Single-payer Research Articles

Alberta Cellular and Immunotherapy (ACIT) 001, Results of Decentralized Production of Second Generation, Anti-CD19/41BB/CD3z Chimeric Antigen Receptor (CAR) T-Cells in Relapsed/Refractory (R/R) Acute Lymphoblastic Leukemia (ALL) and Aggressive Non-Hodgkin Lymphoma (NHL)

Purpose Anti-CD19 CAR T-cells are a standard treatment for aggressive B-cell cancers. Decentralized production may improve access to this important treatment and provide a platform for additional translational science in a single payer, public health care system such as Canada where implementation of CAR T-cells has been non-uniform and slow. ACIT001/EXC002 is a phase 1b/2 clinical trial examining the feasibility, safety, and efficacy of decentralized production of anti-CD19 CAR T-cell using the CliniMACS Prodigy bioreactor to treat R/R ALL and NHL patients. We report the phase 1b results in adults. Methods ACIT001/EXC002 launched following ethics approval with 2 manufacturing sites to service 4 clinical delivery sites. The phase 1b study used a 3+3 dose escalation design with two arms, one for adults (NHL or ALL, competitive enrollment) and one for children (ALL). CD19 expression was confirmed on their fresh or archival tumor samples and all patients had received a minimum of 2 prior lines of therapy. Patients with transformed disease or central nervous system involvement were allowed to participate. Anti-CD19 CAR T-cells were manufactured using freshly apheresed peripheral blood T-cells using a Lentigen anti-CD19 vector. Patients received cyclophosphamide (500 mg/m2) and fludarabine (30 mg/m2) as outpatient intravenous lymphodepleting chemotherapy on Days -5, -4 and -3 prior to infusion of CAR T-cells. Infusion of fresh CAR T-cells was favored but cryopreservation was permitted if clinical circumstances dictated a delay between apheresis and treatment. Patients were suggested to remain in hospital for 7 days at minimum but length of stay was not mandated. Results 10 patients were accrued to the phase 1b portion of the study. One extra patient was accrued due to an unexpected, treatment unrelated death (COVID 19). In-specification products were manufactured for each of the 9 evaluable patients (5 NHL and 4 ALL) and all patients received fresh CAR T-cells a median of 14 days after apheresis ("vein-to-vein", range 14-15 days). Grade 1 or 2 cytokine release syndrome (CRS) occurred in 7 (78%) of patients; tocilizumab was used in 5 (56%) of patients. Grade 1 or 2 Neurotoxicity (ICANS) occurred in 2 (22%) patients, and responded to limited dexamethasone. Median length of stay in hospital was 11 days (range 9-17 days). Investigator-assessed, objective response rate was 78% (7 of 9). All 4 ALL patients demonstrated a complete response (CR) to therapy with 3 negative for minimal residual disease (MRD) by flow cytometry (10-4). 3 (75%) of NHL patients showed a response to therapy including 2 CR's. With a median 8 months of follow-up time, 5 patients remain in remission (3 ALL, 2 NHL). Of 3 NHL patients demonstrating progression on trial, 1 had partial response prior to progression and 2 had refractory disease. T-cell exhaustion was associated with poor response to CAR T-cell therapy (see related abstract). Additional correlative analyses and health economics analyses are underway. Summary Our phase 1b results provide evidence that decentralized production is feasible in a single payer, public health care system. With a consistent vein-to-vein time of 14 days, we remove the inconsistency of manufacturing windows from standard of care products and have direct control over supply of CAR T-cells for our patient population. This method also implies that having smaller local manufacturing facilities allows a savings of scale while promoting improved and faster service than the creation and maintenance of a large, centralized manufacturing facility. This particular CAR T-cell product demonstrates a safety profile and efficacy similar to standard-of-care products through completion of the phase 1b portion of this trial. These results have prompted expansion to phase 2 in separate arms for ALL and NHL.

