Andrew J Epstein

Massachusetts General Hospital, Boston, Massachusetts, United States

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Publications (93)683.01 Total impact

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    ABSTRACT: Purpose: We assessed the associations between the 21-gene recurrence score assay (RS) receipt, subsequent chemotherapy use, and medical expenditures among patients with early-stage breast cancer. Patients and methods: Data from the Pennsylvania Cancer Registry were used to assemble a retrospective cohort of women with early-stage breast cancer from 2007 to 2010 who underwent initial surgical treatment. These data were merged with administrative claims from the 12-month periods before and after diagnosis to identify comorbidities, treatments, and expenditures (n = 7,287). Propensity score-weighted regression models were estimated to identify the effects of RS receipt on chemotherapy use and medical spending in the year after diagnosis. Results: The associations between RS receipt and outcomes varied markedly by patient age. RS use was associated with lower chemotherapy use among women younger than 55 (19.2% lower; 95% CI, 10.6 to 27.9). RS use was associated with higher chemotherapy use among women 75 to 84 years old (5.7% higher; 95% CI, 0.4 to 11.0). RS receipt was associated with lower adjusted 1-year medical spending among women younger than 55 ($15,333 lower; 95% CI, $2,841 to $27,824) and with higher spending among women who were 75 to 84 years old ($3,489 higher; 95% CI, $857 to $6,122). Conclusion: RS receipt was associated with reduced use of adjuvant chemotherapy and lower health care spending among women with breast cancer who were younger than 55. Conversely, among women 75 and older, RS testing was associated with a modest increase in chemotherapy use and slightly higher spending. From a population perspective, the impact of RS testing on breast cancer treatment and health care costs is much greater in younger women.
    Journal of Clinical Oncology 11/2015; DOI:10.1200/JCO.2015.61.9023 · 18.43 Impact Factor

