Video Visits are Practical for the Follow-up and Management of Established Male Infertility Patients

ObjectiveTo study the use of video visits for male infertility care prior to the COVID-19 pandemic METHODS: We reviewed video visits for male infertility patients completed at a tertiary academic center in southeast Michigan. These patients had follow-up after an initial in-person evaluation. We designed this retrospective case series to describe the diagnostic categories seen through telehealth, management steps completed during video visits, and to understand whether additional in-person care was required within 90 days of video visits. In addition, we estimated time and cost savings for patients attributed to video visits.ResultsMost men seen during video visits had an endocrinologic (29%) or anatomic (21%) cause for their infertility. 73% of video visits involved reviewing results; 30% included counseling regarding assistive reproductive technologies; and 25% of video visits resulted in prescribing hormonally active medications. The two patients (3%) who were seen in clinic after their video visit underwent a varicocelectomy in the interim. No patients required an unplanned in-person visit. From a patient perspective, video visits were estimated to save a median of 97 minutes (IQR 64-250) of travel per visit. Median cost savings per patient- by avoiding travel and taking time off work for a clinic visit-were estimated to range from $149 (half day off) to$252 (full day off).ConclusionVideo visits for established male infertility patients were used to manage different causes of infertility while saving patients time and money. Telehealth for established patients did not trigger additional in-person evaluations

What Is a Normal Testosterone Level for Young Men? Rethinking the 300 ng/dL Cutoff for Testosterone Deficiency in Men 20-44 Years Old

PurposeThere is an age-related decline in male testosterone production. It is therefore surprising that young men are evaluated for testosterone deficiency with the same cutoff of 300 ng/dL that was developed from samples of older men. Our aim is to describe normative total testosterone levels and age-specific cutoffs for low testosterone levels in men 20 to 44 years old.Materials and methodsWe analyzed the 2011-2016 National Health and Nutrition Examination Surveys, which survey nationally representative samples of United States residents. Men 20 to 44 years old with testosterone levels were included. Men on hormonal medications, with a history of testicular cancer or orchiectomy, and with afternoon/evening laboratory values were excluded. We separated men into 5-year intervals and evaluated the testosterone levels of each age group, and for all men 20 to 44 years old. We used the American Urological Association definition of a "normal testosterone level" (the "middle tertile") to calculate age-specific cutoffs for low testosterone levels.ResultsOur final analytic cohort contained 1,486 men. Age-specific middle tertile levels were 409-558 ng/dL (20-24 years old), 413-575 ng/dL (25-29 years old), 359-498 ng/dL (30-34 years old), 352-478 ng/dL (35-39 years old), and 350-473 ng/dL (40-44 years old). Age-specific cutoffs for low testosterone levels were 409, 413, 359, 352, and 350 ng/dL, respectively.ConclusionsDiagnosis of testosterone deficiency has traditionally been performed in an age-indiscriminate manner. However, young men have different testosterone reference ranges than older men. Accordingly, age-specific normative values and cutoffs should be integrated into the evaluation of young men presenting with testosterone deficiency

Favorable Selection in Medicare Advantage is Linked to Inflated Benchmarks and Billions in Overpayments to Plans

Increases in Medicare Advantage (MA) enrollment, coupled with concerns about overpayment to plans, have prompted calls for change. Benchmark setting in MA, which determines plan payment, has received relatively little attention as an avenue for reform. In this study we used national data from the period 2010-20 to examine the relationships among unobserved favorable selection, benchmark setting, and payments to plans in MA. We found that unobserved favorable selection in MA led to underpayment to counties with lower MA penetration and overpayment to counties with higher MA penetration. Because the distribution of MA beneficiaries has shifted over time toward counties that were overpaid, we estimate that plans were overpaid by an average of $9.3 billion per year between 2017 and 2020. Changes to risk adjustment in benchmark setting could likely mitigate the impact of favorable selection in MA

The impact of BRAF mutation status on clinical outcomes with anti- PD- 1 monotherapy versus combination ipilimumab/nivolumab in treatment- naïve advanced stage melanoma

