Direct Medical Care Research Articles

6.P. Scientific session: Economic evaluation of health impacts for better decision choices

Abstract The strategy of Health in All Policies (HiAP) pursues to analyse the wider determinants of health affected by the decision-making process of traditionally non-health sectors, seeking to enhance population health benefits while avoiding health inequalities. This usually involves the use of health impact assessment (HIA) or health lens analysis to any policy, program, plan or project (PPPP), preferably prior to its implementation. On the other hand, decision-makers from a wide range of public and private sectors also demand a better insight of the meaning of the health impacts quantified under HIA. Assuming the (ubiquitous) situation of limited resources and budgets, decisions need to be based on cost effectiveness criteria and, whenever possible, direct and indirect health costs should be part of the impact assessment. Economic appraisal attempts to define whether a proposal makes a net contribution to social welfare, quantifying and valuing changes to individuals’ utility from the societal perspective, taking into account the impact of health on the individual, their family, employers, healthcare providers and the state. This approach can incorporate different components of the welfare costs of illness, including direct medical and paid care expenses, indirect lost opportunity costs such as productivity and the value of informal care time, as well as a value that monetises the disutility or pain and suffering associated with disease. The range of methods and estimated benefits can make it challenging to identify a best practice approach. The present session aims to address certain methodological aspects related to the economic evaluation of health impacts, which still generate some controversy and debate, with particular emphasis on the following topics: • Approaches for synthesizing evidence on health impact pathways and economic evaluation of health impacts for a better decision choice; • Health metrics: influence on the conclusions of economic analysis within HIA; • Sources of metrics used for economic analysis; • Uncertainties inherent to economic valuation of health outcomes: how to deal with it. Key messages • The economic analysis of health impacts can help prioritizing aspects with the greatest impact on population health, facilitating a more effective use of human and economic resources. • The economic analysis within HIA can improve decision-making but requires careful consideration of health metrics, sourcing of data, and management of uncertainties.

The Direct Medical Cost of Essential Tremor.

To determine the direct medical cost of illness from essential tremor (ET) from a patient perspective. Secondary data from the Optum's de-identified Clinformatics® Data Mart Database (CDM) from 2018-2019 was used to assess medical resource utilization and costs. Propensity score matching was used to match patients age 40+ with to statistically similar controls. Generalized linear models were used to estimate average, adjusted total costs of care per year, by health care setting, and provider specialty. The final sample included 41,200 patients with at least one ET claim and 36,871 matched patients. Overall, ET patients ages 40+ had about $28,217 in direct medical costs per year, which was about $1,601 more than matched comparisons (p < 0.001). This was driven by greater number of outpatient visits overall and with specialists. Extrapolating the estimates from our study and pairing them with published age-specific disease prevalence statistics for ET, we calculated an annual cost for direct medical care of ET patients ages 40+ to be about $9.4 billion. The estimated direct medical costs among adults age 40+ with an ET diagnosis aggregated to the population-level are non-trivial.

Examining Physicians' Approaches to Treating Relatives in Primary Health Care Centers: Insights from a Qualitative Study.

Introduction: Family medicine physicians take care of a diverse population of patients with a variety of acute and chronic diseases. These patients include family, friends, and acquaintances who may ask for direct medical care or help in accessing healthcare products and services within or outside of officially approved procedures. This is ethically challenging due to an ambiguous medical code of ethics, but it is commonly accepted as normal behavior by society. The aim of this study was to explore family medicine physicians' perspectives regarding the benefits, difficulties, and ethics of responding to medical care requests and/or favors from family, relatives, friends, and acquaintances and to make recommendations. Methods: The study sample consisted of junior and senior family medicine physicians working in primary healthcare centers affiliated with the Ministry of Health in Saudi Arabia. In-depth semi-structured interviews were conducted to collect data. Using social exchange theory, this qualitative study explores how family medicine physicians perceive and handle requests for medical favors from family members and others. Results: Semi-structured interviews were conducted with 19 family medicine physicians (six focus groups) with clinical experience ranging from 3 to 20 years. The data analysis identified three themes: perceived benefits and costs of cultural and social connectedness, shortcomings in patient management and healthcare systems, and recommendations to address challenges between physicians and patients who are relatives. Discussion and Conclusions: This study shows that treating others outside of normal access to healthcare services presents several ethical, moral, and professional challenges. Therefore, policy adaptation requires understanding this intricate dilemma and improving laws, system regulations, and guidelines for physicians and community members to improve access to care, reduce system abuse, empower providers, and enhance community awareness and compliance.

