Specialist Visits Research Articles

CML-353: Health Care Resource Utilization (HCRU) with Asciminib and Bosutinib among Patients with Chronic Myeloid Leukemia in Chronic Phase (CML-CP) Previously Treated with ≥2 Tyrosine Kinase Inhibitors (TKIs): Results from the Multicenter, Open-Label Phase 3 ASCEMBL Trial

Objective: To investigate HCRU among CML-CP patients who received asciminib or bosutinib after previously being treated with ≥2 TKIs in a clinical trial setting. Design: ASCEMBL enrolled adults with CML-CP who had previously been treated with ≥2 TKIs. Patients were randomized in a 2:1 ratio to receive asciminib 40 mg twice daily (n=157) or bosutinib 500 mg once daily (n=76). Data were collected while on randomized treatment for the following HCRU categories: hospitalizations, emergency hospital visits, general practitioner visits, specialist visits, and urgent care visits. The reasons (adverse events, CML, and other) for accessing services were also captured. The number of patients in each arm with any HCRU, by category, was calculated and used to estimate rates per patient-year. Main Outcomes Measures: Median exposure to treatment; number of patients with HCRU, by category; rate of HCRU per patient-year. Results: As of the 25 May 2020 cut-off, the median duration of exposure was 43.4 and 29.2 weeks in the asciminib and bosutinib arms, respectively. In the asciminib arm, 24.2% (n=38) had HCRU compared to 36.8% (n=28) of those who received bosutinib, corresponding to rates per person-year of 0.32 and 0.80. The percentage of patients (and rates per person-year) with HCRU by category for asciminib and bosutinib were 14.0% (0.16) versus 18.4% (0.32) for hospitalizations, 1.9% (0.02) versus 5.3% (0.08) for emergency hospital visits, 4.5% (0.05) versus 6.6% (0.11) for general practitioner visits, 10.8% (0.13) versus 13.2% (0.24) for specialist visits, and 0% (0) versus 5.3% (0.08) for urgent care visits. A higher percentage of patients treated with bosutinib compared to asciminib required hospitalization (7.9% [n=6] versus 1.9% [n=3]) or a visit to a hospital emergency department (2.6% [n=2] versus 1.3% [n=2]) due to adverse events related to therapy. Length of stay in the hospital was also generally higher with bosutinib compared to asciminib, regardless of ward type (e.g., mean/median number of days: 10.2/6.5 versus 9.2/6.0 in general wards, 19.0/19.0 versus 13.0/5.0 in intensive care units, and 12.0/12.0 versus 7.3/3.0 in other care units). Conclusions: These results suggest that HCRU may be lower for CML-CP patients treated with asciminib compared with bosutinib.

Black-White racial disparities in health care utilization and self-reported health among cancer survivors: The role of food insecurity.

Non-Hispanic Blacks continue to have worse cancer outcomes than non-Hispanic Whites. Suboptimal health care utilization and poor self-reported health among non-Hispanic Blacks contribute to these disparities. The relationship between race, food security status (FSS), and health care utilization or self-reported health among cancer survivors is not clear. This study aims to fill this gap in the science. The 2011-2018 National Health Interview Survey data were used. Bivariate and multivariable logistic regression analyses were used to examine the relationship between race (non-Hispanic Whites or non-Hispanic Blacks), FSS (high, marginal, low, or very low), health care utilization, and self-reported health among cancer survivors. Analyzed health care utilization measures included cost-related medication underuse (CRMU), cost-related delayed care, cost-related forgone care, seeing/talking to a medical specialist, seeing/talking to a general doctor, and overnight hospital stay. A higher proportion of Blacks reported very low food security in comparison with Whites (10.58% vs 4.24%; P ≤ .0001). Blacks were significantly less likely to report a medical specialist visit and more likely to report fair/poor health in the past 12 months even after adjustments for FSS. There was a dose-response relationship between FSS and CRMU, cost-related delayed care, cost-related forgone care, overnight hospital stay, and self-reported health status for both Whites and Blacks. Significant disparities in health care utilization and self-reported health across race and FSS persist among cancer survivors. Interventions that target food insecurity have the potential to reduce suboptimal health care utilization and self-reported health among cancer survivors.

