Nevin Manimala

JAMA Netw Open. 2023 Nov 1;6(11):e2341836. doi: 10.1001/jamanetworkopen.2023.41836.

ABSTRACT

IMPORTANCE: Tiered physician network (TPN) health plans sort physicians into tiers based on their cost and quality, and patients pay lower copays for visits with physicians in the lower-cost and better-quality tiers. When the plans are first introduced, they lead patients to seek care from higher-value physicians.

OBJECTIVES: To examine whether TPNs are associated with patient choice of physician when the plans have been in place for 8 to 12 years and whether there are inequities in patient out-of-pocket costs associated with inequities in access to physicians in lower-copay tiers.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study comprising 46 645 physicians and 585 399 patients in TPNs, including 54 683 patients who had a new patient visit with a physician in a TPN, used health insurance claims data from a large employer purchaser from July 1, 2014, to June 30, 2019. Statistical analysis was performed from November 2020 to August 2023.

EXPOSURE: Evaluation and management visit with a physician in a TPN.

MAIN OUTCOMES AND MEASURES: Main outcomes were new patient market share per physician-carrier-zip code-year, distance from centroid of patient zip code to centroid of zip code of nearest low- or medium-copay physician, and mean TPN physician office visit copay per patient. A regression discontinuity design was used to estimate the association of a physician’s tier ranking, and a difference-in-differences analysis was used to estimate the association of copayment differences across tiers with market share among new patients. Equity in access was measured by comparing travel distance to the nearest physician in a low-copay or medium-copay tier and mean copayments across patient incomes.

RESULTS: The main analysis sample included 46 645 physician-carrier-zip code-year observations, 9506 (20.4%) of which were in the low-copay tier, 31 798 (68.2%) in the medium-copay tier, and 5341 (11.5%) in the high-copay tier. The 54 683 new patients in the sample had a mean (SD) age of 46.4 (16.7) years and included 33 542 women (61.3%). There was no association of having a worse tier ranking (0.045 percentage points [95% CI, -0.058 to 0.148 percentage points]) or of copayment differences between tiers (0.001 percentage points [95% CI, -0.002 to 0.004 percentage points]) with physician market share among new patients. The patients with the lowest income paid slightly lower mean (SD) copayments for office visits to a TPN physician than the patients with high income ($48.08 [$16.42] vs $51.59 [$16.79], a 6.8% difference).

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of TPN health plans, there was no association between physician tier ranking and physician market share among any group of patients. These findings suggest there are limitations in TPNs’ steering of patients toward high-value physicians. These plans were not associated with exacerbated health inequity in this setting.

PMID:37943560 | DOI:10.1001/jamanetworkopen.2023.41836

JAMA Netw Open. 2023 Nov 1;6(11):e2342464. doi: 10.1001/jamanetworkopen.2023.42464.

ABSTRACT

IMPORTANCE: Medical test overuse and resulting care cascades represent a costly, intractable problem associated with inadequate patient-clinician communication. One possible solution with potential for broader benefits is priming routine, high-quality medical test conversations.

OBJECTIVE: To assess if a peer comparison and educational intervention for physicians and patients improved medical test conversations during annual visits.

DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial and qualitative evaluation at an academic medical center conducted May 2021 to October 2022. Twenty primary care physicians (PCPs) were matched-pair randomized. For each physician, at least 10 patients with scheduled visits were enrolled. Data were analyzed from December 2022 to September 2023.

INTERVENTIONS: In the intervention group, physicians received previsit emails that compared their low-value testing rates with those of peer PCPs and included point-of-care-accessible guidance on medical testing; patients received previsit educational materials via email and text message. Control group physicians and patients received general previsit preparation tips.

MAIN OUTCOMES AND MEASURES: The primary patient outcome was the Shared Decision-Making Process survey (SDMP) score. Secondary patient outcomes included medical test knowledge and presence of test conversation. Outcomes were compared using linear regression models adjusted for patient age, gender, race and ethnicity, and education. Poststudy interviews with intervention group physicians and patients were also conducted.

