Factors Influencing Treatment Selection Research Articles

Efficacy of Microneedling and CO2 Laser for Acne Scar Remodelling: A Comprehensive Review.

Acne scarring is a prevalent issue affecting millions worldwide, with significant psychological and social implications. Microneedling and CO2 laser therapy have emerged as promising modalities for acne scar remodelling. Microneedling induces controlled micro-injuries to stimulate collagen production, while CO2 laser therapy precisely ablates scar tissue. This comprehensive review evaluates the efficacy, safety, and comparative benefits of microneedling and CO2 laser therapy. Literature synthesis reveals both modalities to improve acne scars, albeit with different mechanisms and risks. Factors influencing treatment selection and the role of combination therapy are discussed. Future directions include optimising protocols and exploring novel techniques. Overall, microneedling and CO2 laser therapy offer valuable options for acne scar management, empowering individuals to address the physical and emotional burden of scarring.

Research priorities regarding the use of bisphosphonates for osteoporosis: a UK priority setting exercise.

Worldwide, many people who would benefit from osteoporosis drugs are not offered or receiving them, resulting in an osteoporosis care gap. Adherence with bisphosphonates is particularly low. This study aimed to identify stakeholder research priorities relating to bisphosphonate treatment regimens for prevention of osteoporotic fractures. A three-step approach based on the James Lind Alliance methodology for identification and prioritisation of research questions was used. Research uncertainties were gathered from a large programme of related research studies about bisphosphonate regimens and from recent published international clinical guidelines. Clinical and public stakeholders refined the list of uncertainties into research questions. The third step prioritised the questions using a modified nominal group technique. In total, 34 draft uncertainties were finalised into 33 research questions by stakeholders. The top 10 includes questions relating to which people should be offered intravenous bisphosphonates first line (1); optimal duration of treatment (2); the role of bone turnover markers in treatment breaks (3); support patient need for medicine optimisation (4); support primary care practitioner need regarding bisphosphonates (5); comparing zoledronate given in community vs hospital settings (6); ensuring quality standards are met (7); the long-term model of care (8); best bisphosphonate for people aged under 50 (9); and supporting patient decision-making about bisphosphonates (10). This study reports, for the first time, topics of importance to stakeholders in the research of bisphosphonate osteoporosis treatment regimens. These findings have implications for research into implementation to address the care gap and education of healthcare professionals. Using James Lind Alliance methodology, this study reports prioritised topics of importance to stakeholders in the research of bisphosphonate treatment in osteoporosis. The priorities address how to better implement guidelines to address the care gap, understanding patient factors influencing treatment selection and effectiveness, and how to optimise long-term care.

P082 Research priorities regarding the use of bisphosphonates for osteoporosis: a UK priority setting exercise

Abstract Background/Aims Worldwide, many people who would benefit from osteoporosis treatment are not offered or receiving them, resulting in an osteoporosis care gap. Adherence with bisphosphonates is particularly low. This study aimed to identify stakeholder research priorities relating to bisphosphonate regimens for the treatment of osteoporosis. Methods A three-step approach based on the James Lind Alliance methodology for identification and prioritisation of research questions was used. Research uncertainties were gathered (Step 1) from recent published international clinical guidelines and a large programme of related research studies about bisphosphonate regimens: the ‘Bisphosphonate aLternAtive regimenS for the prevenTion of Osteoporotic Fragility Fractures’ (Blast Off) study, which consisted of six discrete individual research studies conducted between May 2019 and February 2022, relating to the experience, effectiveness and cost-effectiveness of different bisphosphonate regimens. Clinical and public stakeholders refined the list of uncertainties into research questions (step 2) and then prioritised the questions using a modified nominal group technique (step 3) in two, day-long online workshops. Results In total, 34 draft uncertainties were finalised into 33 research questions by stakeholders. Twenty nine stakeholders were involved in refining uncertainties and prioritisation, including 16 public contributors, 2 Allied Health Professionals, 3 GPs and 8 Consultants. The top 10 questions are shown in Table 1. Conclusion This study reports, for the first time, topics of importance to stakeholders in the research of bisphosphonate osteoporosis treatment regimens. The priorities address how to better implement guidelines to address the care gap, understanding patient factors influencing treatment selection and effectiveness, and how to optimise long-term care. These findings have implications for research into implementation to address the care gap and education of healthcare professionals in the treatment of osteoporosis. Disclosure Z. Paskins: None. A. Moult: None. N. Corp: None. A. Bastounis: None. S. Davis: Grants/research support; Grant from Roche Diagnostics to her employing insitution to fund research into the cost-effectiveness of using a biomarker to monitor response to treatment with antifracture medication. M. Narayanasamy: None. J. Griffin: None. N. Gittoes: None. J. Leonardi-Bee: None. T. Langley: None. S. Bishop: None. O. Sahota: None.

