<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_3305"
                     title="Scars Increase Risk for Kidney Grafts (CME/CE)"
                     score="0.011"
                     href="http://www.medpagetoday.com/Nephrology/KidneyTransplantation/tb/22073?impressionId=1284026457171"
                     
      &lt;p&gt;Scarring and mild inflammation of kidney transplants that develop in the first year predict eventual graft failure, researchers found.&lt;/p&gt;
&lt;p&gt;Graft survival rates were 85% at five years for those with fibrosis and inflammation present at one year, compared with 97% in normal grafts (&lt;em&gt;P&lt;/em&gt;=0.04), Mark D. Stegall, MD, of the Mayo Clinic in Rochester, Minn., and colleagues reported.&lt;/p&gt;
&lt;p&gt;Fibrosis alone did not distinguish kidney grafts destined for failure, they noted online in the &lt;em&gt;Journal of the American Society of Nephrology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;These findings highlighted an important role for routine biopsy of even seemingly healthy transplants to pick up on early trouble signs that could be targeted for treatment, they suggested.&lt;/p&gt;
&lt;p&gt;&quot;Early interventions aimed at altering rejection-like inflammation may improve long-term survival of kidney allografts,&quot; Stegall&apos;s group wrote in the paper.&lt;/p&gt;
&lt;p&gt;Their single-center study included 151 recipients of living-donor kidney transplants who didn&apos;t develop defined complications during the first year and who were treated with a single immunosuppressive regimen (tacrolimus [Prograf] plus mycophenolate [CellCept, Myfortic]).&lt;/p&gt;
&lt;p&gt;The majority of these patients (86) had normal histology at the protocol biopsy at one year. Another 45 had interstitial fibrosis alone seen on the surveillance biopsy. Both of those groups showed stable renal function between years one and five.&lt;/p&gt;
&lt;p&gt;&quot;Because most failing kidney transplants have severe interstitial fibrosis,&quot; the researchers wrote, &quot;one might assume that the presence of interstitial fibrosis early after transplantation would identify allografts destined for decline in function leading to graft loss.&quot;&lt;/p&gt;
&lt;p&gt;But it was actually the combination of fibrosis and subclinical inflammation demonstrated by interstitial cellular infiltrate that predicted functional problems down the line.&lt;/p&gt;
&lt;p&gt;The 20 patients who showed both fibrosis and inflammation subsequently declined in glomerular filtration rate (GFR) and experienced reduced graft survival.&lt;/p&gt;
&lt;p&gt;These patients had a death-censored graft survival rate of 85%, lower than the 99% seen with grafts that had neither fibrosis nor inflammation, and the 98% seen with those that had fibrosis alone (&lt;em&gt;P&lt;/em&gt;=0.003 and &lt;em&gt;P&lt;/em&gt;=0.05, respectively).&lt;/p&gt;
&lt;p&gt;Their GFR was moderately lower at one month post-transplantation at 61 ml/min (&lt;em&gt;P&lt;/em&gt;=0.04 versus normal but &lt;em&gt;P&lt;/em&gt;=0.5 versus fibrosis alone). GFR then further dropped by the 12-month biopsy to an average of 55 ml/min and then 44 ml/min by year four for the inflammation and fibrosis group, whereas it remained at an average 68 ml/min for normal grafts and 64 ml/min for those with fibrosis only (&lt;em&gt;P&lt;/em&gt;=0.01 and &lt;em&gt;P&lt;/em&gt;=0.05, respectively).&lt;/p&gt;
&lt;p&gt;The researchers highlighted that the inflammation in this group that also showed fibrosis at 12 months wasn&apos;t severe. Histology scores for inflammation were generally mild with a mean of 1.4, which is below the threshold for diagnosis of acute cellular rejection.&lt;/p&gt;
&lt;p&gt;The researchers cautioned that they had too few patients treated with corticosteroid therapy on the basis of the inflammation and fibrosis results on biopsy to determine an effect. But microarray analysis of gene expression showed that grafts with inflammation and fibrosis had overactivation of numerous pathways, most linked to innate and adaptive immune responses, compared with the other groups.&lt;/p&gt;
&lt;p&gt;This was most striking for gene expression signatures associated with cytotoxic T lymphocytes, interferon-gamma response, B cells, and acute rejection, Stegall&apos;s group noted.&lt;/p&gt;
&lt;p&gt;Thus, conventional anti-rejection therapy would likely be effective in these cases, they suggested.&lt;/p&gt;
