Tag: pubmed

J Clin Oncol. 2024 Sep 3:JCO2302510. doi: 10.1200/JCO.23.02510. Online ahead of print.

ABSTRACT

PURPOSE: To investigate the use of radiation with radiosensitizing chemotherapy following repeated transurethral resection (trimodality therapy) as an alternative to radical cystectomy in T1 bladder cancer which has failed Bacillus Calmette-Guerin (BCG).

PATIENTS AND METHODS: Patients with recurrent T1 bladders who had failed BCG and were recommended to undergo cystectomy were treated with trimodality therapy. The primary end point was 3-year freedom from cystectomy. Secondary end points were distant metastasis at 3 and 5 years, local recurrence, disease-specific and overall survival (OS), and safety.

RESULTS: This single-arm phase II study enrolled 37 patients. Efficacy and safety were evaluated in 34 patients after three exclusions. The median follow-up was 5.1 years. The 3-year freedom from cystectomy rate was 88% (lower one-sided 97.5% confidence limit [CI], 72%), meeting the primary study goal. OS at 3 and 5 years was 69% (95% CI, 54 to 85) and 56% (95% CI, 39 to 74), respectively. The distant metastasis rates at 3 and 5 years were 12% (95% CI, 4 to 26) and 19% (95% CI, 7 to 34), respectively. Eight patients died due to urothelial cancer, 12 exhibited local recurrence at 3 years (cumulative incidence: 32%; 95% CI, 17 to 48), 18 experienced grade 3 adverse events, mostly hematological, and one developed grade 4 neutropenia.

CONCLUSION: Trimodality therapy is an effective potential alternative to radical cystectomy for recurrent high-grade T1 urothelial cancer of the bladder. At 3 years, 88% of the patients remained free of cystectomy.

PMID:39226514 | DOI:10.1200/JCO.23.02510

Health Aff (Millwood). 2024 Sep;43(9):1263-1273. doi: 10.1377/hlthaff.2023.01637.

ABSTRACT

Bundled payments are increasingly used globally to move health care delivery in a value-based direction. However, evidence remains scant in key clinical areas. We evaluated bundled payments for maternity care in the Netherlands during the period 2016-18. We used a quasi-experimental difference-in-differences design to measure the association between the bundled payment model and changes in key clinical and economic outcomes. Bundled payments were associated with an increase in outpatient, midwife-led births and a reduction in in-hospital, obstetrician-led births, along with changes in the use of labor inductions and planned versus emergency cesarean deliveries. Total spending on maternity care decreased by US$328 (5 percent) per pregnancy. No changes in maternal or neonatal health outcomes were observed. Several policy lessons emerged. First, bundled payments appeared to help affect providers’ behavior in the maternity care setting. Second, bundled payments seemed to exert heterogeneous effects across participating maternity care networks, as the same financial incentive translated into different changes in clinical practices and outcomes. Third, alternative payment models should be designed with clear goals and definitions of success to guide evaluation and implementation.

PMID:39226512 | DOI:10.1377/hlthaff.2023.01637

Health Aff (Millwood). 2024 Sep;43(9):1209-1218. doi: 10.1377/hlthaff.2024.00230.

ABSTRACT

Value-based care models, such as Medicaid accountable care organizations (ACOs), have the potential to improve access to and quality of care for pregnant and postpartum Medicaid enrollees. We leveraged a natural experiment in Massachusetts to evaluate the effects of Medicaid ACOs on quality-of-care-sensitive measures and care use across the prenatal, delivery, and postpartum periods. Using all-payer claims data on Medicaid-covered live deliveries in Massachusetts, we used a difference-in-differences approach to compare measures before (the first quarter of 2016 through the fourth quarter of 2017) and after (the third quarter of 2018 through the fourth quarter of 2020) Medicaid ACO implementation among ACO and non-ACO patients. After three years of implementation, the Medicaid ACO was associated with statistically significant increases in the probability of a timely postpartum visit, postpartum depression screening, and number of all-cause office visits in the prenatal and postpartum periods, with no changes in severe maternal morbidity, preterm birth, postpartum glucose screening, or prenatal or postpartum emergency department visits. Changes in cesarean deliveries were inconclusive. Results suggest that implementing Medicaid ACOs in the thirty-eight states without them could improve maternal health care outpatient engagement, but alone it may be insufficient to improve maternal health outcomes.

PMID:39226509 | DOI:10.1377/hlthaff.2024.00230

Health Aff (Millwood). 2024 Sep;43(9):1311-1318. doi: 10.1377/hlthaff.2024.00052.

ABSTRACT

In this study of 2022 Medicare fee-for-service claims, we found that female physicians, primary care physicians, psychiatrists, and physicians in nonrural practices delivered relatively higher proportions of visits via telehealth.

PMID:39226507 | DOI:10.1377/hlthaff.2024.00052

Health Aff (Millwood). 2024 Sep;43(9):1244-1253. doi: 10.1377/hlthaff.2023.01547.

ABSTRACT

Legislative policies that criminalize immigrants have a “chilling effect” on public program participation among eligible immigrants. However, little is known about the effect of local enforcement actions by Immigration and Customs Enforcement (ICE). In this study, we linked county-level data on the number of detainer requests (or immigration holds) issued by ICE to individual-level data from the 2011, 2016, and 2019 American Community Surveys. We fit adjusted logistic regression models to assess the association between detainer requests and enrollment in Medicaid and the Supplemental Nutrition Assistance Program (SNAP) among those likely eligible for each program in US-born versus immigrant households. A higher volume of detainer requests was associated with lower enrollment in both Medicaid and SNAP, particularly among adults in households with at least one immigrant relative to US-born households. We observed the most pronounced effects in 2011 and 2019.

