Lifetime Of Patient Research Articles

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Cost-effectiveness of rituximab as maintenance therapy in patients with follicular non-Hodgkin lymphoma after responding to first-line rituximab plus chemotherapy

A recent phase III trial demonstrated that maintenance rituximab® therapy after response to first-line treatment with rituximab plus chemotherapy (R-chemo) increases progression-free survival (PFS) for follicular non-Hodgkin lymphoma (f-NHL). A cost-effectiveness analysis of R-maintenance versus observation was conducted from a US payer perspective to estimate PFS and overall survival (OS) over a representative patient's lifetime. Primary outcomes were cost per life-year gained (LYG) and cost per quality-adjusted life-year (QALY) gained. Compared with observation, R-maintenance increased mean PFS by 1.50 years, OS by 1.21 years and QALYs gained by 1.11 years. The incremental cost of maintenance therapy was $38 545. The costs per LYG and QALY gained were $31 934 and $34 842, respectively. Within the limitations of modeling long-term outcomes, R-maintenance therapy in patients who received R-chemo for previously untreated f-NHL compared with observation alone after R-chemo for first-line treatment for f-NHL is cost-effective from the US payer perspective.

Ventriculoperitoneal shunt surgery and the incidence of shunt revision in adult patients with hemorrhage-related hydrocephalus

ObjectiveVentriculoperitoneal shunt surgery remains the most widely accepted neurosurgical procedure for the management of hydrocephalus. However, shunt failure and complications are common and may require multiple surgical procedures during a patient's lifetime. The purpose of this study is to evaluate the ventriculoperitoneal shunt surgery and the incidence of shunt revision in adult patients with hemorrhage-related hydrocephalus. MethodsAdult patients who underwent ventriculoperitoneal shunt placement for hemorrhage-related hydrocephalus from October 1990 to October 2009 were included in this study. Medical charts, operative reports, imaging studies, and clinical follow-up evaluations were reviewed and analyzed retrospectively. ResultsA total of 133 adult patients with the median age of 54.5 years were included. Among patients, 41% were males, and 62% Caucasians. The overall shunt revision rate was 51.9%. The shunt revision rate within the first 6 months after the initial placement of ventriculoperitoneal shunts was 45.1%. The median time to first shunt revision was 0.50 (95% CI, 0.24–9.2) months. No significant association was observed between perioperative variables (gender, ethnicity, hydrocephalus type, or hemorrhage type) and the shunt revision rate in these patients. Major causes of shunt revision include infection (3.6%), overdrainage (7.6%), obstruction (4.8%), proximal shunt complication (7.6%), distal shunt complication (3.6%), old shunt dysfunction (6.8%), valve malfunction (10.0%), externalization (3.6%), shunt complication (12.0%), shunt adjustment/replacement (24.0%) and other (16.4%). ConclusionAlthough ventriculoperitoneal shunting remains to be the treatment of choice for adult patients with post hemorrhage-related hydrocephalus, a thorough understanding of predisposing factors related to the shunt failure is necessary to improve treatment outcomes.

Surface Mosaics of the Bladder Reconstructed From Endoscopic Video for Automated Surveillance

Flexible cystoscopy is frequently performed for recurrent bladder cancer surveillance, making it the most expensive cancer to treat over the patient's lifetime. An automated bladder surveillance system is being developed to robotically scan the bladder surface using an ultrathin and highly flexible endoscope. Such a system would allow cystoscopic procedures to be overseen by technical staff while urologists could review cystoscopic video postoperatively. In this paper, we demonstrate a method for reconstructing the surface of the whole bladder from endoscopic video using structure from motion. Video is acquired from a custom ultrathin and highly flexible endoscope that can retroflex to image the entire internal surface of the bladder. Selected frames are subsequently stitched into a mosaic and mapped to a reconstructed surface, creating a 3-D surface model of the bladder that can be expediently reviewed. Our software was tested on endoscopic video of an excised pig bladder. The resulting reconstruction possessed a projection error of 1.66 pixels on average and covered 99.6% of the bladder surface area.

