Ravi B. Parikh

Early Specialty Palliative Care — Translating Data in Oncology into Practice

For most patients with serious illness, palliative care is provided only near the end of life. The authors review studies showing that earlier palliative care can improve quality of life and reduce health care costs and argue that such care should be standard in serious illness.

Integrating Predictive Analytics Into High-Value Care: The Dawn of Precision Delivery

United States health care costs are twice as high as spending in most industrialized countries. One key opportunity for health systems to improve value is by limiting overuse of costly resources, in part by focusing these resources toward high-risk patient groups.1 Some health systems have been using retrospective claims data or other approaches, like the Framingham risk model, to identify high-risk individuals. However, most systems today are doing little in the way of risk stratification, and physicians often find it difficult to apply these characterizations of risk to the care of an individual patient. Electronic health records (EHRs) have held the promise of allowing clinicians and health systems to determine an individual’s real-time risk of a clinical event through predictive analytics. The use of EHRs is becoming ubiquitous in the United States. This sea change can be linked with advances in big data techniques and computerized decision support to transform health care delivery. Just as “precision medicine” is generally linked to the concept of using genetic and genomic data to personalize treatments, “precision delivery” involves using an individual’s electronic health data to predict risk and personalize care to substantially improve value. In this Viewpoint, we make the case for precision delivery by describinghowsomehealthsystemsarebeginningtosuccessfully implement analytics into practice and discussing future directions for using predictive analytics to improve value.

Cost-effectiveness analysis of SBRT versus IMRT for low-risk prostate cancer.

Objectives:Intensity-modulated radiation therapy (IMRT) has been established as the standard external-beam modality in treating low-risk prostate cancer. Stereotactic body radiotherapy (SBRT) is a novel approach involving high-dose radiotherapy in 5 fractions. This analysis compared their cost-effectiveness. Methods:A Markov model was constructed to delineate the health states after treatment with IMRT and SBRT. Disease, treatment, and toxicity data were extracted from the literature. Costs included both robotic (R-SBRT) and nonrobotic (NR-SBRT) reimbursement. Deterministic and probabilistic sensitivity analyses (PSA) were performed over a wide range of potential parameters. Results:The quality-adjusted life expectancy after IMRT was slightly higher than after SBRT, because we assumed worse toxicity after SBRT. However, the incremental cost-effectiveness ratios (ICER) for IMRT over R-SBRT and NR-SBRT were

Early specialty palliative care.

285,000 and

Primary radiotherapy versus radical prostatectomy for high-risk prostate cancer: a decision analysis.

591,100/quality-adjusted life year (QALY), respectively. On sensitivity analysis, SBRT was almost always the cost-effective therapy, in which the ICER for IMRT was generally over

Beyond Genes and Molecules — A Precision Delivery Initiative for Precision Medicine

100,000/QALY. Reimbursement for R-SBRT versus NR-SBRT significantly influenced its ICER. Treatment efficacy, rectal toxicity and impotence, and the potential for unforeseen SBRT late effects were the most critical parameters in the model; when including these uncertain parameters in a PSA, SBRT was still most likely to be cost-effective at a willingness to pay of

The Older Americans Act at 50 — Community-Based Care in a Value-Driven Era

100,000/QALY. Conclusions:SBRT clearly contained more value than IMRT for external-beam treatment. Given the increasing prevalence of the disease and its superb convenience, intensive research should be performed on this novel modality, including the marginal benefit and cost of robotic treatment.

Getting Real about Health Care Costs — A Broader Approach to Cost Stewardship in Medical Education

n engl j med 370;11 nejm.org march 13, 2014 1074 DNA mutations and deficiencies in mitochondrial oxidative phosphorylation in aging skeletal muscle.2 The expression of the peroxisome-proliferator–activated receptor γ coactivator 1α (PGC-1α), nuclear respiratory factor 1, and cytochrome c is substantially lower in the heart and skeletal muscle of old persons.3 An age-associated lack of PGC-1α induction has also been reported in the skeletal muscle of old animals.4 The transgenic overexpression of PGC-1α efficiently prevents sarcopenia in old mice by limiting the degradation of muscle proteasome and apoptosis.5 All these facts highlight the role of most mitochondrial proteins, and probably those involved in mitochondrial fission and fusion, in the loss of muscle mass associated with aging and emphasize the importance of mitochondria as targets for pharmacologic interventions intended to prevent sarcopenia.

Ocular findings at initial pan retinal photocoagulation for proliferative diabetic retinopathy predict the need for future pars plana vitrectomy.

Two evidence‐based therapies exist for the treatment of high‐risk prostate cancer (PCA): external‐beam radiotherapy (RT) with hormone therapy (H) (RT + H) and radical prostatectomy (S) with adjuvant radiotherapy (S + RT). Each of these strategies is associated with different rates of local control, distant metastasis (DM), and toxicity. By using decision analysis, the authors of this report compared the quality‐adjusted life expectancy (QALE) between men with high‐risk PCA who received RT + H versus S + RT versus a hypothetical trimodality therapy (S + RT + H).

Risk factors associated with the relapse of uveitis in patients with juvenile idiopathic arthritis: a preliminary report

The Precision Medicine Initiative’s advances may add complexity to delivering high-quality, cost-effective care in keeping with patients’ values. A complementary effort could investigate delivery-system interventions that are tailored to individual needs and wishes.