To assess the national prevalence and cost of inappropriate MRI in patients with wrist pain prior to and following American College of Radiology (ACR) guideline publication.
We used administrative claims from the IBM MarketScan Research Databases to evaluate the appropriateness of wrist MRI in a national cohort of patients with commercial insurance or Medicare Advantage.
Adult patients with a diagnosis of wrist pain between 2016 and 2019 were included and followed for 1 year. We made assessments of appropriateness based on ACR guidelines for specific wrist pain etiologies. We tabulated the total costs and out-of-pocket expenses associated with inappropriate MRI studies using weighted mean payments for facility and professional fees. We performed segmented logistic regression on interrupted time series data to identify predictors of receiving inappropriate imaging and the impact of guideline publication on MRI use.
The study cohort consisted of 867,119 individuals. Of these, 40,164 individuals (4.6%) had MRI, of whom 52.6% received an inappropriate study. Inappropriate studies accounted for $44,493,234 in total payments and $8,307,540 in out-of-pocket expenses. The interrupted time series found an approximately 1% monthly decrease in the odds of receiving an inappropriate study after guideline dissemination.
MRI as a diagnostic tool for wrist pain is often inappropriate and expensive. Our findings support interventions to increase guideline adherence, such as integrated clinical decision support tools.

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BACKGROUND: Obesity is increasing. Previous studies have demonstrated an association between obesity and adverse events after lumbar fusion. There is limited evidence on the effect of obesity on minimally invasive SI joint fusion (SIJF) outcomes.
OBJECTIVE: The purpose of this study was to investigate the impact of obesity on patient-reported outcomes in patients undergoing SIJF surgery using triangular titanium implants (TTI).
METHODS: Retrospective cohort study based on four prospective clinical trials (INSITE [NCT01681004], SIFI [NCT01640353], iMIA [NCT01741025], and SALLY [NCT03122899]).
METHODS: Adult patients ≥18 years of age who underwent minimally invasive surgery (MIS) sacroiliac joint (SIJ) fusion between 2012 and 2021.
METHODS: Visual analog scale (VAS Pain), Oswestry Disability Index (ODI).
METHODS: Participants were classified using the National Institutes of Health body mass index (BMI). Patients with a BMI of 30 to 39 with no significant comorbidity are considered obese, patients with a BMI of 35 to 39 with a significant comorbidity or a BMI of 40 or greater are considered morbidly obese. All subjects underwent either minimally invasive SIJ fusion with TTI or nonsurgical management (INSITE and iMIA studies only). All subjects completed SIJ pain scale scores (measured with a 100-point VAS) and disability scores (measured with ODI) at baseline and at scheduled visits to 24 months. Repeated measures analysis of variance was used to examine the impact of BMI category on score changes.
RESULTS: In the SIJF group, mean SIJ pain improved at 24 months by 53.3 points (p<.0001). Over the 24-month follow-up period, BMI category did not impact mean improvement in SIJ pain scale score (repeated measures analysis of variance (ANOVA) p=.44). In the SIJF group, mean ODI at 24 months improved by 25.8 points (p<.0001). BMI category did not impact mean improvement in ODI (ANOVA p=.60). In the nonsurgical management (NSM) group, mean improvements in SIJ pain scale and ODI were clinically small (8.7 and 5.2 points, respectively) and not affected by BMI category (ANOVA p=.49 and .40).
CONCLUSIONS: This study demonstrates similar benefits and risks of minimally invasive SIJ fusion with TTI across all BMI categories. This analysis suggests that obese patients benefit from minimally invasive SIJ fusion and should not be denied this procedure based solely on elevated BMI.

