Kristine M Erlandson, Linda N Geng, Caitlin A Selvaggi, Tanayott Thaweethai, Peter Chen, Nathan B Erdmann, Jason D Goldman, Timothy J Henrich, Mady Hornig, Elizabeth W Karlson, Stuart D Katz, C Kim, Sushma K Cribbs, Adeyinka O Laiyemo, Rebecca Letts, Janet Y Lin, Jai Marathe, Sairam Parthasarathy, Thomas F Patterson, Brittany D Taylor, Elizabeth R Duffy, Monika Haack, Boris Julg, Gabrielle Maranga, Carla Hernandez, Nora G Singer, Jenny Han, Priscilla Pemu, Hassan Brim, Hassan Ashktorab, Alexander W Charney, Juan Wisnivesky, Jenny J Lin, Helen Y Chu, Minjoung Go, Upinder Singh, Emily B Levitan, Paul A Goepfert, Janko Ž Nikolich, Harvey Hsu, Michael J Peluso, J Daniel Kelly, Megumi J Okumura, Valerie J Flaherman, John G Quigley, Jerry A Krishnan, Mary Beth Scholand, Rachel Hess, Torri D Metz, Maged M Costantine, Dwight J Rouse, Barbara S Taylor, Mark P Goldberg, Gailen D Marshall, Jeremy Wood, David Warren, Leora Horwitz, Andrea S Foulkes, Grace A McComsey
Background: There are currently no validated clinical biomarkers of postacute sequelae of SARS-CoV-2 infection (PASC).
Objective: To investigate clinical laboratory markers of SARS-CoV-2 and PASC.
Design: Propensity score-weighted linear regression models were fitted to evaluate differences in mean laboratory measures by prior infection and PASC index (≥12 vs. 0). (ClinicalTrials.gov: NCT05172024).
Setting: 83 enrolling sites.
Participants: RECOVER-Adult cohort participants with or without SARS-CoV-2 infection with a study visit and laboratory measures 6 months after the index date (or at enrollment if >6 months after the index date). Participants were excluded if the 6-month visit occurred within 30 days of reinfection.
Measurements: Participants completed questionnaires and standard clinical laboratory tests.
Results: Among 10 094 participants, 8746 had prior SARS-CoV-2 infection, 1348 were uninfected, 1880 had a PASC index of 12 or higher, and 3351 had a PASC index of zero. After propensity score adjustment, participants with prior infection had a lower mean platelet count (265.9 × 109 cells/L [95% CI, 264.5 to 267.4 × 109 cells/L]) than participants without known prior infection (275.2 × 109 cells/L [CI, 268.5 to 282.0 × 109 cells/L]), as well as higher mean hemoglobin A1c (HbA1c) level (5.58% [CI, 5.56% to 5.60%] vs. 5.46% [CI, 5.40% to 5.51%]) and urinary albumin-creatinine ratio (81.9 mg/g [CI, 67.5 to 96.2 mg/g] vs. 43.0 mg/g [CI, 25.4 to 60.6 mg/g]), although differences were of modest clinical significance. The difference in HbA1c levels was attenuated after participants with preexisting diabetes were excluded. Among participants with prior infection, no meaningful differences in mean laboratory values were found between those with a PASC index of 12 or higher and those with a PASC index of zero.
Limitation: Whether differences in laboratory markers represent consequences of or risk factors for SARS-CoV-2 infection could not be determined.
Conclusion: Overall, no evidence was found that any of the 25 routine clinical laboratory values assessed in this study could serve as a clinically useful biomarker of PASC.
Primary funding source: National Institutes of Health.