Association of Race and Ethnicity and Medicare Program Type With Ambulatory Care Access and Quality Measures

There are racial inequities in health care access and quality in the United States. It is unknown whether such differences for racial and ethnic minority beneficiaries differ between Medicare Advantage and traditional Medicare or whether access and quality are better for minority beneficiaries in 1 of the 2 programs. To compare differences in rates of enrollment, ambulatory care access, and ambulatory care quality by race and ethnicity in Medicare Advantage vs traditional Medicare. Exploratory observational cohort study of a nationally representative sample of 45 833 person-years (26 887 persons) in the Medicare Current Beneficiary Survey from 2015 to 2018, comparing differences in program enrollment and measures of access and quality by race and ethnicity. Minority race and ethnicity (Black, Hispanic, Native American, or Asian/Pacific Islander) vs White or multiracial; Medicare Advantage vs traditional Medicare enrollment. Six patient-reported measures of ambulatory care access (whether a beneficiary had a usual source of care in the past year, had a primary care clinician usual source of care, or had a specialist visit) and quality (influenza vaccination, pneumonia vaccination, and colon cancer screening). The final sample included 6023 persons (mean age, 68.9 [SD, 12.6] years; 57.3% women) from minority groups and 20 864 persons (mean age, 71.9 [SD, 10.8] years; 54.9% women) from White or multiracial groups, who accounted for 9816 and 36 017 person-years, respectively. Comparing Medicare Advantage vs traditional Medicare among minority beneficiaries, those in Medicare Advantage had significantly better rates of access to a primary care clinician usual source of care (79.1% vs 72.5%; adjusted marginal difference, 4.0%; 95% CI, 1.0%-6.9%), influenza vaccinations (67.3% vs 63.0%; adjusted marginal difference, 5.2%; 95% CI, 1.9%-8.5%), pneumonia vaccinations (70.7% vs 64.6%; adjusted marginal difference, 6.1%; 95% CI, 2.7%-9.4%), and colon cancer screenings (69.4% vs 61.1%; adjusted marginal difference, 7.1%; 95% CI, 3.8%-10.3%). Comparing minority vs White or multiracial beneficiaries across both programs, minority beneficiaries had significantly lower rates of access to a primary care clinician usual source of care (adjusted marginal difference, 4.7%; 95% CI, 2.5%-6.8%), specialist visits (adjusted marginal difference, 10.8%; 95% CI, 8.3%-13.3%), influenza vaccinations (adjusted marginal difference, 4.3%; 95% CI, 1.2%-7.4%), and pneumonia vaccinations (adjusted marginal difference, 6.4%; 95% CI, 3.9%-9.0%). The interaction of race and ethnicity with insurance type was not statistically significant for any of the 6 outcome measures. In this exploratory study of Medicare beneficiaries in 2015-2018, enrollment in Medicare Advantage vs traditional Medicare was significantly associated with better outcomes for access and quality among minority beneficiaries; however, minority beneficiaries were significantly more likely to experience worse outcomes for most access and quality measures than White or multiracial beneficiaries in both programs.

Differences in health care spending and utilization among older frail adults in high-income countries: ICCONIC hip fracture persona.

ObjectiveThis study explores differences in spending and utilization of health care services for an older person with frailty before and after a hip fracture.Data SourcesWe used individual‐level patient data from five care settings.Study DesignWe compared utilization and spending of an older person aged older than 65 years for 365 days before and after a hip fracture across 11 countries and five domains of care as follows: acute hospital care, primary care, outpatient specialty care, post–acute rehabilitative care, and outpatient drugs. Utilization and spending were age and sex standardized..Data Collection/Extraction MethodsThe data were compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries as follows: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States.Principal FindingsThe sample ranged from 1859 patients in Spain to 42,849 in France. Mean age ranged from 81.2 in Switzerland to 84.7 in Australia. The majority of patients across countries were female. Relative to other countries, the United States had the lowest inpatient length of stay (11.3), but the highest number of days were spent in post–acute care rehab (100.7) and, on average, had more visits to specialist providers (6.8 per year) than primary care providers (4.0 per year). Across almost all sectors, the United States spent more per person than other countries per unit ($13,622 per hospitalization, $233 per primary care visit, $386 per MD specialist visit). Patients also had high expenditures in the year prior to the hip fracture, mostly concentrated in the inpatient setting.ConclusionAcross 11 high‐income countries, there is substantial variation in health care spending and utilization for an older person with frailty, both before and after a hip fracture. The United States is the most expensive country due to high prices and above average utilization of post–acute rehab care.

After COVID‐19, telemedicine may be used in addition to usual care and not in lieu of: Implications for health systems

After <scp>COVID</scp>‐19, telemedicine may be used in addition to usual care and not in lieu of: Implications for health systems

Employer-sponsored behavioral health program impacts on care utilization and cost.

