Changes In Practice Patterns Research Articles

Antibiotic Prophylaxis in the Management of Distal Fingertip Amputation and Crush Injury

We sought to investigate the role of prophylactic antibiotics for distal fingertip crush injury or transphalangeal amputation treated outside of an operating room and better understand the factors that contribute to antibiotic-prescribing decisions. We hypothesized that prophylactic antibiotics do not meaningfully reduce the incidence of infection and that antibiotics are prescribed in a predictable way. This is a retrospective review of all patients treated in a MedStar-affiliated emergency department or urgent care for nonsurgical distal fingertip trauma in 2019. Patient demographics, comorbidities, injury characteristics, interventions, and follow-up details were recorded. Exclusion criteria included signs of infection at the time of presentation, minor injuries not requiring intervention, bite wounds, one-time intravenous antibiotic administration without oral course, and surgical intervention. Outcomes included infection and interventions at follow-up. Chi-square analysis was performed, comparing antibiotic and no-antibiotic groups. A stepwise binomial regression was used to evaluate for variables predictive of antibiotic prescription. We identified eight infections in 323 patients included in the study (2.5% incidence of infection). There was no statistically significant difference in the incidence of infection between patients treated with antibiotics (2.7%) and those who did not receive antibiotics (2.2%). However, due to the low incidence of infections, we were likely underpowered for this analysis. We also created a model to predict antibiotic prescribing, which achieved an area under the receiver operating characteristic curve of 0.86 (P < .0001) based on age, bleeding disorders, depressive disorders, open wound status, amputation, fractures, and encounter type. The low incidence of infection (2.5%) and lack of a meaningful difference between the groups call into question prophylactic antibiotic prescribing after these distal fingertip injuries. Our model does predict provider prescribing habits, identifying areas for potential practice pattern change. Therapeutic III.

Suboptimal Guideline Adherence and Biomarker Underutilization in Monitoring of Post-operative Crohn's Disease.

Crohn's disease recurrence after ileocecal resection is common. Guidelines suggest colonoscopy within 6-12months of surgery to assess for post-operative recurrence, but use of adjunctive monitoring is not protocolized. We aimed to describe the state of monitoring in post-operative Crohn's. We conducted a retrospective study of patients with Crohn's after ileocolic resection with ≥ 1-year follow-up. Patients were stratified into high and low risk based on guidelines. Post-operative biomarker (C-reactive protein, fecal calprotectin), cross-sectional imaging, and colonoscopy use were assessed. Biomarker, radiographic, and endoscopic post-operative recurrence were defined as elevated CRP/calprotectin, active inflammation on imaging, and Rutgeerts ≥ i2b, respectively. Data were stratified by surgery year to assess changes in practice patterns over time. P-values were calculated using Wilcoxon test and Fisher exact test. Of 901 patients, 53% were female and 78% high risk. Median follow-up time was 60m for LR and 50m for high risk. Postoperatively, 18% low and 38% high risk had CRPs, 5% low and 10% high risk had calprotectins, and half of low and high risk had cross-sectional imaging. 29% low and 38% high risk had colonoscopy by 1year. Compared to pre-2015, time to first radiography (584days vs. 398days) and colonoscopy (421days vs. 296days) were significantly shorter for high-risk post-2015 (P < 0.001). Probability of colonoscopy within 1year increased over time (0.48, 2011 vs. 0.92, 2019). Post-operative colonoscopy completion by 1year is low. The use of CRP and imaging are common, whereas calprotectin is infrequently utilized. Practice patterns are shifting toward earlier monitoring.

CLRM-10 ENHANCED PATIENT CARE FOR BRAIN METASTASIS PATIENTS UTILIZING A DEDICATED METASTASIS TUMOR BOARD

Abstract BACKGROUND Patients with brain metastases are a heterogeneous population. In contrast to patients with primary brain tumors, these patients require individualized therapy based on the type and status of systemic cancer, number and volume of brain metastases, anticipated efficacy of therapy and survival. Therapeutic options for brain metastasis; surgical, radiation and precision medicine approaches have increased in recent years as has survival for a number of cancers, leading to more sophisticated care. To meet this challenge in January 2023 we organized a dedicated brain metastasis tumor board. METHODS We reviewed the number of total patients, and those newly-diagnosed, presented at the dedicated brain metastasis board in the first 10 weeks of 2023 as compared with the same time interval the prior year where similar cases were presented at a general brain tumor board. We also assessed change in practice pattern based on the dedicated metastasis tumor board. RESULTS 89 patients were presented in the first 10 weeks of 2023, including 75 who were newly diagnosed. The total number and those newly diagnosed are 17% higher than the prior year. The dedicated brain metastasis board, staffed by experts in brain metastases, allowed for earlier identification of patients eligible for clinical trial and additionally our review of patients identified the need for standardizing advanced imaging techniques including high resolution, higher contrast-dose MRI scans for better assessment of brain metastases across our hospital sites. CONCLUSION We found that a dedicated brain metastasis board increased the number of patients presented for multidisciplinary review, including new patients, which served to better identify those eligible for clinical trial. It led to a consensus to incorporate advanced imaging techniques for assessing treatment response. The experience is superior to inclusion of these patients in a general brain tumor board.

