Naessens, James M.

Background: This paper assesses obesity- and smoking-related incremental healthcare costs for the employees and dependents of a large U.S. employer. Objectives: Unlike previous studies, this study evaluates the distributional effects of obesity and smoking on healthcare cost distribution using a recently developed econometric framework: the unconditional quantile regression (UQR). Methods: Results were compared with the traditional conditional quantile regression (CQR), and the generalized linear modeling (GLM) framework that is commonly used for modeling healthcare cost. Results: The study found strong evidence of association of healthcare costs with obesity and smoking. More importantly, the study found that these effects are substantially higher in the upper quantiles of the healthcare cost distribution than in the lower quantiles. The insights on the heterogeneity of impacts of obesity and smoking on healthcare costs would not have been captured by traditional mean-based approaches. The study also found that UQR impact estimates were substantially different from CQR impact estimates in the upper quantiles of the cost distribution. Conclusions: These results suggest the potential role that smoking cessation and weight management programs can play in arresting the growth in healthcare costs. Specifically, given the finding that obesity and smoking have markedly higher impacts on high-cost patients, such programs appear to have significant cost saving potential if targeted toward high-cost patients.

PURPOSE: Quality payment programs aim to adjust payments on the basis of quality and cost; however, few quality metrics exist in radiation oncology. This study evaluates and predicts the top spenders (TS) after radiation therapy (RT). MATERIALS AND METHODS: Patient characteristics, cancer details, treatments, toxicity, and survival data were collected for patients treated with RT at Mayo Clinic from 2007 to 2016. Standardized costs were obtained and adjusted for inflation. TSs were identified as those with greater than 93rd percentile costs (≥ $120,812). Prediction models were developed to predict TSs using training and validation sets using information available at consultation, after RT, and at last follow-up. RESULTS: A total of 15,131 patients were included and 1,065 TSs identified. Mean cost overall was $55,290 (median, $39,996) for all patients. Prediction models 1, 2, and 3 had concordance statistics of 0.83 to 0.83, 0.85 to 0.85, and 0.87 to 0.88, respectively in training and validation, indicating excellent prediction of TSs. Factors that were most predictive of TSs included stage N/A and stage 4 ( v stage 0; odds ratio [OR], 18.23 and 8.44, respectively; P < .001); hematologic, upper GI, skin and lung cancers ( v breast; OR, 11.45, 7.69, 3.81, and 2.43, respectively; P < .01); immunotherapy, surgery, and chemotherapy use (OR, 4.36, 2.51, and 1.61, respectively; P < .01); hospitalizations within 90 days of RT (OR, 2.26; P < .01); or death during the episode (OR, 1.56; P < .01). CONCLUSION: This is the first study of its kind to predict with high accuracy the highest spenders in radiation oncology. These patients may benefit from pre-emptive management to mitigate costs, or may require exclusion or adjustment from quality payment programs.

6633 Background: Quality based payment programs in medicine are currently being introduced nationally, aimed to improve care and reduce cost. This study aimed to evaluate the top spenders (TS) after cancer diagnosis and predict TS at two separate time points using predictive analytics. Methods: Patient characteristics, cancer details, treatments, adverse events, and outcomes were collected for patients treated for cancer at Mayo Clinic from 2007 - 2017. Standardized costs over a 2 year period after first treatment were obtained from the Mayo Clinic Cost Data Warehouse with Medicare reimbursements assigned to all services and adjusted to the 2017 GDP Implicit Price Deflator for inflation. TS were identified as those with greater than 93rd percentile costs (≥$113,158) due to a sharp rise in cost at that level. Descriptive statistics and univariate analysis were used for comparison. A prediction model with a training (80%) and validation set (20%) using multivariate selection was used to predict TS and was repeated using information available at 1) the time of consultation and 2) at last follow-up. Results: A total of 80,385 patients were included and 5,626 TS were identified. Mean cost (25th, 75th percentile) overall was $44,953 ($16,776, $51,889). Prediction models at time 1 and 2 had ROC AUC statistics of 0.82 and 0.89 in training and 0.82 and 0.88 in the validation indicating good prediction of high costs. Factors most predictive of TS included need for blood transfusions within 90 days of treatment (OR 5.3), bone marrow transplant (OR 4.0), mild liver disease (OR 3.5), hemiplegia (OR 3.4), weight loss > 10% within 90 days of treatment (OR 3.3), upper GI cancer (OR 3.0), ‘other’ cancer type (OR 2.8), immunotherapy use (OR 2.7), and hospitalizations within 90 days (OR 2.4), all p < 0.001, among others. The largest costs were due to hospital services in the TS and non-TS groups, mean costs $114,258 and $13,185 respectively. Conclusions: This is the first study to predict with high accuracy the top spenders in Oncology. Patient comorbidities and toxicities were among the strongest predictors of high costs, along with certain treatments (bone marrow transplant and immunotherapy). Our findings suggest that quality payment programs should adjust for comorbidities, and that reducing toxicity may be an effective method at reducing costs.

