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Recent Research Articles from JPS Health Network

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Cognitive Behavior Therapy for Postpartum Depression.

Fri, 08/16/2019 - 07:54
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Cognitive Behavior Therapy for Postpartum Depression.

Am Fam Physician. 2019 Aug 15;100(4):244-245

Authors: Buck K, Zekri S, Nguyen L, Ogar UJ

PMID: 31414780 [PubMed - in process]

Comparison of pharmacy students' self-efficacy to address cessation counseling needs for traditional and electronic cigarette use.

Wed, 08/14/2019 - 05:12
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Comparison of pharmacy students' self-efficacy to address cessation counseling needs for traditional and electronic cigarette use.

Curr Pharm Teach Learn. 2018 07;10(7):955-963

Authors: Nduaguba SO, Ford KH, Bamgbade BA, Ubanyionwu O

Abstract
BACKGROUND AND PURPOSE: This study assessed pharmacy students' self-rated ability to provide cessation counseling for e-cigarette use and traditional cigarette smoking.
EDUCATIONAL ACTIVITY AND SETTING: A cross-sectional study was conducted in spring 2014 at The University of Texas at Austin. Participants included first through fourth year (P1-P4) doctor of pharmacy (PharmD) students. Perceived confidence and knowledge to counsel on cigarette smoking cessation and e-cigarette cessation were self-rated and based on the Ask-Advise-Assess-Assist-and Arrange (5 A's) follow-up model as well as general counseling skills for recreational nicotine product use cessation. Comparisons were made between students' confidence to counsel patients on traditional cigarette smoking cessation and e-cigarette cessation and by class level.
FINDINGS: Compared to cigarette smoking cessation counseling, students were less confident in their ability to counsel on e-cigarette cessation using the 5 A's model and general counseling skills. Students perceived themselves to be less knowledgeable about the harmful effects of e-cigarettes, pharmacists' role in counseling on e-cigarette cessation, and how patients can benefit from e-cigarette cessation counseling. A higher proportion of students reported having no training on e-cigarette cessation compared to cigarette smoking cessation (59% vs 9%).
SUMMARY: Targeted training on how to counsel patients on e-cigarette cessation should be included in pharmacy curricula. Such training is expected to increase the confidence of pharmacists-in-training to address the needs of patients who use e-cigarettes.

PMID: 30236434 [PubMed - indexed for MEDLINE]

Financial Incentives to Promote Colorectal Cancer Screening: A Longitudinal Randomized Control Trial.

Thu, 08/08/2019 - 09:00
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Financial Incentives to Promote Colorectal Cancer Screening: A Longitudinal Randomized Control Trial.

Cancer Epidemiol Biomarkers Prev. 2019 Aug 06;:

Authors: Lieberman A, Gneezy A, Berry E, Miller S, Koch M, Ahn C, Balasubramanian BA, Argenbright KE, Gupta S

Abstract
BACKGROUND: Financial incentives may improve health behaviors. We tested the impact of offering financial incentives for mailed fecal immunochemical test (FIT) completion annually for three years.
METHODS: Patients, aged 50-64 years, not up-to-date with screening were randomized to receive either a mailed FIT outreach (n=6,565), outreach plus $5 (n=1,000), or $10 (n=1,000) incentive for completion. Patients who completed the test were re-invited using the same incentive the following year, for 3 years. In Year 4, patients who returned the kit in all preceding three years were re-invited without incentives. Primary outcome was FIT completion among patients offered any incentive versus outreach alone each year. Secondary outcomes were FIT completion for groups offered $5 vs. outreach alone, $10 vs. outreach alone, and $5 vs. $10.
RESULTS: Year 1 FIT completion was 36.9% with incentives vs. 36.2% outreach alone (P=0.59) and was not statistically different for $10 (34.6%; P=0.31) or $5 (39.2%; P=0.070) vs. outreach alone. Year 2 completion was 61.6% with incentives vs. 60.8% outreach alone (P=0.75) and not statistically different for $10 or $5 vs. outreach alone. Year 3 completion was 79.4% with incentives vs. 74.8% outreach alone (P=0.080), and was higher for $10 (82.4%) vs. outreach alone (P=.033), but not for $5 vs. outreach alone. Completion was similar across conditions in Year 4 (no incentives).
CONCLUSIONS: Offering small incentives did not increase FIT completion relative to standard outreach.
IMPACT: This was the first longitudinal study testing the impact of repeated financial incentives, and their withdrawal, on FIT completion.

PMID: 31387970 [PubMed - as supplied by publisher]

Novel Investigation of the Deep Band of the Lateral Plantar Aponeurosis and Its Relationship With the Lateral Plantar Nerve.