&lt;p&gt;The patient population in the study was tightly defined to exclude those with deceased donor grafts, cyclosporine-based immunosuppression, a history of delayed graft function, and early complications. But the results might be generalized somewhat, the researchers posited.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by an award from the State of Minnesota Partnership for Biotechnology and Medical Genomics and by a grant from Science Foundation Ireland.&lt;/p&gt;&lt;p&gt;The researchers reported having no conflicts of interest to disclose.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_3243"
                     title="Similar Survival with Two Ovarian Cancer Strategies (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/HematologyOncology/OvarianCancer/tb/22002?impressionId=1284026457171"
                     
      Patients with bulky, advanced ovarian cancer survived just as long whether treated with neoadjuvant chemotherapy and surgery or with primary surgery followed by adjuvant chemotherapy, investigators in a multinational trial reported.&lt;br&gt;
&lt;br&gt;Both treatment strategies led to a median overall survival of about 30 months and median progression-free survival of 12 months, according to an article in the Sept. 2 issue of the &lt;em&gt;New England Journal of Medicine&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;Intention-to-treat analysis resulted in a hazard ratio for death of 0.98 for neoadjuvant chemotherapy versus primary surgery&lt;em&gt;&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;&quot;Neoadjuvant chemotherapy followed by interval debulking surgery was not inferior to primary debulking surgery followed by chemotherapy as a treatment option for patients with bulky stage IIIC or IV ovarian carcinoma in this study,&quot; Ignace Vergote, MD, of University Hospitals in Leuven, Belgium, and co-authors wrote in conclusion.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;&quot;Complete resection of all macroscopic disease, whether performed as primary treatment or after neoadjuvant chemotherapy, remains the objective whenever cytoreductive surgery is performed.&quot;&lt;/p&gt;
&lt;p&gt;The results warrant a cautious interpretation, according to a gynecologic oncologist familiar with the study. Robert Coleman, MD, of MD Anderson Cancer Center in Houston, noted that the study involved patients with specific tumor characteristics that might not be generalizable to other patient populations.&lt;/p&gt;
&lt;p&gt;Moreover, the 30-month median survival is well below what most patients with advanced ovarian cancer might expect with surgery and chemotherapy, Coleman added.&lt;/p&gt;
&lt;p&gt;Primary debulking surgery followed by chemotherapy has formed the basis of treatment for extensive advanced ovarian cancer. Investigators in several prospective studies have evaluated outcomes with neoadjuvant chemotherapy before cytoreductive surgery as an alternative to primary surgery. One meta-analysis of such trials showed worse outcomes with neoadjuvant chemotherapy compared with primary surgery (&lt;em&gt;Gynecol Oncol&lt;/em&gt; 2006; 103: 1070-1076).&lt;/p&gt;
&lt;p&gt;Considering the issue of optimal therapy unresolved, Vergote and colleagues at 59 centers conducted a randomized trial comparing primary surgery followed by platinum-based chemotherapy versus neoadjuvant platinum-based therapy followed by cytoreductive surgery and additional chemotherapy.&lt;/p&gt;
&lt;p&gt;Eligible patients had stage IIIC or IV epithelial ovarian, primary peritoneal, or fallopian-tube carcinoma. Investigators enrolled 718 patients, 670 of whom were randomized and included in the intention-to-treat analysis. The primary endpoint was overall survival, and the trial was statistically powered to evaluate the noninferiority of neoadjuvant chemotherapy versus primary surgery.&lt;/p&gt;
&lt;p&gt;After a median follow-up of 4.7 years, patients treated with neoadjuvant chemotherapy had a median overall survival of 30 months versus 29 months for the primary-surgery cohort. The hazard ratio for the noninferiority of neoadjuvant chemotherapy versus primary surgery proved to be statistically significant (&lt;em&gt;P&lt;/em&gt;=0.01).&lt;/p&gt;
&lt;p&gt;Subgroup analysis failed to identify any patient or tumor characteristics associated with better outcomes with one treatment strategy or the other.&lt;/p&gt;
