Modifying the current fee-for-service payment system for cancer therapy with feedback data and financial incentives that reward outcomes and cost efficiency resulted in a significant total cost reduction. Eliminating existing financial chemotherapy drug incentives paradoxically increased the use of chemotherapy.

How much space do drivers provide when passing cyclists? Understanding the impact of motor vehicle and infrastructure characteristics on passing distance. Accident Analysis & Prevention

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BackgroundNewer systemic therapies have the potential to decrease morbidity and mortality from metastatic colorectal cancer, yet such therapies are costly and have side effects. Little is known about their non-evidence-based use.MethodsWe conducted a retrospective cohort study using commercial insurance claims from UnitedHealthcare, and identified incident cases of metastatic colon cancer (mCC) from July 2007 through April 2010. We evaluated the use of three regimens with recommendations against their use in the National Comprehensive Cancer Center Network Guidelines, a commonly used standard of care: 1) bevacizumab beyond progression; 2) single agent capecitabine as a salvage therapy after failure on a fluoropyridimidine-containing regimen; 3) panitumumab or cetuximab after progression on a prior epidermal growth factor receptor antibody. We performed sensitivity analyses of key assumptions regarding cohort selection. Costs from a payer perspective were estimated using the average sales price for the entire duration and based on the number of claims.ResultsA total of 7642 patients with incident colon cancer were identified, of which 1041 (14%) had mCC. Of those, 139 (13%) potentially received at least one of the three unsupported off-label (UOL) therapies; capecitabine was administered to 121 patients and 49 (40%) likely received it outside of clinical guidelines, at an estimated cost of $718,000 for 218 claims. Thirty-eight patients received panitumumab and six patients (16%) received it after being on cetuximab at least two months, at an estimated cost of $69,500 for 19 claims. Bevacizumab was administered to 884 patients. Of those, 90 (10%) patients received it outside of clinical guidelines, at an estimated costs of $1.34 million for 636 claims.ConclusionsIn a large privately insured mCC cohort, a substantial number of patients potentially received UOL treatment. The economic costs and treatment toxicities of these therapies warrant increased efforts to stem their use in settings lacking sufficient scientific evidence.

Introduction: Microaggressions are subtle statements or actions that reinforce stereotypes. Medical students, residents, and faculty report experiences of microaggressions, with higher incidences among women and marginalized groups. An educational tool utilizing the acronym VITALS (validate, inquire, take time, assume, leave opportunities, speak up) provided a framework for processing and addressing microaggressions encountered in the academic health center environment. Methods: We developed a 60-minute workshop designed to raise awareness of microaggressions encountered by medical students and trainees. The workshop consisted of a didactic presentation and multiple interactive exercises shared in small-and large-group formats. Participants also completed pre-and postsurvey instruments to assess changes in their knowledge and attitudes about promoting an environment that prevents microaggressions from occurring. Results: There were 176 participants who completed our workshop. In comparing anonymized pre-and postworkshop responses submitted by attendees, an increase in recognition of one's own potential stereotypical beliefs about social identity groups was observed. Participants also expressed a greater sense of empowerment to foster mutual respect in health care settings. After completing the workshop, attendees indicated a greater likelihood to engage in difficult conversations, including responding to microaggressions, which both peers and superiors encountered in both academic and clinical environments. Discussion: The workshop provided an interactive format for medical students and trainees to gain awareness, knowledge, and tools for addressing microaggressions encountered in health care settings.