Thu, 08/08/2019 - 09:00
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Novel Investigation of the Deep Band of the Lateral Plantar Aponeurosis and Its Relationship With the Lateral Plantar Nerve.

Foot Ankle Int. 2019 Aug 06;:1071100719864352

Authors: Beck CM, Dickerson AR, Kadado KJ, Cohen ZA, Blair SE, Motley TA, Holcomb JC, Fisher CL

Abstract
BACKGROUND: We describe a thick fascial band arising from the medial aspect of the lateral plantar aponeurosis diving deep into the forefoot crossing over a branch of the lateral plantar nerve. Because a review of current literature resulted in limited and outdated sources, we sought to first determine the frequency of this fascial band and the location where it crosses the lateral plantar nerve and, second, discuss the clinical applications these anatomical findings could have.
METHODS: 50 pairs of cadaveric feet (n = 100) were dissected to investigate for presence of the fascial band and its interaction with the lateral plantar nerve. Images were taken of each foot with the fascial band. ImageJ was used to take 2 measurements assessing the relationship of the tuberosity of the base of the fifth metatarsal to where the nerve crossed deep to the fascial band.
RESULTS: Overall, 38% of the feet possessed the fascial band. It was found unilaterally in 10 pairs and bilaterally in 14 pairs. On average, the point at which the lateral plantar nerve passed deep to the fascial band was 2.0 cm medial and 1.7 cm anterior to the tuberosity of the base of the fifth metatarsal.
CONCLUSION: When present, the deep band of the lateral plantar aponeurosis (PA) was consistently found to be crossing the lateral plantar nerve. The discovery of the location where this most commonly occurs has not been previously reported and adds an interesting dimension that elevates an anatomical study to one that has clinical potential.
CLINICAL RELEVANCE: The established target zone gives a precise location for where the relationship between the deep band of the lateral PA and the lateral plantar nerve exists when evaluating the foot. The target zone provides a potential springboard for future investigations concerning said relationship clinically.

PMID: 31387386 [PubMed - as supplied by publisher]

Emergency Medicine Resident Efficiency and Emergency Department Crowding.

Wed, 07/31/2019 - 06:37
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Emergency Medicine Resident Efficiency and Emergency Department Crowding.

AEM Educ Train. 2019 Jul;3(3):209-217

Authors: Kirby R, Robinson RD, Dib S, Mclarty D, Shaikh S, Cheeti R, Ho AF, Schrader CD, Zenarosa NR, Wang H

Abstract
Objectives: Provider efficiency has been reported in the literature but there is a lack of efficiency analysis among emergency medicine (EM) residents. We aim to compare efficiency of EM residents of different training levels and determine if EM resident efficiency is affected by emergency department (ED) crowding.
Methods: We conducted a single-center retrospective observation study from July 1, 2014, to June 30, 2017. The number of new patients per resident per hour and provider-to-disposition (PTD) time of each patient were used as resident efficiency markers. A crowding score was assigned to each patient upon the patient's arrival to the ED. We compared efficiency among EM residents of different training levels under different ED crowding statuses. Dynamic efficiency changes were compared monthly through the entire academic year (July to next June).
Results: The study enrolled a total of 150,920 patients. A mean of 1.9 patients/hour was seen by PGY-1 EM residents in comparison to 2.6 patients/hour by PGY-2 and -3 EM residents. Median PTD was 2.8 hours in PGY-1 EM residents versus 2.6 hours in PGY-2 and -3 EM residents. There were no significant differences in acuity across all patients seen by EM residents. When crowded conditions existed, residency efficiency increased, but such changes were minimized when the ED became overcrowded. A linear increase of resident efficiency was observed only in PGY-1 EM residents throughout the entire academic year.
Conclusion: Resident efficiency improved significantly only during their first year of EM training. This efficiency can be affected by ED crowding.

PMID: 31360813 [PubMed]

Management of Orbital Fractures.

Sun, 07/28/2019 - 06:07
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Management of Orbital Fractures.

Atlas Oral Maxillofac Surg Clin North Am. 2019 Sep;27(2):157-165

Authors: Kholaki O, Hammer DA, Schlieve T

PMID: 31345491 [PubMed - in process]

Ankle Fractures: An Expert Survey of Orthopaedic Trauma Association (OTA) Members and Evidence-Based Treatment Recommendations.

Wed, 07/24/2019 - 11:31
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Ankle Fractures: An Expert Survey of Orthopaedic Trauma Association (OTA) Members and Evidence-Based Treatment Recommendations.

