Higher levels of the omega-3 fatty acid eicosapentaenoic acid (EPA) found in the blood appear to explain why icosapent ethyl drives down the risk of a cardiovascular (CV) event.

REDUCE-IT: Serum EPA Levels Key to Vascepa's CV Benefits

We interview experts on investigational treatments such as liso-cel, and ask how to bring them to community practice.

Spotlight on CAR T-Cell Therapy

The American Journal of Accountable Care® features research and commentary on new payment models.

New Members for AJAC Board

AMCP 2021, held virtually April 12-16, 2021, will bring together pharmacists, providers, payers, biopharmaceutical and life science industry leaders, digital health innovators, and policy makers.

Coverage of AMCP 2021 Is Coming

The 2021 Virtual Spring Managed Care Forum will be held virtually April 21-23, 2021. Topics include the future of health care beyond COVID-19, virtual health in the era of COVID-19, type 2 diabetes, multiple sclerosis, chronic cough, oncology, and more.

Coverage of the NAMCP Spring Forum Is Coming

Autoimmune complications occur frequently in both lymphoid and myeloid neoplasms, say researchers, who have also found that the complications are sometimes hard to diagnose and are often severe and life-threatening.

The findings come from the group’s review of over 30 years’ worth of research of the presence of autoimmune cytopenias (AICy) and autoimmune diseases (AID) in lymphoid and myeloid neoplasms.

Complications include not just the well-known complications, such as autoimmune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP), but also the poorly recognized AICy, such as autoimmune neutropenia (AIN) and aplastic anemia (AA), and poorly recognized AID, such as systemic lupus erythematosus and rheumatoid arthritis.

The review showed that nearly 10% of chronic lymphocytic leukemia (CLL) cases are impacted by AICy and are common in certain subtypes of non-Hodgkin lymphoma. Meanwhile, they are uncommon in low-risk myelodysplastic syndrome and chronic myelomonocytic leukemia, present in less than 1% of cases.

“Whilst AIHA and ITP are known complications, the rarer AIN, [pure red cell aplasia], and AA should be considered in the diagnostic algorithm of the cytopenic patient, taking into account bone marrow infiltration and/or peripheral destruction,” wrote the researchers. “Pitfalls for the latter include DAT-negative AIHA and the low sensitivity of anti-platelet and anti-neutrophil autoantibodies, whereas the kinetics of clinical presentation and response to steroid/[intravenous immunoglobulins] may help the diagnosis. CLL/lymphoma-specific therapy is generally required in relapsed/refractory AICy cases or in patients with progressive [lymphoproliferative disorders]-disease.”

AID are documented in nearly 1 in 3 lymphoid and myeloid cases, according to the literature, which found that these complications include those that may be severe and fatal.

When it comes to identifying AID, the researchers explained that identifying the complication and determining treatment has proven difficult as a result of their high heterogeneity and variable organ involvement, as well as a lack of specific diagnostic tests and low awareness from hematologists.

“AICy are generally related to LPD activity and may worsen the prognosis of the underlying disease, whereas AID may develop before the hematologic neoplasm or during its course, not clearly affecting its prognosis,” explained the researchers. “Likewise, AID-specific treatment may be required independently from the hematologic therapy. It is even more difficult to attribute a pathogenetic, clinical and prognostic value to the several autoimmune serological positivities reported in hematologic neoplasms, as they are not predictive of overt AICy/AID.”

The researchers also drew attention to emerging autoimmune complications, such as AICy in hematopoietic stem cell transplant and in the context of chimeric antigen receptor-T cell treatment, as well as AID during treatment with checkpoint inhibutors.

Barcellini W, Giannotta J, Fattizzo B. Autoimmune complications in hematologic neoplasms. 

Articles

The findings come from the group’s review of over 30 years’ worth of research of the presence of autoimmune cytopenias and autoimmune diseases in lymphoid and myeloid neoplasms.



Autoimmune Complications Common in Lymphoid, Myeloid Neoplasms, Says Review

's parent company, MJH Life Sciences, since 2011. She has an MA in business and economic reporting from New York University.