背景:目前尚无有效的 SARS-CoV-2 感染后遗症(PASC)临床生物标志物:目前尚无有效的 SARS-CoV-2 感染急性后遗症(PASC)临床生物标志物:研究SARS-CoV-2和PASC的临床实验室标志物:设计:拟合倾向得分加权线性回归模型,评估先前感染和PASC指数(≥12 vs. 0)对平均实验室指标的影响。(临床试验:NCT05172024):83个报名点:RECOVER-成人队列参与者,无论是否感染 SARS-CoV-2,均应在指数日期后 6 个月(如果指数日期后超过 6 个月,则在注册时)进行研究访问和实验室测量。如果 6 个月的就诊时间是在再感染后 30 天内,则排除参与者:测量:参与者填写调查问卷并进行标准临床实验室检测:在 10 094 名参与者中,8746 人曾感染过 SARS-CoV-2,1348 人未感染,1880 人的 PASC 指数达到或超过 12,3351 人的 PASC 指数为零。经过倾向得分调整后,曾感染者的平均血小板计数(265.9 × 109 cells/L [95% CI, 264.5 to 267.4 × 109 cells/L])低于未感染者(275.2 × 109 cells/L [CI, 268.5 to 282.0 × 109 cells/L]),平均血红蛋白 A1c (HbA1c) 水平(5.58% [CI, 5.56% to 5.60%] vs. 5.46% [CI, 5.40% to 5.51%])和尿白蛋白-肌酐比值(81.9 mg/g [CI, 67.5 to 96.2 mg/g] vs. 43.0 mg/g [CI, 25.4 to 60.6 mg/g])也更高,但差异的临床意义不大。在剔除原有糖尿病患者后,HbA1c水平的差异有所减小。在既往有感染的参与者中,PASC 指数为 12 或更高的参与者与 PASC 指数为零的参与者之间的平均实验室值没有发现有意义的差异:局限性:无法确定实验室指标的差异是感染 SARS-CoV-2 的后果还是风险因素:总体而言,在本研究评估的 25 项常规临床实验室指标中,没有发现任何一项指标可作为 PASC 的临床有用生物标志物:主要资金来源:美国国立卫生研究院。
{"title":"Differentiation of Prior SARS-CoV-2 Infection and Postacute Sequelae by Standard Clinical Laboratory Measurements in the RECOVER Cohort.","authors":"Kristine M Erlandson, Linda N Geng, Caitlin A Selvaggi, Tanayott Thaweethai, Peter Chen, Nathan B Erdmann, Jason D Goldman, Timothy J Henrich, Mady Hornig, Elizabeth W Karlson, Stuart D Katz, C Kim, Sushma K Cribbs, Adeyinka O Laiyemo, Rebecca Letts, Janet Y Lin, Jai Marathe, Sairam Parthasarathy, Thomas F Patterson, Brittany D Taylor, Elizabeth R Duffy, Monika Haack, Boris Julg, Gabrielle Maranga, Carla Hernandez, Nora G Singer, Jenny Han, Priscilla Pemu, Hassan Brim, Hassan Ashktorab, Alexander W Charney, Juan Wisnivesky, Jenny J Lin, Helen Y Chu, Minjoung Go, Upinder Singh, Emily B Levitan, Paul A Goepfert, Janko Ž Nikolich, Harvey Hsu, Michael J Peluso, J Daniel Kelly, Megumi J Okumura, Valerie J Flaherman, John G Quigley, Jerry A Krishnan, Mary Beth Scholand, Rachel Hess, Torri D Metz, Maged M Costantine, Dwight J Rouse, Barbara S Taylor, Mark P Goldberg, Gailen D Marshall, Jeremy Wood, David Warren, Leora Horwitz, Andrea S Foulkes, Grace A McComsey","doi":"10.7326/M24-0737","DOIUrl":"10.7326/M24-0737","url":null,"abstract":"<p><strong>Background: </strong>There are currently no validated clinical biomarkers of postacute sequelae of SARS-CoV-2 infection (PASC).</p><p><strong>Objective: </strong>To investigate clinical laboratory markers of SARS-CoV-2 and PASC.</p><p><strong>Design: </strong>Propensity score-weighted linear regression models were fitted to evaluate differences in mean laboratory measures by prior infection and PASC index (≥12 vs. 0). (ClinicalTrials.gov: NCT05172024).</p><p><strong>Setting: </strong>83 enrolling sites.</p><p><strong>Participants: </strong>RECOVER-Adult cohort participants with or without SARS-CoV-2 infection with a study visit and laboratory measures 6 months after the index date (or at enrollment if >6 months after the index date). Participants were excluded if the 6-month visit occurred within 30 days of reinfection.</p><p><strong>Measurements: </strong>Participants completed questionnaires and standard clinical laboratory tests.</p><p><strong>Results: </strong>Among 10 094 participants, 8746 had prior SARS-CoV-2 infection, 1348 were uninfected, 1880 had a PASC index of 12 or higher, and 3351 had a PASC index of zero. After propensity score adjustment, participants with prior infection had a lower mean platelet count (265.9 × 10<sup>9</sup> cells/L [95% CI, 264.5 to 267.4 × 10<sup>9</sup> cells/L]) than participants without known prior infection (275.2 × 10<sup>9</sup> cells/L [CI, 268.5 to 282.0 × 10<sup>9</sup> cells/L]), as well as higher mean hemoglobin A<sub>1c</sub> (HbA<sub>1c</sub>) level (5.58% [CI, 5.56% to 5.60%] vs. 5.46% [CI, 5.40% to 5.51%]) and urinary albumin-creatinine ratio (81.9 mg/g [CI, 67.5 to 96.2 mg/g] vs. 43.0 mg/g [CI, 25.4 to 60.6 mg/g]), although differences were of modest clinical significance. The difference in HbA<sub>1c</sub> levels was attenuated after participants with preexisting diabetes were excluded. Among participants with prior infection, no meaningful differences in mean laboratory values were found between those with a PASC index of 12 or higher and those with a PASC index of zero.</p><p><strong>Limitation: </strong>Whether differences in laboratory markers represent consequences of or risk factors for SARS-CoV-2 infection could not be determined.</p><p><strong>Conclusion: </strong>Overall, no evidence was found that any of the 25 routine clinical laboratory values assessed in this study could serve as a clinically useful biomarker of PASC.</p><p><strong>Primary funding source: </strong>National Institutes of Health.</p>","PeriodicalId":7932,"journal":{"name":"Annals of Internal Medicine","volume":null,"pages":null},"PeriodicalIF":19.6,"publicationDate":"2024-08-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141970498","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Bruce Leff, Christine Ritchie, Sarah Szanton, Oren Shapira, Amanda Sutherland, Andrew Lynch, Brian W Powers, Mona Siddiqui, Katherine A Ornstein
Background: Interest in home-based care is increasing among Medicare Advantage (MA) plans. The epidemiology of homebound MA beneficiaries is unknown.