J Orthop Trauma. 2019 Jun 26;:

Authors: Coles CP, Tornetta P, Obremskey WT, Spitler CA, Ahn J, Mirick G, Krause P, Nana A, Rodriguez-Buitrago A, Orthopaedic Trauma Association’s Evidence-Based Quality Value and Safety Committee

Abstract
OBJECTIVES: The goal of this study was to describe current practice patterns of orthopaedic trauma experts regarding the management of ankle fractures, to review the current literature, and to provide recommendations for care based on a standardized grading system.
DESIGN: Web-based survey PARTICIPANTS:: Orthopaedic Trauma Association (OTA) members METHODS:: A 27-item web-based questionnaire was advertised to members of the OTA. Using a cross-sectional survey study design, we evaluated the preferences in diagnosis and treatment of ankle fractures.
RESULTS: One hundred and sixty-six of 1967 OTA members (8.4%) completed the survey (16% of active members). There is considerable variability in the preferred method of diagnosis and treatment of ankle fractures among the members surveyed. The majority of responses are in keeping with best evidence available.
CONCLUSIONS: Current controversy remains in the management of ankle fractures. This is reflected in the treatment preferences of the OTA members who responded to this survey.
LEVEL OF EVIDENCE: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

PMID: 31335507 [PubMed - as supplied by publisher]

Successful implementation of an appendectomy process improvement protocol.

Sat, 07/20/2019 - 07:28
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Successful implementation of an appendectomy process improvement protocol.

Trauma Surg Acute Care Open. 2019;4(1):e000303

Authors: Bradley M, Kindvall A, Logan J, Bailey J, Elster E, Rodriguez C

Abstract
Background: A key component of a process improvement program is the institution of hospital-specific protocols to address certain disparities and streamline patient care. In that regard, we evaluated the implementation of an outpatient laparoscopic appendectomy (OLA) protocol at a tertiary military hospital. We hypothesized that OLA would reduce length of stay (LOS) without increasing complications.
Methods: In August 2016, our institution implemented an OLA protocol-defined as discharge within 24 hours of surgery. Exclusion criteria included age <18 years old, grade 4 or 5 appendicitis, immunosuppression, current pregnancy, and no supervision during the first 24 hours postdischarge. To determine OLA's effect on LOS, analysis of variance was used to perform a comparison between the years 2014 and 2017. Successful outpatient appendectomies were recorded preprotocol and postprotocol, as well as readmission complications.
Results: In 2017, the first full year of protocol implementation, 44 of 59 (75%) patients met the inclusion criteria, and all but 2 (42 of 44, 95%) stayed for less than 24 hours. Of the two outliers, one developed acute on chronic kidney disease and one had a slow return of bowel function following grade 3 appendicitis. Complications were low across all years (one per year). In 2017, the readmission was for percutaneous drainage of an abscess. Overall, protocol implementation produced a significant decrease in LOS.
Discussion: OLA protocol decreased LOS at a military hospital and should be expanded to other department of defense (DoD) facilities. Further research is needed to identify cost benefit to the military health system.
Level of evidence: III.

PMID: 31321311 [PubMed]

Common step-wise interventions improved primary care clinic visits and reduced emergency department discharge failures: a large-scale retrospective observational study.

Sat, 07/06/2019 - 07:14
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Common step-wise interventions improved primary care clinic visits and reduced emergency department discharge failures: a large-scale retrospective observational study.

BMC Health Serv Res. 2019 Jul 04;19(1):451

Authors: Schrader CD, Robinson RD, Blair S, Shaikh S, Ho AF, D'Etienne JP, Kirby JJ, Cheeti R, Zenarosa NR, Wang H

Abstract
BACKGROUND: It is critical to understand whether providing health insurance coverage, assigning a dedicated Primary Care Physician (PCP), and arranging timely post-Emergency Department (ED) clinic follow-up can improve compliance with clinic visits and reduce ED discharge failures. We aim to determine the benefits of providing these common step-wise interventions and further investigate the necessity of urgent PCP referrals on behalf of ED discharged patients.
METHODS: This is a single-center retrospective observational study. All patients discharged from the ED over the period Jan 1, 2015 through Dec 31, 2017 were included in the study population. Step-wise interventions included providing charity health insurance, assigning a dedicated PCP, and providing ED follow-up clinics. PCP clinic compliance and ED discharge failures were measured and compared among groups receiving different interventions.
RESULT: A total of 227,627 patients were included. Fifty-eight percent of patients receiving charity insurance had PCP visits in comparison to 23% of patients without charity insurance (p < 0.001). Seventy-seven percent of patients with charity insurance and PCP assignments completed post-ED discharge PCP visits in comparison to only 4.5% of those with neither charity insurance nor PCP assignments (p < 0.001).
CONCLUSIONS: Step-wise interventions increased patient clinic follow-up compliance while simultaneously reducing ED discharge failures. Such interventions might benefit communities with similar patient populations.