  • 10/2015; DOI:10.4300/JGME-D-15-00092.1

  • Chest 10/2015; 148(4_MeetingAbstracts):584A. DOI:10.1378/chest.2281384 · 7.48 Impact Factor
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    ABSTRACT: Background: Rapid growth in the provision of cardiac imaging tests has led to concerns about overuse. Little is known about the degree to which health care delivery system characteristics influence use and variation in echocardiography. Methods: We analyzed administrative claims of veterans with heart failure older than 65 years from 2007 to 2010 across 34 metropolitan service areas (MSAs). We compared overall rates and geographic variation in use of transthoracic echocardiography (TTE) between veterans who used the Veterans Health Administration (VA) and propensity-matched veterans who used Medicare. "Dual users" were excluded. Results: There were no significant differences in clinical characteristics or mortality between the propensity-matched cohorts (overall n = 30,404 veterans, mean age 76 years, mortality rate 52%). The Medicare cohort had a significantly higher overall rate of TTE use compared with the VA cohort (1.25 vs 0.38 TTEs per person-year, incidence rate ratio 2.89 [95% CI 2.80-3.00], both P < .001), but a similar coefficient of variation across MSAs (0.36 [95% CI 0.27-0.45] vs 0.48 [95% CI 0.37-0.59]). There was a moderate to strong correlation in variation at the MSA level between cohorts (Spearman r = 0.58, P < .001). Conclusion: Overall rates of TTE use were significantly higher in a Medicare cohort compared with a propensity score-matched VA cohort of veterans with heart failure living in urban areas, with similar relative degrees of geographic variation and moderate to strong regional correlation. Rates of TTE use may be strongly influenced by health care system characteristics, but local practice styles influence echocardiography rates irrespective of health system.
    American heart journal 09/2015; 170(4):805-11. DOI:10.1016/j.ahj.2015.07.016 · 4.46 Impact Factor
  • Kira L Ryskina · C Jessica Dine · Esther J Kim · Tara F Bishop · Andrew J Epstein ·
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    ABSTRACT: Despite increased emphasis on cost-consciousness in graduate medical training, there is little empirical evidence of the role of attending physician supervision on resident practice in this area. To study whether the prescribing practices of attendings influence residents' prescribing of brand-name statin medications in the ambulatory clinic setting. A retrospective study of statin prescriptions by residents at two internal medicine residency programs, using electronic medical record data from July 2007 through November 2011. We estimated multivariable hierarchical logistic regression models to assess the independent effect of the supervising attending's rate of brand-name prescribing in the preceding quarter on the likelihood of a resident prescribing a brand-name statin. The sample included 342 residents and 58 attendings, accounting for 10,151 initial statin prescriptions, including 3,942 by residents. Brand-name statins were prescribed in about one-fourth of encounters. After adjusting for patient-, physician-, and practice-level factors, the supervising attendings' brand-name prescribing rate in the quarter preceding the encounter was positively associated with a postgraduate year (PGY)-1 resident's prescribing a brand-name statin, but not for PGY-2 or PGY-3 residents. For PGY-1 residents, the adjusted probability of a resident prescribing a brand-name statin ranged from 22.6 % (95 % CI 17.3-28.0 %, p < 0.001) for residents supervised by an attending who prescribed < 20 % brand-name statins in the previous quarter to 41.6 % (95 % CI 24.6-58.5 %, p < 0.001) for residents supervised by an attending who prescribed at least 80 % brand-name statins in the previous quarter. A higher PGY level was associated with brand-name prescribing (aOR 2.07, 95 % CI 1.28-3.35, p = 0.003 for PGY-2; aOR 2.15, 95 % CI 1.31-3.55, p = 0.003 for PGY-3, vs. PGY-1). Supervising attendings' prescribing of brand-name medications may have a significant influence on PGY-1 residents' prescribing of brand-name medications, but not on prescribing by more senior residents.
    Journal of General Internal Medicine 07/2015; 30(9). DOI:10.1007/s11606-015-3323-5 · 3.42 Impact Factor
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    ABSTRACT: Health care systems are increasingly moving toward models that emphasize the delivery of high-quality health care at lower costs. Rates of repeat echocardiography (two or more transthoracic echocardiographic studies performed within a short interval) are high and can contribute substantially to the cost of providing cardiovascular care. Certain findings from handheld ultrasound scans performed by echocardiographers have been shown to correlate well with findings on transthoracic echocardiography (TTE). It therefore may be feasible and cost effective to use expert focused cardiac ultrasound (eFCU) in place of repeat TTE for highly selected indications in certain settings. The aim of this study was to determine the reliability and cost implications of using eFCU in place of repeat TTE in selected inpatients.
    Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 07/2015; 28(9). DOI:10.1016/j.echo.2015.06.002 · 4.06 Impact Factor
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    ABSTRACT: Little is known about recent trends in surveillance among the more than 1 million US colorectal cancer (CRC) survivors. Moreover, for stage I disease, which accounts for more than 30% of survivors, the guidelines are limited, and the use of surveillance has not been well studied. Guidelines were changed in 2005 to include recommendations for computed tomography (CT) surveillance in select patients, but the impact of these changes has not been explored. A retrospective analysis of patients who were identified in the Survival, Epidemiology, and End Results-Medicare database and underwent resection of stage I to III CRC between 2001 and 2009 was performed. The receipt of guideline-determined sufficient surveillance, including office visits, colonoscopy, carcinoembryonic antigen (CEA) testing, and CT imaging, in the 3 years after resection was evaluated. The study included 23,990 colon cancer patients and 5665 rectal cancer patients. Rates of office visits and colonoscopy were high and stable over the study period. Rates of CEA surveillance increased over the study period but remained low, even for stage III disease. Rates of CT imaging increased gradually during the study period, but the 2005 guideline change had no effect. Stage II patients, including high-risk patients, received surveillance at significantly lower rates than stage III patients despite similar recommendations. Conversely, up to 30% of stage I patients received nonrecommended CEA testing and CT imaging. There continues to be substantial underuse of surveillance for CRC survivors and particularly for stage II patients, who constitute almost 40% of survivors. The 2005 guideline change had a negligible impact on CT surveillance. Conversely, although guidelines are limited, many stage I patients are receiving intensive surveillance. Cancer 2015. © 2015 American Cancer Society. © 2015 American Cancer Society.
    Cancer 06/2015; 121(19). DOI:10.1002/cncr.29469 · 4.89 Impact Factor
  • A.J. Epstein · C.L. Barry · D.A. Fiellin · S.H. Busch ·

    Value in Health 05/2015; 18(3):A277. DOI:10.1016/j.jval.2015.03.1616 · 3.28 Impact Factor
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    Andrew J Epstein · Colleen L Barry · David A Fiellin · Susan H Busch ·
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    ABSTRACT: Most individuals with substance use disorders and with mental disorders do not receive treatment. If treatment options were more attractive, treatment rates might increase. The advantages of novel approaches, including primary care-based treatment and collaborative care in a primary care setting, have been documented. However, less is known about consumers' valuation of these options. The authors assessed monetary valuation of these treatment types compared with usual care in a specialty treatment setting. Contingent valuation methods were used in a Web-based randomized vignette experiment that involved 2,146 individuals who screened positive for a drug or alcohol use disorder or a mental disorder. Participants valued a primary care-based treatment visit over usual care in a specialty treatment setting by $9.00 and a collaborative care visit over usual care in a specialty treatment setting by $5.85.
    Psychiatric services (Washington, D.C.) 05/2015; 66(8):appips201500077. DOI:10.1176/ · 2.41 Impact Factor