Patterns in Decompression and Fusion Procedures for Patients With Lumbar Stenosis After Major Clinical Trial Results, 2016 to 2019

Use of lumbar fusion has increased substantially over the last 2 decades. For patients with lumbar stenosis and degenerative spondylolisthesis, 2 landmark prospective randomized clinical trials (RCTs) published in the New England Journal of Medicine in 2016 did not find clear evidence in favor of decompression with fusion over decompression alone in this population. To assess the national use of decompression with fusion vs decompression alone for the surgical treatment of lumbar stenosis and degenerative spondylolisthesis from 2016 to 2019. This retrospective cohort study included 121 745 hospitalized adult patients (aged ≥18 years) undergoing 1-level decompression alone or decompression with fusion for the management of lumbar stenosis and degenerative spondylolisthesis from January 1, 2016, to December 31, 2019. All data were obtained from the National Inpatient Sample (NIS). Analyses were conducted, reviewed, or updated on June 9, 2023. The primary outcome of this study was the use of decompression with fusion vs decompression alone. For the secondary outcome, multivariable logistic regression analysis was used to evaluate factors associated with the decision to perform decompression with fusion vs decompression alone. Among 121 745 eligible hospitalized patients (mean age, 65.2 years [95% CI, 65.0-65.4 years]; 96 645 of 117 640 [82.2%] non-Hispanic White) with lumbar stenosis and degenerative spondylolisthesis, 21 230 (17.4%) underwent decompression alone, and 100 515 (82.6%) underwent decompression with fusion. The proportion of patients undergoing decompression alone decreased from 2016 (7625 of 23 405 [32.6%]) to 2019 (3560 of 37 215 [9.6%]), whereas the proportion of patients undergoing decompression with fusion increased over the same period (from 15 780 of 23 405 [67.4%] in 2016 to 33 655 of 37 215 [90.4%] in 2019). In univariable analysis, patients undergoing decompression alone differed significantly from those undergoing decompression with fusion with regard to age (mean, 68.6 years [95% CI, 68.2-68.9 years] vs 64.5 years [95% CI, 64.3-64.7 years]; P < .001), insurance status (eg, Medicare: 13 725 of 21 205 [64.7%] vs 53 320 of 100 420 [53.1%]; P < .001), All Patient Refined Diagnosis Related Group risk of death (eg, minor risk: 16 900 [79.6%] vs 83 730 [83.3%]; P < .001), and hospital region of the country (eg, South: 7030 [33.1%] vs 38 905 [38.7%]; Midwest: 4470 [21.1%] vs 23 360 [23.2%]; P < .001 for both comparisons). In multivariable logistic regression analysis, older age (adjusted odds ratio [AOR], 0.96 per year; 95% CI, 0.95-0.96 per year), year after 2016 (AOR, 1.76 per year; 95% CI, 1.69-1.85 per year), self-pay insurance status (AOR, 0.59; 95% CI, 0.36-0.95), medium hospital size (AOR, 0.77; 95% CI, 0.67-0.89), large hospital size (AOR, 0.76; 95% CI, 0.67-0.86), and highest median income quartile by patient residence zip code (AOR, 0.79; 95% CI, 0.70-0.89) were associated with lower odds of undergoing decompression with fusion. Conversely, hospital region in the Midwest (AOR, 1.34; 95% CI, 1.14-1.57) or South (AOR, 1.32; 95% CI, 1.14-1.54) was associated with higher odds of undergoing decompression with fusion. Decompression with fusion vs decompression alone was associated with longer length of stay (mean, 2.96 days [95% CI, 2.92-3.01 days] vs 2.55 days [95% CI, 2.49-2.62 days]; P < .001), higher total admission costs (mean, $30 288 [95% CI, $29 386-$31 189] vs $16 190 [95% CI, $15 189-$17 191]; P < .001), and higher total admission charges (mean, $121 892 [95% CI, $119 566-$124 219] vs $82 197 [95% CI, $79 745-$84 648]; P < .001). In this cohort study, despite 2 prospective RCTs that demonstrated the noninferiority of decompression alone compared with decompression with fusion, use of decompression with fusion relative to decompression alone increased from 2016 to 2019. A variety of patient- and hospital-level factors were associated with surgical procedure choice. These results suggest the findings of 2 major RCTs have not yet produced changes in surgical practice patterns and deserve renewed focus.

The Evolution of Genetic Testing from Focused Testing to Panel Testing and from Patient Focused to Population Testing: Are We There Yet?

The field of cancer genetics has evolved significantly over the past 30 years. Genetic testing has become less expensive and more comprehensive which has changed practice patterns. It is no longer necessary to restrict testing to those with the highest likelihood of testing positive. In addition, we have learned that the criteria developed to determine who has the highest likelihood of testing positive are neither sensitive nor specific. As a result, the field is moving from testing only the highest risk patients identified based on testing criteria to testing all cancer patients. This requires new service delivery models where testing can be mainstreamed into oncology clinics and posttest genetic counseling can be provided to individuals who test positive and those with concerning personal or family histories who test negative. The use of videos, testing kiosks, chatbots, and genetic counseling assistants have been employed to help facilitate testing at a larger scale and have good patient uptake and satisfaction. While testing is important for cancer patients as it may impact their treatment, future cancer risks, and family member's cancer risks, it is unfortunate that their cancer could not be prevented in the first place. Population testing for all adults would be a strategy to identify individuals with adult-onset diseases before they develop cancer in an attempt to prevent it entirely. A few research studies (Healthy Nevada and MyCode) have offered population testing for the three Centers for Disease Control and Prevention Tier 1 conditions: hereditary breast and ovarian cancer syndrome, Lynch syndrome, and familial hypercholesterolemia finding a prevalence of 1 in 70 individuals in the general population. We anticipate that testing for all cancer patients and the general population will continue to increase over the next 20 years and the genetics community needs to help lead the way to ensure this happens in a responsible manner.

