The Intersection of Long-Term Care and End-of-Life Care, by Haiden A. Huskamp, Christine Kaufmann and David G. Stevenson (Medical Care Research and Review)
High-quality end-of-life care is an important component of high-quality long-term care, yet many elderly individuals receiving long-term care services do not obtain good care as they approach death. This study provides a systematic review of articles that describe care received at the nexus of long-term care and end-of-life care. The articles identified three primary types of barriers to high-quality end-of-life care in long-term care settings: delivery system barriers intrinsic to long-term care settings, barriers related to features of coverage and reimbursement, and barriers resulting from the current regulatory approach for long-term care providers. The authors recommend areas for future research that would help to support progress on public policy that governs the provision of care at this important intersection.
Active Surveillance in Men With Localized Prostate Cancer. A Systematic Review, by Issa J. Dahabreh, Mei Chung, Ethan M. Balk, Winifred W. Yu, Paul Mathew, Joseph Lau and Stanley Ip (Archives of Internal Medicine)
Background: Active surveillance (AS) and watchful waiting (WW) have been proposed as management strategies for low-risk, localized prostate cancer.
Purpose: To systematically review strategies for observational management of prostate cancer (AS or WW), factors affecting their utilization, and comparative effectiveness of observational management versus immediate treatment with curative intent.
Data Sources: MEDLINE and Cochrane databases (from inception to August 2011).
Study Selection: Screened abstracts and reviewed full-text publications to identify eligible studies.
Data Extraction: One reviewer extracted data, and another verified quantitative data. Two independent reviewers rated study quality and strength of evidence for comparative effectiveness.
Data Synthesis: Sixteen independent cohorts defined AS, 42 studies evaluated factors that affect the use of observational strategies, and 2 evidence reports and 22 recent studies reported comparisons of WW versus treatment with curative intent. The most common eligibility criteria for AS were tumor stage (all cohorts), Gleason score (12 cohorts), prostate-specific antigen (PSA) concentration (10 cohorts), and number of biopsy cores positive for cancer (8 cohorts). For monitoring, studies used combinations of periodic PSA testing (all cohorts), digital rectal examination (14 cohorts), and rebiopsy (14 cohorts). Predictors of receiving no active treatment included older age, comorbid conditions, lower Gleason score, tumor stage, PSA concentration, and favorable risk group. No published studies compared AS with immediate treatment with curative intent. Watchful waiting was generally less effective than treatment with curative intent; however, applicability to contemporary patients may be limited.
Limitations: Active surveillance and WW often could not be differentiated in the reviewed studies. Published randomized trials have assessed only WW and did not enroll patients diagnosed by PSA screening.
Conclusion: Evidence is insufficient to assess whether AS is an appropriate option for men with localized prostate cancer. A standard definition of AS that clearly distinguishes it from WW is needed to clarify scientific discourse.
National Institutes of Health State-of-the-Science Conference: Role of Active Surveillance in the Management of Men With Localized Prostate Cancer, by Patricia A. Ganz, John M. Barry, Wylie Burke, Nananda F. Col, Phaedra S. Corso, Everett Dodson, M. Elizabeth Hammond, Barry A. Kogan, Charles F. Lynch, Lee Newcomer, Eric J. Seifter, Janet A. Tooze, Kasisomayajula Viswanath and Hunter Wessells (Archives of Internal Medicine)
Moral Hazard And Supplier-Induced Demand: Empirical Evidence In General Practice, by Christel E. van Dijk, Bernard van den Berg, Robert A. Verheij, Peter Spreeuwenberg, Peter P. Groenewegen and Dinny H. de Bakker (Health Economics)
Changes in cost sharing and remuneration system in the Netherlands in 2006 led to clear changes in financial incentives faced by both consumers and general practitioner (GPs). For privately insured consumers, cost sharing was abolished, whereas those socially insured never faced cost sharing. The separate remuneration systems for socially insured consumers (capitation) and privately insured consumers (fee-for-service) changed to a combined system of capitation and fee-for-service for both groups. Our first hypothesis was that privately insured consumers had a higher increase in patient-initiated GP contact rates compared with socially insured consumers. Our second hypothesis was that socially insured consumers had a higher increase in physician-initiated contact rates. Data were used from electronic medical records from 32 GP-practices and 35 336 consumers in 2005–2007. A difference-in-differences approach was applied to study the effect of changes in cost sharing and remuneration system on contact rates. Abolition of cost sharing led to a higher increase in patient-initiated utilisation for privately insured consumers in persons aged 65 and older. Introduction of fee-for-service for socially insured consumers led to a higher increase in physician-initiated utilisation. This was most apparent in persons aged 25 to 54. Differences in the trend in physician-initiated utilisation point to an effect of supplier-induced demand. Differences in patient-initiated utilisation indicate limited evidence for moral hazard.
Fair Enough? Inviting Inequities in State Health Benefits, by Jennifer Prah Ruger (The New England Journal of Medicine)
The Value of Federalism in Defining Essential Health Benefits, by Alan Weil (The New England Journal of Medicine)
The Medicare Advantage Success Story — Looking beyond the Cost Difference, by Jeet S. Guram and Robert E. Moffit (The New England Journal of Medicine)
Medicare Advantage — Lessons for Medicare’s Future, by Marsha Gold (The New England Journal of Medicine)
The Relationship Between Geographic Variations and Overuse of Healthcare Services: A Systematic Review, by Salomeh Keyhani, Raphael Falk, Tara Bishop, Elizabeth Howell and Deborah Korenstein (Medical Care)
Objective: To examine the relationship between overuse of healthcare services and geographic variations in medical care.
Design: Systematic Review.
Data Sources: Articles published in Medline between 1978, the year of publication of the first framework to measure quality, and January 1, 2009.
Study Selection: Four investigators screened 114,830 titles and 2 investigators screened all selected abstracts and articles for possible inclusion and extracted all data.
Data Extraction: We extracted data on rates of overuse in different geographic areas. We also extracted data on underuse, if available, for the same population in which overuse was measured.
Results: Five papers examined the relationship between geographic variations and overuse of healthcare services. One study in 2008 compared the appropriateness of coronary angiography (CA) for acute myocardial infarction in high-cost areas versus low cost areas in the Medicare population and found largely similar rates of inappropriateness (12.2% vs. 16.2%). A study in 2000 using national data concluded that overuse of CA explained little of the geographic variations in the use of this procedure in the Medicare program. An older study of Medicare patients found similar rates of inappropriate use of CA (15% to 17% vs. 18%), endoscopy (15% vs. 18% 19%), and carotid endarterectomy (29% vs. 30%) in low-use and high-use regions. A small area reanalysis of data from this study of 3 procedures found no evidence of a relationship between inappropriate use of procedures and volume in 23 adjacent counties of California. Another 2008 study found that inappropriate chemotherapy for stage I cancer was less common in low-cost areas compared with high-cost areas (3.1% vs. 6.3%).
Conclusions: The limited available evidence does not lend support to the hypothesis that inappropriate use of procedures is a major source of geographic variations in intensity and/or costs of care. More research is needed to improve our understanding of the relationship between geographic variations and the quality of care.