RESUMO
The current study evaluated whether total cost of care (TCOC) and target price were aligned in Oncology Care Model (OCM) hematologic malignancy episodes and identified factors associated with episodes exceeding target price. Hematologic malignancy episodes from OCM performance period 1-4 reconciliation reports were identified from a large academic medical center. Of the 516 hematologic malignancies episodes included in the analysis, 283 (54.8%) exceeded the target price. Episode characteristics found to be statistically significantly associated with exceeding target price were Medicare Part B drug use and Part D drug use, novel therapy use, home health agency, and >730 days from last chemotherapy. The mean TCOC was $85 374 (± $26 342) for the episodes that exceeded target price while the mean target price was $56 106 (±$16 309). The results found a substantial misalignment between the TCOC and target price for hematologic malignancy episodes, adding to the existing evidence on the lack of adequate adjustment to the OCM target price.
Assuntos
Neoplasias Hematológicas , Medicare , Idoso , Humanos , Estados Unidos , Oncologia , Neoplasias Hematológicas/tratamento farmacológicoRESUMO
PURPOSE: Guidelines for prostate cancer (PCA) germline testing (GT) have expanded, with impact on clinical management and hereditary cancer assessment. African American (AA) men have lower engagement in GT, with concern for widening disparities in genetically informed care. We evaluated the germline spectrum in a cohort of men with PCA enriched for AA men who underwent GT to inform tailored genetic evaluation strategies. METHODS: Participants included AA and White men with PCA tested with a 14-gene PCA panel: ATM, BRCA1, BRCA2, CHEK2, EPCAM, HOXB13, MLH1, MSH2, MSH6, NBN, PALB2, PMS2, RAD51D, and TP53. Germline analysis was performed per standard clinical testing and variant classification protocols. Data were compared with Fisher's exact, chi-squared, or two sample t-tests, as appropriate. Multivariable analysis was conducted using Akaike's Information Criterion. The significance level was set a priori at .05. RESULTS: The data set included 427 men all tested using the 14-gene PCA panel: AA (n = 237, 56%) and White (n = 190, 44%). Overall, the pathogenic/likely pathogenic (P/LP) variant rate was 8.2%, with AA men having lower rates of P/LP variants then White men (5.91% v 11.05%, respectively; P = .05). Borderline associations with P/LP variant status were observed by race (AA v White; odds ratio = 0.51; P = .07) and age (> 50 v ≤ 50 years; odds ratio = 0.48; P = .06). The P/LP spectrum was narrower in AA men (BRCA2, PALB2, ATM, and BRCA1) than White men (BRCA2, ATM, HOXB13, CHEK2, TP53, and NBN). A significant difference was noted in rates of variants of uncertain significance (VUSs) between AA men and White men overall (25.32% v 16.32%; P = .02) and for carrying multiple VUSs (5.1% v 0.53%, P = .008). CONCLUSION: Germline evaluation in a cohort enriched for AA men highlights the narrower spectrum of germline contribution to PCA with significantly higher rates of multiple VUSs in DNA repair genes. These results underscore the imperative to engage AA men in GT, the need for larger panel testing in AA men, and the necessity to incorporate novel genomic technologies to clarify VUS to discern the germline contribution to PCA. Furthermore, tailored genetic counseling for AA men is important to ensure understanding of VUS and promote equitable genetics care delivery.
Assuntos
Negro ou Afro-Americano , Neoplasias da Próstata , Negro ou Afro-Americano/genética , Genes BRCA2 , Testes Genéticos/métodos , Células Germinativas/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias da Próstata/diagnósticoRESUMO
PURPOSE: To explore mean difference between Oncology Care Model (OCM) total costs and target price among breast cancer episodes by stage under the Centers for Medicare and Medicaid Services OCM payment methodology. METHODS: Breast cancer episodes from OCM performance period 1-4 reconciliation reports (July 1, 2016-July 1, 2018) were linked with health record data from a large, academic medical center. Demographics, total cost of care (TCOC), and target price were measured by stage. Adjusted differences between TCOC and target price were compared across cancer stage using multivariable linear regression. RESULTS: A total of 539 episodes were evaluated from 252 unique patients with breast cancer, of which 235 (44%) were stage I, 124 (23%) stage II, 33 (6%) stage III, and 147 (27%) stage IV. About 37% of episodes exceeded target price. Mean differences from target price were -$1,782, $2,246, -$6,032, and $11,379 all in US dollars (USD) for stages I through IV, respectively. Stage IV episodes had highest mean TCOC ($44,210 USD) and mean target price ($32,831 USD) but also had higher rates of chemotherapy, inpatient admission, and novel therapy use. After adjusting for covariates, stage IV and ≥ 65-year-old patients had the highest mean difference from target price ($17,175 USD; 95% CI, $12,452 to $21,898 USD). CONCLUSION: Breast cancer episodes in older women with distant metastases most frequently exceeded target price, suggesting that target price did not adequately account for complexity of metastatic cancers. A metastatic adjustment introduced in PP7 represents a promising advancement in the target price methodology and an impact evaluation will be needed.