PCR124 First-Line Treatment Patterns Among Patients With Locally Advanced or Metastatic Urothelial Cancer (la/mUC): A Systematic Literature Review

The outcomes of patients with la/mUC are poor; however, systemic treatments (STs) including chemotherapy sequenced by maintenance immunotherapy (IO) are available to extend survival. First-line (1L) treatment patterns and reasons for no receipt of ST (NST) are not well known. We aimed to characterize 1L treatment patterns, NST, attrition rates across line of therapy, and factors influencing treatment selection for patients with la/mUC.

Esthetic Rehabilitation of Anterior Dentition with Different Types of Ceramic Restorations: Two Case Reports.

All-ceramic systems represent an excellent restorative alternative for fixed dental prostheses, single crowns, and veneers in the anterior dentition. With respect to improved mechanical properties, lithium disilicate ceramic material provide a broad range of indications, and extended veneers can serve as an alternative to full crowns. Although ceramic veneers represent a more conservative approach compared to crowns, the correct indication is essential to achieving the ideal outcome. The following case reports describe two types of fixed restorations of the anterior dentition: extended lithium disilicate ceramic veneers and lithium disilicate full crowns. Factors influencing treatment selection for each type of restorations are presented.

Real-world practice patterns in treatment of metastatic breast cancer in Washington State.

e13038 Background: Evidence-based, national guidelines for the management of metastatic breast cancer (MBC) recommend numerous treatment options that do not capture the nuances of real-world practice. Disparities may exist across Washington State with financial implications for patients and health systems. The objective of this study was to assess practice patterns around treatment of ER+/HER2- MBC in actual clinical practice. Methods: We collaborated with Hutchinson Institute for Cancer Outcomes Research (HICOR) to link enrollment and insurance claims records with Washington State cancer registries from 2008-2017. Our cohort comprised of women >18 years old with de novo ER+/HER2- MBC who met enrollment criteria in one of four payors (Premera, Regence, Medicare, or Medicaid). We identified receipt of first line treatment, categorized as CDK4/6 inhibitors plus endocrine therapy (CDKi+ET), chemotherapy (CT), or endocrine therapy alone (ET). We examined factors influencing treatment selection using Fisher's and Kruskal-Wallis tests. Total costs (defined as costs from inpatient and outpatient claims one year after diagnosis) was estimated for patients and payors. Results: We identified 140 patients with de novo ER+/HER2- MBC with median age of 64 (range 28-95). The majority of the cohort were Caucasian (90%) with the rest comprising of Asian, Black, American Indian, and Hispanic patients. Based on the Rural Urban Commuting Area (RUCA) classification, patients predominantly lived in metropolitan neighborhoods (96%). Over 20% of patients lived in areas of high deprivation (area of deprivation index, ADI, 8-10). Patients had either Commercial (40.7%), Medicaid/Medicare (43.6%) or multiple (15.7%) insurance. Our data show that 17 patients (12%) received first line therapy with CDKi + ET, 64 patients (46%) with CT, and 59 patients (42%) with ET alone. Factors influencing treatment selection include age, co-morbidity score, and payor type. Older patients (>65 years old) were more likely to receive ET alone compared to younger patients (56% vs 44%, p value <0.001). Patients with high co-morbidity score were more likely to receive ET (30%) compared to CT (5%) or CDKi + ET (23%), p value <0.001. Patients with commercial insurance made up over 50% of patients in our cohort who received CDKi +ET, while Medicare-insured patients were most likely to receive ET alone (p value <0.001). We estimated the mean cost of receiving first line therapy with CDKi +ET ($20,368 and $175,932), CT ($10,624 and $117,847) and ET alone ($13,292 and $60,338) for patients and payors, respectively (costs inflated to December 2019). Conclusions: Our study shows substantial variation across Washington state in treatment selection and costs for patients with metastatic breast cancer in the first-line setting. Our findings demonstrate the need for initiatives to standardize quality of care relative to clinical guidelines in metastatic breast cancer care.

