Pulsatility and resistance indices in intrarenal arteries of normal adults

In order to establish the normal range of values of Pulsatility (PI) and Resistance (RI) Indices in the intrarenal vasculature, a study of 50 healthy volunteers (23 males, 27 females), divided into five groups of 10 according to age, was performed with Duplex Doppler ultrasound. Both kidneys were examined in all individuals and, in 12, indices were also compared between upper and lower poles of both kidneys. In addition, repeat examinations were performed in nine subjects on three different days, in order to assess the reproducibility of the method. No differences were found in the mean values of both indices between males and females, upper and lower poles, right and left kidneys. A statistically significant increase (p < 0.01, unpaired t-test) was demonstrated when the oldest age group (7th decade) was compared to the youngest age group (3rd decade). The method appeared remarkably reproducible for RI (4.2–7%), with wider variation in the PI (9.5–22.7%).     

Primary esophageal lymphoma in AIDS

In a patient with acquired immunodeficiency syndrome (AIDS) and primary esophageal lymphoma, esophagography and computed tomography (CT) demonstrated a large ulcerated mass involving the distal esophagus. Although rare, the diagnosis of esophageal lymphoma should be considered in patients at risk for AIDS when the radiologic findings are not typical for infectious esophagitis or Kaposi's sarcoma.     

The Effect of Gasoline Taxes and Public Transit Investments on Driving Patterns

This paper analyzes how driving patterns are affected by gasoline taxes and the availability of a substitute for driving—public transportation. We develop a measure of transportation substitutability based on the difference between individuals’ predicted commute times by private and public transit, conditional upon their demographic characteristics and geographic location. Improved substitutability decreases annual vehicle miles traveled (VMT) by inducing modal shifts to public transit, though gasoline taxes are found to have a much larger impact on VMT. Our results imply that a policy that raises gasoline taxes and recycles the revenues into public transit improvements can have even larger impacts on driving patterns than either policy alone.     

Comparative evaluation of treatment patterns and healthcare utilization of newly-diagnosed rheumatoid arthritis patients by anti-cyclic citrullinated peptide antibody status

Background: Anti-cyclic citrullinated peptide (CCP) antibody positivity is an established diagnostic factor for severe disease activity and joint damage and a prognostic factor for aggressive disease in rheumatoid arthritis (RA).

Objective: To compare RA-related treatment, healthcare utilization, and joint erosion between anti-CCP-positive and anti-CCP-negative RA patients.

Methods: Newly-diagnosed RA patients were identified from the Henry Ford Health System database between January 1, 2009 and December 31, 2014; the date of the first RA diagnosis within the study period was the index date. Baseline anti-CCP test was used to categorize patients as anti-CCP-positive or anti-CCP-negative, and outcomes were evaluated in the 6 months post-index.

Results: There were 217 anti-CCP-positive and 191 anti-CCP-negative RA patients included in the study. A higher proportion of anti-CCP-positive patients were initiated on RA treatment than anti-CCP-negative patients (70.5% vs 23.0%; p?<?.0001). More anti-CCP-positive patients received methotrexate (73.2% vs 56.8%; p?=?.0374), while more anti-CCP-negative patients received hydroxychloroquine (31.8% vs 13.1%; p?=?.0037) in first-line therapy. A higher proportion of anti-CCP-negative patients were tested for rheumatoid factor (RF) and erythrocyte sedimentation rate (ESR). Of those tested, there were more positive test results in the anti-CCP-positive cohort compared to the anti-CCP-negative cohort (RF: 84.4% vs 18.2%, p?<?.0001; C-reactive protein [CRP]: 69.7% vs 48.3%, p?=?.0008; and ESR: 89.5% vs 53.9%, p?<?.0001). Outpatient utilization predominated, with more anti-CCP-positive patients having any outpatient physician office visit (96.3% vs 77.5%, p?<?.0001) and a higher mean number of visits (5.3 vs 2.5, p?<?.0001) than anti-CCP-negative patients. Among anti-CCP-positive (n?=?113) and anti-CCP-negative (n?=?58) patients with imaging results, more anti-CCP-positive patients had joint erosion compared to anti-CCP-negative patients (18.6% vs 8.6%; p?=?.0858); however, statistical significance was not reached.