Cost-Effectiveness of Transcatheter Aortic Valve Replacement Compared With Standard Care Among Inoperable Patients With Severe Aortic Stenosis

Background— In patients with severe aortic stenosis who cannot have surgery, transcatheter aortic valve replacement (TAVR) has been shown to improve survival and quality of life compared with standard therapy, but the costs and cost-effectiveness of this strategy are not yet known. Methods and Results— The PARTNER trial randomized patients with symptomatic, severe aortic stenosis who were not candidates for surgery to TAVR (n=179) or standard therapy (n=179). Empirical data regarding survival, quality of life, medical resource use, and hospital costs were collected during the trial and used to project life expectancy, quality-adjusted life expectancy, and lifetime medical care costs to estimate the incremental cost-effectiveness of TAVR from a US perspective. For patients treated with TAVR, mean costs for the initial procedure and hospitalization were $42 806 and $78 542, respectively. Follow-up costs through 12 months were lower with TAVR ($29 289 versus $53 621) because of reduced hospitalization rates, but cumulative 1-year costs remained higher ($106 076 versus $53 621). We projected that over a patient's lifetime, TAVR would increase discounted life expectancy by 1.6 years (1.3 quality-adjusted life-years) at an incremental cost of $79 837. The incremental cost-effectiveness ratio for TAVR was thus estimated at $50 200 per year of life gained or $61 889 per quality-adjusted life-year gained. These results were stable across a broad range of uncertainty and sensitivity analyses. Conclusions— For patients with severe aortic stenosis who are not candidates for surgery, TAVR increases life expectancy at an incremental cost per life-year gained well within accepted values for commonly used cardiovascular technologies. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00530894.

Alcohol consumption in patients with primary sclerosing cholangitis

To assess the alcohol drinking patterns in a cohort of primary sclerosing cholangitis (PSC) patients and the possible influence on the development of fibrosis. Ninety-six patients with PSC were evaluated with a validated questionnaire about a patient's lifetime drinking habits: the lifetime drinking history (LDH) questionnaire. In addition, clinical status, transient elastography and biochemistry values were analysed and registered. Patients were defined as having either significant or non-significant fibrosis. Significant fibrosis was defined as either an elastography value of ≥ 17.3 kPa or the presence of clinical signs of cirrhosis. Patients were divided into two groups depending on their alcohol consumption patterns; no/low alcohol consumption (one drink or unit/d) and moderate/high alcohol consumption (≥ 1 drink or unit/d). LDH data were calculated to estimate lifetime alcohol intake (LAI), current alcohol intake, drinks per year before and after diagnosis of PSC. We also calculated the number of episodes of binge-drinking (defined as consuming ≥ 5 drinks per occasion) in total, before and after the diagnosis of PSC. The mean LAI was 3882 units of alcohol, giving a mean intake after onset of alcohol consumption of 2.6 units per week. Only 9% of patients consumed alcohol equal to or more than one unit per day. Current alcohol intake in patients with significant fibrosis (n = 26) was less than in patients without significant fibrosis (n = 70), as shown by lower values of phosphatidylethanol (B-PEth) (0.1 μmol/L vs 0.33 μmol/L, respectively, P = 0.002) and carbohydrate-deficient transferrin (CDT) (0.88% vs 1.06%, respectively, P = 0.02). Self-reported LAI was similar between the two groups. Patients with significant fibrosis reduced their alcohol intake after diagnosis from 103 to 88 units per year whereas patients without fibrosis increased their alcohol intake after PSC diagnosis from 111 to 151 units/year. There were no correlations between elastography values and intake of alcohol (units/year) (r = -0.036). PSC patients have low alcohol consumption. The lack of correlation between fibrosis and alcohol intake indicates that a low alcohol intake is safe in these patients.

Delorme's Procedure for Complete Rectal Prolapse: Does It Still Have It's Own Role?

PurposeAlthough there are more than a hundred techniques, including the transabdominal and the perineal approaches, for the repair of the rectal prolapsed, none of them is perfect. The best repair should be chosen not only to correct the prolapse but also to restore defecatory function and to improve fecal incontinence throughout the patient's lifetime. The aim of this retrospective review is to evaluate clinical outcomes of the Delorme's procedure for the management of the complete rectal prolapse.MethodsA total of 19 patients (13 females and 6 males) with complete rectal prolapses were treated by using the Delorme's procedure in St. Vincent's Hospital, The Catholic University of Korea, from February 1997 to February 2007. Postoperative anal incontinence was evaluated using the Cleveland Clinic Incontinence Score.ResultsAll 19 patients had incontinence to liquid stool, solid stool, and/or flatus preoperatively. Three (15.8%) patients reported recurrence of the rectal prolapse (at 6, 18, 29 months, respectively, after the operation). Information on postoperative incontinence was available for 16 of the 19 patients. Twelve of the 16 patients (75%) reported improved continence (5 [31.3%] were improved and 7 [43.7%] completely recovered from incontinence) while 4 patients had unchanged incontinence symptoms. One (6.3%) patient who did not have constipation preoperatively developed constipation after the operation.ConclusionThe Delorme's procedure is associated with a marked improvement in anal continence, relatively low recurrence rates, and low incidence of postoperative constipation. This allows us to conclude that this procedure still has its own role in selected patients.