PMID: 31272442 [PubMed - in process]

Making Sense of Family Medicine Resident Wellness Curricula: A Delphi Study of Content Experts.

Thu, 07/04/2019 - 05:23

Making Sense of Family Medicine Resident Wellness Curricula: A Delphi Study of Content Experts.

Fam Med. 2019 Jul 02;:

Authors: Penwell-Waines L, Runyan C, Kolobova I, Grace A, Brennan J, Buck K, Ross V, Schneiderhan J

Abstract
BACKGROUND AND OBJECTIVES: The Association of Family Medicine Residency Directors (AFMRD) Physician Wellness Task Force released a comprehensive Well-Being Action Plan as a guide to help programs create a culture of wellness. The plan, however, does not offer a recommendation as to which elements may be most important, least resource intensive, or most feasible. This study sought to identify the most essential components of the AFMRD's Well-Being Action Plan, as rated by expert panelists using a modified Delphi technique.
METHODS: Sixty-eight selected experts were asked to participate; after three rounds of surveys, the final sample included 27 participants (7% residents, 38% MD faculty, 54% behavioral science faculty).
RESULTS: Fourteen elements were rated as essential by at least 80% of the participants. These components included interventions at both the system and individual level. Of those elements ranked in the top five by a majority of the panel, all but one do not mention specific curricular content, but rather discusses the nature of a wellness curriculum.
CONCLUSIONS: The expert consensus was that an essential curriculum should begin early, be longitudinal, identify a champion, and provide support for self-disclosure of struggles.

PMID: 31269221 [PubMed - as supplied by publisher]

Family Physician Burnout and Resilience: A Cross-Sectional Analysis.

Thu, 07/04/2019 - 05:23

Family Physician Burnout and Resilience: A Cross-Sectional Analysis.

Fam Med. 2019 Jul 02;:

Authors: Buck K, Williamson M, Ogbeide S, Norberg B

Abstract
BACKGROUND AND OBJECTIVES: Current physician burnout levels are at historically high levels, especially in family medicine, with many factors playing a role. The goal of this study was to understand demographic, psychological, environmental, behavioral, and workplace characteristics that impact physician wellness and burnout, focusing on family medicine physicians and residents.
METHODS: Survey respondents were 295 family medicine residents and faculty members across 11 residency programs within the Residency Research Network of Texas (RRNeT). Subjects completed multiple measures to assess resilience, burnout, psychological flexibility, and workplace stress. Respondents also reported personal wellness practices and demographic information. The primary outcome variables were burnout (depersonalization, emotional exhaustion, and personal achievement) and resilience.
RESULTS: The predictor variables contributed significant variance (depersonalization=27.1%, emotional exhaustion=39%, accomplishment=37.7%, resilience=37%) and resulted in large effect sizes (depersonalization f²=.371, emotional exhaustion f²=.639, accomplishment f²=.605, resilience f²=.587) among the three burnout models and the resilience model for the sample. Similar variance and effect sizes were present for independent resident and program faculty samples, with resilience being the only outcome variable with significant differences in variance between the samples.
CONCLUSIONS: This study demonstrates the roles of both individual and organization change needed to impact provider wellness, with special attention to resilience across faculty and residents. The results of this study may inform workplace policies (ie, organizational practice change) and wellness programming and curricula (ie, individual level) for family medicine residents and program faculty.

PMID: 31269220 [PubMed - as supplied by publisher]

Identifying diverse concepts of discharge failure patients at emergency department in the USA: a large-scale retrospective observational study.

Sun, 06/30/2019 - 06:49
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Identifying diverse concepts of discharge failure patients at emergency department in the USA: a large-scale retrospective observational study.

BMJ Open. 2019 Jun 27;9(6):e028051

Authors: Schrader CD, Robinson RD, Blair S, Shaikh S, d'Etienne JP, Kirby JJ, Cheeti R, Zenarosa NR, Wang H

