The Permanente journal最新文献

Introduction: The Merit-Based Incentive Payment System (MIPS) affects Medicare reimbursements for over 600,000 clinicians, including ~ 15,000 orthopedic surgeons in the United States. MIPS policies are rapidly evolving, yet limited research exists to guide orthopedic surgeons in optimizing performance. This study evaluates whether recent MIPS policy changes have led to increased payment adjustments for orthopedic surgeons and examines the role of MIPS in enhancing care quality.

Methods: A retrospective analysis of 2021-2022 MIPS performance data from nearly 9000 orthopedic surgeons assessed the impact of policy changes on payment adjustments using McNemar's test and mixed effects logistic regression.

Results: Raising the MIPS performance threshold to 75 points significantly reduced the likelihood of receiving bonus payments (χ ² = 803.21, degrees of freedom = 1; P < .01). Surgeons in smaller practices had 60% lower odds of earning bonus payments (odds ratio, 0.40; 95% confidence interval, 0.33-0.48; P < .008), though this disparity was smaller than previously reported. The updated complex patient bonus scoring policy showed the strongest positive effect on the likelihood of receiving bonus payments (odds ratio, 6.49; 95% confidence interval, 3.31-12.76; P < .017). Nonetheless, MIPS continues to fall short in encouraging the reporting of specialty-specific, outcome-based, and patient-experience measures.

Discussion: Raising the MIPS performance threshold further may lead to greater dissatisfaction. Despite some improvements, equity gaps remain for small and rural practitioners. However, the revised complex patient bonus policy effectively rewards clinicians caring for high-risk populations.

Background: Fertility preservation (FP) services are a critical piece of family planning for patients with iatrogenic infertility, which is defined as infertility resulting from undergoing a gonadotoxic medical treatment or procedure. There is currently no national mandate for health care plans to cover FP services, and state mandates for coverage are quite heterogenous.

Methods: Between 2016 and 2024, 18 states have passed FP mandates that vary greatly in which diagnoses are covered, for how long the coverage lasts, and if there are additional measures impacting the coverage. Particularly as the legislative landscape around FP rapidly changes, this study aimed to analyze state-level mandates to characterize which patients have reliable access to FP services. This study analyzed state-level mandates on FP services for iatrogenic infertility to build a standardized framework that compares the language in each bill.

Results: Based on close review of each state-level mandate, the following comparison coverage factors were identified for the policy review: clinical diagnoses; type of health plan, including Medicaid; FP services mandated; the time period of coverage; maximum cost; and any religious exemptions.

Conclusion: Key takeaways include: nonspecific legislative language appears to cover a broader set of patients; there remains insufficient detail on storage logistics of cryopreserved tissue, if covered; most states do not cover Medicaid patients; religious exemption conditions can pose barriers for patients seeking gender-affirming care; and experimental treatments are not commonly covered.

Introduction: The objective was to compare the diagnostic and therapeutic yield of neck imaging studies ordered by otolaryngologists (OHNS) compared with non-OHNS clinicians and identify factors associated with higher imaging value in adult neck mass workup.

Methods: Retrospective chart review was conducted on a cohort of patients who underwent neck mass imaging (computed tomography, magnetic resonance imaging, or ultrasound) from 2021-2022. Imaging studies for suspected thyroid masses, incidental findings, or surveillance of known masses were excluded. The authors analyzed the impact of clinician specialty and preimaging workup (physical examination, flexible nasopharyngolaryngoscopy, point-of-care ultrasound) on diagnostic yield.

Results: Imaging ordered by OHNS had a higher diagnostic yield than imaging by non-OHNS clinicians (78.6% vs 52.3%, P < .001). In contrast, lack of physical examination reduced yield to 42.4%. OHNS-ordered imaging also had higher therapeutic yield (45.9% vs 29.5%, P = .0437) and required less repeat imaging. Incidental findings were common (14%), with no difference between ordering specialties, and led to downstream testing in 59% of cases, with 1 case of papillary thyroid cancer.

Discussion: A triage model favoring initial OHNS consultation may reduce unnecessary imaging, associated costs, and patient burden.

