Large variations in the prices of urologic procedures at academic medical centers 1 year after implementation of the Price Transparency Final Rule

IMPORTANCE: Patients with urologic diseases often experience financial toxicity, defined as high levels of financial burden and concern, after receiving care. The Price Transparency Final Rule, which requires hospitals to disclose both the commercial and cash prices for at least 300 services, was implemented to facilitate price shopping, decrease price dispersion, and lower health care costs. OBJECTIVE: To evaluate compliance with the Price Transparency Final Rule and to quantify variations in the price of urologic procedures among academic hospitals and by insurance class. DESIGN, SETTING, AND PARTICIPANTS: This was a cross-sectional study that determined the prices of 5 common urologic procedures among academic medical centers and by insurance class. Prices were obtained from the Turquoise Health Database on March 24, 2022. Academic hospitals were identified from the Association of American Medical Colleges website. The 5 most common urologic procedures were cystourethroscopy, prostate biopsy, laparoscopic radical prostatectomy, transurethral resection of the prostate, and ureteroscopy with laser lithotripsy. Using the corresponding Current Procedural Terminology codes, the Turquoise Health Database was queried to identify the cash price, Medicare price, Medicaid price, and commercial insurance price for these procedures. EXPOSURES: The Price Transparency Final Rule, which went into effect January 1, 2021. MAIN OUTCOMES AND MEASURES: Variability in procedure price among academic medical centers and by insurance class (Medicare, Medicaid, commercial, and cash price). RESULTS: Of 153 hospitals, only 20 (13%) listed a commercial price for all 5 procedures. The commercial price was reported most often for cystourethroscopy (86 hospitals [56%]) and least often for laparoscopic radical prostatectomy (45 hospitals [29%]). The cash price was lower than the Medicare, Medicaid, and commercial price at 24 hospitals (16%). Prices varied substantially across hospitals for all 5 procedures. There were significant variations in the prices of cystoscopy (χ23 = 85.9; P = .001), prostate biopsy (χ23 = 64.6; P = .001), prostatectomy (χ23 = 24.4; P = .001), transurethral resection of the prostate (χ23 = 51.3; P = .001), and ureteroscopy with laser lithotripsy (χ23 = 63.0; P = .001) by insurance type. CONCLUSIONS AND RELEVANCE: These findings suggest that, more than 1 year after the implementation of the Price Transparency Final Rule, there are still large variations in the prices of urologic procedures among academic hospitals and by insurance class. Currently, in certain situations, health care costs could be reduced if patients paid out of pocket. The Centers for Medicare & Medicaid Services may improve price transparency by better enforcing penalties for noncompliance, increasing penalties, and ensuring that hospitals report prices in a way that is easy for patients to access and understand

Age-related endolysosome dysfunction in the rat urothelium.

Lysosomal dysfunction is associated with a number of age-related pathologies that affect all organ systems. While much research has focused on neurodegenerative diseases and aging-induced changes in neurons, much less is known about the impact that aging has on lower urinary tract function. Our studies explored age-dependent changes in the content of endo-lysosomal organelles (i.e., multivesicular bodies, lysosomes, and the product of their fusion, endolysosomes) and age-induced effects on lysosomal degradation in the urothelium, the epithelial tissue that lines the inner surface of the bladder, ureters, and renal pelvis. When examined by transmission electron microscopy, the urothelium from young adult rats (~3 months), mature adult rats (~12 months), and aged rats (~26 months old) demonstrated a progressive age-related accumulation of aberrantly large endolysosomes (up to 7μm in diameter) that contained undigested content, likely indicating impaired degradation. Stereological analysis confirmed that aged endolysosomes occupied approximately 300% more volume than their younger counterparts while no age-related change was observed in multivesicular bodies or lysosomes. Consistent with diminished endolysosomal degradation, we observed that cathepsin B activity was significantly decreased in aged versus young urothelial cell lysates as well as in live cells. Further, the endolysosomal pH of aged urothelium was higher than that of young adult (pH 6.0 vs pH 4.6). Our results indicate that there is a progressive decline in urothelial endolysosomal function during aging. How this contributes to bladder dysfunction in the elderly is discussed

Second primary malignancies in patients with haematological cancers treated with lenalidomide: a systematic review and meta-analysis

Background Lenalidomide has been standard therapy for multiple myeloma and other haematological malignancies for more than a decade. Previous meta-analyses identified an association between lenalidomide and second primary malignancies (SPM) in patients with multiple myeloma. However, newer randomised controlled trials using lenalidomide for other indications have not reported an increased incidence of SPM. The aim of this study was to investigate the risk of developing SPM with lenalidomide use in all disease settings. Methods We did a systematic review of randomised controlled trials that reported SPM in patients treated with lenalidomide. PubMed, Embase, CENTRAL, Europe PubMed Central, and ClinicalTrials.gov were searched from Jan 1, 2004, to March 18, 2022. Randomised controlled trials with at least one lenalidomide group and one non-lenalidomide group were selected, regardless of the disease setting. Studies with a median follow-up of less than 12 months were excluded. Summary data were extracted by two reviewers (KS and KL) independently and verified by a third reviewer (JF). We then conducted a meta-analysis to assess the risk ratio (RR) of SPM with lenalidomide use across various disease subtypes using a random-effects model. We chose random effects for the primary analysis because of anticipated heterogeneity between different diseases, but we used fixed effects for stratified meta-analysis of multiple myeloma studies. Risk of bias was assessed with the PROTECT tool. The study was registered with PROSPERO, CRD42021257508. Findings Our search yielded 9078 studies, and 38 trials that included 14 058 patients were eligible for meta-analysis after screening, 18 of which were in multiple myeloma. The RR across all malignancies was 1·16 (95% CI 0·96–1·39). However, there was heterogeneity across indications (p=0·020). The RR when lenalidomide was used for multiple myeloma was 1·42 (1·09–1·84). There was no increase in SPM in lymphoma or chronic lymphocytic leukaemia (0·90 [0·76–1·08]) and myelodysplastic syndrome (0·96 [0·23–3·97]) trials. In the setting of multiple myeloma, lenalidomide increased both solid and haematological SPM, both in the no-transplantation and post-transplantation settings. From the 38 trials, 21 (55%) had low risk of bias, 12 (32%) had unclear risk of bias, and five (13%) had high risk of bias. Interpretation Based on the current data, lenalidomide-induced SPM seem to occur exclusively in patients with multiple myeloma. Thus, lenalidomide can be used for other indications without the major concern of a therapy-related neoplasm. In the multiple myeloma setting, lenalidomide is an effective drug, but patients should be monitored both for haematological and solid tumour SPM. This monitoring includes patients that have not received autologous haematopoietic stem-cell transplantation. Further investigations are needed to improve understanding on why lenalidomide only promotes SPM in patients with multiple myeloma