Practice Patterns: An American Society of Plastic Surgeons (ASPS) Member Survey, 2000 and 2020-How Much Has Brow Lifting Changed?

In 2001, Elkwood and Matarasso published an American Society of Plastic Surgeons (ASPS) member survey detailing brow lift practice patterns. Interval changes in practice patterns have not been studied. The previous survey was revised to elucidate current trends in brow lift surgery. A 34-question descriptive survey was distributed to a random group of 2360 ASPS members. Results were compared to the 2001 survey. A total of 257 responses were collected (11% response rate; ± 6% margin of error at 95% CI). The most frequent technique for the correction of brow ptosis in both surveys was the endoscopic approach. The use of hardware fixation has increased in endoscopic brow lifting, whereas the use of cortical tunnels has decreased. Although coronal brow lifting has decreased in frequency, hairline and isolated temporal lift have increased. Neuromodulators have replaced resurfacing techniques as the most common nonsurgical adjunct. Frequent use of neuromodulators has risen from 11.2% to 88.5%. Nearly 30% of current surgeons feel that neuromodulators have replaced formal brow lifting procedures to a significant degree. In comparing the 2001 and current ASPS member survey there has been a clear transition to less invasive procedures over time. Although the endoscopic approach was the most popular means of forehead correction in both surveys, coronal brow lifting has decreased in frequency and the hairline and temporal approaches have increased. Neurotoxins have replaced laser resurfacing and chemical peeling methods as an adjunct, and in some cases replaced the invasive procedure entirely. Possible explanations for these findings will be discussed.

Looking Back: International Practice Patterns in Breast Radiation Oncology From a Case-Based Survey Across 54 Countries During the First Surge of the COVID-19 Pandemic.

The COVID-19 pandemic has profoundly affected cancer care worldwide, including radiation therapy (RT) for breast cancer (BC), because of risk-based resource allocation. We report the evolution of international breast RT practices during the beginning of the pandemic, focusing on differences in treatment recommendations between countries. Between July and November 2020, a 58-question survey was distributed to radiation oncologists (ROs) through international professional societies. Changes in RT decision making during the first surge of the pandemic were evaluated across six hypothetical scenarios, including the management of ductal carcinoma in situ (DCIS), early-stage, locally advanced, and metastatic BC. The significance of changes in responses before and during the pandemic was examined using chi-square and McNemar-Bowker tests. One thousand one hundred three ROs from 54 countries completed the survey. Incomplete responses (254) were excluded from the analysis. Most respondents were from the United States (285), Japan (117), Italy (63), Canada (58), and Brazil (56). Twenty-one percent (230) of respondents reported treating at least one patient with BC who was COVID-19-positive. Approximately 60% of respondents reported no change in treatment recommendation during the pandemic, except for patients with metastatic disease, for which 57.7% (636/1,103; P < .0005) changed their palliative practice. Among respondents who noted a change in their recommendation during the first surge of the pandemic, omitting, delaying, and adopting short-course RT were the most frequent changes, with most transitioning to moderate hypofractionation for DCIS and early-stage BC. Early in the COVID-19 pandemic, significant changes in global RT practice patterns for BC were introduced. The impact of published results from the FAST FORWARD trial supporting ultrahypofractionation likely confounded the interpretation of the pandemic's independent influence on RT delivery.

A Qualitative Assessment of Clinical Practice Guidelines and Patterns for Congenital Cytomegalovirus in the United States.

Cytomegalovirus (CMV) infection during pregnancy may result in long-term health problems for children with congenital CMV (cCMV). Currently, no prevention or treatment interventions are approved by the Food and Drug Administration for a cCMV indication. Healthcare provider and public awareness is low, and formal clinical practice guidelines and local practice patterns vary. A pilot study of eight cCMV experts was performed using qualitative semi-structured interviews to better understand clinical practice guidelines and patterns in the United States. Results from participant interviews highlighted the need for better prenatal diagnostic techniques, broader neonatal screening opportunities, and more robust evidence supporting intervention strategies. Healthcare provider and public partnerships are essential for advancing cCMV guidelines and improving care delivery. Our results provide a preliminary knowledge base and framework for developing a consensus cCMV research agenda to address evidence gaps that limit the revision of clinical practice guidelines. The changes in clinical practice patterns that may arise as a result of further research have the potential to reduce risk during pregnancy and improve care for children with cCMV infection.

Changes in Surgical Management of the Axilla Over 11 Years - Report on More Than 1500 Breast Cancer Patients Treated with Neoadjuvant Chemotherapy on the Prospective I-SPY2 Trial.

