Physician Office Research Articles

COVID-19 Vaccine Hesitancy in the Perinatal Period: A Survey Among Residents of Hawaii

IntroductionDescribe the vaccination status among people in Hawaiˈi who are attempting pregnancy, currently pregnant, recently delivered (<6 months) and/or breastfeeding and document common concerns and information sources associated with vaccine decision-making. MethodsWe conducted a cross-sectional online survey between April and September 2022 throughout Hawaiˈi. The anonymous surveys were disseminated via flyers and online links posted by physician offices and community partners throughout Hawaiˈi. ResultsFinal analyses included 165 responses. Almost half of respondents (n= 75, 45%) were unvaccinated, 38% (n=62) were fully vaccinated, and 17 % (n=28) of respondents were partially vaccinated. Most influential sources for vaccine decision- making for vaccinated respondents were their healthcare providers (n=28, 45%), and official healthcare organizations (n=22, 36%), while unvaccinated respondents reported friends/family (n=28, 37%) and their healthcare providers (n=26, 35%) as their most influential sources. Top COVID-19 vaccine concerns for unvaccinated individuals were reactions to vaccine (n=78, 76%), and concerns for safety of the vaccine (n=75, 73%). ConclusionsEfforts should be made to increase and expand vaccine education about the benefits and safety of vaccines during pregnancy beyond the pregnant person in order to create more supportive social norms for COVID-19 vaccination in the perinatal period. Consistent and unequivocal support across medical specialties, including obstetrics, pediatrics and family medicine, is also crucial for encouraging uptake of the vaccine during pregnancy or when breastfeeding.

Pediatric diabetes mellitus hospitalizations and COVID-19 pandemic response measures

AimsIn the United States, evidence suggests that during the COVID-19 pandemic, admissions of patients with diabetes mellitus (DM) have increased. This study assessed hospital admission rates for pediatric type 1 (T1DM) and type 2 (T2DM) diabetes mellitus during 2019–2021, and the potential influence of the timing of various pandemic response measures. MethodsRetrospective chart reviews were conducted of 854 T1DM and 135 T2DM hospital admissions between January 2019 and December 2021 in patients < 20 years old to collect demographic data, admission type, body mass index (BMI), and area deprivation index (ADI, a measure of socioeconomic vulnerability). Patients were divided into three cohorts based on their admission year: 2019 (Pre-pandemic), 2020 (Pandemic, Pre-vaccine), and 2021 (Pandemic, Post-vaccine). Admissions were categorized within each cohort by diagnosis (T1DM or T2DM) and clinical presentation (new onset, diabetic ketoacidosis: DKA). Cohorts were compared using an independent samples t-test for continuous variables or a chi-square test for categorical variables. ResultsThe incidence of T2DM hospitalizations tripled during the pandemic, increasing from 18 in 2019 (Pre-pandemic), to 55 in 2020 (Pandemic, Pre-vaccine), and 62 in 2021 (Pandemic, Post-vaccine). The rate of patients presenting with DKA was 15.4 % (95 % CI: 4 %-26.9 %) higher in 2020 (Pandemic, Pre-vaccine) among patients with new-onset T1DM (72/139 vs. 52/143), and 22.5 % (95 % CI: 9.6 %-35.4 %) higher in 2020 (Pandemic, Pre-vaccine) among T2DM patients (9/40 vs. 0/14). This increased rate of new onset T2DM significantly correlated with younger age (P = 0.046) and higher ADI score (P = 0.017), but not with BMI. ConclusionThe incidence of T1DM hospitalizations did not increase during the pandemic; however, they tripled for T2DM patients. All new onset DM pediatric patients during the pandemic were more likely to present in DKA. Patients admitted with new onset T2DM were socioeconomically more vulnerable. For T1DM, the peak of local pediatric diabetes admissions in 2020 occurred slightly later coinciding with the reopening of primary care physicians (PCP) offices and schools.