Shift in First-Line Therapies for United States Veterans Health Administration (VHA) Patients with Chronic Lymphocytic Leukemia (CLL) from 2014 to 2021

Introduction: The emergence of novel agents (NAs) in chronic lymphocytic leukemia (CLL) management marks a move away from a chemotherapy-based paradigm in less than a decade. This has resulted in better treatment tolerance and improved overall survival. The Veteran Health Administration (VHA) offers an attractive population for examining CLL treatments patterns because of two main reasons. It serves mainly older white male population, where incidence of CLL is higher, and is the only single payer national health program that provides equal access to medications. This aim of the study is to assess large population-based uptake of the NAs and to analyze the trends in chemotherapy-based regimen replacement by NA in front-line (1L) CLL. Methods: This is a retrospective study of structured EMR data for adult patients with ICD9 and ICD10 CLL codes within the VHA who initiated 1L treatment with one of 14 CLL treatment [eight NAs and six chemotherapy-based regimens] from 1/1/2014 to 12/31/2021. Data were extracted from the VHA electronic health record. Patients came from all 18 Veterans Integrated Service Networks, spanning all 50 states and US territories. Descriptive statistics were used to summarize baseline characteristics and treatments by calendar year. Results: A cohort of 4,473 patients were identified who received at least one 1L CLL therapy of interest. The median age was 69 years and 98% were male. The proportion of patients who received an NA as 1L treatment for CLL increased from 2014 to 2021, with a corresponding decrease in chemotherapy-based regimens (Figure 1). In 2017, the proportion of NAs surpassed chemotherapy-based regimen use (52 vs 48%, respectively). This gap continued to widen throughout the study period, with the use of chemotherapy-based regimens plateauing for the last three fiscal years of the study period at ~20%. The use of ibrutinib (90%) accounted for the greatest proportion of 1L NA use over the study period, followed by venetoclax (5%), acalabrutinib (4%), and idelalisib (1%). Until 2018, ibrutinib made up nearly 100% of the NA use with a steady decline thereafter reaching 62% in 2021. The proportion of patients on 1L venetoclax increased annually from 2018 (2%) to 2021 (19%). Similarly, the proportion of patients on 1L acalabrutinib increased annually from 2019 (0%) to 2021 (19%). The proportion of patients on 1L idelalisib increased early in 2015 (4%) but declined throughout the remaining study period (0-1%) (Figure 2). Conclusions: This is one of the largest studies that provides important epidemiological data regarding emerging 1L treatment patterns among VHA patients with CLL. There has been a major shift in 1L treatments with NAs outpacing chemotherapy-based regimens from 2017-2021. Within NAs, there is an ongoing transition from first generation Bruton Tyrosine Kinase (BTK) inhibitor to fixed duration treatments and second generations BTK inhibitors with better side effect profiles. The trend shift will continue to evolve as multiple NAs combinations that offer deeper response and limited/guided treatment duration enter the treatment landscape. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Outcomes Associated With Colorectal Cancer After Population-Based Colonoscopy Screening: Results From a European Pragmatic Randomized Trial

