Community-based Group Practice Research Articles

Thermal Balloon Endometrial Ablation in Patients with Prior Low Transverse Cesarean Section: Safety Analysis and Protocol Description

Objective: The purpose of this study was to evaluate the safety of thermal balloon endometrial ablation in patients who had had prior low transverse cesarean section(s) (CS). Design: This is a subanalysis of our previously published prospective, single-arm cohort study on treatment outcomes following Thermachoice III ablations. Time endpoints were 2 weeks, and 3 and 6 months post-ablation. Setting: The study took place in an inner-city community-based group practice. Outcome measures: Outcome measures included incidence of uterine perforation, vesicouterine fistula, or other transmural thermal injury possibly related to defective lower uterine structure. Vesicouterine fistulas were screened for by patient questionnaire. Positive screens were to be confirmed by in-office cystoscopy. Methods: Patients were recruited between November 2006 and November 2007. Prior inclusion/exclusion criteria have been described previously in the literature. The entire cohort was 148 patients. All underwent concurrent office hysteroscopy, dilation and curettage, and Thermachoice III ablation under local paracervical block of dilute mepivacaine. Patients with low transverse CS histories all underwent CS scar measurements pre-ablation. Those with measurements under 10 mm underwent thermal balloon catheter placement and insufflations under transabdominal sonographic guidance. The ablation cycle was performed without ultrasound guidance. Results: Forty-one patients had had a history of prior low transverse CS. Mean uterine scar thickness was 12.3 mm for the entire CS cohort. Mean thickness decreased as the number of CS increased. No patient had had more than three CS. Three patients had a uterine scar thickness of less than10 mm (2 had thickness of 8 mm and 1 had thickness of 9 mm, in the third CS cohort). No vesicouterine fistulas or uterine perforations were noted in the CS cohort, up to 6 months after the performance of the uterine ablation procedure. Serious adverse events did not differ between the CS cohort and the remainder. Conclusions: Thermal balloon ablation can be accomplished safely in patients with prior CS. No conclusion can be drawn in those with more than three prior CS. Measurement of the CS scar and balloon catheter placement under sonogram guidance may be considered in these patients as a conservative measure to aid in perforation or visceral injury prevention. (J GYNECOL SURG 27:63)

Correlates of Alcohol‐Related Discussions Between Older Adults and Their Physicians

To identify predictors of alcohol-related patient-physician discussions. Cross-sectional study using baseline data from a randomized controlled trial. Community-based group practice. Thirty-one physicians in Project Senior Health and Alcohol Risk Education and 3,305 of their patients aged 60 and older who use alcohol and completed a survey that included the Comorbidity Alcohol Risk Evaluation Tool (CARET). At study baseline, older adults were asked whether alcohol-related discussions with a physician had occurred in the prior year. This outcome was modeled using logistic regression models with physician random effects. Predictor variables included patient-level variables such as demographics and seven CARET-defined risk factors, specifically a medical or psychiatric comorbidity that alcohol might worsen, a potentially alcohol-related symptom, use of a medication that may interact negatively with alcohol, excessive quantity or frequency of alcohol use, binge drinking, concern from others about drinking, and drinking and driving. Physician-level predictors (age, sex, years since graduation, specialty) were also included. The probability of reporting alcohol-related discussions declined with patient age (e.g., odds ratio (OR)=0.40 for patients aged ≥80) and was significantly lower for Latinos (OR=0.38). Drinking and driving (OR=1.69) or concern from others (OR=6.04) were significantly associated with alcohol-related discussions; having comorbidities or using medications that may interact with alcohol were not. Although patient demographics, including age and ethnicity, are associated with the occurrence of alcohol-related discussions, clinical factors that may negatively interact with alcohol to increase risk are not. This suggests that physicians may not be attuned to the entire spectrum of alcohol-related risks for older adults.

Improved Survival of Patients with Metastatic Breast Cancer in Routine Care: Results of a Retrospective Study in a Community-Based Oncology Group Practice 1995–2005

Background: Little is known about the treatment reality in metastatic breast cancer (MBC) outside clinical trials. We undertook this analysis to evaluate the actual treatment reality for unselected patients with MBC in routine care. Patients and Methods: All patients with MBC, who were treated in our community-based group practice between 1995 and 2005, were analyzed retrospectively concerning prognostic factors, treatment, and survival. Results: 403 consecutive patients were evaluated with a median age of 60 years (range 32–93). Aromatase inhibitor therapy was used in 87% of all patients. 83% received chemotherapy with the median number of lines being 3 (1–15). An anthracycline was given to 49%, a taxane was used in 55%, vinorelbine in 42%, capecitabine in 36%, gemcitabine in 28%, and a platinum compound in 9%. 94% of patients with bone metastasis received a bisphosphonate, and 63% of HER-2/neu-positive patients were treated with trastuzumab. Median survival since the start of palliative therapy was 30 months. Statistical analysis revealed as major prognostic factors hormone receptor status and prevalence of only bone metastasis. Conclusions: Treatment reality of MBC in routine care reveals a prolonged median survival of 30 months which is probably due to the sequential use of the most effective treatment modalities.