Prevalence and Cost of Routine Preoperative Care for Low-Risk Cataract Surgery a Decade after Choosing Wisely

ObjectiveExamine the frequency and cost of procedural clearance tests and exams in preparation for low-risk cataract surgery among members of a commercial healthcare organization in the US. Determine what characteristics most strongly predict receipt of preoperative care and the probability that preoperative care impacts post-surgical adverse events. DesignRetrospective health care claims analysis and medical records review from a large, blended-health organization headquartered in Western Pennsylvania, USA. ParticipantsMembers aged ≥65 years who were continuously enrolled 6 months before and after having cataract surgery from 2018 through 2021 and had approved surgery claim(s). MethodsPreoperative exams or tests occurring in the 30 days prior to surgery were identified via procedural and diagnosis codes on claims of eligible members (e.g., CPT codes for blood panels and preprocedural ICD-10 CM codes). Prevalence and cost were directly estimated from claims; variables predictive of preoperative care receipt and adverse events were tested using mixed effects modeling. Main Outcome MeasuresTotal costs, prevalence, and strength of association as indicated by odds ratios. ResultsUp to 42% of members having cataract surgery had a physician office visit for surgical clearance, and up to 23% of members had testing performed either in isolation or along with clearance visit(s). The combined costs for the preoperative visits and tests were $4.3M (approximately $107-114 per impacted member). There was little difference in member characteristics between those receiving and not receiving either preoperative testing or exams. Mixed effects models showed that the most impactful determinants of preoperative care were the surgical facility and member’s care teams; for preoperative testing, facilities were a stronger predictor than care teams. Adverse events were rare and unassociated with receipt of preoperative testing, exams, or a combination of the two. ConclusionsRates of routine preoperative testing before cataract surgery have not declined despite intervening guidance from the Choosing Wisely campaign to reduce this utilization. Additionally, preoperative evaluations, many likely unnecessary, were very common. Further attention to and reconsideration of current policies and practice for preoperative care may be warranted, especially at the facility level.

Women's Information Needs and Educational Preferences Regarding Lung Cancer Screening.

Background: Physicians are less likely to discuss lung cancer screening (LCS) with women, and women have lower awareness of LCS availability. The objective of this qualitative study was to determine information needs, patient-provider communication barriers, and preferences for LCS education among women. Materials and Methods: Eight semistructured qualitative focus groups were conducted with 28 self-identified women meeting LCS eligibility criteria. Participants were recruited through a large health system, from a community-based LCS program, and through a national online database between October 2020 and March 2021. Focus groups were led by a trained moderator via Zoom. Audio recordings were transcribed and analyzed using thematic analysis by investigators. Results: LCS decision-making influences included: (1) Health care provider recommendation; (2) Self-advocacy; (3) Insurance coverage and cost; (4) Family; and (5) Interest in early detection. Participants preferred video and print materials, available at physician's office or shared by physician, without scare tactics or shaming about smoking, use clear language, with diverse participants and images. Preferred content focused on: (1) Benefits of early detection; (2) Lung cancer definition, statistics, and risk factors; (3) Benefits of quitting smoking; (4) Demonstration or explanation of how LCS is done; and (5) Availability of other tests and potential harms of screening. Conclusion: Women in our study had limited awareness of LCS and their eligibility and wanted recommendation and support for LCS from their health care providers. We identified addressable information needs about lung cancer and the screening process that can be used to improve LCS uptake in women and shared decision-making processes.

Pre-Accessioning in Anatomic Pathology – Utilizing a Cloud-Based Laboratory Information System Reducing Error in Anatomic Pathology and Improving Patient Safety

Abstract Introduction/Objective Typical workflow in Anatomic Pathology (AP) starts from accessioning of cases to sign out. Most Laboratory Information System (LIS) follow this cycle of sample tracking. However, at certain times, either samples are not received or get lost in transit without lab being notified. There is a need of pre-accessioning in AP especially for samples received from outpatients’ sites, so labs not only track samples during transit but also reduce typographical errors (name, DOB, Unique ID) and assess workload before arrival. Methods/Case Report From 2020-2022, we initiated e-requisition utilizing online cloud-based portal for submitting AP cases obtained at physician offices, clinics, and outreach satellite sites. Insurance information and clinical history were scanned and uploaded with e-requisition submission. Retrospective analysis was performed, and data was analyzed and compared for errors, QA metrics and workflow analysis on samples obtained with PRE (840 cases) and without pre-accessioning NON-PRE (1280 cases). Results (if a Case Study enter NA) PRE and NON-PRE (handwritten and manual submission) were compared. Results were as follows for PRE vs NON-PRE: 1) Typographical errors (0.1% vs 8%); 2) Insufficient clinical history and ICD-10 (1% vs 9%); 3) Sample types errors (0.2% vs 5%); and 4) Efficient workflow for data entry per case at accessioning (1min vs 4min) Conclusion We demonstrated pre-accessioning feature for AP samples utilizing cloud-based portal of LIS is an important tool that can 1) prevent/reduce laboratory accessioning errors; 2) help labs monitor sample tracking from the time sample is obtained to the time it got accessioned in the lab; 3) help labs improve turn around time in their workflow for quick accessioning and 4) improve patient safety by reducing errors for AP samples; and 5) can be integrated with any clinical electronic medical record.