Metastatic breast cancer has a poor prognosis, but emerging targeted therapies are providing some progress in the treatment of the disease, Filipa Lynce, MD, medical oncologist at Dana-Farber Cancer Institute and Harvard Medical School, explained during her session at the 

National Association of Managed Care Physicians Virtual Spring Managed Care Forum

When first consulting with new patients, Lynce often provides a snapshot of the disease, making sure they understand that breast cancer is a very common disease, affecting 1 in 8 women in the United States. However, patients who are initially diagnosed with metastatic breast cancer only have a 5-year survival rate of 28%.

“Although we have a lot of survivors of breast cancer, still we are losing a lot of lives to breast cancer,” Lynce said.

 mutations and poly (ADP-ribose) polymerase (PARP) inhibitors. Currently, there are only 2 PARP inhibitors approved in breast cancer: olaparib and talazoparib. Other PARP inhibitors that have been approved are only for use in ovarian cancer at this time.

The various PARP inhibitors available have different PARP trapping potency and different capacities for inhibition, and it is unclear whether those differences are clinically significant, she said. In order to determine that, there would need to be head-to-head comparisons of the PARP inhibitors, which has not happened yet and likely won’t happen, according to Lynce.

A table of toxicities highlighted the different toxicity profiles of the PARP inhibitors, during which Lynce reminded the audience that they are being used instead of chemotherapy.

“So even if you look at these and think, ‘There’s a lot of hematological malignancy,’ all studies have shown that the quality of life is far better with PARP inhibitors than chemotherapy, which is the alternative for most of these patients,” she said.

The adverse effects of PARP inhibitors are mainly hematological, with thrombocytopenia and anemia more prevalent in talazoparib than olaparib. The labels for these therapies also mention that there is the potential to develop myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). While these may be rare, PARP inhibitors are fairly new, and more long-term follow-up data are needed to understand how significant the risk is.

In addition, Lynce pointed out that these patients have metastatic breast cancer, and the development of MDS or AML down the road in an already deadly disease takes on different significance than if these drugs move to earlier use.

She highlighted a few studies evaluating the use of PARP inhibitors in metastatic breast cancer and 

 carriers. First, the OlympiAD study showed an improvement in quality of life using olaparib compared with chemotherapy in patients who had received 1 to 2 prior lines of chemotherapy.

 The median progression-free survival (PFS), which was the primary end point, was 2.8 months longer; however, the overall survival (OS) did not differ significantly between the groups.

The EMBRACA study had a similar study design evaluating talazoparib, and the primary end point was PFS again.

 While there was an improvement in PFS vs chemotherapy, “we see that we still need to do better for these patients.” The median PFS for the PARP inhibitor was 8.6 months vs 5.6 months on chemotherapy. Again, OS did not differ significantly.

In TBCRC 048, olaparib was studied in patients with metastatic breast cancer who had germline or somatic mutations.

 All patients in the study received olaparib. Cohort 1 had germline mutations (no 

 mutations) and cohort 2 had somatic mutations (including 

). A total of 15 patients in cohort 2 had somatic 

 mutations. The partial response (PR) in this cohort was 31%, and all confirmed PRs had 

 mutations. The PR in cohort 1 was 33%. There were confirmed responses in somatic 

 (objective response rate [ORR], 50%) and germline 

 (ORR, 82%). Although it was only a small number, none of the patients with 

Studies are also now looking at whether PARP inhibitors can be combined with immuno-oncology (IO). MEDIOLA, a phase 1/2 open-label trial of olaparib and durvalumab, studied patients with ovarian, breast, small cell lung, and gastric cancers.

 Patients were treated with olaparib alone for 4 weeks and olaparib and durvalumab until disease progression. There were a total of 34 patients with breast cancer: 47% with the 

 mutation. The ORR was 63.3%, and the median PFS was 8.2 months.

Lynce then did something that isn’t normally recommended: she compared the MEDIOLA results with the OlympiAD results. Although there are many caveats to comparing these trials, such as the different patient populations, the previous treatments, and the various agents, she did this to remind the audience that the ORR for OlympiAD was 59.9% and the PFS was 7.2 months.