Axillary surgery after neoadjuvant chemotherapy (NAC) is becoming less extensive. We evaluated the evolution of axillary surgery after NAC on the multi-institutional I-SPY2 prospective trial. We examined annual rates of sentinel lymph node (SLN) surgery with resection of clipped node, if present), axillary lymph node dissection (ALND), and SLN and ALND in patients enrolled in I-SPY2 from January 1, 2011 to December 31, 2021 by clinical N status at diagnosis and pathologic N status at surgery. Cochran-Armitage trend tests were calculated to evaluate patterns over time. Of 1578 patients, 973 patients (61.7%) had SLN-only, 136 (8.6%) had SLN and ALND, and 469 (29.7%) had ALND-only. In the cN0 group, ALND-only decreased from 20% in 2011 to 6.25% in 2021 (p = 0.0078) and SLN-only increased from 70.0% to 87.5% (p = 0.0020). This was even more striking in patients with clinically node-positive (cN+) disease at diagnosis, where ALND-only decreased from 70.7% to 29.4% (p < 0.0001) and SLN-only significantly increased from 14.6% to 56.5% (p < 0.0001). This change was significant across subtypes (HR-/HER2-, HR+/HER2-, and HER2+). Among pathologically node-positive (pN+) patients after NAC (n = 525) ALND-only decreased from 69.0% to 39.2% (p < 0.0001) and SLN-only increased from 6.9% to 39.2% (p < 0.0001). Use of ALND after NAC has significantly decreased over the past decade. This is most pronounced in cN+ disease at diagnosis with an increase in the use of SLN surgery after NAC. Additionally, in pN+ disease after NAC, there has been a decrease in use of completion ALND, a practice pattern change that precedes results from clinical trials.

Exploring the perception of venous disease within vascular surgery

BackgroundBiases and gender disparities influence career pathways within medicine, and vascular surgery is no exception. Venous disease comprises an estimated 1% to 3% of total health care expenditures. However, its value among vascular surgeons is poorly understood. This study aims to investigate the factors that influence vascular surgeons' current perceptions of superficial and deep venous disease treatments. MethodsAn anonymous survey was distributed electronically to practicing vascular surgeons in December 2021. The respondents were stratified by gender and practice breakdown. A venous-heavy practice was defined as a practice with venous work comprising ≥25% of the total volume. Changes in practice patterns over the respondent's career were also explored. Descriptive, univariate, and multivariate analyses were performed using STATA (StataCorp). ResultsA total of 315 practicing vascular surgeons responded, with 81.5% from the United States. Their mean age was 46.6 ± 9.6 years, and most identified as men (63.3%). The race and ethnicity breakdown was as follows: White (non-Hispanic), 63.0%; Asian or Asian Indian, 17.1%; Hispanic, Latinx, or Spanish, 8.4%; Black, 1.6%; and unknown, 9.9%. The practice settings were academic for 47.0%, private practice for 26.5%, hospital employed for 23.3%, and other for 3.2%. The female respondents were significantly younger (P < .0001), with fewer years in practice (P < .0001) and were more likely to perceive a gender bias within a career encompassing venous disease compared with the male respondents (P = .02). Of the 315 participants, 143 (45.4%) had a venous-heavy practice. No differences were found in age or gender between the venous-heavy and venous-light practices. Those with a venous-heavy practice had significantly more years in practice statistically (P = .02), had sought more venous training after graduation (P < .0001), were more likely to be in private practice (P < .0001), and were more likely to desire a practice change (P = .001) compared with those with a venous-light practice. Overall, 74.3% of respondents indicated that venous work might be less “valued” than arterial work in the field of vascular surgery. On multivariable regression, the predictors for the perception of venous work being less valued were female gender (odds ratio, 2.01; 95% confidence interval, 1.14-4.03) and completion of a vascular surgery fellowship (odds ratio, 2.0; 95% confidence interval, 1.15-3.57). ConclusionsVascular surgeons overwhelmingly perceived the management of venous disease to be of less value than that of arterial disease, particularly by women and fellowship-trained vascular surgeons. The prevalence of venous disease, as measured by its proportion of the U.S. healthcare budget, cannot be overstated. Thus, efforts to elevate the importance of chronic venous disease within the scope of vascular surgery practices are essential to ensure patients are provided with appropriate specialty care.

Comparative Effectiveness of Percutaneous Microaxial Left Ventricular Assist Device vs Intra-Aortic Balloon Pump or No Mechanical Circulatory Support in Patients With Cardiogenic Shock

Recent studies have produced inconsistent findings regarding the outcomes of the percutaneous microaxial left ventricular assist device (LVAD) during acute myocardial infarction with cardiogenic shock (AMICS). To compare the percutaneous microaxial LVAD vs alternative treatments among patients presenting with AMICS using observational analyses of administrative data. This comparative effectiveness research study used Medicare fee-for-service claims of patients admitted with AMICS undergoing percutaneous coronary intervention from October 1, 2015, through December 31, 2019. Treatment strategies were compared using (1) inverse probability of treatment weighting to estimate the effect of different baseline treatments in the overall population; (2) instrumental variable analysis to determine the effectiveness of the percutaneous microaxial LVAD among patients whose treatment was influenced by cross-sectional institutional practice patterns; (3) an instrumented difference-in-differences analysis to determine the effectiveness of treatment among patients whose treatment was influenced by longitudinal changes in institutional practice patterns; and (4) a grace period approach to determine the effectiveness of initiating the percutaneous microaxial LVAD within 2 days of percutaneous coronary intervention. Analysis took place between March 2021 and December 2022. Percutaneous microaxial LVAD vs alternative treatments (including medical therapy and intra-aortic balloon pump). Thirty-day all-cause mortality and readmissions. Of 23 478 patients, 14 264 (60.8%) were male and the mean (SD) age was 73.9 (9.8) years. In the inverse probability of treatment weighting analysis and grace period approaches, treatment with percutaneous microaxial LVAD was associated with a higher risk-adjusted 30-day mortality (risk difference, 14.9%; 95% CI, 12.9%-17.0%). However, patients receiving the percutaneous microaxial LVAD had a higher frequency of factors associated with severe illness, suggesting possible confounding by measures of illness severity not available in the data. In the instrumental variable analysis, 30-day mortality was also higher with percutaneous microaxial LVAD, but patient and hospital characteristics differed across levels of the instrumental variable, suggesting possible confounding by unmeasured variables (risk difference, 13.5%; 95% CI, 3.9%-23.2%). In the instrumented difference-in-differences analysis, the association between the percutaneous microaxial LVAD and mortality was imprecise, and differences in trends in characteristics between hospitals with different percutaneous microaxial LVAD use suggested potential assumption violations. In observational analyses comparing the percutaneous microaxial LVAD to alternative treatments among patients with AMICS, the percutaneous microaxial LVAD was associated with worse outcomes in some analyses, while in other analyses, the association was too imprecise to draw meaningful conclusions. However, the distribution of patient and institutional characteristics between treatment groups or groups defined by institutional differences in treatment use, including changes in use over time, combined with clinical knowledge of illness severity factors not captured in the data, suggested violations of key assumptions that are needed for valid causal inference with different observational analyses. Randomized clinical trials of mechanical support devices will allow valid comparisons across candidate treatment strategies and help resolve ongoing controversies.