Tiered Physician Network Plans and Patient Choices of Specialist Physicians

Tiered physician network (TPN) health plans sort physicians into tiers based on their cost and quality, and patients pay lower copays for visits with physicians in the lower-cost and better-quality tiers. When the plans are first introduced, they lead patients to seek care from higher-value physicians. To examine whether TPNs are associated with patient choice of physician when the plans have been in place for 8 to 12 years and whether there are inequities in patient out-of-pocket costs associated with inequities in access to physicians in lower-copay tiers. This cross-sectional study comprising 46 645 physicians and 585 399 patients in TPNs, including 54 683 patients who had a new patient visit with a physician in a TPN, used health insurance claims data from a large employer purchaser from July 1, 2014, to June 30, 2019. Statistical analysis was performed from November 2020 to August 2023. Evaluation and management visit with a physician in a TPN. Main outcomes were new patient market share per physician-carrier-zip code-year, distance from centroid of patient zip code to centroid of zip code of nearest low- or medium-copay physician, and mean TPN physician office visit copay per patient. A regression discontinuity design was used to estimate the association of a physician's tier ranking, and a difference-in-differences analysis was used to estimate the association of copayment differences across tiers with market share among new patients. Equity in access was measured by comparing travel distance to the nearest physician in a low-copay or medium-copay tier and mean copayments across patient incomes. The main analysis sample included 46 645 physician-carrier-zip code-year observations, 9506 (20.4%) of which were in the low-copay tier, 31 798 (68.2%) in the medium-copay tier, and 5341 (11.5%) in the high-copay tier. The 54 683 new patients in the sample had a mean (SD) age of 46.4 (16.7) years and included 33 542 women (61.3%). There was no association of having a worse tier ranking (0.045 percentage points [95% CI, -0.058 to 0.148 percentage points]) or of copayment differences between tiers (0.001 percentage points [95% CI, -0.002 to 0.004 percentage points]) with physician market share among new patients. The patients with the lowest income paid slightly lower mean (SD) copayments for office visits to a TPN physician than the patients with high income ($48.08 [$16.42] vs $51.59 [$16.79], a 6.8% difference). In this cross-sectional study of TPN health plans, there was no association between physician tier ranking and physician market share among any group of patients. These findings suggest there are limitations in TPNs' steering of patients toward high-value physicians. These plans were not associated with exacerbated health inequity in this setting.

Abstract 15387: Outpatient Intravenous Diuresis for Acute Exacerbation of Heart Failure: A Claims-Based Analysis

Introduction There is evidence that selected patients with HF exacerbation can be treated with outpatient IV diuresis (OIVD), delaying or avoiding subsequent acute care services and reducing cost. Hypothesis In selected HF patients, OIVD reduces or delays hospitalization and lowers medical cost. Methods Retrospective claims analysis using the Truven Market Scan database of medical and pharmacy claims (200 million USA lives). We identified all patients with claims for HF (Oct 2015- Sept 2022) receiving OIVD within 12 months after HF diagnosis.OIVD was administered as single day or multiple days events (OIVD over 10-day window). Care episodes and cost within 12 months after initiation of OIVD were defined by location of care: Hospital, ER, Observation, Skilled Nursing Facilities (SNFS) Outpatient Clinics. Results Out of 924,174 patients (age 63.4; SD 14.8) with an ICD 10 for HF, 42,132 received OIVD in hospital clinics, other clinics, physician's offices andER/Observation. One OVID episode was documented in 37,178; multipe in 4,954 (1.4-1.5 episodes per patient). After initiation of OVID, 33,172 patients required care for HF in ER, Observation, Hospital and SNFS (average of 5.9 events per patient). Hospitalization and SNFS were delayed by a mean of 4.60 months from OIVD. The remaing 8,960 patients did not require subsequent acute care or SNFS services for HF. The cost per OIVD episode was higher for ER and Observation (range $952 -$1730) than for outpatient clinics (range $190 -$ 786). The cost of hospitalization ranged $14,500-$57,488. Conclusions In selected patients with HF, OIVD is effective in delaying or preventing use of acute care services and it is associated with cost avoidance. New care protocols are needed to expand the use of OIVD in outpatient clinics and even in the home as an alternative to ER/Observation/Inpatient.