BACKGROUND: Black patients with peripartum cardiomyopathy (PPCM) have disproportionately worse outcomes than White patients, possibly related to variable involvement of cardiovascular specialists in their clinical care. We sought to determine whether race was associated with cardiology involvement in clinical care during inpatient admission and whether cardiology involvement in care was associated with higher claims of guideline-directed medical therapy (GDMT) a week after hospital discharge.
METHODS: Using Optum\'s de-identified Clinformatics® Data Mart (CDM), we included Black and White patients\' first hospital admission for PPCM from 2008 to 2021. Cardiology involvement in clinical care was defined as the receipt of attending care from a cardiovascular specialist during admission. GDMT included beta-blockers (BB) for all patients and triple therapy (BB, angiotensin-responsive medications, and mineralocorticoid receptor antagonists) for non-pregnant patients. Logistic regression was used to determine the associations between cardiology involvement in clinical care during admission and (1) patient race and (2) GDMT prescription, adjusting for age and comorbidities.
RESULTS: Among 668 patients (32.6% Black, 67.4% White, 93.3% commercially insured), there was no significant difference in the odds of cardiology involvement in clinical care by race (aOR: 1.41; 95%CI: 0.87-2.33, P=0.17). Inpatient cardiology care was associated with 2.75 times increased odds of having a prescription claim for GDMT (BB) for White patients (aOR: 2.75; 95%CI 1.50-5.06, P=0.001), and the estimated effect size was similar but not statistically significant for Black patients (aOR: 2.20, 95% CI, 0.84-5.71, P=0.11). The interaction between race and cardiology involvement in clinical care was not statistically significant for the receipt of BB prescription. Among 274 non-pregnant patients with PPCM (37.2% Black, 62.8% White), 5.8% received triple GDMT. Of these, none of the Black patients lacking cardiology care had triple GDMT. However, cardiology involvement in care was not significantly associated with triple GDMT for either race.
CONCLUSIONS: Among a commercially insured population within PPCM, race was not associated with cardiology involvement in clinical care during hospitalization. However, cardiology involvement in care was associated with significantly higher odds of prescription claims for BB for only White patients. Additional strategies are needed to support equitable GDMT prescription.

Acquired Brain Injury and Work Participation - A Dutch Interdisciplinary Guideline for Occupational and Insurance Physicians Abstract. This article discusses the Dutch interdisciplinary guideline \'Acquired brain injury and work participation\'. Its development follows the methodology of evidence-based medicine and supports all professionals involved in the vocational re-integration of workers with traumatic (e.g., traffic accident) and non-traumatic (e.g., stroke) acquired brain injury.
Zusammenfassung. Dieser Artikel behandelt die interdisziplinäre niederländische Leitlinie «Erworbene Hirnschädigung und Teilhabe am Arbeitsleben». Sie wurde nach der Methodik der evidenzbasierten Medizin entwickelt und unterstützt alle Fachleute, die an der beruflichen Wiedereingliederung von Arbeitnehmern mit traumatischer (z.B. Verkehrsunfall) und nichttraumatischer (z.B. Schlaganfall) erworbener Hirnschädigung beteiligt sind.

暂无摘要。

The European Union (EU) has a strong reputation and track record for the development of guidelines for the ethical use of artificial intelligence (AI) generally. In this paper, we discuss the development of an AI and ethical framework by the European Insurance and Occupational Pensions Authority (EIOPA), for the European insurance market. EIOPA\'s earlier report on big data analytics (EIOPA, 2019) provided a foundation to analyze the complex range of issues associated with AI being deployed in insurance, such as behavioral insurance, parametric products, novel pricing and risk assessment algorithms, e-service, and claims management. The paper presents an overview of AI in insurance applications throughout the insurance value chain. A general discussion of ethics, AI, and insurance is provided, and a new hierarchical model is presented that describes insurance as a complex system that can be analyzed by taking a layered, multi-level approach that maps ethical issues directly to specific level(s).