Conclusion: RA patients with positive anti-CCP antibodies had higher degrees of inflammation and disease activity as indicated by laboratory results, which likely contributed to their higher rates of healthcare utilization, joint erosion, and proportions of RA treatment.     

Cost comparison of radiofrequency catheter ablation versus cryoablation for atrial fibrillation in hospitals using both technologies

Objective: The objective of this study was to compare the cost of radiofrequency (RF) ablation vs cryoablation (Cryo) for atrial fibrillation (AF).

Methods: This retrospective cohort study used 2013–2014 records from the Premier Healthcare Database for adults with AF catheter ablation. Exclusions included non-AF ablation, surgical ablation, valve replacement or repair, or cardiac implant. Hospitals were required to perform ≥20 procedures using each technology, with the technology identifiable in at least 90% of cases. The primary endpoint was total variable visit cost, modeled separately for inpatient and outpatient visits, and adjusted for patient and hospital characteristics. Technology was categorized as RF or Cryo, with dual-technology procedures classified as Cryo. The Cryo cohort was further divided into Cryo only and Cryo with RF for sensitivity analyses. A composite adverse event endpoint was also compared.

Results: A total of 1261?RF procedures and 1276 Cryo procedures, of which 500 also used RF, met study criteria. RF patients were slightly older and sicker, and had more cardiovascular disease and additional arrhythmias. Adjusted inpatient costs were $2803 (30.0%) higher for Cryo, and adjusted outpatient costs were $2215 (19.5%) higher. Sensitivity models showed higher costs in both Cryo sub-groups compared with RF. Procedural complication rates were not significantly different between cohorts (p-values: 0.4888 inpatient, 0.5072 outpatient).

Conclusion: AF ablation using RF results in significantly lower costs compared with Cryo, despite an RF population with more cardiovascular disease. This saving cannot be attributed to a difference in complication rates.     

Prevalence and impact of constipation and bowel dysfunction induced by strong opioids: a cross-sectional survey of 520 patients with cancer pain: DYONISOS study

Abstract

Objective:

To describe the prevalence of opioid-induced constipation (OIC) in patients with cancer pain according to the Knowles-Eccersley-Scott symptom score (KESS), the different symptoms of opioid-induced bowel dysfunction (OIBD), and to assess the impact of OIBD on patient’s quality-of-life.

Methods:

A cross-sectional observational study, using the KESS questionnaire and the physician’s subjective assessment of constipation, and other questionnaires and questions on constipation, OIBD, and quality-of-life, carried out on 1 day at oncology day centres and hospitals.

Results:

Five hundred and twenty patients were enrolled at 77 centres in France; 61.7% of patients (n?=?321) showed a degree of constipation that is problematic for the patient according to KESS (between 9–39). Even more patients, 85.7% (n?=?438), were considered constipated according to the physician’s subjective assessment—despite laxative use (84.7% of patients). Quality-of-life was significantly reduced in constipated vs non-constipated patients for both PAC-QoL (p?<?0.0001 for total score and each dimension) and the SF-12 questionnaires (statistically significant for all dimensions except physical state and role physical). OIC and OIBD led to hospitalization (16% of patients), pain (75% of patients), and frequent changes in opioid and laxative treatment.

Key limitations:

This cross-sectional study, in a selected population of cancer patients, has measured prevalence and impact of OIBD. Further confirmation could be sought through the use of longitudinal studies, and larger populations, such as non-cancer pain patients treated with opioids

Conclusions:

Cancer patients taking opioids for pain are very frequently constipated, even if they are prescribed laxatives. This leads to relevant impairments of quality-of-life.     