Impact of the end of public health emergency oral dispensing flexibilities for at-risk patients in a community oncology practice.

209 Background: Many studies have shown the benefit of medically integrated pharmacies for cancer specialty oral drugs in improving patient adherence and reducing waste compared to external pharmacies. Anti-kickback regulations have limited practice’s ability to deliver prescriptions to patient’s homes from physician offices. During the Covid Public Health Emergency (PHE), flexibility for prescription delivery by a physician owned pharmacy was allowed leading many practices to deliver oral cancer therapies to patients who could not otherwise come to clinics to fill their medications. With the end of the PHE, CMS reversed this flexibility. We sought to determine the impact on patients with this change in CMS regulations. Methods: Utilizing the pharmacy database of prescriptions delivered to a patient’s home for a large statewide community oncology practice in Texas during the PHE, we identified patients with Medicare part D who would no longer be able to utilize their physician’s pharmacy for home delivery of their specialty medications. We determined the distance of those patient’s primary address to the nearest clinic and further matched them to the address deprivation index (ADI) a well-validated approach that rank orders zip codes in deciles from lowest to highest need. Results: We found 970 patients receiving home delivered prescriptions with traditional Medicare Part D. 687 or 71% of patients lived within 20 miles of the nearest clinic. 213 or 22% lived between 20 and 50 miles with 70 or 7% more than 50 miles from the nearest clinic. 60 addresses could not be matched to the ADI database. Focusing on those available addresses in the top half of the ADI at highest need, we found that 40% of patients living within 20 miles of the clinic are at significant risk of disparity vs 67% of those 20-50 miles and 61 % of those living more than 50 miles from the clinic. Conclusions: The removal of the PHE flexibility for home delivery of prescriptions from physician offices will significantly increase the burden on patients in Texas, forcing many to drive long distances to obtain drugs and disproportionately affecting those at greatest risk of disparity. We encourage revising policies to allow medically integrated pharmacies to allow home delivery of cancer specialty drugs to meet CMS stated goals of improving health equity.

Impact of COVID-19 measures on exacerbation rates and healthcare visits in US asthma patients.

Objective: To compare exacerbation rates and healthcare resource utilization (HCRU) in real-world patients in the United States who had moderate-to-severe asthma on medium- or high-dose inhaled corticosteroid/long-acting β₂-agonist therapy at different stages before and after the pandemic. Methods: This noninterventional, retrospective study described demographics, exacerbations, HCRU, and medication use in patients from a US-wide healthcare claims database in 4 consecutive years anchored around March 15, 2020 (start date of the first emergency health measures against coronavirus disease 2019 [COVID-19], or the first lockdown, in the United States, termed "restriction onset" hereafter). Four cohorts of patients potentially eligible for moderate-to-severe asthma clinical trials at the beginning (index) of each of four 1-year periods (March 15, 2018, 2019, 2020, 2021, respectively) were built. Exacerbations, healthcare visits, and asthma medication use were counted in the 1-year period after the index for each cohort. Results: The prevalence of patients with one or more exacerbation per year decreased by 10.00% in the first year after the restriction onset compared with the year before and attenuated over time to 6.37% in the second year. The proportion of inpatient, emergency department, and physician's office visits remained stable over the time periods evaluated for all patients and those patients who experienced one or more exacerbations. Asthma treatment of patients who experienced one or more exacerbations also remained stable over the 4 years. Conclusion: The effect of COVID-19 public health measures on asthma exacerbation rates might have affected clinical trials being run during this period and should be considered in their analysis. Asthma clinical trials run under pandemic hygiene restrictions should consider lower exacerbation frequency in their study design, while treatment and healthcare visits seem unchanged.

Economic and Health Care Resource Use Burden of Systemic Sclerosis.

