Large Health Care Delivery System Research Articles

(764) - Recipient Outcomes in Donation After Circulatory Determination of Death Lung Donors Within the United States

Donation after circulatory determination of death (DCDD) lung donor recipients are generally considered to have as favorable outcomes as donation after brain death (DBD) lung donor recipients. Given limitations of prior studies, the outcomes of DCDD lung donors in a large and heterogeneous health care delivery system like that of the United States (US) needs to be studied.

Pediatric vancomycin dosing: Trends over time and the impact of therapeutic drug monitoring

Monitoring of vancomycin trough concentrations is recommended for pediatric patients in the product label and by several professional societies. However, among a network of freestanding children's hospitals vancomycin therapeutic drug monitoring (TDM) practices were reported to be highly variable. In this study, we sought to evaluate whether trends in vancomycin use and TDM changed across a large healthcare delivery system in Utah and Idaho from 2006 to 2012. Children ≤18 years who received ≥2 vancomycin doses were included. Overall, vancomycin TDM was performed during 5,035 (80%) of 6,259 hospital encounters, in which 85,442 doses were administered and 7,935 concentrations were obtained. Across this time period, the median trough concentration increased from 10.9 to 13.7 µg/mL (P < .001), which temporally coincided with recommendations published by the Infectious Disease Society of America that recommend targeting higher trough concentrations. Two or more abnormally low trough concentrations were accompanied by an increase in the dose 75% of the time. Similarly, ≥2 abnormally high trough concentrations were followed by a decrease in the dose 35% of the time. In aggregate, these data suggest that vancomycin TDM is commonly performed among children and the majority of abnormal trough concentrations were associated with an appropriate modification to the dosing regimen.

Improving Value Is Improving Health Care, Not Rationing

Improving Value Is Improving Health Care, Not Rationing

Characterization of adverse events detected in a large health care delivery system using an enhanced global trigger tool over a five-year interval.

To report 5 years of adverse events (AEs) identified using an enhanced Global Trigger Tool (GTT) in a large health care system. Records from monthly random samples of adults admitted to eight acute care hospitals from 2007 to 2011 with lengths of stay ≥3 days were reviewed. We examined AE incidence overall and by presence on admission, severity, stemming from care provided versus omitted, preventability, and category; and the overlap with commonly used AE-detection systems. Professional nurse reviewers abstracted 9,017 records using the enhanced GTT, recording triggers and AEs. Medical record/account numbers were matched to identify overlapping voluntary reports or AHRQ Patient Safety Indicators (PSIs). Estimated AE rates were as follows: 61.4 AEs/1,000 patient-days, 38.1 AEs/100 discharges, and 32.1 percent of patients with ≥1 AE. Of 1,300 present-on-admission AEs (37.9 percent of total), 78.5 percent showed NCC-MERP level F harm and 87.6 percent were "preventable/possibly preventable." Of 2,129 hospital-acquired AEs, 63.3 percent had level E harm, 70.8 percent were "preventable/possibly preventable"; the most common category was "surgical/procedural" (40.5 percent). Voluntary reports and PSIs captured <5 percent of encounters with hospital-acquired AEs. AEs are common and potentially amenable to prevention. GTT-identified AEs are seldom caught by commonly used AE-detection systems.

Adapting the Group Lifestyle Balance™ Program for Weight Management Within a Large Health Care System Diabetes Education Program

The purpose of this translation study was to evaluate the feasibility and effectiveness of an adapted Group Lifestyle Balance (GLB) intervention for weight management implemented through an existing diabetes education program within a large health care delivery system for overweight/obese individuals with diabetes, prediabetes, or neither condition. Adults with BMI ≥ 25 kg/m2 participated in an adapted GLB intervention designed to be appropriate regardless of diabetes status. Effectiveness was based on changes in weight and minutes of physical activity between baseline and completion of the 12-week core. Differences between subjects based on diabetes status were also examined. A total of 111 subjects with diabetes, prediabetes, and no diabetes completed baseline survey data and attended at least 9 of the 12 core sessions from April 2010 through December 2011. All achieved significant weight loss, and the proportion of subjects who reported exercising at least 150 minutes/week increased. The adapted GLB intervention for weight management implemented through an existing diabetes education program in a large health care system was feasible and effective in the population, regardless of participants' diabetes status.

