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Findings from the 2023 Future of Payments Survey published by the corporate disbursement platform Onbe suggest that digital payments continue to drive US consumer preferences in today’s economy. The survey showed that 70% of respondents prefer to receive payments digitally, and 73% prefer to shop and pay with digital methods, including in-app and peer-to-peer payments.

Onbe’s second annual survey comes at a time when understanding how consumers’ preferences for digital payments solutions is a significant issue. With myriad new options, many physician practice groups are trying to figure out the right mix of payment forms to meet the needs of their patients. Many medical practices, however, may not be overly excited about changing some long-held traditions. “Quite simply, we find that habit is the biggest barrier for providers to adopt digital payments. Checks are a legacy payment technology and preferred because they’re comfortable for many people, both health care providers and payers,” said Melissa Hentschel, Chief Client Officer at Onbe.

Training staff and providing the education to patients may seem burdensome at first, but the convenience and efficiency may prove more than worth it in the long term, Hentschel said.“If we want to provide the fast, secure and convenient payment methods that we know people want, but in an industry comfortable with checks, then we must promote a shift in mindset and provide better education,” she said.

During January 2023, the survey asked 1230 consumers 29 questions seeking to identify their payment preferences. The participants were asked what they value most when receiving payments from businesses and transferring money. Other questions covered which payment technologies they plan to try and which ones they plan to use less frequently.

The survey showed that 48% of consumers reported that global payment capabilities and the ability to exchange their payments to a foreign currency are important and valuable. The survey showed that 63% of consumers believe digital payments are the most secure as opposed to other forms of payments, including money order, cash, or check.

Interestingly, nearly one-fourth of respondents said they plan to use cash less frequently or not at all in 2024. Just 8% said they planned to use cash more in 2024, down from one-third in 2022. Each month, more companies are going cashless and that is a trend that is not expected to change, only accelerate due to consumer preferences for fast, secure, and easy digital options.

“Digital payments enable physicians and health care organizations to reduce their costs, improve patient experience, and streamline back-office payouts, while offering popular lower-cost payment options, such as virtual cards and digital wallet payouts,” Hentschel said. 

Lower Fraud Risk

By replacing checks with more secure payment methods, providers can also lower their fraud risk and the high costs of managing fraud incidents, according to Hentschel. “The cost of writing checks can be as high as $12 per check, and sending checks has the highest labor cost compared to other common forms of payment,” she said. “When checks go uncashed, health care organizations are responsible for following up with patients and adhering to their state’s escheatment regulations, if funds remain unclaimed.”

Health care providers have an opportunity to streamline the payment experience by leveraging new payment technologies. In most clinicians’ offices, a check or credit card at the end of the visit is common. “But if that payment is part of an overpayment and leads to an eventual refund, you may not see a check for a few weeks,” Hentschel said. “We want to enable providers to make the refund experience as convenient, simple and fast as the payment experience.”

Faster Payments, Reduced Costs

Tom Furr, CEO of PatientPay, a digital payment platform that focuses on specialty groups, said by leveraging digital payment models, medical groups can receive payments faster, create more positive patient experiences, and reduce costs associated with paper statements. “Our client groups see reductions in the cost of paper statements from 40% to 50%,” Furr said. “Postage costs continue to rise, so by going paperless practices are being more efficient in collections, while seeing substantial cost reduction.”

 His company has found that 71% of patients who pay via their platform do so via a mobile device within 14 days. Since paper statements normally take at least 7 to 10 days to arrive, this faster payment helps with tighter cash flow. Patients who use the company’s platform can pay their co-pays with an existing card-on-file, expediting the payment process and making for a better user experience, Furr said.

"
Quite simply, we find that habit is the biggest barrier for providers to adopt digital payments.

Document Confusion

Patients want to pay their health care bills if a procedure is not covered by insurance, Furr said, but there is often confusion between a separate paper explanation of benefits (EOB) from their payer and patient statements from their provider. “These separate documents are formatted differently and arrive on different days,” Furr said. “Clinicians should partner with technology vendors with the capability to include electronic EOB with the health care statement so patients can review both at the same time.”

