To examine how care for breast cancer survivors compares with controls.
Using the Surveillance, Epidemiology, and End Results-Medicare database, we examined five cohorts of stages 1 to 3 breast ...cancer survivors diagnosed from 1998 to 2002. For each survivor cohort (defined by diagnosis year), we calculated the number of visits to oncology specialists, primary care providers (PCPs), and other physicians and the percentage who received influenza vaccination, cholesterol screening, colorectal cancer screening, bone densitometry, and mammography during survivorship year 1 (days 366 to 730 postdiagnosis). We compared survivors' care to that of five cohorts of screening controls who were matched to survivors on age, ethnicity, sex, and region and who had a mammogram in the survivor's year of diagnosis and to that of five cohorts of comorbidity controls who were matched on age, ethnicity, sex, region, and comorbidity. We examined whether survivors' care was associated with the mix of physician specialties that were visited.
A total of 23,731 survivors were matched with 23,731 screening controls and 23,396 comorbidity controls. There was no difference in trends over time in PCP visits between survivors and either control group. The survivors' rate of increase in other physician visits was greater than screening controls (P = .002) but was no different from comorbidity controls. Survivors were less likely to receive preventive care than screening controls but were more likely than comorbidity controls. Trends over time in survivors' care tended to be better than screening controls but were no different than comorbidity controls. Survivors who visited both a PCP and oncology specialist were most likely to receive recommended care.
Involvement by both PCPs and oncology specialists can facilitate appropriate care for survivors.
Working is critical to personal health and well-being. We examine the association of vision measured objectively with work status using a nationally representative sample of working-age Americans.
A ...total of 19 849 participants from the 1999-2008 National Health and Nutrition Examination Survey completed a vision examination and employment/demographic questionnaires. Employment rates for men with visual impairment, uncorrected refractive error, and normal vision were 58.7%, 66.5%, and 76.2%, respectively; employment rates for women with visual impairment, uncorrected refractive error, and normal vision were 24.5%, 56.0%, and 62.9%, respectively. In multivariable models adjusting for age, sex, race/ethnicity, and chronic disease status, both uncorrected refractive error (odds ratio OR, 1.36; 95% CI, 1.15-1.60) and visual impairment (OR, 3.04; 95% CI, 1.93-4.79) were associated with a higher likelihood of not working. Subgroups in which visual impairment was associated with even higher odds of not working included women (OR, 4.9; 95% CI, 2.5-9.6), participants younger than 55 years (OR, 4.3; 95% CI, 2.9-6.5), and diabetic individuals (OR, 14.8; 95% CI, 5.8-37.3).
Decreased vision is associated with a significantly higher likelihood of not working. Visually impaired diabetic individuals, women, and those younger than 55 years have a particularly high risk of not working. Further investigation is warranted to understand barriers for employment in individuals with decreased vision.
Objective
To examine 30‐day readmission rates and associations with risk factors, survival, length of hospitalization, and costs in elderly patients with laryngeal and oropharyngeal squamous cell ...cancer (SCC).
Study Design
Retrospective cross‐sectional analysis of Surveillance, Epidemiology, and End Results‐Medicare data.
Methods
We evaluated 1,518 patients diagnosed with laryngeal or oropharyngeal SCC from 2004 to 2007 who underwent primary surgery using cross‐tabulations, multivariate regression modeling, and survival analysis.
Results
Thirty‐day readmission occurred in 14.1% of hospitalizations. Readmission was more likely in patients with postoperative complications during initial hospitalization (24.8% vs. 4.5%, P < 0.001), and was associated with an increased 30‐day mortality incidence rate (5.1% vs. 0.9%; P < 0.001). On multivariate analysis, 30‐day readmission was significantly associated with advanced stage (odds ratio OR = 1.81 1.13–2.90), comorbidity (OR = 2.69 1.65–4.39), divorced/separated marital status (OR = 2.00 1.19–3.38), preoperative tracheostomy (OR = 3.39 1.55–7.44), major surgical procedures (OR = 2.58 1.68–3.97), greater length of initial hospitalization (OR = 1.72 1.09–2.71), pneumonia (OR = 2.86 1.28–6.40), postoperative dysphagia (OR = 5.97 2.48–15.83), and cardiovascular events (OR = 5.84 1.89–17.96). Thirty‐day readmission was significantly associated with 30‐day mortality (OR = 5.89 2.21–15.70) and higher 1‐year mortality (68.0% vs. 89.2%, P < 0.001). The mean incremental costs of surgical care were significantly greater for patients with unplanned readmission ($15,123 $10,514–$19,732), after controlling for all other variables.
Conclusion
Unplanned readmissions are associated with increased short‐ and long‐term mortality and costs. Elderly patients with advanced disease, advanced comorbidity, lack of spousal support, pretreatment organ dysfunction, more extensive surgery, postoperative pneumonia, postoperative dysphagia, and prolonged hospitalization are at increased risk of 30‐day readmission. These findings suggest a need for targeted interventions before, during, and after hospitalization to reduce morbidity, mortality, and excess costs in this high‐risk population.
