2 Minute Medicine Rewind January 2, 2017
Recent years has seen an increased emphasis on decreasing readmission rates for hospitalization and linking financial reimbursement to patient outcomes. The Hospital Readmission Reduction Program sought to penalized hospitals with excess readmissions for myocardial infarction, heart failure, and pneumonia by withholding a proportion of reimbursements. In this analysis of 48,137,102 hospitalizations of Medicare beneficiaries, investigators sought to determine the rate of readmissions for both target and nontarget diagnoses and assess the impact of the HRRP. Baseline readmission rates were stable between January 2008 and March 2010 before the announcement of HRRP, however afterwards there were decreases for both hospitals subject to financial penalties as well as hospitals not subject to financial penalties. Hospitals subject to financial penalties had readmission rates decrease faster than those at non-penalized hospitals (-1.24% for acute myocardial infarction, -1.25% for heart failure, -1.37% for pneumonia, and -0.27% for nontarget conditions). There were larger decreases in readmission rates for target conditions compared to nontarget conditions at penalized hospitals. The program linking financial incentives to readmissions rates appeared to incentivize efforts to reduce readmission rates, however all hospitals in this time period reduced readmission rates.
Randomized Trial of Bilateral versus Single Internal-Thoracic-Artery Grafts
In coronary artery bypass graft (CABG) surgery, the use of the left internal mammary artery has superior durability and improved long-term outcomes compared to vein grafts. With the use of both the left and right internal mammary artery, there is potential for improved long term outcomes but also concern for chest wall and sternal wound complications. In this multi-center, international randomized trial, 3102 patients scheduled for CABG surgery were randomized to single internal mammary artery or bilateral internal mammary artery graft and followed for complications, all-cause mortality, and cardiovascular outcomes. At five years, the rate of sternal wound complication was higher in the bilateral graft group (3.5% vs. 1.9%, p = 0.005) and the rate of sternal reconstruction was also higher (1.9% vs. 0.6%, p = 0.002). There was no difference in all-cause mortality (12.2% vs. 12.7%, p = 0.69). While there were is still ten-year follow-up ongoing, current 5 year follow-up results are not supportive of bilateral internal mammary artery graft use during CABG.
With renewed focus on quality and improving patient outcomes, there have been many approaches to decreasing hospital length of stay and minimizing hospitalizations. There has been many attempts to integrate care and provide additional resources for “high-utilization” patients with multiple comorbidities. In this single center Veteran Affairs facility trial, 583 patients with top 5 percentile healthcare costs or hospitalization risk, patients were randomized 1:3 to an intensive outpatient program with a patient-centered medical home vs. standard outpatient care to assess if there were changes in utilization patterns. For this trial, enrollees were sick (mean number of chronic conditions: 10) with high rates of mental health diagnoses (65%) and history of homelessness (22%). After 17 month follow-up, there was no significant difference in mortality (12.1% vs. 13.6%, p = 0.69), number of hospitalizations (0.7 vs. 0.7) or number of monthly ED visits (2.1 vs. 2.1), however there were higher numbers of primary care visits (21.8 vs. 7.4 over 16 months, p < 0.001). There was also no significant difference in change in monthly costs from baseline between the two groups. In this study, intensive outpatient care for high utilization VA patients did not improve clinical outcomes or reduce costs.
Activity of Selumetinib in Neurofibromatosis Type 1–Related Plexiform Neurofibromas
There are no effective medical treatments for neurofibromatosis type 1-related plexiform neurofibromas, with only surgical management for symptomatic lesions. In this early, single center phase I trial, 24 children with inoperable plexiform neurofibromas were given selumetinib, a MEK 1 and 2 inhibitor, to assess pharmacokinetics and identify maximum tolerated dose. Patients were able to tolerate a median of 30 cycles with a maximum tolerated dose of 25mg per square meter body-surface area, with common side effects of rash and GI sid effects at dose-limiting concentrations. There was a partial response (>20% reduction in tumor size) in 71% of subjects without disease progression on selumetinib. This study suggests that long term selumetinib could benefit children with neurofibromatosis type 1 and inoperable plexiform neurofibromas and selumetinib can be well tolerated in this population.
US Spending on Personal Health Care and Public Health, 1996-2013
American healthcare spending represents a significant proportion of the US economy, representing 17% of gross domestic product. Despite attempts to minimize costs and create more value, national spending estimates continue to rise. In this study, investigators aggregated 183 sources of data to estimate spending for 155 conditions between 1996 and 2013. Over the time period, 30.1 trillion dollars were spent, of which diabetes had the highest expenditure at 101.4 billion dollars in 2013 alone. Ischemic heart disease accounted for the second highest amount of healthcare expenditure at 88.1 billion dollars in 2013. Throughout the time period, the vast majority, 143 of 155 conditions had personal healthcare spending increases, for which low back pain, neck pain, and diabetes ad the fastest increase. Emergency care and retail pharmaceutical spending were the two fastest growing spending categories. This article was an attempt to disaggregate healthcare spending information to delineation the types of diseases and categories of cost that most greatly affect Americans.
Image: PD
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