Comparing direct medical care costs of patients with bladder cancer who received an ileal conduit vs. neobladder in the year following cystectomy

PurposeBladder cancer is 1 of the most costly cancers, however there is limited research on medical care costs by type of urinary diversion. The objective of our study was to compare medical care costs of the 2 most common urinary diversions in the year following radical cystectomy. MethodsThe Bladder Cancer Quality of Life Study included patients diagnosed with bladder cancer who underwent radical cystectomy and received an ileal conduit (IC, n = 821) or neobladder (NB, n = 181) in 3 integrated health systems. Medical care costs per patient per quarter were estimated for the year following cystectomy. Multivariable generalized linear models with a gamma distribution and log link were used to estimate mean monthly medical care costs (2022 USD$), adjusted for patient demographic and clinical characteristics. ResultsIn multivariable analysis, mean monthly costs per quarter were not significantly different between IC and NB patients in the 12 months following cystectomy. Overall, mean monthly costs in IC and NB patients were highest during the first quarter and decreased thereafter. Factors associated with higher mean costs across all quarters included presence of any complications and advanced tumor stage at cystectomy (all P < 0.001). ConclusionOur study addresses an important knowledge gap by quantifying the medical costs of bladder cancer patients by urinary diversion type and comparing costs of different treatment approaches. Studies that assess patient-reported outcomes and out-of-pocket costs, by urinary diversion type, are warranted to inform treatment decision-making and cost conversations.

Burn Care in the Street: A Survey of the Current Landscape of Burn Care Provided by Street Medicine Teams.

People experiencing homelessness are at increased risk for serious burn injuries and face additional barriers to care such as inability to perform wound care and difficulty with follow-up. Although not burn-specific, street medicine programs provide direct medical care to people experiencing unsheltered homelessness in their own environment and may be well positioned to bridge this gap in burn care for this population. We conducted a cross-sectional survey to characterize the burn care experience of street medicine teams with providing burn care for people experiencing homelessness. The 60 respondents included 18 (30%) physicians, 15 (25%) nurse practitioners or physician assistants, 15 (25%) registered nurses, and 6 (10%) medical students, and 6 (10%) other team members. The most common reported barriers to care were prior negative experiences with emergency departments, and transportation to burn centers. There was regional variability in frequency of providing burn care, which was reflected in respondent comfort with assessing and treating burns. Burns were most often dressed with daily dressings such as a non-adherent dressing over silver sulfadiazine or bacitracin. Silver-based contact dressings were rarely used. Street medicine teams in the United States are treating burn injuries among people experiencing homelessness, though management practices and experience treating burns was variable. As street medicine programs continue to grow, burn-related education, training, and connections to local burn centers for team members is important. Through strengthened partnerships between burn centers and street medicine teams, these programs may be well positioned to bridge the gap in burn care for people experiencing homelessness.

Comparative Cost-Effectiveness of Gemcitabine and Cisplatin in Combination with S-1, Durvalumab, or Pembrolizumab as First-Line Triple Treatment for Advanced Biliary Tract Cancer.

The clinical effectiveness of triple chemotherapy consisting of gemcitabine, cisplatin plus either S-1 (GCS), durvalumab (DGC), or pembrolizumab (PGC) as first-line treatment for advanced biliary tract cancer (BTC) has been reported. However, their comparative cost-effectiveness is unclear. We conducted a model-based cost-effectiveness analysis from the perspective of Japanese healthcare payer. A 10-year partitioned survival model was constructed by comparing the time-dependent hazards of the KHBO1401-MITSUBA, TOPAZ-1, and KEYNOTE-966 trials. The cost and utility came from previously published reports. Quality-adjusted life years (QALY) were used to measure the effects on health. Costs for direct medical care were taken into account. There was a one-way analysis and a probability sensitivity analysis. A willingness-to-pay threshold of 7.5 million yen (57,034 USD) per QALY was defined. The incremental costs per QALY for GCS, DGC, and PGC in the base case study were 3,779,374 JPY (28,740 USD), 86,058,056 JPY (65,4434 USD), and 28,982,059 JPY (220,396 USD), respectively. No parameter had an influence beyond the threshold in a one-way sensitivity analysis. A probabilistic sensitivity analysis revealed that the probability of GCS, DGC, and PGC being cost-effective at the threshold was 85.6%, 0%, and 0%, respectively. Given the current circumstances, it is probable that triple therapy utilizing GCS will emerge as a plausible and efficient primary chemotherapy strategy for patients with advanced BTC in the Japanese healthcare system, as opposed to DGC and PGC.