Abstract Background: Laparoscopy and more recently robotics are increasingly used for colorectal cancer surgery in the United States. We examined the current trends of minimally invasive surgical resections for colorectal cancer in Florida. Methods: The Florida Inpatient Discharge Dataset was used to examine the clinical data of patients who underwent elective surgery for colorectal cancer during 2013–2015. Multivariate analyses were performed to compare patient characteristics associated with the use of open and minimally invasive surgeries. Results: A total of 10,513 patients were analyzed; 5451 (52%) had open surgery, 4403 (42%) laparoscopy, and 659 (6%) robotic surgery. The rates of minimally invasive surgery (MIS) increased from 46.95% in 2013 to 48.72% in 2015. Among minimally invasive surgical procedures, the use of robotics increased from 9.82% in 2013 to 15.48% in 2015. Metastatic cancer (odds ratio [OR] 0.61, confidence interval [CI] 0.55–0.67), Elixhauser score of 3–5 (OR 0.85, CI 0.76–0.95) or more than 5 (OR 0.78, CI 0.63–0.97), Medicaid insurance (OR 0.73, CI 0.6–0.89), Black race (OR 0.88, CI 0.77–0.99), and rural residence (OR 0.83, CI 0.69–0.99) were associated with lower odds of MIS than open surgery. Conclusions: This study demonstrates that the overall rates of MIS for colorectal cancer in Florida increased from 2013 to 2015. Socially deprived and very sick patient populations with colorectal cancer are less likely to undergo MIS.

AbstractRational, aims, and objectivesUnderstanding of barriers and successes associated with the implementation of electronic patient self‐reported measures (ePSRMs) within clinical settings are limited and have not been pursued utilizing implementation science frameworks. This qualitative study is designed to assess staff perceptions of an ePSRM implementation.MethodsThe study took place in an academic hospital's Consultation Liaison Psychiatry practice. Qualitative interviews were conducted with the staff and clinicians from the practice. Participants were directly involved with the implementation and use of the ePSRM system within the Psychiatry practice. Interviews were structured around the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE‐AIM) framework.ResultsParticipants reported increased patient engagement as well as efficiency and time savings. The intervention was perceived to be more challenging for older patients. Facilitators include communicating the ePSRM to patients prior to the care visit, having enough trained staff or super‐users who can assist with technical problems, and having a shorter questionnaire.ConclusionsOverall, assessment of the ePSRM implementation was positive. Staff and clinicians indicated benefits in time, effectiveness, and improvements in patient treatment. Results indicate that defining how the system would fit within the clinical workflow was key, as was a flexible and user‐friendly technology platform. The ePSRM implementation was dependent upon clinical involvement and interest in adoption, while barriers were associated with technical challenges as well as some patient difficulties, such as cognitive impairment. The use of the RE‐AIM framework is valuable as it allows for systematic assessment of the implementation and identifies areas in that implementation has succeeded or is lacking.

Abstract Background Transverse abdominis plane (TAP) block is considered an effective alternative to neuraxial analgesia for abdominal surgery. However, limited evidence supports its use over traditional analgesic modalities in colorectal surgery. This study compared the analgesic efficacy of liposomal bupivacaine TAP block with intrathecal (IT) opioid administration in a multicentre RCT. Methods Patients undergoing elective small bowel or colorectal resection were randomized to receive TAP block or a single injection of IT analgesia with hydromorphone. Patients were assessed at 4, 8, 16, 24 and 48 h after surgery. Primary outcomes were mean pain scores and morphine milligram equivalents (MMEs) administered within 48 h after surgery. Secondary outcomes included duration of hospital stay, incidence of postoperative ileus and use of intravenous patient-controlled analgesia. Results In total, 209 patients were recruited and 200 completed the trial (TAP 102, IT 98). The TAP group had a 1·6-point greater mean pain score than the IT group at 4 h after surgery, and this difference lasted for 16 h after operation. The TAP group received more MMEs within the first 24 h after surgery than the IT group (median difference in MMEs 10·0, 95 per cent c.i. 3·0 to 20·5). There were no differences in MME use at 24 and 48 h, or with respect to secondary outcomes. Conclusion IT opioid administration provided better immediate postoperative pain control than TAP block. Both modalities resulted in low pain scores in patients undergoing elective colorectal surgery and should be considered in multimodal postoperative analgesic plans. Registration number: NCT02356198 ( http://www.clinicaltrials.gov).