Trichoblastoma: management of a rare skin lesion

A 15-year-old girl presented with a 2-year history of an enlarging parietal scalp lesion. Excisional biopsy revealed trichoblastoma, a benign secondary tumor arising from a nevus sebaceous. There is no consensus in the literature about the surgical management of nevus sebaceous in children owing to the low incidence of secondary malignancy. There is a 20% lifetime risk of transformation to a soft tissue neoplasm, most of which are benign; but malignant neoplasms have also been reported. At minimum, these lesions need to be followed clinically over the patient's lifetime if left in situ. Recurrence after excision is rare.

PD06-03: Cost Effectiveness Analysis of BRCA1/2 Genetic Testing.

Abstract Background: Family history of breast and/or ovarian cancer is associated with an increased risk to carry a BRCA1 or BRCA2 gene mutationmutations which significantly increase a woman's risk to develop breast and/or ovarian cancer. This study examines whether BRCA1/2 genetic testing (intervention) remains cost-effective compared to no genetic testing strategy (control) from the societal and private payer perspectives given updates in healthcare practice, policy and clinical specificity of testing in the last 10 years. Data and method: We updated a previous published semi-Markov model (Holland et al., Value in Health, 2009. 12(2): p. 207) to include new information about associated costs and treatment strategies and test specificity. The target population is 35 year old asymptomatic US women with an elevated risk of BRCA1/2 genetic mutation. The estimates of probability (prevalence, risk, preference and mortality), cost, and utility are derived from published reports and BRCA1/2 test technical documentation. We conducted the basecase cost-utility analysis and a series of sensitivity analyses by varying pretest probability of BRCA1/2 mutation, clinical sensitivity of BRCA1/2 testing, initial utility after BC diagnosis and patient preference in the first year after mastectomy, cost of BRCA1/2 testing, and out-of-pocket costs. Results: From the societal perspective, the “no test” strategy was estimated to cost $162K and resulted in 20.2 QALY gain over a patient's lifetime. The “test” strategy was estimated to cost $172K and result in 20.5 QALY gain, resulting in the incremental cost effectiveness ratio (ICER) of $30.6K/QALY. From a private payer perspective, the ICER was $36.8K/QALY. By conducting sensitivity analyses, we concluded that the model was robust to variation in the model parameters. Within the ranges of most variable estimates, the test strategy was more cost effective compared to the no-test strategy. The initial utility after BC diagnosis (basecase value 0.75) does not impact the choice of preferred strategy (testing is always preferred). Based on the probability of mutation for women with family history (basecase value 8.7%), testing is preferred if probability is greater than 3.1%, while no testing is preferred for values &amp;lt;3.1%. Only if cost of genetic testing is greater than $8,948 testing would it no longer be cost effective, which is however far beyond even the upper bound of cost estimate ($4,500). As long as the sensitivity of BRCA testing remains greater than 80% and initial utility after mastectomy &amp;lt;0.9, the testing is preferred over no testing. Discussion: The strategy of BRCA1/2 testing of women at high risk for BRCA1/2 mutations and treatment of BRCA1/2 positive women is cost-effective compared to “no genetic testing” strategy. Cost of the actual test is not a barrier to its cost-effectiveness. Despite adding MRI to breast cancer surveillance in high risk population and increases in healthcare costs, BRCA1/2 testing remains cost-effective from both the societal and from a private payer perspectives for an unaffected population with BRCA1/2 prevalence of greater than 3%. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD06-03.

P5-15-01: Words Matter: Influence of DCIS Diagnosis Terminology on Patient Treatment Decisions.