和胃解毒汤治疗食道癌患者的疗效和安全性

目的探讨和胃解毒汤治疗食道癌患者的疗效以及安全性,为临床治疗食道癌提供新思路。方法选取2019年1月至2020年5月梅州市人民医院收治的食道癌患者62例作为研究对象,按照不同的治疗方案分为对照组(30例)和试验组(32例)。对照组给予调强适形放射治疗加紫杉醇(TXL)联合洛铂(LBP)化疗,即TP化疗方案;试验组在对照组基础上加用和胃解毒汤。比较分析两组患者的治疗效果,并评价两组患者的胃肠道不良反应发生情况。结果试验组治疗有效率及疾病控制率分别为78.13%和87.50%,显著高于对照组的53.33%和66.67%,差异有统计学意义(P<0.05);主要不良反应为胃肠道反应,以恶心呕吐、食欲下降为主,可耐受,其中试验组胃肠道不良反应发生率9.38%,显著低于对照组的30.00%(P<0.05)。结论和胃解毒汤在食道癌患者综合治疗中具有良好的疗效,减轻了不良反应,对治疗食道癌有积极的意义。     

Cost-impact of cardiac magnetic resonance imaging with Fast-SENC compared to SPECT in the diagnosis of coronary artery disease in the U.S

Aims: The purpose of this study is to assess the economic cost differences and the associated treatment resource changes between the developing coronary artery disease (CAD) diagnostic tool fast strain-encoded cardiac imaging (Fast-SENC) and the current commonly used stress test single-photon emission computed tomography (SPECT).

Materials and methods: A “payer perspective” model was created first, consisting of long-term and short-term components that used a hypothetical cohort of patients of average age (60.8?years) presenting with chest pain and suspected CAD to assess cost-impact. A cost impact model was then built that assessed likely savings from a “hospital perspective” from substituting Fast-SENC for a portion of SPECTs assuming an average number of annual SPECT tests performed in US hospitals.

Results: In the payer model, using Fast-SENC followed by coronary angiography (CA) and percutaneous coronary intervention (PCI) treatment when necessary is less costly than the SPECT method when considering both direct and indirect costs of testing. Expected costs of the Fast-SENC were between $2,510 and $2,632 per correct diagnosis, while expected costs for the SPECT were between $3,157 and $4,078. Fast-SENC reduced false positives by 50% and false negatives by 86%, generating additional cost savings. The hospital model showed total costs per CAD patient visit of $825 for SPECT and $376 for Fast-SENC.

Limitations: Limitations of this study are that clinical data are sourced from other published clinical trials on how CAD diagnostic strategies impact clinical outcome, and that necessary assumptions were made which impact health outcomes.

Conclusion: The lower cost, higher sensitivity and specificity rates, and faster, less burdensome process for detecting CAD patients make Fast-SENC a more capable and economically beneficial stress test than SPECT. The payer model and hospital model demonstrate an alignment between payer and provider economics as Fast-SENC provides monetary savings for patients and resource benefits for hospitals.     

Economic burden of selected adverse events in patients aged ≥65 years with metastatic renal cell carcinoma

Abstract

Objective:

To estimate the costs of adverse events (AEs) in patients aged ≥65 years with metastatic renal cell carcinoma (mRCC).