&lt;p&gt;In both treatment groups, the success of cytoreductive surgery was the strongest predictor of survival.&lt;/p&gt;
&lt;p&gt;In the primary surgery group, median overall survival declined from 45 to 32 to 26 months, respectively, for patients who had no residual tumor, residual tumors 1 to 10 mm, and residual tumors &amp;gt;10 mm. Corresponding survival figures in the neoadjuvant therapy group were 38, 27, and 25 months.&lt;/p&gt;
&lt;p&gt;&quot;Given our findings and the results of other studies, a potential approach for debulking surgery could be the elimination of all macroscopic residual disease, rather than the elimination of lesions larger than 1 cm in diameter,&quot; the authors wrote in the discussion of their findings.&lt;/p&gt;
&lt;p&gt;&quot;A potential drawback of neoadjuvant chemotherapy followed by debulking surgery is that the occurrence of fibrosis after chemotherapy may make complete resection of macroscopic disease more difficult.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Vergote and the co-authors reported that they had no relevant disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_3287"
                     title="Consumer Reports Ranks Bypass Surgery Centers"
                     score="0.01"
                     href="http://www.medpagetoday.com/Surgery/ThoracicSurgery/tb/22049?impressionId=1284026457171"
                     
      The group responsible for &lt;em&gt;Consumer Reports&lt;/em&gt; on everything from vacuums to cars today released a report card for CABG outcomes at roughly 20% of the nation&apos;s heart surgery centers.&lt;br&gt;
&lt;br&gt;The ratings identify the 50 top-performing centers based on risk-adjusted clinical data submitted to the Society of Thoracic Surgeons registry.&lt;br&gt;
&lt;br&gt;This list, which was posted online, included Massachusetts General Hospital and a group at George Washington University Hospital but most of the centers were community medical centers. The ranking will also be published in the October print edition of &lt;em&gt;Consumer Reports&lt;/em&gt;.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;Mass General and the surgeons group at George Washington were among 50 centers that received three stars  --  the top rating.&lt;/p&gt;
&lt;p&gt;Only five of the 221 surgical groups that agreed to public release of their CABG outcomes data garnered a below average or one star rating on the three-star scale, according to &lt;em&gt;Consumer Reports&lt;/em&gt; publisher Consumer Union.&lt;/p&gt;
&lt;p&gt;The centers with significantly below average performance were: &lt;ul&gt; &lt;li&gt;Allied Physicians affiliated with Lutheran Hospital of Indiana&lt;/li&gt; &lt;li&gt;Baylor All Saints Medical Center at Fort Worth, Texas&lt;/li&gt; &lt;li&gt;Desert Springs Hospital Medical Center in Las Vegas&lt;/li&gt; &lt;li&gt;Regional Heart Center Thoracic Surgical Associates affiliated with Mercy Medical Center in Canton, Ohio&lt;/li&gt; &lt;li&gt;United Regional Physician Group of Wichita Falls, Texas&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;A Perspective article in the &lt;em&gt;New England Journal of Medicine&lt;/em&gt; called release of the ratings &quot;a watershed event in healthcare accountability.&quot;&lt;/p&gt;
&lt;p&gt;In the article, timed to the release of the doctor ratings, Timothy G. Ferris, MD, MPH, and David F. Torchiana, MD, both of Massachusetts General Hospital in Boston (a three-star center), explained that the quality of data that went into the scores far exceeds anything that healthcare consumers have had access to before in any field on a national basis.&lt;/p&gt;
&lt;p&gt;A few states, notably New York and Pennsylvania, already provide access to clinical outcomes data.&lt;/p&gt;
&lt;p&gt;The STS Adult Cardiac Surgery Database, though, includes voluntary reporting by more than 90% of the approximately 1,100 cardiac surgery programs in the nation. The data are collected from patient charts, which the report card aggregates into a physician group-level performance score on 11 rigorously-validated measures.&lt;/p&gt;