Socioeconomic and clinical factors influencing treatment selection in microtia and aural atresia

ObjectivesPatients with microtia and aural atresia have multiple options for treatment of conductive hearing loss (CHL) and auricle reconstruction; however, little is known about the factors influencing treatment selection. This study aims to review the socioeconomic and clinical data of microtia/atresia patients to evaluate congruency with national data and whether these factors affect treatment decisions. MethodsRetrospective review of patients evaluated in the microtia and atresia multidisciplinary clinic (MDC) at a tertiary academic children's hospital between 2008 and 2018. Outcomes included demographic, socioeconomic and clinical factors associated with hearing surgery and framework surgery. Results373 patients were seen in the Microtia MDC: 193 (51.7%) were male, 187 (50.1%) identified as Hispanic and 23 (6.2%) identified as Asian. 267 (75.6%) patients received a nonsurgical bone conduction hearing device (BCHD); fitting at a younger age was associated with better nonsurgical BCHD compliance. Multivariate analysis was performed on the patients that were eligible for surgery based on age and appropriate follow-up. 70 (18.8%) patients had placement of an osseointegrated BCHD; inconsistent compliance with nonsurgical BCHD decreased the odds of proceeding with osseointegrated BCHD placement. 60 (16.1%) patients underwent framework surgery for external reconstruction. Placement of osseointegrated BCHD was the only factor that was associated with proceeding with framework surgery. Other assessed demographic and socioeconomic factors were statistically not associated with selection of surgical intervention. ConclusionFitting a nonsurgical BCHD at a younger age is associated with higher likelihood of nonsurgical BCHD compliance, that is in turn associated with patients and families proceeding with osseointegrated BCHD and framework surgery.

"It's important to me": A qualitative analysis on shared decision-making and patient preferences in older adults with early-stage breast cancer.

Shared decision-making (SDM) occurs when physicians and patients jointly select treatment that aligns with patient care goals. Incorporating patient preferences into the decision-making process is integral to successful decision-making. This study explores factors influencing treatment selection in older patients with early-stage breast cancer (EBC). This qualitative study included women age ≥65 years with EBC. To understand role preferences, patients completed the Control Preferences Scale. Semi-structured interviews were conducted to explore patients' treatment selection rationale. Interview transcripts were analyzed using a constant comparative method identifying major themes related to treatment selection. Of 33 patients, the majority (48%) desired shared responsibility in treatment decision-making. Interviews revealed that EBC treatment incorporated three domains: Intrinsic and extrinsic influences, clinical characteristics, and patient values. Patients considered 19 treatment selection themes, the most prioritized including physician trust and physical side effects. Because preferences and approach to treatment selection varied widely in this sample of older, EBC patients, more research is needed to determine best practices for preference incorporation to optimize SDM at the time of treatment decisions.

Breast cancer surgery in older women: outcomes of the Bridging Age Gap in Breast Cancer study.