“I think that all that we can say from these [results] is that the combination of a PARP inhibitor with IO, at least just based on this trial…does not strike us as a home run,” Lynce said.

However, she noted the benefit of IO is the durability of the response, which means it would be important to follow the patients of the MEDIOLA trial for a longer period of time.

 niraparib plus pembrolizumab was evaluated in 55 patients with triple-negative breast cancer (TNBC) who had 1 prior line of therapy. Unlike MEDIOLA, all patients started immediately on the combination treatment. The ORR for all patients with TNBC was 21%, and for just those patients with 

These trials show that progress is being made, but there are still limitations, and trials are still looking at moving PARP inhibitors beyond the metastatic setting.

“You see these drugs work, but we need to find a way to bring more durable responses to these patients,” Lynce said. “But definitely, PARP inhibitors have changed how we treat these patients.”

1. Robson M, Im S-A, Senkus E, et al. Olaparib for metastatic breast cancer in patients with a germline 

. 2017;377(6):523-533. doi:10.1056/NEJMoa1706450

2. Litton JK, Rugo HS, Ettl J, et al. Talazoparib in patients with advanced breast cancer and a germline 

. 2018;379(8):753-763. doi:10.1056/NEJMoa1802905

3. Tung NM, Robson ME, Ventz S, et al. TBCRC 048: phase II study of olaparib for metastatic breast cancer and mutations in homologous recombination-related genes. 

. 2020;38(36):4274-4282. doi:10.1200/JCO.20.02151

4. Domchek SM, Postel-Vinay S, Im S-A, et al. Olaparib and durvalumab in patients with germline BRCA-mutated metastatic breast cancer (MEDIOLA): an open-label, multicentre, phase 1/2, basket study. 

. 2020;21(9):1155-1164. doi:10.1016/S1470-2045(20)30324-7

5. Vinayak S, Tolaney SM, Schwartzberg L, et al. Open-label clinical trial of niraparib combined with pembrolizumab for treatment of advanced or metastatic triple-negative breast cancer. 

2019;5(8):1132-1140. doi:10.1001/jamaoncol.2019.1029

Metastatic breast cancer has a poor prognosis, but emerging targeted therapies are providing some progress in the treatment of the disease, explained Filipa Lynce, MD, medical oncologist at Dana-Farber Cancer Institute and Harvard Medical School.

PARP Inhibitors Have Made Significant Progress in BRCA1/2 Metastatic Breast Cancer, but Limitations Remain

Workers with commercial health insurance are impacted by social determinants of health (SDOH) in ways similar to those who are uninsured, according to an Aetna executive who spoke at the 

Steven Serra, MD, MPH, MSc, FACOEM, the executive director of Physician Consulting in Aetna’s Plan Sponsor Insights team, shared an analysis of an early pilot with a large, self-insured employer in a session about health equity.

Poor SDOH lowers employee productivity and raises plan costs by 5% or more, he said, so the insurer has begun using predictive analytics with their clients.

Aetna has created its own SDOH index, comprised of median household income, poverty, diversity, disability, education, physical inactivity, family structure, public transport, and employment. The dataset uses US Census tract data and CDC data.

Serra described the customer as one with about 20,000 employees; the majority of the employees (70%) were female, which he said was “not uncommon” for a health system. About half of the employees were physicians, nurses, and other health care workers.

Twenty percent of the workers lived in low-income neighborhoods, and the majority were female. The average age of workers in low-income neighborhoods was 43, about 2 years younger than those in high-income neighborhoods.

Risk scores were also assigned to the population, and those living in a low-income neighborhood had a retrospective risk score of 1.77, compared with 1.56 in high-income neighborhoods, meaning they were unhealthier and may have been using more costlier services.

By medical cost per member per month (PMPM), the low-income members of the plan spent more annually than high-income workers (a difference of $49). They spent more on specialty physicians, inpatient facilities, and ambulatory facilities. Notably, high-income workers spent considerably more on mental health ($18 compared with $8 for low-income workers).

Low-income members had more potentially preventable chronic conditions—diabetes, hypertension, and obesity—than high-income members.

They had more potentially avoidable care, such as emergency department visits or hospitalizations.

They had higher 30-day readmission rates, but lower 90-day and 180-day readmission rates.