Timing and setting of billed advance care planning among Medicare decedents in 2017-2019.

The Centers for Medicare & Medicaid Services (CMS) began to reimburse clinicians for advance care planning (ACP) discussions, effective January 1, 2016. We sought to characterize the timing and setting of first-billed ACP discussions among Medicare decedents to inform future research on ACP billing codes. Using a random 20% sample of Medicare fee-for-service beneficiaries aged 66 years and older who died in 2017-2019, we described the timing (relative to death) and setting (inpatient, nursing home, office, or outpatient with or without Medicare Annual Wellness Visit [AWV], home or community, or elsewhere) of the first-billed ACP discussion for each beneficiary. Our study included 695,985 decedents (mean [SD] years of age, 83.2 [8.8]; 54.2% female); the proportion of decedents who had at least one billed ACP discussion increased from 9.7% in 2017 to 21.9% in 2019. We found that the proportion of first-billed ACP discussions held during the last month of life decreased from 37.0% in 2017 to 26.2% in 2019, while the proportion of first-billed ACP discussions held more than 12 months before death increased from 11.1% in 2017 to 35.2% in 2019. We also found that the proportion of first-billed ACP discussions held in the office or outpatient setting along with AWV increased over time (from 10.7% in 2017 to 14.1% in 2019), while the proportion held in the inpatient setting decreased (from 41.7% in 2017 to 38.0% in 2019). We found that with increasing exposure to the CMS policy change, uptake of the ACP billing code has increased; first-billed ACP discussions are occurring sooner before the end-of-life stage and are more likely to occur with AWV. Future studies should evaluate changes in ACP practice patterns, rather than only an increasing uptake in ACP billing codes, following the policy implementation.

#6283 REGIONAL VARIATION OF ACUTE KIDNEY INJURY IN COVID-19 IN ENGLAND

Abstract Background and Aims The recent worldwide COVID-19 pandemic has identified acute kidney injury (AKI) as a serious complication of COVID-19. Previous reports suggest that AKI associated with COVID-19 has higher morbidity and mortality compared to AKI due to other causes. Limited data has suggested that regional variation in COVID-19 incidence is related to population density. However, little is known about the effect of region, SARS CoV-2 strains, steroid treatment and other determinants on incidence and mortality in patients with COVID-19 complicated by AKI. The aim of this study was to determine the regional variation of COVID-19 AKI and predictors of mortality in these patients. Method This retrospective cohort study used hospital episode statistics. Data were collected from all adult hospitalised patients with COVID-19 infection and AKI (diagnostic code U07.1 and N17 in any of the 20 diagnoses codes) between 1st March 2020 and 31st March 2021 until discharge. We also extracted all available secondary diagnoses and procedure codes. Patients with codes for chronic dialysis were excluded. We divided the observation period as per the dominant SARS CoV-2 variant and in relation to publication of the RECOVERY trial. SARS CoV-2 “Other” strain was prevalent between 1st March 2020 and 21st December 2020, “Alfa” between 22nd December 2020 to 17th May 2021. The end date of each phase was based on more than 50% decline in each variant. Results We extracted 749,844 unique admission spells in 337,029 patients with U071 code in any of the 20 diagnostic codes from 3,324,748 FCEs and admitted during the study period. We excluded patients not resident in England, multiple and duplicate FCEs within a spell. Out of 749,844 admissions, 63,147 patients had 227,268 admissions with AKI. Population incidence of AKI was highest in London at 6316 pmp and lowest in South West 2394 pmp. Mean length of stay was lowest in North East at 15.6 ± 15.9 days and highest in South West at 19.3 ± 18.3 days. London had highest proportion of patients with Asian (15.1%) and Black ethnicity (16.1%). Proportion of AKI patients dialysed varied from 2.5% in North West to 6.5% in London. Unadjusted mortality was highest in North West at 31.8% and lowest in London at 25.4%. In multivariable analysis, increasing age (OR 1.04, 95%CI 1.04, 1.04), Asian ethnicity (OR 1.13, 95%CI 1.08, 1.17), emergency admissions (OR 1.7, 95%CI 1.51, 1.9), and transfers (OR 1.18, 95%CI 1.03, 1.34), ITU admission (OR 5.16, 95%CI 4.98, 5.34) and acute dialysis (OR 2.74, 95%CI 2.6, 2.89) had higher odds of death (Figure 1a). All regions had higher adjusted odds of death as compared to London (Figure 1b). Post RECOVERY trial, the odds of death was lower with prevalent “Other” SARS CoV-2 (OR 0.78, 95%CI (0.76, 0.8) and "alfa” variant (OR 0.80, 95%CI 0.78, 0.82). Conclusion In this large national study of COVID AKI, London had lowest adjusted odds of death despite a higher proportion of patients receiving dialysis. The odds of death were lower after the publication of RECOVERY trial which may have resulted in practice pattern change.

