Medical School Affiliation Research Articles

Differences and Trends in DNR Among California Inpatients With Heart Failure

BackgroundDo-not-resuscitate (DNR) orders reflect an important means of respecting patient autonomy while minimizing the risk of nonbeneficial interventions. We sought to clarify trends and differences in rates of DNR orders for patients hospitalized with heart failure. MethodsWe used statewide data from California's Healthcare Cost and Utilization dataset (2007–2010) to determine trends in DNR orders within 24 hours of admission for patients with a primary discharge diagnosis of heart failure. ResultsAmong 347,541 hospitalizations for heart failure, the rate of DNR order within 24 hours increased from 10.4% in 2007 to 11.3% in 2010 (P < .0001). After adjustment, DNR status correlated with older age, female gender, white race, frequent comorbidities (Charlson Score), and residence in higher income area (P < .0001). DNR use was more likely in hospitals with public or nonprofit financing or medical school affiliation, but not being a member of the Council on Teaching Hospitals (all P < .001). ConclusionDNR order use among inpatients with heart failure is low but increasing slowly and varies by patient demographics and hospital characteristics.

Hospital Characteristics Associated with Stage II/III Rectal Cancer Guideline Concordant Care: Analysis of Surveillance, Epidemiology and End Results-Medicare Data

BackgroundEvidence suggests that high-volume facilities achieve better rectal cancer outcomes. MethodsLogistic regression was used to evaluate association of facility type with treatment after adjusting for patient demographics, stage, and comorbidities. SEER-Medicare beneficiaries who were diagnosed with stage II/III rectal adenocarcinoma at age ≥66 years from 2005 to 2009 and had Parts A/B Medicare coverage for ≥1 year prediagnosis and postdiagnosis plus a claim for cancer-directed surgery were included. Institutions were classified according to National Cancer Institute (NCI) designation, presence of residency program, or medical school affiliation. ResultsTwo thousand three hundred subjects (average age = 75) met the criteria. Greater proportions of those treated at NCI-designated facilities received transrectal ultrasound (TRUS) or magnetic resonance imaging (MRI)-pelvis (62.1 vs. 29.9 %), neoadjuvant chemotherapy (63.9 vs. 41.8 %), and neoadjuvant radiation (70.8 vs. 46.3 %), all p < 0.0001. On multivariate analysis, odds ratios (95 % confidence intervals) for receiving TRUS or MRI, neoadjuvant chemotherapy, or neoadjuvant radiation among beneficiaries treated at NCI-designated facilities were 3.51 (2.60–4.73), 2.32 (1.71–3.16), and 2.66 (1.93–3.67), respectively. Results by residency and medical school affiliation were similar in direction to NCI designation. ConclusionsThose treated at hospitals with an NCI designation, residency program, or medical school affiliation received more guideline-concordant care. Initiatives involving provider education and virtual tumor boards may improve care.

Risk Adjustment for Determining Surgical Site Infection in Colon Surgery: Are All Models Created Equal?

Colon surgical site infections (SSIs) are being utilized increasingly as a quality measure for hospital reimbursement and public reporting. The Centers for Medicare and Medicaid Services (CMS) now require reporting of colon SSI, which is entered through the U.S. Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN). However, the CMS's model for determining expected SSIs uses different risk adjustment variables than does NHSN. We hypothesize that CMS's colon SSI model will predict lower expected infection rates than will NHSN. Colon SSI data were reported prospectively to NHSN from 2012-2014 for the six Fairview Hospitals (1,789 colon procedures). We compared expected quarterly SSIs and standardized infection ratios (SIRs) generated by CMS's risk-adjustment model (age and American Society of Anesthesiologist [ASA] classification) vs. NHSN's (age, ASA classification, procedure duration, endoscope [including laparoscope] use, medical school affiliation, hospital bed number, and incision class). The patients with more complex colon SSIs were more likely to be male (60% vs. 44%; p = 0.011), to have contaminated/dirty incisions (21% vs. 10%; p = 0.005), and to have longer operations (235 min vs. 156 min; p < 0.001) and were more likely to be at a medical school-affiliated hospital (53% vs. 40%; p = 0.032). For Fairview Hospitals combined, CMS calculated a lower number of expected quarterly SSIs than did the NHSN (4.58 vs. 5.09 SSIs/quarter; p = 0.002). This difference persisted in a university hospital (727 procedures; 2.08 vs. 2.33; p = 0.002) and a smaller, community-based hospital (565 procedures; 1.31 vs. 1.42; p = 0.002). There were two quarters in which CMS identified Fairview's SIR as an outlier for complex colon SSIs (p = 0.05 and 0.04), whereas NHSN did not (p = 0.06 and 0.06). The CMS's current risk-adjustment model using age and ASA classification predicts lower rates of expected colon SSIs than does NHSN. This may lead to financial penalties because of the use of limited risk factors. Further efforts at elucidating appropriate risk adjustment measures without unnecessarily burdening hospitals with expensive data collection are necessary.