The Promise of Artificial Intelligence in Neuroanesthesia: An Update

AbstractArtificial intelligence (AI) is poised to transform health care across medical specialties. Although the application of AI to neuroanesthesiology is just emerging, it will undoubtedly affect neuroanesthesiologists in foreseeable and unforeseeable ways, with potential roles in preoperative patient assessment, airway assessment, predicting intraoperative complications, and monitoring and interpreting vital signs. It will advance the diagnosis and treatment of neurological diseases due to improved risk identification, data integration, early diagnosis, image analysis, and pharmacological and surgical robotic assistance. Beyond direct medical care, AI could also automate many routine administrative tasks in health care, assist with teaching and training, and profoundly impact neuroscience research. This article introduces AI and its various approaches from a neuroanesthesiology perspective. A basic understanding of the computational underpinnings, advantages, limitations, and ethical implications is necessary for using AI tools in clinical practice and research. The update summarizes recent reports of AI applications relevant to neuroanesthesiology. Providing a holistic view of AI applications, this review shows how AI could usher in a new era in the specialty, significantly improving patient care and advancing neuroanesthesiology research.

Cost Offset of Dapagliflozin in the US Medicare Population with Cardio-Kidney Metabolic Syndrome.

Cardiovascular-kidney-metabolic (CKM) syndrome is highly prevalent in the US Medicare population and is projected to increase further. Sodium-glucose co-transporter2 inhibitors have indications in chronic kidney disease (CKD), heart failure (HF), and type2 diabetes (T2D), providing protective efficacy across conditions within CKM syndrome. The objective of this study was to develop a model to extrapolate key outcomes observed in pivotal clinical trials to the US Medicare population, and to assess the potential direct cost offsets associated with dapagliflozin therapy. All US 2022 Medicare beneficiaries (≥ 65years of age) eligible to receive dapagliflozin were estimated according to drug label indication and Medicare enrollment and claims data. Incidence of key outcomes from the dapagliflozin clinical program were modelled over a 4-year time horizon based on patient-level data with CKD, HF, and T2D. Published cost data of relevant clinical outcomes were used to calculate direct medical care cost-offset associated with treatment with dapagliflozin. In a population of 13.1million patients with CKM syndrome, treatment with dapagliflozin in addition to historical standard of care (hSoC) versus hSoC alone led to fewer incidents of HF-related events (hospitalization for HF, 613,545; urgent HF visit, 98,896), renal events (kidney failure, 285,041; ≥ 50% sustained decline in kidney function, 375,137), and 450,355fewer deaths (of which 225,346 and 13,206 incidences of cardiovascular and renal death were avoided). In total this led to medical care cost offsets of $99.3billion versus treatment with hSoC only (dapagliflozin plus hSoC, $310.3billion; hSoC, $211.0billion). By extrapolating data from trials across multiple indications within CKM syndrome, this broader perspective shows that considerable medical care cost offsets may result through attenuated incidence of clinical events in CKD, T2D, and HF populations if treated with dapagliflozin in addition to hSoC over a 4-year time horizon. Graphical abstract available for this article.

Meaningful benefit of disease-modifying treatment: Evaluating changes in health-related resource use.