Patients are more likely to pay their bill when there is clarity and transparency on their statements. Paul Troutt, vice president of product management at Relatient, an intelligent patient scheduling and engagement technology company, said in today’s fast-paced digital age, mobile technology continues to transform various industries, and health care payments are no exception. “There are many benefits to both the patient and the organization as well as increased efficiencies for administrative staff,” Troutt said.

Health care providers need to take a multi-faceted and omni-channel approach and meet people where they are when it comes to payments, according to Troutt. They can do this by providing multiple payment modalities (such as credit card, check, Apple Pay, Google Pay) and providing multiple ways for a person to pay a bill.

“Automated, digital payment reminders, providing recurring payment plans, and offering multiple payment modalities allows patients multiple ways to settle their bills that best suits their situation, which improves an organization's bottom line,” Troutt said. “People expect digital capabilities in health care, and digital payment programs should be part of an organization’s normal operations, and if they aren’t, patients will choose to go elsewhere."

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The Kidney Disease: Improving Global Outcomes (KDIGO) organization has released a new 2024 clinical practice guideline document on evaluating and managing nondialysis-dependent chronic kidney disease (CKD).

The guideline – a much anticipated update from 2012 – contains mostly new recommendations based on a systematic review of moderate- to high-quality studies conducted up to July 2023. It is designed to assist health care providers with decision-making with respect to the evaluation and management of CKD, defined as abnormalities of kidney structure or function persisting for more than 3 months (excluding dialysis and kidney transplantation).

Key highlights include guidance updates on the measurements of estimated glomerular filtration rate (eGFR) and albuminuria, use of CKD risk prediction equations, and personalized treatment recommendations for kidney and cardiovascular risk reductions tailored to individual patient needs and preferences. Managing blood pressure, diabetes, lipids, CKD-MBD, and anemia (to be updated in 2024) has been addressed in detail in other KDIGO guidelines.

It remains important to determine the cause of each patient’s CKD, whether congenital or genetic, a consequence of systemic diseases, or primary using serum and urine tests, imaging, biopsy, and/or genetic testing.

“Recent advancements in GFR evaluation, risk prediction, and the arrival of novel treatments are poised to enhance CKD prognosis and management,” work group co-chair Adeera Levin, MD, stated in a KDIGO news release. “We also hope the guideline’s emphasis on multidisciplinary teamwork, patient engagement, and a holistic, evidence-based approach to care will help catalyze positive change, resulting in more coordinated CKD care management worldwide.”

Gauging Glomerular Filtration Rate

The guideline provides actionable recommendations based on graded evidence as well as consensus-based practice points on established CKD, staged preferably using the race-free eGFRcr-cys equation and albumin-to-creatinine ratio. If a more accurate assessment of GFR is needed for clinical decision-making, clinicians may measure GFR using plasma or urinary clearance of exogenous filtration markers.

In patients with CKD G3-G5, the guideline recommends using an externally validated risk equation to estimate the absolute risk of kidney failure. Patients believed to have immunoglobulin A nephropathy (IgAN) or autosomal dominant polycystic kidney disease (ADPKD) may want to use disease-specific, externally validated prediction equations, according to a practice point. Risk prediction tools for cardiovascular disease or mortality need to include eGFR and albuminuria or be specific to the CKD population.

Delaying CKD Progression

A practice point encourages clinicians to form a comprehensive and tailored treatment strategy to reduce patients’ risks of progression of CKD and its associated complications. Clinicians should prevent and treat clinical symptoms and signs, such as blood pressure; maintain physical function; and monitor and treat laboratory abnormalities such as anemia, CKD-MBD, potassium disorders, and acidosis, as appropriate.

Activity: According to the guideline, adults with CKD should undertake moderate-intensity physical activity for at least 150 minutes per week, if tolerable.

Diet: The guideline suggests maintaining a dietary protein intake of 0.8 g/kg body weight/d in adults with CKD G3-G5 (evidence level 2C). A practice point suggests avoiding high protein intake exceeding 1.3 g/kg body weight/d. Plant-based, Mediterranean style diets appear prudent, and working with a renal dietitian and receiving appropriate medical nutrition therapy can be beneficial. The guideline also suggests limiting sodium intake to less than 2 g of sodium per day. Special considerations are given for children and older adults.