Objective: To determine the prevalence, characteristics, predictors, health service use, and mortality outcomes of homebound beneficiaries of a large national MA plan.
Design: Cross-sectional.
Setting: National MA plan.
Participants: Humana MA beneficiaries in 2022 (n = 2 435 519).
Measurements: Homebound status was assessed via in-home assessment using previously defined categories: homebound (never or rarely left home in the past month), semihomebound (left home with assistance, had difficulty, or needed help leaving home), and not homebound. Demographic, clinical, health service use, and mortality outcomes were compared by homebound status.
Results: In 2022, the overall prevalence of homebound beneficiaries was 22.0% (8.4% of beneficiaries were homebound, and 13.6% were semihomebound). In adjusted models, female sex (odds ratio [OR], 1.36 [95% CI, 1.35 to 1.37), low-income status or dual eligibility for Medicare and Medicaid (OR, 1.56 [CI, 1.55 to 1.57]), dementia (OR, 2.36 [CI, 2.33 to 2.39]), and moderate to severe frailty (OR, 4.32 [CI, 4.19 to 4.45]) were predictive of homebound status. In multivariable logistic regression, homebound status was associated with increased odds of any emergency department visit (OR, 1.14 [ CI, 1.14 to 1.15]), any inpatient hospital admission (OR, 1.44 [CI, 1.42 to 1.46]), any skilled-nursing facility admission (OR, 2.18 [CI, 2.13 to 2.23]), and death (OR, 2.55 [CI, 2.52 to 2.58]).
Limitation: The study period overlapped the tail end of the COVID-19 pandemic, and data were derived from a single national MA plan, which limits generalizability.
Conclusion: Overall homebound prevalence in a national MA plan was 22.0% and was independently associated with increased health service use and mortality. Study findings can inform strategic initiatives to identify and manage care for homebound beneficiaries.
Primary funding source: Humana, under a collaborative research agreement with Johns Hopkins University.
{"title":"Epidemiology of Homebound Population Among Beneficiaries of a Large National Medicare Advantage Plan.","authors":"Bruce Leff, Christine Ritchie, Sarah Szanton, Oren Shapira, Amanda Sutherland, Andrew Lynch, Brian W Powers, Mona Siddiqui, Katherine A Ornstein","doi":"10.7326/M24-0011","DOIUrl":"https://doi.org/10.7326/M24-0011","url":null,"abstract":"<p><strong>Background: </strong>Interest in home-based care is increasing among Medicare Advantage (MA) plans. The epidemiology of homebound MA beneficiaries is unknown.</p><p><strong>Objective: </strong>To determine the prevalence, characteristics, predictors, health service use, and mortality outcomes of homebound beneficiaries of a large national MA plan.</p><p><strong>Design: </strong>Cross-sectional.</p><p><strong>Setting: </strong>National MA plan.</p><p><strong>Participants: </strong>Humana MA beneficiaries in 2022 (<i>n</i> = 2 435 519).</p><p><strong>Measurements: </strong>Homebound status was assessed via in-home assessment using previously defined categories: homebound (never or rarely left home in the past month), semihomebound (left home with assistance, had difficulty, or needed help leaving home), and not homebound. Demographic, clinical, health service use, and mortality outcomes were compared by homebound status.</p><p><strong>Results: </strong>In 2022, the overall prevalence of homebound beneficiaries was 22.0% (8.4% of beneficiaries were homebound, and 13.6% were semihomebound). In adjusted models, female sex (odds ratio [OR], 1.36 [95% CI, 1.35 to 1.37), low-income status or dual eligibility for Medicare and Medicaid (OR, 1.56 [CI, 1.55 to 1.57]), dementia (OR, 2.36 [CI, 2.33 to 2.39]), and moderate to severe frailty (OR, 4.32 [CI, 4.19 to 4.45]) were predictive of homebound status. In multivariable logistic regression, homebound status was associated with increased odds of any emergency department visit (OR, 1.14 [ CI, 1.14 to 1.15]), any inpatient hospital admission (OR, 1.44 [CI, 1.42 to 1.46]), any skilled-nursing facility admission (OR, 2.18 [CI, 2.13 to 2.23]), and death (OR, 2.55 [CI, 2.52 to 2.58]).