Level of Evidence
2c. Laryngoscope, 127:631–641, 2017
To identify the potential effect on global economic productivity of successful interventions, that are planned as part of the “VISION 2020—right to sight” initiative. The initiative aims to eliminate ...avoidable blindness.
This study used economic and epidemiologic modeling.
Existing data and assumptions about blindness prevalence, national populations, gross domestic product (GDP) per capita, labor force participation, and unemployment rates were used to project the economic productivity loss associated with unaccommodated blindness.
Without extra interventions, the global number of blind individuals would increase from 44 million in the year 2000 to 76 million in 2020. A successful VISION 2020 initiative would result in only 24 million blind in 2020 and lead to 429 million blind person-years avoided. A conservative estimate of the economic gain is $102 billion.
The VISION 2020 initiative has the potential to increase global economic productivity.
To evaluate longitudinal vision-related quality of life (VRQoL) in patients with noninfectious uveitis.
Cohort study using randomized controlled trial data.
Patients with active or recently active ...intermediate uveitis, posterior uveitis, or panuveitis enrolled in the Multicenter Steroid Treatment Trial and Follow-up Study.
Data from the 25-item National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25) for the first 3 years after randomization were evaluated semiannually. Analyses were stratified by assigned treatment (129 implants vs. 126 systemic therapies) because of substantial differences in the trajectories of VRQoL. The impact of baseline measurements of visual function (visual acuity and visual field), demographics, and disease characteristics was assessed using generalized estimating equations.
Primary outcome was the NEI-VFQ-25 composite score over 3 years after randomization.
Individuals in both treatment groups showed similar improvement in NEI-VFQ-25 scores after 3 years of follow-up (implant: 11.9 points; 95% confidence interval CI, 8.6-15.2; P < 0.001; systemic: 9.0 points; 95% CI, 5.6-12.3; P < 0.001; P = 0.21 for interaction). Individuals in the implant group showed a substantial improvement during the first 6 months followed by stable scores, whereas individuals in the systemic group showed a steady improvement over the course of follow-up. Worse initial visual acuity and visual fields were associated with lower initial NEI-VFQ-25 scores for both treatment groups. In the systemic group, these differences were maintained throughout follow-up. In the implant group, individuals with initial visual acuity worse than 20/40 showed additional improvement in NEI-VFQ-25 score to come within -7 points (95% CI, -15.0 to 0.9) of those with visual acuity 20/40 or better initially, a clinically meaningful but not statistically significant difference (P = 0.081). Results based on sensitivity analyses showed similar patterns.
Both treatment groups demonstrated significant improvements in NEI-VFQ-25 scores; however, the improvement was immediate for the implant group as opposed to gradual for the systemic group. Poorer visual function was associated significantly with initial differences in NEI-VFQ-25 scores. However, only individuals in the implant group with poor visual acuity were able to overcome their initial deficits by the end of 3 years.
Rising health care costs, decreasing reimbursement rates, and changes in American health care are forcing physicians to become increasingly business-minded. Both academic and private plastic surgeons ...can benefit from being educated in business principles. The authors conducted a systematic review to identify existing business curricula and integrated a business principles curriculum into residency training.
The authors anonymously surveyed their department regarding perceived importance of business principles and performed a systematic literature review from 1993 to 2013 using PubMed and Embase to identify residency training programs that had designed/implemented business curricula. Subsequently, the authors implemented a formal, quarterly business curriculum.
Thirty-two of 36 physicians (88.9 percent; 76.6 percent response rate) stated business principles are either "pretty important" or "very important" to being a doctor. Only 36 percent of faculty and 41 percent of trainees had previous business instruction. The authors identified 434 articles in the systematic review: 29 documented formal business curricula. Twelve topics were addressed, with practice management/administration (n = 22) and systems-based practice (n = 6) being the most common. Four articles were from surgical specialties: otolaryngology (n = 1), general surgery (n = 2), and combined general surgery/plastic surgery (n = 1). Teaching formats included lectures and self-directed learning modules; outcomes and participant satisfaction were reported inconsistently. From August of 2013 to June of 2015, the authors held eight business principles sessions. Postsession surveys demonstrated moderately to extremely satisfied responses in 75 percent or more of resident/fellow respondents (n = 13; response rate, 48.1 percent) and faculty (n = 9; response rate, 45.0 percent).
Business principles can be integrated into residency training programs. Having speakers familiar with the physician audience and a session coordinator is vital to program success.
Objective
To examine associations between quality, short‐term and long‐term treatment‐related outcomes, and costs in elderly patients treated for oropharyngeal squamous cell cancer (OPSCC).
