Community Hospital-based Practice Research Articles

BI-RADS 3 (short-interval follow-up) assessment rate at diagnostic mammography: Correlation with recall rates and utilization as a performance benchmark.

The purpose of this study was to identify a correlation between the screening BI-RADS 0 (recall) rates and diagnostic BI-RADS 3 (short-interval follow-up) rates of individual interpreting radiologists, with the goal of utilizing the BI-RADS 3 rate as an acceptable performance metric in the diagnostic population. A multicenter retrospective analysis of medical audit statistics was conducted on annual radiologist performance data collected over a 14-year period in a community hospital-based practice. Mixed regression models were used to estimate the association between screening BI-RADS 0 and diagnostic BI-RADS 3 examinations while adjusting for calendar year, annual radiologist screening volume, annual radiologist diagnostic volume, and diagnostic examination indication. A moderate statistically significant positive correlation was established between the screening BI-RADS 0 rates and Diagnostic BI-RADS 3 rates (Pearson correlation coefficient+0.349, P≤.001). Furthermore, when utilizing a national benchmark range of 8%-12% as an acceptable BI-RADS 0 rate within a screening population, the correlative BI-RADS 3 assessment rate was demonstrated to be approximately 16%. We propose that this BI-RADS category 3 rate may represent an additional acceptable performance metric in the diagnostic population. Routine inclusion of an interpreting mammographer's diagnostic BI-RADS 3 rate in the annual medical audit may help reduce inappropriate and/or excess use of the BI-RADS 3 category, which may lead to significant potential reductions in follow-up examinations with their associated healthcare-related costs, resource expenditure, and induced patient anxiety.

Patterns of chemotherapy (CT) use in a population-based US-wide cohort of patients (pts) with metastatic pancreatic cancer (MPC).

4131 Background: Few population studies have examined the frequencies and durations of specific CT treatment regimens in MPC. Methods: We assessed 3,796 consecutive MPC pts who received CT between Jan 2005 and Aug 2013 at academic, private and community hospital-based practices participating in a US-wide CT order entry system that captures pt, provider and treatment data. Multivariate analyses of prospectively recorded pt and provider characteristics identified predictors of specific therapeutic approaches. Results: Among all pts, median age was 70; 55% male. In 1st-line CT, 48% of pts received gemcitabine (GEM) monotherapy, 16% received a GEM-based doublet (incl. GEM + nab-paclitaxel [NAB-P]), 9% received fluoropyrimidine (FU) + oxaliplatin (OX) + irinotecan (FOLFIRINOX), 9% received FU monotherapy, and 5% received FU + OX (FOLFOX). The remaining 13% received other regimens. GEM monotherapy use peaked at 58% in 2009 but declined to 28% in 2013. FOLFIRINOX use emerged in 2010 with 4% usage and peaked at 2...

Patterns of chemotherapy (CT) use in a U.S.-wide population-based cohort of patients (pts) with metastatic colorectal cancer (mCRC).

3537 Background: Few population studies have examined treatment regimens and duration in mCRC since the introduction of biologic therapies in 2004. Methods: We assessed 4,877 consecutive mCRC pts who received CT between Jan 2004 and Mar 2011 at academic, private, and community hospital-based practices participating in a US-wide CT order entry (COE) system that captures patient demographics, stage and treatment data. Multivariate analyses of prospectively recorded patient and provider characteristics identified significant predictors of specific therapeutic approaches. Results: Among all pts, median age was 64; 55% male; (ECOG PS 0/1/2+) (56%/33%/11%). In first-line CT, 17% of pts received fluoropyrimidine (FU) only, while 16% received FU and irinotecan and 65% received FU and oxaliplatin. Older pts, those with poorer ECOG PS, and those treated in private practices were significantly more likely to receive FU only (all p ≤0.05). 53% of all pts received treatment in line 2, 28% in line 3, and 13% in line 4. Mean duration of treatment was 170 days (line 1), 139 (line 2), 135 (line 3) and 126 (line 4). Bevacizumab (bev) was administered to 65% of pts at some point in their treatment. Among the 51% who received bev in line 1, 33% continued bev beyond progression (BBP) in line 2. Pts treated at academic centers, pts who received longer duration of line 1 therapy, and pts whose providers had greater CRC pt volume were significantly more likely to continue BBP. Overall, 23% of pts received cetuximab (cet) (4% of all line 1 pts, 17% of line 2, 31% of line 3, and 29% of line 4). Mean duration of cet use was 168 days (line 1), 125 (line 2), 133 (line 3) and 129 (line 4). Pts treated at academic centers, pts who received longer duration of line 1 therapy, and pts treated in the West US were significantly more likely to ever receive cet. Cet use decreased by 18% following FDA label change restricting use to KRAS wt pts in Jun 2009 (p <0.001). Of all pts, 6% received panitumumab at some point. Of those, 39% had previously received cet. Conclusions: This population-based study provides insight into treatment patterns of mCRC in the US. Usage of biologic agents varies significantly according to patient, practice, and provider characteristics.

Outcomes of a hybrid technique for video-assisted thoracoscopic surgery (VATS) pulmonary resection in a community setting.