&lt;p&gt;Consumers get to see not only a center&apos;s total score but also the following: &lt;ul&gt; &lt;li&gt;30-day survival (such as &quot;patients have a 98% chance of surviving at least 30 days after the procedure and of being discharged from the hospital&quot;)&lt;/li&gt; &lt;li&gt;Complications (such as &quot;patients have an 89% chance of avoiding all five of the major complications&quot;)&lt;/li&gt; &lt;li&gt;Use of appropriate medications, such as aspirin, statins, and beta-blockers (such as &quot;patients have a 90% chance of receiving all four of the recommended medications&quot;)&lt;/li&gt; &lt;li&gt;Surgical technique, such as use of an internal thoracic artery for the graft (such as &quot;patients have a 98% chance of receiving at least one optimal surgical graft&quot;)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;&quot;This is objective data that is about as good as you can get,&quot; David M. Shahian, MD, also of Massachusetts General Hospital, said in an interview.&lt;/p&gt;
&lt;p&gt;As chair of the STS committee responsible for the database, he worked extensively with Consumer Union on the public release of the data his organization has been collecting since 1989.&lt;/p&gt;
&lt;p&gt;One of the big concerns for physicians is getting misclassified in these public ratings, which the state-based experience has shown leads providers to shy away from taking on the highest-risk patients, who although they may stand to benefit most from CABG also carry higher risk of mortality that could ding a physician&apos;s numbers.&lt;/p&gt;
&lt;p&gt;Cardiac surgeons should instead see public reporting of their results as an incentive to excel, Shahian urged.&lt;/p&gt;
&lt;p&gt;&quot;We want to assure our providers that our methods of adjusting for patient severity are quite good,&quot; he told &lt;em&gt;MedPage Today&lt;/em&gt; in an interview.&lt;/p&gt;
&lt;p&gt;Doctor ratings available online previously have relied on patient reviews (which are notoriously subject to selection bias for only the most positive and negative impressions), reputation, or administrative data that rarely takes into account how sick the patient population treated was, Consumer Union noted in a press release.&lt;/p&gt;
&lt;p&gt;However, the new reporting card still falls short in some respects, Ferris and Torchiana noted.&lt;/p&gt;
&lt;p&gt;Selective participation of programs  --  only about a quarter of those in the database allowed public release of outcomes  --  as well as lack of physician-specific ratings or long-term outcome reporting are likely to draw criticism, they wrote in the editorial.&lt;/p&gt;
&lt;p&gt;Despite state-required reporting in some areas, centers there may still have been reluctant to release their full data.&lt;/p&gt;
&lt;p&gt;Ferris explained that states typically provide only mortality figures, which vary little. The primary determinant of center-to-center variability  --  and thus ratings  --  is complication rates, which have not been public, he noted.&lt;/p&gt;
&lt;p&gt;Advocates of transparency can be expected to pressure nonparticipating cardiac surgery programs, he and Torchiana added in the editorial.&lt;/p&gt;
&lt;p&gt;Once the participants test the waters and show others how it works, others are likely to be willing to follow, Shahian said.&lt;/p&gt;
&lt;p&gt;In the era of increasing emphasis on transparency and accountability, few surgeons or groups have suggested public reporting is the wrong thing to do, he explained.&lt;/p&gt;
&lt;p&gt;&quot;In the new healthcare environment we&apos;re in, many if not most [medical professional] societies are going to have to come to grips with this very quickly,&quot; Shahian predicted in the interview.&lt;/p&gt;
&lt;p&gt;While Ferris agreed, he expressed skepticism that others would find the transition so easy.&lt;/p&gt;
&lt;p&gt;CABG has the advantage of being a procedure for which oftentimes people have a choice of providers, that is fairly reproducible, and has relatively layperson-friendly performance measures, he pointed out.&lt;/p&gt;
&lt;p&gt;&quot;There aren&apos;t a lot of examples of medical services that meet those criteria,&quot; he told &lt;em&gt;MedPage Today&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;In the end, public reporting data is only useful if used, and many patients likely won&apos;t turn to &lt;em&gt;Consumer Reports &lt;/em&gt;when choosing a thoracic surgeon, he said.&lt;/p&gt;
&lt;p&gt;Patients should use the report card when in a nonemergent situation, Shahian argued.&lt;/p&gt;
&lt;p&gt;But &quot;it&apos;s only one part,&quot; he cautioned. &quot;We want them to still listen to the advice of their referring cardiologists and other physicians caring for them.&quot;&lt;/p&gt;
