The impact of a Medicare Public Health Emergency policy change for continuous glucose monitors on utilization and total cost of care for diabetes

Home glucose monitoring was revolutionized in 1999 when the U.S. Food and Drug Administration (FDA) approved the first professional continuous glucose monitor (CGM). With the advancements in technology, newer CGMs are available for personal use and have greatly impacted the way diabetes is managed. Although there are data regarding the benefits of CGMs in lowering hemoglobin A1c, data is currently lacking regarding whether the use of CGM affects the number of hospitalization/emergency department visits as well as the effect on cost of care. In addition, while CGMs have been traditionally used in patients with type 1 diabetes due to their insulin necessity, they have also shown benefit in patients with type 2 diabetes on basal-bolus insulin therapy. According to Ruedy et al, “Continuous Glucose Monitoring in Older Adults with Type 1 and Type 2 Diabetes using Multiple Daily Injections of Insulin”, use of CGMs was associated with improvements in hemoglobin A1c as well as reduction in glycemic variability. Criteria for coverage of CGMs for Medicare beneficiaries is outlined in the Local Coverage Determination (LCD) L33822 “Glucose Monitors;” use is restricted to patients with diabetes using multiple daily insulin injections that had been testing blood sugar at least four times per day with traditional finger stick tests. On March 30th, 2020, the Centers for Medicare and Medicaid Services (CMS), in response to the COVID-19 Public Health Emergency (PHE), issued a memo allowing Medicare plans to relax requirements on coverage of CGMs to provide better access. At this time, PHA lifted the prior authorization requirement on the preferred therapeutic CGM (Dexcom®) for Medicare beneficiaries. The purpose of this study is to explore the effects of the PHE removal of PA on utilization of CGMs, impact on management of diabetes, and total cost of care related to diabetes. This is a single institution, retrospective data and chart review of PHA Medicare members with a diagnosis of diabetes utilizing a CGM and continuous enrollment from April 2019 through March 2021. Patients were identified using eligibility information, primary ICD-10 codes for diabetes (type 1 diabetes, type 2 diabetes, or other diabetes), and if members had a claim for a CGM from April 2020 through March 2021. The primary outcome is the utilization of CGM and total cost of care related to diabetes to the health plan and members pre and post removal of PA. The secondary outcomes include member’s hemoglobin A1c and number of hospitalization/ED visits related to diabetes pre and post removal of PA. The outcomes will be compared against two different reporting periods: the baseline reporting period from April 2019 through March 2020 and the comparator reporting period from April 2020 through March 2021. Data regarding utilization, cost, hospitalization/ED visits, and adherence will be pulled from claims data. Chart review will be conducted for Medicare members with access to electronic medical records (EMR) to analyze hemoglobin A1c. Results and conclusions will be shared when the project is completed. (IRB Approved)https://digitalcommons.psjhealth.org/oaa_ppmcstvin_22/1016/thumbnail.jp

Data quality predicts care quality: findings from a national clinical audit

Background: Missing clinical outcome data are a common occurrence in longitudinal studies. Data quality in clinical audit is a particular cause for concern. The relationship between departmental levels of missing clinical outcome data and care quality is not known. We hypothesise that completeness of key outcome data in a national audit predicts departmental performance. Methods: The National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis (NCAREIA) collected data on care of patients with suspected rheumatoid arthritis (RA) from early 2014 to late 2015. This observational cohort study collected data on patient demographics, departmental variables, service quality measures including time to treatment, and the key RA clinical outcome measure, disease activity at baseline, and 3 months follow-up. A mixed effects model was conducted to identify departments with high/low proportions of missing baseline disease activity data with the results plotted on a caterpillar graph. A mixed effects model was conducted to assess if missing baseline disease activity predicted prompt treatment. Results: Six thousand two hundred five patients with complete treatment time data and a diagnosis of RA were recruited from 136 departments. 34.3% had missing disease activity at baseline. Mixed effects modelling identified 13 departments with high levels of missing disease activity, with a cluster observed in the Northwest of England. Missing baseline disease activity was associated with not commencing treatment promptly in an adjusted mix effects model, odds ratio 0.50 (95% CI 0.41 to 0.61, p < 0.0001). Conclusions: We have shown that poor engagement in a national audit program correlates with the quality of care provided. Our findings support the use of data completeness as an additional service quality indicator