Are reductions in the rate of decline from the new disease-modifying treatments (DMTs) in early Alzheimer's disease (AD) meaningful? We examined whether such reductions may be reflected in changes in health-related resource use. Patients with Clinical Dementia Rating (CDR) = 0.5 or 1 with a clinical diagnosis of mild cognitive impairment or AD, reflecting clinical trial populations. Health-related resource use was reported using the Resource Use Inventory (RUI) including direct medical care, non-medical care, unpaid informal care, and time use. Faster decline in CDR-Sum of Boxes (CDR-SB) from baseline was independently associated with higher likelihood and hours of informal care received, and lower likelihood of employment/volunteer work, but not with direct medical care. Reductions in the rate of decline in CDR-SB seen from DMTs significantly affect patients' work capacity and need for informal care, indicators of economic impact meaningful to patients, families, and health systems. These measures are not readily captured in administrative data sets. Following a cohort of participants with MCI or mild dementia due to AD that mimics participants targeted for AD trials, this study showed slower decline in CDR-SB have significant effects on patients' work capacity and need for informal care, but not on their direct medical care utilization such as hospitalizations, ED use, and doctors' visits.Capturing potential benefits in health-related resource use may require direct measures of informal care and work/volunteer effort which are meaningful outcomes to patients, families and health systems.Caution is needed in our effort to assess benefits of recently developed disease modifying treatment in AD using electronic health records and administrative data from which utilization of direct medical care are routinely collected as these data sources may not capture the most apparent changes in resource utilization during early disease stages.

Health care utilization, productivity losses, and burden of adverse childhood experiences in Singapore: Findings from a national survey.

There is poor understanding on health care utilization, productivity losses, and burden of adverse childhood experiences (ACEs) in multiethnic Asian populations. Part of this research gap stems from the limited epidemiological data on neglect, emotional abuse, bullying, and dysfunctional home environments. This study estimated health care utilization, productivity losses, and burden of ACEs (at least one exposure and multiple exposures) in Singapore. A total of 4,441 adult residents were recruited via door-to-door surveys in a nationally representative study in Singapore. All participants were assessed for ACEs, health care utilization, productivity losses, chronic physical disorders, and mental disorders on structured interviews. Approximation formulas were applied to calculate the estimated cost of ACEs in Singapore. ACEs were prevalent (63.9%) in the Singapore population. Individuals exposed to ≥ 3 ACEs (13.1%) utilized more direct medical care (e.g., primary care doctor and accident and emergency visits) and experienced greater productivity losses than those without ACEs (36.1%). The adjusted excess costs associated with ACEs per person were estimated to be S$767.40 (at least one ACE; 63.9%) and S$2167.84 (≥ 3 ACEs; 13.1%). The adjusted incremental costs of ACEs in the Singapore population were estimated to be S$1.18 billion (at least one ACE) and S$680 million (≥ 3 ACEs) per year. The health and economic burden of ACEs is substantial in Singapore. Our results highlight the importance of investing in novel, population-based ACEs interventions, and the potential return on investment through preventive care and alleviation of the health care burden. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Costs associated with novel first-line (1L) treatments in patients (pts) with locally advanced or metastatic urothelial carcinoma (la/mUC) from a United States (US) Medicare and commercial payer perspective.

e16552 Background: Recent drug approvals in the 1L treatment (tx) setting have expanded options for pts with la/mUC. It is important to understand the economic burden of these novel therapies within the current tx landscape. This study estimated first-year cost of care in the US from a Medicare and commercial payer perspective for pts with la/mUC treated with the following 1L tx: enfortumab vedotin (EV) + pembrolizumab (PEM) in platinum-eligible pts, nivolumab (NIV) + platinum-based chemotherapy (PBC) in cisplatin-eligible pts, and 1L PBC with or without avelumab (AVE) 1L maintenance (1LM). Methods: A cost of care model was developed to estimate direct medical care costs in the first year of tx with EV + PEM, NIV + PBC, and PBC with and without AVE 1LM in pts with la/mUC who are eligible for 1L PBC; pts treated with NIV + PBC were eligible for cisplatin. The latest available costs (2023 USD)—including drug acquisition and administration, disease management, adverse event (AE) management, and subsequent therapy (second-line or later line) costs—were calculated based on tx duration, progression-free survival, overall survival, and AE incidence with various therapies. Efficacy and safety data were sourced from key published trials (EV-302, CheckMate-901, JAVELIN Bladder 100) and product prescribing information. Results: Estimated first-year costs per treated pt are shown in the Table. Cost per treated pt was estimated to range between $56,952 to $438,660 and $90,918 to $457,390 for Medicare and commercial payers, respectively, with the highest cost for EV+PEM and the lowest for PBC only. Drug acquisition costs in the 1L represented the majority of the costs except PBC, for which subsequent tx and administration costs represented the largest cost component. Conclusions: Costs per treated pt were lower for PBC with AVE 1LM than for EV+PEM and NIV+PBC. As value-based oncology care is becoming increasingly important in the US, comprehensive understanding of costs across different tx options and sequences can facilitate informed tx choice. [Table: see text]