Abstract P2-11-08: IHC 2+ FISH (-) breast cancer (BC): Patient characteristics and outcomes: A comparison to HER2 IHC 0, 1+ and HER2 + BC diagnosed 2000-2006

Abstract Background: HER2 IHC 2+ results are equivocal and lead to FISH testing. FISH(+) results lead to HER2(+) treatment often with trastuzumab. FISH(-) results lead to treatment without trastuzumab. We examined the characteristics and breast cancer-specific mortality of HER2 2+ FISH (-) BC in consecutive patients in a large health care delivery system. Methods: Using the KPNC cancer registry and electronic medical record, we identified 13,845 consecutive stage I-III BC patients diagnosed between 1/2000 and 12/2006 not treated with adjuvant trastuzumab. Patient demographics, disease stage, IHC and FISH results, and breast cancer mortality were obtained. IHC and FISH testing were performed in a single central laboratory. Results: After excluding any adjuvant trastuzumab, 10,760 (78%) patients had HER2 IHC scores of 0,1+, 1,533 (11%) were IHC2+/FISH (-), and 1,552 (11%) were IHC3+ or FISH (+). Compared to patients with IHC 0,1+ tumors, those with IHC2+FISH (-) tumors were younger (mean age 61 vs 62 years, p = 0.03) and more often node+ (36% vs 30%, p = &amp;lt;0.0001); their tumors were more often poorly differentiated (29% vs 22%, p = &amp;lt;0.0001),) and T2 vs T1 (31% vs 24%, p = &amp;lt;0.0001), and less frequently T1ab (20% vs 29%, p = &amp;lt;0.0001), ER+ (81% vs 85%, p = 0.0003), or PR+ (70% vs 74%, p = &amp;lt;0.0002). Among the ER+ patients, the 10-year BC-specific mortality was higher for those with IHC2+/FISH (-) than IHC 0, 1+ tumors (11.4% vs 8.9%, p = 0.0014). Within disease stages, there were trends but no statistical difference in BC-specific mortality. IHC3+/FISH (+) ER+ patients had greater differences in the above characteristics and significant increased mortality among middle, and higher stages. In multivariable analysis adjusting for age, tumor size, differentiation, hormonal therapy and chemotherapy, risk of BC death among ER+ patients was similar for IHC2+FISH (-) and IHC 0,1+ disease; but risk was higher for IHC3+/FISH (+) disease. Table 1: 10-year breast cancer (BC) survival of women with stage I-III ER-positive BC by HER2 subtype, 2000-2006. 10-year BC survival of stage I-III ER+ patients by IHC FISH statusHER2 SubtypeNo of PatientsBC Deathsat Risk%BC Survival95% CILogRank P-valueIHC 0,1+9,1616212,45491.190.4-91.8-IHC2+FISH(-)1,24811222388.686.3-90.60.0014IHC3+ and/or FISH(+)93512523783.680.6-86.2&amp;lt;0.0001 Conclusions: In ER+ patients, those with IHC2+FISH (-) tumors have prognostic characteristics that are intermediate between those with IHC 0,1+ and IHC3+/FISH(+) tumors. Compared to IHC 0,1+ disease, they are at increased risk of BC mortality overall but not within stages. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-11-08.

Optimizing outcomes of robotic mitral valve repair for all prolapse anatomy: the Suri-Burkhart technique.

Early mitral valve (MV) repair is the evidence-based care standard for those with severe degenerative MV regurgitation and has been shown to improve long-term patient outcomes in comparison to non-surgical management (1). Despite evidence favoring the performance of MV repair prior to symptom onset or the appearance of left ventricular (LV) dysfunction, some physicians are hesitant to refer asymptomatic patients for MV repair involving traditional median sternotomy (2). Alternatively, cardiac surgical procedures including MV repair performed through small incisions utilizing videoscopic assistance are now common-place, and have been shown to be capable of sparing patients the physiological challenge of recuperating from a sternum-dividing operation (3,4). The spectrum of benefits potentiated by use of minimally invasive incisions is well documented in the literature (5). Several large health care delivery systems have embraced minimally invasive surgical approaches aiming to replicate the “gold standard” results of a trans-sternal (open) MV repair aiming to improve patient acceptance and facilitate earlier referral. This thereby minimizes the delayed but substantial costs associated with the evolution of chronic debilitating heart failure or the poor outcomes of rescue surgery once symptoms or LV dysfunction develop (3,6). Recent efforts to uphold the safety and efficacy of standard open operations while decreasing costs have launched robotic MV repair to the forefront of available treatment options for asymptomatic mitral regurgitation (MR).