Abstract
OBJECTIVES: Identifying patients who are at high risk for discharge failure allows for implementation of interventions to improve their care. However, discharge failure is currently defined in literature with great variability, making targeted interventions more difficult. We aim to derive a screening tool based on the existing diverse discharge failure models.
DESIGN, SETTING AND PARTICIPANTS: This is a single-centre retrospective cohort study in the USA. Data from all patients discharged from the emergency department were collected from 1 January 2015 through 31 December 2017 and followed up within 30 days.
METHODS: Scoring systems were derived using modified Framingham methods. Sensitivity, specificity and area under the receiver operational characteristic (AUC) were calculated and compared using both the broad and restricted discharge failure models.
RESULTS: A total of 227 627 patients were included. The Screening for Healthcare fOllow-Up Tool (SHOUT) scoring system was derived based on the broad and restricted discharge failure models and applied back to the entire study cohort. A sensitivity of 80% and a specificity of 71% were found in SHOUT scores to identify patients with broad discharge failure with AUC of 0.83 (95% CI 0.83 to 0.84). When applied to a 3-day restricted discharge failure model, a sensitivity of 86% and a specificity of 60% were found to identify patients with AUC of 0.79 (95% CI 0.78 to 0.80).
CONCLUSION: The SHOUT scoring system was derived and used to screen and identify patients that would ultimately become discharge failures, especially when using broad definitions of discharge failure. The SHOUT tool was internally validated and can be used to identify patients across a wide spectrum of discharge failure definitions.

PMID: 31248927 [PubMed - in process]

Association Between Empathy and Burnout Among Emergency Medicine Physicians.

Thu, 06/27/2019 - 06:09
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Association Between Empathy and Burnout Among Emergency Medicine Physicians.

J Clin Med Res. 2019 Jul;11(7):532-538

Authors: Wolfshohl JA, Bradley K, Bell C, Bell S, Hodges C, Knowles H, Chaudhari BR, Kirby R, Kline JA, Wang H

Abstract
Background: The association between physician self-reported empathy and burnout has been studied in the past with diverse findings. We aimed to determine the association between empathy and burnout among United States emergency medicine (EM) physicians using a novel combination of tools for validation.
Methods: This was a prospective single-center observational study. Data were collected from EM physicians. From December 1, 2018 to January 31, 2019, we used the Jefferson scale of empathy (JSE) to assess physician empathy and the Copenhagen burnout inventory (CBI) to assess burnout. We divided EM physicians into different groups (residents in each year of training, junior/senior attendings). Empathy, burnout scores and their association were analyzed and compared among these groups.
Results: A total of 33 attending physicians and 35 EM residents participated in this study. Median self-reported empathy scores were 113 (interquartile range (IQR): 105 - 117) in post-graduate year (PGY)-1, 112 (90 - 115) in PGY-2, 106 (93 - 118) in PGY-3 EM residents, 112 (105 - 116) in junior and 114 (101 - 125) in senior attending physicians. Overall burnout scores were 43 (33 - 50) in PGY-1, 51 (29 - 56) in PGY-2, 43 (42 - 53) in PGY-3 EM residents, 33 (24 - 47) in junior attending and 25 (22 - 53) in senior attending physicians separately. The Spearman correlation (ρ) was -0.11 and β-weight was -0.23 between empathy and patient-related burnout scores.
Conclusion: Self-reported empathy declines over the course of EM residency training and improves after graduation. Overall high burnout occurs among EM residents and improves after graduation. Our analysis showed a weak negative correlation between self-reported empathy and patient-related burnout among EM physicians.

PMID: 31236173 [PubMed]

Initiation of the ABCD3-I algorithm for expediated evaluation of transient ischemic attack patients in an emergency department.

Tue, 06/25/2019 - 07:56
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Initiation of the ABCD3-I algorithm for expediated evaluation of transient ischemic attack patients in an emergency department.

Am J Emerg Med. 2019 Jun 10;:

Authors: Dahlquist RT, Young JM, Reyner K, Farzad A, Moleno RB, Gandham G, Ho AF, Wang H

Abstract
BACKGROUND: The use of ABCD3-I score for Transient ischemic attack (TIA) evaluation has not been widely investigated in the ED. We aim to determine the performance and cost-effectiveness of an ABCD3-I based pathway for expedited evaluation of TIA patients in the ED.
METHODS: We conducted a single-center, pre- and post-intervention study among ED patients with possible TIA. Accrual occurred for seven months before (Oct. 2016-April 2017) and after (Oct. 2017-April 2018) implementing the ABCD3-I algorithm with a five-month wash-in period (May-Sept. 2017). Total ED length of stay (LOS), admissions to the hospital, healthcare cost, and 90-day ED returns with subsequent stroke were analyzed and compared.
RESULTS: Pre-implementation and post-implementation cohorts included 143 and 118 patients respectively. A total of 132 (92%) patients were admitted to the hospital in the pre-implementation cohort in comparison to 28 (24%) patients admitted in the post-implementation cohort (p < 0.001) with similar 90-day post-discharge stroke occurrence (2 in pre-implementation versus 1 in post-implementation groups, p > 0.05). The mean ABCD2 scores were 4.5 (1.4) in pre- and 4.1 (1.3) in post-implementation cohorts (p = 0.01). The mean ABCD3-I scores were 4.5 (1.8) in post-implementation cohorts. Total ED LOS was 310 min (201, 420) in pre- and 275 min (222, 342) in post-implementation cohorts (p > 0.05). Utilization of the ABCD3-I algorithm saved an average of over 40% of total healthcare cost per patient in the post-implementation cohort.
CONCLUSIONS: The initiation of an ABCD3-I based pathway for TIA evaluation in the ED significantly decreased hospital admissions and cost with similar 90-day neurological outcomes.