Methods:

Retrospective study using the linked Surveillance, Epidemiology and End Results (SEER) Medicare database. Study subjects consisted of persons in SEER-Medicare, aged ≥65 years, with evidence of newly diagnosed mRCC between January 1, 2007 and December 31, 2007. Adverse events of interest consisted of Grade 3 or 4 toxicities that have been reported with frequency ≥5% in randomized controlled trials of sunitinib, sorafenib, bevacizumab, and pazopanib (i.e., targeted therapies for mRCC), and included abdominal pain, back pain, diarrhea, dyspnea, extremity pain, fatigue/asthenia, hand-foot syndrome, hypertension, lymphopenia, nausea/vomiting, neutropenia, proteinuria, and thrombocytopenia. Patients in SEER-Medicare with these events were identified based on ICD-9-CM diagnosis codes on Medicare claims. For each AE of interest, costs were tallied among evented patients over 30 days, beginning with the date of each patient’s first mention of the AE, and were compared with those of non-evented patients over a similar 30-day period beginning with an identical ‘shadow’ index date. Total costs were compared on an unadjusted basis and with adjustment for differences in baseline characteristics using a generalized linear model.

Results:

A total of 881 patients with mRCC met study entry criteria; 60% of these patients had Medicare claims with mention of one or more AEs of interest. Events occurring with frequency >20% included abdominal pain, dyspnea, and fatigue/asthenia; 10–20% of study subjects had encounters for back pain, extremity pain, and nausea/vomiting. Mean (standard deviation) total cost of care over 30 days was substantially higher among patients with AEs ($13,944 [$14,529]) compared with those without mention of these events ($1878 [$5264]). Adjusting for differences in baseline characteristics, the mean (95% confidence interval) difference in costs between evented and non-evented patients was $12,410 ($9217–$16,522). Study limitations include problems in event ascertainment due to inaccuracies in ICD-9-CM coding on Medicare claims data, and restriction of the study population to patients with metastatic involvement at initial diagnosis of RCC.

Conclusions:

Costs of care are substantially higher in patients aged ≥65 years with mRCC who experience AEs commonly associated with sunitinib, sorafenib, bevacizumab, and pazopanib. Efforts to prevent and/or better manage these events potentially can reduce healthcare costs.     

Analysis of chronic emergency department use

This retrospective emergency department (ED) chart review study examined the relationship between acuity level and the type of insurance in a patient population who used the ED on a chronic basis (seven or more times in the calendar year 1996). Of 1,185 patients seen in the ED in 1996, 122 had between 7 and 29 visits. In the study population: 62.5% of their visits were classified as nonurgent; 42.6% of the nonurgent visits were made by those with insurance; the highest frequency of visits took place between 8:00 am and 4:00 pm when most alternative nonemergency facilities are open. Some of the factors seen as influencing overuse of the ED include: the fact that some chronic use appeared to be associated with psychiatric conditions including substance abuse and patients with recurrent chest pain; and patient's perceptions that access to lab and X-ray facilities are readily available within the ED.     

How does your kindergarten classroom affect your earnings? Evidence from Project Star

In Project STAR, 11,571 students in Tennessee and their teachers were randomly assigned to classrooms within their schools from kindergarten to third grade. This article evaluates the long-term impacts of STAR by linking the experimental data to administrative records. We first demonstrate that kindergarten test scores are highly correlated with outcomes such as earnings at age 27, college attendance, home ownership, and retirement savings. We then document four sets of experimental impacts. First, students in small classes are significantly more likely to attend college and exhibit improvements on other outcomes. Class size does not have a significant effect on earnings at age 27, but this effect is imprecisely estimated. Second, students who had a more experienced teacher in kindergarten have higher earnings. Third, an analysis of variance reveals significant classroom effects on earnings. Students who were randomly assigned to higher quality classrooms in grades K–3—as measured by classmates' end-of-class test scores—have higher earnings, college attendance rates, and other outcomes. Finally, the effects of class quality fade out on test scores in later grades, but gains in noncognitive measures persist.     

The effects of alternative urban transit subsidy formulas

This paper demonstrates that for a given cost to the taxpayer, the effects of a transit subsidy depend on the subsidy formula, the objective function of the transit firm, and the transit demand function. Under most assumptions, a subsidy would lead to a lower fare, more service, and more riders, but under some assumptions the fare would remain unchanged or increase. If a transit firm maximizes ridership, lump sum and passenger subsidies will have the same effects but a cost subsidy with the same cost to taxpayers will lead to a higher fare, more service, and lower ridership.     