RESULTS: There were 166 intervention group patients and 148 control group patients (mean [SD] patient age, 50.2 [15.3] years; 210 [66.9%] female; 246 [78.3%] non-Hispanic White). Most patients discussed at least 1 test with their physician (95.4% for intervention group; 98.3% for control group; difference, -2.9 percentage points; 95% CI, -7.0 to 1.2 percentage points). There were no statistically significant differences in SDMP scores (2.11 out of 4 for intervention group; 1.97 for control group; difference, 0.14; 95% CI, -0.25 to 0.54) and knowledge scores (2.74 vs 2.54 out of 4; difference, 0.19; 95% CI, -0.05 to 0.43). In poststudy interviews with 3 physicians and 16 patients, some physicians said the emails helped them reexamine their testing approach while others noted competing demands. Most patients said they trusted their physicians’ advice even when inconsistent with educational materials.

CONCLUSIONS AND RELEVANCE: In this randomized clinical trial of a physician-facing and patient-facing peer comparison and educational intervention, there was no significant improvement in medical test conversation quality during annual visits. These results suggest that future interventions to improve conversations and reduce overuse and cascades should further address physician adoption barriers and leverage patient-clinician relationships.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04902664.

PMID:37943557 | DOI:10.1001/jamanetworkopen.2023.42464

JAMA Oncol. 2023 Nov 9. doi: 10.1001/jamaoncol.2023.4513. Online ahead of print.

ABSTRACT

IMPORTANCE: The COVID-19 pandemic led to disruptions in access to health care, including cancer care. The extent of changes in receipt of cancer treatment is unclear.

OBJECTIVE: To evaluate changes in the absolute number, proportion, and cancer treatment modalities provided to patients with newly diagnosed cancer during 2020, the first year of the pandemic.

DESIGN, SETTING, AND PARTICIPANTS: In this cohort study, adults aged 18 years and older diagnosed with any solid tumor between January 1, 2018, and December 31, 2020, were identified using the National Cancer Database. Data analysis was conducted from September 19, 2022, to July 28, 2023.

EXPOSURE: First year of the COVID-19 pandemic.

MAIN OUTCOMES AND MEASURES: The expected number of procedures for each treatment modality (surgery, radiotherapy, chemotherapy, immunotherapy, and hormonal therapy) in 2020 were calculated using historical data (January 1, 2018, to December 31, 2019) with the vector autoregressive method. The difference between expected and observed numbers was evaluated using a generalized estimating equation under assumptions of the Poisson distribution for count data. Changes in the proportion of different types of cancer treatments initiated in 2020 were evaluated using the additive outlier method.

RESULTS: A total of 3 504 342 patients (1 214 918 in 2018, mean [SD] age, 64.6 [13.6] years; 1 235 584 in 2019, mean [SD] age, 64.8 [13.6] years; and 1 053 840 in 2020, mean [SD] age, 64.9 [13.6] years) were included. Compared with expected treatment from previous years’ trends, there were approximately 98 000 fewer curative intent surgical procedures performed, 38 800 fewer chemotherapy regimens, 55 500 fewer radiotherapy regimens, 6800 fewer immunotherapy regimens, and 32 000 fewer hormonal therapies initiated in 2020. For most cancer sites and stages evaluated, there was no statistically significant change in the type of cancer treatment provided during the first year of the pandemic, the exception being a statistically significant decrease in the proportion of patients receiving breast-conserving surgery and radiotherapy with a simultaneous statistically significant increase in the proportion of patients undergoing mastectomy for treatment of stage I breast cancer during the first months of the pandemic.

CONCLUSIONS AND RELEVANCE: In this large national cohort study, a significant deficit was noted in the number of cancer treatments provided in the first year of the COVID-19 pandemic. Data indicated that this deficit in the number of cancer treatments provided was associated with decreases in the number of cancer diagnoses, not changes in treatment strategies.

PMID:37943539 | DOI:10.1001/jamaoncol.2023.4513

Ophthalmol Ther. 2023 Nov 9. doi: 10.1007/s40123-023-00844-4. Online ahead of print.

ABSTRACT

INTRODUCTION: This study aimed to compare the accuracy of seven implantable collamer lens (ICL) implantation vault prediction formulae.

METHODS: We retrospectively analyzed 328 patients (328 eyes) who underwent ICL implantation and the prediction accuracy of seven formulae: NK, KS, WH, Luo, Zhu, Hun, and ZZ were compared. Moreover, the accuracy of the seven formulae for different ICL sizes was compared. The formulae were tested using mean absolute prediction error (MAE), median absolute prediction error (MedAE), prediction error (PE) percentages at ± 50 µm, ± 100 µm, ± 200 µm, and ± 300 µm, and Bland-Altman analysis.