To examine the impact of an employer-sponsored behavioral health (BH) program on all-cause health care utilization and cost. Retrospective analysis of health insurance claims data obtained from a large employer in western New York covering a 25-month period between 2016 and 2018. Those employees treated by the employer-sponsored BH program were compared against a contemporaneous comparison group of employees of the same employer who had eligible BH diagnoses for the program but were treatedelsewhere. A difference-in-differences method was used to estimate the program's impact on all-cause care utilization (physician office visits and acute care utilization) and total cost of care, including prescription drug costs. Program participation was associated with a reduction of approximately 28% in total cost of care including prescription drug costs (P = .043) over an 18-month period following the initial program encounter, as well as 27% reductions in primary care provider (PCP) visits (P = .001) and non-BH specialist visits (P = .005). No significant impacts were observed for acute care utilization and BH specialist visit rates. The results suggest that the employer-sponsored BH program implementation may have shifted treatments of certain BH conditions away from PCPs and non-BH specialists who may not have the proper training or resources to manage such conditions. Therefore, these results are consistent with the expectation that improved access to BH care is likely to improve efficiency in the health care system via provision of more appropriate care for those who need it.

A Budget Impact Analysis of the VENTANA PD-L1 SP142 Immunohistochemistry Assay Versus the Dako PD-L1 IHC 22C3 Assay in Patients With Advanced or Metastatic Triple-Negative Breast Cancer Treated With Atezolizumab in Combination With Nab-Paclitaxel

OBJECTIVE: To estimate the budget impact determined by the adoption of two different diagnostic strategies, SP142 assay or 22C3 assay, in the identification (in terms of PD-L1 status) of patients with mTNBC eligible for treatment with atezolizumab in combination with nab-paclitaxel.METHODS: The budget impact analysis (BIA) was conducted using a budget impact model (BIM) considering the Italian National Health Service’s (iNHS) perspective. The analysis assessed only the direct medical cost (tissue biopsy, PD-L1 assay, specialist visit, pharmacological treatment with atezolizumab in combination with nab-paclitaxel) of patients with PD-L1 positive mTNBC, and management of the adverse events associated with the pharmacological treatment administered. The BIM also considered the clinical benefits (progression free survival, PFS) resulting from the drug therapy administered on the basis of the results of the post-hoc analysis of the IMpassion130 clinical trial. The BIA was conducted over a 1-year time horizon. The median cost per patient in the progression-free state was also calculated. The costs were calculated using the net ex-factory prices (cancer drugs) and regional or national tariffs (tissue biopsy, PD-L1 assay, specialist visit and adverse events management). A sensitivity analysis was conducted to evaluate the base case result.RESULTS: The SP142 assay diagnostic pathway would result in a reduction of the iNHS expenditure of approximately 5.6 million euros (-12%). Almost all of the reduction in iNHS expenditure would be determined by the lower number of patients treated (SP142: 689 patients vs 22C3: 786 patients) with immunotherapy (-€ 5,530,871). Compared with 22C3 assay, the SP142 assay shows a cost per PFS month reduction of € 736 (€ 7,010 vs € 7,746).CONCLUSIONS: The use of the SP142 assay proved to be cost-effective compared to the 22C3 assay; the SP142 assay can support the choice of the most appropriate cancer drug, maximizing the effectiveness and minimizing the waste of healthcare resources.

Cognitive Behavioral Therapy of Patients with Somatic Symptoms-Diagnostic and Therapeutic Difficulties.

In every somatic disease we can find a psychological element, just as it is not uncommon for numerous physical symptoms to occur in a mental disease. Nowadays, the patient is no longer just the “owner” of the sick organ but is considered and treated as a “whole”. The interpenetration of somatic manifestations with mental health problems forces patients who experience subjective suffering, including mental suffering, from current symptoms to visit specialists from different fields of medicine, and their treatment does not bring about any improvement. Cognitive behavioral psychotherapy (CBT) is one form of therapy that attempts to respond to the needs of an increasing—in recent years—number of patients who demonstrate somatic disorders of a multifaceted nature. The co-occurrence of physical and mental disorders repeatedly makes it impossible to determine which symptoms were the cause and which were the effect; hence, it is difficult to establish clear boundaries between the categories of these disorders and diseases. The therapist, to whom the patient with somatic diseases is eventually referred, may be faced with a diagnostic dilemma, the solution of which will give direction to further psychotherapeutic work. The common feature of this group of patients is a strong focus on physical ailments, while omitting or almost completely ignoring the psychological factors involved. The purpose of this paper is to present the causally diverse circumstances in which a patient with physical symptoms needs diagnosis and therapeutic support from the perspective of a cognitive behavioral approach.