Evaluating the Use of the Case Mix Index for Risk Adjustment of Healthcare-Associated Infection Data: An Illustration using Clostridium difficile Infection Data from the National Healthcare Safety Network

BACKGROUND Case mix index (CMI) has been used as a facility-level indicator of patient disease severity. We sought to evaluate the potential for CMI to be used for risk adjustment of National Healthcare Safety Network (NHSN) healthcare-associated infection (HAI) data. METHODS NHSN facility-wide laboratory-identified Clostridium difficile infection event data from 2012 were merged with the fiscal year 2012 Inpatient Prospective Payment System (IPPS) Impact file by CMS certification number (CCN) to obtain a CMI value for hospitals reporting to NHSN. Negative binomial regression was used to evaluate whether CMI was significantly associated with healthcare facility-onset (HO) CDI in univariate and multivariate analysis. RESULTS Among 1,468 acute care hospitals reporting CDI data to NHSN in 2012, 1,429 matched by CCN to a CMI value in the Impact file. CMI (median, 1.49; interquartile range, 1.36-1.66) was a significant predictor of HO CDI in univariate analysis (P<.0001). After controlling for community onset CDI prevalence rate, medical school affiliation, hospital size, and CDI test type use, CMI remained highly significant (P<.0001), with an increase of 0.1 point in CMI associated with a 3.4% increase in the HO CDI incidence rate. CONCLUSIONS CMI was a significant predictor of NHSN HO CDI incidence. Additional work to explore the feasibility of using CMI for risk adjustment of NHSN data is necessary. Infect. Control Hosp. Epidemiol. 2015;37(1):19-25.

Nationwide study of publication misrepresentation in applicants to residency.

This study was conducted to assess the prevalence of research publication misrepresentation amongst Canadian Resident Matching Service (CaRMS) applicants to a single surgical subspecialty residency as a potential means of assessing professional behaviour. The authors reviewed CaRMS application forms to Canadian otolaryngology residency programmes over a 3-year period (2006-2008) for peer-reviewed publications reported as 'published', 'accepted' and 'in press'. Citations were verified by searching PubMed, Google Scholar and electronic journals. Misrepresentation was defined as any of: (i) falsely claimed authorship of an existing article; (ii) claimed authorship of a non-existing article, and (iii) improper ordering of authorship. Outcomes included descriptive statistics, as well as sub-analyses pertaining to age, gender, affiliated medical school and academic degree, and number of publications per applicant. A total of 427 peer-reviewed publications were reported by 124 of 182 applicants (68% of applicants reported at least one publication). Of the 385 verifiable publications, 47 (12% of articles) were misrepresented by 29 applicants (23% of applicants claiming publication) self-reporting at least one publication. Age, gender, location of medical training, prior academic degree and number of citations per applicant did not relate to likelihood of misrepresentation (p>0.05). This study documents the nationwide prevalence of publication misrepresentation amongst applicants to Canadian otolaryngology residency programmes. The high rate of misrepresentation aligns with data reported in the literature and highlights the need to institute measures to dissuade graduates from this form of unprofessional behaviour.

Impact of Employee Wellness Programming with Health and Wellness Coaching on Health Status