Abstract Background: Treatment of ductal carcinoma in-situ (DCIS) poses significant challenges. Although retrospective studies suggest that most cases of low grade DCIS will never progress to invasive disease, it remains difficult to accurately identify those patients at greatest risk. In this situation where many diagnosed tumors could follow an indolent course for the patient's lifetime, both systemic therapy and watchful waiting could be reasonable options, similar to those currently offered to patients with early prostate cancer. One strategy that has been suggested to reduce overtreatment is to use terms other than “ductal carcinoma in situ” when explaining a diagnosis of DCIS to a patient. In the current study, we have investigated the effect of terminology on women's stated treatment preference for DCIS. Methods: Women 40–65 years of age were recruited from a database of volunteers at an academic hospital. Subjects with a personal history of breast cancer were excluded. Endpoints were gathered from a web-based survey. Each subject was presented with three different scenarios, each of which used a different terminology for DCIS: non-invasive breast cancer, breast lesion, and abnormal cells. The scenarios included a detailed explanation of the risks and benefits of three treatment options: surgery, systemic treatment only and active surveillance. After reading each scenario, the subject was asked to choose among the treatment options and to explain her choice. Results: 187 subjects completed the survey. More women chose active surveillance when DCIS was described using the terms “abnormal cells” or “breast lesion” than using the term “non-invasive cancer” (Table 1). The majority of women (97/187, 52%) changed their treatment preference when a different term was used to describe DCIS. Of the 97 women who changed their treatment preference, 47 (48%) chose surgery when the term “non-invasive cancer” was used to describe DCIS, but chose a less invasive treatment when “cancer” was not used in the diagnosis. Of 90 people who did not change their treatment preference, 39 (43%) chose active surveillance. Among the three treatments, the percent of women who chose surgery was the highest (84/187; 46%) when the term “non-invasive cancer” was used. 47/84 (56%) of the women who chose surgery when using the term “non-invasive breast cancer” changed their treatment preference when a different term was used. 36/84 (43%) switched to active surveillance while 11/84 (13%) switched to medication. Conclusion: These results support that the specific terminology used to explain a diagnosis of DCIS influences patients’ treatment preference. Moreover, we found that women may entertain treatment preferences other than surgery for DCIS when the tradeoffs of each choice are clearly explained. Avoiding the word “cancer” in the diagnosis may offer a strategy that reduces fear-based treatment decisions and may reduce the burden of overtreatment for DCIS. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-15-01.

The cost-effectiveness of exercise referral schemes

BackgroundExercise referral schemes (ERS) aim to identify inactive adults in the primary care setting. The primary care professional refers the patient to a third party service, with this service taking responsibility for prescribing and monitoring an exercise programme tailored to the needs of the patient. This paper examines the cost-effectiveness of ERS in promoting physical activity compared with usual care in primary care setting.MethodsA decision analytic model was developed to estimate the cost-effectiveness of ERS from a UK NHS perspective. The costs and outcomes of ERS were modelled over the patient's lifetime. Data were derived from a systematic review of the literature on the clinical and cost-effectiveness of ERS, and on parameter inputs in the modelling framework. Outcomes were expressed as incremental cost per quality-adjusted life-year (QALY). Deterministic and probabilistic sensitivity analyses investigated the impact of varying ERS cost and effectiveness assumptions. Sub-group analyses explored the cost-effectiveness of ERS in sedentary people with an underlying condition.ResultsCompared with usual care, the mean incremental lifetime cost per patient for ERS was £169 and the mean incremental QALY was 0.008, generating a base-case incremental cost-effectiveness ratio (ICER) for ERS at £20,876 per QALY in sedentary individuals without a diagnosed medical condition. There was a 51% probability that ERS was cost-effective at £20,000 per QALY and 88% probability that ERS was cost-effective at £30,000 per QALY. In sub-group analyses, cost per QALY for ERS in sedentary obese individuals was £14,618, and in sedentary hypertensives and sedentary individuals with depression the estimated cost per QALY was £12,834 and £8,414 respectively. Incremental lifetime costs and benefits associated with ERS were small, reflecting the preventative public health context of the intervention, with this resulting in estimates of cost-effectiveness that are sensitive to variations in the relative risk of becoming physically active and cost of ERS.ConclusionsERS is associated with modest increase in lifetime costs and benefits. The cost-effectiveness of ERS is highly sensitive to small changes in the effectiveness and cost of ERS and is subject to some significant uncertainty mainly due to limitations in the clinical effectiveness evidence base.