Bretthauer M, Løberg M, Wieszczy P, et al. Effect of colonoscopy screening on risks of colorectal cancer and related death. N Engl J Med 2022;387:1547–1556. Colorectal cancer (CRC) is an ideal target for both opportunistic and population-based screening. Currently recommended screening strategies rely primarily on stool-based modalities such as fecal immunochemical testing (FIT) and endoscopic modalities such as sigmoidoscopy and colonoscopy. Bretthauer et al performed the first randomized trial to assess the effects of population-based screening colonoscopy on CRC and CRC-associated death. Screening-naïve healthy participants aged 55 to 64 years from 4 European countries were identified from population registries and, in a 1:2 ratio, randomly invited to undergo screening colonoscopy or not invited for screening. Screening colonoscopies were performed from 2009 to 2014. Importantly, no participants received any competing CRC screening modalities outside of the trial during either the screening or follow-up periods. Follow-up data were available for 84,585 patients. Among the invited group, 42.0% of participants accepted their invitation and underwent colonoscopy. The mean adenoma detection rate (ADR) was 30.7%. In intention-to-treat analyses, the 10-year risk ratio (RR) of CRC was 0.82 (95% confidence interval [CI] 0.70–0.93) in the screening arm, although the risk of CRC-related death was not significantly different (RR 0.90, 95% CI 0.64–1.16). In per-protocol analyses, RRs of CRC and CRC-related death with screening were 0.69 (95% CI 0.55–0.83) and 0.50 (95% CI 0.27–0.77), respectively. These results have triggered a broad range of reactions. Given the acceptance rate of 42%, one widely repeated stance is that colonoscopy can be effective only if performed, and that the per-protocol analyses may be a better representation of colonoscopy’s benefits (Dominitz and Robertson, N Engl J Med 2022;387:1609–1611). While perhaps true at the patient level, the aims of this study were to assess the efficacy of colonoscopy as a population-based screening tool. Therefore, barriers to dissemination, acceptability, and uptake are all relevant. Put another way, one might ask whether offering screening colonoscopy as a primary population-based screening modality increases or decreases health equity. Furthermore, existing cohort studies, which likely overestimate colonoscopy’s effectiveness given healthy user bias and inability to adjust for poor uptake, have demonstrated similar results (Nishihara et al, N Engl J Med 2013;369:1095–1105). The issue of justifying the costs (and risks) of colonoscopy as a primary screening modality is therefore also paramount, especially in single-payer resource-limited health care systems, given the established benefits of FIT in reducing CRC incidence and mortality (Chiu et al, Cancer 2015;121:3221–3229). Another debatable point is that the mean ADR was potentially suboptimal at 30.7%. However, given (1) the study period (2009–2014), (2) the screening-naïve non-FIT population, and (3) the upper age limit of 64 years (with established increases in ADR with increasing age [Shaukat et al, Am J Gastroenterol 2021;116:1946–1949]), these results are likely generalizable. Furthermore, inter-endoscopist variations in ADR are well established, with outliers prevalent in most practice settings (Mazurek et al, Clin Gastroenterol Hepatol 2022;20:1931–1946; Bishay et al, Gastrointest Endosc 2020;92:1030–1040.e9). Although the benefits of screening colonoscopy are clear at the patient level, providers and policy makers should carefully consider its role in population-based average-risk screening. Similar studies with long(er) follow-up periods, studies comparing colonoscopy and FIT for population screening, and studies carried out in different populations are all needed. Regardless of the modalities employed, ongoing efforts should be made to provide widespread patient education on CRC screening to improve uptake and optimize health equity.

Abstract 14016: Marked Geographic Variation in Atrial Fibrillation Ablation Rates in a Universal Single Payer Health Care System

Introduction: Atrial fibrillation (AF) ablation is increasingly commonly performed for patients with symptomatic AF. In Canada, AF ablation occurs at specialized electrophysiology centers (“EP centers”), which are clustered in major urban centers. Hypothesis: People with AF who live closer to an EP center are more likely to undergo an AF ablation. Methods: Data was compiled from Ontario Health datasets (e.g. emergency department (ED) visits, hospital discharges, physician billing) and Canadian census data for people presenting to an ED in Ontario, Canada with a new diagnosis of AF between 2007-16. The primary outcome was ablation within one year of the index ED visit. Secondary outcomes include ablation at two years. Multivariate logistic regression was conducted to assess the relationship between distance to EP centers and likelihood of ablation. We also studied ablation frequency in relation to material deprivation (e.g. income, housing quality and education). Geospatial analyses were performed using QGIS. Results: Of the 135,681 people with newly diagnosed AF, 3911 (2.9%) had an ablation within one year of AF diagnosis and 5827 (4.3%) within two. There was a significant inverse relationship between a doubling of distance to the closest EP center and ablation within one year (OR: 0.93, 95% CI: 0.91-0.94), and two years (OR: 0.95, 95% CI: 0.94-0.97). Higher deprivation (measured in standard deviations from the mean) was associated with significantly less ablation at one year (OR: 0.89, 95% CI: 0.85-0.92). There was wide regional variation with relatively low rates near the largest urban center (Figure 1). Conclusions: Living further from an EP center and greater material deprivation are associated with lower AF ablation rates. Ablation rates vary by region, with the highest rates not consistently observed in areas most concentrated with EP centers. Figure 1. Age and sex adjusted AF ablation rates per 100,000 patients within a year of AF diagnosis in Ontario, Canada

How do countries plan, purchase and use imaging technologies to prevent over-purchase and overuse?