Temporal Trends and Contemporary Regional Variation in Management of Patients Undergoing Carotid Endarterectomy.

The purpose of this study is to investigate regional variation and temporal trends in seven quality metrics amongst CEA patients: discharge on antiplatelet after CEA; discharge on statin after CEA; protamine administration during CEA; patch placement at conventional CEA site; continued statin usage at the time of most recent follow-up; continued antiplatelet usage at the time of most recent follow-up; and smoking cessation at the time of long term follow up. There are 19 de-identified regions within the VQI database in the United States. Patients were placed into one of three temporal eras based on the time of their CEA: 2003-2008; 2009-2015; and 2016-2022. We first investigated temporal trends across the seven quality metrics for all regions combined on a national basis. The percentage of patients in each time era with the presence/absence of each metric was identified. Chi-squared testing was performed to confirm statistical significance of the differences across eras. Next, analysis was performed within each region and within each time metric. We separated out the 2016-2022 patients within each region to serve as the status of each metric application in the most modern era. We then compared the frequency of metric non-adherence in each region utilizing Chi-squared testing. There was statistically significant improvement in achievement of all seven metrics between the initial 2003-2008 era and the modern 2016-2022 era. The most marked change in practice pattern was noted for lack of protamine usage at surgery (decreased from 48.7% to 25.9%), discharge home postoperatively without statin (decreased from 50.6% to 15.3%), and lack of statin usage confirmed at time of most recent long term follow up (decreased from 24% to 8.9%). Significant regional variation exists across all metrics (P < .01 for all). Lack of patch placement at the time of conventional endarterectomy ranges from 1.9% to 17.8% across regions in the modern era. Lack of protamine utilization ranges from 10.8% to 49.7%. Lack of antiplatelet and statin at the time of discharge varies from 5.5% to 8.2% and 4.8% to 14.4% respectively. Adherence to the various measures at the time of most recent follow up are more tightly aligned across regions with ranges of: 5.3% to 7.5% for lack of antiplatelet usage; 6.6% to 11.7% lack of statin utilization; and 13.3 to 15.4% for persistent smoking. Prior studies and societal initiatives on CEA documenting the beneficial effects of patch angioplasty, protamine use at surgery, smoking cessation, antiplatelet utilization and statin compliance have positively impacted adherence to these measures over time. In the modern 2016-2022 era the widest regional variation is noted in patch placement, protamine utilization and discharge medications allowing individual geographic areas to identify areas for potential improvement via internal VQI administrative feedback.

Recent changes in practice patterns and outcomes in patients with severe traumatic brain injury

BackgroundDespite recent advances in the management of severe traumatic brain injury, the role of decompressive craniectomy remains unclear. The purpose of this study was to compare practice patterns and patient outcomes between 2 study periods over the past decade. MethodsThis is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Project database. We included patients (age ≥18 years) with isolated severe traumatic brain injury. The patients were divided into the early (2013–2014) and late (2017–2018) groups. The primary outcome was the rate of craniectomy, and secondary outcomes included in-hospital mortality and discharge disposition. A subgroup analysis of patients undergoing intracranial pressure monitoring was also performed. A multivariable logistic regression analysis assessed the association between the early/late period and study outcomes. ResultsA total of 29,942 patients were included. In the logistic regression analysis, the late period was associated with decreased use of craniectomy (odds ratio: 0.58, P < .001). Although the late period was associated with higher in-hospital mortality (odds ratio: 1.10, P = .013), it was also associated with a higher likelihood of discharge to home/rehab (odds ratio: 1.61, P < .001). Similarly, the subgroup analysis of patients with intracranial pressure monitoring showed that the late period was associated with a lower craniectomy rate (odds ratio: 0.26, P < .001) and a higher likelihood of discharge to home/rehab (odds ratio:1.98, P < .001). ConclusionThe use of craniectomy for severe traumatic brain injury has decreased over the study period. Although further studies are warranted, these trends may reflect recent changes in the management of patients with severe traumatic brain injury.

Adjuvant therapy for HR+/HER2– early-stage breast cancer (EBC): Changes in practice patterns among community oncologists in Brazil.