Breast cancer surgery in older women is variable and sometimes non-standard owing to concerns about morbidity. Bridging the Age Gap in Breast Cancer is a prospective multicentre cohort study aiming to determine factors influencing treatment selection and outcomes from surgery for older patients with breast cancer. Women aged at least 70 years with operable breast cancer were recruited from 57 UK breast units between 2013 and 2018. Associations between patient and tumour characteristics and type of surgery in the breast and axilla were evaluated using univariable and multivariable analyses. Oncological outcomes, adverse events and quality-of-life (QoL) outcomes were monitored for 2 years. Among 3375 women recruited, surgery was performed in 2816 patients, of whom 24 with inadequate data were excluded. Sixty-two women had bilateral tumours, giving a total of 2854 surgical events. Median age was 76 (range 70-95) years. Breast surgery comprised mastectomy in 1138 and breast-conserving surgery in 1716 procedures. Axillary surgery comprised axillary lymph node dissection in 575 and sentinel node biopsy in 2203; 76 had no axillary surgery. Age, frailty, dementia and co-morbidities were predictors of mastectomy (multivariable odds ratio (OR) for age 1·06, 95 per cent c.i. 1·05 to 1·08). Age, frailty and co-morbidity were significant predictors of no axillary surgery (OR for age 0·91, 0·87 to 0·96). The rate of adverse events was moderate (551 of 2854, 19·3 per cent), with no 30-day mortality. Long-term QoL and functional independence were adversely affected by surgery. Breast cancer surgery is safe in women aged 70 years or more, with serious adverse events being rare and no mortality. Age, ill health and frailty all influence surgical decision-making. Surgery has a negative impact on QoL and independence, which must be considered when counselling patients about choices.

Determinants of selection into buprenorphine/naloxone among people initiating opioid agonist treatment in British Columbia

BackgroundStudies assessing the comparative effectiveness of methadone versus buprenorphine/naloxone for opioid use disorder in real-world settings are rare - challenged by structural differences in delivery across settings and factors influencing treatment selection. We identified determinants of selection into buprenorphine/naloxone and quantified contributions of individual and provider-level covariates in a setting delivering both medications within the same healthcare settings. MethodsUtilizing linked health administrative datasets, we conducted a retrospective cohort study of people with opioid use disorder (PWOUD) receiving opioid agonist treatment (OAT) in British Columbia, Canada, from 2008-2017. Determinants of buprenorphine/naloxone selection were identified using a generalized linear mixed model with random intercept terms for providers and individuals. We determined the influence of individual demographics, clinical history, measures of provider experience and preference, and dates of key policy changes. ResultsA total of 39,605 individuals experienced 178,976 OAT episodes (methadone:139,439(77.9 %);buprenorphine/naloxone:39,537(22.1 %)). Male sex, less OAT experience, younger age, mental health conditions and chronic pain were associated with higher odds of buprenorphine/naloxone prescription. For providers, higher client-attachment, more complex OAT case-mixes, and higher buprenorphine/naloxone prescribing-preference were also associated with higher odds of buprenorphine/naloxone prescription. Observed individual-level covariates explained 9.7 % of variance in odds of buprenorphine/naloxone selection, while observed provider-level covariates explained 20.0 %. Controlling for covariates, residual unmeasured between-individual variance accounted for 18.5 % of the explained variation in the odds of buprenorphine/naloxone selection, while unmeasured between-provider variance accounted for 28.4 %. ConclusionProvider characteristics were more influential in selection of buprenorphine/naloxone over methadone informing subsequent analyses of comparative effectiveness of these regimens.

Factors influencing treatment selection and prognosis in patients with small cell lung cancer

Factors influencing treatment selection and prognosis in patients with small cell lung cancer

Factors influencing treatment selection and 30-day mortality after chemotherapy for people with small-cell lung cancer: An analysis of national audit data