Blood pressure: With respect to blood pressure control in adults, the guideline recommends that high blood pressure and CKD be treated to a target systolic blood pressure (SBP) of less than 120 mm Hg, when tolerated, using standardized office BP measurement. In children, 24-hour mean arterial pressure by ambulatory blood pressure monitoring should be lowered to the 50th percentile or less for age, sex, and height.

The guideline recommends starting renin-angiotensin-system inhibitors (RASi) (eg, angiotensin-converting enzyme inhibitor [ACEi] or angiotensin II receptor blocker [ARB]) for patients with severely increased albuminuria (G1-G4, A3) without diabetes and suggests this step for patients with moderately increased albuminuria (G1-G4, A2) without diabetes. It also recommends RASi for patients with moderately-to-severely increased albuminuria (G1-G4, A2, and A3) who have diabetes. Avoid any combination of ACEi, ARB, and direct renin inhibitor therapy in the CKD population.

At RASi initiation or dose change, practice points suggest checking within 2-4 weeks for changes in blood pressure, serum creatinine, and serum potassium. Clinicians should continue ACEi or ARB therapy unless serum creatinine rises by more than 30% within 4 weeks. Consider reducing the dose or discontinuing ACEi or ARB if there is symptomatic hypotension or uncontrolled hyperkalemia despite medical treatment, or to reduce uremic symptoms while treating kidney failure.

The guideline suggests a nonsteroidal mineralocorticoid receptor antagonist with proven kidney or cardiovascular benefit for adults with type 2 diabetes, an eGFR exceeding 25 mL/min/1.73m2, normal serum potassium concentration, and albuminuria exceeding 30 mg/g despite maximum tolerated dose of RASi.

Glycemic control: The guideline recommends treating patients with type 2 diabetes, CKD, and an eGFR of at least 20 mL/min/1.73m2 with a sodium-glucose cotransporter-2 inhibitors (SGLT2i). This advice also applies to patients with CKD alone (without diabetes) who have heart failure or a urine ACR of 200 mg/g or more. SGLT2i is also suggested for adults with an eGFR of 20 to 45 mL/min/1.73m2 with urine ACR less than 200 mg/g.

In adults with type 2 diabetes and CKD who have not achieved individualized glycemic targets despite use of metformin and SGLT2i, or who are unable to use those medications, the guideline recommends a long-acting glucagon-like peptide-1 receptor agonist (GLP-1 RA).

Hyperuricemia: The guideline recommends patients with CKD and symptomatic hyperuricemia should be offered uric acid-lowering intervention. Practice points suggest xanthine oxidase inhibitors rather than uricosuric agents. For acute gout, low-dose colchicine or intra-articular/oral glucocorticoids are preferable to nonsteroidal anti-inflammatory drugs (NSAIDs). Patients without symptoms should not receive uric acid-lowering drugs.

Preventing and Managing Cardiovascular Disease

Lipid management: Statins are recommended for adults aged 50 years and older with stage 1-5 CKD (not on dialysis or receiving a transplant). A statin/ezetimibe combination should only be considered for patients with stage 3-5 CKD. Younger adults with coronary disease (myocardial infarction or coronary revascularization), diabetes mellitus, prior ischemic stroke, or an estimated 10-year incidence of coronary death or nonfatal myocardial infarction exceeding 10% should also consider a statin.

Antiplatelet therapy: The guideline recommends oral low-dose aspirin for secondary prevention of recurrent ischemic cardiovascular disease events.

Coronary artery disease: In stable, stress-test confirmed ischemic heart disease, clinicians may first attempt intensive medical therapy. Unstable or acute conditions may warrant an invasive strategy.

Atrial fibrillation: The guideline recommends non-vitamin K antagonist oral anticoagulants rather than vitamin K antagonists such as warfarin for thromboprophylaxis in atrial fibrillation in people with CKD G1-G4.

Imaging: The guideline suggests following advice from radiology societies. Patients with CKD, acute kidney injury (AKI), diabetes, reduced intravascular volume, or concomitant nephrotoxic drugs have increased risk for contrast-associated AKI.

