Peter A. Learn

PURPOSE: Same-day, colocated multidisciplinary clinics (MDCs) aim to expedite complex cancer care, yet their added value over sequential referral remains uncertain. We systematically reviewed comparative studies to assess their effects on treatment decisions, timelines, guideline adherence, and survival in newly diagnosed solid tumors. MATERIALS AND METHODS: We searched MEDLINE, Embase, and CENTRAL through April 15, 2025, for studies comparing MDCs with routine care. Eligible studies involved same-day, on-site evaluation by ≥2 oncology specialties and at least one clinical or patient-centered outcome. Risk of bias was assessed with Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I). RESULTS: Twenty-seven observational cohorts (>18,000 patients) met inclusion criteria: 17 studies (63%) were rated serious risk of bias and 10 (37%) were rated critical risk on ROBINS-I. Across studies, MDCs shortened the diagnosis-to-treatment interval and improved guideline concordance. A pooled analysis of two comparable cohorts showed that therapy began 9.5 days sooner (95% CI, –16.2 to –2.7 days; I ² = 0%). Guideline adherence averaged 91% with MDCs versus 68% with routine pathways. Eleven series reported management change rates of 24%-52%, most often escalation to multimodality therapy or evidence-based de-escalation. Patient-reported satisfaction exceeded 90% in all five studies capturing this outcome, and two economic analyses documented reduced diagnostic expenditures without shifting cost to patients. A random-effects meta-analysis of two risk-adjusted cohorts showed improved overall survival (pooled hazard ratio, 0.77 [95% CI, 0.68 to 0.87]; τ ² = 0.004; I ² = 51%). CONCLUSION: Observational evidence suggests that same-day MDCs compress care timelines, raise guideline adherence, and may improve survival, while maintaining high patient satisfaction and neutral out-of-pocket costs. Randomized or quasi-experimental designs are needed to confirm causality and identify the clinic features that drive benefit.

Introduction: Facing the COVID-19 pandemic, many hospitals implemented severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) screening protocols before aerosol-generating procedures (AGPs) in an effort to protect patients and health care workers. Given the limited prior evidence on the effectiveness of such protocols, we report the process improvement experience at a military treatment facility. Materials and Methods: We evaluated the outcomes of patients undergoing AGPs from March to September 2020, divided into three cohorts: a preprotocol (PP) cohort who did not receive screening, an early testing (ET) cohort representing the early months of the screening protocol, and a late testing (LT) cohort managed under adaptive modifications to the screening protocol. We recorded identifiable post-procedure COVID-19 diagnoses. The study was approved as a process improvement protocol and was determined not to meet criteria for human subject research through an institutional approval process. Results: Across the three cohorts, 4520 procedures were performed: 422 PP, 1297 ET, and 2801 LT. Among 4098 procedures in the ET and LT cohorts, 12 asymptomatic patients tested positive for SARS-CoV-2 (0.29% positivity rate). One left the health system before completing the procedure and another proceeded urgently under COVID precautions, while 10 were rescheduled and completed at a later date; 7 were cleared using a test-based strategy, while 3 were cleared using a time-based strategy. Of 445 patients who had SARS-CoV-2 tests performed within 30 days following their procedures, three patients with negative preoperative tests had a positive test within 30 days, all in the LT cohort but had evidence of acquiring the infection after the procedure or had a false-positive test. Conclusions: Our strategy of preprocedural SARS-CoV-2 testing successfully identified asymptomatic infected patients before surgery. Care was delayed for most of these patients without apparent detriment. Adaptation to a time-based strategy for clearance might reduce such delays, but other considerations may still influence how soon procedures should be completed after a positive test.

Objective: Ongoing health care reforms within the US Military Health System (MHS) are expected to shift >1.9 million MHS beneficiaries from military treatment facilities (MTFs) into local civilian hospitals over the next 1–2 years. The objective of this study was to examine how such health care reforms are likely to affect the quality of MHS care.Data sources: Adult MHS beneficiaries, aged 18–64 years, treated in MTFs (under a program known as Direct Care) were compared against (1) MHS beneficiaries treated in locally available civilian hospitals (under a program known as Purchased Care) and (2) similarly‐aged adult civilian patients across the United States. MHS beneficiaries in Direct and Purchased Care were identified from fiscal‐year 2016–2018 MHS inpatient claims. National inpatients were identified in the 2017 Nationwide Readmissions Database.Study design: Retrospective cohort.Data collection: Differences in quality were compared using two sets of quality metrics endorsed by the US Agency for Healthcare Research and Quality (AHRQ): Inpatient Quality Indicators, 19 quality metrics that look at differences in in‐hospital mortality, and Patient Safety Indicators, 18 quality metrics that look at differences in in‐hospital morbidity and adverse events. Among MHS beneficiaries (Direct and Purchased Care), we further simulated what changes in quality indicators might look like under various proposed scenarios of reduced access to Direct Care.Principal findings: A total of 502,252 MHS admissions from 37 MTFs and surrounding civilian hospitals were included (326,076 Direct Care, 179,176 Purchased Care). Nationwide, 9.34 million adult admissions from 2453 hospitals were included. On average, MHS beneficiaries treated in MTFs experienced better inpatient quality and improved patient safety compared with MHS beneficiaries treated in locally available civilian hospitals (e.g., summary observed‐to‐expected ratio for medical mortality: 0.98 vs. 1.03, p < 0.001) and adult patients across the United States (0.98 vs. 1.02, p < 0.001). Simulations of proposed changes resulted in consistently worse outcomes for MHS patients, whether reducing MTF access by 10%, 20%, or 50% nationwide; limiting MTF access to active‐duty beneficiaries; or closing MTFs with the worst performance on patient safety (p < 0.001 for overall quality indicators for each).Conclusions: Reducing access to MTFs could result in significant harm to MHS patients. The results underscore the importance of health‐policy planning based on evidence‐based evaluation and the need to consider the consequential downstream effects caused by changes in access to care.

