ABSTRACT The COVID-19 pandemic led to temporary relaxations for telehealth with respect to physician licensure, geographic location, and eligible sites for reimbursement. Earlier policies had impacted the rate of adoption of telehealth and retarded the ability to derive full benefits related to cost, access to care, and quality of care. This aspect is analyzed using 2018 Medicare fee-for-service codes and rates for 10 telemedicine services. Based on the analysis of these data, additional research, and literature review, this report describes how interstate practices can be better leveraged to achieve maximum potential for direct and indirect savings that can accrue through such pragmatic approaches for certain services. The interstate collaborations proposed in this report provide examples of broader telehealth policies that could foster increasing access to quality health care for Medicare beneficiaries and can potentially be used as insight to assist federal and state agencies as they review the continuation, cessation, or modifications of relaxations granted due to the COVID-19 pandemic.
Background: The purpose of this study was to examine the association between baseline skeletal muscle measurements, acute toxicity (immune effector cell–associated neurotoxicity syndrome [ICANS], cytokine release syndrome), and treatment efficacy in patients undergoing CAR T-cell therapy for B-lineage lymphoma. Patients and Methods: Skeletal muscle measurements were obtained from automated CT measurements in 226 consecutive patients who received CAR T-cell therapy between 2015 and 2021. The Kaplan-Meier method was used to examine progression-free survival (PFS) and overall survival (OS) at 1-year. Multivariable regression was used to calculate the hazard ratio (HR) with 95% confidence intervals, adjusted for covariates. Results: The median age of the cohort was 63.1 years (range, 18.5–82.4 years), and most patients were male (66%) and had primary refractory disease (58%). Patients with abnormally low skeletal muscle at baseline were at greater risk of ICANS (HR, 1.74; 95% CI, 1.05–2.87) and had longer length of hospitalization (mean 27.7 vs 22.9 days; P<.05) compared with those with normal muscle mass. Abnormal skeletal muscle was independently associated with risk of disease progression (HR, 1.70; 95% CI, 1.11–2.57) and worse survival (HR, 2.44; 95% CI, 1.49–4.00) at 1 year compared with normal skeletal muscle. Individuals who had abnormal skeletal muscle and high lactate dehydrogenase (LDH) levels at baseline had poor 1-year PFS (17%) and OS (12%) compared with those with normal skeletal muscle and LDH levels (72% and 82%, respectively; P<.001). Patients who had abnormal skeletal muscle and LDH levels had a 5-fold risk (HR, 5.34; 95% CI, 2.97–9.62) of disease progression and a 10-fold risk (HR, 9.73; 95% CI, 4.81–19.70) of death (reference: normal skeletal muscle, normal LDH), independent of prior lines of therapy, extent of residual disease at time of CAR T-cell therapy, functional status, or product. Conclusions: This information can be used for risk stratification prior to CAR T-cell therapy or to implement prehabilitation and nutritional optimization before lymphodepletion as well as thereafter. These efforts will be complementary to ongoing efforts toward sustained efficacy after CAR T-cell therapy.
PURPOSE:Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in patients treated with hematopoietic cell transplantation (HCT), possibly due to depletion of cardiovascular reserve capacity (CVRC) induced by cancer treatment and pre-existing comorbidities. However, there is a paucity of information regarding pre-HCT CVRC, as measured by cardiopulmonary exercise testing (CPET). Less is known about the determinants of CVRC in patients planning to undergo HCT. METHODS: Consecutive patients (N=121) with hematological malignancies underwent symptom limited CPET at a single center <30 days prior to HCT. Patients were excluded if they had clinically significant CVD. Pulmonary function test (PFT) was performed on all participants, and body composition including fat/muscle mass was assessed using a bio-electrical impedance analyzer. Descriptive statistics were used to describe the characteristics of pre-HCT CVRC. Multivariable linear regression was performed to evaluate the relative contribution of PFT-obtained measures to the baseline determinants (age, resting heart rate; rHR, body fat mass) of CVRC. RESULTS: Mean age was 52 years (range: 20-76), 65% were male, 55% were non-Hispanic White, 39% were Hispanic; diagnoses included: acute leukemia (40%), lymphoma (27%) and multiple myeloma (21%). Mean peak expiratory flow (PEF): 7.1 (range:3.6-12.1), rHR: 78.6 bpm (range 51-124), body fat mass: 27.3kg (7.3-50.1). No adverse events were observed during CPET, and 91% were able to achieve peak effort (respiratory exchange ratio >1.10) or >90% of age-predicted heart rate). Among patients who achieved peak effort, mean relative VO 2 peak was 18.7 ml/kg/min (range:12.9-36.4); 76% of participants had impaired CVRC (VO 2 peak <80% of predicted) and 17% had VO 2 peak <16ml/kg/min. Age, rHR, fat mass explained 32% of the variance in VO 2 peak (R 2 : 0.32); the inclusion of PEF improved VO 2 peak prediction (R 2 : 0.41). CONCLUSION: A high proportion of patients planning to undergo HCT had markedly impaired CVRC. Integration of CPET and other physiological assessments prior to HCT may provide detailed characterization of CVRC that can inform prognosis in patients with hematological cancer undergoing HCT, setting the stage for evidence-based interventions to prevent future cardiovascular events.
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