Medication Management and Drug Stewardship

The guideline offers myriad practice points for safe medication use including limiting over-the-counter medicines and herbal and dietary supplements, considering the nephrotoxic effects of medications, reviewing teratogenicity in case of pregnancy, and monitoring eGFR to balance effectiveness and potential adverse effects.

Dose adjustments by eGFR are frequently required for medications cleared by the kidneys. While creatinine-based eGFR is appropriate for drug dosing in most cases, using equations that combine both creatinine and cystatin C, or measured GFR may be indicated when drugs have a narrow therapeutic or toxic range. Use eGFR nonindexed for body surface area in people with extremes of body weight. Adapt drug dosing when the volume of distribution is not in steady state.

Medications discontinued due to illness or prior to elective surgery or acute management of adverse effects should have a plan for restart.

Periodic medication review and pharmacist involvement is necessary.

"
Recent advancements in GFR, risk prediction, and the arrival of novel treatments are poised to enhance CKD prognosis and management.

Optimal Models of Care

The guideline offers a series of practice points to optimize care. Referral to specialist kidney care services is warranted when the cause of CKD is uncertain and in cases of  hereditary kidney disease or recurrent extensive nephrolithiasis. It is also warranted when the 5-year risk for kidney replacement therapy exceeds 5%, eGFR drops by 20%-30%, or eGFR falls below 30 mL/min/1.73m2. Significant albuminuria and microscopic hematuria also require further evaluation and management.

Referral of children and adolescents to specialist kidney care services is indicated when urine ACR is 30 mg/g or PCR is 200 mg/g or more or there is persistent hematuria, a sustained decrease in eGFR, hypertension, kidney outflow obstruction, kidney and urinary tract anomalies, suspected CKD, or recurrent urinary tract infection. Transition from pediatric to adult care should begin at age 11 to 14 years using checklists to assess readiness and guide preparation. Kidney transplantation is recommended, either preemptively or when kidney failure occurs.

Timely referral to specialist kidney care is paramount to avoid poor outcomes, such as hospitalization.

Symptoms: A practice point suggests screening people with CKD G4-G5, age older than 65 years, poor growth, or symptoms such as involuntary weight loss, frailty, or poor appetite twice annually for malnutrition using a validated assessment tool. The guideline also offers lifestyle and pharmacologic options for managing other symptoms such as pain, poor sleep, and uremic pruritus.

Multidisciplinary care: Clinicians should ensure access to dietary counseling, medication management, education, and counseling about kidney replacement modalities, transplant options, dialysis access surgery, and ethical, psychological, and social care for people with CKD.

Dialysis Initiation

According to practice points, dialysis is indicated when symptoms or signs attributable to kidney failure are present, such as neurologic signs of uremia, pericarditis, anorexia, medically resistant acid-based or electrolyte abnormalities, intractable pruritus, serositis, and acid-base or electrolyte abnormalities or the patient has inability to control volume status or blood pressure. This often occurs when GFR is 5 to 10 mL/min/1.73 m2.

Consider planning for preemptive kidney transplantation and/or dialysis access in adults when the GFR is less than 15 to 20 mL/min/1.73m2 or risk of KRT exceeds 40% over 2 years. Pediatric patients have special considerations and should ideally seek transplantation.

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A new clinical practice guideline on salvage therapy for prostate cancer has been released by the American Urological Association (AUA), the American Society for Radiation Oncology (ASTRO), and the Society of Urologic Oncology (SUO).

“With a focus on evidence-based approaches and a commitment to patient-centered care, this guideline will make a real difference for patients dealing with recurrence of their prostate cancer following initial treatment,” guideline panel chair Todd Morgan, MD, stated in an AUA news release. This guideline was based on research published up to July 2023 and expert consensus. The full guideline contains 30 recommendations and is now available at auanet.org/STPCGuideline.