Interestingly, a reversal of these trends was seen when it came to behavioral health; although overall prevalence of issues related to behavioral health were similar across income groups, high-income employees had more outpatient visits as well as inpatient stays.

When looking at behavioral health and comorbidities, low-income workers had a higher incidence of comorbid cardiovascular issues and diabetes.

"So what can be done to remediate health care inequities?" Serra asked. "I think the answer is, a lot."

Serra said employers have a variety of options at their disposal to improve health equity and eliminate disparities:

Reimbursement for education, since education is a factor of SDOH

Creating a culture of health, such as promoting ergonomic workplaces and worker safety

Extending health plan benefits to the entire workforce, including part-time workers

Basing premiums and deductibles on salary

Offering travel and lodging reimbursement for care sought at Aetna's Institutes of Quality and Excellence 

He also said employers can ask their payer to implement programs that increase access to high-quality, low-cost care and use value-based benefit design. Serra also urged the audience to view prescription carve-outs and exclusions through the lens of health equity. 

"Unless we force ourselves to look at these decisions though the lens of health equity, we are violating the Hippocratic oath," he said.

At a session at the National Association of Managed Care Physicians Virtual Spring Managed Care Forum, an Aetna executive discussed how one employer used the payer's data to see how its workforce was affected by social determinants of health (SDOH).



Examining SDOH in a Commercially Insured Health Care Workforce

In recent years, Congress has taken legislative action to allow veterans to more easily access care in the community that is paid for by the Department of Veterans Affairs, or VA. While this has helped dismantle some barriers to accessing care, it has also raised concerns about care fragmentation, or the extent to which a patient’s health care is spread across multiple providers. An ample body of literature has shown worse care outcomes and higher costs in the presence of care fragmentation, which is thought to arise when the different providers and organizations do not communicate effectively with one another.

On this episode of Managed Care Cast, we’re talking with two coauthors of an Original Research article published in our April 2021 issue. The article, “

Ambulatory Care Fragmentation and Hospitalization Among Veterans With Diabetes

,” examines the association between the system of one’s usual care provider and their level of care fragmentation with their odds of being hospitalized.

The authors joining us today are Lisa M. Kern MD, MPH, associate professor of medicine and of population health sciences at Weill Cornell Medicine, and Drew Helmer, MD, deputy director of the Center for Innovations in Quality, Effectiveness, and Safety at Michael E. DeBakey VA Medical Center in Houston, as well as senior faculty at Baylor College of Medicine.

Listen above or through one of these podcast services:

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The authors of a study in the April 2021 issue of The American Journal of Managed Care® discuss the possible reasons behind the link between care fragmentation and hospitalizations in veterans with diabetes, as well as potential opportunities to address disjointed care in the context of the widespread telehealth uptake seen during the COVID-19 pandemic.

Balancing Care Access and Fragmentation for Better Outcomes in Veterans With Diabetes

Cascades of care are common and can lead to significant harms for patients, clinicians, and the health care system at large. In this commentary, we argue that there are 2 ways to reduce cascades: decrease the use of unnecessary services that often initiate cascades (ie, close the floodgates) and mitigate cascades once they begin (ie, slow the flow through the floodgates). So far, most efforts to address cascades have focused on identifying, measuring, and educating clinicians on low-value services, with only modest success. We explore potential solutions for both closing the floodgates and slowing a cascade once the floodgates have been opened, including information to assist patients and clinicians in making better decisions, relationships that enable shared decision-making, and policy changes. Ultimately, reducing cascades while maintaining our commitment to high-quality care requires equipping patients and clinicians with the information, tools, and support needed to embrace uncertainty.

Reducing cascades while maintaining our commitment to high-quality care requires equipping patients and clinicians with the information, tools, and support to embrace uncertainty.

Addressing harmful cascades of care requires strategies to decrease the use of unnecessary, low-value services that often initiate cascades and also stop cascades once they begin.

Decreasing the use of low-value care is challenging, but there is an opportunity to implement policies that incentivize patients and clinicians to put recommendations around avoiding low-value services into practice.

