Sexually transmitted infection laboratory testing and education trends in US outpatient physician offices, 2009–2016

ObjectiveTo describe national rates of sexually transmitted infection (STI) testing and education overall and among patient subgroups in US outpatient physician offices from 2009 to 2016.DesignThis was a cross-sectional study of the Centers for Disease Control and Prevention’s National Ambulatory Medical Care Survey from 2009 to 2016. Data weights were applied to extrapolate to national estimates.SettingData were collected from a systematic random sample of outpatient physician office visits throughout USA. Physician office types include free standing clinics, private or group setting practices, centres offering community and mental health services, family planning clinics and health maintenance organisations/other prepaid clinics.ParticipantsAll sampled patient visits were eligible for inclusion and were assessed for the provision of STI prevention education and STI testing for chlamydia, gonorrhoea, hepatitis, human papillomavirus (HPV) and HIV.ResultsOf 7.6 billion total visits, 123 million included an STI test. Hepatitis was the most commonly tested STI (9.12 per 1000), followed by chlamydia (6.67 per 1000), gonorrhoea (6.00 per 1000), HIV (5.40 per 1000) and HPV (5.03 per 1000). Testing rates for the three STIs measured for the entire 8-year period increased over time and peaked in 2015 compared with 2009: chlamydia (R2=0.36), HPV (R2=0.28) and HIV (R2=0.51). Testing was highest among women (21.93 per 1000), 15–24-year olds (46.04 per 1000), non-Hispanic blacks (37.33 per 1000) and those seen by obstetrics/gynaecology specialists (103.75 per 1000). STI prevention education was provided to 4.89 per 1000 patients and remained relatively unchanged from 2013 to 2016.ConclusionSTI testing in outpatient physician offices increased over the study period but varied by patient characteristics and site of care. Few patients received STI prevention education, highlighting a potential gap in resource utilisation in these settings.

Healthcare utilization and costs associated with cancer-related diarrhea.

e18623 Background: Diarrhea is a common toxicity of cancer treatments, including radiotherapy, chemotherapy, and/or targeted therapies. Cancer-related diarrhea (CRD) leads to increased healthcare utilization and cost. This study evaluated the all-cause and CRD-specific healthcare utilization and cost of patients with CRD compared to a matched non-CRD cohort. Methods: We conducted a longitudinal observational study among adult patients ( > 18 years) with CRD using diagnosis codes or pharmacy claims compared to matched non-CRD patients using claims data from the IQVIA PharMetrics Plus database (October 2015 to March 2020). The index date was the date of the first cancer claim, and we re-indexed patients based on their CRD claim. Each patient had a 6-month pre-index period and a minimum 3-month post-index period. Patients were also required to have ≥12 months of continuous enrollment following the CRD index date. We directly matched patients 1:1 from the CRD cohort to the non-CRD cohort to adjust for selection bias and baseline differences. Our aim was to compare all-cause healthcare costs over a fixed 12-month post-index period, converting all costs to 2020 USD using the Consumer Price Index's medical component. We analyzed healthcare utilization for CRD-treated, CRD-inadequately treated, and CRD-untreated sub-cohorts (per Buono et al., J Econ 2017). Secondary endpoints included healthcare cost (proportion of patients, per-patient mean and median) and healthcare utilization (prescription fills and visits to the emergency department [ED], physician office, lab/pathology and outpatient ancillary services). We built one generalized estimating equation model with log link and gamma distribution adjusted for type of cancer, therapy and Charlson Comorbidity Index (CCI) to estimate the difference in total healthcare cost between CRD and non-CRD cohorts. Results: We evaluated a total of 104,135 matched pairs of CRD and non-CRD adult patients with solid or hematologic cancer receiving either targeted or chemotherapy, with 12-month continuous enrollment. Patients with CRD incurred significantly higher mean ($104,880 vs $39,664, p < 0.0001) and median ($59,969 vs $8,914, p < 0.0001) all-cause healthcare cost compared to patients without CRD over the 12-month post-index period. Inadequately treated CRD patients had the mean highest cost ($129,531) vs adequately CRD-treated ($107,050) or untreated CRD patients ($56,350) (all p < 0.0001). Mean pharmacy cost for CRD and non-CRD patients were ($35,190 vs $15,883); visits to the ED ($1,107 vs $431), physician office ($3,457 vs $2,058), lab/pathology ($4,074 vs $1,404), and outpatient ancillary services ($15,805 vs $4,940) (all p-values < 0.0001). Conclusions: Our findings show that patients with CRD had nearly 2.9 times higher all-cause total cost than patients without CRD after adjusting for covariates. Prevention of CRD may result in a significant reduction in cancer-treatment cost.

Characteristics of Office-based Physician Visits, 2018

Examines physician office visit rates by age and sex and visit characteristics, including insurance status, reason for visit, and services.

Use of bone modifying agents in patients with metastatic castrate-sensitive prostate cancer.