Adequacy and quality of immunization data in a comprehensive electronic health record system.

Background and Purpose: Timely, simultaneous and combined vaccination is important to protect children from common infectious diseases. In a large health care delivery system in Western Kenya, we examined the adequacy and quality of data within the electronic health record (EHR) to assess the feasibility of developing a clinical decision support system to improve childhood vaccination uptake and coverage. Methods: The study evaluated vaccination information collected and stored in an EHR between 2006 and 2012 involving 23,270 children. Encounters for 10,299 children lacked immunization information and were excluded. Results: Documentation of vaccination coverage and timeliness is rendered in Kaplan–Meier time-to-event plots. Vaccination coverage at the end of one year ranges from 60% to 90% for all vaccines assessed individually that are part of the Kenya Expanded Program on Immunization (KEPI). Timely documentation of vaccination is low, with 52.8 weeks (95% CI: 52.1, 53.5) for measles vaccine and 29.2 weeks (95% CI: 28.5, 29.8) for the Bacillus Calmette–Guerin (BCG) vaccine. Complete vaccine observations were recorded in 16% of the encounters. Combination and simultaneous vaccine administration had high congruence and consistency. Conclusion: A clinical decision support system that generates reminders to clinicians and caretakers of children would optimize vaccination uptake and improve overall immunization coverage. To achieve this, immunization data in the EHR must be timely, complete and consistent. Assessed vaccination timeliness is low, despite high coverage. Vaccine observations are often incomplete. There is need to improve the data collection process to achieve data quality levels that can adequately support a clinical decision support system. Keywords: Vaccination, Electronic health records, Developing countries, Data quality

Patients With Lower Activation Associated With Higher Costs; Delivery Systems Should Know Their Patients’ ‘Scores’

Patient activation is a term that describes the skills and confidence that equip patients to become actively engaged in their health care. Health care delivery systems are turning to patient activation as yet another tool to help them and their patients improve outcomes and influence costs. In this article we examine the relationship between patient activation levels and billed care costs. In an analysis of 33,163 patients of Fairview Health Services, a large health care delivery system in Minnesota, we found that patients with the lowest activation levels had predicted average costs that were 8percent higher in the base year and 21percent higher in the first half of the next year than the costs of patients with the highest activation levels, both significant differences. What's more, patient activation was a significant predictor of cost even after adjustment for a commonly used "risk score" specifically designed to predict future costs. As health care delivery systems move toward assuming greater accountability for costs and outcomes for defined patient populations, knowing patients' ability and willingness to manage their health will be a relevant piece of information integral to health care providers' ability to improve outcomes and lower costs.

Incorporating Patient Decision Aids into Standard Clinical Practice in an Integrated Delivery System

Randomized controlled trials show that patient decision aids (DAs) can promote shared decision making and improve decision quality. Despite this evidence, integration of DAs into routine clinical practice has proceeded slowly. To identify factors that promote or impede integrating DAs into clinical practice in a large health care delivery system. Mixed-methods case study. Group Health, an integrated health plan and care delivery system in Washington state. Intervention. The project was carried out in 6 specialty service lines using 12 video-based DAs for preference-sensitive conditions related to elective surgical procedures. Process data, site visits, meeting observations, and in-depth interviews conducted with clinical staff, project staff, and health plan leaders in 2009 and 2010. The project established systemwide and clinic-specific processes that facilitated the distribution of approximately 10,000 DAs over 2 years. Several factors were identified as important for success in this implementation, including strong support from senior leaders, establishing a system for previsit ordering and providing timely feedback to teams about distribution rates, engaging providers and staff in development of the implementation process, and finding ways to address concerns about conditions that were perceived as life-threatening and/or time sensitive. Limitations included lack of data on patient perspectives, an implementation setting with salaried providers, and frontline provider interviews conducted in only selected service lines. With strong leadership, financial support, and a well-defined implementation strategy, 12 video-based DAs in 6 specialty service lines were integrated into routine practice over 2 years. Findings from this demonstration may advance the ability of other organizations to use DAs effectively and promote widespread adoption of shared decision making in routine patient care.