To describe the health care resource use (HCRU) and costs of patients with systemic sclerosis (SSc) prior to and after diagnosis. This retrospective study used a claims data set (Merative MarketScan; 2015-2019). Eligible patients with SSc were identified by diagnosis codes and required at least 24 months of enrollment without an SSc diagnosis before their first SSc claim and at least 12 months of enrollment thereafter. Total HCRU and costs were reported for three intervals: 2 years and 1 year before and 1 year after index diagnosis. A general population cohort without SSc was matched 1:1 to the SSC cohort on age and sex for comparison. Eligibility criteria identified 902 patients with SSc (mean age: 54 years old; 85% female). Mean per-member per year costs increased each year from $22,383 to $29,708 to $47,095, 2 years before, 1 year before, and 1 year after index diagnosis versus $10,232 to $9656 to $9714 in the general population cohort. Outpatient settings represented the largest proportion of cost 1 year after SSc diagnosis ($16,392), followed by prescription drugs ($10,692), physician office ($10,523), and inpatient ($9448) settings. Patients with SSC accrued greater costs and required more services than a general population cohort. These elevated expenditures and HCRU were observed at least 2 years before an SSc diagnosis and increased over time, reflecting both the progressive, multisystem nature of SSc and potential challenges in diagnosis. These findings suggest that SSc poses a substantial burden on the US health care system and highlights the need for early diagnosis and effective therapies.

The Importance of Medical Device Reporting by Health Technology Managers Before and After Recalls Are Posted

The Food and Drug Administration (FDA) performs postmarket surveillance of medical devices as part of its mission to ensure that devices remain safe and effective while they are on the market. Medical device reporting by manufacturers, user facilities, and the public plays an important role in the agency identifying and resolving medical device safety signals. User facilities are defined as a hospital, ambulatory surgical facility, nursing home, outpatient diagnostic facility, or outpatient treatment facility and do not include physician's offices. The Safe Medical Devices Act requires user facilities to report medical-device–related deaths to the FDA and the device manufacturer, to report device-related serious injuries to the manufacturer, and to submit an annual summary of all device reports to the FDA. If the manufacturer is unknown for a serious injury report, the user facility then submits the report to the FDA. Healthcare technology managers in user facilities use their expertise to recognize, communicate, and evaluate medical device concerns. This article highlights the importance of identifying and reporting medical device issues to the FDA to ensure continued safety and effectiveness of devices on the market.

B-236 Portable 2 Hour Sample-to-Answer Multi-pathogen Phenotypic Antibiotic Susceptibility Test (AST)

Abstract Background Antimicrobial Resistance is a rapidly growing issue worldwide, arising from the overuse and misuse of antibiotics. The strongest tool the medical community has available to combat AMR is rapid, correct application of antibiotics to identified bacterial infections. Clinics and physician offices seek on-site rapid solutions to speed the pathway to timely and appropriate antibiotic therapies. GeneCapture is prototyping a rapid, sample-to-answer product to provide antibiotic susceptibility results directly from infected urine or wound samples. The test provides a susceptible vs non-susceptible call in under two hours and can be applied to samples with single or mixed pathogens. With support from the Defense Health Agency, a portable table-top instrument and disposable cartridge are being engineered to run this test at the point of care, allowing same-day prescriptions. The process is currently operational on the lab bench. Methods Fluorescent labeling of bacterial species, followed by optical counting, determines population growth with/without a suite of antibiotics. An on-board algorithm instantly converts raw cell numbers into a differential call of Susceptible or Non-susceptible for each bug/drug pair. A disposable cartridge with on-board antibiotics has been designed and is being finalized for fabrication. The optical counting is operating in a desktop device. Results Testing to date includes 124 strains from 7 of the most common Urinary Tract Infection and wound pathogens against a panel of six antibiotics. A total of 541 antibiotic/bacterial strain pairs in single or multiple pathogen antibiotic susceptibility testing (AST), are producing an initial 88.7% agreement to gold standard culture results. These results are all generated in two hours or less of assay time and represent a strong preliminary data set. Conclusion This 2-hour portable, novel, phenotypic AST profiling will produce informed and effective treatment options for medics, clinics and physician offices long before existing AST methods could return results.

Lost in Translation: Why Are Rates of Hypertension Control Getting Worse Over Time?

Treatment of hypertension to decrease rates of cardiovascular disease is the most well studied and most broadly applicable treatment in cardiovascular prevention. Blood pressure can be measured anywhere, not just in a physician's office; medications are readily available, inexpensive, and have highly favorable benefit/harm ratios with relatively minimal side effects; and stepped medication regimens can be prescribed in algorithmic fashion by a variety of practitioners. Yet overall hypertension control rates in the United States have never exceeded 60%, and the last 5-10 years have seen decreased, rather than increased, rates of control. Here, I describe the scale of this massive failure to deliver on the promise of preventive hypertension care; outline the populations most affected and the contemporaneous events that have impacted hypertension control; discuss the disparate paths of hypertension science and health care delivery; and highlight novel interventions, approaches, and future opportunities to bend the curve back toward improvements in hypertension control.