</p><p><strong>Limitation: </strong>The study period overlapped the tail end of the COVID-19 pandemic, and data were derived from a single national MA plan, which limits generalizability.</p><p><strong>Conclusion: </strong>Overall homebound prevalence in a national MA plan was 22.0% and was independently associated with increased health service use and mortality. Study findings can inform strategic initiatives to identify and manage care for homebound beneficiaries.</p><p><strong>Primary funding source: </strong>Humana, under a collaborative research agreement with Johns Hopkins University.</p>","PeriodicalId":7932,"journal":{"name":"Annals of Internal Medicine","volume":null,"pages":null},"PeriodicalIF":19.6,"publicationDate":"2024-08-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141970443","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Kratom: An Emerging Issue for Research and Physician Education.","authors":"Amanda L Collar, Eileen D Barrett","doi":"10.7326/ANNALS-24-00209","DOIUrl":"https://doi.org/10.7326/ANNALS-24-00209","url":null,"abstract":"","PeriodicalId":7932,"journal":{"name":"Annals of Internal Medicine","volume":null,"pages":null},"PeriodicalIF":19.6,"publicationDate":"2024-08-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141970446","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Barbara E Jones, Alec B Chapman, Jian Ying, Elizabeth D Rutter, McKenna R Nevers, Alden Baker, Nathan C Dean, Megan L Fix, Hardeep Singh, Karen S Cosby, Peter A Taber, Charlene D Weir, Makoto M Jones, Matthew H Samore, Jorie M Butler
Background: Evidence-based practice in community-acquired pneumonia often assumes an accurate initial diagnosis.
Objective: To examine the evolution of pneumonia diagnoses among patients hospitalized from the emergency department (ED).
Design: Retrospective nationwide cohort.
Setting: 118 U.S. Veterans Affairs medical centers.
Patients: Aged 18 years or older and hospitalized from the ED between 1 January 2015 and 31 January 2022.
Measurements: Discordances between initial pneumonia diagnosis, discharge diagnosis, and radiographic diagnosis identified by natural language processing of clinician text, diagnostic coding, and antimicrobial treatment. Expressions of uncertainty in clinical notes, patient illness severity, treatments, and outcomes were compared.
Results: Among 2 383 899 hospitalizations, 13.3% received an initial or discharge diagnosis and treatment of pneumonia: 9.1% received an initial diagnosis and 10.0% received a discharge diagnosis. Discordances between initial and discharge occurred in 57%. Among patients discharged with a pneumonia diagnosis and positive initial chest image, 33% lacked an initial diagnosis. Among patients diagnosed initially, 36% lacked a discharge diagnosis and 21% lacked positive initial chest imaging. Uncertainty was frequently expressed in clinical notes (58% in ED; 48% at discharge); 27% received diuretics, 36% received corticosteroids, and 10% received antibiotics, corticosteroids, and diuretics within 24 hours. Patients with discordant diagnoses had greater uncertainty and received more additional treatments, but only patients lacking an initial pneumonia diagnosis had higher 30-day mortality than concordant patients (14.4% [95% CI, 14.1% to 14.7%] vs. 10.6% [CI, 10.4% to 10.7%]). Patients with diagnostic discordance were more likely to present to high-complexity facilities with high ED patient load and inpatient census.
Limitation: Retrospective analysis; did not examine causal relationships.
Conclusion: More than half of all patients hospitalized and treated for pneumonia had discordant diagnoses from initial presentation to discharge. Treatments for other diagnoses and expressions of uncertainty were common. These findings highlight the need to recognize diagnostic uncertainty and treatment ambiguity in research and practice of pneumonia-related care.
Primary funding source: The Gordon and Betty Moore Foundation.