Does demand for health services depend on cost-sharing? Evidence from Italy

Many health systems adopt cost-sharing plans – requiring individuals to pay a part of the costs of medical services – to tackle the problem of overconsumption. It is not clear how effective cost-sharing is since the empirical evidence is mainly based on the US system, quite different from the European systems. Using an Italian dataset of about 87000 individuals for 2013, we investigate to what extent the exemption from cost-sharing affects the demand for health services. Estimating a model with Instrumental Variables, we exploit the threshold of age 65 giving complete exemption from cost-sharing, comparing the demand for health services by individuals below and above age 65. We find that individuals with exemption significantly increase their demand for specialist visits, diagnostic checks and drug consumption. This is probably due to the attempt of individuals to over-protect against very low health risks, when they bear no cost.

Prediction of risk of prolonged post-concussion symptoms: Derivation and validation of the TRICORDRR (Toronto Rehabilitation Institute Concussion Outcome Determination and Rehab Recommendations) score.

Approximately 10% to 20% of people with concussion experience prolonged post-concussion symptoms (PPCS). There is limited information identifying risk factors for PPCS in adult populations. This study aimed to derive a risk score for PPCS by determining which demographic factors, premorbid health conditions, and healthcare utilization patterns are associated with need for prolonged concussion care among a large cohort of adults with concussion. Data from a cohort study (Ontario Concussion Cohort study, 2008 to 2016; n = 1,330,336) including all adults with a concussion diagnosis by either primary care physician (ICD-9 code 850) or in emergency department (ICD-10 code S06) and 2 years of healthcare tracking postinjury (2008 to 2014, n = 587,057) were used in a retrospective analysis. Approximately 42.4% of the cohort was female, and adults between 18 and 30 years was the largest age group (31.0%). PPCS was defined as 2 or more specialist visits for concussion-related symptoms more than 6 months after injury index date. Approximately 13% (73,122) of the cohort had PPCS. Total cohort was divided into Derivation (2009 to 2013, n = 417,335) and Validation cohorts (2009 and 2014, n = 169,722) based upon injury index year. Variables selected a priori such as psychiatric disorders, migraines, sleep disorders, demographic factors, and pre-injury healthcare patterns were entered into multivariable logistic regression and CART modeling in the Derivation Cohort to calculate PPCS estimates and forward selection logistic regression model in the Validation Cohort. Variables with the highest probability of PPCS derived in the Derivation Cohort were: Age >61 years ([Formula: see text] = 0.54), bipolar disorder ([Formula: see text] = 0.52), high pre-injury primary care visits per year ([Formula: see text] = 0.46), personality disorders ([Formula: see text] = 0.45), and anxiety and depression ([Formula: see text] = 0.33). The area under the curve (AUC) was 0.79 for the derivation model, 0.79 for bootstrap internal validation of the Derivation Cohort, and 0.64 for the Validation model. A limitation of this study was ability to track healthcare usage only to healthcare providers that submit to Ontario Health Insurance Plan (OHIP); thus, some patients seeking treatment for prolonged symptoms may not be captured in this analysis. In this study, we observed that premorbid psychiatric conditions, pre-injury health system usage, and older age were associated with increased risk of a prolonged recovery from concussion. This risk score allows clinicians to calculate an individual's risk of requiring treatment more than 6 months post-concussion.

Effect of Different Treatment Patterns to Cost Effectiveness in Chronic Lymphocytic Leukemia Patients, Turkish CLL Study Group