PMID: 31230922 [PubMed - as supplied by publisher]

Where Are the Opportunities for Reducing Health Care Spending Within Alternative Payment Models?

Sat, 06/22/2019 - 07:34
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Where Are the Opportunities for Reducing Health Care Spending Within Alternative Payment Models?

J Oncol Pract. 2018 06;14(6):e375-e383

Authors: Rocque GB, Williams CP, Kenzik KM, Jackson BE, Halilova KI, Sullivan MM, Rocconi RP, Azuero A, Kvale EA, Huh WK, Partridge EE, Pisu M

Abstract
PURPOSE: The Oncology Care Model (OCM) is a highly controversial specialty care model developed by the Centers for Medicare & Medicaid aimed to provide higher-quality care at lower cost. Because oncologists will be increasingly held accountable for spending as well as quality within new value-based health care models like the OCM, they need to understand the drivers of total spending for their patients.
METHODS: This retrospective cohort study included patients ≥ 65 years of age with primary fee-for-service Medicare insurance who received antineoplastic therapy at 12 cancer centers in the Southeast from 2012 to 2014. Medicare administrative claims data were used to identify health care spending during the prechemotherapy period (from cancer diagnosis to antineoplastic therapy initiation) and during the OCM episodes of care triggered by antineoplastic treatment. Total health care spending per episode includes all types of services received by a patient, including nononcology services. Spending was further characterized by type of service.
RESULTS: Average total health care spending in the three OCM episodes of care was $33,838 (n = 3,427), $23,811 (n = 1,207), and $19,241 (n = 678). Antineoplastic drugs accounted for 27%, 32%, and 36% of total health care spending in the first, second, and third episodes. Ten drugs, used by 31% of patients, contributed 61% to drug spending ($18.8 million) in the first episode. Inpatient spending also substantially contributed to total costs, representing 17% to 20% ($30.5 million) of total health care spending.
CONCLUSION: Health care spending was heavily driven by both antineoplastic drugs and hospital use. Oncologists' ability to affect these types of spending will determine their success under alternative payment models.

PMID: 28981388 [PubMed - indexed for MEDLINE]

Rethinking the definition of major trauma: The Need For Trauma Intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric trauma centers.

Tue, 06/18/2019 - 07:20
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Rethinking the definition of major trauma: The Need For Trauma Intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric trauma centers.

J Trauma Acute Care Surg. 2019 Jun 13;:

Authors: Roden-Foreman JW, Rapier NR, Foreman ML, Zagel AL, Sexton KW, Beck WC, McGraw C, Coniglio RA, Blackmore AR, Holzmacher J, Sarani B, Hess JC, Greenwell C, Adams CA, Lueckel SN, Weaver M, Agrawal V, Amos JD, Workman CF, Milia DJ, Bertelson A, Dorlac W, Warne MJ, Cull J, Lyell CA, Regner JL, McGonigal MD, Flohr SD, Steen S, Nance ML, Campbell M, Putty B, Sherar D, Schroeppel TJ