A Novel Approach in Elucidating the Interaction of Ecology, Biology and Social (Eco-bio-social) Factors with Serum Metabolites and Its Pathway among Polyps and Colorectal Cancer: A Study Protocol

The increasing number of colorectal cancer (CRC) incidences and mortality rates have caused an increasing burden on the healthcare system of the involved countries. This will impact the important economic components as a burden including direct medical care and non-medical costs and have caused productivity losses among patients and caregivers. Early diagnosis is important to help in reducing mortality rates of CRC and enhancing disease treatments. Besides genetic pathways, lifestyle imbalance and environmental factors also are reported as the main causes of CRC.However, most of the previous studies only focused on one factor at a time which limit the understanding of how these factors could be manipulated in the disease biomarkers finding. Hence, this study helps to build a novel protocol to provide a better insight into the effects of the ecology, biology, and social factors on the differential level of a polyp and CRC serum metabolites that could potentially be used to distinguish patients with polyp or CRC. The finding of the study could serve as a potential biomarker that could be used in the development of new screening tools to enhance early screening of polyps and CRC.

CMS releases tobacco cessation bulletin

The Centers for Medicare and Medicaid Services' Center for Medicaid and CHIP [Children's Health Insurance Program] Services on March 7 released a new informational bulletin, “Strategies to Improve Delivery of Tobacco Cessation Services.” The purpose of this informational bulletin is to highlight strategies that states have used to improve the delivery of tobacco cessation services to help more Medicaid and CHIP beneficiaries quit smoking. The bulletin includes an overview of state tobacco cessation coverage requirements and authorities in Medicaid and CHIP and outlines the benefits of helping beneficiaries quit smoking. Smoking is the leading preventable cause of disease and death in the United States, causing about 480,000 deaths annually and costing more than $600 billion each year in direct medical care and lost productivity, according to the bulletin. Tobacco use is particularly salient for the populations enrolled in Medicaid. In 2021, approximately one in five (21.5%) adults who were enrolled in Medicaid smoked cigarettes, compared to about one in nine (8.6%) adults with private health insurance and about one in 10 (11.5%) adults overall.

The evaluation of the burden of multisystem inflammatory syndrome in children on health economics.

This study aimed to evaluate the diagnostic tests and treatments applied in patients with multisystem inflammatory syndrome in children (MIS-C) and to determine the effect of the disease on health costs. This retrospective cohort study included 59 MIS-C patients (40 males, 19 females; mean age: 7.7±4.2 years; range, 4 months to 16.5 years) who were admitted and treated between April 1, 2020, and November 1, 2021. Demographic and clinical features with hospital costs and length of stay were retrospectively reviewed from the medical files and computerized system of the hospital. Direct medical care costs of items were calculated with the hospital perspective using a combination of microcosting technique (resource-based accounting method) and hospital list data. Cases were classified as mild, moderate, or severe, and the patients were divided into two groups: the mild group and the moderate-severe group. Classification was determined by the vasoactive inotropic score (VIS), degree of respiratory support, and evidence of organ damage. The mean age of the cases in the mild group was 6.5±3.7 years, and the mean age of the cases in the moderate-severe group was 9.2±4.3 years. Of 59 patients, 19 (32.2%) were followed up in the pediatric intensive care unit. The median duration of hospitalization in the hospital was 8 (interquartile range: 7-12) days. The total cost of the patients hospitalized with the diagnosis of MIS-C during the study period was 849,242.93$, and the mean cost per patient was 14,393.94±9,631.92$. In the distribution of the total cost of hospitalization according to expenses, the highest rate was pharmacy and blood products (51.99%) and IVIG costs (43.99%). While the mean total cost per person was 13,682.87±8,799.63$ in mild cases, it was 16,433.82±9,440.02$ in moderate-severe cases, and no statistically significant relationship was found between the two groups (p>0.05). There was no difference in the mean cost per patient between the cases with and without heart, lung, kidney, or neurologic involvement and advanced respiratory support (p>0.05). There was a strong positive correlation between the total costs and age (r=0.883, n=59, p<0.0001), with increased amount of costs with increased age. In the study, no statistically significant correlation was found between the total cost of per person in the mild group and the moderate-severe group (p>0.05). This finding may be due to the wide use of IVIG in MIS-C treatment, in addition to low transfer rates to pediatric intensive care units due to high-flow nasal cannula usage.

