversion of Real Biomass into Platform and Fine Chemicals: What Are the Main Improvable Key Aspects?

Nowadays, the solvothermal conversion of biomass has reached a good level of development, and now it is necessary to improve the process intensification, in order to boost its further growth on the industrial scale. Otherwise, most of these processes would be limited to the pilot scale or, even worse, to exclusive academic investigations, intended as isolated applications for the development of new catalysts. For this purpose, it is necessary to improve the work-up technologies, combining, where possible, reaction/purification unit operations, and enhancing the feedstock/liquid ratio, thus improving the final concentration of the target product and reducing the work-up costs. Furthermore, it becomes decisive to reconsider more critically the choice of biomass, solvent(s), and catalysts, pursuing the biomass fractionation in its components and promoting one-pot cascade conversion routes. Screening and process optimization activities on a laboratory scale must be fast and functional to the flexibility of these processes, exploiting efficient reaction systems such as microwaves and/or ultrasounds, and using multivariate analysis for an integrated evaluation of the data. These upstream choices, which are mainly of the chemist’s responsibility, are fundamental and deeply interconnected with downstream engineering, economic, and legislative aspects, which are decisive for the real development of the process. In this Editorial, all these key issues will be discussed, in particular those aimed at the intensification of solvothermal processes, taking into account some real case studies, already developed on the industrial scale.

I.18-1 NTRK Fusion Proteins

We have a new approach to cancer therapy “the Agnostic Tumor” approach. Molecular mechanisms (DNA mutations, translocations, deletions, fusions, etc.) are now the ones responsible of the origin and behavior of most of the tumors, instead of the location of the tumor as we used to think. We are in the beginning of changing the focus of cancer therapy from a single organ to a molecular marker envision. One of the best examples are the NTRK fusion proteins, NTRK genes encode for the Trk-family proteins: TrkA, TrkB, and TrkC (encoded by NTRK1, NTTRK2, and NTRK3). Normally, the NTRK family plays a role in the development of the nervous system, however, NTRK fusions are also present in solid tumors as fusion proteins responsible for growth of cancer cells, and the presence of these oncogenes is associate with poor survival in lung cancers and other tumor types. It is not surprising that these oncogenes are present in several different tumors (They are actionable in at least 17 tumor types) including adults and children. These genomic alterations are becoming a great example why the tumor agnostic approach might be the new paradigm in fighting cancer. However, there are still many challenges ahead; first for example, the diagnostic of these genetic aberrations: we can do fluorescence in situ hybridization (FISH), immunohistochemistry (IHC), reverse-transcriptase polymerase chain reaction (RT-PCR) and next generation sequencing (NGS) of DNA or RNA (or cfDNA in blood: liquid biopsies). Each of these approaches has strengths and weaknesses, but we also have to play this in the context of workups for other genetic abnormalities and keeping into consideration that tumor tissue specimen is very limited in many instances. Nowadays, for example, we do FISH for ALK and ROS-1 translocations, if we add three more FISH tests for each of the NTRK alterations (and maybe one more for RET fusions) will markedly increase the costs of workup in a lung cancer patient, and the gene fusion partner, that might become relevant, still might not be identified if we don’t have the right probe. RT-PCR is a great technique, but we will need a lot of primers (there are more than 60 NTRK fusions documented) to cover all the NTRK genetic abnormalities. Probably the solution is to develop better IHC? as we are doing for ALK translocations and hopefully get one day as IHC for ROS-1 and the other NTRK oncogenes so we can have a more cost-effective work up. A more practical approach might be to establish NGS in tissue or blood as the standard of care that can detect all these genetic alterations at once at the time of the diagnosis of the patient? Later we can do a more limited work up if we are looking for ALK and now NTRK resistant variants in patients that have failed treatment clinically. Nonetheless, for those who are not fans of NGS and don’t advocate this approach we can say that several NTRK 1-3 introns are not well covered by NGS. Then, we need to do whole genome gene sequencing to find them increasing the costs of the workup. These are some of the questions that remain open while we make all these diagnostic techniques more accurate and more cost effective. Some of these reasons are responsible to consider the treatment for NTRK challenging: how we can treat a patient if we can’t discover the genetic aberration? We are fortunate to have two agents: entrectenib and larotrectenib that have already been FDA approved for NTRK fusions with acceptable toxicities regardless of tumor type, patient age, and fusion type, and more data coming from other agents in development CEP-701, ARRRY-470 DS-6051b, TPX-0005. Probably LOXO 195 is the one that has been more studied for now and it’s able to rescue patients that develop resistance mutations during the treatment with larotrectenib or entrectinib.