&lt;p&gt;The ratings can be found at &lt;a href=&quot;http://www.consumerreports.org/health/home.htm&quot; mce_href=&quot;http://www.consumerreports.org/health/home.htm&quot; target=&quot;_blank&quot;&gt;www.ConsumerReportsHealth.org&lt;/a&gt;.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Ferris and Torchiana reported having no conflicts of interest to disclose.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_3317"
                     title="Healthcare Reform Covers More and Costs More"
                     score="0.01"
                     href="http://www.medpagetoday.com/Washington-Watch/Reform/tb/22089?impressionId=1284026457171"
                     
      &lt;p&gt;WASHINGTON  --  The healthcare reform law will not slow the growth of healthcare spending in the next decade  --  in fact, it will accelerate healthcare spending slightly  --  but it will also significantly expand healthcare coverage, a new government report found.&lt;/p&gt;
&lt;p&gt;The report, issued by Centers for Medicare and Medicaid Services (CMS) Office of the Actuary, casts doubt on predictions from the Obama administration and congressional Democrats that healthcare reform would slow the trajectory of healthcare spending.&lt;/p&gt;
&lt;p&gt;The CMS analysis pegs healthcare spending growth at an average rate of 6.3% over the next decade, or 0.2 percentage points faster than healthcare spending would have grown had the Affordable Care Act (ACA) not become law.&lt;/p&gt;
&lt;p&gt;Put another way, nearly 20% of the U.S. gross domestic product (GDP)  --  or one in five U.S. dollars spent  --  will be devoted to healthcare costs in 2019. (That projection is 0.3 percentage points higher than pre-reform projections).&lt;/p&gt;
&lt;p&gt;However, the projection  --  which was published Thursday in the policy journal &lt;em&gt;Health Affairs&lt;/em&gt;  --  does support another promise of reform  --  to expand coverage to 32 million people.&lt;/p&gt;
&lt;p&gt;The CMS actuaries who wrote the report estimate that nearly 93% of the U.S population will have health insurance in 2019, which is an additional 32.5 million above the current number of insured people.&lt;/p&gt;
&lt;p&gt;This is the second 10-year health spending projection released by CMS this year. The first, which was released in &lt;a href=&quot;http://www.medpagetoday.com/Washington-Watch/Washington-Watch/18302&quot; mce_href=&quot;http://www.medpagetoday.com/Washington-Watch/Washington-Watch/18302&quot; target=&quot;_blank&quot; title=&quot;In&amp;#8200;Bad&amp;#8200;Economy,&amp;#8200;Record&amp;#8200;Growth&amp;#8200;in&amp;#8200;Health&amp;#8200;Spending&quot;&gt;February&lt;/a&gt;, did not account for the impact of the &lt;a href=&quot;http://www.medpagetoday.com/Washington-Watch/Reform/19351&quot; mce_href=&quot;http://www.medpagetoday.com/Washington-Watch/Reform/19351&quot; target=&quot;_blank&quot; title=&quot;What&apos;s&amp;#8200;in&amp;#8200;the&amp;#8200;Healthcare&amp;#8200;Reform&amp;#8200;Law&quot;&gt;Affordable Care Act &lt;/a&gt;(ACA), which was signed into law in March.&lt;/p&gt;
&lt;p&gt;The main driver of increased spending according to this latest report is the estimated $38 billion cost for establishing the new health insurance exchanges. Close behind is the expected $31 billion increase in the cost of Medicaid. Under ACA, any person under the age of 65 who has an income under 138% of the federal poverty level will be eligible for Medicaid.&lt;/p&gt;
&lt;p&gt;Taken together, the insurance exchanges and the Medicaid expansion, provide the new structure that will provide care to the uninsured.&lt;/p&gt;
&lt;p&gt;Healthcare reform could bring down costs after 2019, but the CMS researchers didn&apos;t look beyond the next decade.&lt;/p&gt;
&lt;p&gt;The projection outlines some healthcare spending patterns that will likely emerge over the upcoming years as a result of the ACA.&lt;/p&gt;
&lt;p&gt;For example, in 2010, healthcare spending is estimated to grow at a rate of 5.8%, but it&apos;s scheduled to slow in 2011 to 4.2%.&lt;/p&gt;
