JAMA otolaryngology-- head & neck surgery最新文献

Importance: In 2024, the US Senate Committee on Finance released a white paper outlining future reforms to the Medicare payment models.

Objective: To characterize trends in Medicare reimbursement for thyroid surgery and to provide evidence for future discussions on payment reforms.

Design and setting: This retrospective economic evaluation used data on reimbursement for thyroid surgeries from the Centers for Medicare & Medicaid Services' Physician Fee Schedule from 2000 to 2023. Data were analyzed from May to June 2024.

Main outcomes and measures: The main outcomes were reimbursement rates for thyroid surgery and changes in reimbursement over time. Dollar amounts were adjusted to January 2023 US dollars. Annual reimbursement was averaged nationally, and compound annual growth rate and Pearson correlation coefficient were used to characterize trends.

Results: Between 2000 and 2023, Medicare reimbursement for thyroid surgeries decreased 38.7%, from $1517.59 to $929.55, when adjusted for inflation. The reimbursement for total thyroidectomy demonstrated the greatest decline at 47.8%, from $1803.16 to $942.07. Thyroid lobectomy and completion thyroidectomy both had reduced reimbursements at 41.7% (from $1250.38 to $729.02) and 25.5% (from $1499.26 to $1117.54), respectively. The compound annual growth rate for thyroid surgeries as a whole was 0.4% when not adjusted for inflation and -2.1% when adjusted for inflation. There was 0% growth in work relative value units between 2012 and 2023 for all thyroid surgeries.

Conclusions and relevance: This economic evaluation found an almost 40% decrease in the rate of reimbursement for thyroid surgery, with total thyroidectomy having the greatest decrease at 47.8%. These findings provide evidence that current trends are not sustainable. Thyroid surgeons should take a proactive approach to improving reimbursements before these changes impact patient access to thyroid surgery.

Importance: Neoadjuvant immunotherapy shows promise in the treatment of head and neck squamous cell carcinoma (HNSCC). Pathologic treatment effect (pTE) is one way to assess response to treatment; however, the association of this response with survival outcomes is not yet clear. The current study sought to determine whether treatment response to neoadjuvant nivolumab, as measured by pTE, correlates with survival outcomes.

Objective: To determine whether patients with HNSCC with pathologic response to neoadjuvant nivolumab have improved survival outcomes.

Design, setting, and participants: A cohort study performing a pooled analysis of 2 multi-institutional neoadjuvant clinical trials (NCT03238365, NCT03854032) enrolling patients from July 2017 to January 2022, was performed. Patients with resectable HNSCC enrolled in 1 of 2 clinical trials and treated with neoadjuvant immunotherapy and surgical resection were included in the analysis. Patients were followed up for a median (range) of 36 (4-72) months. Analysis took place on April 15, 2024.

Intervention: Patients were treated with neoadjuvant nivolumab with or without the addition of immunomodulating medications (tadalafil or indoleamine 2,3 dioxygenase inhibitor).

Main outcome and measure: Pooled analysis was performed to plot Kaplan-Meier 3-year survival outcomes for pTE responders and low or nonresponders. A pTE response threshold was determined using recursive partitioning analysis.

Results: Seventy-nine patients were included in the analysis, of whom 40 (51%) had human papillomavirus (HPV)-negative disease. Recursive partitioning analysis identified a pTE threshold of 57%, which was used to define pathologic responders vs low or nonresponders. Pathologic responders with HPV-negative disease had significantly improved disease-free survival (100% for responders vs 66.8% for low or nonresponders; 95% CI, 46.1%-80.6%) and overall survival (100% for responders vs 73.3% for low or nonresponders; 95% CI, 53.4%-85.7%). In patients with HPV-positive disease, disease-free survival was high for both responders (90%; 95% CI, 47.3%-98.5%) and low or nonresponders (92.4%; 95% CI, 72.8%-98.1%).

Conclusion and relevance: This cohort study found that patients with HPV-negative disease who are deemed pathologic responders (pTE >57%) to neoadjuvant nivolumab may have improved survival outcomes compared with those who are low or nonresponders. Not only does this suggest a role for using pathologic response as a surrogate marker, but it further highlights the neoadjuvant strategy in HNSCC as associated with improved survival.

Importance: Most estimates of hearing loss prevalence and hearing aid use among US adults 65 years and older are based on samples with limited Hispanic representation. Accurate and representative data are essential to guide public health efforts and improve hearing care access in this underserved group.