To mitigate cascades once they begin, we need information to assist patients and clinicians in making better decisions, relationships that enable shared decision-making, and accompanying policy changes.

 refers to a succession of medical services that are often fueled by the desire to avoid even the smallest risk of a serious condition.

 They can follow from incidental or marginal findings on screening and diagnostic tests, some of which are themselves of low value. Regardless of their origins, they can be difficult to stop once the floodgates are opened, often leading to harms for patients, clinicians, and the health care system at large.

In certain cases, further evaluation of unexpected findings can serve a useful purpose, such as uncovering a dangerous yet treatable cancer.

 More often, these pursuits are ultimately futile and costly. For example, consider an unwarranted preoperative electrocardiogram prior to a low-risk procedure like cataract surgery, where an inconclusive result may prompt additional referrals, diagnostic testing, and catheterization that rarely confirms significant cardiovascular disease.

 The process can be emotionally and physically exhausting for patients without offering them any real benefits.

Cascades of care are extremely common. In a recent survey of US internists, more than 99% of respondents reported that they had experienced cascades from incidental findings. One-third experienced cascades with no clinically important or intervenable outcome on at least a monthly basis. Notably, more than half of respondents said cascades led to physical, psychological, and financial harm to patients and wasted time, frustration, and anxiety for physicians.

There are 2 ways to reduce cascades: (1) decrease the use of unnecessary services that often initiate cascades (ie, close the floodgates) and (2) mitigate cascades once they begin (ie, slow the flow through the floodgates). Both are critical to preventing these floods from causing catastrophic damage.

So far, most efforts to address low-value care, including the Choosing Wisely campaign and the US Preventive Services Task Force (USPSTF) rating system, have focused on identifying, measuring, and educating patients and clinicians on low-value services.

 However, these initiatives have had only modest success in reducing the use of low-value care.

 One reason for this might be the lack of policies that incentivize clinicians or patients to put recommendations into practice. Of note, Section 4105 of the Patient Protection and Affordable Care Act authorizes Medicare plans to remove coverage for preventive care services that are deemed harmful or unnecessary by the USPSTF (ie, D rating).

 By pushing implementation of this provision, the new administration has an opportunity to meaningfully address the prevalence of low-value care.

Closing the floodgates makes sense when it is possible to identify a specific service as low value. However, this can be difficult in many cases, given the poor consensus around how to incorporate clinical nuance, patient preferences, and cost-benefit trade-offs into this designation.

 Moreover, cascades are often triggered by initial tests that are clinically appropriate.

 Given these factors, it is also important to mitigate cascades once they begin.

Slowing the flow may be more challenging; it is easier to avoid discovering an “incidentaloma” than to unsee it. Clinicians order that second or third test because they fear missing something important, fear being sued, feel an obligation to follow practice and community norms, or believe they are responding to patient preferences.

 To slow a cascade once the floodgates have been opened, we need (1) information to assist patients and clinicians in making better decisions, (2) relationships that enable shared decision-making, and (3) policy changes.

Information to help patients and clinicians make better decisions. 

Physicians often feel frustrated but compelled to pursue additional testing for incidental findings when results are unfamiliar and are not accompanied by information to contextualize their clinical importance.

 Yet, cascades may occur even when such information is provided. For example, a multicenter study showed that including data on the prevalence of age- and sex-specific abnormalities in healthy adults on spine imaging reports (thereby “normalizing” these abnormalities) did not decrease subsequent spine-related utilization.

This speaks to the importance of providing the right information at the right time. In the spine imaging study, the information included in reports was based on population-level estimates, making it challenging to generalize to individual patients, and did not include recommendations for follow-up. For information to be useful to clinicians, it should be clear, specific, and provided at the point of care. The information should also be guided by high-quality evidence rather than just expert opinion, which tends to be more conservative and promote cascades. To this end, there is a need for more research on when a laboratory “abnormality” does or does not require further testing and on best practices for evaluation of various incidentalomas.

In the wake of the 21st Century Cures Act, patients increasingly have access to their test results, and any deviation from “normal” can provoke anxiety. Ideally, test results would be presented alongside interpretative comments in language that is easily understood. Another solution might be allowing patients to review imaging results with radiologists directly. In general, the public should be better sensitized to the idea that medical tests and procedures carry harms and that attempts to “prevent” devastating but rare outcomes can have risks of their own.