RESULTS: The PE of the seven formulae were statistically significant (P < 0.001). The KS (101.00 µm) and WH formulae (116.65 µm) had the smallest MedAE, followed by the Luo (123.62 µm), NK (141.50 µm), Hun (152.68 µm), ZZ (196.00 µm) and Zhu formula (225.98 µm). The highest percentage of PE in the range of ± 300µm was 94.3% and 93% for the KS and WH formulae, respectively. Among the different ICL size groupings, the KS formula predicted the smallest MedAE for 12.1 mm and 12.6 mm, whereas the Luo and WH formulae predicted the smallest MedAE for 13.2 mm and 13.7 mm, respectively.

CONCLUSIONS: The KS and WH formulae provided better outcomes by predicting the vault with higher accuracy than of the NK, Hun, Luo, ZZ, and Zhu formulae.

TRIAL REGISTRATION: ChiCTR2200065501.

PMID:37943482 | DOI:10.1007/s40123-023-00844-4

Indian J Gastroenterol. 2023 Nov 9. doi: 10.1007/s12664-023-01440-x. Online ahead of print.

ABSTRACT

BACKGROUND: Pediatric inflammatory bowel disease (IBD) has been known to be a disease predominant in the west. There is scarcity of data on pediatric IBD (P-IBD) from northern India. The objective of our study was to analyze the clinical spectrum of P-IBD in northern India.

METHODS: A retrospective analysis of 126 children (<18-year old) diagnosed with IBD from January 1999 to December 2019 was done on a pre-designed proforma. It was systematically entered in a MS Excel spreadsheet and analyzed using Statistical Package for the Social Sciences (SPSS) version 21.0. The descriptive phenotypes of Ulcerative colitis (UC) and Crohn’s disease (CD) were revised according to the Paris classification.

RESULTS: Of 126 children, UC was diagnosed in 76 (60.3%), CD in 44 (34.9%) and IBD-unclassified (IBD-U) in six (4.76%) patients. The mean age at diagnosis was 11.3 years; 38.8% were < 10 years with the male: female ratio of 1.6:1. Sixteen children (12.7%) had very early onset IBD (VEOBD). Overall, the median time to diagnosis in IBD was 12 months (interquartile range [IQR]: 3.25-24), which was as high as 52.5 months (IQR: 11-98) in CD. Pancolitis with bleeding per rectum and ileocolonic involvement with pain in abdomen were the commonest presentations in UC and CD, respectively. Stricturing disease was seen in 27% of CD cases. Relapses were seen in 46% (35/76) of U.C and 23% (10/44) of CD kids. Step-up treatment protocol was employed in them with the use of biologicals in 12% of cases. There was a 2.75-fold rise in the IBD cases in the last 10 years (2010-20). There was reduction in time to diagnosis (21 months vs. 90 months; p – 0.012) and empirical anti-tubercular therapy use (90% vs. 5.8%) in CD over two decades.

CONCLUSION: From our experience in a tertiary care centre in northern India, P-IBD is on the rise. UC is more common than CD. Pancolitis and ileocolonic disease are the commonest disease sites in UC and CD, respectively There is a significant delay in the time to diagnosis in CD. Stricturing disease was seen in a quarter of children with CD.

PMID:37943479 | DOI:10.1007/s12664-023-01440-x

Environ Sci Pollut Res Int. 2023 Nov 9. doi: 10.1007/s11356-023-30791-3. Online ahead of print.

ABSTRACT

Concentrations of 4 potentially toxic elements (As, Cd, Hg, Pb) were investigated in the feather, liver, kidney, and bone of great cormorants (Phalacrocorax carbo). The tissue samples were taken at the Central Tisza – Jászság Nature Conservation Area in Hungary. They were analysed by inductively coupled plasma optical emission spectroscopy (ICP-OES). The goal of the investigation was to analyse the metal burden of the above-mentioned elements in the various tissues of these wild birds and to provide important information for monitoring the environmental pollution.Amongst the examined potentially toxic elements no statistical gender difference was observed, so the data were not separated based on them during the statistical analysis. The concentration of mercury was the highest in the feather, followed by the liver, kidney, and bone. The lead was detected in the feather with the highest level followed by the kidney, liver, and bone. The cadmium was determined in all investigated tissues with the next descending order: kidney > bone > liver > feather. Highest arsenic concentration was measured in the feather, followed by liver, kidney, and bone with the same concentration.The detected concentrations of the investigated potentially toxic elements in different tissues of great cormorants (feathers, liver, kidney, bone) means that the living area of this birds is not highly contaminated to induce health problems or toxic signs, or even other undesirable effect in the animals.