BACKGROUNDAlthough posthospitalization care transitions programs (CTP) are highly diverse, their overall program thoroughness is most predictive of their success.OBJECTIVETo identify components of a successful homebased CTP and patient characteristics that are most predictive of reduced 30‐day readmissions.DESIGNRetrospective cohort.PATIENTSA total of 315 community‐dwelling, hospitalized, older adults (≥60 years) at high risk for readmission (Elder Risk Assessment score ≥16), discharged home over the period of January 1, 2011 to June 30, 2013.SETTINGMidwest primary care practice in an integrated health system.INTERVENTIONEnrollment in a CTP during acute hospitalization.MEASUREMENTSThe primary outcome was all‐cause readmission within 30 days of the first CTP evaluation. Logistic regression was used to examine independent variables, including patient demographics, comorbidities, number of medications, completion, and timing of program fidelity measures, and prior utilization of healthcare.RESULTSThe overall 30‐day readmission rate was 17.1%. The intensity of follow‐up varied among patients, with 17.1% and 50.8% of the patients requiring one and ≥3 home visits, respectively, within 30 days. More than half (54.6%) required visits beyond 30 days. Compared with patients who were not readmitted, readmitted patients were less likely to exhibit cognitive impairment (29.6% vs 46.0%; P = .03) and were more likely to have high medication use (59.3% vs 44.4%; P = .047), more emergency department (ED; 0.8 vs 0.4; P = .03) and primary care visits (4.0 vs 3.0; P = .018), and longer cumulative time in the hospital (4.6 vs 2.5 days; P = .03) within 180 days of the index hospitalization. Multivariable analysis indicated that only cognitive impairment and previous ED visits were important predictors of readmission.CONCLUSIONSNo single CTP component reliably predicted reduced readmission risk. Patients with cognitive impairment and polypharmacy derived the most benefit from the program.

145 Background: Palliative radiation treatment (pRT) is used for symptomatic bone metastases (mets). Several fractionation schedules show equal efficacy for pain relief, and ASTRO’s Choosing Wisely recommends 8Gy x1, 4Gy x5, or 3Gy x10. This study aims to investigate the cost implications of pRT for bone mets. Methods: Patients (Pts) treated with pRT for bone mets at Mayo Clinic from 2007 - 2016 were included in this study. Costs for all services were subdivided into RT and total costs at 30 & 90 days (30D & 90D). Standardized costs were obtained from the Mayo Clinic Cost Data Warehouse and Medicare reimbursements were assigned to all services with cost to charge adjustments and 2017 GDP Implicit Price Deflator for inflation. Cost means were compared via the Kruskal-Wallis test. Results: 538 pts were treated with pRT, 124 receiving 8Gy x1, 204 receiving 4Gy x5, and 210 receiving 3Gy x10. Pts with breast and prostate cancer were most likely to be treated with 3Gy x10 and pts with GI and lung cancer were most likely to be treated with 8Gy x1. RT costs at 30D were $1,497, $1,891, and $1,982 (p=0.03) and RT costs at 90D were $2,602, $2,753, and $3,032 (p=0.08) for initial RT regimens of 8Gy x1, 4Gy x5, and 3Gy x10. Total costs of care at 30D were similar from $15,969 - 17,687 (p=0.6) and total costs at 90D were similar from $22,361 - 23,219 (p=0.7) between arms. A total of 23%, 28%, and 39% of pts were alive 2 years following pRT from each arm (p=0.07). Conclusions: This is the first study of its kind to analyze actual treatment costs for the three most common pRT regimens in bone mets. Single fraction RT was most used for pts with poor prognoses and was associated with lower RT costs at 30D, but similar RT costs at 90D, possibly due to retreatment. RT choice had no impact on overall costs of care at 30D or 90D. pRT remains of high value, representing only 11-13% of total costs.[Table: see text]

126 Background: Palliative radiation treatment (pRT) is a common and effective treatment for patients with symptomatic bone metastases. However, patients receiving RT for bone metastases often may have a poor performance status and are more likely to experience toxicity during or after treatment. This study aims to investigate the number and type of toxicity event occurring during or after pRT for bone metastases. Methods: Patients treated with RT for bone metastases at Mayo Clinic from 2007 to 2016 were included in this study. Demographic, disease, treatment, and toxicity information were collected. Specifically, toxicity events were identified as emergency department (ED) visits and inpatient hospitalization (IH) within 90 days, breaks in treatment >4 days, and excessive 30 day financial toxicity defined as standardized Medicare costs >1 standard deviation above the mean. RT treatment was compared by dose and fractionation via descriptive statistics. Results: A total of 538 patients treated with pRT were identified, 124 receiving 8Gy x1, 204 receiving 4Gy x5, and 210 receiving 3Gy x10. Patients with breast and prostate cancer were most likely to be treated with 3Gy x10 and patients with GI and Lung cancer were most likely to be treated with 8Gy x1. A description of the patient characteristics and toxicities are shown in Table 1. For 8Gy x1, 4Gy x5, and 3Gy x10 breaks in treatment were rare (0%, 2%, and 3.3%), ED visits (15%, 24%, & 28%), IH (12%, 23%, & 19%), and financial toxicity (13%, 18%, & 21%) were common. A total of 22.6%, 27.5%, and 38.6% of patients were alive two years following pRT from each group. Conclusions: Toxicity during or shortly after pRT of bone metastases is common. This study confirms that additional steps should be taken to monitor and mitigate toxicity in this vulnerable patient group. [Table: see text]