e18820 Background: The management of HR+/HER2– early breast cancer (EBC) has changed significantly, with more patients are being classified as low-risk and spared adjuvant chemotherapy (CT) and de-escalating endocrine therapy (ET); on the other hand, other patient groups have experienced treatment escalation, such as high-risk premenopausal women. This study aims to assess practice patterns and real-world data for patients with HR+/HER2- EBC treated in Brazil's largest network of community oncology practices. Methods: Retrospective real-world study from the Oncoclínicas with longitudinal EHR data merged in a platform where structured variables were integrated with unstructured elements from physician notes using technology-based abstraction and expert human curators that follow mCODE standards and predefined ontology. Index data was EBC diagnosis date, and we restricted the study to patients diagnosed between Jan 2017 and Jun 2022, with comparative analysis of adjuvant CT/ET practice trends in 2017-2019 versus 2020-2022. Results: From over 30k patients with breast cancer in Oncoclínicas Database, 19k had HR+/HER2– EBC, 12k were treated in high-volume clinics, and 2,988 were selected for the study due to data accessibility in the pre-specific observation period. Stage distribution: I in 45%, II in 37%, and III in 18%. Pre-menopausal status at diagnosis: 22%. Less than 5% of the study population had access to breast cancer prognostic risk scores. The disease-free survival rate in the entire cohort was 87% (CI95% 86-89) at 2 years and 74% (CI95% 70-78) at 5 years. Overall, we observed a decrease in adjuvant CT use from 51% during 2017-2019 to 41% during 2020-2022. In pre- menopausal patients, CT use reduced from 68% in stage I during 2017-2019 to 41% during 2020-2022; for stage II or III, the reduction was less noticeable (83% in 2017-2019 to 75% in 2020-2022). In post-menopausal patients, CT use reduced from 36% in stage I during 2017-2019 to 18% during 2020-2022; while it remained stable in stage II or III (55% in 2017-2019 versus 52% in 2020-2022). Concerning ET, there were no evident changes in treatment practice. In pre-menopausal, tamoxifen alone was the first option in 90% with stage I and in 64% with stage II or III, with the stability over the years. In post-menopausal, aromatase inhibitors were the first option in 61% with stage I, 70% with stage II and 77% with stage III, with the stability over the years. Conclusions: We perceived a reduction in chemotherapy use in HR+/HER2– stage I breast cancer over time. Reasons for treatment selection must be investigated further, including other prognostic factors, but might be related to greater physician confidence in avoiding CT and access to genomic signatures. There were no significant changes in patterns of adjuvant ET, with most pre- and postmenopausal patients receiving tamoxifen alone and an aromatase inhibitor respectively.

Phase II study of lenvatinib plus pembrolizumab for patients with immunotherapy-naive advanced gastric cancer following first line therapy.

4042 Background: Immune checkpoint inhibitor (ICI) therapy has demonstrated efficacy in some patients (pts) with advanced gastric cancer (AGC) and is now approved in 1st line combination with chemotherapy. Preclinical studies suggest interplay between angiogenesis and the immune system, with VEGF exerting effects on the anti-tumor immune response including antigen presentation, effector mechanisms and immune cell trafficking. We hypothesized that the combination of VEGF inhibition and ICI may be more beneficial than either agent alone. We designed an open-label prospective phase II trial to evaluate the efficacy of lenvatinib (Len) plus pembrolizumab (Pem) beyond first line therapy in ICI-naïve AGC. Methods: Eligible pts included advanced gastric or gastroesophageal junction adenocarcinoma regardless of PD-L1 status, with measurable disease per RECIST 1.1, ECOG ≤1, and progressive disease on ≥1 prior regimen, no prior ICI. Pts received an initial lead-in week of Len 20mg PO daily which was then continued in combination with Pem 200mg IV every 3 weeks from day 8. Therapy was continued until progression or intolerance. Imaging was performed every 6 wks for the first 12 wks and then every 9 wks. Primary end point was objective response rate (ORR). Using the Simon optimal 2 stage design, planned sample size was 29 patients (pts) with 80% power and one-sided alpha of 5%. The study would be considered positive if ≥6 pts achieved an objective response. Secondary endpoints included safety and tolerability, PFS and OS. Results: During the course of this study, ICI was approved in the 1st line setting and as a result of changing practice patterns, enrollment was prematurely suspended in 7/2022 with 24 of 29 planned pts. All enrolled pts were included for the safety analysis. All subjects were mismatch repair proficient, 15 pts (62.5%) were CPS positive (≥ 1), data was missing for 1 pt. 19 pts who completed at least 2 cycles were evaluable for response; 15 were treated in 2nd line and 4 in 3rd line. Five pts (21%) had a partial response, including 1 with CPS=0 and 1 with CPS=1. Median PFS and OS was 12.9 and 21.4 weeks for the entire cohort. The combination was generally tolerable without new safety signals. Dose reductions were required in 3 (13%) pts, overall compliance with len was 79% of planned doses across the study. Eleven (46%) pts experienced at least one G3 toxicity and one (4%) pt experienced G4 toxicity. Most common G3 toxicities included fatigue (27%), anorexia (18%), lymphopenia (18%), and hyperbilirubinemia (18%). Conclusions: Lenvatinib combined with pembrolizumab was well tolerated, responses were seen, but the study did not meet the primary endpoint in ICI naïve AGC. Given the changing landscape of care, ICI is now more broadly used in first line therapy, additional studies are warranted to determine the role of this combination in ICI exposed pts. Clinical trial information: NCT03321630 .

The Impact Associated with Changing Practice Patterns for the Treatment of Abdominal Aortic Aneurysms in the United States