Health-Care Resource Utilization and Treatment Patterns in Men with Erectile Dysfunction and Benign Prostatic Hyperplasia-Associated Lower Urinary Tract Symptoms in the United States: A Retrospective Database Study.

To compare health-care resource utilization (HCRU) outcomes in patients with erectile dysfunction (ED) and benign prostatic hyperplasia-associated lower urinary tract symptoms (BPH-LUTS) treated with tadalafil or non-phosphodiesterase-5 inhibitor (PDE5i), adherence to and persistence with tadalafil by dose in the United States (US). This was a noninterventional, real-world evidence study of men (aged ≥45 years) with ED and BPH-LUTS treated with tadalafil or non-PDE5i. The IQVIA US PharMetrics Plus claims database was used. Outcomes included all-cause and disease-specific HCRU over a 12-month follow-up. Persistence with and adherence to tadalafil were evaluated stratified by dose (10 or 20 mg as needed; 2.5 or 5 mg as once daily [OD]). The final sample comprised 11,351 tadalafil and 48,722 non-PDE5i patients. For all-cause and disease-specific HCRU, including prescription fills, physician office visits, emergency room visits, laboratory tests, radiology examinations, outpatient surgical services, ancillary services, hospitalizations, mean number of utilizations, and proportions of patients with one or more utilizations, were lower for tadalafil compared with non-PDE5i patients. For all-cause HCRU, proportions of patients with one or more emergency room visits (18.6% vs 21.7%, p<0.0001) and outpatient surgical visits (63.0% vs 68.8%, p<0.0001) were significantly lower for tadalafil compared with non-PDE5i patients. For disease-specific HCRU, the proportion with one or more disease-specific physician office visits (55.1% vs 91.4%), laboratory tests (34.8% vs 58.2%), outpatient surgery (24.3% vs 38.9%), or outpatient ancillary services (18.0% vs 29.8%) were significantly lower for tadalafil compared with non-PDE5i patients (all comparisons, p<0.0001). Mean persistence days (179.8 vs 61.2), proportion persistence (35.8% vs 6.5%), and mean adherence (0.5 vs 0.2) were higher for tadalafil OD doses than as-needed tadalafil doses. Patients on tadalafil demonstrated less HCRU and higher persistence and adherence (OD versus as-needed tadalafil) than non-PDE5i patients, which demonstrates its benefit in the management of ED and BPH-LUTS in the US.

Racial/Ethnic Residential Segregation, Neighborhood Health Care Provision, and Choice of Pediatric Health Care Provider Across the USA.

Much research has been conducted that demonstrates a link between racial/ethnic residential segregation and health care outcomes. We suggest that minority segregated neighborhoods may have diminished access to organizations and that this differential access may contribute to differences in health care outcomes across communities. We analyze this specifically using the case of pediatric health care provider choice. To examine this association, we estimate a series of multinomial logistic regression models using restricted data with ZIP code level geoidentifiers from the 2011-2012 National Survey of Children's Health (NSCH). We find that racial/ethnic residential segregation is related to a greater reliance on non-ideal forms of health care, such asclinics, and hospital outpatient departments, instead of pediatric physician's offices. This association is at least partially attenuated by the distribution of health care facilities in the local area, physician's offices, and health care practitioners in particular. Additionally, families express greater dissatisfaction with these other forms of care compared to physician's offices, demonstrating that the lack of adequate health care provision is meaningful for health care outcomes. This study expands the literature by examining how the siting of health organizations has consequences for individuals residing within these areas.