The positive effects of employee wellness programs are well documented but how those “at-risk” adapt compared to low-risk participants when exposed to different levels of health and wellness coaching is unknown. PURPOSE: Examine effects on wellness programming on health status of risk-stratified employees after adding various doses of health and wellness coaching (HWC). METHODS: After risk stratification using ASCM standards, more than 300 volunteers were randomly assigned to one of three levels of telephonic HWC or a control. Assessments of blood pressure, resting heart rate, body weight, health risk appraisal, LDL-C, and glucose were completed at baseline, three and six months. RESULTS: For all participants, most outcome variables positively responded to wellness programming with participant blood pressure, resting heart rate and weight becoming significantly (p < .05) lower while health risk appraisal was significantly (p < .05) improved by the end of six months. Circulating LDL-C and glucose were not affected by treatment. A 2 (risk) x 4 (coaching) x 3 (time) repeated measures ANOVA revealed only systolic blood pressure to be positively affected (p < .05) by health coaching and risk stratification. CONCLUSIONS: College employees in a well-orchestrated wellness initiative respond equally well, improving health status, regardless of risk stratification or level of HWC. In this population (well-informed, supported, and great access to wellness programming), those “at risk” and “low risk” experience a limited yet valuable benefit from health coaching on systolic blood pressure. Much of the potential impact of HWC may be lost to the random assignment process as participants with little desire to be coached are sometimes assigned to HWC. It is informative to know that all levels of risk stratification respond favorably to wellness programming. Supported by Institute of Coaching at McLean Hospital, a Harvard Medical School affiliate

Gonadotropin-releasing hormone agonist overuse: urologists' response to reimbursement and characteristics associated with persistent overuse.

BACKGROUNDMedicare reimbursement cuts have been associated with declining Gonadotropin-releasing Hormone (GnRH) agonist overuse in localized prostate cancer. Medical school affiliation and foreign training have been associated with persistent overuse. However, physician-level prescribing changes and the practice type of persistent overusers have not been examined. We sought to describe physician-level changes in GnRH agonist overuse and test the association of time in practice and solo practice type with GnRH agonist overuse.METHODSWe matched American Medical Association physician data for 2,138 urologists to SEER–Medicare data for 12,943 men diagnosed with early stage and lower grade adenocarcinoma of the prostate between 2000 and 2007. We conducted a population-based, retrospective study using multi-level modeling to control for patient and provider characteristics.RESULTSThree distinct patterns of GnRH agonist overuse were observed. Urologists’ time in practice was not associated with GnRH agonist overuse (OR 0.89; 95% CI 0.75–1.05).However, solo practice type (OR 1.65; 95% CI 1.34–2.02), medical school affiliation (OR 0.65; 95% CI 0.55–0.77), and patient race were. Compared to non-Hispanic whites, non-Hispanic blacks (OR 1.76; 95% CI 1.37–2.27), Hispanics (OR 1.41; 95% CI 1.12–1.79) and men of “other” race (OR 1.44; 95% CI 1.04–1.99) had greater odds of receiving unnecessary GnRH agonists.CONCLUSIONSGnRH agonist overuse remains high among some urologists who may be professionally isolated and difficult to reach. These urologists treat more vulnerable populations, which may contribute to health disparities in prostate cancer treatment quality. Nonetheless, these findings provide guidance to develop interventions to address overuse in prostate cancer.

Sa1056 Predictors of Colonoscopy Attendance in a Patient Navigator Program Population

noma. The survey was distributed electronically via the American College of Physicians (ACP) Research Center's Internal Medicine Insider Panel, a representative group of ACP members who have voluntarily agreed to participate in periodic physician surveys. Participants were excluded if they reported spending less than 25% of their time in primary care or reported not placing any referrals for screening colonoscopy. Results: Of 442 PCPs invited to participate, 210 responded (response rate = 210/442, or 48%), and 29 were excluded, yielding 181 completed surveys. The mean age was 53 years. 48% practiced in a small group practice, solo practice, or community health center, and only 9% practiced in an academic center. Nearly all (96%) were board certified, and 44% had a medical school affiliation. In a 60-year-old with a normal high-quality screening colonoscopy, 88% (159/ 181) correctly recommended repeat colonoscopy in 10 years. However, if an endoscopist recommended a shorter interval (5 years) in such a patient, 41% (65/159) reported that they would follow the endoscopist's recommendation. For a 55-year-old with a 4 mm adenoma, 73% (133/181) correctly recommended a 5-10 year interval. However, if an endoscopist recommended a shorter interval (3 years) in such a patient, 62% (83/133) reported that they would follow the endoscopist's recommendation. In multivariable analysis, PCPs who referred to larger GI practices, referred more patients for colonoscopy, and worked in non-academic settings, were significantly more likely to follow an early surveillance recommendation. Conclusions: An endoscopist's recommendation for when to repeat a colonoscopy has a powerful impact on the decision-making of referring PCPs. In situations where a guideline-discordant interval is recommended, endoscopists should specify their clinical reasoning and/or indicate the strength of their recommendation.