Trusting patient-clinician relationships. 

Using reliable, point-of-care information, we can leverage trusting patient-clinician relationships to engage patients in shared decision-making to minimize the harms of cascades. When faced with a dilemma (eg, after an incidental finding is found, should testing be pursued to rule out a rare but life-threatening diagnosis?), clinicians need to understand and factor in what is important to patients. In an open conversation, clinicians can explain the clinical implications of findings and potential harms and benefits of further testing; similarly, patients can share their concerns and reasons for and against further testing. These conversations should start early—when deciding to order a test in the first place—and may reassure clinicians who pursue cascades due to fears of litigation.

Clinicians need training and resources to navigate these conversations. Although most clinicians report having conversations about cascades with patients, they are often limited to specific use cases (eg, pulmonary nodules incidentally found on chest radiography).

 Education on overuse should be baked into the medical curriculum such that clinicians feel comfortable talking to patients about uncertainty. Decision aids and scripts can be integrated into the electronic health record to help guide these conversations.

It is important to consider the legal and policy context in which these conversations are happening. For instance, the shift to value-based payment may incentivize clinicians to reduce unnecessary medical tests and treatments, although evidence remains mixed.

 Alongside efforts to reduce the number of low-value tests ordered, future models should invest in point-of-care solutions to stem low-value cascades once they are triggered.

Medical malpractice reform is another solution that is appealing in theory, although reforms to date have had limited impact on low-value care utilization. A fear of malpractice lawsuits can propel cascades

—in one study, the possibility of a lawsuit increased the intensity of care that patients received, although this extra testing and treatment did not improve outcomes.

 One promising approach is the creation of “safe harbor” laws that protect clinicians from liability if they adhere to clinical practice guidelines based on rigorous evidence.

 There is also evidence that specific communication behaviors, such as educating patients on the purpose of tests and procedures, soliciting patients’ opinions, and checking understanding, are associated with fewer malpractice claims.

 Thus, safe harbor laws that encourage clinicians to follow guidelines and explain the context and implications of incidental findings may mitigate cascades motivated by legal concerns.

Ultimately, reducing cascades while maintaining our commitment to high-quality care requires becoming more comfortable with uncertainty.

 Although the increasing attention to low-value care is an important step forward, to really stop the flood, we need strategies that provide patients and clinicians with the information, tools, and support to embrace the uncertainty inherent in medicine.


 Harvard Medical School (PC, IG), Boston, MA; Department of Internal Medicine and Center for Value-Based Insurance Design (AMF), Ann Arbor, MI; Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital (IG), Boston, MA.

 Dr Fendrick has been a consultant for AbbVie, Amgen, Centivo, Community Oncology Alliance, Covered California, EmblemHealth, Exact Sciences, Freedman Health, GRAIL, Harvard University, Health & Wellness Innovations, Health at Scale Technologies, MedZed, Merck, Montana Health Cooperative, Penguin Pay, Risalto, Sempre Health, State of Minnesota, US Department of Defense, Virginia Center for Health Innovation, Wellth, Yale–New Haven Health System, and Zansors; has performed research for the Agency for Healthcare Research and Quality, Arnold Ventures, Boehringer Ingelheim, Gary and Mary West Health Policy Center, National Pharmaceutical Council, Patient-Centered Outcomes Research Institute, PhRMA, Robert Wood Johnson Foundation, and State of Michigan/CMS; and holds outside positions as co-editor-in-chief of 

®, member of the Medicare Evidence Development & Coverage Advisory Committee, and partner in V-BID Health, LLC. Dr Ganguli has received a grant from the Agency for Healthcare Research and Quality on cascades of care and has presented on cascades at conferences. Ms Chandrashekar reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (PC, AMF, IG); drafting of the manuscript (PC, AMF, IG); critical revision of the manuscript for important intellectual content (PC, AMF, IG); and supervision (AMF, IG).

 Ishani Ganguli, MD, MPH, Brigham and Women’s Hospital, 1620 Tremont St, 3rd Floor, Boston, MA 02120. Email: iganguli@bwh.harvard.edu.