Predictors of Persistence After a Positive Depression Screen Among Adolescents

To examine predictors of depression persistence after a positive screening test to inform management protocols for screened youth. We conducted a cohort study of 444 youth (aged 13-17 years) from a large health care delivery system. Youth with depressive symptoms, based on a 2-item depression screen, were oversampled for the baseline interview. Baseline assessments included the Patient Health Questionnaire 9-item (PHQ-9) depression screen as well as clinical factors that were hypothesized to influence depression persistence (family history of depression, functional impairment, perceived social support, anxiety symptoms, externalizing symptoms, and medical comorbidity). Logistic regression analysis was used to examine factors associated with the persistence of depression at 6 months postbaseline. Of 113 youth with a positive baseline screen (PHQ-9 ≥11), 47% and 35% continued to be positive at 6-week and 6-month follow-up, respectively. After controlling for treatment status, only 2 factors were significantly associated with depression persistence at 6 months: baseline depressive symptom score and continuing to have a positive screen at 6 weeks. For each 1-point increase on the PHQ-9 score at baseline, youth had a 16% increased odds of continuing to be depressed at 6 months (odds ratio: 1.16, 95% confidence interval: 1.01-1.34). Youth who continued to screen positive 6 weeks later had almost 3 times the odds of being depressed at 6 months (odds ratio: 2.89, 95% confidence interval: 1.09-7.61). Depressive symptom severity at presentation and continued symptoms at 6 weeks postscreening are the strongest predictors of depression persistence. Patients with high depressive symptom scores and continued symptoms at 6 weeks should receive active treatment.

Stakeholder Approach to Better Understand the Psychological Health Services in the Military

AbstractEnsuring the psychological well‐being of service members and their families has emerged as one of the principal challenges of today's armed services. Given that the system of care of psychological health services in the United States Military cannot be divorced from the large healthcare delivery system, an enterprise perspective is needed to truly understand the dynamics of care. This paper makes two key contributions: it identifies the key stakeholders of the military health enterprise with respect to psychological health, and analyzes the espoused senior leadership values over the last decade as seen in the stakeholder reports. This stakeholder analysis highlights the challenges faced in melding the constituent organizations into an enterprise, especially in the face of leadership turnover. The thematic analysis of senior leadership values shows an evolution of focus from managing execution of care to emphasizing healthy lifestyles and psychological health.

NIH Panel Finds No Alzheimer's Prevention to Endorse

BETHESDA, Md. – Current knowledge about the epidemiology of Alzheimer's disease and cognitive decline has not provided enough evidence to recommend specific, preventive interventions, according to a “state-of-the-science” report issued by a panel of experts assembled by the National Institutes of Health. The 15-member panel found that there is not enough evidence to support the use of pharmaceutical agents or dietary supplements to prevent cognitive decline or Alzheimer's disease, but ongoing additional studies of antihypertensive medications, omega-3 fatty acids, physical activity, and cognitive engagement “may provide new insight into the prevention of delay of cognitive decline or Alzheimer's disease.” “We're hoping that our report is going to supply physicians with accurate information that they can give to their patients” to clarify what interventions may be worth continuing or pursuing and which should be discontinued, said panelist Carl C. Bell, MD, director of the Institute for Juvenile Research in the department of psychiatry at the University of Illinois at Chicago, at a press briefing. A wide range of modifiable factors have been reported to be associated with risk for Alzheimer's disease, such as diabetes, elevated blood cholesterol in midlife, and depression, but also relatively benign changes in diet, medication, or lifestyle. However, the overall quality of evidence from these studies is low, the panel said, and it did not find enough evidence to draw firm conclusions about the association of modifiable risk factors with cognitive decline or Alzheimer's disease. In light of the fact that there are no proven interventions that prevent cognitive decline or Alzheimer's disease, panel member Arnold L. Potosky, PhD, of Georgetown University in Washington said that it is important for physicians to discuss participation in clinical studies with their patients. The panel recommended that further research should include: ▸The development and use of rigorous, consensus-based diagnostic criteria for Alzheimer's disease and mild cognitive impairment.▸The development and use of standardized, validated, and culturally sensitive outcome measures for research.▸The collection of data from caregivers of people with mild cognitive impairment or early Alzheimer's disease in a systematic manner in observational studies and randomized, controlled trials.▸The conduct of large-scale, long-term population-based studies with well-validated exposure and outcome measures in people followed from middle to old age. Existing cohorts from ongoing studies of this type also could be explored for timely, cost-effective identification of individuals at high risk of cognitive decline or Alzheimer's disease.▸The leveraging of alternative research resources and platforms that facilitate long-term longitudinal assessments, such as a multicenter Alzheimer's disease registry or observational studies within large health care delivery systems with defined populations and well-developed electronic health records.▸The creation of a simple, inexpensive, quantitative instrument that can be administered by a trained nonexpert to assess change in cognitive status over time. The statement was restricted to studies of people aged 50 years or older that were conducted in developed countries. The minimum sample size in these studied was at least 50 patients in randomized, controlled trials and at least 300 patients in observational studies. The duration between exposure to a preventive intervention and study outcomes had to be at least 1 year for studies of mild cognitive impairment and at least 2 years for studies of Alzheimer's disease. The panel based its statement on a report from the Evidence-Based Practice Center at Duke University's Clinical Research Institute, which was commissioned by the Agency for Healthcare Research and Quality. The evidence report is available at www.ahrq.gov/clinic/tp/alzcogtp.htm. The statement is available at consensus.nih.gov. Jeff Evans is a clinical news editor with Elsevier Global Medical News.

