The review process used by U.S. health care plans to evaluate new medical technology for coverage

OBJECTIVE: To examine the process and information used by medical directors (MDs) of private health plans to make medical coverage determinations for new medical technologies, and to assess the influence of plan characteristics on the process. DESIGN: Cross-sectional national survey. PARTICIPANTS: Two hundred thirty-one MDs at private health plans representing 66% and 72% of the U.S. population covered by HMOs and indemnity plans, respectively. MEASUREMENTS: Actual and optimal review process, final decision authority, sources, and evidence used for technology coverage decisions. RESULTS: In 96% of plans, MDs take part in the medical policy review process for new technology. However, MDs have final authority over coverage decisions in only 27% of plans. Indemnity plans are more likely to assert that MDs should be responsible for final decisions, odds ratio (OR)=3.3 (95% confidence interval [95% CI] 1.4, 10). Optimal sources of information on new technology were journals, medical society statements or practice guidelines, and opinions of national experts. Actual sources of information used differed from optimal ones; local experts were used more often than is considered optimal (p<.001). For-profit plans were more likely than nonprofit plans to use national experts, OR 2.5 (95% CI 1.3, 5.0), and practice guidelines, OR 5.0 (95% CI 2.5, 10). Randomized trials (94% of MDs) meta-analyses (61%), and reviews (42%) were considered the best evidence for making coverage decisions. Barriers to making optimal decisions were lack of timely evidence on effectiveness and cost-effectiveness, not legal or regulatory issues; HMO, small, and nonprofit plans were two to three times more likely to list lack of cost-effectiveness data than their counterparts (p<.05). CONCLUSIONS: Although MDs are nearly always involved in the technology evaluation process, a minority of MDs retain final authority over coverage decisions. Evidence from strong scientific research designs is the most frequently cited basis for decisions, but there is need for more timely, rigorous scientific evidence on medical interventions. How a health plan evaluates a new medical technology for coverage varies with identifiable plan characteristics. Presented in part at the 18th annual meeting of the Society of General Internal Medicine and the American Federation for Clinical Research national meeting, San Diego, Calif., May 1995. Supported in part by the Office of Technology Assessment, U.S. Congress, Washington, DC, and computational assistance from General Clinical Research Center grants 5M01RR00722 and RR0035 from the National Center for Research Resources, Bethesda, Md. This paper does not represent policy of either the Agency for Health Care Policy and Research or the U.S. Department of Health and Human Services (DHHS). The views expressed herein are those of the authors and no official endorsement by AHCPR or DHHS is intended or should be inferred.     

Assessment of aldehyde dehydrogenase in viable cells

Cytosolic aldehyde dehydrogenase (ALDH), an enzyme responsible for oxidizing intracellular aldehydes, has an important role in ethanol, vitamin A, and cyclophosphamide metabolism. High expression of this enzyme in primitive stem cells from multiple tissues, including bone marrow and intestine, appears to be an important mechanism by which these cells are resistant to cyclophosphamide. However, although hematopoietic stem cells (HSC) express high levels of cytosolic ALDH, isolating viable HSC by their ALDH expression has not been possible because ALDH is an intracellular protein. We found that a fluorescent aldehyde, dansyl aminoacetaldehyde (DAAA), could be used in flow cytometry experiments to isolate viable mouse and human cells based on their ALDH content. The level of dansyl fluorescence exhibited by cells after incubation with DAAA paralleled cytosolic ALDH levels determined by Western blotting and the sensitivity of the cells to cyclophosphamide. Moreover, DAAA appeared to be a more sensitive means of assessing cytosolic ALDH levels than Western blotting. Bone marrow progenitors treated with DAAA proliferated normally. Furthermore, marrow cells expressing high levels of dansyl fluorescence after incubation with DAAA were enriched for hematopoietic progenitors. The ability to isolate viable cells that express high levels of cytosolic ALDH could be an important component of methodology for identifying and purifying HSC and for studying cyclophosphamide-resistant tumor cell populations.     