&lt;p&gt;But there are problems with that projection since spending slow-down hinges on a planned 23% pay cut for physicians who treat Medicare patients going into effect. In June, Congress passed a &lt;a href=&quot;http://www.medpagetoday.com/Washington-Watch/Washington-Watch/20889&quot; mce_href=&quot;http://www.medpagetoday.com/Washington-Watch/Washington-Watch/20889&quot; target=&quot;_blank&quot; title=&quot;&amp;#8200;Log&amp;#8200;in&amp;#8200;or&amp;#8200;create&amp;#8200;a&amp;#8200;free&amp;#8200;account&amp;#8200;for&amp;#8200;complete&amp;#8200;access&amp;#8200;to&amp;#8200;everything&amp;#8200;MedPage&amp;#8200;Today&amp;#8200;has&amp;#8200;to&amp;#8200;offer!&amp;#8200;House&amp;#8200;Passes&amp;#8200;Six-Month&amp;#8200;SGR&amp;#8200;Delay&quot;&gt;law &lt;/a&gt;to update physician Medicare rates by 2.2%, but that temporary fix runs out on Dec. 1. Come Jan. 1, 2011, physicians would also be slapped with an additional 3% cut in Medicare reimbursement.&lt;/p&gt;
&lt;p&gt;If history is any indication, Congress will likely vote again to override the cut, likely making the projection that healthcare spending will slow in 2011 no longer applicable.&lt;/p&gt;
&lt;p&gt;Some immediate changes brought by the law will cause a near-term spike in total national health expenditures to occur, the researchers found. For example, implementing the &lt;a href=&quot;http://www.medpagetoday.com/Washington-Watch/Reform/20991&quot; mce_href=&quot;http://www.medpagetoday.com/Washington-Watch/Reform/20991&quot; target=&quot;_blank&quot; title=&quot;Enrollment&amp;#8200;in&amp;#8200;Temporary&amp;#8200;High-Risk&amp;#8200;Pools&amp;#8200;Begins&amp;#8200;Today&quot;&gt;temporary high-risk insurance pool&lt;/a&gt;, and providing coverage to dependents under the age of 26 will add more than $10 billion to national health spending through 2013.&lt;/p&gt;
&lt;p&gt;  &lt;/p&gt;
&lt;p&gt;CMS researchers said that while reform won&apos;t tamp down healthcare spending in the next decade, that&apos;s far from the complete picture.&lt;/p&gt;
&lt;p&gt;&quot;While the impacts are relatively moderate on net spending, the underlying effects on coverage and financing are more pronounced,&quot; Andrea Sisko, an economist with CMS&apos; Office of the Actuary and lead author of the study, told reporters Wednesday.&lt;/p&gt;
&lt;p&gt;&quot;When you peel back the onion, and you look past the surface, you start to see much more pronounced impacts,&quot; said John Poisal, deputy director of the National Health Statistics Group at CMS&apos; Office of the Actuary, and one of the authors of the study.&lt;/p&gt;
&lt;p&gt;One of those layers, he said, is the high projected rate of insured people likely by 2019.&lt;/p&gt;
&lt;p&gt;Of the newly insured, about eight million will be enrolled in their state&apos;s Children&apos;s Health Insurance Plan (CHIP), and nearly 31 million will be enrolled in the new insurance exchanges that the ACA will establish beginning in 2014.&lt;/p&gt;
&lt;p&gt;Enrollment in Medicaid and CHIP will increase by one-third over the next decade, and enrollment in private insurance will increase from 15.8 million in 2014 to 30.6 million in 2019, the researchers wrote.&lt;/p&gt;
&lt;p&gt;The researchers also determined that when federally-mandated COBRA subsidies expire in 2011, the unemployed will be stuck paying for a large share of their insurance coverage, which will lead to slightly higher out-of-pocket health costs starting that year. But by 2014, when many people who did not have insurance will be insured, out-of-pocket spending will drop by 1.1%, instead of rising by 6.4% percent, which was the pre-reform projection.&lt;/p&gt;
&lt;p&gt;However, the reduction in out-of-pocket spending won&apos;t last, and, by 2018, employee spending will actually grow faster than had reform not passed. The CMS actuaries told reporters the projected increase would be caused by the tax on high-benefit, expensive plans. The actuaries predicted that employers would do an end-run to avoid the financial penalty for offering the so-called &quot;Cadillac&quot; plans by passing the extra costs onto all employees.&lt;/p&gt;
&lt;p&gt;Finally, crystal balls are notoriously inaccurate so the researchers cautioned that as the provisions of the ACA are implemented, the &quot;actual impacts may well differ considerably form these estimates.&quot;&lt;/p&gt;


    </recommendedItem>
    <recommendedItem id="20100101_19_3316"
                     title="New HIV Cases High Among French MSM (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/clinical-context/HIVAIDS/tb/22088?impressionId=1284026457171"
                     
      &lt;p&gt;HIV appears to be out of control among French men who have sex with men, researchers reported.&lt;/p&gt;