BackgroundThirty-day mortality after treatment for lung cancer is a measure of unsuccessful outcome and where treatment should have been avoided. Guidelines recommend offering chemotherapy to individuals with small-cell lung cancer (SCLC) who have poorer performance status (PS) because of its high initial response rate. However, this comes with an increased risk of toxicity and early death. We quantified real-world 30-day mortality in SCLC after chemotherapy, established the factors associated with this and compared these with the factors that influence receipt of chemotherapy. MethodsWe used linked national English data sets to define the factors associated with both receiving chemotherapy and 30-day mortality after chemotherapy. ResultsWe identified 3715 people diagnosed with SCLC, of which 2235 (60.2%) received chemotherapy. There were 174 (7.8%) deaths within 30 days of chemotherapy. The adjusted odds of receiving chemotherapy decreased with older age, worsening PS and increasing comorbidities. Thirty-day mortality was independently associated with poor PS [PS 2 vs PS 0, adjusted odds ratio (OR) 3.75, 95% confidence interval (CI) 1.71–8.25] and stage (extensive vs limited adjusted OR 1.68, 95% CI 1.03–2.74) but in contrast was not associated with increasing age. Both chemotherapy administration and 30-day mortality varied by hospital network. ConclusionsTo reduce variation in chemotherapy administration, predictors of 30-day mortality could be used as an adjunct to improve suboptimal patient selection. We have quantified 30-day mortality risk by the two independently associated factors, PS and stage, so that patients and clinicians can make better informed decisions about the potential risk of early death after chemotherapy.

Clinical and sociodemographic associations with treatment selection in major depression.

To investigate treatment selection in a naturalistic sample of MDD outpatients and the factors influencing treatment selection in specialized psychiatric care. Multinomial Logistic Regression analysis investigated associations between treatment selection and patients' sociodemographic and clinical characteristics, using retrospective chart review data and Routine Outcome Monitoring (ROM) data of MDD outpatients. Of the patients included for analyses (N = 263), 34% received psychotherapy, 32% received an antidepressant (AD) and 35% received a combination. Men were more likely than women to receive AD with reference to psychotherapy (ORAD = 5.57, 95% CI 2.38-13.00). Patients with severe depression and patients with AD use upon referral, prescribed by their general practitioner, were more likely to receive AD (ORsevere depression = 5.34, 95% CI 1.70-16.78/ORAD GP = 9.26, 95% CI 2.53-33.90) or combined treatment (ORsevere depression = 6.32, 95% CI 1.86-21.49/ORAD GP = 22.36, 95% CI 5.89-83.59) with respect to psychotherapy. More severe patients with AD upon referral received combined treatment less often compared to psychotherapy (OR = 0.14, 95% CI 0.03-0.68). AD prescriptions in primary care, severity and gender influenced treatment selection for depressive disorders in secondary psychiatric care. Other factors such as the accessibility of treatment and patient preferences may have played a role in treatment selection in this setting and need further investigation.

Colorectal cancer with Synchronous liver-limited Metastases: the protocol of an Inception Cohort study (CoSMIC)

IntroductionColorectal cancer is the fourth most common cancer in the UK and an important cause of cancer-related death. In 20% of patients, there is metastasis to the liver or beyond...

Factors influencing treatment selection and survival in advanced lung cancer.

Despite numerous breakthrough therapies, inoperable lung cancer still places a heavy burden on patients who might not be candidates for chemotherapy. To identify potential candidates for the newly emerging immunotherapy-based treatment paradigms, we explored the clinical and biologic factors affecting treatment decisions. We retrospectively reviewed the records of patients diagnosed at our university-affiliated cancer centre between 1 January 2011 and 31 December 2013. Patient demographics, systemic treatment, and survival were examined. During the 3-year study period, 683 patients fitting the inclusion criteria were identified. First-line therapy was administered in 49.5% of patients; only 22.4% received further lines of therapy. The main reasons for withholding therapy were poor performance status [ps (43.2%)], rapidly deteriorating ps (31.9%), patient refusal of therapy (20.9%), and associated comorbidities (4%). Older age, the presence of brain metastasis at diagnosis, and non-small-cell histology were also associated with therapeutic restraint. Oncology referrals were infrequent in patients who did not receive therapy (32.2%). Older patients and those with a poor ps experienced superior survival when treatment was administered (hazard ratio: 0.25; 95% confidence interval: 0.16 to 0.38; and hazard ratio: 0.44; 95% confidence interval: 0.23 to 0.87 respectively; p < 0.001). Advanced lung cancer still poses a therapeutic challenge, with a high proportion of patients being deemed unfit for therapy. This issue cannot be resolved until appropriate measures are taken to ensure the inclusion of older patients and those with a relatively poor ps in large clinical trials. Immunotherapy might be interesting in this setting, given that it appears to be more tolerable. Another consequential undertaking would be the deployment of strategies to reduce wait times during the diagnostic process for patients with a high index of suspicion for lung cancer.