68 Background: Bone modifying agents (BMAs) do not prevent skeletal related events (SREs) among patients with metastatic, castration-sensitive prostate cancer (mCSPC). Within this population, BMAs are recommended for prevention of osteoporotic fractures but not for SRE prevention. Utilization patterns of BMAs among patients with mCSPC have not been described, and it is unknown whether these patients may receive BMAs intended for SRE prevention unnecessarily. We conducted this study to measure BMA use among mCSPC patients who are unlikely to have an indication for osteoporotic fracture prevention. Methods: We used linked SEER-Medicare data. Our cohort included men newly diagnosed with de-novo stage IV prostate adenocarcinoma during 2007-2015. We included those age > = 66 at diagnosis, who lived at least 60 days after diagnosis, had continuous enrollment in Medicare Parts A and B from 180 days prior to diagnosis through the outcome period and Part D from diagnosis through outcome period, and who received androgen deprivation or antiandrogen therapy after diagnosis. We excluded patients who had previously received BMAs, or who had existing osteoporosis, osteopenia, hypercalcemia, or prior bone fracture. Our primary outcome was receipt of a BMA (zoledronic acid or denosumab) within 180 days of prostate cancer diagnosis, during which time the development of castrate-resistant disease is unlikely to arise. We also assessed receipt of BMAs within 90 days of diagnosis as a secondary outcome. We used multivariable logistic regression to assess patient factors associated with BMA use. Results: Our sample included 2,998 patients. Median age at diagnosis was 77. 77% of patients were white, 12% were Black, and 11% were of other race/ethnicity. 77% of patients were treated in the physician office setting and 23% the hospital outpatient setting. Overall, 24% received a BMA within 180 days of diagnosis; 18% did within 90 days. BMA therapy was more common among patients treated in the hospital outpatient vs. physician office setting (OR 1.25, 95%CI 1.03-1.52). Age, race/ethnicity, comorbidity, and renal disease were not associated with likelihood of BMA therapy. There was substantial variation across the study period: 19% of patients received BMAs from 2007-2009 (19% zoledronic acid, 0% denosumab), and 29% from 2012-2015 (9% zoledronic acid, 21% denosumab). Conclusions: Use of BMAs among patients with mCSPC is common. In this cohort of mCSPC patients, who were unlikely to have a BMA indication for osteoporotic fracture prevention based on the absence of history of osteoporosis, osteopenia, or fracture, nearly one-quarter received BMAs. The increase in BMA use which occurred during the 2007-2015 study period appears to have been driven by increased utilization of denosumab following its approval in 2010. Use of BMAs in patients with mCSPC without a need for osteoporotic fracture prevention may constitute overuse.

29. Impact of Enhanced Influenza Vaccines on Direct Healthcare Costs for the U.S. Elderly: A Comprehensive Real-World Evaluation of Adjuvanted Trivalent Influenza Vaccine Compared to Trivalent High-Dose Influenza Vaccine for the 2018–19 Influenza Season

Background Influenza generates a substantial economic burden ($3.2B in the U.S. annually) due to direct medical costs such as physician office visits or hospitalizations, especially among the elderly. Recent published literature for the 2018–19 influenza season has demonstrated similar clinical effectiveness between adjuvanted trivalent influenza vaccine (aTIV) and trivalent high dose influenza vaccine (TIV-HD). This research aimed to assess the annualized mean all-cause and influenza-related healthcare costs among subjects 65+ years vaccinated with aTIV or TIV-HD during the 2018–19 influenza season. Methods A retrospective cohort analysis was conducted using professional fee, prescription claims and hospital charge master data in the U.S. Baseline characteristics included age, gender, payer type, region, Charlson Comorbidity Index, comorbidities, indicators of frail health status, and pre-index hospitalization rates. Treatment selection bias was adjusted through 1:1 propensity score matching (PSM). Economic outcomes included annualized mean all-cause costs and influenza-related costs, which comprised influenza-related hospitalizations, emergency room (ER) visits, and physician office visits costs. Mean costs were compared using paired t-test. Adjusted analyses were conducted using generalized estimating equation (GEE) models, with two-part models for influenza-related costs. With the GEEs, adjustment for outliers (99th percentile) were addressed and predicted healthcare costs were obtained through bootstrapping (500 replications). Results During the 2018–19 influenza season, the PSM sample comprised 561,243 recipients of aTIV and 561,243 recipients of TIV-HD. Following GEE adjustment, predicted mean annualized all-cause and influenza-related costs per patient were statistically similar between aTIV and TIV-HD (US$9,676 vs. US$9,625 and US$23.75 vs. US$21.79, respectively). Both aTIV and TIV-HD were comparable in terms of predicted mean annualized costs for influenza-related hospitalizations (US$20.28 vs. US$18.13) and influenza-related office visits (US$1.29 vs. US$1.34). Conclusion In adjusted analyses, total all-cause and influenza-related healthcare costs were comparable among elderly subjects vaccinated with either aTIV or TIV-HD. Disclosures Maarten Postma, Dr., IQVIA (Consultant) Stephen I. Pelton, MD, Merck vaccine (Consultant, Grant/Research Support)Pfizer (Consultant, Grant/Research Support)Sanofi Pasteur (Consultant, Other Financial or Material Support, DSMB)Seqirus Vaccine Ltd. (Consultant) Victoria Divino, PhD, Seiqrus Vaccines Ltd. (Consultant) Joaquin F. Mould-Quevedo, PhD, Seqirus Vaccines Ltd. (Employee, Shareholder) Drishti Shah, PhD, Seqirus Vaccines Ltd. (Consultant) Mitchell DeKoven, PhD, Seqirus Vaccines Ltd. (Consultant) Girishanthy Krishnarajah, PhD, Seqirus Vaccines Ltd. (Employee, Shareholder)