Video-assisted thoracoscopic surgery (VATS) for pulmonary resection was first described 18 years ago; however, it has yet to gain widespread acceptance in community hospitals in the United States. The majority of surgeons who routinely perform VATS resections work in academic or government institutions. There is little data reporting outcomes of VATS pulmonary resections by community-based surgeons. This article reports the outcomes of a hybrid technique for VATS pulmonary resection in a single-surgeon, community-based practice. A retrospective study was performed on all VATS pulmonary resections performed from January 2000 to March 2008 by a community-based, solo-practice surgeon using a hybrid VATS technique, which utilizes dual access through a thoracoscopy port and a utility incision. A total of 1170 VATS pulmonary resections were performed over the study period, which is the largest single-surgeon series on VATS pulmonary resection to our knowledge. Among them, 746 cases were for malignant disease. Mean operative time was 52 minutes (median 48 minutes). Mean length of stay was 7 days (median 4 days). Mean length of ICU stay was 1.4 days, with 83% of patients having no days spent in the ICU. Mean length of chest tube duration was 4.5 days. The morbidity rate was 21.1 %, with neuropraxia as the most frequent complication. Perioperative mortality was 4.3% and overall mortality was 16.4%, with a mean follow-up of 425 days. This series shows that our hybrid VATS approach to pulmonary resection is safe and feasible at community hospital-based practices.

A hybrid technique: video-assisted thoracoscopic surgery (VATS) pulmonary resections for community-based surgeons

Although video-assisted thoracoscopic surgery (VATS) for pulmonary resection was first described more than 15 years ago, it has yet to gain grass-roots acceptance. The majority of surgeons who routinely perform VATS resections work in academic or government institutions. The perceived complexity of the technique, inadequate instrumentation and resources, and concern regarding the potential compromise of surgical and oncologic principles may present a greater barrier to adoption by community-based surgeons. This article illustrates some of the technical aspects of a hybrid technique that enables a single surgeon to perform VATS pulmonary resection on a routine basis in a community-based practice. From January 2005 to March 2008, 492 VATS pulmonary resections were performed by a community-based, solo-practice surgeon using a hybrid VATS technique. The highlight of this technique is utilization of a thoracoscopy port and a utility incision. The advantages of this dual access are ease in instrumentation, visualization, lighting, and retraction. In addition, this technique allows immediate access under direct vision for urgent control of bleeding, which can be difficult using a conventional thoracoscopic approach. Mean operative time was 52 (median, 48) minutes. Mean length of stay was 7 (median, 4) days. Mean length of ICU stay was 1.7 days, with 85% of patients having no days spent in the ICU. Mean length of chest tube duration was 4 days. Perioperative mortality was 3.5% and overall mortality was 9.8%, with a mean follow-up of 239 days. These results compare favorably with the conventional VATS approach. This series shows that our hybrid VATS approach to pulmonary resection is safe and feasible at community hospital-based practices.

Performance Parameters for Screening and Diagnostic Mammography in a Community Practice: Are There Differences Between Specialists and General Radiologists?

The purpose of this study was to compare the performance of general radiologists in interpretation of mammograms with that of breast imaging specialists in a high-volume community hospital-based private practice. A retrospective observational study was conducted with data prospectively collected over a 5-year period in a community hospital-based practice in which 106,405 screening and 52,149 diagnostic mammograms were performed. The performance of three radiologists specializing in breast imaging was compared with that of six general radiologists. The following data were extracted and analyzed: recall rate, biopsy recommendation rate, and cancer detection rate. Statistical analysis was performed with a chi-square test and two-tailed calculation of p values. The recall rates of the specialists and generalists were nearly the same at 6.5% and 6.7%, respectively. The biopsy recommendation rate at recall from screening examinations was nearly the same for generalists and specialists (1.2% and 1.1%, respectively; p = 0.4504). This rate also was similar for diagnostic examinations (8.5% for generalists; 8.4% for specialists; p = 0.4086). The cancer detection rate in the screening setting was slightly higher for specialists than for generalists: 2.5 and 2.0 cancers per 1,000 cases, respectively (p = 0.0614). The cancer detection rate in the diagnostic setting was 24.2% higher among specialists (20.0 cancers per 1,000 cases) compared with generalists (16.1 cancers per 1,000 cases) (p = 0.0177). The only statistically significant difference between generalists and specialists was in cancer detection rate among patients undergoing diagnostic mammography. No statistically significant difference was identified between the two groups in terms of recall rate, biopsy recommendation rate, or percentage of favorable-prognosis cases of cancer detected. There was a trend toward greater cancer detection by specialists in the screening setting.

Results of 101 ruptured abdominal aortic aneurysm repairs from a single surgical practice.

Hypotheses The results of ruptured abdominal aortic aneurysm repairs from a solo community hospital-based practice are comparable to those reported from large university referral medical centers. Patients younger than 70 years, arriving in the emergency department with stable hemodynamics, and undergoing prompt operation have better outcome. A retrospective review from an ongoing vascular surgery registry. Two midsized (300-bed) community hospitals. One hundred one consecutive patients with ruptured abdominal aortic aneurysms who were undergoing open surgical repair by a single surgeon (S.S.H.) during a 21-year period were reviewed. Operative mortality; cardiac, pulmonary, renal, and gastrointestinal complications; and coagulation abnormalities were recorded. Iatrogenic complications and length of hospital stay were noted. Preoperative and intraoperative factors affecting mortality were studied. Fifty-three patients survived ruptured abdominal aortic aneurysm repair (operative mortality, 47.5%). A favorable outcome was observed in patients (1). younger than 70 years, (2). with a hematocrit of more than 35% at presentation, and (3). with emergency department to operating room times of less than 120 minutes. Increasing experience of the surgeon did not result in improved survival. The results of ruptured abdominal aortic aneurysm repairs from community-based practice are comparable to those reported from university referral medical centers.