Changing Treatment Paradigms for Myelodysplastic Syndromes in a Community Oncology Practice: Georgia Cancer Specialists' Experience

BackgroundCriteria for adoption of new therapies and treatment paradigms in community oncology practices can differ substantively from that of academic medical centers. Differences arise, in part, from the influence of patient mix, available resources and services offered, physician/staff experiences, and the adherence to uniform treatment guidelines. Georgia Cancer Specialists (GCS) is a 31-site community-based group practice with 41 hematologists/oncologists motivated to standardize medical decision-making and optimize patient outcomes and health-care resource utilization. Patients and MethodsUsing our integrated electronic medical records and billing database (OASIS), we conducted a retrospective evaluation to assess the impact of 3 new agents (decitabine, 5-azacitidine, and lenalidomide) on practice patterns and outcomes in an elderly population with myelodysplastic syndrome (MDS) in the community setting. From January 2006 to June 2007, data from 1161 patients with MDS (mean age, 71 years; 63% women; 60% Medicare/Medicaid recipients) were collected. Of these, 76 patients (6.5%) received ≥ 1 MDS-indicated therapeutic agent (47% decitabine, 32% 5-azacitidine, 46% lenalidomide; 25% received ≥ 2 agents) for a median of 3, 2, and 3 cycles, respectively. ResultsIn general, the data suggest that patients receiving MDS-therapeutic agents had hematologic improvement and experienced reductions in transfusion requirements. The GCS population and treatment-related data reflect the uptake of new MDS therapeutic agents introduced proactively into a real-world community oncology practice and supplements information from randomized clinical trials. ConclusionData derived from the community setting have the potential to provide important insights about actual disease prevalence, patient demographics, factors that influence medical careseeking, clinical management, and outcomes outside of academic institutions.

Significant postoperative refractive errors in vivo with the Mentor Memorylens intraocular lens

Purpose: To determine the difference between the predicted and postoperative refraction in eyes after implantation of the Mentor MemoryLens® intraocular lens (IOL) and compare these results with those of 2 other types of foldable IOLs implanted by the same surgeons. Setting: Community-based group practice ophthalmology clinic. Methods: All operated eyes (341) of all patients who had routine phacoemulsification with implantation of a MemoryLens IOL performed by 1 of 2 surgeons were evaluated retrospectively. The predicted refractive error and actual postoperative refractive error were compared in each eye in the MemoryLens group and in 2 smaller control groups with an AcrySof® acrylic (Alcon) or SI-40 silicone (Allergan Medical Optics) IOL implanted by the same surgeons using identical technique and IOL calculation parameters. Patients in whom the difference between the predicted and actual postoperative refraction fell significantly outside expected parameters were rechecked with repeat axial length and keratometric readings, and these measurements were used to back-calculate the effective in vivo IOL power. Results: The MemoryLens group had significantly greater variability in postoperative refractive results from those predicted by the Hoffer program than the 2 control groups. The postoperative refractive error in the MemoryLens group differed from +1.50 to –5.50 diopters (D) from that predicted by the IOL calculation formulas. When the outlier groups (ie, greater than +0.50 D or less than −1.00 D from predicted refractive error) were evaluated and compared to the rest of the MemoryLens group and the 2 control groups, no significant difference in axial length, keratometric measurements, operative surgeon, surgical technique, or patient age was found. Repeat axial length and keratometric measurements in the outlier group were not significantly different from those in the same eyes preoperatively. Back-calculation using postoperative axial length and keratometric measurements in the highly myopic outlier group showed that the mean difference between the labeled IOL power and actual in vivo IOL power in the outlier group was –3.08 D (range –1.98 to –7.54 D). The best corrected visual acuity was not affected in patients in the outlier groups despite the refractive variability. Conclusion: The variation in postoperative refractive results in the MemoryLens group was significantly greater than in the 2 other foldable IOL groups.

Midwives' burnout and continuity of care

This study aimed to examine the impact of Changing Childbirth (Department of Health, 1993) on midwives' work and personal lives. It reports findings from a multiple site case study of community-based maternity care. Each site represented a model of continuity of carer along a continuum from complete one-to-one continuity to continuity within a team. The three sites represented the traditional model of GP-attached community midwives, a community team and a community-based group practice. Three key themes emerged from the data relating to sustainable practice, the avoidance of burnout and the provision of flexible woman-centred care. These were occupational autonomy, social support and developing meaningful relationships with women. Control over work and continuity of care are as important to midwives in how well they balance their work and home life as they are to women experiencing childbirth. Models of care such as personal caseloads that incorporate these factors may be more sustainable in terms of less burnout and greater personal accomplishment than team caseloads.

Cohort, gender and practice organization: examining the bounds of collaborative medicine among newly established female and male family physicians in Ontario.

This paper analyzes data from a 1993 survey of 395 newly established female and male family physicians in Ontario, Canada, to examine the relationship between practice organization and gender. Previous research suggests that younger physicians, particularly women, tend to enter group practice. Compared to solo practice, groups may offer more predictable incomes, more manageable workloads, peer collaboration and review, and economies of scale. Further, female physicians in groups may develop distinctive styles of collaborative medicine. The results show that a majority of physicians in our cohort are in private community-based group practice. However, while many groups share premises, staff and expenses, and many have common charts and practice guidelines, only a minority incorporate regular meetings to discuss business or patient care, have shared care of hospitalized patients, or audits of physicians' practices. Few gender differences are observed in private group practice: although women physicians attract larger proportions of female patients than do their male colleagues, women and men organize their groups in similar ways and have similarity strong patient-centered attitudes.