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Health Services Research Jun 2014Patients are treated using observation services (OS) when their care needs exceed standard outpatient care (i.e., clinic or emergency department) but do not qualify for...
BACKGROUND
Patients are treated using observation services (OS) when their care needs exceed standard outpatient care (i.e., clinic or emergency department) but do not qualify for admission. Medicare and other private payers seek to limit this care setting to 48 hours.
DATA SOURCE/STUDY SETTING
Healthcare Cost and Utilization Project data from 10 states and data collected from two additional states for 2009.
STUDY DESIGN
Bivariate analyses and hierarchical linear modeling were used to examine patient- and hospital-level predictors of OS stays exceeding 48 (and 72) hours (prolonged OS). Hierarchical models were used to examine the additional cost associated with longer OS stays.
PRINCIPAL FINDINGS
Of the 696,732 patient OS stays, 8.8 percent were for visits exceeding 48 hours. Having Medicaid or no insurance, a condition associated with no OS treatment protocol, and being discharged to skilled nursing were associated with having a prolonged OS stay. Among Medicare patients, the mean charge for OS stays was $10,373. OS visits of 48-72 hours were associated with a 42 percent increase in costs; visits exceeding 72 hours were associated with a 61 percent increase in costs.
CONCLUSION
Patient cost sharing for most OS stays of less than 24 hours is lower than the Medicare inpatient deductible. However, prolonged OS stays potentially increase this cost sharing.
Topics: Female; Health Care Costs; Humans; Male; Middle Aged; Time Factors; United States; Watchful Waiting
PubMed: 24344860
DOI: 10.1111/1475-6773.12143 -
European Urology Sep 2020Although the use of multiparametric magnetic resonance imaging (mpMRI) in active surveillance (AS) for prostate cancer is of increasing interest, existing data are...
BACKGROUND
Although the use of multiparametric magnetic resonance imaging (mpMRI) in active surveillance (AS) for prostate cancer is of increasing interest, existing data are derived from small cohorts.
OBJECTIVE
We describe clinical, histological, and radiological outcomes from an established AS programme, where protocol-based biopsies were omitted in favour of MRI-led monitoring.
DESIGN, SETTING, AND PARTICIPANTS
Data on 672 men enrolled in AS between August 2004 and November 2017 (inclusion criteria: Gleason 3 + 3 or 3 + 4 localised prostate cancer, presenting prostate-specific antigen <20 ng/ml, and baseline mpMRI) were collected from the University College London Hospital (UCLH) database.
OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS
Primary outcomes were event-free survival (EFS; event defined as prostate cancer treatment, transition to watchful waiting, or death) and treatment-free survival (TFS). Secondary outcomes included rates of all-cause or prostate cancer-related mortality, metastasis, and upgrading to Gleason ≥4 + 3. Data on radiological and histological progression were also collected.
RESULTS AND LIMITATIONS
More than 3800 person-years (py) of follow-up were accrued (median: 58 mo; interquartile range 37-82 mo). Approximately 84.7% (95% confidence interval [CI]: 82.0-87.6) and 71.8% (95% CI: 68.2-75.6) of patients remained on AS at 3 and 5 yr, respectively. EFS and TFS were lower in those with MRI-visible (Likert 4-5) disease or secondary Gleason pattern 4 at baseline (log-rank test; p < 0.001). In total, 216 men were treated. There were 24 deaths, none of which was prostate cancer related (6.3/1000 py; 95% CI: 4.1-9.5). Metastases developed in eight men (2.1 events/1000 py; 95% CI: 1.0-4.3), whereas 27 men upgraded to Gleason ≥4 + 3 on follow-up biopsy (7.7 events/1000 py; 95% CI: 5.2-11.3).
CONCLUSIONS
The rates of discontinuation, mortality, and metastasis in MRI-led surveillance are comparable with those of standard AS. MRI-visible disease and/or secondary Gleason grade 4 at baseline are associated with a greater likelihood of moving to active treatment at 5 yr. Further research will concentrate on optimising imaging intervals according to baseline risk.
PATIENT SUMMARY
In this report, we looked at the outcomes of magnetic resonance imaging (MRI)-based surveillance for prostate cancer in a UK cohort. We found that this strategy could allow routine biopsies to be avoided. Secondary Gleason pattern 4 and MRI visibility are associated with increased rates of treatment. We conclude that MRI-based surveillance should be considered for the monitoring of small prostate tumours.
