Up to half of Medicare beneficiaries lack financial resources to pay for a single hospital stay

Embargoed for release until 5:00 p.m. ET on Monday 28 October 2024    

@Annalsofim         
Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.         
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1. Up to half of Medicare beneficiaries lack financial resources to pay for a single hospital stay

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-00787

URL goes live when the embargo lifts          

A nationally representative study of Medicare beneficiaries with modest incomes found that up to half of them may not have sufficient funds to cover out-of-pocket costs associated with a single hospital stay. This financial precarity was more prevalent among Black and Hispanic beneficiaries, beneficiaries with lower levels of education, and those with multiple chronic conditions. The findings are published in Annals of Internal Medicine.

Researchers from the University of Pennsylvania Perelman School of Medicine used data from the 2018 wave of the Health and Retirement Study (HRS) to identify Medicare-enrolled respondents who would face financial precarity if exposed to the Medicare Part A hospital deductible of $1,600. The researchers focused on respondents making greater than 100% to 400% or less of the federal poverty level, or the so-called “economic middle” of Medicare recipients. This group includes people who earn too much to qualify for Medicaid but still may qualify for financial assistance in other programs. Financial precarity was defined as having insufficient funds to pay the Medicare hospital deductible and examined across 4 scenarios that considered checking and savings account balances, total liquid assets (with a reserve for future living costs), and supplemental insurance. 

The researchers found that between 34.6% and 50.7% of the beneficiaries studied would face financial precarity if hospitalized because they would not have sufficient resources or supplemental insurance to cover associated out-of-pocket costs. While the prevalence of financial precarity varied by scenario, the proportion of beneficiaries who could not pay their hospital bill across all four scenarios exceeded 30%. Considering that just one hospitalization could deplete the financial resources of a large proportion of Medicare beneficiaries, these findings suggest a need to broaden financial protections for those with moderate incomes and limited assets. 

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Paula Chatterjee, MD, MPH, please email pchat@pennmedicine.upenn.edu.

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2. Novel blood-based screening for colorectal cancer less effective, less cost-effective compared to colonoscopies or stool tests

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-00910

URL goes live when the embargo lifts   

A projected impact and cost-effectiveness analysis estimated reductions in colorectal cancer (CRC) incidence and mortality with novel blood-based and stool-based CRC screening tests versus established alternatives. The results revealed that first-generation novel cell free blood DNA (cf-bDNA) tests have the potential to meaningfully decrease the incidence and mortality of CRC compared with no screening, but substantially less profoundly than colonoscopy or stool tests. The findings can inform the implementation of novel screening methods in clinical practice. This study is published in Annals of Internal Medicine. 

Despite the emergence of multiple noninvasive screening methods, screening adherence among eligible people and follow up colonoscopy rates after an abnormal screen remain low. Researchers from Stanford University School of Medicine and colleagues used the Model of Screening and Surveillance for Colorectal Cancer (MOSIAC) to estimate the long-term clinical and economic impacts of novel CRC screening tests. The researchers compared CRC cases, CRC deaths, quality-adjusted life-years (QALYs), and costs among patients using established screening methods of fecal immunochemical tests (FIT), colonoscopies or multitarget stool DNA test (Exact Sciences Cologuard) vs. four emerging screening methods: two novel cell-free DNA blood tests (Guardant Shield and Freenome), an enhanced, next generation multitarget stool test, and a novel FIT-RNA test (Geneoscopy ColoSense). The researchers modeled idealized 100% adherence and colonoscopy completion after an abnormal noninvasive screening, as well as multiple dimensions of non-ideal participation in CRC screening. They also included the possibility of the blood test being taken by those who consistently declined colonoscopy or stool tests as well as substituting the blood test for other screening alternatives. 

The researchers found that assuming 100% participation in all steps of screening, colonoscopy and FIT yielded reductions of more than 70% in CRC incidence and 75% in CRC mortality versus no screening. CRC incidence and mortality reductions were 68% and 73% with a multi-target stool DNA test, and similar rates were found for the enhanced multi-target stool DNA test and FIT-RNA test compared with no screening. The blood tests saw CRC incidence and mortality reductions of 42% and 56%. FIT and colonoscopy were more effective and less costly than blood and multi-target stool DNA tests, and the multi-target stool DNA test was more effective and less costly than the blood test. Participation rates through the various steps in the screening continuum substantially affected the estimated benefits. Achieving blood-based screening among persons unwilling or unable to undergo stool-based screening or colonoscopy improved population-level outcomes.  However, substituting first generation blood-based screening in persons who would otherwise undergo stool-based screening or colonoscopy worsened population-level outcomes.