Evaluation of the Patient Health Questionnaire-9 Item for Detecting Major Depression Among Adolescents

The purpose of this study was to examine the performance characteristics and validity of the Patient Health Questionnaire-9 Item (PHQ-9) as a screening tool for depression among adolescents. The PHQ-9 was completed by 442 youth (aged 13-17 years) who were enrolled in a large health care-delivery system and participated in a study on depression outcomes. Criterion validity and performance characteristics were assessed against an independent structured mental health interview (the Child Diagnostic Interview Schedule [DISC-IV]). Construct validity was tested by examining associations between the PHQ-9 and a self-report measure of functional impairment, as well as parental reports of child psychosocial impairment and internalizing symptoms. A PHQ-9 score of 11 or more had a sensitivity of 89.5% and a specificity of 77.5% for detecting youth who met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for major depression on the DISC-IV. Receiver-operator-curve analysis revealed that the PHQ-9 had an area under the curve of 0.88 (95% confidence interval: 0.82-0.94), and the cut point of 11 was optimal for maximizing sensitivity without loss of specificity. Increasing PHQ-9 scores were significantly correlated with increasing levels of functional impairment, as well as parental report of internalizing symptoms and psychosocial problems. Although the optimal cut point is higher among adolescents, the sensitivity and specificity of the PHQ-9 are similar to those of adult populations. The brief nature and ease of scoring of this instrument make this tool an excellent choice for providers and researchers seeking to implement depression screening in primary care settings.