Herbicide-Resistant Soybeans in Arkansas: Lessons Learned and Future Direction

In Arkansas Delta soybean production, glyphosate resistant (GR) Palmer amaranth has significantly impacted weed management. The incidence of herbicide resistant (HR) weeds has farreaching crop science, economic, and communications implications, which have been explored by the corresponding expertise of our research team members to form a comprehensive literature review. The review was used to develop policy recommendations to address current and future HR genetically modified (GM) crop use and the associated issues. The review of crop science research indicated an overall increase in herbicide application, as well as an increase in weed management programs focused around glyphosate rather than the application of multiple herbicides. The review also revealed some management methods have potential to resolve the problem, including alternating herbicide application, avoiding sub-lethal rates, using “burn down” herbicides prior to planting, crop rotation, tillage, and zero tolerance weed policies. The use of fewer herbicides rather than multiple types creates a monopolistic edge for the companies producing those few herbicides, allowing greater market control. Crisis communication methods, including developing internal readiness, conducting needs assessments, developing a relevant message, and conveying the message through appropriate channels, can be used to develop a response to the issue that will best communicate necessary information to the target audience. The team used these findings to formulate policy recommendations, which include management, economic, and communication plans that may provide a starting point to address the issue

Harm Reduction in West Virginia: Do Needle Exchange Programs Reduce Disease and Decrease Costs?

Needle Exchange Programs (NEP)s were created to help users exchange used needles for new sterile ones and become aware of treatment and rehabilitation options. This study aimed to determine the effectiveness of NEPs and their impact on reducing HIV and Hepatitis C infections in West Virginia and decreasing health care costs for the community. Based on studies conducted on the past implementation of needle exchange programs, it is suggested that there has been evidence that closing these programs can have a broad societal impact on the spread of HIV and hepatitis C and the associated costs. In addition, the community consequences of closing one extensive SNP in Charleston, West Virginia, were reported

MEMS practice, from the lab to the telescope

Micro-electro-mechanical systems (MEMS) technology can provide for deformable mirrors (DMs) with excellent performance within a favorable economy of scale. Large MEMS-based astronomical adaptive optics (AO) systems such as the Gemini Planet Imager are coming on-line soon. As MEMS DM end-users, we discuss our decade of practice with the micromirrors, from inspecting and characterizing devices to evaluating their performance in the lab. We also show MEMS wavefront correction on-sky with the "Villages" AO system on a 1-m telescope, including open-loop control and visible-light imaging. Our work demonstrates the maturity of MEMS technology for astronomical adaptive optics.Comment: 14 pages, 15 figures, Invited Paper, SPIE Photonics West 201

Stroke saturation on a MEMS deformable mirror for woofer-tweeter adaptive optics

High-contrast imaging of extrasolar planet candidates around a main-sequence star has recently been realized from the ground using current adaptive optics (AO) systems. Advancing such observations will be a task for the Gemini Planet Imager, an upcoming "extreme" AO instrument. High-order "tweeter" and low-order "woofer" deformable mirrors (DMs) will supply a >90%-Strehl correction, a specialized coronagraph will suppress the stellar flux, and any planets can then be imaged in the "dark hole" region. Residual wavefront error scatters light into the DM-controlled dark hole, making planets difficult to image above the noise. It is crucial in this regard that the high-density tweeter, a micro-electrical mechanical systems (MEMS) DM, have sufficient stroke to deform to the shapes required by atmospheric turbulence. Laboratory experiments were conducted to determine the rate and circumstance of saturation, i.e. stroke insufficiency. A 1024-actuator 1.5-um-stroke MEMS device was empirically tested with software Kolmogorov-turbulence screens of r_0=10-15cm. The MEMS when solitary suffered saturation ~4% of the time. Simulating a woofer DM with ~5-10 actuators across a 5-m primary mitigated MEMS saturation occurrence to a fraction of a percent. While no adjacent actuators were saturated at opposing positions, mid-to-high-spatial-frequency stroke did saturate more frequently than expected, implying that correlations through the influence functions are important. Analytical models underpredict the stroke requirements, so empirical studies are important.Comment: 16 pages, 10 figure

Occupational impacts of early inflammatory arthritis : results from the National Early Inflammatory Arthritis Audit

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