An evaluation of geographic trends in the otolaryngology residency match: home is where the heart is.

Securing an otolaryngology residency position has become an increasingly competitive endeavor in recent years. Recent studies have investigated the applicant criteria used by residency programs as part of the ranking process. However, to our knowledge, no studies have comprehensively investigated the role of geographic location in the match process. To evaluate geographic trends in the otolaryngology national residency match process. We conducted a cross-sectional examination of 56 otolaryngology residency programs including 810 residents to determine resident demographic information, including matriculated medical schools. The geographic locations of residency programs and the residents' matriculated medical schools were evaluated for trends. Residents' program locations were compared with the locations of their medical schools of matriculation, and the numbers of residents attending a program affiliated with their medical schools were also identified. Overall, 810 residents were identified from the 56 programs included in our study. Of these, 169 residents (20.9%) attended the program affiliated with their medical school. The Midwest had the highest proportion of residents graduating from the affiliated medical school (25.7%), and the West had the lowest proportion (12.5%) (P = .008). A total of 473 residents attended a program within the same region as their medical school (58.4%). The South had the highest proportion of residents from the same region (68.2%), and the West had the lowest proportion (31.3%) (P < .001). While it is not clear why a geographic bias was identified, a significant proportion of residents in our study attended a program in the same region as their medical school. This geographic association was strongest in the Midwest and South. Furthermore, a significant proportion of residents attended the program affiliated with their medical schools. This information is valuable to all future applicants as they choose where to apply, and to all residency programs as they decide how geographic location factors in to whom they decide to interview.

Association between urologist characteristics and radiation oncologist consultation for patients with locoregional prostate cancer.

Physicians managing patients with prostate cancer play a critical role in subsequent specialist consultations and initial treatment choice, especially in cases for which no consensus exists regarding optimal treatment strategy. The NCCN Guidelines for Prostate Cancer recommend radiation as a therapy option for patients with locoregional prostate cancer. The authors examined the association of urologist characteristics with the likelihood that patients would consult radiation oncologists. A retrospective cohort of 39,934 patients aged 66 years or older who were diagnosed with locoregional prostate cancer between 2004 and 2007, and the 2405 urologists who performed the patient diagnostic biopsies were constructed using the SEER-Medicare linked database and the American Medical Association Physician Masterfile. Logistic multilevel regression analysis was used to evaluate the influence of urologists' characteristics on radiation oncologist consultation within 9 months of locoregional prostate cancer diagnosis. Overall, 24,549 (61.5%) patients consulted a radiation oncologist. After adjusting for patient and urologist characteristics, patients diagnosed by urologists in noninstitutional settings (eg, physician office) were significantly more likely to consult a radiation oncologist (odds ratio [OR], 1.40; 95% CI, 1.17-1.67; P=.0002) compared with those diagnosed by urologists in institutional settings with a major medical school affiliation. In addition, patients diagnosed by urologists older than 57 years were significantly more likely to consult a radiation oncologist (OR, 1.21; 95% CI, 1.07-1.38, P=.003).

Accessibility of academic plastic surgeons as mentors to medical students.

Determining a field of specialty can be a difficult decision for medical students. Career plans are often fostered through exposure to the field and mentorship, but it is often hard to identify accessible mentors. The purposes of this study were to determine the prevalence of accessible mentors among academic plastic surgery faculty and to characterize predictors of accessibility. An audit was conducted of academic plastic surgeon faculty affiliated with integrated and combined residency programs. A request for mentorship was sent from a medical student enrolled at the faculty member's affiliated medical school. Sources for e-mail addresses included residency program Web sites, the American Society of Plastic Surgeons Web site, and a manual PubMed search. Independent predictors of accessible mentors were determined. There were 498 e-mails delivered and 363 responses received (response rate of 73%). In total, there were 283 positive responses, resulting in 56.8% of plastic surgeons contacted identifying themselves as accessible for mentorship. Younger age [odds ratio (OR), 1.72; P = 0.005], Fellow of the American College of Surgeons (OR, 1.49; P = 0.035), and faculty members of medical schools ranked in the top 20 (OR, 1.75; P = 0.003) were associated with an increased odds of accessibility. Most academic plastic surgeons are accessible as mentors (78%). Medical students enrolled at a highly ranked medical school seeking younger faculty mentors may have the greatest access to research opportunities and career advice. Encouraging faculty to participate in mentorship is important in developing the next generation of plastic surgeons.