Collaborative practice trends in US physician office visits: an analysis of the National Ambulatory Medical Care Survey (NAMCS), 2007–2016

ObjectivePractice arrangements in physician offices were characterised by examining the share of visits that involved physician assistants (PAs) and nurse practitioners (NPs). The hypothesis was that collaborative practice (ie, care delivered by a dyad of physician-PA and/or physician-NP) was increasing.DesignTemporal ecological study.SettingNon-federal physician offices.ParticipantsPatient visits to a physician, PA or NP, spanning years 2007–2016.MethodsA stratified random sample of visits to office-based physicians was pooled through the National Ambulatory Medical Care Survey public use linkage file. Among 317 674 visits to physicians, PAs or NPs, solo and collaborative practices were described and compared over two timespans of 2007–2011 and 2012–2016. Weighted patient visits were aggregated in bivariate analyses to achieve nationally representative estimates. Survey statistics assessed patient demographic characteristics, reason for visit and visit specialty by provider type.ResultsWithin years 2007–2011 and 2012–2016, there were 4.4 billion and 4.1 billion physician office visits (POVs), respectively. Comparing the two timespans, the rate of POVs with a solo PA (0.43% vs 0.21%) or NP (0.31% vs 0.17%) decreased. Rate of POVs with a collaborative physician-PA increased non-significantly. Rate of POVs with a collaborative physician-NP (0.49% vs 0.97%, p<0.01) increased. Overall, collaborative practice, in particular physician-NP, has increased in recent years (p<0.01), while visits handled by a solo PA or NP decreased (p<0.01). In models adjusted for patient age and chronic conditions, the odds of collaborative practice in years 2012–2016 compared with years 2007–2011 was 35% higher (95% CI 1.01 to 1.79). Furthermore, in 2012–2016, NPs provided more independent primary care, and PAs provided more independent care in a non-primary care medical specialty. Preventive visits declined among all providers.ConclusionsIn non-federal physician offices, collaborative care with a physician-PA or physician-NP appears to be a growing part of office-based healthcare delivery.

Just the Facts: how to teach emergency department flow management

Even before starting your evening shift you know it's going to be busy. Ambulances are lined up in front of the hospital, and the charge nurse already seems stressed out. The senior Emergency Medicine (EM) resident is standing in the physician office, ready to start her shift as well. You have worked with her a few times during this rotation. She is competent, you trust in her management plans for all her individual patients. Together you both review the patient tracker: a variety of patient presentations ready to be seen, plus an additional 20 patients in the waiting room. Negotiating the learning objective for the shift, the resident indicates that she would like to work on more efficiently managing patient flow and the administration of the emergency department (ED). But…isn't that a skill you just learn from experience? You wonder what evidence-informed strategies might exist for training her for this next step.

Physician Specialty and Office Visits Made by Adults With Diagnosed Multiple Chronic Conditions: United States, 2014-2015

Objectives Adults with multiple chronic conditions (MCCs; ≥2 chronic conditions) account for a substantial number of visits to health care providers. The complexity of a patient’s care, including the number of chronic conditions, may differ by physician specialty. The objectives of this study were to (1) examine differences in physician office visits among adults with MCCs by physician specialty and (2) identify the types of MCC dyads (combinations of 2 chronic conditions) most common among visits to office-based physicians. Methods We used data from the 2014-2015 National Ambulatory Medical Care Survey (unweighted analytic sample, n = 61 682), a nationally representative survey of physician office–based ambulatory visits, to examine differences in physician office visits among adults with MCCs by physician specialty. We also identified the most commonly observed MCC dyads among these visits. Results During 2014-2015, 40.0% of physician office visits were made by adults with MCCs. Compared with visits for all specialties combined (40.0%), a significantly higher percentage of physician office visits among adults with MCCs were to specialists in cardiovascular disease (74.7%) and internal medicine (57.6%). For all physician specialties except psychiatry, the MCC dyads of hyperlipidemia and hypertension and diabetes and hypertension were among the most commonly observed MCC dyads among visits made by adults with MCCs. Conclusions Awareness of these findings may help specialists improve care for adults with MCCs. The recognition among physicians of common MCC dyads is relevant to the care management of persons with MCCs.