1. Mold JW, Stein HF. The cascade effect in the clinical care of patients. 

. 1986;314(8):512-514. doi:10.1056/NEJM198602203140809

2. Ganguli I, Simpkin AL, Lupo C, et al. Cascades of care after incidental findings in a US national survey of physicians. 

. 2019;2(10):e1913325. doi:10.1001/jamanetworkopen.2019.13325

3. Ganguli I, Lupo C, Mainor AJ, et al. Prevalence and cost of care cascades after low-value preoperative electrocardiogram for cataract surgery in fee-for-service Medicare beneficiaries. 

. 2019;179(9):1211-1219. doi:10.1001/jamainternmed.2019.1739

4. Korenstein D, Chimonas S, Barrow B, Keyhani S, Troy A, Lipitz-Snyderman A. Development of a conceptual map of negative consequences for patients of overuse of medical tests and treatments. 

. 2018;178(10):1401-1407. doi:10.1001/jamainternmed.2018.3573

5. Choosing Wisely. Accessed December 22, 2020. https://www.choosingwisely.org

6. U.S. Preventive Services Task Force Ratings. U.S. Preventive Services Task Force. Accessed April 1, 2021. https://www.uspreventiveservicestaskforce.org/uspstf/us-preventive-services-task-force-ratings

7. Ganguli I, Lupo C, Mainor AJ, et al. Assessment of prevalence and cost of care cascades after routine testing during the Medicare annual wellness visit. 

. 2020;3(12):e2029891. doi:10.1001/jamanetworkopen.2020.29891

8. Mafi JN, Reid RO, Baseman LH, et al. Trends in low-value health service use and spending in the US Medicare fee-for-service program, 2014-2018. 

. 2021;4(2):e2037328. doi:10.1001/jamanetworkopen.2020.37328

9. Compilation of Patient Protection and Affordable Care Act. HHS. 2010. Accessed April 1, 2021. https://www.hhs.gov/sites/default/files/ppacacon.pdf

10. Beaudin-Seiler B, Ciarametaro M, Dubois RW, Lee J, Fendrick AM. Reducing low-value care. 

. September 20, 2016. Accessed April 1, 2021. https://www.healthaffairs.org/do/10.1377/hblog20160920.056666/full/

11. Zafar HM, Bugos EK, Langlotz CP, Frasso R. “Chasing a ghost”: factors that influence primary care physicians to follow up on incidental imaging findings. 

. 2016;281(2):567-573. doi:10.1148/radiol.2016152188

12. Jarvik JG, Meier EN, James KT, et al. The effect of including benchmark prevalence data of common imaging findings in spine image reports on health care utilization among adults undergoing spine imaging: a stepped-wedge randomized clinical trial. 

. 2020;3(9):e2015713. doi:10.1001/jamanetworkopen.2020.15713

13. Schwartz AL, Chernew ME, Landon BE, McWilliams JM. Changes in low-value services in year 1 of the Medicare Pioneer Accountable Care Organization Program. 

. 2015;175(11):1815-1825. doi: 10.1001/jamainternmed.2015.4525

14. Ganguli I, Simpkin AL, Colla CH, et al. Why do physicians pursue cascades of care after incidental findings? a national survey. 

. 2020;35(4):1352-1354. doi:10.1007/s11606-019-05213-1

15. Frakes MD, Gruber J. Defensive medicine: evidence from military immunity. National Bureau of Economic Research working paper No. 24846. July 2018. Accessed December 21, 2020. https://www.nber.org/system/files/working_papers/w24846/w24846.pdf

16. Mello MM, Kachalia A, Studdert DM. Medical liability — prospects for federal reform. 

. 2017;376(19):1806-1808. doi:10.1056/NEJMp1701174

17. Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. the relationship with malpractice claims among primary care physicians and surgeons. 

. 1997;277(7):553-559. doi:10.1001/jama.277.7.553

18. Colla CH, Kinsella EA, Morden NE, Meyers DJ, Rosenthal MB, Sequist TD. Physician perceptions of Choosing Wisely and drivers of overuse. 