Medical Leadership in an Increasingly Complex World

GREECE IS GOING BANKRUPT. THE EURO IS SHAKY. The oil inundating the Gulf Coast may eliminate one-third of the US seafood catch. In the midst of this chaos, the nightly news focuses on a medical breakthrough. At a cost of about $100 000, a man with metastatic prostate cancer can be treated with an infusion of his own cells and live, on average, a few months longer. The commentator questions whether insurance companies will pay for this therapy and wonders whether men who do not have metastatic cancer will demand access to the therapy, even if they have to pay for it themselves. Perhaps Yeats was right—“Things fall apart; the centre cannot hold.” The United States spends more money per person on medical care than any other developed country in the world. But Americans are not the healthier for it. Life expectancy in the United States is lower than in virtually any other developed country, and variation in life expectancy, as a function of where a person lives or grows up, is high. In the context of this dismal reality, consider the assertion in the Declaration of Independence that every citizen has the right to life, liberty, and the pursuit of happiness. What should be expected from a physician leader in this complex world? Physicians are found in leadership positions throughout US society but are rarely at the top. Physicians have been elected to both houses of Congress, but no physician has been elected president. Medical leaders are found in the executive branch of the Department of Health and Human Services, but virtually never at its highest levels. But physicians have extraordinary influence. They run the programs that spend large amounts of money to treat the elderly and the poor, at both state and national levels. They provide a moral compass when they serve as surgeon general. And most frequently, they are responsible for running large health care delivery systems and for training the future health workforce of the United States. Indeed, the teaching role has expanded from being a dean of a medical school to overseeing the entire health enterprise of an academic campus, including teaching hospitals and schools of medicine, nursing, pharmacy, and public health. Physicians also control all of the organizations that set professional standards in medicine, from individual specialty societies to organizations cutting across the entire medical establishment. What defines a successful leader of such organizations? That’s more than a rhetorical question. Medicine now makes up 17% of the US gross domestic product; thus, a large part of the country’s ability to ensure life, liberty, and the pursuit of happiness is in the hands of medical leaders. There are several possible definitions of successful leadership. Is it an indication of success if the leader of an academic medical center keeps the institution financially solvent, constructs new buildings—especially those for basic science research—moves the institution higher on the National Institutes of Health grant list, and trains physicians to concentrate on the patient by using all tools at their disposal? Are leaders of professional societies successful when they persuade Congress that the society’s members provide great scientific value and thus merit higher salaries; or if those leaders convince philanthropies to donate a disproportionate amount of money to that specialty? Is the leader of a major program, such as Medicare, successful when bills are paid promptly, adequate reimbursement is made for services rendered, and services are provided with high quality and little waste? Is the medical leader of a pharmaceutical company successful when the company develops a product that increases life expectancy by 3 months at a price of $100 000 and then convinces the public and insurers that patients must have the product and that it must be paid for with public money? Many would answer yes in all of these cases. Who wants a leader of an academic medical center who builds nothing, does not attract research grants, and fails to maintain financial stability? Certainly not the center’s board of governance. But in this complex world, are these sufficiently inclusive definitions of a successful physician leader? There are 3 competing models for improving health in a population. The first, for which virtually all of the resources are used, is the medical model, in which an individual patient visits a physician who uses his or her clinical training to diagnose and treat the patient. The second is the

Responding to the Language Challenge: Kaiser Permanente's Approach

To inform current debates on improving health care quality for patients with limited English proficiency by identifying the drivers and processes for one large health care delivery system's implementation of particular models, key success factors, and remaining challenges for the field. A qualitative case study of the Kaiser Permanente (KP) San Francisco Medical Center's approach to developing linguistic access services and subsequent organizationwide initiatives. We conducted semistructured interviews with eight current and former clinical and administrative leaders from the KP San Francisco Medical Center and national headquarters. Interviews were analyzed for key themes. KP San Francisco Medical Center developed linguistic and cultural services in response to a confluence of external and internal factors, including changing demographics, care quality challenges, and patient and clinician satisfaction issues. Early strategies included development of language-specific care modules focused on Chinese- and Spanish-speaking members while meeting broader linguistic access and cultural-competency needs through a centralized Multicultural Services Center. Additional approaches across KP regions have focused on improving interpreter services, optimizing use of bilingual staff, and creating a translation infrastructure to improve quality and reduce redundancy in written translation efforts. KP's experiences developing linguistic and cultural care and services since the 1990s provide lessons about decision-making processes and approaches that may guide other health systems, insurers, and policy makers striving to improve care quality and safety for patients with limited English proficiency.

Randomized clinical trial eligibility rates for chemotherapy (CT) and antiangiogenic therapy (AAT) in a population-based cohort of newly diagnosed non-small cell lung cancer (NSCLC) patients