Assuntos
Neoplasias da Mama , Idoso , Neoplasias da Mama/terapia , Feminino , Hospitalização , Humanos , Oncologia , Medicare , Estados UnidosRESUMO
BACKGROUND: Mobile electrocardiograms (mECGs) utilizing smartphone applications are an emerging technology. Typically, a Lead I rhythm strip is recorded. However, interpretation can be difficult in patients with sinus rhythm and low amplitude P-waves (SR-LAP) or atrial flutter (AFL). We hypothesized that patients could independently obtain multi-lead tracings using a commercial mECG device, and that cardiologists who interpreted the multi-lead tracings would make more accurate diagnoses and have more confidence in their interpretation compared to a single lead only. METHODS: Thirty sets of recordings were obtained from 10 patients with either SR-LAP or AFL that was not apparent on Lead I on a standard ECG. Patients recorded Lead I, Lead II, and Lead V1 tracings using AliveCor's KardiaMobile mECG device. Twenty-nine cardiologists reviewed each patient's Lead I tracing, multi-lead tracings (Leads I, II, V1), and 12-lead ECG. Accuracy was noted and each cardiologist rated their level of confidence in their interpretation. RESULTS: All patients were able to record their own single and multi-lead tracings. Single lead, multi-lead, and the 12-lead ECG yielded 36.4%, 84.3%, and 97.7% agreement with the established diagnosis, respectively (P < .01 for each comparison). Overall mean confidence scores (out of a score of 5) were 2.95, 3.50, and 4.47 for single lead, multi-lead, and the 12-lead ECG, respectively (P < .01 for each comparison). CONCLUSIONS: Patients were able to record their own multi-lead mECG tracings. Compared to a single lead recording, multi-lead mECGs significantly improved cardiologists' diagnostic accuracy and confidence in their interpretation approaching that of a standard 12-lead ECG.
Assuntos
Arritmias Cardíacas/diagnóstico , Eletrocardiografia/instrumentação , Eletrocardiografia/normas , Aplicativos Móveis , Idoso , Técnicas de Diagnóstico Cardiovascular/normas , Eletrodos , Desenho de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos TestesRESUMO
OBJECTIVES: Fibroblast growth factor-23 (FGF23) is a biomarker for cardiovascular disease. Obesity may promote FGF23 production in the absence of chronic kidney disease. We sought to determine among normotensive African American adolescents whether FGF23 levels are greater in obese compared with normal-weight adolescents and to determine the relationship of FGF23 with markers of cardiac structure and insulin resistance. STUDY DESIGN: Cross-sectional data were obtained from a cohort of 130 normotensive, African American adolescents ages 13-18 years without chronic kidney disease; 74 were obese; 56 were normal weight. Plasma C-terminal FGF23, fasting glucose and insulin, and high-sensitivity C-reactive protein were measured; participants underwent M-mode echocardiography. RESULTS: FGF23 was skewed and approximately normally distributed after natural log transformation (logFGF23). FGF23 levels were greater in obese vs normal-weight participants (geometric mean 43 vs 23 RU/mL, P < .01). FGF23 values were significantly greater in participants with eccentric or concentric cardiac hypertrophy compared with those without hypertrophy P < .01). LogFGF23 directly correlated with body mass index, body mass index z-score, waist circumference, fasting insulin levels, and homeostasis model assessment scores. Regression models adjusted for age, sex, and high-sensitivity C-reactive protein suggest that each 10% increase in FGF23 is associated with a 1.31 unit increase in left ventricular mass (P < .01), a 0.29-unit increase in left ventricular mass index (P < .01), and a 0.01-unit increase in left atrial dimension indexed to height (P = .02). CONCLUSIONS: In this sample of obese African American adolescents, FGF23 blood levels were associated with abnormal cardiac structure. We postulate that FGF23 may be an early marker of cardiac injury in obese but otherwise-healthy African American adolescents.