Nearly half of all metastatic melanoma patients possess the BRAF V600 mutation. Several therapies are approved for advanced stage melanoma, but it is unclear if there is a differential outcome to various immunotherapy regimens based on BRAF mutation status. We retrospectively analyzed a cohort of metastatic or unresectable melanoma patients who were treated with combination ipilimumab/nivolumab (ipi/nivo) or anti- PD- 1 monotherapy, nivolumab, or pembrolizumab, as first- line treatment. 235 previously untreated patients were identified in our study. Our univariate analysis showed no statistical difference in progression- free survival (PFS) or overall survival (OS) with ipi/nivo versus anti- PD- 1 monotherapy in the BRAF V600 mutant cohort, but there was improved PFS [HR: 0.48, 95% CI, 0.28- 0.80] and OS [HR: 0.50, 95% CI, 0.26- 0.96] with ipi/nivo compared to anti- PD- 1 monotherapy in the BRAF WT group. After adjusting for known prognostic variables in our multivariable analysis, the BRAF WT cohort continued to show PFS and OS benefit with ipi/nivo compared to anti- PD- 1 monotherapy. Our single- institution analysis suggests ipi/nivo should be considered over anti- PD- 1 monotherapy as the initial immunotherapy regimen for metastatic melanoma patients regardless of BRAF mutation status, but possibly with greater benefit in BRAF WT.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/167487/1/pcmr12944_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/167487/2/pcmr12944.pd

Individualized Out-of-Pocket Price Estimators for “Shoppable” Surgical Procedures: A Nationwide Cross-Sectional Study of US Hospitals

Objective:. To estimate the nationwide prevalence of individualized out-of-pocket (OOP) price estimators at US hospitals, characterize patterns of inclusion of 14 specified “shoppable” surgical procedures, and determine hospital-level characteristics associated with estimators that include surgical procedures. Background:. Price transparency for shoppable surgical services is a key requirement of several recent federal policies, yet the extent to which hospitals provide online OOP price estimators remains unknown. Methods:. We reviewed a stratified random sample of 485 U.S. hospitals for the presence of a tool to allow patients to estimate individualized OOP expenses for healthcare services. We compared characteristics of hospitals that did and did not offer online price estimators and performed multivariable modeling to identify facility-level predictors of hospitals offering price estimator with and without surgical procedures. Results:. Nearly two-thirds (66.0%) of hospitals in the final sample (95% confidence interval 61.6%–70.1%) offered an online tool for estimating OOP healthcare expenses. Approximately 58.5% of hospitals included at least one shoppable surgical procedure while around 6.6% of hospitals included all 14 surgical procedures. The most common price reported was laparoscopic cholecystectomy (55.1%), and the least common was recurrent cataract removal (20.0%). Inclusion of surgical procedures varied by total annual surgical volume and health system membership. Only 26.9% of estimators explicitly included professional fees. Conclusions:. Our findings highlight an ongoing progress in price transparency, as well as key areas for improvement in future policies to help patients make more financially informed decisions about their surgical care

Multi‐Institutional Analysis of Outcomes in Supraglottic Jet Ventilation with a Team‐Based Approach

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/170206/1/lary29431.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/170206/2/lary29431_am.pd

Bone Metastases, Skeletal-Related Events, and Survival in Patients With Metastatic Non-Small Cell Lung Cancer Treated With Immune Checkpoint Inhibitors

BACKGROUND: Bone metastases and skeletal-related events (SREs) are a frequent cause of morbidity in patients with metastatic non-small cell lung cancer (mNSCLC). Data are limited on bone metastases and SREs in patients with mNSCLC treated using immune checkpoint inhibitors (ICIs), and on the efficacy of bone-modifying agents (BMAs) in this setting. Here we report the incidence, impact on survival, risk factors for bone metastases and SREs, and impact of BMAs in patients with mNSCLC treated with ICIs in a multi-institutional cohort. PATIENTS AND METHODS: We conducted a retrospective study of patients with mNSCLC treated with ICIs at 2 tertiary care centers from 2014 through 2017. Overall survival (OS) was compared between patients with and without baseline bone metastases using a log-rank test. A Cox regression model was used to evaluate the association between OS and the presence of bone metastases at ICI initiation, controlling for other confounding factors. RESULTS: We identified a cohort of 330 patients who had received ICIs for metastatic disease. Median patient age was 63 years, most patients were treated in the second line or beyond (n=259; 78%), and nivolumab was the most common ICI (n=211; 64%). Median OS was 10 months (95% CI, 8.4-12.0). In our cohort, 124 patients (38%) had baseline bone metastases, and 43 (13%) developed SREs during or after ICI treatment. Patients with bone metastases had a higher hazard of death after controlling for performance status, histology, line of therapy, and disease burden (hazard ratio, 1.57; 95% CI, 1.19-2.08; P=.001). Use of BMAs was not associated with OS or a decreased risk of SREs. CONCLUSIONS: Presence of bone metastases at baseline was associated with a worse prognosis for patients with mNSCLC treated with ICI after controlling for multiple clinical characteristics. Use of BMAs was not associated with reduced SREs or a difference in survival