{"title":"Diagnostic Discordance, Uncertainty, and Treatment Ambiguity in Community-Acquired Pneumonia : A National Cohort Study of 115 U.S. Veterans Affairs Hospitals.","authors":"Barbara E Jones, Alec B Chapman, Jian Ying, Elizabeth D Rutter, McKenna R Nevers, Alden Baker, Nathan C Dean, Megan L Fix, Hardeep Singh, Karen S Cosby, Peter A Taber, Charlene D Weir, Makoto M Jones, Matthew H Samore, Jorie M Butler","doi":"10.7326/M23-2505","DOIUrl":"https://doi.org/10.7326/M23-2505","url":null,"abstract":"<p><strong>Background: </strong>Evidence-based practice in community-acquired pneumonia often assumes an accurate initial diagnosis.</p><p><strong>Objective: </strong>To examine the evolution of pneumonia diagnoses among patients hospitalized from the emergency department (ED).</p><p><strong>Design: </strong>Retrospective nationwide cohort.</p><p><strong>Setting: </strong>118 U.S. Veterans Affairs medical centers.</p><p><strong>Patients: </strong>Aged 18 years or older and hospitalized from the ED between 1 January 2015 and 31 January 2022.</p><p><strong>Measurements: </strong>Discordances between initial pneumonia diagnosis, discharge diagnosis, and radiographic diagnosis identified by natural language processing of clinician text, diagnostic coding, and antimicrobial treatment. Expressions of uncertainty in clinical notes, patient illness severity, treatments, and outcomes were compared.</p><p><strong>Results: </strong>Among 2 383 899 hospitalizations, 13.3% received an initial or discharge diagnosis and treatment of pneumonia: 9.1% received an initial diagnosis and 10.0% received a discharge diagnosis. Discordances between initial and discharge occurred in 57%. Among patients discharged with a pneumonia diagnosis and positive initial chest image, 33% lacked an initial diagnosis. Among patients diagnosed initially, 36% lacked a discharge diagnosis and 21% lacked positive initial chest imaging. Uncertainty was frequently expressed in clinical notes (58% in ED; 48% at discharge); 27% received diuretics, 36% received corticosteroids, and 10% received antibiotics, corticosteroids, and diuretics within 24 hours. Patients with discordant diagnoses had greater uncertainty and received more additional treatments, but only patients lacking an initial pneumonia diagnosis had higher 30-day mortality than concordant patients (14.4% [95% CI, 14.1% to 14.7%] vs. 10.6% [CI, 10.4% to 10.7%]). Patients with diagnostic discordance were more likely to present to high-complexity facilities with high ED patient load and inpatient census.</p><p><strong>Limitation: </strong>Retrospective analysis; did not examine causal relationships.</p><p><strong>Conclusion: </strong>More than half of all patients hospitalized and treated for pneumonia had discordant diagnoses from initial presentation to discharge. Treatments for other diagnoses and expressions of uncertainty were common. These findings highlight the need to recognize diagnostic uncertainty and treatment ambiguity in research and practice of pneumonia-related care.</p><p><strong>Primary funding source: </strong>The Gordon and Betty Moore Foundation.</p>","PeriodicalId":7932,"journal":{"name":"Annals of Internal Medicine","volume":null,"pages":null},"PeriodicalIF":19.6,"publicationDate":"2024-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141892671","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Inaccuracy of Pneumonia Diagnosis: The More Things Change, the More They Stay the Same.","authors":"Mark L Metersky, Grant W Waterer","doi":"10.7326/M24-0889","DOIUrl":"https://doi.org/10.7326/M24-0889","url":null,"abstract":"","PeriodicalId":7932,"journal":{"name":"Annals of Internal Medicine","volume":null,"pages":null},"PeriodicalIF":19.6,"publicationDate":"2024-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141892679","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Michael T Halpern, Benmei Liu, Douglas R Lowy, Samir Gupta, Jennifer M Croswell, V Paul Doria-Rose
Background: Cancer has substantial health, quality-of-life, and economic impacts. Screening may decrease cancer mortality and treatment costs, but the cost of screening in the United States is unknown.
Objective: To estimate the annual cost of initial cancer screening (that is, screening without follow-up costs) in the United States in 2021.
Design: Model using national health care survey and cost resources data.
Setting: U.S. health care systems and institutions.
Participants: People eligible for breast, cervical, colorectal, lung, and prostate cancer screening with available data.
Measurements: The number of people screened and associated health care system costs by insurance status in 2021 dollars.
Results: Total health care system costs for initial cancer screenings in the United States in 2021 were estimated at $43 billion. Approximately 88.3% of costs were attributable to private insurance; 8.5% to Medicare; and 3.2% to Medicaid, other government programs, and uninsured persons. Screening for colorectal cancer represented approximately 64% of the total cost; screening colonoscopy represented about 55% of the total. Facility costs (amounts paid to facilities where testing occurred) were major drivers of the total estimated costs of screening.
Limitations: All data on receipt of cancer screening are based on self-report from national health care surveys. Estimates do not include costs of follow-up for positive or abnormal screening results. Variations in costs based on geography and provider or health care organization are not fully captured.
Conclusion: The $43 billion estimated annual cost for initial cancer screening in the United States in 2021 is less than the reported annual cost of cancer treatment in the United States in the first 12 months after diagnosis. Identification of cancer screening costs and their drivers is critical to help inform policy and develop programmatic priorities, particularly for enhancing access to recommended cancer screening services.