Objective: To estimate the prevalence of hearing loss and hearing aid use by age in a nationally representative sample that purposefully oversampled Hispanic adults 65 years and older.

Design, setting, and participants: Using data from the 2022 National Study of Aging and Health Trends, the prevalence estimates of hearing loss and hearing ais use by age and sex among participants who identify as Hispanic were calculated. Survey weights were applied to generate nationally representative estimates for the Hispanic US older adult population. Data for this study were collected in 2022 and analyzed between March and April 2025.

Main outcomes and measures: Standard audiometric measures of hearing loss over a wide frequency range (0.25 to 8 KHz) and self-reported hearing aid use.

Results: This nationally representative sample included 591 participants, corresponding to a weighted estimate of 5.17 million Hispanic individuals 65 years and older. Among them, 50.2% (95% CI, 44.1%-56.2%) were female individuals, 45.6.% (95% CI, 39.6%-51.7%) were aged 65 to 69, 14.4% (95% CI, 39.6%-51.7%) were 75 to 79, and 3.2% (95% CI, 2.5%-4.1%) were aged 85 years or older. In weighted analyses, 54.6% (95% CI, 49.2%-59.9%) of approximately 2.8 million individuals had hearing loss in the better ear (>25 dB HL). This included mild hearing loss in 38.4% (95% CI, 32.6%-44.6%), moderate in 12.8% (95% CI, 10.0%-16.2%), and severe in 3.4% (95% CI, 2.1%-5.6%). The overall prevalence of hearing loss was higher in male individuals than in female individuals: 48.5% vs 60.8%, respectively. Hearing thresholds increased with age and frequency, from 21.8 and 29.0 dB HL (in participants aged 65-69 years and those aged ≥85 years at 0.25 and 8.0 kHz, respectively) to 55.2 and 79.3 dB HL (in participants aged 65-69 years and those aged ≥85 years at 0.25 and 8.0 kHz, respectively) in the right ear. The results were similar for the left ear. Hearing aid use was 8.3% of those with hearing loss.

Conclusions and relevance: This cross-sectional study found that more than half of Hispanic adults 65 years or older living in the US experience hearing loss, highlighting the need for targeted hearing health policies.

Importance: Older adults with head and neck squamous cell carcinoma (HNSCC) are underrepresented in clinical trials, limiting evidence-based treatment decisions. Artificial neural networks (ANNs) have demonstrated the ability to personalize treatment recommendations using patient-specific characteristics.

Objective: To develop and externally validate ANNs for overall survival (OS) and progression-free survival (PFS) in older adults with HNSCC undergoing definitive chemoradiation.

Design, setting, and participants: This international cohort study included retrospective clinical data from 19 academic cancer centers across Germany, Switzerland, Czech Republic, Cyprus, and the US from the SENIOR registry. ANNs were developed and validated using data from patients 65 years and older with locoregionally advanced HNSCC treated with definitive chemoradiation. Exclusion criteria included induction or adjuvant chemotherapy, history of head and neck cancer, and metastatic disease at treatment initiation. Data were collected from January 2021 to December 2023, and data were analyzed from December 2023 to April 2025.

Exposures: All patients received definitive radiotherapy with concurrent systemic therapy between 2005 and 2019.

Main outcomes and measures: OS and PFS were predicted using 2 separate ANN models. Patients were classified as high or low risk based on median prediction thresholds. Model performance was assessed with receiver operating characteristic (ROC) area under the curve (AUC) and precision recall AUC. Model explainability was assessed with Shapley additive explanations values.

Results: Of 898 patients included in the OS analysis (738 in training cohort and 160 in testing cohort), 665 (74.1%) were male, and the median (IQR) age was 71 (68-76) years. Of 945 included in the PFS analysis (770 in training cohort and 175 in testing cohort), 696 (73.7%) were male, and the median (IQR) age was 71 (68-76) years. The OS ANN stratified patients into high-risk and low-risk groups with significantly different survival, achieving an ROC-AUC of 0.68 (95% CI, 0.60-0.76). The PFS ANN showed similar discrimination, with an ROC-AUC of 0.64 (95% CI, 0.56-0.72). Human papillomavirus status, kidney function (estimated glomerular filtration rate), Eastern Cooperative Oncology Group Performance Status score, and nodal classification were among the most predictive features.

Conclusions and relevance: In this study, ANN-based models using routine clinical data effectively stratified older adults with HNSCC into prognostic groups. Integration of ANNs into clinical workflows could support personalized treatment decisions for this vulnerable population.