  • Value in Health 05/2015; 18(3):A217-A218. DOI:10.1016/j.jval.2015.03.1262 · 3.28 Impact Factor
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    ABSTRACT: The relationship between oncologic hospital academic status and the value of care for stage II and III colon cancer is unknown. Retrospective SEER-Medicare analysis of patients age ≥ 66 years with stage II or III colon cancer and seen by medical oncology. Eligible patients were diagnosed 2000 to 2009 and followed through December 31, 2010. Hospitals reporting a major medical school affiliation in the NCI Hospital File were classified as academic medical centers. The association between hospital academic status and survival was assessed using Kaplan-Meier curves and Cox proportional hazards models. The association with mean cost of care was estimated using generalized linear models with log link and gamma family and with cost of care at various quantiles using quantile regression models. Of 24,563 eligible patients, 5,707 (23%) received care from academic hospitals. There were no significant differences in unadjusted disease-specific median survival or adjusted risk of colon cancer death by hospital academic status (stage II hazard ratio = 1.12; 95% CI, 0.98 to 1.28; P = .103; stage III hazard ratio = 0.99; 95% CI, 0.90 to 1.08; P = .763). Excepting patients at the upper limits of the cost distribution, there was no significant difference in adjusted cost by hospital academic status. We found no survival differences for elderly patients with stage II or III colon cancer, treated by a medical oncologist, between academic and nonacademic hospitals. Furthermore, cost of care was similar across virtually the full range of the cost distribution. Copyright © 2015 by American Society of Clinical Oncology.
    Journal of Oncology Practice 04/2015; 11(3). DOI:10.1200/JOP.2014.003137
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    ABSTRACT: Academic medical centers (AMCs) have increasingly adopted conflict of interest policies governing physician-industry relationships; it is unclear how policies impact prescribing. To determine whether 9 American Association of Medical Colleges (AAMC)-recommended policies influence psychiatrists' antipsychotic prescribing and compare prescribing between academic and nonacademic psychiatrists. We measured number of prescriptions for 10 heavily promoted and 9 newly introduced/reformulated antipsychotics between 2008 and 2011 among 2464 academic psychiatrists at 101 AMCs and 11,201 nonacademic psychiatrists. We measured AMC compliance with 9 AAMC recommendations. Difference-in-difference analyses compared changes in antipsychotic prescribing between 2008 and 2011 among psychiatrists in AMCs compliant with ≥7/9 recommendations, those whose institutions had lesser compliance, and nonacademic psychiatrists. Ten centers were AAMC compliant in 2008, 30 attained compliance by 2011, and 61 were never compliant. Share of prescriptions for heavily promoted antipsychotics was stable and comparable between academic and nonacademic psychiatrists (63.0%-65.8% in 2008 and 62.7%-64.4% in 2011). Psychiatrists in AAMC-compliant centers were slightly less likely to prescribe these antipsychotics compared with those in never-compliant centers (relative odds ratio, 0.95; 95% CI, 0.94-0.97; P<0.0001). Share of prescriptions for new/reformulated antipsychotics grew from 5.3% in 2008 to 11.1% in 2011. Psychiatrists in AAMC-compliant centers actually increased prescribing of new/reformulated antipsychotics relative to those in never-compliant centers (relative odds ratio, 1.39; 95% CI, 1.35-1.44; P<0.0001), a relative increase of 1.1% in probability. Psychiatrists exposed to strict conflict of interest policies prescribed heavily promoted antipsychotics at rates similar to academic psychiatrists and nonacademic psychiatrists exposed to less strict or no policies.
    Medical care 04/2015; 53(4):338-345. DOI:10.1097/MLR.0000000000000329 · 3.23 Impact Factor
  • Colleen Barry · S. Busch · Andrew Epstein · David Fiellin ·