Varying practices in tumor regression grading of gastrointestinal carcinomas after neoadjuvant therapy: results of an international survey.

Tumor regression grading is routinely performed on neoadjuvantly treated gastrointestinal cancer resections. Challenges in tumor regression grading include grossing standards, multiple grading systems, and difficulty interpreting therapy-induced changes. We surveyed gastrointestinal pathologists around the world for their practices in handling neoadjuvantly treated gastrointestinal cancer specimens and reporting tumor regression using a 23-question online survey. Topics addressed grossing, histologic work-up, tumor regression grading systems, and degree of difficulty identifying and estimating residual cancer within treatment effect. Two-hundred three responses were received, including 173 participants who completed the entire questionnaire. Fifty percent of the participants were from Europe, 29% from North America, 10% from Australia, and 11% from other continents. Ninety-five percent routinely report a tumor regression grade and 92% have standardized grossing and histologic work-up: 27% always completely embed the entire tumor bed, 54% embed the complete tumor site if not a grossly apparent, large mass. Fifty-nine percent use hematoxylin & eosin alone for assessment; the remaining use additional stains. In North America and Australia, the American Joint Committee on Cancer (AJCC)/College of American Pathologists (CAP)/Ryan system is routinely used for gastroesophageal (71%) and rectal carcinomas (77%). In Europe, the Mandard system is common (36%) for gastroesophageal tumors, followed by AJCC/CAP/Ryan (22%), and Becker (10%); for rectal CA, the Dworak system (30%) is followed by AJCC/CAP/Ryan (24%) and Mandard (14%). This regional differences were significant (p < 0.001 each). Fifty-one percent prefer a four-tiered system. Sixty-six percent think that regressive changes in lymph nodes should be part of a regression grade. Sixty-nine percent consider identifying residual tumor straight-forward, but estimating therapy-induced fibrosis difficult (57%). Free comments raised issues of costs for work-up and clinical relevance. In conclusion, this multinational survey provides a comprehensive overview of grossing and histologic work-up with regards to tumor regression grading in gastrointestinal cancers with partly significant regional differences particularly between North America and Europe.

No Apparent Workup for most new Indeterminate Pulmonary Nodules in US Commercially-Insured Patients.

BackgroundA recent study estimated that more than 1.5 million Americans have an indeterminate pulmonary nodule (IPN) identified on a chest computed tomography (CT) scan each year outside of lung cancer screening programs. However, the cost and pattern of subsequent IPN workup have not been described for real-world settings.ObjectivesTo examine the pattern and cost of IPN workup in real-world practice using insurer administrative claims data for commercially-insured individuals.MethodsThe primary source for this retrospective observational study was the MarketScan® 2013–2016 databases, which include information on 28 to 47 million insured lives. The newly diagnosed IPN study population consisted of members with an IPN diagnosis code on a claim in 2014 who did not have prior diagnosis of an IPN or lung cancer in 2013 and who had coverage from 2014 to 2016. Subsequent claims were examined for workups included in the American College of Chest Physicians (ACCP) guideline recommendations and the costs of workup were tabulated.ResultsOf the 15 064 patients in the study population, only 5471 (36%) received any subsequent workup. The average and median costs of workup for these patients were $3270 and $2068, respectively. Spread across the commercially-insured population, the workup is estimated to cost between $1 and $2 per member per year.ConclusionsThe majority of commercially-insured members with newly identified IPNs do not appear to have any guideline-recommended workup, despite a low incremental cost of such workup services on a population basis.

No Apparent Workup for most new Indeterminate Pulmonary Nodules in US Commercially-Insured Patients

Background: A recent study estimated that more than 1.5 million Americans have an indeterminate pulmonary nodule (IPN) identified on a chest computed tomography (CT) scan each year outside of lung cancer screening programs. However, the cost and pattern of subsequent IPN workup have not been described for real-world settings. Objectives: To examine the pattern and cost of IPN workup in real-world practice using insurer administrative claims data for commercially-insured individuals. Methods: The primary source for this retrospective observational study was the MarketScan® 2013-2016 databases, which include information on 28 to 47 million insured lives. The newly diagnosed IPN study population consisted of members with an IPN diagnosis code on a claim in 2014 who did not have prior diagnosis of an IPN or lung cancer in 2013 and who had coverage from 2014 to 2016. Subsequent claims were examined for workups included in the American College of Chest Physicians (ACCP) guideline recommendations and the costs of workup were tabulated. Results: Of the 15 064 patients in the study population, only 5471 (36%) received any subsequent workup. The average and median costs of workup for these patients were $3270 and $2068, respectively. Spread across the commercially-insured population, the workup is estimated to cost between $1 and $2 per member per year. Conclusions: The majority of commercially-insured members with newly identified IPNs do not appear to have any guideline-recommended workup, despite a low incremental cost of such workup services on a population basis.