Abstract Background The adoption of new and expensive technologies is one of the main causes of the growing expenditure on health. Regulators are concerned that health care providers purchase (and use) imaging technologies in quantities that exceed the need, increasing expenditure with little value. We review how countries regulate the purchase and use of imaging technologies. Methods Qualitative. We collected data using a questionnaire completed by researchers from 17 high-income countries purposefully selected based on variation of policies. We built and compared case studies. Results Eleven of the 17 countries analyzed have clear criteria for planning and purchasing imaging technologies. Countries plan different areas, such as supply of specialist care, hospitals by level and type of services, quantity or type of equipment, as well as expenditure on health services and resource allocation. Most countries combine three mechanisms that manage the purchase or use of imaging technologies: (1) seven countries regulate by requiring certificates of need, licenses, or purchase approvals; others regulate by directly limiting the amounts, types and quality of technologies. (2) All countries use financial tools such as activity-based payment, limited and conditional budgets, and caps on income or volume of services. (3) Nine countries centralize purchase by a government agency. The literature provides inconclusive evidence regarding the impact of these mechanisms on expenditure on health and access to imaging services. Conclusions Planning the imaging technologies market with clear criteria is essential to avoid abuse. Most countries combine the three mechanisms (regulation, financial tools, centralized purchase). Financial tools are more common and effective. Countries with single payers implement more regulation than countries with multiple, competing, payers. In the later, regulated competition seems to replace regulation. There is a trend of adopting centralized procurement. Key messages • Planning the imaging technology market is a precondition to avoid abuse. • Regulation, financial tools, and centralized purchase can be combined to manage the use of imaging technologies.

State-Based and National U.S. Registries: The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI), California Joint Replacement Registry (CJRR), and American Joint Replacement Registry (AJRR).

The concept of a total joint registry as a tool to gather and compare longitudinal clinical outcome data emerged in the early 1970s; although initially begun as a single-institution effort, it soon spread to the development of large nationwide registries, first in Scandinavia and subsequently around the world. These national registries established the value of population-wide results, large cohorts, and the importance of ongoing implant surveillance efforts, as detailed elsewhere in this series. In the United States, concerted efforts to establish a national total joint registry for the hip and knee began in earnest in the early 2000s and culminated with the incorporation of the American Joint Replacement Registry (AJRR) in 2009. Parallel efforts soon followed to establish state-based total joint registries, either as stand-alone entities or in affiliation with the AJRR. Some of these state-based efforts succeeded, and some did not.In the first section of this article, Brian Hallstrom, MD, details the highly successful Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI). This state-based effort was made possible by a unique partnership between a single dominant statewide private payer and the Michigan orthopaedic surgery community; it has already successfully advanced the quality of care for patients in Michigan, and efforts are ongoing.The second section, by James I. Huddelston, MD, details a different path to the establishment of a focused state-based registry. The California Joint Replacement Registry (CJRR) was the result of a partnership with representatives of the statewide business community and resulted in a pioneering effort to successfully collect and publicly report patient-reported outcome measures as part of the registry data set. Further discussed are the establishment, development, and status of the AJRR and its current place among the family of American Academy of Orthopaedic Surgeons (AAOS) registries, which were inspired by the AJRR and span a range of orthopaedic specialties.

Location and outcomes of rehospitalizations after critical illness in a single-payer healthcare system.

Unplanned rehospitalization at a hospital other than the initial hospital may contribute to poor outcomes. We examined the location of rehospitalizations and assessed outcomes following critical illness in a single-payer healthcare system. Population-based retrospective cohort study using linked datasets (2012-2017) from Ontario, Canada including adults (≥18 years) with an unplanned rehospitalization within 30-days after an index hospitalization that included an ICU stay with mechanical ventilation. Outcomes were the percentage of 30-day rehospitalizations at non-index hospitals, mortality and costs. We employed logistic regression and generalized linear models to assess associations. There were 14,997 (16.4%) 30-day rehospitalizations. Of these 2765 (18.4%) occurred in a non-index hospital. Distance of home residence from the index hospital was the strongest predictor of a non-index rehospitalization (adjusted odds ratio (aOR) 8.40, 95%CI 7.05-10.01, highest vs. lowest distance quintile). Within 30-days of rehospitalization, deaths (aOR 0.91, 95%CI (0.80-1.04)) and total healthcare costs (adjusted relative risk 1.03 (1.00-1.06)), were similar for patients readmitted to the index or a non-index hospital. Non-index rehospitalization within 30-days of initial discharge is common following critical illness. These rehospitalizations were not significantly associated with an increased risk of harm or higher costs in a single-payer healthcare system.