Capacity for Development of Primary Care Residency Programs in Non-Teaching Hospitals in New York State (NYS)

Purpose: The demand for physicians in the U.S., especially those practicing adult primary care, is accelerating and will inevitably require the expansion of residencies, despite current constraints on funding for graduate medical education (GME). A previous study showed little interest in or capacity for expansion of primary care residencies in current teaching hospitals in NYS. This study examines the interest in and capacity for establishing new programs among current non-teaching hospitals in that state. Design and Methods: Chief Executive Officers of eligible non-teaching hospitals in NYS were surveyed and asked if they had interest in establishing a residency program, what medical specialties they would choose assuming availability of additional funds, and what barriers there were to residency development. Results: Fourteen of 46 (30%) NYS sites completed the survey. All but one was interested in establishing residencies; 85 percent would establish new programs in Emergency Medicine; 76 percent in Family Medicine; and 54 percent in Internal Medicine and/or Primary Care Internal Medicine. Virtually all cited significant concerns related to funding, faculty supply, and need for medical school affiliations. Conclusions: A minimum of 28 percent of non-teaching hospitals in NYS have a significant interest in establishing a GME program. If implemented this could increase training in Family Medicine by 40 percent and Internal Medicine by 11 percent. However, there are formidable financial and structural barriers to doing so. Enhanced support programs that go beyond lifting of the current GME cap will be necessary to increase the training of primary care physicians.

Quality of Breast Cancer Care in the U.S.: A National Analysis of Medicare Beneficiaries, 2003-2007

Quality of Breast Cancer Care in the U.S.: A National Analysis of Medicare Beneficiaries, 2003-2007

Variation in Staging and Treatment of Rectal Cancer by National Cancer Institute (NCI) Designation and Medical School Affiliation: Analysis of Surveillance, Epidemiology and End Results (SEER)-Medicare Data

Variation in Staging and Treatment of Rectal Cancer by National Cancer Institute (NCI) Designation and Medical School Affiliation: Analysis of Surveillance, Epidemiology and End Results (SEER)-Medicare Data

Association of reimbursement policy and urologists׳ characteristics with the use of medical androgen deprivation therapy for clinically localized prostate cancer

ObjectivesPhysician characteristics and changes in drug reimbursement rates have been shown to influence practice patterns regardless of clinical guidelines, patient, clinical, or sociodemographic factors. We concurrently examined the association between urologists׳ characteristics and non–evidence-based use of primary medical androgen deprivation therapy (ADT) for clinically localized patients with prostate cancer, before and after the 2003 Medicare Modernization Act׳s reductions in ADT reimbursement rates. Methods and materialsThe Surveillance, Epidemiology, and End Results-Medicare–linked database and the American Medical Association Physician Masterfile are used in a retrospective analysis of 12,255 patients diagnosed between 2001 and 2007 with clinical stage T1-T2, low- to intermediate-grade prostate cancer, and the 1,863 urologists who treated them. Logistic multilevel regression analyses are used to evaluate the association of urologists׳ characteristics on ADT use among patients within 6 months of diagnosis. ResultsOverall, 3,866 (32%) patients received non–evidence-based ADT. After adjusting for patient and urologist characteristics, patients treated by urologists with no medical school affiliations, compared with those treated by urologists with major medical school affiliations, are significantly more likely to receive non–evidence-based medical ADT (odds ratio = 2.35; 95% CI: 1.71–3.23; P<0.0001). Non–US-trained urologists are also more likely to prescribe non–evidence-based medical ADT (odds ratio = 1.64; 95% CI: 1.33–2.04; P<0.0001). ConclusionsPatients treated by non–medical school–affiliated or non–US-trained urologists or both are significantly more likely to receive non–evidence-based ADT before and after the passage of the Medicare Modernization Act. Better strategies to encourage evidence-based ADT use on clinically localized patients with prostate cancer may be of benefit especially among non–medical school–affiliated or non–US-trained urologists or both.