AimThe data of CLL patients from 12 centers were recorded with an aim of constructing a nationwide CLL registry. We present the retrospective arm of the data obtained, with an emphasis on analysis of cost related parameters.Method761 patients included in the retrospective arm. SAS 9.4 was used to analyze data.Results63.34 % of patients were male, and the median age at diagnosis was 62.37 (25-92). Median follow up of all patients was 42 months. Overall 7.75 percent of patients died during follow up. Among 252 (35.14% of all patients) patients who required CLL specific therapy, rate of death was 12.5%. Among patients who required therapy 70% received one line, 18% received two lines and 13% received three or more lines of therapy. Fludarabin based therapies leaded front-line therapies by 47.60%, chlorambucil followed fludarabin based therapies by 26.2%. Considering the second line therapies most patients received either bendamustine based therapies or novel agents. Overall response achieved by front line therapies was 84% with a CR rate of 48%. Remission rates declined by further lines of therapy. In patients undergoing front-line therapy, del17p rate was %5.3, and del17p was the worst prognostic factor regarding therapy response and outcome. Among all patients median OS was not achieved, and 10 years OS rates for patients requiring therapy was 63,5% which was significantly less than patients who did not require therapy (p=0.027).Cost analysis data, which included duration of hospitalization, total number of specialist visits and G-CSF use, was available for 115 patients. Treatments were classified as fludarabine (FCR- fludarabine, cyclophosphamide, rituximab), bendamustine (benda) and chlorambucil (clb) based. Benda and clb chemotherapy consisted of anti CD20 treatment or not. Median treatment durations were 6 cycles for FCR, 6 cycles for benda and 7.4 months for clb arm. Hospitalization days and G-CSF administration rate was significantly higher in FCR arm compared to benda and clb arms altough mean age in FCR arm was lower. There was a slight significance in terms of specialist visits between FCR and benda arms. No statistical significance was noted between benda and clb regarding age and other cost related parameters (Table 1).ConclusionThis study confirms that the costs for FCR therapy is higher due to its toxicity. Lack of statistical significance between FCR and Clb regarding hospitalization duration and specialist visits might be related with older age of Clb arm. Cost related information in CLL treatment is becoming more important for reimbursement decisions of new generation expensive drugs. Cost effectiveness ratios should be calculated both in daily practice and clinical trial setting using data from prospective patient registries. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Patient-reported burden of symptoms in neuromyelitis optica: A secondary analysis on pain and quality of life

IntroductionRelapses of neuromyelitis optica spectrum disorder (NMOSD) result in cumulative neurologic disabilities, are unpredictable, and are interspersed with remissions. Pain in NMOSD is often severe and intractable, with a significant impact on patient quality of life (QoL). We performed a more detailed analysis of previously published survey data on the association of pain and QoL, comparing patients who were seropositive and seronegative for antibodies against aquaporin-4 (AQP4-IgG). MethodsWe conducted a secondary analysis of questionnaire data from 193 NMOSD patients across North America. The study population was predominantly female (88.6%) and aged 19–76 years. Results were reported for three groups: AQP4-IgG-seropositive (61.1%), AQP4-IgG-seronegative and the total cohort including patients with unknown serostatus. We measured the strength of associations and interactions between pain and variables including QoL, patient satisfaction, frequency of hospital visits, and number of relapses versus other symptoms. ResultsPain severity was the strongest negative predictor of QoL. In the total and AQP4-IgG-seropositive groups, pain was the most common symptom that patients wanted their physician to be concerned about; in the AQP4-IgG-seronegative group, this was fatigue. For all patients, frequent hospital visits and relapses were associated with more severe pain, but not frequency of NMOSD specialist visits. Patients without recent relapse still commonly reported moderate or severe pain (>25%). ConclusionThis study confirms the heavy burden of pain on NMOSD patients and its effect on QoL and healthcare utilization. Prevention or early treatment of relapses and more effective pain management may reduce this burden.

Real-World Assessment of Asthma Specialist Visits Among U.S. Patients with Severe Asthma

U.S. guidelines recommend that patients with severe asthma be referred to specialists (allergists/immunologists or pulmonologists) for systematic assessment or comanagement; however, contemporary, real-world data on the frequency and impact of specialist care among U.S. severe asthma patients are lacking. To quantify the frequency of asthma specialist visits among U.S. patients with severe asthma, identify patient demographic and clinical characteristics associated with specialist visits and describe health outcomes following specialist care. Severe asthma patients aged 6 years or older were identified between January 1, 2015, and December 31, 2017, in the IQVIA PharMetrics® Plus database of commercially insured individuals, based on Healthcare Effectiveness Data and Information Set (HEDIS) criteria and Global Initiative for Asthma (GINA) step 4 or 5 treatment regimens. The frequency of asthma specialist (allergist/immunologist or pulmonologist) visits was described over 2 years. Patient characteristics associated with having 1 or more specialist visits were analyzed using multivariate regressions. Asthma exacerbations and health care resource utilization before and after specialist visit were compared. Of 54,332 patients identified, 38.2% had 1 or more specialist visits over 2 years. Patient characteristics predictive of specialist visits were asthma exacerbation frequency, younger age, and allergy/respiratory comorbidity burden (all P < .001). Among patients with 1 or more specialist visits, a lower prevalence of asthma exacerbations and rescue inhaler use was observed following the first observed specialist visit. Specialist care was observed in fewer than half of U.S. patients with severe asthma and was least frequent among older adult patients and those with more nonrespiratory comorbidities. Increased specialist involvement in managing severe asthma may help improve care and patient outcomes.