{"title":"The Annual Cost of Cancer Screening in the United States.","authors":"Michael T Halpern, Benmei Liu, Douglas R Lowy, Samir Gupta, Jennifer M Croswell, V Paul Doria-Rose","doi":"10.7326/M24-0375","DOIUrl":"https://doi.org/10.7326/M24-0375","url":null,"abstract":"<p><strong>Background: </strong>Cancer has substantial health, quality-of-life, and economic impacts. Screening may decrease cancer mortality and treatment costs, but the cost of screening in the United States is unknown.</p><p><strong>Objective: </strong>To estimate the annual cost of initial cancer screening (that is, screening without follow-up costs) in the United States in 2021.</p><p><strong>Design: </strong>Model using national health care survey and cost resources data.</p><p><strong>Setting: </strong>U.S. health care systems and institutions.</p><p><strong>Participants: </strong>People eligible for breast, cervical, colorectal, lung, and prostate cancer screening with available data.</p><p><strong>Measurements: </strong>The number of people screened and associated health care system costs by insurance status in 2021 dollars.</p><p><strong>Results: </strong>Total health care system costs for initial cancer screenings in the United States in 2021 were estimated at $43 billion. Approximately 88.3% of costs were attributable to private insurance; 8.5% to Medicare; and 3.2% to Medicaid, other government programs, and uninsured persons. Screening for colorectal cancer represented approximately 64% of the total cost; screening colonoscopy represented about 55% of the total. Facility costs (amounts paid to facilities where testing occurred) were major drivers of the total estimated costs of screening.</p><p><strong>Limitations: </strong>All data on receipt of cancer screening are based on self-report from national health care surveys. Estimates do not include costs of follow-up for positive or abnormal screening results. Variations in costs based on geography and provider or health care organization are not fully captured.</p><p><strong>Conclusion: </strong>The $43 billion estimated annual cost for initial cancer screening in the United States in 2021 is less than the reported annual cost of cancer treatment in the United States in the first 12 months after diagnosis. Identification of cancer screening costs and their drivers is critical to help inform policy and develop programmatic priorities, particularly for enhancing access to recommended cancer screening services.</p><p><strong>Primary funding source: </strong>None.</p>","PeriodicalId":7932,"journal":{"name":"Annals of Internal Medicine","volume":null,"pages":null},"PeriodicalIF":19.6,"publicationDate":"2024-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141892681","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Duco T Mülder, James F O'Mahony, Chyke A Doubeni, Iris Lansdorp-Vogelaar, Maartje H N Schermer
Racial and ethnic disparities in incidence and mortality are well documented for many types of cancer. As a result, there is understandable policy and clinical interest in race- and ethnicity-based clinical screening guidelines to address cancer health disparities. Despite the theoretical benefits, such proposals do not typically address associated ethical considerations. Using the examples of gastric cancer and esophageal adenocarcinoma, which have demonstrated disparities according to race and ethnicity, this article examines relevant ethical arguments in considering screening based on race and ethnicity.
Race- and ethnicity-based clinical preventive care services have the potential to improve the balance of harms and benefits of screening. As a result, programs focused on high-risk racial or ethnic groups could offer a practical alternative to screening the general population, in which the screening yield may be too low to demonstrate sufficient effectiveness. However, designing screening according to socially based categorizations such as race or ethnicity is controversial and has the potential for intersectional stigma related to social identity or other structurally mediated environmental factors. Other ethical considerations include miscategorization, unintended negative effects on health disparities, disregard for underlying risk factors, and the psychological costs of being assigned higher risk.
Given the ethical considerations, the practical application of race and ethnicity in cancer screening is most relevant in multicultural countries if and only if alternative proxies are not available. Even in those instances, policymakers and clinicians should carefully address the ethical considerations within the historical and cultural context of the intended population. Further research on alternative proxies, such as social determinants of health and culturally based characteristics, could provide more adequate factors for risk stratification.