    Drug and Alcohol Dependence 01/2015; 146:e218. DOI:10.1016/j.drugalcdep.2014.09.061 · 3.42 Impact Factor
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    ABSTRACT: Based on randomized evidence, expert guidelines in 2011 endorsed shorter, hypofractionated whole breast irradiation (WBI) for selected patients with early-stage breast cancer and permitted hypofractionated WBI for other patients. To examine the uptake and costs of hypofractionated WBI among commercially insured patients in the United States. Retrospective, observational cohort study, using administrative claims data from 14 commercial health care plans covering 7.4% of US adult women in 2013, we classified patients with incident early-stage breast cancer treated with lumpectomy and WBI from 2008 and 2013 into 2 cohorts: (1) the hypofractionation-endorsed cohort (n = 8924) included patients aged 50 years or older without prior chemotherapy or axillary lymph node involvement and (2) the hypofractionation-permitted cohort (n = 6719) included patients younger than 50 years or those with prior chemotherapy or axillary lymph node involvement. Hypofractionated WBI (3-5 weeks of treatment) vs conventional WBI (5-7 weeks of treatment). Use of hypofractionated and conventional WBI, total and radiotherapy-related health care expenditures, and patient out-of-pocket expenses. Patient and clinical characteristics included year of treatment, age, comorbid disease, prior chemotherapy, axillary lymph node involvement, intensity-modulated radiotherapy, practice setting, and other contextual variables. Hypofractionated WBI increased from 10.6% (95% CI, 8.8%-12.5%) in 2008 to 34.5% (95% CI, 32.2%-36.8%) in 2013 in the hypofractionation-endorsed cohort and from 8.1% (95% CI, 6.0%-10.2%) in 2008 to 21.2% (95% CI, 18.9%-23.6%) in 2013 in the hypofractionation-permitted cohort. Adjusted mean total health care expenditures in the 1 year after diagnosis were $28 747 for hypofractionated and $31 641 for conventional WBI in the hypofractionation-endorsed cohort (difference, $2894; 95% CI, $1610-$4234; P < .001) and $64 273 for hypofractionated and $72 860 for conventional WBI in the hypofractionation-permitted cohort (difference, $8587; 95% CI, $5316-$12 017; P < .001). Adjusted mean total 1-year patient out-of-pocket expenses were not significantly different between hypofractionated vs conventional WBI in either cohort. Hypofractionated WBI after breast conserving surgery increased among women with early-stage breast cancer in 14 US commercial health care plans between 2008 and 2013. However, only 34.5% of patients with hypofractionation-endorsed and 21.2% with hypofractionation-permitted early-stage breast cancer received hypofractionated WBI in 2013.
    JAMA The Journal of the American Medical Association 12/2014; 312(23). DOI:10.1001/jama.2014.16616 · 35.29 Impact Factor
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    ABSTRACT: Background: Case managers are employed in medical homes to coordinate care for clinically complex patients. Objective: To measure the association of patient perceptions of case manager performance with overall satisfaction and subsequent health care utilization. Design: Retrospective cohort study. Setting: Integrated health system in Pennsylvania. Patients: Members of the health system-owned health plan who 1) received primary care in the health system's clinics, 2) were exposed to clinic-embedded case managers, and 3) completed a survey of satisfaction with care. Measurements: Survey assessment of case manager performance and overall satisfaction with care and claims-based assessment of case manager performance and subsequent hospitalizations or emergency department visits. Survey measures were dichotomized into very good versus less than very good. Results: A total of 1755 patients (44%) completed the survey and 1415 met study criteria. Survey respondents who reported very good ratings of case manager performance across all items had a higher probability of reporting very good overall satisfaction with care (92.2% vs. 62.5%; P < 0.001) and had a lower incidence of subsequent emergency department visits (incidence rate ratio, 0.79 [95% CI, 0.64 to 0.98]; P = 0.029) but not hospitalizations (incidence rate ratio, 0.92 [CI, 0.75 to 1.11]; P = 0.37) up to 2 years after the survey compared with survey respondents who reported less-than-very good case manager performance on 1 or more questions on the survey. Limitations: Satisfaction data demonstrated substantial ceiling effects. Survey nonresponse may have introduced bias in the results. Conclusion: Patients' favorable perceptions of case managers are associated with higher overall satisfaction with care and may lower risk for future acute care use. Primary funding source: Robert Wood Johnson Foundation and the U.S. Department of Veterans Affairs.
    Annals of internal medicine 11/2014; 161(10 Suppl):S59-65. DOI:10.7326/M13-3007 · 17.81 Impact Factor
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    ABSTRACT: Background: The effect of care setting on value of colon cancer care is unknown. Methods: A Surveillance, Epidemiology, and End Results (SEER)-Medicare cohort study of 6544 patients aged ≥ 66 years with stage IV colon cancer (based on the American Joint Committee on Cancer staging system) who were diagnosed between 1996 and 2005 was performed. All patients were followed through December 31, 2007. Using outpatient and carrier claims, patients were assigned to a treating hospital based on the hospital affiliation of the primary oncologist. Hospitals were classified academic or nonacademic using the SEER-Medicare National Cancer Institute Hospital File. Results: Of the 6544 patients, 1605 (25%) received care from providers affiliated with academic medical centers. The unadjusted median cancer-specific survival was 16.0 months at academic medical centers versus 13.9 months at nonacademic medical centers (P < .001). After adjustment, treatment at academic hospitals remained significantly associated with a reduced risk of death from cancer (hazard ratio, 0.87; 95% confidence interval [95% CI], 0.82-0.93 [P < .001]). Adjusted mean 12-month Medicare spending was $8571 higher at academic medical centers (95% CI, $2340-$14,802; P = .007). The adjusted median cost was $1559 higher at academic medical centers; this difference was not found to be statistically significant (95% CI, -$5239 to $2122; P = .41). A small percentage of patients who received very expensive care skewed the difference in mean cost; the only statistically significant difference in adjusted costs in quantile regressions was at the 99.9th percentile of costs (P < .001). Conclusions: Among Medicare beneficiaries with stage IV colon cancer, treatment by a provider affiliated with an academic medical center was associated with a 2 month improvement in overall survival. Except for patients in the 99.9th percentile of the cost distribution, costs at academic medical centers were not found to be significantly different from those at nonacademic medical centers.
    Cancer 10/2014; 120(20). DOI:10.1002/cncr.28874 · 4.89 Impact Factor
  • Justin E. Bekelman · Andrew J. Epstein · Ezekiel J. Emanuel ·