Topics: Aged; Biopsy; Cohort Studies; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Prostatic Neoplasms; Retrospective Studies; Survival Rate; Time Factors; Treatment Outcome; Watchful Waiting
PubMed: 32360049
DOI: 10.1016/j.eururo.2020.03.035 -
Turkish Neurosurgery 2021To evaluate the clinical outcomes of incidental meningiomas (IM) treated with stereotactic radiosurgery (SRS) or observation. (Comparative Study)
Comparative Study Meta-Analysis
AIM
To evaluate the clinical outcomes of incidental meningiomas (IM) treated with stereotactic radiosurgery (SRS) or observation.
MATERIAL AND METHODS
The PubMed, Cochrane Library and MEDLINE (Ovid) databases were comprehensively searched for eligible studies about IM that were managed with serial imaging follow-up or SRS. We performed a systematic review and metaanalysis of the tumor progression rate between these two groups. The SRS-related morbidity was qualitatively analyzed. To predict potential tumor growth, the correlation between rapid tumor growth and the following factors, MRI T2 hyperintensity, initial tumor diameter and age were also analyzed by meta-analysis.
RESULTS
Sixteen studies were included. The SRS treatment group had significantly higher tumor control than the observation group in a mean follow-up of more than 3 years (pooled OR: 0.06, 95% CI: 0.01-0.20, p < 0.0001; random effects model). Additionally, there was an acceptable level of SRS-associated morbidity. Tumor progression was positively associated with MRI T2 hyperintensity (pooled OR: 1.93, 95% CI: 1.30-2.87, p < 0.05, fixed effects model), initial large tumor diameter (pooled OR: 3.19, 95% CI: 0.94- 5.44, p < 0.05, fixed effects model) and younger age to some extent (pooled OR: -3.80, 95% CI: -9.13-1.53, p > 0.05, random effects model). Absence of calcification was consistently shown to be a risk factor for progressive IM based on the existing literature.
CONCLUSION
SRS is a rational treatment for incidental meningioma in consideration of the higher tumor control rate and acceptable complications compared with treatment via observation. The integration of risk factors such as absence of calcification, MRI T2 hyperintensity and initial large tumor size may contribute to accurately predicting rapid tumor growth.
Topics: Adult; Aged; Databases, Factual; Female; Humans; Magnetic Resonance Imaging; Male; Meningeal Neoplasms; Meningioma; Middle Aged; Observational Studies as Topic; Radiosurgery; Retrospective Studies; Treatment Outcome; Watchful Waiting
PubMed: 33624282
DOI: 10.5137/1019-5149.JTN.31405-20.2 -
Ear, Nose, & Throat Journal May 2020
Topics: Aged; Humans; Laryngeal Diseases; Male; Medical Illustration; Melanosis; Watchful Waiting
PubMed: 30961386
DOI: 10.1177/0145561319838724 -
Current Urology Reports Jul 2017Previously considered an absolute contraindication, the use of testosterone therapy in men with prostate cancer has undergone an important paradigm shift. Recent data... (Review)
Review
PURPOSE OF REVIEW
Previously considered an absolute contraindication, the use of testosterone therapy in men with prostate cancer has undergone an important paradigm shift. Recent data has changed the way we approach the treatment of testosterone deficiency in men with prostate cancer. In the current review, we summarize and analyze the literature surrounding effects of testosterone therapy on patients being treated in an active surveillance protocol as well as following definitive treatment for prostate cancer.
RECENT FINDINGS
The conventional notion that defined the relationship between increasing testosterone and prostate cancer growth was based on limited studies and anecdotal case reports. Contemporary evidence suggests testosterone therapy in men with testosterone deficiency does not increase prostate cancer risk or the chances of more aggressive disease at prostate cancer diagnosis. Although the studies are limited, men who received testosterone therapy for localized disease did not have higher rates of recurrences or worse clinical outcomes. Current review of the literature has not identified adverse progression events for patients receiving testosterone therapy while on active surveillance/watchful waiting or definitive therapies. The importance of negative effects of testosterone deficiency on health and health-related quality of life measures has pushed urologists to re-evaluate the role testosterone plays in prostate cancer. This led to a paradigm shift that testosterone therapy might in fact be a viable option for a select group of men with testosterone deficiency and a concurrent diagnosis of prostate cancer.