Missing Components of Receptor Status Among Women With Invasive Breast Cancer

There are well-known differences in patient outcomes and effective therapeutic options across subtypes of breast cancer (BC), defined by the status of estrogen receptor, progesterone receptor, and erb-B2 receptor tyrosine kinase 2 (ERBB2 [formerly HER2]) expression, making testing for these receptors part of the routine workup for all patients with a diagnosis of invasive BC. Despite its importance, this information is missing in some BC cases. To identify female patients with BC without record of testing for estrogen receptor, progesterone receptor, or ERBB2 status, defined as missing components of receptor status (MCRS). This cross-sectional study used data from National Cancer Institute's Surveillance, Epidemiology and End Results Program of 18 population-based registries from women with a diagnosis of invasive BC (excluding death certificate-only and autopsy cases) from January 2012 to December 2016. The final analyses were completed in February 2022. The primary outcome was MCRS. Those with MCRS were summarized by age, race, stage at diagnosis, reporting source, primary payer, and geography. Multivariable logistic regression was used to estimate adjusted odds ratios (aORs) for MCRS. Overall, 321 913 patients with invasive BC were included (1928 [1%] American Indian or Alaska Native, 28 173 [9%] Asian or Pacific Islander, 36 357 [11%] Black, and 252 447 [78%] White individuals); of these, 15 250 (4.7%) had MCRS. The multivariable model showed that the odds of MCRS were higher in women 80 years or older compared with those younger than 49 years (aOR, 1.75; 95% CI, 1.65-1.88), Black compared with White women (aOR, 1.09; 95% CI, 1.00-1.16), and those with distant stage or unknown/unstaged cancer at diagnosis compared with a local stage at diagnosis (aOR, 3.33; 95% CI, 3.17-3.50; and aOR, 19.39; 95% CI, 18.15-20.72; respectively). With hospital inpatient/outpatient or clinic as the reference group, cases reported by laboratory only, nursing/convalescent home/hospice, and a physician's office were more likely to have MCRS (aOR, 1.42; 95% CI; 1.28-1.60; aOR, 9.37; 95% CI, 6.03-14.53; and aOR, 2.32; 95% CI, 2.06-2.62; respectively). Adjusted odds of MCRS were higher for the categories of insured/no specifics and insurance status unknown compared with those who were insured. The adjusted odds of MCRS were higher in rural compared with urban areas (aOR, 1.08; 95% CI, 1.03-1.15). The results of this cross-sectional study of women with a diagnosis of invasive BC suggest that despite a standard of care recommended by all expert guidelines, there needs to be greater focus on hormone receptor and ERBB2 testing in all women with invasive BC. The results of this study may help clinicians, public health practitioners, and policymakers target affected populations to minimize or eliminate this critical health disparity and help save more lives.

Patient Experiences With Hand Surgery in the Office Versus Ambulatory Surgery Center.

Background In hand surgery, physicians are working to improve patient satisfaction by offering several minor procedures in the physician's office via the Wide-Awake Local Anesthesia No Tourniquet (WALANT) method.This study investigates the degree of patient satisfaction, out-of-pocket costs, peri- and postoperative pain, convenience, and comfort experienced with in-office hand procedures compared to ambulatory surgery center (ASC) procedures. Methods A 10-question survey consisting of a 10-point Likert scale of agreement and numerical questions was administered to patients treated with minor hand operations in the office and ASC settings in Florida, USA. The surgical procedures included are bony reconstruction, percutaneous pinning, open reduction internal fixation, closed fracture reduction, mass removal, endoscopic carpal tunnel release, Dupuytren's release/tendon repair, and trigger finger release. Procedures and patient demographics were assessed via chart review. Independent samples t-test was used to determine statistical associations with significance defined as p < 0.05. Results Patients reported a strong level of agreement in response to questions 1-3 and 6-8, indicating a high degree of convenience, comfort, and overall satisfaction with both in-office and ASC procedures. Positive metrics gauged in questions 1-3 and 6-8 averaged 9.64 ± 0.14 in the office setting and 9.62 ± 0.16 in the ASC setting.Questions 4 and 5 averaged 2.74 ± 0.29 in the office setting and 2.84 ± 4.12 in the ASC setting, indicating mild disagreement that the surgery or recovery period was painful. In-office patients reported taking 0.91 ± 2.80 days off work and ASC patients reported taking 12.43 ± 22.51 days off work following surgery (p = 0.0039). Respondents reported an out-of-pocket cost averaging $348 ± $943 in the office setting and $574 ± $1262 in the ASC setting, depending on insurance coverage (p = 0.3019). Conclusions Though costs and time off of work differed between the two groups due to the different procedures in either setting, patient satisfaction metrics were comparable. While patient satisfaction depends on the operating physician, these results demonstrate that patients treated in-office and in an ASC have similar levels of approval with their hand surgery care.

Association of the Range of Outpatient Services Provided by Primary Care Physicians with Subsequent Health Care Costs and Utilization.