Conclusion: Imaging for adult neck masses ordered by OHNS clinicians was associated with significantly higher diagnostic and therapeutic yield. Preimaging evaluation, including flexible nasopharyngolaryngoscopy and point-of-care ultrasound, showed a further improvement in yield. These findings suggest OHNS evaluation prior to formal neck imaging may reduce unnecessary imaging studies.

Value-based care (VBC) focuses on delivering effective and efficient health care that improves patient outcomes while reducing costs. As health care systems shift toward VBC, it is increasingly important for graduate medical education to prepare residents with the necessary competencies. This review examines the current integration of VBC principles in residency training, identifies persistent barriers, and highlights educational innovations, including resident-led projects, case-based learning, and interactive modules. Despite broad recognition of the importance of VBC, formal training remains inconsistent across different specialties. To address these gaps, the authors reviewed how developing a standardized, specialty-specific curriculum, expanding faculty development, and incorporating VBC throughout clinical training can enhance VBC competency. Equipping future physicians with VBC skills is essential for advancing high-value, equitable health care.

Introduction: Annual variations in the population-based incidence of acute urticaria (AU) and chronic urticaria (CU) are poorly understood, specifically in relationship to non-COVID-19 viral respiratory infections (NCVRIs).

Objective: To determine the annual incidence of AU and CU, health care utilization for NCVRIs and demographic associations across 3 periods: pre-COVID-19, COVID-19 without vaccinations, and COVID-19 with vaccinations.

Methods: The researchers reviewed the medical records from 2017 to 2022 of all Kaiser Permanente Southern California Health Plan members with and without urticaria leading to health care utilization.

Results: There was a total of 7,404,343 unique individuals with any Kaiser Permanente Southern California Health Plan coverage between 2017 and 2022, contributing to 26,852,884 patient-years of follow-up. The annual incidence of AU per 100,000 patient-years was 1543 in 2017, 1533 in 2018, 1586 in 2019, 1194 in 2020, 1345 in 2021, and 1434 in 2022. The annual incidence of CU per 100,000 patient-years was 101 in 2017, 113 in 2018, 123 in 2019, 95 in 2020, 113 in 2021, and 129 in 2022. The number of annual health care visits for NCVRIs per 100,000 patient-years was 14,588 in 2017, 13,409 in 2018, 14,843 in 2019, 8671 in 2020, 6507 in 2021, and 11,191 in 2022. There was a significant correlation between NCVRIs and AU (r = 0.82, P = .05) but not between NCVRIs and CU (r = 0.10, P = .86).

Conclusion: There was a decrease in AU incidence during the COVID-19 era before and after vaccines. AU may be associated with NCVRIs.

Introduction: To evaluate the impact of increasing access to immediate postpartum (IPP) long-acting reversible contraceptions (LARCs) on pregnancy and contraceptive outcomes in patients that desired permanent contraception prior to delivery.

Methods: This retrospective cohort study compared patients aged > 18 years at gestational age 24 weeks 0 days and above, who desired permanent contraception before and after an organization-wide intervention to increase access to IPP LARCs. The authors collected demographic information, birth control method documented at discharge, LARC usage within 3 months of delivery, LARC type, and unintended pregnancy 1 year after delivery. Patients specified whether their pregnancies were unintended at time of first pregnancy-related care. Patients who obtained permanent contraception during their delivery encounter were excluded. Mann-Whitney and χ² tests were used to assess group differences.

Results: The authors reviewed 1607 patient records (846 preintervention; 761 postintervention). The cohorts were similar in age, body mass index, parity, and gestational age at delivery. Out of the 846 preintervention patients, 183 (22%) underwent LARC placement (39 [21%] arm implant; 144 [79%] intrauterine device), and 16 (1.9%) patients had a 1-year interval unintended pregnancy. Out of the 761 postintervention patients, 190 (25%) underwent LARC placement (54 [28%] arm implant; 136 [72%] intrauterine device), and 7 (0.9%) patients had a 1-year interval unintended pregnancy.