Patient-Reported Experiences with Treatment of Chronic Lymphocytic Leukemia (CLL) and Mantle Cell Lymphoma (MCL): Results of a Quantitative Survey

IntroductionHistorically, the predominant treatments for CLL and MCL have included intravenously (IV) administered chemotherapeutic regimens. However, there has been a rapid growth recently in new CLL/MCL treatment options, including orally administered products. Moreover, the therapeutic profiles of these newer agents are generally improving, particularly for patients with relapsed or refractory disease. There is currently a paucity of research evaluating patients’ experiences with current and emerging treatments for both CLL and MCL. The objective of this study was to explore patients’ experiences with, and preferences for, CLL/MCL therapies.MethodsData were collected from 27 May to 30 June 2014 via a self-administered, online, quantitative survey that was developed based on qualitative interviews with CLL and MCL patients. Patients with CLL or MCL were recruited from a market research panel or were referred by a physician or other patients. Patients were eligible for the survey if they had been diagnosed with CLL or MCL by a physician, had been treated for ≥ 2 weeks in the past 12 months, and were not a clinical trial participant. Quantitative data were collected regarding treatment history, factors influencing treatment selection, opinions of treatment, experiences with IV treatment, and patient-reported health and wellness.ResultsA total of 75 patients (52 with CLL, 23 with MCL) completed the survey. CLL and MCL patients provided similar responses to most questions. The majority of patients were white (72%), < 65 years of age (92%), and privately insured (81%); 51% were female. The mean EQ-5D self-reported score for health state (0 = worst imaginable to 100 = best imaginable) was 61. Almost half of both CLL and MCL patients had received one (44%) or two (40%) lines of treatment. A much smaller proportion of patients had received three or more lines of treatment (3rd line=4%, 4th line=8%, and 5th line or more=4%). For the following questions, patients were asked to check all reasons that applied to them. The most common reasons for changing/stopping past CLL/MCL treatments were: too many side effects (38%), medication did not work to treat the disease (36%), symptoms were not relieved (33%), and work productivity declined because of side effects (26%). When asked about reasons for dissatisfaction with CLL/MCL treatments, the most commonly reported reasons were safety concerns (33%) and side effects (32%); 37% said none applied. Common reasons for satisfaction with CLL/MCL treatment were: medication is covered by my insurance (49%), convenient dosing schedule (39%), easy to use (33%), works most of the time (32%), works all of the time (31%), works better than other drugs I have tried (28%), and is affordable (28%). 65% of patients visited their doctor together with a spouse, family member, friend, or paid helper. Frequency of IV treatment was every 1-2 weeks for 67% of patients and required an average of 3 hours for infusion and 4 hours overall, including travel and waiting time. Mean satisfaction with treatment (1 = extremely dissatisfied to 7 = extremely satisfied) was 5.3. Longer duration of effect was the most important treatment feature for CLL/MCL patients.ConclusionsThe results of this survey show that the greatest source of patients’ dissatisfaction with their current or most recent treatment for CLL/MCL was the treatment’s safety and tolerability. Many patients receive IV treatment for CLL/MCL every 1-2 weeks, and each IV treatment requires several hours of time not only for the patient, but in nearly two-thirds of cases, also for a family member or friend who accompanies the patient. These survey results suggest that substantial unmet needs remain for the care of patients with CLL and MCL. DisclosuresSchenkel:Janssen Scientific Affairs, LLC: Employment, Stock ownership Other. Naim:Janssen Scientific Affairs, LLC: Employee of Janssen Scientific Affairs, LLC at the time of the study Other. Roland:Janssen Scientific Affairs, LLC: Consultancy. Wyant:Janssen Scientific Affairs, LLC: Consultancy.