6538 Background: NSCLC leads the US in cancer deaths, but randomized clinical trials (RCT) of CT with/without antiangiogenic therapy (AAT) are relatively slow to accrue. Treatment guidelines for NSCLC are based on RCTs that enroll patients with a mean age of 62–64 without serious comorbidities. SEER mean age of NSCLC diagnosis in the US is 70. Methods: 326 consecutively diagnosed (from January 1, 2006) NSCLC patients from a large prepaid health care delivery system (Kaiser Permanente Northern California-KPNC), were retrospectively evaluated by manual chart and electronic medical record review for eligibility criteria (EC) to enter treatment defining RCTs, i.e. E4599, S0023. The KPNC members are representative of the regional population. Ineligibility, the main endpoint, was determined on imaging and laboratory tests and history in the medical record. This may overestimate eligibility. Results: Age at diagnosis:&lt;60years-18%, &lt;65–28%, &lt;70–50%, &gt;75–34%, &gt;80–18%; mean (SD)age- 69.3 (10.6). Male:Female 51:49%. Adeno-49%; Squamous-22%; LargeCell-2.5%; NSC NOS-27%. Current/former smokers-90%. Staging: IA-14%; IB-13%; IIA+B-4%; IIIA-17%; IIIB+IV-52%. Surgical resection-26%. When standard RCT eligibility criteria were applied to the entire cohort, 34% (CI 29%-39%) were eligible. Only 23% (CI 19%-28%) were both eligible and &lt;75yo. stage IIIB+IV patients were 29% (CI 24%-36%) eligible at all ages, 20% (15%-26%) were both eligible and &lt;75yo. When AAT EC were added, 21% (17%-26%) were eligible for all ages, 14% (CI 10%-18%) eligible and &lt;75yo., and 9%(CI 6%-13%) eligible and &lt;70yo. Conclusions: Treatment guidelines for NSCLC are based on RCTs enrolling the healthiest quartile of the youngest half of patients. The majority of NSCLC patients are excluded by trial eligibility criteria or subjective age criteria from entering CT and/or AAT RCTs. Toxicities in these older and more comorbid NSCLC patients likely alter the risk:benefit ratio. RCTs specific for the 70+yo and comorbid NSCLC patients are needed to help define the best therapy for this understudied majority of lung cancer patients. No significant financial relationships to disclose.

Motivating Factors for Physician Ordering of Factor V Leiden Genetic Tests

The factor V Leiden (FVL) genetic test is used by many physicians despite its uncertain clinical utility. We investigate whether self-reported motivations and behaviors concerning FVL genetic testing differ between 2 groups of primary care physicians defined by frequency of previous FVL test use. In January 2007, 112 physicians (60 frequent and 52 infrequent FVL test users) at Group Health, a large health care delivery system, were surveyed. Survey content areas included primary reasons and motivating factors for ordering the FVL test, the likelihood of ordering the FVL test for hypothetical patients, potential barriers to genetic testing, and practices and skills regarding FVL test ordering. Responses between groups agreed concerning most clinical- and patient-related factors. Frequent-FVL physicians were more likely than infrequent-FVL physicians to report ordering the FVL test for hypothetical patients with mesenteric venous thrombosis (adjusted odds ratio, 4.57; 95% confidence interval, 1.55-13.53) or venous thrombosis after hospital discharge (adjusted odds ratio, 3.42; 95% confidence interval, 1.30-8.95). Frequent-FVL physicians were also less likely to identify several items on the survey as barriers to genetic testing and were more likely to report high confidence in interpreting and explaining FVL test results. Generally, both physician groups reported similar motivating factors for ordering FVL tests, and reported behaviors were consistent with existing guidelines. More striking differences were observed for measures such as barriers to and confidence in using genetic tests. Although additional research is necessary to evaluate the impact of these results, they inform several knowledge-to-practice translation issues that are important for the successful integration of genetic testing into primary care.

Variation in the Rates of Operative Delivery in the United States

Objectives This study was undertaken to examine the national and regional rates of operative delivery among almost one quarter million births in a single year in the nation’s largest healthcare delivery system, using variation as an arbiter of the quality of decision making. Study Design We compared the variation in rates of primary cesarean and operative vaginal delivery in facilities of the Hospital Corporation of America during the year 2004. Results In 124 facilities representing almost 220,000 births during a 1-year period, the primary cesarean and operative vaginal delivery rates were 19% ± 5% (range 9-37) and 7% ± 4% (range 1-23). Within individual geographic regions, we consistently found variations of 200-300% in rates of primary cesarean delivery and variations approximating an order of magnitude for operative vaginal delivery. Conclusion Within broad upper and lower limits, rates of operative delivery in the United States are highly variable and suggest a pattern of almost random decision making. This reflects a lack of sufficient reliable, outcomes-based data to guide clinical decision making.

Common VKORC1 variants are not associated with arterial or venous thrombosis.

Common VKORC1 variants are not associated with arterial or venous thrombosis.