PMID:39226506 | DOI:10.1377/hlthaff.2023.01547

Health Aff (Millwood). 2024 Sep;43(9):1235-1243. doi: 10.1377/hlthaff.2023.01524.

ABSTRACT

In the Affordable Care Act (ACA) Marketplaces, enrollees must periodically demonstrate their eligibility to receive income-linked health insurance premium subsidies. Marketplaces can verify eligibility using existing records, but only with consumers’ consent, which must be renewed at specified times. In a randomized experiment in September 2020, we tested the effect of email nudges reminding consumers to provide consent for verification of their continued eligibility for premium subsidies in California’s ACA Marketplace. More than 20,000 households that had applied for subsidies but whose consent for eligibility verification would soon expire were sent one, two, or three emails reminding them to renew consent. Sending three emails increased consent updates by 1.9 percentage points (3.2 percent) and increased receipt of subsidies by 2.0 percentage points (4.0 percent). However, nearly 40 percent of households receiving three emails did not update their consent by the end of the open enrollment period, thus preventing their continued receipt of subsidies. To improve the affordability of Marketplace coverage, new policies and structural changes may be needed to reduce administrative barriers that can inhibit access to subsidies.

PMID:39226504 | DOI:10.1377/hlthaff.2023.01524

Health Aff (Millwood). 2024 Sep;43(9):1296-1305. doi: 10.1377/hlthaff.2023.01579.

ABSTRACT

Dual-eligible beneficiaries have insurance through two distinct and uncoordinated programs: Medicaid, which pays for long-term care; and Medicare, which pays for medical care, including hospital stays. Concern that this system leads to poor quality and inefficient care, particularly for dual-eligible nursing home residents, has led policy makers to test managed care plans that provide incentives for coordinating care across Medicare and Medicaid. We examined enrollment in three such plans among dual-eligible beneficiaries receiving long-term nursing home care. Two of those plans, Medicare-Medicaid plans and Fully Integrated Dual Eligible Special Needs Plans, are integrated care plans that establish a global budget including Medicare and Medicaid spending. The third, Institutional Special Needs Plans, puts insurers and nursing homes at risk for Medicare spending but not Medicaid spending. Among dual-eligible nursing home residents, enrollment in these plans increased from 6.5 percent of residents per month in 2013 to 16.9 percent in 2020. Enrollment varied across counties but did not vary appreciably with respect to nursing home characteristics, including the share of residents with Medicaid. As policy makers pursue strategies to coordinate medical and long-term care for dual-eligible beneficiaries, it remains critical to evaluate how these plans influence the care of dual-eligible nursing home residents.

PMID:39226503 | DOI:10.1377/hlthaff.2023.01579

Health Aff (Millwood). 2024 Sep;43(9):1219-1224. doi: 10.1377/hlthaff.2023.00982.

ABSTRACT

Miscarriage and abortion require similar clinical management. Restrictions placed on abortion threaten the quality of miscarriage care, a policy spillover that affects many Americans. We combined vital statistics with life-table parameters to estimate that 1,034,000 miscarriages occur annually, including nearly 400,000 in US states with abortion bans. Attempts to restrict mifepristone access further threaten miscarriage management.

PMID:39226500 | DOI:10.1377/hlthaff.2023.00982

Health Aff (Millwood). 2024 Sep;43(9):1284-1289. doi: 10.1377/hlthaff.2023.01344.

ABSTRACT

The rising price of branded drugs has garnered considerable attention from the public and policy makers. This article investigates the complexities of pharmaceutical pricing, with an emphasis on the overlooked aspects of manufacturer rebates and out-of-pocket prices. Rebates granted by pharmaceutical manufacturers to insurers reduce the actual prices paid by insurers, causing the true prices of prescriptions to diverge from official statistics. We combined claims data on branded retail prescription drugs with estimates on rebates to provide new price index measures based on pharmacy prices, negotiated prices (after rebates), and out-of-pocket prices for the commercially insured population during the period 2007-20. We found that although retail pharmacy prices increased 9.1 percent annually, negotiated prices grew by a mere 4.3 percent, highlighting the importance of rebates in price measurement. Surprisingly, consumer out-of-pocket prices diverged from negotiated prices after 2016, growing 5.8 percent annually while negotiated prices remained flat. The concern over drug price inflation is more reflective of the rapid increase in consumer out-of-pocket expenses than the stagnated inflation of negotiated prices paid by insurers after 2016.

PMID:39226496 | DOI:10.1377/hlthaff.2023.01344

Health Aff (Millwood). 2024 Sep;43(9):1329-1337. doi: 10.1377/hlthaff.2023.01250.

ABSTRACT

COVID-19-related school closures may have had unintended consequences affecting the ability of health professionals with school-age children to work-particularly female professionals, who often have disproportionate child care responsibilities. We combined labor-force participation data from the Current Population Survey with measures of school closures based on cell phone mobility data to examine the association between local school closures and labor supply among female nurses during the COVID-19 pandemic. During the six months after large-scale closure of schools at the end of the 2019-20 school year (March-August 2020), among counties with above-median school closure rates, the employment rate of female nurses with young children declined by 12.5 percentage points versus the rate during the prior four months (November 2019-February 2020); the change in the employment rate in below-median counties was not statistically significant. No statistically significant changes were observed among female nurses who had only older children or among male nurses. During public health emergencies, policies should consider how disruptions to schooling may affect the labor supply of health care professionals. Strategies might include direct provision of child care by health care facilities, subsidies and other aid to child care centers, or subsidies to health care workers for affordable child care.

PMID:39226495 | DOI:10.1377/hlthaff.2023.01250