MAKNA UANG BAGI MAHASISWA DALAM PERSPEKTIF SOSIOLOGI

This study aims to determine the meaning of money and its social implications for students who are bidikmisi scholarship recipients and single tuition payers V FISIP UNRI. This study uses a qualitative research method with a phenomenological approach. Data collection was carried out using in-depth interviews, observation, and documentation techniques. The subjects in this study were six students of the Bidikmisi scholarship and single tuition fee payers (STF) V FISIP UNRI using a purposive sampling technique based on certain criteria. The results of this research show that money is very important. Almost all aspects of human life are related to money. because the different socio-economic conditions in each student lead to different meanings in interpreting money. For students receiving Bidikimisi: Money is something valuable and valuable, Money as a fulfillment of basic needs, No money will have an impact on psychological and inner peace, Money as a form of gratitude, Money as a symbol of equality or not. For Students Paying Single Tuition Fees (STF) V: The meaning of money as a measure of behavior and attitudes, as a tool to achieve something in the future, as a creator of happiness by helping others, and upholding the value of simplicity. Likewise with the implications of the meaning of money which is something that is produced or as a consequence of the implementation of the meaning of money. For bidikmisi students, the meaning of money implies that they have to work hard to earn money to meet basic needs. while for students who pay single tuition payers (STF) V the implication of the meaning of money being present is freedom, appreciation, and social recognition as well as a point of self-actualization.

Original work by women

Unplanned rehospitalization at a hospital other than the initial hospital may contribute to poor outcomes. We examined the location of rehospitalizations and assessed outcomes following critical illness in a single-payer healthcare system.Population-based retrospective cohort study using linked datasets (2012–2017) from Ontario, Canada including adults (≥18 years) with an unplanned rehospitalization within 30-days after an index hospitalization that included an ICU stay with mechanical ventilation. Outcomes were the percentage of 30-day rehospitalizations at non-index hospitals, mortality and costs. We employed logistic regression and generalized linear models to assess associations.There were 14,997 (16.4%) 30-day rehospitalizations. Of these 2765 (18.4%) occurred in a non-index hospital. Distance of home residence from the index hospital was the strongest predictor of a non-index rehospitalization (adjusted odds ratio (aOR) 8.40, 95%CI 7.05–10.01, highest vs. lowest distance quintile). Within 30-days of rehospitalization, deaths (aOR 0.91, 95%CI (0.80–1.04)) and total healthcare costs (adjusted relative risk 1.03 (1.00–1.06)), were similar for patients readmitted to the index or a non-index hospital.Non-index rehospitalization within 30-days of initial discharge is common following critical illness. These rehospitalizations were not significantly associated with an increased risk of harm or higher costs in a single-payer healthcare system.

What counts? Policy evidence in public hearing testimonies: the case of single-payer healthcare in New York State

What counts? Policy evidence in public hearing testimonies: the case of single-payer healthcare in New York State

Beyond borders: cystic fibrosis survival between Australia, Canada, France and New Zealand

BackgroundLife expectancy for people with cystic fibrosis (CF) varies considerably both within and between countries. The objective of this study was to compare survival among countries with single-payer healthcare systems...

Financing of Public Health Care for the Population of the Russian Federation: To Maintain Multichannel or Switch to a Single Payer System?

The subject of the research is the models of collection and consolidation (pooling) of resources for payment of public (free at the place of delivery) medical care to the population in developed countries and in the Russian Federation. The purpose of the study is to develop practical recommendations on the development of a system for financing medical guarantees for the population of the Russian Federation. The relevance of the study is due to the lack of resources to pay for public health care for the entire population in our country. The scientific novelty lies in the comparison of single-channel and multichannel pooling models used by developed countries in terms of their financial-economic and medico-social efficiency with the conclusion about a higher level of costs of the multichannel model with a comparable level of coverage with medical services of the population and indicators of its health compared to the model single payer. The research methodology is based on the use of complex, statistical, comparative and retrospective analyzes. It was concluded that the use of a multichannel pooling model in the financing of healthcare in the Russian Federation with the participation of competing insurers and the use of different channels of budgetary financing for different groups of the population is an important reason for the low efficiency of the Russian healthcare system. The prospect of further research is in the formation of a scientific and methodological justification for replacing the multichannel pooling model, which has historically developed in healthcare in Russia, with a single-channel model of a single payer represented by the Federal Compulsory Medical Insurance Fund (hereinafter- CMIF).