Assuntos
Fatores de Crescimento de Fibroblastos/sangue , Cardiopatias Congênitas/sangue , Obesidade/sangue , Adolescente , Negro ou Afro-Americano , Fatores Etários , Biomarcadores/sangue , Pressão Sanguínea , Proteína C-Reativa/metabolismo , Estudos de Coortes , Creatinina/sangue , Estudos Transversais , Ecocardiografia , Feminino , Fator de Crescimento de Fibroblastos 23 , Taxa de Filtração Glomerular , Cardiopatias Congênitas/diagnóstico por imagem , Cardiopatias/sangue , Cardiopatias/etnologia , Homeostase , Humanos , Resistência à Insulina , Masculino , Estrutura Terciária de ProteínaRESUMO
BACKGROUND: The purpose of this study is to evaluate conditional survival probabilities for patients with resected pancreatic adenocarcinoma (PC). METHODS: Patients with resected PC from 1998 to 2008 were identified from the Surveillance, Epidemiology and End Results Database. Data on patient, tumor, and treatment characteristics were extracted. Overall survival (OS) rates were calculated using the Kaplan-Meier method. A multivariable analysis at different time points from survival was performed to determine independent prognostic factors associated with all-cause mortality hazard ratios using Cox proportional hazards models. RESULTS: A total of 4883 patients with resected PC were identified. The 1-, 3-, and 5-year survival estimates for patients at diagnosis were 67%, 29%, and 21%, respectively. The probability of surviving an additional 1-, 3-, or 5-year conditional upon already surviving 5 years after diagnosis were 89%, 76%, and 71%, respectively. Prognostic factors significantly correlated with improved OS at the time of diagnosis on multivariable analysis include: earlier stage, younger age, later year of diagnosis, white ethnicity, female sex, and residence in a high income district (P<0.05). Among those already surviving 3 years after diagnosis, younger age was the only prognostic factor statistically significantly correlated with improved OS (P<0.05). CONCLUSIONS: Conditional survival estimates provide additional prognostic information that may be used to counsel PC patients on how their prognosis may change over time. Further research using prospectively collected data is warranted to help determine recommended follow-up intervals and benchmarks for future clinical trials.
Assuntos
Adenocarcinoma/mortalidade , Adenocarcinoma/cirurgia , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/cirurgia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Probabilidade , Prognóstico , Programa de SEERRESUMO
This study investigates the organizational culture and associated characteristics of the newly established primary care units (PCUs)-collaborative teams of general practitioners (GPs) who provide patients with integrated health care services-in the Emilia-Romagna Region (RER), Italy. A survey instrument covering 6 cultural dimensions was administered to all 301 GPs in 21 PCUs in the Local Health Authority (LHA) of Parma, RER; the response rate was 79.1%. Management style, organizational trust, and collegiality proved to be more important aspects of PCU organizational culture than information sharing, quality, and cohesiveness. Cultural dimension scores were positively associated with certain characteristics of the PCUs including larger PCU size and greater proportion of older GPs. The presence of female GPs in the PCUs had a negative impact on collegiality, organizational trust, and quality. Feedback collected through this assessment will be useful to the RER and LHAs for evaluating and guiding improvements in the PCUs.
Assuntos
Cultura Organizacional , Atenção Primária à Saúde/organização & administração , Feminino , Clínicos Gerais/organização & administração , Clínicos Gerais/estatística & dados numéricos , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Atenção Primária à Saúde/estatística & dados numéricos , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: To examine the relative effects of high blood pressure (HBP) and obesity on left ventricular mass (LVM) among African-American adolescents; and if metabolic or inflammatory factors contribute to LVM. STUDY DESIGN: Using a 2 × 2 design, African-American adolescents were stratified by body mass index percentile (body mass index <95th percentile = non-obese; ≥ 95th percentile = obese) and average blood pressure (BP) (normal BP <120/80 mm Hg; HBP ≥ 120/80). Glucose, insulin, insulin resistance, lipids, and inflammatory cytokines were measured. From echocardiography measures of LVM, calculated LVM index (LVMI) ≥ 95th percentile defined left ventricular hypertrophy (LVH). RESULTS: Data included 301 adolescents (48% female), mean age 16.2 years, 51% obese, and 29% HBP. LVMI was highest among adolescents with both obesity and HBP. The multiplicative interaction of obesity and HBP on LVH was not significant (OR = 2.35, P = .20) but the independent additive associations of obesity and HBP with log-odds of LVH were significant; obesity OR = 3.26, P < .001; HBP OR = 2.92, P < .001. Metabolic and inflammatory risk factors were associated with obesity, but had no independent association with LVMI. Compared with those with average systolic BP (SBP) <75th percentile, adolescents with SBP from the 75th percentile to 90th percentile had higher LVMI (33.2 vs 38.7 g/m(2.7), P < .001) and greater LVH (18% vs 43%, P < .001), independent of obesity. CONCLUSIONS: Prevalence of LVH is highest among African-American adolescents with average BP ≥ 120/80 mm Hg and obesity. There also is an independent association of LVMI with BP, beginning at the 75th SBP percentile.