Real-life use of onabotulinumtoxinA reduces healthcare resource utilization in individuals with chronic migraine: the REPOSE study

BackgroundChronic migraine (CM) is associated with substantial economic burden. Real-world data suggests that onabotulinumtoxinA treatment for CM reduces healthcare resource utilisation (HRU) and related costs.MethodsREPOSE was a 2-year prospective, multicentre, non-interventional, observational study to describe the real-world use of onabotulinumtoxinA in adult patients with CM. This analysis examined the impact of onabotulinumtoxinA on HRU. Patients received onabotulinumtoxinA treatment approximately every 12 weeks according to their physicians’ discretion, guided by the summary of product characteristics (SPC) and PREEMPT injection paradigm. HRU outcome measures were collected at baseline and all administration visits and included headache-related hospitalizations and healthcare professional (HCP) visits. Health economic data, including family doctor and specialist visits, inpatient treatment for headache, acupuncture, technical diagnostics, use of nonpharmacologic remedies, and work productivity were also collected for patients enrolled at German study centres.ResultsOverall, 641 patients were enrolled at 78 study centres across 7 countries (Germany, UK, Italy, Spain, Norway, Sweden, and Russia), 633 received ≥1 onabotulinumtoxinA dose, and 128 completed the 2-year study. Patients were, on average, aged 45 years, 85% were female, and 60% (n = 377) were from Germany. At the end of the 2-year observation period, significantly fewer patients reported headache-related hospitalizations (p < 0.02) and HCP visits (p < 0.001) within the past 3 months than in the 3 months before baseline. In the German population, reductions were observed across all health services at all follow-up visits compared with baseline. The percentage of patients who saw a family doctor decreased from 41.7% at baseline to 13.5% at administration visit 8 and visits to a medical specialist decreased from 61.7% to 5.2% of patients. Inpatient acute treatment and technical diagnostics declined from 6.4% and 19.7% of patients at baseline to 0.0% and 1.0% at administration 8, respectively. The use of nonpharmacologic remedies and medication for the acute treatment of migraine also decreased with continued onabotulinumtoxinA treatment. Work incapacity, disability, absenteeism, and impaired performance at school/work improved with onabotulinumtoxinA treatment for CM over the 2-year observation period.ConclusionsReal-world evidence from REPOSE demonstrates that onabotulinumtoxinA treatment is associated with decreased HRU and supports the long-term benefits associated with the use of onabotulinumtoxinA for CM in clinical practice.Trial registrationNCT01686581. Name of registry: ClinicalTrials.gov. URL of registry: Date of retrospective registration: September 18, 2012. Date of enrolment of first patient: July 23, 2012.

Economic Impact of COVID-19 Lockdown on Italian NHS: Focus on Diabetes Mellitus.

BackgroundIn Italy, the adoption of a total lockdown has generated almost total suspension of outpatient visits except for emergencies. Even after lockdown, the pandemic fear created additional barriers to access the health services. The aim of our study is to evaluate the economic impact of the lockdown for COVID-19 on public health in Italy, focusing on its effects on diabetic population.Materials and MethodsWe analyzed the impact of the lockdown on excess mortality and morbidity in the Italian diabetic population during 2020. The analysis was divided into several steps: a quantification of specialist visit reduction, the calculation of excess mortality in the diabetic population, the economic evaluation of the slowdown in the use of innovative diabetic therapies. Furthermore, the impact of the lockdown on the reduction of procedures and follow-up visits in diabetic population was evaluated. The overall impact of the pandemic and lockdown effects on costs and quality of life was then calculated.ResultsDuring 2020, a drop of 28% in patient access has been observed. Diabetic patients recorded a twice higher mortality value compared to general population (20.4% vs 10.2%). The analysis of market data revealed a slowdown in consumption of new antidiabetic therapies (−14%, 27% vs 41%). We estimated an expense of €26.6 million for NHS and a loss of 257 utilities in diabetic population due to the missed benefits related to slowdown in innovative antidiabetic drugs use and non-optimal follow-up and control of diabetes complications. In simulation scenarios, we also estimated an overall expenditure ranging from €38.7 to 94.0 million and a loss of 294–836 utilities.ConclusionDiabetic population paid a high tribute to pandemic and lockdown, both in terms of number of deaths and burden of diabetic complications, together with an overall deterioration of quality of life.

Solidarity and Voluntarism Amid the COVID-19 Pandemic: Skin Cancer Screening for Blood Donors.