Chromosomal microarray analyses from 5778 patients with neurodevelopmental disorders and congenital anomalies in Brazil

Chromosomal microarray analysis (CMA) has been recommended and practiced routinely since 2010 both in the USA and Europe as the first-tier cytogenetic test for patients with unexplained neurodevelopmental delay/intellectual disability, autism spectrum disorders, and/or multiple congenital anomalies. However, in Brazil, the use of CMA is still limited, due to its high cost and complexity in integrating the results from both the private and public health systems. Although Brazil has one of the world’s largest single-payer public healthcare systems, nearly all patients referred for CMA come from the private sector, resulting in only a small number of CMA studies in Brazilian cohorts. To date, this study is by far the largest Brazilian cohort (n = 5788) studied by CMA and is derived from a joint collaboration formed by the University of São Paulo and three private genetic diagnostic centers to investigate the genetic bases of neurodevelopmental disorders and congenital abnormalities. We identified 2,279 clinically relevant CNVs in 1886 patients, not including the 26 cases of UPD found. Among detected CNVs, the corresponding frequency of each category was 55.6% Pathogenic, 4.4% Likely Pathogenic and 40% VUS. The diagnostic yield, by taking into account Pathogenic, Likely Pathogenic and UPDs, was 19.7%. Since the rational for the classification is mostly based on Mendelian or highly penetrant variants, it was not surprising that a second event was detected in 26% of those cases of predisposition syndromes. Although it is common practice to investigate the inheritance of VUS in most laboratories around the world to determine the inheritance of the variant, our results indicate an extremely low cost–benefit of this approach, and strongly suggest that in cases of a limited budget, investigation of the parents of VUS carriers using CMA should not be prioritized.

Quantifying Improved Outcomes, Cost Savings, and Hospital Volume Changes From Optimized Emergency Stroke Transport.

A previously published conditional probability model optimizes prehospital emergency transport protocols for patients with suspected large-vessel occlusion by recommending the transport strategy, drip-and-ship or mothership, that results in a higher probability of an excellent outcome. In this study, we create generalized models to quantify the change in annual hospital patient volume, the expected annual increase in the number of patients with an excellent outcome, and the annual cost savings to a single-payer healthcare system resulting from these optimized transport protocols. We calculated the expected number of patients with suspected large-vessel occlusion transported by ambulance over a 1-year period in a region of interest, using the annual stroke incidence rate and a large-vessel occlusion screening tool. Assuming transport to the closest hospital is the baseline transport policy across the region (drip-and-ship), we determined the change in annual hospital patient volume from implementing optimized transport protocols. We also calculated the resulting annual increase in the number of patients with an excellent outcome (modified Rankin Score of 0-1 at 90 days) and associated cost savings to a single-payer healthcare system. We then performed a case study applying these generalized models to the stroke system serving the Greater Vancouver and Fraser Valley Area, BC, Canada. In the Greater Vancouver and Fraser Valley Area, there was an annual increase of 36 patients with an excellent outcome, translating to an annual cost savings of CA$2 182 824 to the British Columbia healthcare system. We also studied how these results change depending on our assumptions of treatment times at the regional stroke centers. Our framework quantifies the impact of optimized emergency stroke transport protocols on hospital volume, outcomes, and cost savings to a single-payer healthcare system. When applied to a specific region of interest, these models can help inform health policies concerning emergency transport of patients with suspected large-vessel occlusion.

Editor's Spotlight/Take 5: Are Income-based Differences in TKA Use and Outcomes Reduced in a Single-payer System? A Large-database Comparison of the United States and Canada.