Hypertension with unsatisfactory sleep health (HUSH): study protocol for a randomized controlled trial

Abstract Background Insomnia is common in primary care medical practices. Although behavioral treatments for insomnia are safe, efficacious, and recommended in practice guidelines, they are not widely-available, and their effects on comorbid medical conditions remain uncertain. We are conducting a pragmatic clinical trial to test the efficacy of two cognitive behavioral treatments for insomnia (Brief Behavioral Treatment for Insomnia (BBTI) and Sleep Healthy Using the Internet (SHUTi)) versus an enhanced usual care condition (EUC). Methods/Design The study is a three-arm, parallel group, randomized controlled trial. Participants include 625 adults with hypertension and insomnia, recruited via electronic health records from primary care practices affiliated with a large academic medical center. After screening and baseline assessments, participants are randomized to treatment. BBTI is delivered individually with a live therapist via web-interface/telehealth sessions, while SHUTi is a self-guided, automated, interactive, web-based form of cognitive behavioral therapy for insomnia. Participants in EUC receive an individualized sleep report, educational resources, and an online educational video. Treatment outcomes are measured at 9 weeks, 6 months, and 12 months. The primary outcome is patient-reported sleep disturbances. Secondary outcomes include other self-reported sleep measures, home blood pressure, body mass index, quality of life, health functioning, healthcare utilization, and side effects. Discussion This randomized clinical trial compares two efficacious insomnia interventions to EUC, and provides a cost-effective and efficient examination of their similarities and differences. The pragmatic orientation of this trial may impact sleep treatment delivery in real world clinical settings and advance the dissemination and implementation of behavioral sleep interventions. Trial registration ClinicalTrials.gov (Identifier: NCT02508129 ; Date Registered: July 21, 2015)

Ultrastructure of endo-lysosomal organelles in the umbrella cell of young adult rats.

<p>(A) TEM of subapical region of umbrella cells showing the hinge regions of the apical plasma membrane (green arrows), and scattered discoidal/fusiform vesicles (DFVs). (B) Ultrastructure of multivesicular bodies (MVBs) in umbrella cells including those with angular limiting membrane (asterisk) and those with a more spherical morphology and containing numerous intraluminal vesicles (ILVs; indicated by arrows). MVBs have a relatively clear lumen. (C) The lumens of lysosomes (LYS) are electron dense and have a fine granular appearance. (D) Endolysosomes (EL) contain numerous luminally disposed vesicles that are larger than the ILVs within MVBs and are contained within a more electron dense lumen. (E) Autophagosomes (AP) are identified by the presence of a double limiting membrane (yellow arrow).</p

Comparison of endolysosomes in the umbrella cells of young and aged rats.

<p>(A) Umbrella cell from young rat showing typical endolysosomes (EL) ≤ 1 μm in diameter. (B-D) Endolysosomes in aged umbrella cells are generally much larger than those observed in the young and have a tendency to cluster (D). In C, black asterisks denote large luminally disposed vesicles that may represent undigested MVBs. In C-D, white asterisks denote lysosomes that have not yet dispersed their content. In D, the red arrow marks stacked undigested membrane, whereas the dashed red circles highlight areas of possible fusion between adjacent endolysosomes (magnified in the boxed region as an inset.</p

The volume of endolyosomes increases in umbrella cells with age.

<p>(A-C) TEM comparing size of MVBs (yellow structures), endolysosomes (green structures), and lysosomes (purple structures) in umbrella cells taken from young, adult, and aged rats. (D,E) Stereological analysis of the fractional volume (V_v) (D) and total organelle volume (E) of MVBs (yellow bars), endolysosomes (green bars), and lysosomes (purple bars) in umbrella cells. Values represent mean ± standard deviation. Asterisks denote significant differences (p value < 0.05).</p

Features of endolysosomes in aged animals.

<p>(A) Luminally disposed vesicles contain particulate matter (lower white arrow), electron dense cores (upper white arrow), and stacked membrane (red arrows). (B) Some luminally disposed vesicles appeared to protrude from the limiting membrane of endolysosomes (black arrows), and based on their size and the presence of faintly stained ILVs, endolysosomes also contained MVBs. Autophagosomes were sometimes observed in direct contact with the outer limiting membrane of the endolysosome (yellow arrow). (C) A large MVB present in the lumen of the endolysosome. (D) In addition, endolysosomes contain autophagosomal content based on the presence of vesicles with a double limiting membrane (yellow arrow in inset).</p