Abstract P5-15-01: Comparative effectiveness of four treatment modalities for early stage breast cancer patients

Abstract Background Although recent work using observational data has shown survival benefits for breast conserving surgery plus radiation (BCS+RT) over mastectomy in early stage breast cancer for elderly women, only one report has compared all four treatment modalities available to these women: BCS+RT, BCS without radiation (BCS-RT), mastectomy with radiation (M+RT), and mastectomy without radiation (M-RT). This study utilized risk adjustment (RA) methods to control for variation in observed characteristics. However, RA methods may result in biased estimates if unobserved characteristics affect both the probability of receiving treatment and survival. Other statistical methods have been developed to address this issue. When valid, Instrumental Variable (IV) analysis can mitigate this bias by effectively randomizing patients into treatment through instruments. Thus our objective is to use IV methods to assess the comparative effectiveness of these treatment modalities on overall survival for elderly women with early stage breast cancer. Methods Using SEER-Medicare data, we identified 35,452 patients diagnosed 1992-1998 with Stage I or II breast cancer. We classified primary therapy as M+RT, M-RT, BCS+RT and BCS-RT using registry data and claims and estimated the effect of primary therapy on 7-year overall survival, with 6 and 8 years as robustness checks. We utilized an instrumental variables (IV) approach to address unobserved confounding. First, we estimated treatment rates for each treatment in an area by including the 50 patients closest to each beneficiary's zip code and adjusting for patient and area characteristics. These areas were then ranked and divided into quintiles, which formed the instruments for our IV analysis. In addition, we control for a number of patient (age, race, comorbidity, chemotherapy use, marital status, urban/rural residence, SEER area, diagnosis year), tumor (size, stage, grade, histology, use ER/PR status, # of positive nodes), physician (sex, specialty, medical school graduation year, foreign graduate status), and hospital characteristics (bed size, ownership, urban/rural location, teaching status, medical school affiliation, cancer center, participation in clinical trials). Results Our IV analysis showed overall survival benefits for elderly women who received BCS+RT compared to M-RT (Table 1). We estimate a 17.5% increase in the probability of surviving 7 years for those who were affected by our instrument. No survival benefit was shown for any other treatment. Conclusion We use IV analysis to address unobserved confounding in treatment and survival for elderly, early stage breast cancer patients. Consistent with previous RA estimates, we find that BCS+RT provides 7-year survival benefits over M-RT. The magnitude of the survival benefits continue to grow, even after 8 years. We find no difference in overall survival for those who received M+RT or BCS-RT compared to M-RT. Table 1. Instrumental Variables results reporting percent change in overall survival by treatment typeOverall SurvivalM-RTM + RTBCS + RTBCS aloneyears% change (p-value)% change (p-value)% change (p-value)% change (p-value)6ref-4.3 (0.61)10.7 (0.008)-0.008 (0.90)7ref-4.5 (0.66)17.5 (0.0003)0.005 (0.95)8ref-2.1 (0.84)19.0 (0.0001)0.008 (0.92) Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-15-01.

The Role of the Urologist in Whether Locoregional Prostate Cancer Patients Consult With a Radiation Oncologist

Multiple treatment options exist for prostate cancer patients, and therapeutic recommendations may differ depending on characteristics of the specialist consulted. The clinical judgment of specialists who advise patients can play a critical role in the initial treatment choice, especially in cases where there is no professional consensus regarding the optimal treatment strategy. We examined the association between the medical school affiliation of a prostate cancer patient's urologist and the likelihood the patient would consult a radiation oncologist. Using the Surveillance, Epidemiology and End Results–Medicare linked database and the American Medical Association Physician Masterfile, we conducted a retrospective cohort study of 39,915 patients aged 66 years or older who were diagnosed between 2004 and 2007 with locoregional prostate cancer, and the 2,404 urologists who performed the patients’ diagnostic biopsies. Multilevel regression analysis was used to evaluate the influence of patients’ urologists’ practice affiliations with medical schools on the patients’ consultation with a radiation oncologist within 9 months of diagnosis. Overall, 25,110 (62.9%) patients consulted with a radiation oncologist. After adjusting for patient, tumor and urologist characteristics, patients who saw urologists practicing within non-institutional settings were significantly more likely to consult with a radiation oncologist (odds ratio [OR], 1.19; 95% confidence interval [95% CI], 1.05-1.34, p = 0.006) when compared to those who saw urologists practicing within settings with a major medical school affiliation. In addition, patients who saw urologists aged 58 years or older were significantly more likely to consult with a radiation oncologist (OR, 1.71; 95% CI, 1.16-2.50, p = 0.006) when compared to those who saw urologists younger than 43 years old. Locoregional prostate cancer patients who received their diagnostic biopsy by urologists practicing in non-institutional settings and those who saw older urologists were significantly more likely to eventually consult with a radiation oncologist. This may have implications on which patient eventually receives radiation as initial therapy.