1Senior Editor, Clinical Orthopaedics and Related Research®, Park Ridge, IL, USA P.A. Manner ✉, Clinical Orthopaedics and Related Research®, 300 S. Northwest Highway, Suite 203, Park Ridge, IL 60068, USA, Email: [email protected] A note from the Editor-In-Chief: In “Editor’s Spotlight,” one of our editors provides brief commentary on a paper we believe is especially important and worthy of general interest. Following the explanation of our choice, we present “Take 5,” in which the editor goes behind the discovery with a one-on-one interview with an author of the article featured in “Editor’s Spotlight.” We welcome reader feedback on our editorials as we do on all of our columns and articles; please send your comments to[email protected]. The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®. This comment refers to the article available at: DOI: 10.1097/CORR.0000000000002207.

Removing anonymity protection and utilization review decisions: a real-world case under a single-payer health system

The effects of anonymity on utilization review has never been examined in the real world. This study aimed to evaluate the impact of removing anonymity protection for claims reviewers on their review decisions. Using a single-blinded repeated measures design, we randomly selected 1457 claims cases (with 12,237 orders) that had been anonymously reviewed and reimbursed in 2016 and had them re-reviewed in a signed review program in 2017 under the Taiwanese National Health Insurance scheme. The signed review policy significantly decreased the likelihood of a deduction decision at the case and the order level (P < 0.001). Furthermore, signed reviewers tended to make more “too lenient” decisions, and were less likely to make “too harsh” decisions. Removing anonymity protection dramatically reduced the deduction rate and overturned the tendency of decisions from “too harsh” to “too lenient”. However, whether to maintain the anonymity of utilization reviews is a challenge for health authorities around the globe.

Population-Level Impact and Cost-effectiveness of Continuous Glucose Monitoring and Intermittently Scanned Continuous Glucose Monitoring Technologies for Adults With Type 1 Diabetes in Canada: A Modeling Study

OBJECTIVEMaintaining healthy glucose levels is critical for the management of type 1 diabetes (T1D), but the most efficacious and cost-effective approach (capillary self-monitoring of blood glucose [SMBG] or continuous [CGM] or intermittently scanned [isCGM] glucose monitoring) is not clear. We modeled the population-level impact of these three glucose monitoring systems on diabetes-related complications, mortality, and cost-effectiveness in adults with T1D in Canada.RESEARCH DESIGN AND METHODSWe used a Markov cost-effectiveness model based on nine complication states for adults aged 18–64 years with T1D. We performed the cost-effectiveness analysis from a single-payer health care system perspective over a 20-year horizon, assuming a willingness-to-pay threshold of CAD 50,000 per quality-adjusted life-year (QALY). Primary outcomes were the number of complications and deaths and the incremental cost-effectiveness ratio (ICER) of CGM and isCGM relative to SMBG.RESULTSAn initial cohort of 180,000 with baseline HbA1c of 8.1% was used to represent all Canadians aged 18–64 years with T1D. Universal SMBG use was associated with ∼11,200 people (6.2%) living without complications and ∼89,400 (49.7%) deaths after 20 years. Universal CGM use was associated with an additional ∼7,400 (4.1%) people living complications free and ∼11,500 (6.4%) fewer deaths compared with SMBG, while universal isCGM use was associated with ∼3,400 (1.9%) more people living complications free and ∼4,600 (2.6%) fewer deaths. Relative to SMBG, CGM and isCGM had ICERs of CAD 35,017/QALY and 17,488/QALY, respectively.CONCLUSIONSUniversal use of CGM or isCGM in the Canadian T1D population is anticipated to reduce diabetes-related complications and mortality at an acceptable cost-effectiveness threshold.

HPR59 Targeted and Immunotherapies for Cancer - Reimbursement and Expenditure in a Single-Payer Healthcare System in Bulgaria

Patient access to innovative targeted (TT) and immunotherapies (IT) varies between healthcare payers and it is often related to reimbursement issues. The aim of this article is to analyse the reimbursement and expenditures for TT and IT in a single-payer healthcare system in Bulgaria.

Lessons for Developing Countries From Outlier Country Health Systems.