Overutilization of Health Care Resources for Breast Pain.

The objective of this study is to analyze the incidence of women with breast pain who present to an imaging center and assess the imaging findings, outcomes, and workup costs at breast imaging centers affiliated with one institution. Demographic characteristics of and imaging findings for female patients presenting with breast pain at three community breast imaging centers between January 1, 2014, and December 31, 2014, were reviewed. Patients who were pregnant, were lactating, had a history of breast cancer, or presented with palpable nipple or skin findings were excluded. A total of 799 patients met the study criteria. Pain was diffuse in 30%, was focal in 30%, and was not localized in 40%. Of the 799 patients with breast pain, 790 (99%) presented for a diagnostic evaluation; 759 (95%) of these evaluated patients had negative findings. A benign sonographic correlate was detected in the area of pain in 5% of patients (39/799). One patient had a single cancer detected in the contralateral asymptomatic breast. When correlations between breast pain and the presence of cancer in the study patients were compared with the concurrent cancer detection rate in the screening population (5.5 cases per 1000 examinations performed), breast pain was not found to be a sign of breast cancer (p = 0.027). Patients younger than 40 years (316/799) underwent a total of 454 workup studies for breast pain; all findings were benign, and the cost of these studies was $87,322. Patients 40 years or older (483/799) underwent 745 workup studies, for a cost of $152,732. Breast pain represents an area of overutilization of health care resources. For female patients who present with pure breast pain, breast imaging centers should consider the following imaging protocols and education for referring physicians: an annual screening mammogram should be recommended for women 40 years or older, and reassurance without imaging should be offered to patients younger than 40 years.

Patient Outcomes and Cost of Referral Patterns of Patients With Proton Pump Inhibitor Refractory Gastroesophageal Reflux Disease Undergoing Esophageal pH and Impedance Testing

Introduction: The American College of Gastroenterology recommends that patients with gastroesophageal reflux disease (GERD) undergo esophageal pH and impedance for symptoms persisting following an 8 week trial of proton pump inhibitor (PPI) therapy. Research suggests that early referral is cost effective in evaluating PPI refractory GERD. Methods: A retrospective chart review was performed on all patients that underwent esophageal pH/impedance studies from December 2010 to June 2015. DeMeester score, total acid and non-acid reflux events, reflux symptom index scores, demographics, prior specialty appointments, and testing related to GERD symptoms was recorded. Workup cost was estimated using the minimum Medicare facility payment. Results: A total of 119 patients underwent pH/impedance testing with a mean age of 48 years (SD 13.0, range 21 - 76). No patients had pH/impedance evaluations prior to 8 weeks of PPI therapy. 46 (39%) patients had positive DeMeester scores, and 64 (53.8%) were referred by a non-primary care provider. Non-primary care specialties and primary care managers (PCM) had 26/64 (41%) and 20/55 (36%) positive pH/impedance tests, respectively. Of 55 patients referred by a PCM, 19 were previously seen by another specialty, with 6/19 (32%) of those having positive pH/impedance studies. No significant difference was found in the prevalence of positive testing between the three referral pattern groups (χ2=0.5068; P=0.7762) (table 1). Evaluation and workup costs averaged (95% CI) $184.00($181.46 - $186.54) from primary care referrals, $420.58 ($302.14 - 539.02) for primary care with previous subspecialty evaluation, and $353.65 ($264.12 - 443.18) for subspecialty referrals independent of PPI usage. Costs differed between primary care referrals and primary care with subspecialty referrals (P=0.0005) and primary care and subspecialty referrals (P=0.0014) but not between primary care with subspecialty referrals and subspecialty referrals (P=0.3649). Conclusion: A majority of the patients referred for pH/impedance testing were previously evaluated by another medical or surgical subspecialty. There was no difference in positive study between referral patterns. Additionally, the cost of workup for the PPI refractory GERD was higher in patients with any previous subspecialty workups when compared to direct primary care referrals. Therefore, the additional cost of workup of symptoms related to GERD does not demonstrate increased prevalence of positive pH and impedance studies. Early referral from primary care to gastroenterology for patients with refractory GERD after a trial of PPIs could reduce costs by eliminating unnecessary referrals to other specialties.Table: Table. Number of positive and negative DeMeester scores based on referral pattern for pH and impedance testing