We have witnessed an evolution in the treatment of abdominal aortic aneurysm (AAA) from open to endovascular repair. The implications that these changes have had on outcomes, have not been thoroughly studied. We evaluated the trends in volume of open and endovascular AAA repairs done nationwide in a recent 20-year period, and the outcomes associated with each type of repair, to assess how outcomes may have changed over this period. Patients with AAA undergoing elective open and endovascular repair between 2000 and 2020 were identified using the TriNetX Analytics Network, a federated network of nationwide healthcare organizations that provides deidentified patient data. Patients undergoing first-time elective endovascular or open AAA repair (infrarenal and visceral) from 2001 to 2020 were separated, plotted over time, and propensity score matched. Primary outcome was mortality; secondary outcomes included myocardial infarction (MI), pneumonia and acute kidney injury (AKI). Over the 20-year period we identified 21,368 endovascular patients and 6473 open patients. The endovascular volume surpassed open volume between 2004 and 2005 and we saw a steady increase in endovascular repairs (Fig 1). From 2001 to 2010, mortality was 2.35% for open and 0.98% for endovascular (P < .001); MI was 1.40% for open and 0.90% for endovascular (P = .0004); pneumonia was 2.77% for open and 1.03% for endovascular (P < .001); and AKI was 1.85% for open and 0.91% for endovascular (P = .0014). From 2011 to 2020 mortality was 5.07% for open and 3.89% for endovascular (P = .09); MI was 2.48% for open and 2.39% for endovascular (P = .375); pneumonia was 4.21% for open and 3.10% for endovascular (P = .02); and AKI was 6.53% for open and 4.65% for endovascular (P = .07). When mortality was plotted over time for endovascular and open repairs they both increased (Fig 2). With respect to open repairs the mortality for infrarenal AAA increased from 2001 to 2010 by 2.07% and from 2011 to 2020 by 16.20% (P = .004); visceral AAA increased from 2001 to 2010 by 5.45% and from 2010 to 2020 by 15.73% (P = .016). Endovascular AAA repair has steadily increased over time, while open repair decreased and subsequently increased to a steady state over the recent 20-year period. It appears our mortality has increased for both endovascular and open repair types despite our increased exposure to endovascular cases in practice. Mortality for endovascular repair was significantly higher from 2000 to 2009, but not for 2010 to 2020. Mortality increased significantly from the first decade for both infrarenal and visceral aneurysms.

Voiding Trial Outcomes After Prolapse Surgery: Before Versus During the COVID-19 Pandemic.

Coronavirus disease 2019 (COVID-19) has changed practice patterns resulting in same-day discharge after most urogynecologic surgical procedures. We aimed to determine if COVID-19 practice patterns changed patients' voiding trial (VT) results after surgery. This is a retrospective cohort study of women undergoing urogynecologic surgery at an academic tertiary care center. We compared patients who had surgery between January 1, 2019, and February 28, 2020, (pre-COVID, discharged on postoperative day [POD] 1) with those who underwent surgery between January 1, 2021, and February 28, 2022, (during COVID, discharged on POD 0 or POD 1). Demographics, surgical characteristics, and VT results were compared using nonparametric tests. A logistic regression was performed to adjust for confounders. P value <0.05 was considered statistically significant. A total of 237 patients were included. Patients were mostly White, older than 65 years (interquartile range, 56-73 years), and had a median parity of 2 (interquartile range, 2-3). Approximately 31% of patients in the pre-COVID group failed their VT, whereas 38% in the during-COVID group failed ( P = 0.275). Moreover, 40.5% of women discharged the day of surgery failed their VT ( P = 0.172). Compared with the pre-COVID group, more patients in the during-COVID group and those discharged on POD 0 contacted their surgeons with questions postoperatively (20.5% vs 35.0% and 35.4%, P = 0.014 and 0.022, respectively). Rates of urinary tract infection were similar by period and discharge day ( P > 0.05). There was no statistical association between day of discharge or the COVID-19 pandemic and VT results. Neither day of discharge nor the presence of the COVID-19 pandemic had a significant effect on postoperative outcomes, including urinary retention, after urogynecologic surgery. Same-day discharge is appropriate for most patients.

Intraoperative Antibiotic Use in Patients With Early-onset Scoliosis: Current Practices and Trends.

Best Practice Guidelines (BPGs) regarding antibiotic prophylaxis in early-onset scoliosis (EOS) patients were published in September 2019. Recommendations included using intravenous cefazolin and topical vancomycin for all index procedures, plus gram-negative coverage for neuromuscular patients. Guideline adherence is unknown. This study aimed to characterize antibiotic prophylaxis at the time of index growth-friendly procedures and assess changes in practice patterns over time. This retrospective review of data collected through a multicenter study group included EOS patients undergoing index growth-friendly procedures between January 2018 and March 2021, excluding revisions, lengthenings, and tetherings. Demographics, clinical measurements, intraoperative antibiotics, and 90-day complications were recorded. Descriptive and univariate statistics were utilized. Antibiotic prophylaxis from April 2018 through September 2019 and October 2019 through March 2021 were compared with evaluate change after BPG publication. A total of 562 patients undergoing growth-friendly procedures were included. The most common scoliosis types included neuromuscular (167, 29.7%), syndromic (134, 23.8%), and congenital (97, 17.3%). Most index procedures involved magnetically controlled growing rods (417, 74%) followed by vertical expandable prosthetic titanium rib or traditional growing rods (105, 19%). Most patients received cefazolin alone at index procedure (310, 55.2%) or cefazolin with an aminoglycoside (113, 20.1%). Topical antibiotics were used in 327 patients (58.2%), with most receiving vancomycin powder. There was increased use of cefazolin with an aminoglycoside after BPG publication (16% vs. 25%) (P=0.01). Surgical site infections occurred in 12 patients (2.1%) within 90 days of index procedure, 10 pre-BPGs (3%), and 2 post-BPGs (0.9%), with no significant difference in surgical site infection rate by type of antibiotic administered (P>0.05). Historical variability exists regarding antibiotic prophylaxis during index growth-friendly procedures for EOS. There continues to be variability following BPG publication; however, this study found a significant increase in antibiotic prophylaxis against gram-negative bacteria after BPG publication. Overall, greater emphasis is needed to decrease variability in practice, improve compliance with consensus guidelines, and evaluate BPG efficacy. Level III-retrospective.