Building good health systems is an important objective for policy makers in any country. Developing countries which are just starting out on their journeys need to do this by using their limited resources in the best way possible. The total health expenditure of a country exerts a significant influence on its health outcomes but, given the well-understood failures of price-based market-mechanisms, countries that spend the most money do not necessarily end-up building the best health systems. To help developing country policy makers gain a deeper insight into what factors matter, in this study the contribution of per-capita total, out-of-pocket, and pooled health expenditures, to the cross-country variation in Disability Adjusted Life Years lost per 100,000 population (DALY Rates), a summary measure of health outcomes, is estimated. The country-specific residuals from these analyses are then examined to understand the sources of the rest of the variation. The study finds that these measures are able to explain between 40 and 50% of the variation in the DALY Rates with percentage increases in per-capita out-of-pocket and pooled expenditures being associated with improvements in DALY Rates of about 0.06% and 0.095%, respectively. This suggests that while increases in per-capita total health expenditures do matter, moving them away from out-of-pocket to pooled has the potential to produce material improvements in DALY Rates, and that taken together these financial parameters are able to explain only about half the cross-country variation in DALY Rates. The analysis of the residuals from these regressions finds that while there may be a minimum level of per-capita total health expenditures (> $100) which needs to be crossed for a health system to perform (Bangladesh being a clear and sole exception), it is possible for countries to perform very well even at very low levels of these expenditures. Colombia, Thailand Honduras, Peru, Nicaragua, Jordan, Sri Lanka, and the Krygyz Republic, are examples of countries which have demonstrated this. It is also apparent from the analysis that while very high rates (> 75%) of pooling are essential to build truly high performing health systems (with DALYRates < 20, 000), a high level of pooling on its own is insufficient to deliver strong health outcomes, and also that even at lower levels of pooling it is possible for countries to out-perform their peers. This is apparent from the examples of Ecuador, Mexico, Honduras, Malaysia, Vietnam, Kyrgyz Republic, and Sri Lanka, which are all doing very well despite having OOP% in the region of 40–60%. The analysis of residuals also suggests that while pooling (in any form) is definitely beneficial, countries with single payer systems are perhaps more effective than those with multiple payers perhaps because, despite their best efforts, they have insufficient market power over customers and providers to adequately manage the pulls and pressures of market forces. It can also be seen that countries and regions such as Honduras, Peru, Nicaragua, Jordan, Sri Lanka, Bangladesh, Kerala, and the Kyrgyz Republic, despite their modest levels of per-capita total health expenditures have delivered attractive DALY Rates on account of their consistent prioritization of public-health interventions such as near 100% vaccine coverage levels and strong control of infectious diseases. Additionally, countries such as Turkey, Colombia, Costa Rica, Thailand, Peru, Nicaragua, and Jordan, have all delivered low DALY Rates despite modest levels of per-capita total health expenditures on account of their emphasis on primary care. While, as can be seen from the discussion, several valuable conclusions can be drawn from this kind of analysis, the evolution of health systems is a complex journey, driven by multiple local factors, and a multi-country cross-sectional study of the type attempted here runs the risk of glossing over them. The study attempts to address these limitations by being parsimonious and simple in its approach toward specifying its quantitative models, and validating its conclusions by looking deeper into country contexts.

Universal healthcare as pandemic preparedness: The lives and costs that could have been saved during the COVID-19 pandemic

The fragmented and inefficient healthcare system in the United States leads to many preventable deaths and unnecessary costs every year. During a pandemic, the lives saved and economic benefits of a single-payer universal healthcare system relative to the status quo would be even greater. For Americans who are uninsured and underinsured, financial barriers to COVID-19 care delayed diagnosis and exacerbated transmission. Concurrently, deaths beyond COVID-19 accrued from the background rate of uninsurance. Universal healthcare would alleviate the mortality caused by the confluence of these factors. To evaluate the repercussions of incomplete insurance coverage in 2020, we calculated the elevated mortality attributable to the loss of employer-sponsored insurance and to background rates of uninsurance, summing with the increased COVID-19 mortality due to low insurance coverage. Incorporating the demography of the uninsured with age-specific COVID-19 and nonpandemic mortality, we estimated that a single-payer universal healthcare system would have saved about 212,000 lives in 2020 alone. We also calculated that US$105.6 billion of medical expenses associated with COVID-19 hospitalization could have been averted by a single-payer universal healthcare system over the course of the pandemic. These economic benefits are in addition to US$438 billion expected to be saved by single-payer universal healthcare during a nonpandemic year.