Broader primary care practice range of services (ROS), defined as the diversity of professional services delivered, is associated with lower utilization. ROS provided by individual primary care physicians (PCPs) varies considerably with unclear implications for patients. Create a PCP-ROS measure covering six categories of outpatient services, including expanded codes for mental health counseling services and point of care ultrasound (POCUS) technology in physician offices. Determine whether PCP-ROS is associated with total Medicare expenditures, inpatient admissions, acute hospital utilization (AHU), and emergency department (ED) visits. Examine physician and practice characteristics associated with PCP-ROS. Retrospective cohort study. 4,569,711 Medicare fee-for-service beneficiaries and 27,008 PCPs observed during the evaluation of the Comprehensive Primary Care Plus (CPC +) initiative. PCP-ROS, hospitalizations, AHU (includes observation stays as well as inpatient admissions), ED visits, and total Medicare expenditures. Physicians varied substantially in the range of services provided. Broader PCP-ROS was significantly, independently associated with 1 - 3% lower Medicare expenditures (p ≤ 0.01), inpatient admissions (p ≤ 0.027), AHU (p ≤ 0.025), and ED visit rates (p ≤ 0.000). PCP-ROS score was associated with improved patient outcomes, independent of physician provision of procedures (such as laceration repair or skin excisions). Physicians in practice sites affiliated with a hospital or health system had narrower PCP-ROS than independent physicians by 0.3 to 0.4 (p < 0.001). Internal medicine specialty was associated with narrower PCP-ROS than family medicine by 0.3 (p < 0.001). Patients cared for by primary care physicians who provide a broader range of services subsequently experience lower acute care utilization and expenditures than do those cared for by physicians with narrower ROS. Practice leaders and professional associations should consider how best to ensure that primary care physicians efficiently and effectively provide the office-based professional services most needed by their patients.

Clinical Guidelines for the Evaluation and Treatment of Lumbar Disc Herniations: How Accurate is the Internet?

To compare information online regarding lumbar disc herniation (LDH) on commonly searched websites and compare those findings with the evidence-based recommendations listed in the North American Spine Society (NASS) clinical practice guidelines. NASS Clinical Practice Guidelines, Internet searches were performed utilizing three common search engines (Google, Bing, Yahoo) and keywords associated with LDH. The top 20 websites from each search were selected. The content regarding diagnosis and treatment of LDH was compared to the NASS clinical practice guidelines. On average, websites mentioned only 59% of recommendations supported by Level I evidence. Websites included an average of 3 recommendations not discussed in the NASS guidelines out of an average of 12 total recommendations. Muscle and sensory testing and physical therapy were the most frequent recommendations, appearing on over 80% of websites. Websites were equally likely to contain recommendations backed by high-quality evidence as recommendations not included in NASS guidelines. This study demonstrates that websites regarding LDH contain a mix of information, with only a fraction of recommendations aligning with NASS clinical guidelines. Patients who use these websites are presented with unsubstantiated information, conceivably impacting their understanding, expectations and decision-making in physician offices.

Costs and Resource Utilization of People with Stable Heart Failure and Insomnia: Evidence from a Randomized Trial of Cognitive Behavioral Therapy for Insomnia

ABSTRACT Objectives Nearly half of patients with chronic heart failure (HF) report insomnia symptoms. The purpose of this study was to examine the impact of CBT-I versus HF self-management on healthcare costs and resource utilization among patients with stable chronic HF who participated in a clinical trial of the effects of CBT-I compared to HF self-management education (attention control) over 1 year. Methods We measured resource utilization as self-reported (medical record review) physician office visits, emergency department visits, and inpatient admissions at 3-month intervals for 1 year after enrollment. Costs were estimated by applying price weights to visits and adding self-reported out-of-pocket and indirect costs. Univariate comparisons were made of resource utilization and costs between CBT-I and the HF self-management group. A generalized linear model (GLM) was used to model costs, controlling for covariates. Results The sample included 150 patients [79 CBT-I; 71 self-management (M age = 62 + 13 years)]. The CBT-I group had 4.2 inpatient hospitalizations vs 4.6 for the self-management group (p = .40). There were 13.1 outpatient visits, in the CBT-I compared with 15.4 outpatient visits (p-value range 0.39–0.81) for the self-management group. Total costs were not significantly different in univariate or ($7,813 CBT-I vs. $7,538 self-management), p = .96) or multivariable analyses. Conclusions Among patients with both HF and insomnia, CBT-I and HF self-management were associated with similar resource utilization and total costs. Additional research is needed to estimate the value of CBT-I relative to usual care and other treatments for insomnia in patients with HF.