Abstract
BACKGROUND: Patients' trauma burdens are a combination of anatomic damage, physiologic derangement, and the resultant depletion of reserve. Typically, Injury Severity Score (ISS) >15 defines major anatomic injury and Revised Trauma Score (RTS) <7.84 defines major physiologic derangement, but there is no standard definition for reserve. The Need For Trauma Intervention (NFTI) identifies severely depleted reserves (NFTI+) with emergent interventions and/or early mortality. We hypothesized NFTI would have stronger associations with outcomes and better model fit than ISS and RTS.
METHODS: Thirty-eight adult and pediatric U.S. trauma centers submitted data for 88,488 encounters. Mixed models tested ISS >15, RTS <7.84, and NFTI's associations with complications, survivors' discharge to continuing care, and survivors' length of stay (LOS).
RESULTS: NFTI had stronger associations with complications and LOS than ISS and RTS (odds ratios (99.5% CI): NFTI = 9.44 (8.46, 10.53), ISS = 5.94 (5.36, 6.60), RTS = 4.79 (4.29, 5.34); LOS incidence rate ratios (99.5% CI): NFTI = 3.15 (3.08, 3.22), ISS = 2.87 (2.80, 2.94), RTS = 2.37 (2.30, 2.45)). NFTI was more strongly associated with continuing care discharge but not significantly more than ISS (relative risk (99.5% CI): NFTI = 2.59 (2.52, 2.66), ISS = 2.51 (2.44, 2.59), RTS = 2.37 (2.28, 2.46)). Cross-validation revealed that in all cases NFTI's model provided a much better fit than ISS>15 or RTS<7.84.
CONCLUSIONS: In this multicenter study, NFTI had better model fit and stronger associations with the outcomes than ISS and RTS. By determining depletion of reserve via resource consumption, NFTI+ may be a better definition of major trauma than the standard definitions of ISS >15 and RTS <7.84. Using NFTI may improve retrospective triage monitoring and statistical risk adjustments.
LEVEL OF EVIDENCE: III, Therapeutic.

PMID: 31205214 [PubMed - as supplied by publisher]

Affordable Care Act and cancer stage at diagnosis in an underserved population.

Fri, 06/14/2019 - 08:49

Affordable Care Act and cancer stage at diagnosis in an underserved population.

Prev Med. 2019 Jun 10;:

Authors: Lu Y, Jackson BE, Gehr AW, Cross D, Neerukonda L, Tanna B, Ghabach B, Ojha RP

Abstract
The Patient Protection and Affordable Care Act (ACA) has increased insurance coverage among underserved individuals, but the effect of ACA on cancer diagnosis is currently debated, particularly in Medicaid non-expansion states. Therefore, we aimed to assess the effect of ACA implementation on stage at diagnosis among underserved cancer patients in Texas, a Medicaid non-expansion state. We used data from the institutional registry of the JPS Center for Cancer Care, which serves an urban population of underserved cancer patients. Eligible individuals were aged 18 to 64 years and diagnosed with a first primary invasive solid tumor between 2008 and 2015. We used a natural experiment framework and interrupted time-series analysis to assess level (i.e. immediate) and slope (over time) changes in insurance coverage and cancer stage at diagnosis between pre- and post-ACA periods. Our study population comprised 4808 underserved cancer patients, of whom 51% were racial/ethnic minorities. The prevalence of uninsured cancer patients did not immediately change after ACA implementation but modestly decreased over time (PR = 0.94; 95% CL: 0.90, 0.98). The prevalence of early- and advanced-stage diagnosis did not appreciably change overall or when stratified by screen-detectable cancers. Our results suggest that ACA implementation decreased the prevalence of uninsured cancer patients but had little effect on cancer stage at diagnosis in an underserved population. Given that Texas is a Medicaid non-expansion state, Medicaid expansion and alternative approaches may need to be further explored to improve earlier cancer diagnosis among underserved individuals.

PMID: 31195020 [PubMed - as supplied by publisher]

Radiation therapy utilization in Medicare beneficiaries with early-stage breast cancer.

Fri, 06/14/2019 - 08:49
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Radiation therapy utilization in Medicare beneficiaries with early-stage breast cancer.

Cancer. 2018 02 01;124(3):475-481

Authors: Wallace AS, Keene KS, Williams CP, Jackson BE, Pisu M, Partridge EE, Rocque GB

Abstract
BACKGROUND: There is increasing evidence that radiation therapy (RT) can be omitted for select older patients who are compliant with hormonal blockade, but there is no recent claim-based analysis for determining patterns of care and guiding possible treatment recommendations.
METHODS: Medicare beneficiaries who were 65 years old or older and were diagnosed with breast cancer at 1 of 12 cancer centers affiliated with an academic center in the southeastern United States were analyzed. Stage 0 or I patients treated with lumpectomy from 2012 to 2014 were identified. Patient, treatment, and center characteristics were analyzed for the utilization of RT.
RESULTS: Among 800 women treated with lumpectomy, 64% received adjuvant radiation. The median age was 74 years. The omission of RT was more likely in older patients, stage 0 patients, and patients with more comorbidities (P < .01). Hormonal blockade was used in 41% of the patients who did not receive RT. The utilization of hormonal blockade with the omission of RT was more likely in patients with fewer comorbidities (P < .01).
CONCLUSIONS: In an older cohort of patients who otherwise would have qualified for the omission of radiation, two-thirds were treated with radiation. Future guideline recommendations should address omission in the context of hormonal blockade compliance because only 41% of the patients used hormonal blockade when radiation was not delivered. Cancer 2018;124:475-81. © 2017 American Cancer Society.