{"title":"The Ethics of Cancer Screening Based on Race and Ethnicity.","authors":"Duco T Mülder, James F O'Mahony, Chyke A Doubeni, Iris Lansdorp-Vogelaar, Maartje H N Schermer","doi":"10.7326/M24-0377","DOIUrl":"https://doi.org/10.7326/M24-0377","url":null,"abstract":"<p><p>Racial and ethnic disparities in incidence and mortality are well documented for many types of cancer. As a result, there is understandable policy and clinical interest in race- and ethnicity-based clinical screening guidelines to address cancer health disparities. Despite the theoretical benefits, such proposals do not typically address associated ethical considerations. Using the examples of gastric cancer and esophageal adenocarcinoma, which have demonstrated disparities according to race and ethnicity, this article examines relevant ethical arguments in considering screening based on race and ethnicity.</p><p><p>Race- and ethnicity-based clinical preventive care services have the potential to improve the balance of harms and benefits of screening. As a result, programs focused on high-risk racial or ethnic groups could offer a practical alternative to screening the general population, in which the screening yield may be too low to demonstrate sufficient effectiveness. However, designing screening according to socially based categorizations such as race or ethnicity is controversial and has the potential for intersectional stigma related to social identity or other structurally mediated environmental factors. Other ethical considerations include miscategorization, unintended negative effects on health disparities, disregard for underlying risk factors, and the psychological costs of being assigned higher risk.</p><p><p>Given the ethical considerations, the practical application of race and ethnicity in cancer screening is most relevant in multicultural countries if and only if alternative proxies are not available. Even in those instances, policymakers and clinicians should carefully address the ethical considerations within the historical and cultural context of the intended population. Further research on alternative proxies, such as social determinants of health and culturally based characteristics, could provide more adequate factors for risk stratification.</p>","PeriodicalId":7932,"journal":{"name":"Annals of Internal Medicine","volume":null,"pages":null},"PeriodicalIF":19.6,"publicationDate":"2024-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141892682","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Dollars and Sense: The Cost of Cancer Screening in the United States.","authors":"H Gilbert Welch","doi":"10.7326/M24-0887","DOIUrl":"https://doi.org/10.7326/M24-0887","url":null,"abstract":"","PeriodicalId":7932,"journal":{"name":"Annals of Internal Medicine","volume":null,"pages":null},"PeriodicalIF":19.6,"publicationDate":"2024-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141892672","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Timothy S Anderson, Robert W Yeh, Shoshana J Herzig, Edward R Marcantonio, Laura A Hatfield, Jeffrey Souza, Bruce E Landon
Background: Timely follow-up after cardiovascular hospitalization is recommended to monitor recovery, titrate medications, and coordinate care.
Objective: To describe trends and disparities in follow-up after acute myocardial infarction (AMI) and heart failure (HF) hospitalizations.
Design: Retrospective cohort study.
Setting: Medicare.
Participants: Medicare fee-for-service beneficiaries hospitalized between 2010 and 2019.
Measurements: Receipt of a cardiology visit within 30 days of discharge. Multivariable logistic regression models were used to estimate changes over time overall and across 5 sociodemographic characteristics on the basis of known disparities in cardiovascular outcomes.
Results: The cohort included 1 678 088 AMI and 4 245 665 HF hospitalizations. Between 2010 and 2019, the rate of cardiology follow-up increased from 48.3% to 61.4% for AMI hospitalizations and from 35.2% to 48.3% for HF hospitalizations. For both conditions, follow-up rates increased for all subgroups, yet disparities worsened for Hispanic patients with AMI and patients with HF who were Asian, Black, Hispanic, Medicaid dual eligible, and residents of counties with higher levels of social deprivation. By 2019, the largest disparities were between Black and White patients (AMI, 51.9% vs. 59.8%, difference, 7.9 percentage points [pp] [95% CI, 6.8 to 9.0 pp]; HF, 39.8% vs. 48.7%, difference, 8.9 pp [CI, 8.2 to 9.7 pp]) and Medicaid dual-eligible and non-dual-eligible patients (AMI, 52.8% vs. 60.4%, difference, 7.6 pp [CI, 6.9 to 8.4 pp]; HF, 39.7% vs. 49.4%, difference, 9.6 pp [CI, 9.2 to 10.1 pp]). Differences between hospitals explained 7.3 pp [CI, 6.7 to 7.9 pp] of the variation in follow-up for AMI and 7.7 pp [CI, 7.2 to 8.1 pp]) for HF.
Limitation: Generalizability to other payers.
Conclusion: Equity-informed policy and health system strategies are needed to further reduce gaps in follow-up care for patients with AMI and patients with HF.
Primary funding source: National Institute on Aging.