Many of the volunteer activities required to raise public awareness on skin cancer screening and prevention are supported by dermatological societies and volunteer dermatologists, and are framed by substantial voluntary groups, often not sufficiently credited for their contribution, including blood donors and Red Cross Samaritans. We herein propose that amid the ongoing pandemic, skin cancer screening and blood donations must not be disrupted with attention paid to patient safety foremost. Although efforts over the last decade have led to a significant reduction in skin cancer, ongoing activities have been suspended and, in many cases, disrupted since the coronavirus disease 2019 (COVID-19) spread has created a Public Health Emergency of International Concern. International Health systems are burdened, and patients ignore symptoms and evade specialist visits due to contamination fear of coronavirus, resulting in a 68.61% reduction in skin cancer diagnoses. However, the COVID-19 pandemic has also major implications for blood transfusion. Currently, there are uncertain patterns of demand, and transfusion institutions need to plan for reductions in donations and loss of crucial staff because of sickness and public health restrictions. Supporting volunteer blood donors through voluntary skin cancer screening could be an excellent initiative, bringing people together, giving us the opportunity to abandon the illusion of power and admit our weakness to the ongoing pandemic. Most of us have not worked through pandemics before but it is time to embrace humanity and solidarity via volunteering, with no profit aims but with social goals of equal skin cancer screening opportunities of vitally important volunteer blood donors, encouraging blood donation. In light of a change in dermatology practice, investing in prevention strategies in public health and social protection is the mark of responsible policy action.

Association of Post-discharge Service Types and Timing with 30-Day Readmissions, Length of Stay, and Costs.

Although early follow-up after discharge from an index admission (IA) has been postulated to reduce 30-day readmission, some researchers have questioned its efficacy, which may depend upon the likelihood of readmission at a given time and the health conditions contributing to readmissions. To investigate the relationship between post-discharge services utilization of different types and at different timepoints and unplanned 30-day readmission, length of stay (LOS), and inpatient costs. The study sample included 583,199 all-cause IAs among 2014 Medicare fee-for-service beneficiaries that met IA inclusion criteria. The outcomes were probability of 30-day readmission, average readmission LOS per IA discharge, and average readmission inpatient cost per IA discharge. The primary independent variables were 7 post-discharge health services (institutional outpatient, primary care physician, specialist, non-physician provider, emergency department (ED), home health care, skilled nursing facility) utilized within 7 days, 14 days, and 30 days of IA discharge. To examine the association with post-discharge services utilization, we employed multivariable logistic regressions for 30-day readmissions and two-part models for LOS and inpatient costs. Among all IA discharges, the probability of unplanned 30-day readmission was 0.1176, the average readmission LOS per discharge was 0.67 days, and the average inpatient cost per discharge was $5648. Institutional outpatient, home health care, and primary care physician visits at all timepoints were associated with decreased readmission and resource utilization. Conversely, 7-day and 14-day specialist visits were positively associated with all three outcomes, while 30-day visits were negatively associated. ED visits were strongly associated with increases in all three outcomes at all timepoints. Post-discharge services of different types and at different timepoints have varying impacts on 30-day readmission, LOS, and costs. These impacts should be considered when coordinating post-discharge follow-up, and their drivers should be further explored to reduce readmission throughout the health care system.

Initial Choice of Spinal Manipulation Reduces Escalation of Care for Chronic Low Back Pain Among Older Medicare Beneficiaries.

We combined elements of cohort and crossover-cohort design. The objective of this study was to compare longterm outcomes for spinal manipulative therapy (SMT) and opioid analgesic therapy (OAT) regarding escalation of care for patients with chronic low back pain (cLBP). Current evidence-based guidelines for clinical management of cLBP include both OAT and SMT. For long-term care of older adults, the efficiency and value of continuing either OAT or SMT are uncertain. We examined Medicare claims data spanning a five-year period. We included older Medicare beneficiaries with an episode of cLBP beginning in 2013. All patients were continuously enrolled under Medicare Parts A, B, and D. We analyzed the cumulative frequency of encounters indicative of an escalation of care for cLBP, including hospitalizations, emergency department visits, advanced diagnostic imaging, specialist visits, lumbosacral surgery, interventional pain medicine techniques, and encounters for potential complications of cLBP. SMT was associated with lower rates of escalation of care as compared to OAT. The adjusted rate of escalated care encounters was approximately 2.5 times higher for initial choice of OAT vs. initial choice of SMT (with weighted propensity scoring: rate ratio 2.67, 95% confidence interval 2.64-2.69, P < .0001). Among older Medicare beneficiaries who initiated long-term care for cLBP with opioid analgesic therapy, the adjusted rate of escalated care encounters was significantly higher as compared to those who initiated care with spinal manipulative therapy.Level of Evidence: 3.