Topics: Androgens; Contraindications, Drug; Disease Progression; Humans; Hypogonadism; Male; Prostatic Neoplasms; Quality of Life; Testosterone; Watchful Waiting
PubMed: 28589395
DOI: 10.1007/s11934-017-0695-6 -
Asian Journal of Surgery Feb 2024The aim was to evaluate the efficacy and safety between the watch-and-wait strategy (WW), radical surgery (RS), and local excision (LE) for rectal cancer with clinical... (Meta-Analysis)
Meta-Analysis Review
The aim was to evaluate the efficacy and safety between the watch-and-wait strategy (WW), radical surgery (RS), and local excision (LE) for rectal cancer with clinical complete response (cCR) after neoadjuvant radiotherapy (nCRT). We searched MEDLINE, EMBASE, the Cochrane Library, and clinical trials to compare WW with RS and LE for patients with cCR until March 2023 and collected the following data: local recurrence (LR), distant metastasis (DM), cancer-related death (CRD), overall survival (OS), and disease-free survival (DFS). In total, 2240 patients from 21 studies were included. Pairwise meta-analysis revealed no statistically significant differences between the three groups in terms of CRD and 2-, 3-, and 5-year OS (P < 0.05). The RS group was significantly better than the WW group in terms of the LR rate (odds ratio [OR] = 0.12, 95 % confidence interval [CI]: 0.06-0.21, P < 0.001, I = 0 %], 3-year DFS (OR = 1.56, 95 % CI: 1.10-2.21, P = 0.01, I = 38 %), and 5-year DFS (OR = 2.30, 95 % CI: 1.53-3.46, P < 0.001, I = 34 %). The results of network meta-analysis were also similar. After sensitivity analysis, the 5-year OS of the RS group was significantly better than that of the WW group (OR = 2.77, 95 % CI: 1.28-6.00, P = 0.009, I = 33 %). Nevertheless, neither regression analysis nor subgroup analysis provided meaningful results. However, the cumulative meta-analysis of LR, DM, and 3- and 5-year DFS revealed significant turning points (P < 0.05). Our meta-analysis recommends using the WW strategy for patients with cCR having poor underlying conditions and high surgical risk; however, there is a risk of higher LR and worse survival after 3 years.
Topics: Humans; Neoadjuvant Therapy; Network Meta-Analysis; Chemoradiotherapy; Watchful Waiting; Neoplasm Recurrence, Local; Rectal Neoplasms; Treatment Outcome
PubMed: 38042663
DOI: 10.1016/j.asjsur.2023.11.047 -
The Journal of Rural Health : Official... Aug 2013Observation care is used to evaluate patients prior to admission or discharge. Often beneficial, such care also imposes greater financial liability on Medicare...
PURPOSE
Observation care is used to evaluate patients prior to admission or discharge. Often beneficial, such care also imposes greater financial liability on Medicare beneficiaries. While the use of observation care has increased recently, critical access hospitals (CAHs) face different policies than prospective payment (PPS) hospitals, which may influence their observation care use.
METHODS
We used 100% Medicare inpatient and outpatient claims files and enrollment data for years 2007 to 2009, and the 2007 American Hospital Association data to compare trends in the likelihood, prevalence and duration of observation stays between CAHs and PPS hospitals in metro and non-metro areas among fee-for-service Medicare beneficiaries over age 65.
FINDINGS
While PPS hospitals are more likely to provide any observation care, the 3-year increase in the proportion of CAHs providing any observation care is approximately 5 times as great as the increase among PPS hospitals. Among hospitals providing any observation care in 2007, the prevalence at CAHs was 35.7% higher than at non-metro PPS hospitals and 72.8% higher than at metro PPS hospitals. By 2009, these respective figures had increased to 63.1% and 111%. Average stay duration increased more slowly for CAHs than for PPS hospitals.
CONCLUSIONS
These data suggest that a growing proportion of CAHs are providing observation care and that CAHs provide relatively more observation care than PPS hospitals, but they have shorter average stays. This may have important financial implications for Medicare beneficiaries.
Topics: Aged; Emergency Service, Hospital; Hospitals, Rural; Humans; Insurance Claim Review; Medicare Part B; United States; Watchful Waiting
PubMed: 23944275
DOI: 10.1111/jrh.12007 -
American Journal of Preventive Medicine Dec 2015Men with prostate cancer face difficult choices when selecting a therapy for localized prostate cancer. Comparative data from controlled studies are lacking and clinical...