Methods
...We retrospectively evaluated Surveillance, Epidemiology, and End Results (SEER)‐Medicare data from 666 patients diagnosed with OPSCC from 2004 to 2007 using multivariate regression and survival analysis. Quality indicators were derived from guidelines for recommended care and performance measures.
Results
Higher quality care was associated with lower risk of death in patients with dysphagia (hazard ratio HR = 0.44 0.32‐0.60), weight loss (HR = 0.42 0.28‐0.62), gastrostomy (HR = 0.47 0.33‐0.68), airway obstruction (HR = 0.41 0.27‐0.62), tracheostomy (HR = 0.17 0.05‐0.67), and pneumonia (HR = 0.53 0.33‐0.85). There were no significant differences in mean incremental costs associated with airway and swallowing impairment for patients receiving higher quality care.
Conclusions
Higher quality OPSCC care was associated with improved survival in elderly patients with airway and swallowing impairment. These data suggest that greater adherence to evidence‐based guidelines has favorable implications for long‐term outcomes.
To develop a simple but more precise model to calculate potential annual productivity losses due to blindness and moderate and severe vision impairment (MSVI) at the national, regional, and global ...level.
Productivity loss was defined as the loss of minimum wage/Gross National Income per capita (GNI) incurred by people aged 50-64 years with blindness or MSVI, who were not able to work or worked with reduced earnings in 2020. We developed a global list of minimum wage data from on-line sources. All other model data were sourced from international, standardised, and open-access databases. For blindness, the total productivity loss (not working) incurred by 64%-90% of the affected population was summed up with partial productivity loss, defined as 10%-36% of the affected population earning one-third of that of the sighted population. For MSVI, the total productivity loss for 30%-55% of the affected population was summed with the partial productivity loss, defined as 45%-70% of the affected population having 35% reduced earnings. The costs of blindness and MSVI were summed to obtain the cost of combined vision loss.
The global cost of vision loss based on minimum wage was US$160-US$216.32 billion for 2020. The global cost of vision loss using GNI was US$449.36-US$584.66 billion.
A parsimonious model that considers minimum wage and GNI potentially lost due to blindness and MSVI can be used for eye care programming planning and advocacy at the national, regional, and global level.
As nurse practitioners (NPs) and physician assistants (PAs) become an integral part of delivering emergency medical services, we examined the involvement of NPs and PAs who billed independently in ...emergency departments (EDs).
We used Medicare provider utilization and payment data from 2012 to 2016 to conduct a retrospective analysis. We examined the changes in the number of each clinician type who billed independently for four common emergency services (CPT codes: 99282-5), the change in their service volume, and the change in their average number of services billed.
Between 2012 and 2016, the proportion of NPs and PAs billing independently increased from 18% to 22% for ED visits of low severity (99282), 23% to 29% for visits with moderate severity (99283), 21% to 27% for visits with high severity (99284), 18% to 24% for visit with the highest severity (99285), and 23% to 29% across all four services. The proportion of services provided by emergency physicians decreased from 66% to 63% across all four services, and from 11% to 9% for internists and family physicians. The number of NPs, PAs billing independently, and emergency physicians increased by 65%, 35% and 12% respectively.
NPs and PAs are increasingly billing emergency services of all levels of severity, independent of physicians. This trend is driven by a growing number of NPs and PAs independently billing services, despite a relatively stable number of emergency physicians (excepting the decline in rural areas), and diminished involvement of family physicians and internists in EDs.
Recently, in-office posterior nasal nerve ablation (PNA) devices have offered a new tool to treat refractory chronic rhinitis, but their cost-effectiveness relative to traditional interventions such ...as vidian neurectomy (VN) and posterior nasal neurectomy (PNN) remains unexplored.
To compare the cost-effectiveness of these interventions in patients with refractory chronic rhinitis.
A decision tree with embedded Markov models was created to compare the cost-effectiveness of PNN, VN, and PNA, measured in quality-adjusted life years (QALYs) over a 30-year time horizon with a $100,000/QALY willingness-to-pay threshold. One- and two-way sensitivity analyses were completed.
Sensitivity analysis found that in-office PNA became cost-effective compared to VN when patients undergoing PNA were less than 20 % more likely than VN to have symptoms recur; this value was assumed to be twice as likely in the base case. In the base case, however, VN and in-office PNA were more effective and less expensive than PNN, while VN was cost-effective when compared to in-office PNA (incremental cost-effectiveness ratio $11,616.24/QALY). Other assumptions were not found to considerably impact incremental cost-effectiveness.
Although highly limited by currently available data, PNA may be cost-effective compared to VN as long-term outcomes on the durability of its effects emerge. These data should not be used by payers considering coverage or utilization since long-term data is still nascent. However, that as new technologies emerge for rhinitis, it will be important to monitor longer-term outcomes to identify high value care, but based on limited data PNA devices may meet this standard.
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