Bus transit technical efficiency using latent class stochastic indirect production frontier

Using an Indirect Production Frontier (IPF), this article examines technical inefficiency within a latent class framework while simultaneously accounting for allocative distortions from operating and capital subsidies. It identifies two latent classes of US public transit systems, one characterized by economies of scale with 16.61% technical inefficiency and the other by diseconomies of scale with 14.16% technical inefficiency. It decomposes technical inefficiency among some of its sources and finds that the incentive tier of federal operating subsidies, regulations regarding years of vehicle use, subsidy-induced allocative distortion from labour overuse relative to capital negatively influence technical inefficiency in all transit systems. For the Latent Class 1 transit systems, the sources of lower technical inefficiency are operating speed, purchased transportation and years-of-vehicle-use regulation. For the Latent Class 2 transit systems, these sources are subsidy-induced capital-labour allocative distortion and the incentive tier component of the federal formula grant.     

Cost of operating room time for endovascular transcatheter aortic valve replacement

Abstract

Background: Procedural efficiencies can contribute to cost reductions in transcatheter aortic valve replacement procedures (TAVR). The objective of this study is to determine operating room (OR) variable cost per minute in endovascular TAVR procedures, in a real-world hospital setting.

Methods: Using Premier data from January 2015–June 2016 for patients undergoing a primary endovascular TAVR (primary ICD-9 code of 35.05, ICD-10 code of 02RF37Z, 02RF38Z, 02RF3JZ, or 02RF3KZ) procedure, the OR cost per minute was calculated for each patient by dividing the total hospital OR variable cost by the OR time (minutes).

Results: Of the 4,573 patients in the cohort, the average age was 80 years, 77% were admitted electively, and the vast majority were discharged home with (30%) or without (45%) home care. Median OR time for endovascular TAVR procedures was 180?min. The trimmed mean OR cost per minute was $43.59 (SD = $28.68). When stratified by Elixhauser Risk score and Charlson comorbidity index, OR cost per minute increased with higher risk and comorbidity (p?<?0.0001 and p?<?0.041, respectively).

Conclusions: This contemporary estimate of the real-world variable OR cost per minute provides researchers with a critical parameter to refine economic models of TAVR and aid clinical program directors in resource planning according to a priori risk and comorbidity.     

EXERCISING WILLPOWER: DIFFERENCES IN WILLPOWER DEPLETION AMONG ATHLETES AND NONATHLETES

This study presents the results from a controlled experiment designed to test for differences in willpower depletion between athletes and nonathletes. Individuals with more willpower are more likely to have high school and college degrees, higher earnings, better jobs, lower crime and poverty rates, and are less likely to be obese. Recent research has established that reserves of willpower get depleted, leaving individuals unable to carry out tasks that require further self‐control. The experimental results show that after administering a willpower‐draining task, athletes persisted for significantly longer—exhibited less willpower depletion—on an unsolvable puzzle than nonathletes. (JEL C91, J24)     

Rational inattention,long-run consumption risk,and portfolio choice

This paper explores how the introduction of rational inattention (RI) – that agents process information subject to finite channel capacity – affects optimal consumption and investment decisions in an otherwise standard intertemporal model of portfolio choice. We first explicitly derive optimal consumption and portfolio rules under RI and then show that introducing RI reduces the optimal share of savings invested in the risky asset because inattentive investors face greater long-run consumption risk. We also show that the investment horizon matters for portfolio allocation in the presence of RI, even if investment opportunities are constant and the utility function of investors is constant relative risk aversion. Second, after aggregating across investors, we show that introducing RI can better explain the observed joint dynamics of aggregate consumption and the equity return. Finally, we show that RI increases the implied equity premium because investors under RI face greater long-run consumption risk and thus require higher compensation in equilibrium.     