Men with prostate cancer face difficult choices when selecting a therapy for localized prostate cancer. Comparative data from controlled studies are lacking and clinical opinions diverge about the benefits and harms of treatment options. Consequently, there is limited guidance for patients regarding the impact of treatment decisions on quality of life. There are opportunities for public health to intervene at several decision-making points. Information on typical quality of life outcomes associated with specific prostate cancer treatments could help patients select treatment options. From 2003 to present, the Division of Cancer Prevention and Control at CDC has supported projects to explore patient information-seeking behavior post-diagnosis, caregiver and provider involvement in treatment decision making, and patient quality of life following prostate cancer treatment. CDC's work also includes research that explores barriers and facilitators to the presentation of active surveillance as a viable treatment option and promotes equal access to information for men and their caregivers. This article provides an overview of the literature and considerations that initiated establishing a prospective public health research agenda around treatment decision making. Insights gathered from CDC-supported studies are poised to enhance understanding of the process of shared decision making and the influence of patient, caregiver, and provider preferences on the selection of treatment choices. These findings provide guidance about attributes that maximize patient experiences in survivorship, including optimal quality of life and patient and caregiver satisfaction with information, treatment decisions, and subsequent care.
Topics: Biomedical Research; Centers for Disease Control and Prevention, U.S.; Choice Behavior; Decision Making; Disease Progression; Humans; Male; Prospective Studies; Prostate-Specific Antigen; Prostatic Neoplasms; Public Health; United States; Watchful Waiting
PubMed: 26590643
DOI: 10.1016/j.amepre.2015.08.016 -
Watch-and-wait Management for Rectal Cancer After Clinical Complete Response to Neoadjuvant Therapy.Advances in Surgery Sep 2021
Review
Topics: Chemoradiotherapy, Adjuvant; Humans; Neoadjuvant Therapy; Neoplasm Recurrence, Local; Rectal Neoplasms; Treatment Outcome; Watchful Waiting
PubMed: 34389102
DOI: 10.1016/j.yasu.2021.05.007 -
Medicine Dec 2016The aim of this study is to determine the most cost-effective strategy for the treatment of primary open-angle glaucoma (POAG) in Brazil, from the payer's perspective...
BACKGROUND
The aim of this study is to determine the most cost-effective strategy for the treatment of primary open-angle glaucoma (POAG) in Brazil, from the payer's perspective (Brazilian Public Health System) in the setting of the Glaucoma Referral Centers.
METHODS
Study design was a cost-effectiveness analysis of different treatment strategies for POAG. We developed 3 Markov models (one for each glaucoma stage: early, moderate and advanced), using a hypothetical cohort of POAG patients, from the perspective of the Brazilian Public Health System (SUS) and a horizon of the average life expectancy of the Brazilian population. Different strategies were tested according to disease severity. For early glaucoma, we compared observation, laser and medications. For moderate glaucoma, medications, laser and surgery. For advanced glaucoma, medications and surgery. Main outcome measures were ICER (incremental cost-effectiveness ratio), medical direct costs and QALY (quality-adjusted life year).
RESULTS
In early glaucoma, both laser and medical treatment were cost-effective (ICERs of initial laser and initial medical treatment over observation only, were R$ 2,811.39/QALY and R$ 3,450.47/QALY). Compared to observation strategy, the two alternatives have provided significant gains in quality of life. In moderate glaucoma population, medical treatment presented the highest costs among treatment strategies. Both laser and surgery were highly cost-effective in this group. For advanced glaucoma, both tested strategies were cost-effective. Starting age had a great impact on results in all studied groups. Initiating glaucoma therapy using laser or surgery were more cost-effective, the younger the patient.
CONCLUSION
All tested treatment strategies for glaucoma provided real gains in quality of life and were cost-effective. However, according to the disease severity, not all strategies provided the same cost-effectiveness profile. Based on our findings, there should be a preferred strategy for each glaucoma stage, according to a cost-effectiveness ratio ranking.
Topics: Age Factors; Antihypertensive Agents; Brazil; Cost-Benefit Analysis; Glaucoma, Open-Angle; Health Care Costs; Humans; Lasers, Gas; Markov Chains; Prostaglandins; Quality of Life; Quality-Adjusted Life Years; Severity of Illness Index; Sulfonamides; Thiophenes; Timolol; Trabeculectomy; Watchful Waiting
PubMed: 28033286
DOI: 10.1097/MD.0000000000005745