Differential receipt of sentinel lymph node biopsy within practice-based research networks.

Practice-based research networks (PBRNs) are promising for accelerating not only research, but also dissemination of research-based evidence into broader community practice. Sentinel lymph node biopsy (SLNB) is an innovation in breast cancer care associated with equivalent survival and lower morbidity, as compared with standard axillary lymph node dissection. We examined the diffusion of SLNB into practice and whether affiliation with the Community Clinical Oncology Program (CCOP), a cancer-focused PBRN, was associated with more rapid uptake of SLNB. Surveillance Epidemiology and End Results-Medicare data were used to study women diagnosed with stage I or II breast cancer in the years 2000-2005 and undergoing breast-conserving surgery with axillary staging (n=6226). The primary outcome was undergoing SLNB. CCOP affiliation of the surgical physician was ascertained from NCI records. Multivariable generalized linear modeling with generalized estimating equations was used to measure association between CCOP exposure and undergoing SLNB, controlling for potential confounders. Women treated by a CCOP physician had significantly higher odds of receiving SLNB compared with women treated by a non-CCOP physician (OR 2.68; 95% CI, 1.35-5.34). The magnitude of this association was larger than that observed among patients treated by physicians operating in medical school-affiliated hospitals (OR 1.76; 95% CI, 1.30-2.39). Women treated by CCOP-affiliated physicians were more likely to undergo SLNB irrespective of the hospital's medical school affiliation, suggesting that the CCOP PBRN may play a role in the rapid adoption of research-based innovation in community practice.

A look at the thoracic surgery workforce in Canada: how demographics and scope of practice may impact future workforce needs

The purpose of this study is to describe the demographics, training and practice characteristics of physicians performing thoracic surgery across Canada to better assess workforce needs. We developed a questionnaire using a modified Delphi process to generate questionnaire items. The questionnaire was administered to all Canadian thoracic surgeons via email (n = 102) or mail (n = 35). In all, 97 surgeons completed the survey (71% response rate). The mean age of respondents was 47.7 (standard deviation 9.1) years; 10.3% were older than 60. Ninety respondents (88.7%) were men, 95 (81.1%) practised in English and 93 (76%) were born in Canada. Most (90.4%) had a medical school affiliation, with an equal proportion practising in community or university teaching hospitals. Only 18% of respondents reported working fewer than 60 hours per week, and 34% were on call more than 1 in 3. Three-quarters of work hours were devoted to clinical care, with the remaining time split among research, administration and teaching. Malignant lung disease accounted for 61.2% of practice time, with the remaining time equally split between benign and malignant thoracic diseases. Preoperative testing (49.4%) and insufficient operating time (49.5%) were the most common factors delaying delivery of care. More than 80% of respondents reported being satisfied with their careers, with 62.1% planning on retiring after age 60. This survey characterizes Canadian thoracic surgeons by providing specific demographic, satisfaction and scope of practice information. Despite challenges in obtaining adequate resources for providing timely care, job satisfaction remains high, with a balanced workforce supply and demand anticipated for the foreseeable future.

Redefining the Standardized Infection Ratio to Aid in Consumer Value Purchasing

The derivations of the standardized infection ratio (SIR) are reviewed in this report. To be most understandable to the consumer, the SIR National Benchmark of 1.0 should reflect what is obtainable.The SIR is a tool intended to be used by consumers in value purchasing to compare differences between facilities and thus should not adjust for these differences. Ideally, factors used in risk adjustment should solely be based upon patient characteristics. Thus, facility-specific adjustments (i.e., medical school affiliation, major teaching institution and unit bed size) should be used with caution in calculating the SIR and their use made clearly transparent to health-care consumers.Using data downloaded from the US Department of Health and Human Services' website, Hospital Compare, we observed an average SIR for central line blood stream infections of 0.568 and an SIR at the peak of the distribution curve approximating 0.35. A suggested methodology to calculate an obtainable SIR is to set the National Benchmark of 1.0 at the location of the distribution curve's peak. The curve's peak is more reflective of higher performing facilities. The SIR needs to reflect the expected performance of facilities, which are using up-to-date methods of infection control. The remainder of the facility SIRs can then be adjusted accordingly.It is recommended that the obtainable SIR be calculated every other year using data from the most recent 3 years. This enables the SIR to be reset as the control of health care-associated infections progressively improves.