Cancers caused by human papillomavirus (HPV) can be prevented with the timely uptake and completion of the HPV vaccine series. Series completion is associated with increased vaccine effectiveness and longevity of protection. Medicaid beneficiaries are among populations with higher HPV vaccine uptake; however, little research describes factors that influence their HPV vaccine series completion. This study reports on a secondary data analysis of Arizona Medicaid data (Arizona Health Care Cost Containment System) from years 2008-2016. We summarized patient data using descriptive statistics and explored relationships between demographic variables and HPV vaccine administration information using bivariate logistic regression. Results of this analysis showed that females were more likely to complete the series as compared to males, and the age group that had the greatest odd of vaccine completion were 13-17-year-olds, the catch-up vaccine population. White Medicaid beneficiaries were most likely to adhere to HPV vaccine guidelines, followed by Hispanic beneficiaries. Patients receiving care in urban settings were more likely to complete the HPV vaccine series than people receiving care in rural areas of the state. Although statistically insignificant, people living with HIV were less likely to complete the 3-dose series. Future work should focus on ensuring that HPV vaccine age-eligible Medicaid, including people living with HIV, adhere to HPV vaccine guidelines. Expanding programs such as Vaccines for Children and scope of practice for dental professionals to offer the vaccine may provide additional options for Medicaid beneficiaries to vaccinate.

OBJECTIVE: The purpose of this study was to assess the validity of the medical insurance guidelines for orthognathic surgery used by the major American medical insurance companies.
METHODS: This study assessed the validity of the medical insurance guidelines for orthognathic surgery used by Aetna, Anthem Blue Cross Blue Shield (BCBS), Cigna, Humana, and UnitedHealthcare (UHC). To evaluate the validity, we calculated the approval and denial rates of the 5 guidelines when we used them to assess the medical necessity for a control group of carefully selected patients. Patients were included in the control group if they met the criteria of a \"prudent provider,\" crafted for this study. All rejected cases were analyzed to determine the root cause of the denials. The validity of the guidelines was also ascertained by determining their completeness and correctness.
RESULTS: The current study proves that no insurance guideline is in agreement with the criteria of a \"prudent provider.\" When applied to carefully chosen patients, the requirements of BCBS, Aetna, Humana, and Cigna produce modest rejection rates of 6 to 12%. UHC is an outlier. Its guideline rejects 86% of patients, a rate about 7 times higher than its peers. Insurance guidelines disqualified patients for 3 different reasons: 1) no significant jaw deformity, 2) no demonstrable health impairment, and 3) the etiology of the condition is not a covered benefit. Additional evaluations demonstrate that the private insurance guidelines are incomplete, and at times, incorrect.
CONCLUSIONS: This study shows that the medical insurance guidelines for orthognathic surgery used by the major American medical insurance plans need revision. The most consequential flaw was considering etiology in judging medical necessity. Fortunately, only one company adopted this policy. Moreover, all guidelines have omissions and errors in the way jaw deformity is determined and how health impairment is determined.

Although treatment of opioid use disorders (OUD) with medications is expanding, the extent to which practitioners are prescribing medications following best practices has received little attention.
The aim of this study was to determine the extent to which privately insured patients being treated for OUD with buprenorphine were treated in a manner consistent with practice guidelines.
Longitudinal analyses of a large commercial claims dataset from 2012 to 2016.
We analyzed data for 38,517 patients with an OUD diagnosis continuously enrolled for 3 months prior to and 6 months after an initial buprenorphine or buprenorphine-naloxone prescription fill.
We evaluated whether practitioners tested patients for hepatitis B, hepatitis C, HIV, and liver function; how often they received urine drug screens; the frequency of outpatient visits; and the extent to which they filled prescriptions for buprenorphine for at least 6 months.
Practitioners tested approximately 4.7% of patients for hepatitis B, 6.5% for hepatitis C, and 29.3% for HIV; they tested 8.0% for liver functioning; and gave 33.3% urine drug tests. Approximately 76% of patients had at least one outpatient visit for their OUD. Among those with at least one visit, the mean number of visits was 7.38. After the initial prescription, 47.5% stayed on buprenorphine for at least 6 months.
A large portion of privately insured patients receiving buprenorphine for OUD did not receive care consistent with guidelines.