&lt;p&gt;Data for 2008 revealed that men who have sex with men (MSM) accounted for 48% of all new HIV infections in France, according to St&amp;#233;phane Le Vu, PhD, of the French National Institute for Public Health, and colleagues.&lt;/p&gt;
&lt;p&gt;The incidence rate in that population was 1%  --  a rate of 1,006 new infections per 100,000 person-years in 2008  --  and 200 times higher than the rate estimated for French heterosexuals, Le Vu and colleagues reported online in&lt;em&gt;The Lancet&lt;/em&gt; &lt;em&gt;Infectious Diseases.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;&quot;The HIV epidemic seems to be out of control in the MSM population,&quot; the researchers contended.&lt;/p&gt;
&lt;p&gt;Over the six years from 2003 through 2008, HIV incidence among MSM was &quot;comparatively high and stable,&quot; the researchers reported  --  although the overall incidence of HIV in France fell by about 3.7% a year.&lt;/p&gt;
&lt;p&gt;The new findings are no surprise to those involved in combating the HIV pandemic, said Robert Hogg, MD, of the British Columbia Centre for Excellence in HIV/AIDS in Vancouver.&lt;/p&gt;
&lt;p&gt;&quot;Rates in North America in terms of HIV incidence among MSM have been relatively stable and very high for the last little while,&quot; he told &lt;em&gt;MedPage Toda&lt;/em&gt;y, although the reasons for that remain unclear.&lt;/p&gt;
&lt;p&gt;Most analyses of HIV rates are based on new diagnoses, but the French study added a new wrinkle. Using an enzyme immunoassay, Le VU and colleagues were able to gauge the proportion of recent infections among the new diagnoses.&lt;/p&gt;
&lt;p&gt;After accounting for under-reporting, Le Vu and colleagues estimated that 42,330 people were newly diagnosed with HIV over the study period and that overall HIV incidence decreased significantly from 8,930 new found infections in 2003 to 6,940 in 2008. The decline was significant at &lt;em&gt;P&lt;/em&gt;=0.002.&lt;/p&gt;
&lt;p&gt;The proportion of recent HIV infections, as determined by the immunoassay, remained stable at about 25% a year, they found.&lt;/p&gt;
&lt;p&gt;Among those with recent infection during the study period, MSM led the way with 40%, compared with French-national heterosexual women and men (at 28% and 22%, respectively), heterosexual non-French-national women and men (at 16% and 12%), and injection drug users (at 15%), Le Vu&apos;s team reported.&lt;/p&gt;
&lt;p&gt;In 2008, however, 48% of some 6,940 new infections were found among MSM, the researchers wrote, with only 1% of new infections seen in injection drug users.&lt;/p&gt;
&lt;p&gt;Overall, HIV incidence in 2008 was 17 per 100,000 person-years, they reported, based on rates of: &lt;ul&gt; &lt;li&gt;Nine per 100,000 person-years among heterosexuals&lt;/li&gt; &lt;li&gt;1,006 per 100,000 person-years among MSM&lt;/li&gt; &lt;li&gt;86 per 100,000 person-years among injection drug users&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;In a comment accompanying the French report in &lt;em&gt;The&lt;/em&gt; &lt;em&gt;Lancet,&lt;/em&gt; Hogg and colleagues at the BC Centre argued that one way to reduce those rates would be to employ a multifaceted approach including both individual and population-based prevention strategies.&lt;/p&gt;
&lt;p&gt;As well, they argued, such an approach should take into account the increasing evidence that expanding antiretroviral therapy to all people who meet eligibility criteria would reduce the number of new cases.&lt;/p&gt;
&lt;p&gt;&quot;It&apos;s not treatment or prevention,&quot; Hogg told&lt;em&gt; MedPage Today&lt;/em&gt;. &quot;It&apos;s both.&quot;&lt;/p&gt;
&lt;p&gt;Hogg added that any prevention strategy will also have to account for the way sexual transmission occurs among men who have sex with men. The pattern, he said, is &quot;like a series of random forest fires,&quot; which can be difficult to extinguish.&lt;/p&gt;
&lt;p&gt;That contrasts with injection drug users, where transmission usually occurs within a small circle of people involved in using drugs and prevention efforts can be closely targeted, Hogg said.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by the French National Institute for Public Health Surveillance and the French National Agency for Research on AIDS and Viral Hepatitis. The authors declared they had no conflicts.&lt;/p&gt;&lt;p&gt;Hogg reported financial links with GlaxoSmithKline and Merck Frosst Laboratories.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
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