Problems of nursing staff in the ophthalmology department

The nurse plays an integral and important role in the health care system, providing direct medical care and supporting the effective work of physicians. One of the most demanding and responsible departments where nurses work is the ophthalmology department. The importance of the work of a nurse in ophthalmology cannot be overemphasized. They help doctors in the diagnosis and treatment of eye diseases, monitor the condition of patients before and after surgical interventions, as well as carry out preventive measures to maintain the health of the organ of vision. Without their professional skills and hard work, it is impossible to provide effective and safe treatment of eye diseases. Despite the challenges, the nurse in the ophthalmology department plays an indispensable role in ensuring the health and well-being of patients.

Median arcuate ligament syndrome: a cost analysis to determine the economic burden of a rarely diagnosed disease.

Chronic abdominal pain (CAP) is a medical condition resulting in enormous economic burden and healthcare utilization costs. One understudied source of CAP is the median arcuate ligament syndrome (MALS). MALS is often not diagnosed and treated for a variety of reasons, including the fact that MALS is highly comorbid with psychological symptoms and psychiatric disorders similar to CAP. To better inform future work on the study of MALS, we undertook a pilot study to estimate the economic impact and public health burden of this condition. We hypothesized that MALS imposes a significant public health burden. Pediatric and adult patients enrolled in a prospective study undergoing multidisciplinary evaluation and treatment for MALS at a tertiary care facility were invited to participate in a brief self-report survey, the Direct and Indirect Medical Care Impact of MALS Form, to capture health care resources including procedures, surgeries, health care visits, and absenteeism (school and work). To estimate costs from the Direct and Indirect Medical Care Impact of MALS Form, the medical care usage data self-reported by patients were converted to dollar value utilizing FSC-93 billing data and corresponding current procedural terminology (CPT) codes for procedures and provider visits one year prior to surgery and then following surgery. Descriptive analyses were conducted to characterize the sample in terms of demographics and reported absences from school and work. One hundred and nineteen patients (mean age = 30.9 ± 13.0) completed the questionnaires, yielding a 57% response rate. 82.4% (n = 98) of the participants were female and 90.8% (n = 108) were non-Hispanic/Latine white. The mean and median surgical follow-up periods were 5.3 and 5.4 years, respectively. Overall, median cost of provider and ancillary healthcare provider visits for each patient was (US)$19,119 including the pre-operative and post-operative visits. The mean cost for providers alone was (US)$28,908. Wilcoxon signed-ranks tests indicated that the postoperative missed number of days of school were significantly lower than the pre-surgical number of missed school days (Z = -3.36, p = 0.001). Similarly, there were significantly less missed work-days following surgery than before for the entire sample (Z = -2.86, p = 0.004). Median arcuate ligament syndrome imposes a large economic burden on patients and the healthcare system. The current findings, although reflective of a homogenous population, are adding to a growing body of literature suggesting that healthcare disparities play a role in the low rates of diagnosis and treatment of MALS.

Healthcare costs associated with first-line (1L) treatment of patients with locally advanced or metastatic urothelial carcinoma (la/mUC) in the United States (US).