PMID: 29053170 [PubMed - indexed for MEDLINE]

Role of Empiric Anti-Fungal Therapy in the Treatment of Perforated Peptic Ulcer Disease: Review of the Evidence and Future Directions.

Thu, 06/13/2019 - 06:57
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Role of Empiric Anti-Fungal Therapy in the Treatment of Perforated Peptic Ulcer Disease: Review of the Evidence and Future Directions.

Surg Infect (Larchmt). 2019 Jun 12;:

Authors: Huston JM, Kreiner L, Ho VP, Sanders JM, Duane TM

Abstract
Background: Peptic ulcer disease (PUD) affects four million people worldwide. Perforated peptic ulcer (PPU) occurs in less than 15% of cases but is associated with significant morbidity and mortality rates. Administration of antibiotics is standard treatment for gastrointestinal perforations, including PPU. Although fungal growth is common in peritoneal fluid cultures from patients with PPU, current data suggest empiric anti-fungal therapy fails to improve outcomes. To examine the role of anti-fungal agents in the treatment of PPU, the Surgical Infection Society hosted an Update Symposium at its 37th Annual Meeting. Here, we provide a synopsis of the symposium's findings and a brief review of prospective and retrospective reports on the subject. Methods: A search of Pubmed/MEDLINE, EMBASE, and the Cochrane Library was performed between January 1, 2000, and November 1, 2018, comparing outcomes of PPU following empiric anti-fungal treatment versus no anti-fungal therapy. We used the search terms "perforated peptic ulcer," "gastroduodenal ulcer," "anti-fungal," and "perforated" or "perforation." Results: There are no randomized clinical trials comparing outcomes specifically for patients with PPU treated with or without empiric anti-fungal therapy. We identified one randomized multi-center trial evaluating outcomes for patients with intra-abdominal perforations, including PPU, that were treated with or without empiric anti-fungal therapy. We identified one single-center prospective series and three additional retrospective studies comparing outcomes for patients with PPU treated with or without empiric anti-fungal therapy. Conclusion: The current evidence reviewed here does not demonstrate efficacy of anti-fungal agents in improving outcomes in patients with PPU. As such, we caution against the routine use of empiric anti-fungal agents in these patients. Further studies should help identify specific subpopulations of patients who might derive benefit from anti-fungal therapy and help define appropriate treatment regimens and durations that minimize the risk of resistance, adverse events, and cost.

PMID: 31188069 [PubMed - as supplied by publisher]

Accuracy of point-of-care ultrasound and radiology-performed ultrasound for intussusception: A systematic review and meta-analysis.

Wed, 06/12/2019 - 05:16
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Accuracy of point-of-care ultrasound and radiology-performed ultrasound for intussusception: A systematic review and meta-analysis.

Am J Emerg Med. 2019 Jun 04;:

Authors: Tsou PY, Wang YH, Ma YK, Deanehan JK, Gillon J, Chou EH, Hsu TC, Huang YC, Lin J, Lee CC

Abstract
OBJECTIVE: It is unclear whether point-of-care ultrasound (POCUS) by emergency medicine physicians is as accurate as radiology-performed ultrasound (RADUS). We aim to summarize the diagnostic accuracy of ultrasonography for intussusception and to compare the performance between POCUS and RADUS.
METHODS: Databases were searched from inception through February 2018 using pre-defined index terms. Peer-reviewed primary studies that investigated the diagnostic accuracy of ultrasound for intussusception in children were included. The study is reported using Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA). Meta-analysis of the diagnostic accuracy of ultrasound for intussusception was conducted using the random-effects bivariate model. Subgroup analysis (POCUS vs RADUS) was also performed. Meta-regression was utilized to determine if the diagnostic accuracy between POCUS and RADUS was significantly different.
RESULTS: Thirty studies (n = 5249) were included in the meta-analysis. Ultrasonography for intussusception has a sensitivity: 0.98 (95% CI: 0.96-0.98), specificity: 0.98 (95% CI: 0.95-0.99), positive likelihood ratio: 43.8 (95% CI: 18.0-106.7) and negative likelihood ratio: 0.03 (95% CI: 0.02-0.04), with an area under ROC (AUROC) curve of 0.99 (95% CI: 0.98-1.00). Meta-regression suggested no significant difference in the diagnostic accuracy for intussusception between POCUS and RADUS (AUROC: 0.95 vs 1.00, p = 0.128).
CONCLUSIONS: Current evidence suggested POCUS has a high diagnostic accuracy for intussusception not significantly different from that of RADUS.

PMID: 31182360 [PubMed - as supplied by publisher]

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