HLA-B13 and chronic calcific pancreatitis

In view of a possible role of genetic factors in the etiology of chronic calcific pancreatitis, we undertook a study of the frequency of HLA antigens in this disease. Sixty-four patients with chronic calcific pancreatitis were typed for the HLA-A,-B and-C loci. Fourteen of these 64 patients (21.9%) were found to have antigen B13 compared to 7.5% of 425 controls. These results have aP value of 0.00059 which remains significant (P=0.020) even when multiplied by the total number of antigens tested. Sex, alcoholism, age at the clinical onset of the disease, presence of pain, and diabetes had no apparent influence on the distribution of HLA alleles. The significant association between chronic calcific pancreatitis and HLA antigen B13 further supports the role of genetic factors in the etiology of the disease.     

Improving awareness,accountability, and access through health coaching: Qualitative study of patients’ perspectives

Objective

To assess patients’ experiences with and perceptions of health coaching as part of their ongoing care.

Design

A qualitative research design using semistructured interviews that were recorded and transcribed verbatim.

Setting

Ottawa, Ont.

Participants

Eleven patients (> 18 years of age) enrolled in a health coaching pilot program who were at risk of or diagnosed with type 2 diabetes.

Methods

Patients’ perspectives were assessed with semistructured interviews. Interviews were conducted with 11 patients at the end of the pilot program, using a stratified sampling approach to ensure maximum variation.

Main findings

All patients found the overall experience with the health coaching program to be positive. Patients believed the health coaching program was effective in increasing awareness of how diabetes affected their bodies and health, in building accountability for their health-related actions, and in improving access to care and other health resources.

Conclusion

Patients perceive one-on-one health coaching as an acceptable intervention in their ongoing care. Patients enrolled in the health coaching pilot program believed that there was an improvement in access to care, health literacy, and accountability, all factors considered to be precursors to behavioural change.     

An Observational Study of Social and Emotional Support in Smoking Cessation Twitter Accounts: Content Analysis of Tweets

Background

Smoking continues to be the number one preventable cause of premature death in the United States. While evidence for the effectiveness of smoking cessation interventions has increased rapidly, questions remain on how to effectively disseminate these findings. Twitter, the second largest online social network, provides a natural way of disseminating information. Health communicators can use Twitter to inform smokers, provide social support, and attract them to other interventions. A key challenge for health researchers is how to frame their communications to maximize the engagement of smokers.

Objective

Our aim was to examine current Twitter activity for smoking cessation.

Methods

Active smoking cessation related Twitter accounts (N=18) were identified. Their 50 most recent tweets were content coded using a schema adapted from the Roter Interaction Analysis System (RIAS), a theory-based, validated coding method. Using negative binomial regression, the association of number of followers and frequency of individual tweet content at baseline was assessed. The difference in followership at 6 months (compared to baseline) to the frequency of tweet content was compared using linear regression. Both analyses were adjusted by account type (organizational or not organizational).

Results

The 18 accounts had 60,609 followers at baseline and 68,167 at 6 months. A total of 24% of tweets were socioemotional support (mean 11.8, SD 9.8), 14% (mean 7, SD 8.4) were encouraging/engagement, and 62% (mean 31.2, SD 15.2) were informational. At baseline, higher frequency of socioemotional support and encouraging/engaging tweets was significantly associated with higher number of followers (socioemotional: incident rate ratio [IRR] 1.09, 95% CI 1.02-1.20; encouraging/engaging: IRR 1.06, 95% CI 1.00-1.12). Conversely, higher frequency of informational tweets was significantly associated with lower number of followers (IRR 0.95, 95% CI 0.92-0.98). At 6 months, for every increase by 1 in socioemotional tweets, the change in followership significantly increased by 43.94 (P=.027); the association was slightly attenuated after adjusting by account type and was not significant (P=.064).

Conclusions

Smoking cessation activity does exist on Twitter. Preliminary findings suggest that certain content strategies can be used to encourage followership, and this needs to be further investigated.     

A normal ovary in an abnormal location: A case of torsion

The clinical and radiologic diagnosis of adnexal torsion is challenging. The patient's history, physical examination, and laboratory evaluation may overlap significantly with other causes of abdominal pain. Ultrasound is the most common radiologic tool to assess for torsion, and the imaging findings can be equally equivocal. We present a case of adnexal torsion in an 18‐year‐old emergency room patient with abdominal pain, diagnosed by ultrasound based solely on an abnormal medial position of the ovary–a finding that has been only rarely mentioned in the literature, and never in isolation. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 43 :578–580, 2015