Abstract P271: Mortality Benefit With Drug-Eluting Stents in Observational Studies: Fact or Artifact? Insights From the Prospective, Multicenter EVENT (Evaluation of Drug Eluting Stents and Ischemic Events) Registry

Background: Both randomized trials and observational studies comparing drug-eluting stents (DES) with bare metal stents (BMS) have demonstrated substantial reductions in target lesion revascularization (TLR) with DES use. Data on mortality, however, are strikingly disparate with only observational studies supporting a benefit of DES. We hypothesized that these differences are related predominantly to residual selection biases in non-randomized studies. Methods: We examined the association between stent type (DES vs. BMS) and both TLR and mortality over one year among 9266 unselected pts who underwent PCI at 55 US centers and were enrolled in the prospective EVENT registry from 2004 to 2007. In addition to standard approaches to risk-adjustment (i.e., multivariable regression and propensity matching), we performed an instrumental variable (IV) analysis using the treatment era (2007 vs. 2004-6) as the instrument. Results: Overall 88% pts received DES, and there was a substantial difference by treatment year (93% in 2004-06, 73% in 2007, p&lt;0.001). Unadjusted event rates over one year were significantly lower with DES compared to BMS (Death: 2.5% vs. 5.6%, TLR: 4.2% vs. 6.9%, p for both &lt;0.001). Both multivariable and propensity-matched Cox regression analyses demonstrated a significantly lower risk of death and TLR with DES use (Table). IV analysis showed a strong trend towards lower TLR with DES but no difference in mortality. Conclusion: Among unselected PCI patients in contemporary practice, DES use is associated with a consistent reduction in TLR regardless of risk-adjustment methodology but no effect on mortality using IV analysis. These findings underscore the limitations of conventional multivariable and propensity score analyses to adequately address both known and unknown factors influencing treatment selection in non-randomized studies. Adjusted * risk of post discharge clinical outcomes over one year after PCI with drug-eluting stents (reference: bare metal stents) Death Any TLR Hazard ratio (95% CI) P value Hazard ratio (95% CI) P value Multivariable Cox regression 0.51 (0.37-0.69) &lt;0.001 0.49 (0.37-0.64) &lt;0.001 Propensity-matched Cox regression 0.54 (0.39-0.74) &lt;0.001 0.52 (0.39-0.69) &lt;0.001 Absolute risk difference(%) (95% CI) P value Absolute risk difference (%) (95% CI) P value Instrumental variable analysis (instrument: treatment era) 1.9 (-1.9, 5.7) 0.33 -4.5 (-9.0, 0.3) 0.07 TLR: Target Lesion revascularization; * Adjusted/ matched for: Age, gender, insurance status, hyperlipidemia, hypertension, diabetes, smoking status, medical history (myocardial infarction, peripheral artery disease, stroke, heart failure), history of PCI or bypass surgery, e Glomerular filtration rate, ejection fraction, multivessel disease, attempted lesion location (left main, LAD, SVG), # lesions treated, stent length, # of stents, maximum stent diameter