Inpatient and outpatient rehabilitation for patients with rheumatoid arthritis: a clinical and economic assessment

Summary

The aim of this study was to compare inpatient and outpatient rehabilitation for patients with active rheumatoid arthritis from clinical and cost perspectives.

A single-centre, randomised trial design was used. Data were recorded at baseline, post treatment and at 6 months follow-up. The primary outcome measure was the Arthritis Impact Measurement Scale 2. Several other disease activity, functional and quality of life measures were also assessed (erythrocyte sedimentation rate, C-reactive protein, visual analogue scale for pain, early morning stiffness, tender and swollen joint count, grip strength, timed ‘Up and Go’ test and Schedule for the Evaluation of the Individual Quality of Life—Direct Weighting). All direct and indirect costs were measured. A total of 47 subjects were randomised to the study.

No sustained significant differences were detected between the two groups for the primary or secondary measures at the end of treatment or at follow-up. Total inpatient costs (€81,590) were more than three times higher than total outpatient costs (€25,450).     

Clinical comorbidities,treatment patterns,and direct medical costs of patients with osteoarthritis in usual care: a retrospective claims database analysis

Abstract

Objective:

Comorbidities and resource utilization among patients with osteoarthritis (OA) in clinical practice have been infrequently characterized. The purpose of this study was to examine comorbidities, pain-related pharmacotherapy, and direct medical costs of patients with OA in clinical practice.

Method:

This retrospective cohort analysis used medical and pharmacy claims data from the LifeLink? Database. OA patients (ICD-9-CM codes 715.XX) were matched (age, gender, and region) with individuals without OA. Comorbidities, pain-related pharmacotherapy, and direct medical costs (pharmacy, outpatient, inpatient, total) were examined for the calendar year 2008.

Results:

The sample consisted of 112,951 OA patients and 112,951 controls (mean age: 56.9 [SD?=?9.5] years; 62% female). Relative to controls, OA patients were significantly more likely (p?<?0.0001) to have comorbidities, including musculoskeletal (84.3 vs. 37.1%) and neuropathic pain (22.0 vs. 6.1%) conditions, depression (12.4 vs. 6.4%), anxiety (6.6 vs. 3.5%), and sleep disorders (11.9 vs. 4.2%). OA patients were significantly more likely (p?<?0.0001) to receive pain-related medications, including opioids (40.7 vs. 17.1%), NSAIDs (37.1 vs. 11.5%), tramadol (9.8 vs. 1.8%), and adjunctive medications for treating depression, anxiety, and insomnia. Mean [SD] total direct medical costs were more than two times higher among OA patients ($12,905 [$21,884] vs. $5099 [$13,855]; p?<?0.001) and median costs were more than three times higher ($6188 vs. $1879; p?<?0.0001). Study limitations include potential errors in coding and recording; overestimation of the comorbidity burden; inability to link condition of interest, OA, with prescribed medications; and possible underestimation of the true costs of OA, because indirect costs were not considered and the direct costs were from a third party payer (commercial insurance) perspective.

Conclusion:

The patient burden of OA was characterized by a high prevalence of comorbidities. The payer burden was also substantial, with significantly greater use of pain-related and adjunctive medications, and higher direct medical costs.     

The Effect of Privatization on Public Transit Costs

In an effort to reduce operating deficits, increase productivity, and improve the quality of services, the public transit sector has been moving away from public ownership and operation and towards a franchising arrangement whereby a local government authorizes a private firm to manage and operate the city's public transit system. Profit maximization considerations imply that private managers have stronger incentives for cost efficiency. One such example is the city of Indianapolis which began privatization efforts in its transit operations in 1996. Based upon monthly data from January 1991 through March 1997, this study examines the effect of privatization on the city's cost of providing mass transit. The primary implication of the study is that Indianapolis has experienced an annual 2.5% reduction in operating costs since privatizing the management of its public transit system.