In The Journal of Urology, the guideline panel presented a 3-part series focusing on key aspects of the guideline including treatment decision-making and delivery at the time of suspected biochemical recurrence (BCR) after definitive radical prostatectomy (RP), radiation therapy (RT), and focal therapy, including for local and regional recurrence and oligometastasis. Here’s a synopsis of some key points:

When to Consider Salvage RT

Clinicians and patients should consider salvage RT when the PSA is 0.5 ng/mL or less for greater effectiveness. For high-risk patients, RT can be considered at a PSA less than 0.2 ng/mL. High-risk features include Grade Group 4-5, stage pT3b-4, positive surgical margins, node-positive disease, short PSA doubling time (PSADT), early PSA recurrence including persistent detectable PSA after RP, and higher post-surgery PSA. Genomic classifier risk and PET imaging findings also may considered. Clinicians may obtain ultrasensitive PSA after RP for patients with high-risk features, but they should confirm a rising trend in PSA before commencing therapy.

Clinicians may obtain a PSMA PET scan instead of conventional imaging or after negative results to identify clinical recurrence. Pelvic MRI may be used with PET/CT for evaluation of local recurrence. Next generation molecular PET imaging should be used when planning RT. Radiation to the salvage prostate bed and diseased pelvic nodes should be in the plan, even if PET/CT imaging is negative.

Clinicians should inform patients that salvage RT after RP poses inherent risks to urinary control and erectile and bowel function.

Nonmetastatic BCR After Surgery

For patients with high-risk features such as node-positive disease, offer androgen deprivation therapy (ADT) at a minimum of 4-6 months and up to 18-24 months with salvage RT. Use expanded radiation fields that include the regional lymph nodes. Do not add docetaxel. Patients without high-risk features can undergo RT alone. Intensified androgen receptor suppression (eg, abiraterone acetate, enzalutamide, apalutamide, and darolutamide) should be used for patients without nodal disease only within a clinical trial setting.

Clinicians should discuss ADT and RT side effects with patients and their influence on medical comorbidities. Applying RT to regional lymph nodes may increase the risk of side effects.

Nonmetastatic Recurrence After RT, Focal Ablation

For BCR after primary RT or ablative therapy, clinicians should perform a prostate biopsy to evaluate patients for local recurrence amenable to local salvage therapy. If clinical recurrence is confirmed, clinicians should offer patients the choice of RP, cryoablation, high intensity focused ultrasound (HIFU), or reirradiation during shared decision-making. For BCR after focal ablation, clinicians should offer whole gland treatment by RP or RT.

Regional Recurrence

In patients with pelvic nodal recurrence following primary RP, clinicians should offer ADT plus salvage RT to the prostate bed and pelvic lymph nodes. For pelvic nodal recurrence following primary RT, clinicians should offer salvage pelvic nodal RT plus ADT. Salvage pelvic lymphadenectomy is possible but has uncertain benefit in this setting.

For regional or metastatic oligorecurrence following primary RP or RT, clinicians may perform metastasis-directed therapy using stereotactic ablative radiation therapy after weighing the risk of toxicity against the potential benefits.

For patients with nonregional disease on PET/CT (but no visible disease on conventional imaging), clinicians may omit salvage RT to the prostate bed and discuss the uncertain role of systemic therapy.

Future Considerations

Studies investigating the ability of prostate-specific membrane antigen PSMA PET/CT to optimize patient selection and guide radiation planning for locoregional recurrences will be completed soon. Efforts are underway to optimize use of systemic therapies, particular suppression of androgen receptor activation, for example, using genomic classifiers. Studies are underway looking at the use of intensified androgen suppression during salvage RT.

“Continuous and deliberate efforts for multidisciplinary care in prostate cancer will be required to optimize and improve the oncologic and functional outcomes of patients treated with salvage therapies in the future,” the panel wrote.

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First-line immuno-oncology (IO)-based regimens and intensive focal therapies are associated with significantly prolonged overall survival (OS) among patients with brain metastases from renal cell carcinoma (RCC), new findings suggest.

In a real-world study, median OS was 32.7 months for patients who received first-line IO-based combination regimens compared with 20.6 months for those who received tyrosine kinase inhibitor (TKI) monotherapy, Kosuke Takemura, MD, of the Tom Baker Cancer Centre at the University of Calgary in Alberta, Canada, and colleagues reported in European Urology. Patients who received intensive focal therapies with stereotactic radiotherapy or neurosurgery have significantly longer OS compared with those who receive whole-brain radiotherapy alone or no focal therapy (31.4 vs 16.5 months).