{"title":"Trends and Disparities in Ambulatory Follow-Up After Cardiovascular Hospitalizations : A Retrospective Cohort Study.","authors":"Timothy S Anderson, Robert W Yeh, Shoshana J Herzig, Edward R Marcantonio, Laura A Hatfield, Jeffrey Souza, Bruce E Landon","doi":"10.7326/M23-3475","DOIUrl":"https://doi.org/10.7326/M23-3475","url":null,"abstract":"<p><strong>Background: </strong>Timely follow-up after cardiovascular hospitalization is recommended to monitor recovery, titrate medications, and coordinate care.</p><p><strong>Objective: </strong>To describe trends and disparities in follow-up after acute myocardial infarction (AMI) and heart failure (HF) hospitalizations.</p><p><strong>Design: </strong>Retrospective cohort study.</p><p><strong>Setting: </strong>Medicare.</p><p><strong>Participants: </strong>Medicare fee-for-service beneficiaries hospitalized between 2010 and 2019.</p><p><strong>Measurements: </strong>Receipt of a cardiology visit within 30 days of discharge. Multivariable logistic regression models were used to estimate changes over time overall and across 5 sociodemographic characteristics on the basis of known disparities in cardiovascular outcomes.</p><p><strong>Results: </strong>The cohort included 1 678 088 AMI and 4 245 665 HF hospitalizations. Between 2010 and 2019, the rate of cardiology follow-up increased from 48.3% to 61.4% for AMI hospitalizations and from 35.2% to 48.3% for HF hospitalizations. For both conditions, follow-up rates increased for all subgroups, yet disparities worsened for Hispanic patients with AMI and patients with HF who were Asian, Black, Hispanic, Medicaid dual eligible, and residents of counties with higher levels of social deprivation. By 2019, the largest disparities were between Black and White patients (AMI, 51.9% vs. 59.8%, difference, 7.9 percentage points [pp] [95% CI, 6.8 to 9.0 pp]; HF, 39.8% vs. 48.7%, difference, 8.9 pp [CI, 8.2 to 9.7 pp]) and Medicaid dual-eligible and non-dual-eligible patients (AMI, 52.8% vs. 60.4%, difference, 7.6 pp [CI, 6.9 to 8.4 pp]; HF, 39.7% vs. 49.4%, difference, 9.6 pp [CI, 9.2 to 10.1 pp]). Differences between hospitals explained 7.3 pp [CI, 6.7 to 7.9 pp] of the variation in follow-up for AMI and 7.7 pp [CI, 7.2 to 8.1 pp]) for HF.</p><p><strong>Limitation: </strong>Generalizability to other payers.</p><p><strong>Conclusion: </strong>Equity-informed policy and health system strategies are needed to further reduce gaps in follow-up care for patients with AMI and patients with HF.</p><p><strong>Primary funding source: </strong>National Institute on Aging.</p>","PeriodicalId":7932,"journal":{"name":"Annals of Internal Medicine","volume":null,"pages":null},"PeriodicalIF":19.6,"publicationDate":"2024-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141892683","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-01Epub Date: 2024-06-04DOI: 10.7326/M23-2735
Scott E Lentz, Anna Ranta, Mario Domenichini, Eugenio Fusco, Francesco Padula
The centennial anniversary of Hans Hinselmann's initial publication describing colposcopy is approaching. In the 100 years since the inventor's seminal paper, colposcopy has become indispensable in the diagnosis and management of cervical cancer. It remains central in diagnosing precancerous and cancerous cervical lesions and has dramatically reduced cervical cancer incidence and mortality since the mid-20th century.
Previous descriptions of colposcopy's development in medical literature obscure the dark history of its earliest days, arising within the center of German Nazism. The pioneers of colposcopy benefited from the Nazi government's public health focus and exploited the environment fostered by the Nazi medical establishment. They made use of the apparatus of the Auschwitz concentration camp to position colposcopy for expanded postwar adoption, ultimately accomplishing Hinselmann's stated goal that colposcopy become a routine part of gynecologic examination and care. This historical exposition clarifies the Nazi past of colposcopy, highlights the important role that unethical treatment of victims of Auschwitz played in cementing this procedure within standard cervical cancer screening programs globally, and offers steps to reckon with this tragic legacy.
{"title":"One Hundred Years of Colposcopy: Reconciling Its Auschwitz Past.","authors":"Scott E Lentz, Anna Ranta, Mario Domenichini, Eugenio Fusco, Francesco Padula","doi":"10.7326/M23-2735","DOIUrl":"10.7326/M23-2735","url":null,"abstract":"<p><p>The centennial anniversary of Hans Hinselmann's initial publication describing colposcopy is approaching. In the 100 years since the inventor's seminal paper, colposcopy has become indispensable in the diagnosis and management of cervical cancer. It remains central in diagnosing precancerous and cancerous cervical lesions and has dramatically reduced cervical cancer incidence and mortality since the mid-20th century.</p><p><p>Previous descriptions of colposcopy's development in medical literature obscure the dark history of its earliest days, arising within the center of German Nazism. The pioneers of colposcopy benefited from the Nazi government's public health focus and exploited the environment fostered by the Nazi medical establishment. They made use of the apparatus of the Auschwitz concentration camp to position colposcopy for expanded postwar adoption, ultimately accomplishing Hinselmann's stated goal that colposcopy become a routine part of gynecologic examination and care. This historical exposition clarifies the Nazi past of colposcopy, highlights the important role that unethical treatment of victims of Auschwitz played in cementing this procedure within standard cervical cancer screening programs globally, and offers steps to reckon with this tragic legacy.</p>","PeriodicalId":7932,"journal":{"name":"Annals of Internal Medicine","volume":null,"pages":null},"PeriodicalIF":19.6,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141236586","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}