    International journal of radiation oncology, biology, physics 08/2014; 89(5):954–957. DOI:10.1016/j.ijrobp.2014.04.022 · 4.26 Impact Factor

  • Thyroid: official journal of the American Thyroid Association 07/2014; 24(10). DOI:10.1089/thy.2014.0237 · 4.49 Impact Factor
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    ABSTRACT: Objectives Variation in care within and across geographic areas remains poorly understood. The goal of this article was to examine whether physician social networks—as defined by shared patients—are associated with rates of complications after radical prostatectomy. Methods In five cities, we constructed networks of physicians on the basis of their shared patients in 2004-2005 Surveillance, Epidemiology and End Results-Medicare data. From these networks, we identified subgroups of urologists who most frequently shared patients with one another. Among men with localized prostate cancer who underwent radical prostatectomy, we used multilevel analysis with generalized linear mixed-effect models to examine whether physician network structure—along with specific characteristics of the network subgroups—was associated with rates of 30-day and late urinary complications, and long-term incontinence after accounting for patient-level sociodemographic, clinical factors, and urologist patient volume. Results Networks included 2677 men in five cities who underwent radical prostatectomy. The unadjusted rate of 30-day surgical complications varied across network subgroups from an 18.8 percentage-point difference in the rate of complications across network subgroups in city 1 to a 26.9 percentage-point difference in city 5. Large differences in unadjusted rates of late urinary complications and long-term incontinence across subgroups were similarly found. Network subgroup characteristics—average urologist centrality and patient racial composition—were significantly associated with rates of surgical complications. Conclusions Analysis of physician networks using Surveillance, Epidemiology and End Results-Medicare data provides insight into observed variation in rates of complications for localized prostate cancer. If validated, such approaches may be used to target future quality improvement interventions.
    Value in Health 07/2014; 17(5). DOI:10.1016/j.jval.2014.04.011 · 3.28 Impact Factor
  • S. Busch · A. Epstein · M. Harhay · David Fiellin · H. Un · D. Leader · C. Barry ·

    Drug and Alcohol Dependence 07/2014; 140:e23. DOI:10.1016/j.drugalcdep.2014.02.085 · 3.42 Impact Factor

Publication Stats

2k Citations
683.01 Total Impact Points


  • 2015
    • Massachusetts General Hospital
      Boston, Massachusetts, United States
  • 2004-2015
    • University of Pennsylvania
      • Center for Health Equity Research
      Filadelfia, Pennsylvania, United States
  • 2006-2014
    • William Penn University
      Filadelfia, Pennsylvania, United States
  • 2003-2013
    • Yale University
      • • Department of Public Health
      • • Department of Internal Medicine
      New Haven, Connecticut, United States
  • 2005-2009
    • Yale-New Haven Hospital
      • Department of Laboratory Medicine
      New Haven, Connecticut, United States
  • 2007
    • Harvard University
      Cambridge, Massachusetts, United States
    • Icahn School of Medicine at Mount Sinai
      Manhattan, New York, United States