11 Background: In 2023 in the US, 82,290 new cases of bladder cancer and 16,670 related deaths were estimated. Prior analyses assessing the economic burden of la/mUC in the current and evolving treatment landscape have been limited. This study aimed to estimate the direct medical costs of treating patients with la/mUC, from US Medicare and commercial perspectives. Methods: A cost model was developed to estimate annual direct medical care costs in patients with la/mUC eligible for 1L platinum-based chemotherapy (PBC) in 2023. Costs (2023 USD)—including drug acquisition and administration, disease management and adverse event (AE) management—were calculated, including subsequent therapy costs. Inputs included estimated number of treated patients per year, treatment duration, progression-free survival and overall survival with various therapies, AEs incidence, and market shares. Efficacy and safety data were sourced from product prescribing information, epidemiology data from Surveillance, Epidemiology, and End Results (SEER) database and published literature. Market share assumptions were based on market research data. Results: For a hypothetical health plan with 1,000,000 members, 108 and 22 patients with la/mUC from Medicare and commercial perspectives, respectively, were estimated to be eligible for 1L PBC in 2023. Estimated total annual costs per treated patient are shown in the Table below. With market share data comprising 1L PBC, with and without avelumab (AVE) 1L maintenance (61% and 25%) and enfortumab vedotin (EV) + pembrolizumab (PEM) (for cisplatin-ineligible patients, 14%), annual costs of $16,673,645 ($12,861 per treated member per month) and $4,637,226 ($17,852 per treated member per month) were estimated for Medicare and commercial perspectives, respectively. Drug acquisition costs in 1L represented most of the total costs (Medicare, 75%; commercial, 64%). Conclusions: Understanding the economic burden associated with la/mUC treatments may facilitate informed decision making on treatment choice and optimal sequencing. Further real-world studies are needed to assess the impact of these innovative treatments on disease and AE management costs of la/mUC. [Table: see text]

Perceived Roles and Barriers in Delivering Community-Based Care: A Qualitative Study of Health and Social Care Professionals.

As healthcare systems increasingly embrace population health management, the integration of health and social care to improve the health and well-being of individuals is crucial. Thus, we conducted a qualitative study in Singapore to understand health and social care professionals' (HCPs and SCPs) perception of the roles they played in delivering community-based care. A descriptive phenomenological research design was adopted. HCPs and SCPs (n = 53) providing services in community settings were recruited purposefully and interviewed through eleven focus group discussions. Each session was recorded and transcribed. Thematic analysis was applied. Our results revealed eight themes in three main categories describing the roles played by HCPs and SCPs, including: (1) delivering needs-based care in community settings; (2) activating and empowering clients in health care, and (3) fostering community-based sustainable support networks. Six barriers encountered while performing these roles were also identified. Our results highlight that the roles of HCPs and SCPs go beyond the provision of direct medical and social care. They were involved in activating and empowering clients to take care of their health, and importantly, fostering community-based sustainable support networks to better empower individuals in coping with health challenges. The identified barriers shed light on areas for potential improvements for integrated community care.

Psychological distress and life satisfaction among Black working adults in the U.S. during the COVID-19 pandemic

BackgroundThe COVID-19 pandemic disproportionately impacted Black Americans. Rates of hospitalization, mortality, and morbidity increased and racial inequities in unemployment, job benefits, and working conditions widened. This study identifies specific factors associated with the well-being of Black adults in the U.S. workforce one year into the pandemic. MethodsData came from the 2021 National Health Interview Survey (N = 1,984). Ordinary least squares regressions were computed to identify correlates of psychological distress and life satisfaction among Black adults in the workforce two weeks prior to the survey. ResultsBlack workers experienced significant distress. Life satisfaction was particularly low among those who provided direct medical care. Having a job with paid sick leave was consistently associated with lower psychological distress. Low household food security was associated with higher psychological distress and with lower life satisfaction. Social support was positively associated with well-being. ConclusionThese findings have important implications for health in Black communities and for recruiting and retaining Black workers in the health care system. Supporting Black physicians matters for their mental health amidst growing rates of suicide in this population. As policymakers continue to develop and legislate policies to promote recovery from the social, economic, and health consequences of the pandemic, attention to how these policies will support all Black workers is critical.