These findings suggest that consideration of all the attributes of novel screening methods, including performance and cost, and the need for colonoscopy follow-up after an abnormal noninvasive screening test must be emphasized when determining the best screening options in clinical settings. 

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Uri Ladabaum, MD, MS please email Lorraine Benigno Ibana at  libana12@stanford.edu.

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3. Rosuvastatin associated with better cardiovascular and mortality benefits compared to atorvastatin

Abstract: https://www.acpjournals.org/doi/10.7326/M24-0178  

URL goes live when the embargo lifts   

A real-world study comparing the effectiveness and safety of rosuvastatin versus atorvastatin found that initiation of rosuvastatin treatment was associated with slightly lower risks of mortality, major adverse cardiovascular events (MACEs), and major adverse liver outcomes (MALOs). While the differences between treatments are relatively small, clinicians may want to consider these outcomes when prescribing one of these drugs to individual patients. The findings are published in Annals of Internal Medicine.

Researchers from Southern Medical University in Guangzhou, China studied data from 285,680 patients using the China Renal Data System (CRDS) and UK Biobank (UKB) databases to compare the real-world effectiveness and safety of rosuvastatin and atorvastatin. The researchers compared all-cause mortality, MACEs, MALOs, development of chronic kidney disease (CKD), development of type 2 diabetes mellitus (T2DM) and occurrence of other statin-related adverse effects between the two treatments using nationally available data. The researchers found that compared with atorvastatin initiation, participants with rosuvastatin initiation had lower risk for all-cause mortality, MACEs and MALOs, but no important differences were observed for risks for developing CKD and other statin-related adverse effects. In the UKB database, initiation of rosuvastatin led to a higher risk of T2DM compared to atorvastatin initiation. The results suggest that clinical outcomes associated with starting rosuvastatin differ from the outcomes associated with starting atorvastatin, and clinicians should consider these differences when prescribing to individual patients. However, many differences were relatively small and did not meet traditional standards for statistical significance, and further research is warranted to use these findings confidently in clinical practice.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding authors Sheng Nie, MD, please email niesheng0202@126.com or Xin Xu, MD, PhD, please email xux007@163.com

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4. VA and DoD publish revised headache treatment advice to include recently approved therapeutics

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-00551

URL goes live when the embargo lifts       

The U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) have updated their clinical practice guidelines for the management of headache to include several treatments recently approved by the U.S. Food and Drug Administration (FDA). The guidelines were revised earlier than the standard 5-year cycle due to the unprecedented expansion of headache medicine and therapeutics that took place since 2020 when the last guidelines were issued. A summary of these guidelines relevant to internal medicine physicians is published in Annals of Internal Medicine.

Researchers reviewed evidence from systematic reviews and studies published between 2019 and 2022 on the benefits and harms of drugs and nondrug options for the prevention and treatment of all types of headaches. The group considered the strength and quality of the evidence, input about value and care from a patient focus group and benefits versus harms on critical outcomes before making consensus recommendations. Since the last guideline update in 2020, two new classes of medications and several devices have been approved for headache indications by the FDA. The revised guidelines include 52 recommendations on evaluation, pharmacotherapy, invasive interventions, and nonpharmacologic interventions for selected primary and secondary headache disorders, including 17 new recommendations.

For acute migraines, primary care clinicians can consider triptans, aspirin-acetaminophen-caffeine, and newer CGRP inhibitors (gepants). To prevent episodic migraines, options include angiotensin-receptor blockers, lisinopril, topiramate, valproate, eptinezumab, and atogepant. AbobotulinumtoxinA is recommended for chronic migraines, but not for episodic migraines. Gabapentin is not recommended for episodic migraine prevention. Ibuprofen (400 mg) and acetaminophen (1000 mg) are suggested for treating tension-type headaches, with amitriptyline for chronic tension headache prevention. Aerobic exercise or physical therapy can also help manage tension headaches and migraines. Clinicians should work with their patients in crafting treatment plans that account for headache type or types, comorbid conditions, values and preferences.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Jason J. Sico, MD, MHS, please email Jason.sico@va.gov.

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Also new in this issue:

A New Horizon: The Promise of the National Institutes of Health’s Landmark Designation of Persons With Disabilities as a Population With Health Disparities

Shahin A. Saberi, BS; Angela Zhang, BA; and Dorothy W. Tolchin, MD, EdM

Ideas and Opinions

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-00676