Discussion: With increased access to IPP LARCs, patients who did not obtain desired permanent contraception were more likely to utilize LARCs at 3 months postpartum and less likely to have another pregnancy within 1 year.

Conclusion: Patients unable to receive requested postpartum permanent contraception appear to benefit from increased access to IPP LARCs.

Small cell neuroendocrine carcinoma (SCNC) of the larynx is an exceptionally rare subset of laryngeal carcinoma with a clinically aggressive course and poor prognosis. Long-term survival is rare, and treatment strategies remain nonstandardized due to limited data. In this report, the authors present a case of a 51-year-old male who presented with stage IVa laryngeal SCNC and no distant metastasis, treated with a combination of platinum-based chemotherapy and radiation, who has survived for more than 5 years. This case represented 1 of few reported instances of extended disease-free survival in laryngeal SCNC, highlighting the potential benefit of aggressive multimodal treatment, even in advanced-stage disease. In addition to diagnosis and management, this case may prompt further discussion about the role of surgery in select patients and the need for individualized, patient-centered survivorship care for management of posttreatment sequalae. Although limited to a single case, these findings underscore the need for further research into effective treatment and surveillance strategies for this rare malignancy.

Introduction: Adults often visit the emergency department (ED) for complications from cancer treatment. Oncology urgent care clinics (UCCs) can manage nonemergent issues, but little is known about how UCC care compares with ED care.

Methods: The authors' university hospital ED and UCC visits (January 1, 2023, through June 30, 2023) were analyzed after coding the Emergency Severity Index (ESI) for UCC visits to make them comparable to ED visits, where ESI was already regularly assigned. ESI ranges from levels 1 to 5 (1 = highest severity). Coarsened exact matching and multivariate models were used to compare the proportion of patients discharged home, the length of stay, and advanced imaging use. Marginally adjusted outcomes were stratified by ESI.

Results: Prior to matching, 31.7% of UCC and 64.0% of ED visits were ESI level 2 severity; 61.0% of UCC and 33.4% of ED visits were ESI level 3. Matching resulted in 1033 UCC and 2782 ED visits (61.0% of patients > age 65; 47.8% female; 65.9% non-Hispanic White). In adjusted analyses, for ESI level 2 visits, the UCC discharged patients home 32.0% more often than the ED (95% confidence interval [CI], 27.5-36.4), with a 7.0-hour shorter length of stay (95% CI, 6.5-7.5), and used advanced imaging 30.3% less often (95% CI, 26.0-34.7). Findings were similar for ESI level 3 visits.

Discussion: The UCC managed a high level of severity and may be more efficient than the ED for nonemergent care.

Conclusion: Future work should more broadly investigate care delivery at each site, including the cost of care.

Introduction: In 2016, the Centers for Medicare & Medicaid Services started reimbursing practitioners for their time spent providing advance care planning (ACP) with patients. This study assessed utilization of this policy by examining trends in ACP billing across medical specialties from 2016 to 2021 and differences in ACP service volume by metropolitan status.

Methods: The authors analyzed Centers for Medicare & Medicaid Services Medicare Provider Utilization and Payment files (2016-2021) from 6 specialty groups using corresponding Healthcare Common Procedure Coding System codes to derive trends in the percentage of practitioners billing any ACP visit. Wilcoxon tests were conducted to compare the average number of visits by metropolitan status.

Results: The percentage of practitioners billing ACP visits tripled from 1.76% in 2016 to 4.56% in 2021, with the highest percentage among hospice and palliative medicine practitioners (36.94%) in 2021. ACP service volume was similar by metropolitan status for hospice and palliative medicine, but it was higher in nonmetropolitan regions for cancer-related specialties, non-cancer terminal disease specialties, and primary and geriatrics care.

Discussion: This nationwide analysis showed low adoption of ACP billing by 2021, and it varied widely across specialties. This may reflect practical challenges of ACP related to comfort level with ACP discussion and documentation burden among the professional communities.

Conclusion: Despite an overall increase in the proportion of physicians billing ACP codes from 2016 to 2021, adoption remained low. Efforts are needed to address barriers to ACP and provide goal-concordant care to patients.