Paper 21: Functional Outcomes of Primary Ulnar Collateral Ligament Repair with Internal Bracing in Athletes

Objectives: The ulnar collateral ligament (UCL) is the primary restraint to valgus stress in the elbow. Injury to this ligament can occur in the setting of acute trauma as well as chronic overuse as seen in baseball players and other overhead athletes. Injury to the UCL continues to be a major source of morbidity in overhead-throwing athletes, with the incidence of UCL tears increasing dramatically over the past 15 years. UCL reconstruction using palmaris longus or hamstring autograft (also known as Tommy John surgery) has been considered the gold standard for the surgical treatment of symptomatic UCL injuries in overhead athletes for decades. Recently, there has been a renewed interest in UCL repair. In 2016, Dugas et al described the novel use of a collagen-dipped internal brace to augment UCL repair with encouraging biomechanical results from a cadaveric study. To date, only two studies have reported outcomes for this novel approach to UCL repair with internal brace (IB) augmentation, both with encouraging results. It is thought that the main advantages of UCL repair with IB augmentation compared to UCL reconstruction are comparable return to sport rates with a more rapid postoperative recovery, as well as restoration of normal anatomy that eliminates the need for an autograft and the associated complications of graft harvesting. Given the paucity of data examining this new surgical approach, this study seeks to add clinical outcome data for UCL repair to the scientific literature. The goal of this project is to evaluate functional outcomes following primary ulnar collateral ligament repair using internal brace augmentation and to describe new advancements in the surgical technique for this procedure. Methods: Approval was obtained from the Columbia University Irving Medical Center Institutional Review Board. A retrospective review of the electronic medical records of all consecutive patients who underwent medial UCL repair with internal brace augmentation between 2016 and 2022 was performed. All procedures were performed at a single tertiary institution and all patients were under the direct medical care of the senior author. Only patients with a focal UCL injury, such as a distal or proximal avulsion tear, were selected for UCL repair with internal brace augmentation. Evidence of chronic attritional disease, including calcification on MRI, or extensive ligamentous injury were contraindications to UCL repair. Additionally, only patients undergoing primary UCL repair with internal brace augmentation were included; those with prior UCL reconstructions or repairs were excluded as were patients with insufficient clinical follow-up data. Included in the chart review were patient demographics, level of sport, injury characteristics, preoperative imaging findings, operative data, and postoperative clinical outcomes including complications and reoperations. Patient reported outcomes were collected from the Pitch Registry, a national database maintained by Major League Baseball (MLB). Primary outcomes for this study include the ability to return to play (RTP) at the same previous level or higher, the time to return to competition, complications, and reoperations. Results: A total of 56 patients were included in this study (mean age at surgery was 19.5 ± 4.5 years; 55 men and 1 woman). The majority were baseball players (n=52) of which 43 were pitchers, while the remaining athletes played football, wrestled, or competed in Jujitsu. Twenty-eight were high school athletes, 23 played at the collegiate level, 4 played recreationally, and 1 played professionally. Symptoms of UCL injury preceded surgery by an average of 7.5 ± 15.0 months. The UCL was partially torn in 39 patients and fully torn in the remaining 17 patients, and it was torn proximally in 18, distally in 37, and mid-substance in 1 patient. The mean preoperative Kerlan-Jobe Orthopaedic Clinic (KJOC) score was 61.5 ± 15.3, the mean preoperative American Shoulder and Elbow Surgeons (ASES) score was 71.6 ± 14.9, and the mean preoperative Youth Throwing Score (YTS) was 40 ± 14. A concomitant arthroscopic osteophyte debridement and synovectomy was performed in 10 cases and a concomitant ulnar nerve transposition was performed in 4 cases. There were no intra-operative complications. The mean length of follow-up was 12.1 ± 7.1 months. Of the total cohort, 51 (91.0%) patients were able to return to play at an average of 7.8 ± 2.4 months. There were 4 reoperations (7.1%) including a single revision UCL reconstruction, 2 ulnar nerve transpositions, and 1 arthroscopic osteophyte debridement. Conclusions: Primary UCL repair with internal brace augmentation is a viable alternative to UCL reconstruction as supported by a rapid return to play and a low complication rate. There remains a paucity of data examining this encouraging and novel surgical approach. Additional data and analysis examining functional outcomes and optimal patient selection will be critical to address the rising epidemic of UCL injuries in young athletes.