1946 CONTEMPORARY PRACTICE PATTERNS IN SURGICAL MANAGEMENT OF STONE DISEASE

You have accessJournal of UrologyStone Disease: New Technology/SWL, Ureteroscopic or Percutaneous Stone Removal1 Apr 20111946 CONTEMPORARY PRACTICE PATTERNS IN SURGICAL MANAGEMENT OF STONE DISEASE Michael Childs, Laureano Rangel, James Lingeman, and Amy Krambeck Michael ChildsMichael Childs Rochester, MN More articles by this author , Laureano RangelLaureano Rangel Rochester, MN More articles by this author , James LingemanJames Lingeman Indianopolis, IN More articles by this author , and Amy KrambeckAmy Krambeck Rochester, MN More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.2127AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Shock wave lithotripsy (SWL) is the most common surgical procedure for stone disease despite the efficacy of ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL). Factors influencing treatment selection for stone disease have not been well evaluated. We assessed treatment preferences for stone disease and identified factors associated with treatment selection. METHODS Electronic surveys were sent to urologists with American Medical Association membership. After selecting a treatment modality for clinical stone scenarios, information was obtained on training, practice, equipment ownership, and clinical factors related to treatment. Survey results were assessed for factors associated with treatment selection. RESULTS Of 600 surveys, 200 were initiated and 180 completed. Additional endourologic training was reported in 29%(55/189). Academic practice (AP) and community practice (CP) were reported in 33%(63/189) and 64%(121/189). High volume stone practices (>100 cases/year) were more likely in CP vs AP (57.8% vs 36.5%, p<0.001). High volume SWL practice was more likely in CP (6.7% vs 1.6%) while high volume URS (19% vs 11.4%) and PCNL (3.2% vs 0%) practices were more common in AP (p<0.001). Time since training was associated with treatment selection for all renal and proximal stones. PCNL and URS were preferred with fewer years since training while SWL was preferred with increasing time since training (p<0.03). Lithotriptor ownership was associated with SWL preference over URS or PCNL for proximal urolithiasis (<5mm to 15mm), renal pelvis and upper pole nephrolithiasis (<5mm to 15mm) and lower pole nephrolithiasis (<5mm to 10mm) (p<0.01). Most trends for SWL preference were independent of urologist age on multivariate analysis. Holmium laser ownership and lithotriptor availability did not influence treatment selection (p>0.05). Clinical factors important in stone treatment selection (stone size, location, composition, age, comorbidities, bilaterality, surgical schedule, or payer status) did not differ based on equipment ownership or time since training (p>0.05). CONCLUSIONS Stone treatment selection preference varied by practice type, with high volume SWL practice in CP and high volume URS and PCNL practice in AP. PCNL and URS were preferred with less time since training and SWL preferred with increasing time since training. Furthermore, lithotriptor ownership was associated with SWL selection over URS or PCNL while lithotriptor availability and holmium laser ownership were not. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e778 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Childs Rochester, MN More articles by this author Laureano Rangel Rochester, MN More articles by this author James Lingeman Indianopolis, IN More articles by this author Amy Krambeck Rochester, MN More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Revascularisation Strategies in Diabetics with Multi-vessel Disease: Factors Influencing Treatment Selection

Revascularisation Strategies in Diabetics with Multi-vessel Disease: Factors Influencing Treatment Selection

Salvage Therapy for Advanced Non-Small Cell Lung Cancer: Factors Influencing Treatment Selection

Novel chemotherapies and molecularly targeted agents have improved outcomes for patients with advanced non-small cell lung cancer (NSCLC). Several efficacious regimens are available, which allows for selection of therapy based on factors such as schedule, toxicity profile, patient-specific needs, and individual preferences of the patient. Treatment guidelines recommend platinum-based chemotherapy first line for patients with a good performance status. These regimens offer a modest survival advantage over best supportive care. The role of targeted biologic agents in this setting is being assessed in phase II trials. Results to date show promising activity and tolerability. Erlotinib, docetaxel, and pemetrexed are all approved for patients who progress following one prior regimen for advanced NSCLC. These agents have different tolerability profiles and routes of administration but appear to have similar effects on tumor response and survival, though comparative trials are required to confirm this. Based on the results of a phase III trial, erlotinib is also recommended for third-line use in patients with NSCLC. Identifying predictive markers of clinical response to therapy may provide an opportunity to better select patient subsets appropriate for specific treatment. Recent data have linked various clinical characteristics and biologic markers with outcome to HER-1/EGFR-targeted agents. However, many of these studies are retrospective and based on small patient numbers, and there is evidence of broad benefit across diverse patient subgroups with erlotinib. Prospective, randomized trials are required to validate potential predictive markers fully before they are applied to clinical practice.