Stopping the Flood: Reducing Harmful Cascades of Care

In the inaugural Oncology Value Coalition from 

®, Kashyap Patel, MD, led a discussion with Debra Patt, MD, PhD, MBA; and Karen Winkfield, MD, PhD, exploring findings that suggest minority groups develop cancer at higher rates and experience worse outcomes than nonminority groups.

In segment 3, the panelists discuss bringing clinical trials to underserved areas.

Videos

In the inaugural Oncology Value Coalition from The American Journal of Managed Care®, Kashyap Patel, MD, led a discussion with Debra Patt, MD, PhD, MBA; and Karen Winkfield, MD, PhD, exploring findings that suggest minority groups develop cancer at higher rates and experience worse outcomes than nonminority groups.

Oncology Value Coalition: Disparities in Cancer Care—Sources and Solutions, Part 3

In segment 2, the panelists discuss bringing equity to genomics and personalized medicine.

Oncology Value Coalition: Disparities in Cancer Care—Sources and Solutions, Part 2

In segment 1, the panelists discuss the many factors involved in cancer disparities.

Oncology Value Coalition: Disparities in Cancer Care—Sources and Solutions, Part 1

More J&J Vaccines May Have Been Contaminated

Following reports of 15 million Johnson & Johnson (J&J) vaccine doses 

 at a Baltimore plant earlier this month, federal regulators have now found more flaws at the facility, 

. FDA officials say Emergent BioSolutions, the company manufacturing the vaccine, may have contaminated additional doses because it failed to fully investigate contamination and had faults in its disinfectant practices, handling of raw materials, and training of workers. No doses made at the plant have gone out to the public and all J&J doses distributed in the United States were manufactured overseas. 

The US House of Representatives passed legislation to extend a provision set to expire that keeps fentanyl listed as a Schedule 1 drug, according to 

. The deadly synthetic opioid has been responsible for a large proportion of drug overdoses in the United States in recent years. Its listing as a Schedule 1 drug, which would have expired May 6, means it has a high potential to be abused and does not have a medical use. In the 12 months preceding September 2020, at least 87,000 individuals died of drug overdoses. Under the revised version of the bill, fentanyl’s status would remain until October 22, 2021, granting lawmakers time to draft more comprehensive legislation.

COVID-19 deaths and cases continue to increase at an above-average pace in Texas, The Associated Press 

. The state recorded 4518 new cases and 82 COVID-19–related deaths compared with a rolling 7-day average of over 3200 cases and 55 deaths, according to researchers at Johns Hopkins University. Over the course of the pandemic, the state has reported just over 3 million cases and nearly 50,000 deaths, while currently, 36% of Texans have received at least 1 dose of a COVID-19 vaccine and 23% of the population is fully vaccinated.

New reports show additional doses of Johnson & Johnson's (J&J) COVID-19 vaccine manufactured in Baltimore may be contaminated; legislation extends fentanyl's regulation as a Schedule 1 drug; COVID-19 cases and deaths increase in Texas. 

What We’re Reading: More J&J Doses Potentially Compromised; Fentanyl as Schedule 1 Drug; COVID-19 in Texas

Susan Weidner is senior vice president, IntrinsiQ Specialty Solutions.

Every year, millions of Americans rely on independently owned and operated specialty practices for care in their communities, ranging from ophthalmology, rheumatology, and gastroenterology to neurology, oncology, and more. Throughout the COVID-19 pandemic, these practices were integral in helping patients access chemotherapy and other critical treatments, participate in clinical trials, and screen for serious diseases. However, the pandemic also presented significant challenges to them, their operations, and their patients.

Within the first months of the pandemic’s “stay at home” orders, community-based physicians saw a 40%  drop in new patient visits as well as a 100%  increase in cancellations and no-shows.

 Lower patient volumes created new financial constraints for these providers, and as a result, 50% of private practices had to furlough office staff. Almost 25% were forced to make permanent layoffs.

Throughout the COVID-19 pandemic, independent community practices were integral in helping patients access chemotherapy and other critical treatments, participate in clinical trials, and screen for serious diseases. However, the pandemic also presented significant challenges to them, their operations, and their patients.