Background: In the move toward value-based care, bundled payments are believed to reduce waste and improve coordination. Some commercial insurers have addressed this through the use of bundled payment, the provision of one fee for all care associated with a given index procedure. This system was pioneered by Medicare, using a population generally over 65 years of age, and despite its adoption by mainstream insurers, little is known of bundled payments’ ability to reduce variation or cost in a working-age population. This study uses a universally-insured, nationally-representative population of adults aged 18–65 to examine the effect of bundled payments for five high-cost surgical procedures which are known to vary widely in Medicare reimbursement: hip replacement, knee replacement, coronary artery bypass grafting (CABG), lumbar spinal fusion, and colectomy. Methods: Five procedures conducted on adults aged 18–65 were identified from the TRICARE database from 2011 to 2014. A 90-day period from index procedure was used to determine episodes of associated post-acute care. Data was sorted by Zip code into hospital referral regions (HRR). Payments were determined from TRICARE reimbursement records, they were subsequently price standardized and adjusted for patient and surgical characteristics. Variation was assessed by stratifying the HRR into quintiles by spending for each index procedure. Results: After adjusting for case mix, significant inter-quintile variation was observed for all procedures, with knee replacement showing the greatest variation in both index surgery (107%) and total cost of care (75%). Readmission was a driver of variation for colectomy and CABG, with absolute cost variation of $17,257 and $13,289 respectively. Other post-acute care spending was low overall (≤$1606, for CABG). Conclusions: This study demonstrates significant regional variation in total spending for these procedures, but much lower spending for post-acute care than previously demonstrated by similar procedures in Medicare. Targeting post-acute care spending, a common approach taken by providers in bundled payment arrangements with Medicare, may be less fruitful in working aged populations.

In an effort to improve surgical quality and reduce clinical variability, the Military Health System (MHS) expanded its participation in the National Surgical Quality Improvement Program to all military hospitals beginning in 2015. This expansion and a partnership with the American College of Surgeons laid the foundation for a surgical quality collaborative in the MHS. We review the history of the program in the MHS and the activities that have contributed to developing the collaborative. We also report promising trends in surgical outcomes at hospitals that were already participating in the program in 2014, when a critical MHS review identified areas for improvement in surgical care. We conclude with a discussion of possible lessons for other health systems and challenges ahead for the MHS, now that full enrollment in the program has been completed.

In Reply We appreciate Jindal’s comments on the importance of cultural competency in the delivery of humanitarian surgical care. Cultural competency has gained

Medical units of the US military have operated for more than 15 years in Afghanistan, a country with among the lowest estimates of access to safe, timely surgical and anesthesia care.¹ Surgeons from the US military have delivered humanitarian surgical care (HSC) to local national civilians throughout the conflict, although previous large reports about this care focused on children.^2,3 To provide a more comprehensive accounting, we conducted a retrospective study on HSC provided by deployed US military medical units to local national civilians during the Afghanistan conflict.

Fee for service reimbursement incentives may affect care. We compared the odds of prostate specific antigen screening among former and active duty United States military service members based on receipt of primary care from integrated military health facilities vs community providers reimbursed via fee for service. We retrospectively studied the records of all active duty and retired male service members 40 to 64 years old who were covered by the TRICARE® military health benefit in 2010. Beneficiaries may receive primary care at military run facilities via the direct care system or with private physicians via the purchased care system. We compared rates of prostate specific antigen screening between propensity score weighted cohorts of 219,290 men who received primary care in the direct care system and 177,748 who received it in the purchased care system. The screening rate was 35% in the direct care system vs 26% in the purchased care system. After propensity score weighting the former men were significantly more likely to undergo prostate specific antigen screening than men who received primary care in the purchased care system (adjusted OR 1.76, 95% CI 1.729-1.781). Age older than 52 years, rank and black race were associated with increased odds of prostate specific antigen screening in each cohort. These results suggest that salaried primary care providers employed at integrated military facilities are more likely to order prostate specific antigen screening compared to those reimbursed in a fee for service fashion by military insurance. Growing understanding of how fee for service incentives impact prostate specific antigen screening by primary care providers may enable advocates and policy makers to leverage reimbursement systems as a tool to change prostate cancer screening.