PMID:37943439 | DOI:10.1007/s11356-023-30791-3

Med Biol Eng Comput. 2023 Nov 9. doi: 10.1007/s11517-023-02961-5. Online ahead of print.

ABSTRACT

Long-term electroencephalogram (Long-Term EEG) has the capacity to monitor over a long period, making it a valuable tool in medical institutions. However, due to the large volume of patient data, selecting clean data segments from raw Long-Term EEG for further analysis is an extremely time-consuming and labor-intensive task. Furthermore, the various actions of patients during recording make it difficult to use algorithms to denoise part of the EEG data, and thus lead to the rejection of these data. Therefore, tools for the quick rejection of heavily corrupted epochs in Long-Term EEG records are highly beneficial. In this paper, a new reliable and fast automatic artifact rejection method for Long-Term EEG based on Isolation Forest (IF) is proposed. Specifically, the IF algorithm is repetitively applied to detect outliers in the EEG data, and the boundary of inliers is promptly adjusted by using a statistical indicator to make the algorithm proceed in an iterative manner. The iteration is terminated when the distance metric between clean epochs and artifact-corrupted epochs remains unchanged. Six statistical indicators (i.e., min, max, median, mean, kurtosis, and skewness) are evaluated by setting them as centroid to adjust the boundary during iteration, and the proposed method is compared with several state-of-the-art methods on a retrospectively collected dataset. The experimental results indicate that utilizing the min value of data as the centroid yields the most optimal performance, and the proposed method is highly efficacious and reliable in the automatic artifact rejection of Long-Term EEG, as it significantly improves the overall data quality. Furthermore, the proposed method surpasses compared methods on most data segments with poor data quality, demonstrating its superior capacity to enhance the data quality of the heavily corrupted data. Besides, owing to the linear time complexity of IF, the proposed method is much faster than other methods, thus providing an advantage when dealing with extensive datasets.

PMID:37943419 | DOI:10.1007/s11517-023-02961-5

Dig Dis Sci. 2023 Nov 9. doi: 10.1007/s10620-023-08134-6. Online ahead of print.

ABSTRACT

BACKGROUND: Cholecystolithiasis is defined as a disease caused by complex and changeable factors. Advanced age, female sex, and a hypercaloric diet rich in carbohydrates and poor in fiber, together with obesity and genetic factors, are the main factors that may predispose people to choledocholithiasis. However, serum biomarkers for the rapid diagnosis of choledocholithiasis remain unclear.

AIMS: This study was designed to explore the pathogenesis of cholecystolithiasis and identify the possible metabolic and lipidomic biomarkers for the diagnosis of the disease.

METHODS: Using UHPLC-MS/MS and GC-MS, we detected the serum of 28 cholecystolithiasis patients and 19 controls. Statistical analysis of multiple variables included Principal Component Analysis (PCA). Visualization of differential metabolites was performed using volcano plots. The screened differential metabolites were further analyzed using clustering heatmaps. The quality of the model was assessed using random forests.

RESULTS: In this study, dramatically altered lipid homeostasis was detected in cholecystolithiasis group. In addition, the levels of short-chain fatty acids and amino acids were noticeably changed in patients with cholecystolithiasis. They detected higher levels of FFA.18.1, FFA.20.1, LPC16.0, and LPC20.1, but lower levels of 1-Methyl-L-histidine and 4-Hydroxyproline. In addition, glycine and L-Tyrosine were higher in choledocholithiasis group. Analyses of metabolic serum in affected patients have the potential to develop an integrated metabolite-based biomarker model that can facilitate the early diagnosis and treatment of the disease.