On multivariable analysis, IO-based regimens were significantly associated with a 51% reduced risk for death compared with TKI regimens. Stereotactic radiotherapy or neurosurgery was significantly associated with a 52% lower risk for death compared with whole-brain radiotherapy alone or no focal therapy.

IMDC favorable- or intermediate-risk disease was significantly associated with a 60% lower risk for death compared with poor-risk disease.

The findings are from an analysis of data from the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC). Of 4799 patients with metastatic RCC, 389 (8.1%) had brain metastases at initiation of systemic therapy. The goal of the study was to define the clinical effectiveness of modern multi-modal cancer treatment for patients with brain metastases from RCC. The investigators did not probe the causal pathways between treatments and outcomes. 

The study included patients who received first-line IO-based combination therapy (nivolumab/ipilimumab, pembrolizumab/axitinib, avelumab/axitinib, nivolumab/cabozantinib, pembrolizumab/lenvatinib, or atezolizumab/bevacizumab) or TKI monotherapy (sunitinib or pazopanib) and had data available on brain metastases before initiation of systemic therapy. Of the 389 patients, 99 (25%) received IO-based regimens.

The patients with brain metastases were more likely to be younger (63 vs 65 years) and to have lung metastases (80% vs 67%), spleen metastases (2.0% vs 0.8%), and multiple sites of metastases (96% vs 80%). The group with brain metastases had a shorter median OS compared with patients without brain metastases (22.8 vs 34.7 months).

The study was limited by its retrospective design and absence of data on PD-L1 expression or intracranial/ extracranial disease status.

“This is a very important study and highlights that this patient population should be considered as the focus of future innovative clinical trials, and there definitely should not be an exclusion simply because they are not anticipated to have a favorable outcome,” said genitourinary surgical oncologist Philippe E. Spiess, MD, assistant chief of surgical services and high-volume kidney cancer surgeon at the Moffitt Cancer Center in Tampa, Florida. “Up until this point, these patients were never eligible for clinical trial participation, as it was thought they would do poorly, but now with promising outcomes with new treatment combinations along with site-directed brain radiation, our clinical approach to these patients needs to adapt to one offering more hope and personalization.”

In addition, the morbidity and mortality of these therapeutic modalities are improving, he said, “and now our focus should be in knowing which of these systemic therapies when used in combinations along with radiation [therapies] can offer a curative potential to a subset of patients.”

Scott S Tykodi, MD, PhD, Director of Kidney Cancer Research at the University of Washington’s Fred Hutchinson Cancer Center in Seattle, said the real-world data used in the study are informative because the outcomes are likely closer to what is seen in the clinic versus clinical trial results, which usually exclude patients with comorbidities and unfavorable disease presentations like brain metastases.

"The trends observed in the IMDC data are consistent with our expectations that front-line IO-based regimens are better than TKI monotherapy, and an oligometastatic pattern of brain metastases amenable to surgery or stereotactic radiation is a better prognosis than widespread disease managed by whole brain radiation or no localized therapy at all," Dr Tykodi said. “While this study reinforces our usual treatment patterns, it also confirms the survival penalty associated with brain involvement by the metastatic disease burden.”

Marc A. Bjurlin, DO, MSc, Director of Clinical Trials at the Lineberger Comprehensive Cancer Center at the University of North Carolina, Chapel Hill, North Carolina, said the new study provides a context in which clinicians can better counsel patients with RCC brain metastases in terms of expected OS by taking into account both focal therapy options and systemic therapy.

The IMDC database enabled investigators to capture a broad selection of clinically important and informative variables in a cohort of patients with a relatively long follow-up, Dr Bjurlin said. He pointed out, however, that there is a selection bias in that only patients who were suitable for stereotactic radiotherapy or neurosurgery were selected for those interventions, whereas those who were unable to receive these treatments due to such issues as the presence of more or larger tumors might have been steered toward whole brain radiotherapy.

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