Gerald F. Kominski

In 2012, updated American Society for Colposcopy and Cervical Pathology (ASCCP) management guidelines for abnormal cervical cytology recommended observation rather than immediate referral to colposcopy for low-grade abnormalities in women ages 21–24. Researchers evaluated the impact of these guidelines on changes in colposcopy procedure rates among young women. They analyzed administrative and claims data from the largest statewide family planning program between July 2011 and June 2015. Using a difference-in-differences approach, researchers estimated changes in colposcopy procedure rates among women ages 21–24 years before and after the 2012 ASCCP management guidelines, relative to a comparison group of women ages 25–44.

Findings: The analysis included 333,977 women from 216 primary care provider sites. After publication of the 2012 ASCCP management guidelines, colposcopy rates significantly declined from 6.70% to 3.94% among women ages 21–24 and from 4.35% to 3.53% among women over 24 years. These declines correspond to a 1.93 percentage point reduction in colposcopy rate among women 21–24 vs. over 24 years, or a two-fold relative reduction.

Among women ages 21–24, colposcopy receipt was associated with speaking primarily English vs. non-English, having a cervical cytology test within the past year vs. not, and receiving care from a public vs. private provider.

Colposcopy procedure rates among young women significantly declined following publication of the 2012 management guidelines, which has implications for reducing potential harms of overtreatment.
 

Recently updated global guidelines for cervical cancer screening incorporated new technologies-most significantly, the inclusion of Human papillomavirus (HPV) DNA detection as a primary screening test-but leave many implementation decisions at countries' discretion. Authors sought to develop recommendations for Malawi as a test case since it has the second-highest cervical cancer burden globally and high HIV prevalence. They incorporated updated epidemiologic data, the full range of ablation methods recommended, and a more nuanced representation of how HIV status intersects with cervical cancer risk and exposure to screening to model outcomes of different approaches to screening.

Using a Markov model, authors estimated the relative health outcomes and costs of different approaches to cervical cancer screening among Malawian women. The model was parameterized using published data, and focused on comparing "triage" approaches-i.e., lesion treatment (cryotherapy or thermocoagulation) at differing frequencies and varying by HIV status. Health outcomes were quality-adjusted life years (QALYs) and deaths averted. 

Findings: Thermocoagulation was more cost-effective than cryotherapy at all screening frequencies. Screening women once per decade would avert substantially more deaths than screening only once per lifetime, at relatively little additional cost. Moreover, at this frequency, it would be advisable to ensure that all women who screen positive receive treatment (rather than investing in further increases in screening frequency): for a similar gain in QALYs, it would cost more than four times as much to implement once-per-5 years screening with only 50% of women treated versus once-per-decade screening with 100% of women treated. Stratified screening schedules by HIV status was found to be an optimal approach.

These results add new evidence about cost-effective approaches to cervical cancer screening in low-income countries. At relatively infrequent screening intervals, if resources are limited, it would be more cost-effective to invest in scaling up thermocoagulation for treatment before increasing the recommended screening frequency. In Malawi or countries in a similar stage of the HIV epidemic, a stratified approach that prioritizes more frequent screening for women living with HIV may be more cost-effective than population-wide recommendations that are HIV status neutral.
 

Black Americans experience the highest prevalence of heart failure (HF) and the worst clinical outcomes of any racial or ethnic group, but little is known about end-of-life care for this population. Researchers compare treatment intensity between Black and white older adults with HF near the end of life. They compared four common measures of treatment intensity at the end of life (number of hospital admissions, receipt of care in an intensive care unit (ICU), utilization of life support, and whether the decedent died in a hospital) between Black and white HF patients, controlling for demographic, social, and health characteristics.

Findings: Racial identity was not significantly associated with the number of hospital admissions or admission to an ICU in the last 24 months of life. However, Black HF patients were more likely to spend time on life support and more likely to die in a hospital than white HF patients. Thoughtful and consistent engagement with HF patients regarding treatment preferences is an important step in addressing inequities.
 

​Summary: California has promoted value-based care in its public hospitals under a Section 1115 Medicaid Waiver called Public Hospital Redesign and Incentives in Medi-Cal (PRIME), a waiver overseen by California’s Department of Health Care Services (DHCS). PRIME required public hospitals to significantly transform their outpatient care delivery to receive payment for improved performance. 

Fifty-four public hospitals in California — including 17 designated public hospitals (DPHs) and 35 district and municipal hospitals (DMPHs) — implemented PRIME to achieve five overarching goals designed to improve care delivery, cultural competence, and patient health outcomes, as well as to move public hospitals towards value-based care.

Nadereh Pourat​, associate center director of the UCLA Center for Health Policy Research and director of the center’s Health Economics and Evaluation Research Program, led a team of researchers who evaluated the PRIME program. This report, Final Summative Evaluation of PRIME, is the third in a series of reports based on their findings.​

In the initial Interim Evaluation of PRIME report, Pourat and the research team evaluated the PRIME program (i.e., following evidence-based guidelines), promoting better care outcomes (i.e., offering increased screening for cancer and tobacco use), and tracking better health (i.e., improvement of hypertension and diabetes control). ​

In the subsequent Preliminary Summative Evaluation pf PRIME, report, Pourat and team evaluated PRIME metric progression, challenges and successes, and plans for sustainability at the end of PRIME implementation. 

Findings: The Final Summative Evaluation of PRIME report shows that PRIME hospitals:

• Reduced hospitalizations (2.33 fewer per 1,000 patients per year among DPHs) and emergency department visits (6.32 fewer per 1,000 patients per year​ among DPHs;15.36 fewer per 1,000 patients per year​ among DMPHs) for PRIME patients compared with patients of other providers. 
• Reduced Medi-Cal payments per patient per year ($836 less among DMPHs; $865 less among DPHs). 
• Used innovative approaches and modifications to implement PRIME projects, mitigating COVID-19 pandemic disruptions. 
• Improved public hospitals’ ability to participate in managed care value-based payments. ​

The findings of this evaluation highlight the importance of federal funding for initiating and promoting progress in quality improvement projects and can be used to inform federal and state Medicaid policies to promote better care, better health, and lower costs.​

*The report is currently with the Centers for Medicare & Medicaid Services (CMS) for review. A final version will be posted once it has been approved.​

Read the Publications:

• Policy Brief: Final Summative Evaluation of California’s Public Hospital Redesign and Incentives in Medi-Cal (PRIME) Program
• Infographic