Impact of insurance payer and socioeconomic status on type of autologous breast reconstruction

IntroductionAutologous breast reconstruction has evolved from more morbid procedures that sacrificed the abdominal muscle (the TRAM or transverse rectus abdominus muscle flap) to “perforator” flaps. Commercial insurers recognized the higher technical demand of perforator flaps by creating procedural codes with higher professional fees. This study examined whether procedure code discrepancies between insurance payers disproportionally incentivize perforator flaps among the commercially insured.MethodsAutologous breast reconstructions identified from the National Inpatient Sample (NIS) were subdivided into microvascular perforator (85.74, 85.75, 85.76), microvascular TRAM (85.73), and pedicled TRAM flaps (85.72). Demographics, comorbidities and access to care were compared. A logistic regression comparing microvascular reconstructions only was used to identify predictors for perforator flap reconstruction.ResultsA total of 66,968 cases of autologous breast reconstruction were identified. Perforator flaps were more likely among the commercially insured (p < 0.001) and higher insurance quartiles (p < 0.001).When comparing microvascular reconstruction, perforator flaps were 1.72 (p < 0.001) times more likely among the commercially insured. As compared to the lowest income quartile, the fourth quartile had an odds ratio of 1.36 (p < 0.001) for perforator flap reconstruction.ConclusionThe presence of a separate perforator flap billing code among the commercially insured may be exacerbating existing socioeconomic disparities in breast cancer reconstruction.     

口腔埋伏牙自体移植的临床研究

目的 探讨埋伏牙、易位牙再植的方法和临床疗效.方法 选择埋伏或易位的上前牙18颗,微创拔出错位牙,修整牙槽窝,立即植入牙槽窝内,结扎固定.术后1、2、3、4、5、6、12个月复查再植牙的松动度、牙髓活力、X线片.结果 18颗牙再植术后6个月各项指标正常,临床效果满意.结论 埋伏牙或易位牙可通过拔牙再植的方法恢复正常的咬合关系和咀嚼功能.     

Clinical outcome after 36 months of treatment with injections of autologous blood for recurrent dislocation of the temporomandibular joint

We investigated the prognosis after three years of treatment for recurrent dislocation of the temporomandibular joint with autologous blood given intravenously in 21 patients with a mean (range) age 64 (17-92) years of whom 16 had coexisting systemic disease. The mean (range) follow up from the first injection was 64 (41-99) months. Eighteen patients had no recurrence during the first 36 months after their first injection, which showed that this minimally-invasive treatment was effective, particularly for those who had conditions that made a mouthpiece or operation unsuitable.     

Autologous Stem Cell Transplantation in Patients With Multiple Myeloma: An Activity-based Costing Analysis,Comparing a Total Inpatient Model Versus an Early Discharge Model

BackgroundActivity-based costing (ABC) was developed and advocated as a means of overcoming the systematic distortions of traditional cost accounting.Materials and MethodsWe calculated the cost of high-dose chemotherapy and autologous stem cell transplantation (ASCT) in patients with multiple myeloma using the ABC method, through 2 different care models: the total inpatient model (TIM) and the early-discharge outpatient model (EDOM) and compared this with the approved diagnosis related-groups (DRG) Italian tariffs.ResultsThe TIM and EDOM models involved a total cost of €28,615.15 and €16,499.43, respectively. In the TIM model, the phase with the greatest economic impact was the posttransplant (recovery and hematologic engraftment) with 36.4% of the total cost, whereas in the EDOM model, the phase with the greatest economic impact was the pretransplant (chemo-mobilization, apheresis procedure, cryopreservation, and storage) phase, with 60.4% of total expenses. In an analysis of each episode, the TIM model comprised a higher absorption than the EDOM. In particular, the posttransplant represented 36.4% of the total costs in the TIM and 17.7% in EDOM model, respectively. The estimated reduction in cost per patient using an EDOM model was over €12,115.72. The repayment of the DRG in Calabrian Region for the ASCT procedure is €59,806. Given the real cost of the transplant, the estimated cost saving per patient is €31,190.85 in the TIM model and €43,306.57 in the EDOM model.ConclusionIn conclusion, the actual repayment of the DRG does not correspond to the real cost of the ASCT procedure in Italy. Moreover, using the EDOM, the cost of ASCT is approximately the half of the TIM model.     

Optimal treatment strategies in myeloma: An argument against maintenance therapy after autologous stem cell transplantation

Despite continuing advancements in novel therapeutics for multiple myeloma (MM), high-dose therapy with autologous stem cell rescue continues to represent the standard approach to treat transplant-eligible, newly diagnosed patients. As the disease remains essentially incurable, and median progression-free survival (PFS) times after autologous transplant are measured in years and not decades, attempts to improve outcomes in the post-transplant setting have been extensive and commonly focused on a “maintenance” approach. Although multiple trials have demonstrated PFS advantages for a variety of maintenance strategies, it is our position that the potential risks outweigh the benefits of this approach and this should not be the standard of care outside of clinical trials.     

Second malignancies in multiple myeloma; emerging patterns and future directions

The changing landscape of treatment options for multiple myeloma has led to a higher proportion of patients achieving deep, long-lasting responses to therapy. With the associated improvement in overall survival, the development of subsequent second malignancies has become of increased significance. The risk of second malignancy after multiple myeloma is affected by a combination of patient-, disease- and therapy-related risk factors. This review discusses recent data refining our knowledge of these contributing factors, including current treatment modalities which increase risk (i.e. high-dose melphalan with autologous stem cell transplant and lenalidomide maintenance therapy). We highlight emerging data towards individualized risk- and response-adapted treatment strategies and discuss key areas requiring future research.