CONCLUSION: Our results highlight the value of integrating lipid, amino acid, and short-chain fatty acid to explore the pathophysiology of cholecystolithiasis disease, and consequently, improve clinical decision-making. Using UHPLC-MS/MS and GC-MS, the serum of 28 cholecystolithiasis patients and 19 controls were analyzed. Through differential metabolite analysis, we found that the cholecystolithiasis group was detected with dramatically altered lipid homeostasis compared with healthy controls. In addition, the levels of short-chain fatty acids and amino acids were noticeably changed in patients with cholecystolithiasis. They detected higher levels of FFA.18.1, FFA.20.1, LPC16.0, and LPC20.1, but lower levels of 1-Methyl-L-histidine and 4-Hydroxyproline. Moreover, glycine and L-Tyrosine were higher in choledocholithiasis group. The results not only identify new targets for the clinical diagnosis and treatment of cholecystolithiasis but may also provide valuable insights for the research of the disease.

PMID:37943386 | DOI:10.1007/s10620-023-08134-6

Dig Dis Sci. 2023 Nov 9. doi: 10.1007/s10620-023-08172-0. Online ahead of print.

ABSTRACT

BACKGROUND: The worldwide incidence of acute pancreatitis (AP) is increasing, but the dominant etiology of AP may vary by country. Mixed etiologies are involved in the increase in the number of AP patients.

AIMS: This study was to analyze the etiological changes and prognosis of AP patients and explore the prognosis of AP patients with mixed etiologies.

METHODS: Using a retrospective analysis method, AP patients hospitalized from January 2007 to December 2021 were selected from a pancreatic center in Nanchang, China. Trends in the main etiologies were analyzed, and the severity and prognosis of different etiologies were compared.

RESULTS: A total of 10,071 patients were included. Cholelithiasis (56.0%), hyperlipidemia (25.3%), and alcohol (6.5%) were the top three etiologies. The proportion of acute biliary pancreatitis (ABP) showed a decreasing trend, while the proportion of hypertriglyceridemic pancreatitis (HTGP) and alcoholic AP showed an increasing trend (all p_trend < 0.001). The incidence of organ failure and necrotizing pancreatitis was higher in patients with HTGP than in those with AP induced by other etiologies (all p < 0.05). There was no statistically significant difference in mortality among patients with different etiologies. Patients with AP due to a mixed hypertriglyceridemia-alcoholic etiology had higher ICU admission rates and were more severe than those with AP induced by other mixed etiologies.

CONCLUSION: In the past 15 years, the proportion of ABP has trended downward, while those of HTGP and alcoholic AP have risen. Among patients with mixed etiologies, those with a mixed hypertriglyceridemia-alcoholic etiology had a worse prognosis.

PMID:37943383 | DOI:10.1007/s10620-023-08172-0

Int J Clin Oncol. 2023 Nov 9. doi: 10.1007/s10147-023-02429-4. Online ahead of print.

ABSTRACT

BACKGROUND: With the rapid aging of populations worldwide, the number of vulnerable patients with liver metastasis from colorectal cancer has increased. This study aimed to examine the association between vulnerability and clinical outcomes in patients with colorectal liver metastasis (CRLM).

METHODS: Consecutive 101 patients undergoing upfront hepatectomy for CRLM between 2004 and 2020 were included. The preoperative vulnerability was assessed using the Clinical Frailty Scale (CFS) score ranging from one (very fit) to nine (terminally ill), and frailty was defined as a CFS score of ≥ 4. A multivariable Cox proportional hazard regression model was utilized to investigate associations of frailty with disease-free survival (DFS), overall survival (OS), and cancer-specific survival (CSS).

RESULTS: Of the 101 patients, 12 (12%) had frailty. Associations between frailty and surgical outcomes, namely, the incidence of 90-day mortality and postoperative complications, were not statistically significant (P > 0.05). In the multivariable analyses, after adjusting for clinical risk scores calculated using six factors (timing of liver metastasis, primary tumor lymph node status, number of liver tumors, size of the largest tumor, extrahepatic metastatic disease, and carbohydrate antigen 19-9 level) to predict recurrence following hepatectomy for CRLM, preoperative frailty was found to be an independent risk factor for DFS (hazard ratio [HR]:2.37, 95% confidence interval [CI] 1.06-4.72, P = 0.036), OS (HR:4.17, 95% CI 1.43-10.89, P = 0.011), and CSS (HR:3.49, 95% CI 1.09-9.60, P = 0.036).

CONCLUSION: Preoperative frailty was associated with worse DFS, OS, and CSS after upfront hepatectomy for CRLM. Assessment and improvement of patient vulnerability may provide a favorable prognosis for patients with CRLM.

PMID:37943377 | DOI:10.1007/s10147-023-02429-4