Associations Between a New York City Paid Sick Leave Mandate and Health Care Utilization Among Medicaid Beneficiaries in New York City and New York State.

ImportanceMore evidence on associations between mandated paid sick leave and health service utilization among low-income adults is needed to guide health policy and legislation nationwide.ObjectiveTo evaluate the association between New York City’s 2014 paid sick leave mandate and health care utilization among Medicaid-enrolled adults.Design, Setting, and ParticipantsThis retrospective cohort study used New York State Medicaid administrative data for adults 18 to 64 years old continuously enrolled in Medicaid from August 1, 2011, through July 31, 2017. A difference-in-differences approach with entropy balancing weights was used to compare New York City with the rest of New York State to assess the association of the paid sick leave mandate with health care utilization, and for those 40 to 64 years old, with preventive care utilization. The data analysis was performed from June through August 2020.ExposuresTemporal and spatial variation in exposure to the mandate.Main Outcomes and MeasuresAnnual health care utilization (emergency care, specialist visits, and primary care clinician visits) per Medicaid-enrolled adult. Secondary outcomes include categories of emergency utilization and utilization of 5 preventive services.ResultsOf 552 857 individuals (mean [SD] age, 43 [12] years; 351 130 [64%] women) who met inclusion criteria, 99 181 (18%) were White, 162 492 (29%) Black, and 138 061 (25%) Hispanic. Paid sick leave was significantly associated with a reduction in the probability of emergency care (−0.6 percentage points [pp]; 95% CI, −0.7 to −0.5 pp; P < .001), including a 0.3 pp reduction (95% CI, −0.4 to −0.2; P < .001) in care for conditions treatable in a primary care setting and an increase in annual outpatient visits (0.124 pp; 95% CI, 0.040 to 0.208 pp; P < .001). Among those 40 to 64 years old, the mandate was significantly associated with increased probabilities of glycated hemoglobin A1c level testing (2.9 pp; 95% CI, 2.5-3.3 pp; P < .001), blood cholesterol testing (2.7 pp; 95% CI, 2.5-2.9 pp; P < .001), and colon cancer screening (0.4 pp; 95% CI, 0.2-0.6 pp; P < .001).Conclusions and RelevanceThis retrospective cohort study of nonelderly adults enrolled in Medicaid New York State showed that mandated paid sick leave in New York City was significantly associated with differences in several dimensions of health care services use.

Influence of hypertension and other risk factors on the onset of sublingual varices

BackgroundSublingual varices (SV) are dilatations of tortuous veins that increased with age. Previous studies showed that this pathology could be correlated to some risk factors such as hypertension, age, gender and diabetes mellitus. In this study we evaluated, on a large number of subjects, the relationship between SV and different grades of hypertension as well as some risk factors extending the analysis to new risk factors such as dyslipidemia, obesity and antihypertensive therapy, modelling a possible dependence of SV on all these factors.MethodsIn the study 1008 subjects, 284 with and 724 without SV, were examined. The blood pressure was measured in office condition and, to exclude subjects with white coat syndrome or masked hypertension, also using a 24 h Holter pressure monitor. Hypertensive subjects were divided in resistant, drugs controlled (compensated) and patients with prior unknown hypertension (new diagnosed) groups. The presence or absence of SV as well as of the risk factors was assessed clinically. We tested the influence of age on the presence of SV by using the chi-square test and the relation between each risk factor and SV by the Cochran–Mantel–Haenszel test. Finally, we carried out a multivariate regression tree analysis in order to predict the presence of SV.ResultsWe confirmed the influence of age on SV and found a significant relationship between SV and both the compensated and resistant hypertension grades. We highlighted a relationship between SV and dyslipidemia in subjects with new diagnosed hypertension, and between SV and smoking in subjects with compensated hypertension grade. The regression tree showed a classification accuracy of about 75% using as variables hypertension grades, age and antihypertensive treatment.ConclusionsWe confirmed the SV dependence on age, resistant hypertension and smoking, highlighting a new association with dyslipidemia in new diagnosed hypertensive subjects and new relations depending on the hypertension grades. Thus, the SV inspection could be used to suggest a lipidologist as well as a hypertension specialist visit for a pharmacological and pressure check particularly in subjects presenting SV and dyslipidemia. However, further parameters are to be considered to improve the sensitivity of the prognostic tree model.