Implementing Personalized Medicine in a Cancer Center

In 2006, the Moffitt Cancer Center partnered with patients, community clinicians, industry, academia, and 17 hospitals in the United States to begin a personalized cancer care initiative called Total Cancer Care. Total Cancer Care was designed to collect tumor specimens and clinical data throughout a patient's lifetime, with the goal of finding "the right treatment, for the right patient, at the right time." Because Total Cancer Care is a partnership with the patient and involves collection of clinical data and tumor specimens for research purposes, a formal protocol and patient consent process was developed, and an information technology platform was constructed to provide a robust "warehouse" for clinical and molecular profiling data. To date, more than 76,000 cancer patients from Moffitt and consortium medical centers have been enrolled in the protocol. The Total Cancer Care initiative has developed many of the capabilities and resources that are building the foundation of personalized medicine.

Cost-effectiveness of saxagliptin (Onglyza®) in type 2 diabetes in Sweden

AimThe objective of this study was to investigate the cost-effectiveness of saxagliptin (Onglyza®), a DPP-4 inhibitor, plus metformin compared with a sulphonylurea (SU) (Glipizide) plus metformin in Swedish patients not well controlled on metformin alone. MethodsData from a 52-week clinical trial comparing saxagliptin and glipizide in combination with metformin was used in a simulation model to estimate long term complications in a cohort of type 2 diabetes patients. The model estimates the incidence of microvascular and macrovascular complications, diabetes-specific mortality, all-cause mortality, and ultimately, costs and quality-adjusted life years (QALYs) associated with the investigated treatment strategies. Costs and QALYs were estimated for a lifetime time horizon. ResultsCompared with SU+metformin, the cost per QALY gained with saxagliptin+metformin is approximately SEK 91,000. Patients on saxagliptin+metformin gain 0.10 QALYs on average, at an incremental cost of around SEK 9500. The cost-effectiveness results were robust to various sensitivity analyses. ConclusionsThis study demonstrates that, over a patient's lifetime, the addition of saxagliptin to metformin is associated with improvements in quality-adjusted life years compared with SU in patients with type 2 diabetes. Saxagliptin treatment is a cost-effective treatment alternative for type 2 diabetes in patients not well-controlled on metformin alone.

Cost-Effectiveness Assessment of Telaprevir Combination Treatment Compared to Pegylated-Interferon+Ribavirin Alone in the Management of Chronic Hepatitis C in Treatment-naïve Patients

Purpose: The addition of telaprevir (T) to the combination of peginterferon alfa-2a/ribavirin (PR) for the treatment of genotype 1 chronic HCV in treatment-naïve patients substantially increased SVR compared to PR alone in the Phase 3 pivotal study ADVANCE. Based on this improvement in SVR rates, an Excel®-based decision-analytic model was developed to explore the potential long-term clinical and economic consequences of telaprevir combination treatment in treatment-naïve patients. Methods: A two-part (Treatment; Post-treatment) model was developed to project incremental clinical and economic consequences of T/PR versus PR alone treatment options. For Treatment, parallel hypothetical cohorts of 1,000 patients were generated and assigned to one of the treatment options. Based on intention-to-treat SVR rates from the ADVANCE trial, a proportion of each cohort was deemed to achieve SVR. Cohorts were directed into the Post-treatment part where long-term treatment consequences and associated economic implications were estimated for remaining lifetimes using a cyclic Markov process. In any cycle, patients could remain in or transition among health states: absence of cirrhosis, cirrhosis, decompensated cirrhosis, hepatocellular carcinoma, liver transplantation, and death. Baseline patient characteristics and SVR rates by baseline fibrosis scores were based on ADVANCE data. Age- and gender-specific health state transition probabilities, which varied with achievement of SVR, mortality, health state utilities, and cost data were obtained from published sources. The perspective of the analysis was that of a third-party payor. Results: The model projected an improvement in life expectancy and qualityadjusted life-years (QALYs) with T/PR treatment versus PR over the lifetime of the patient mainly due to reductions in HCV-related complications (20.1 LYs and 17.2 QALYs versus 19.3 LYs and 16.0 QALYs, respectively). While T/PR treatment was estimated to increase the treatment costs, most of this increase was offset by a reduction in the costs of the management of long-term complications: additional per patient cost associated with T/PR was ˜$16,000 over the patient's lifetime compared to PR alone. Estimated incremental cost-effectiveness ratios in this patient population were $13,500/QALYs and ˜$19,500/LYsgained. Conclusion: Modeling results suggested that telaprevir combination treatment is a cost-effective treatment strategy compared to peginterferon alfa-2a/ribavirin alone in treatment-naïve patients. The cost-effectiveness of telaprevir combination treatment was well within the limits of conventional willingness-to-pay thresholds in the U.S. Disclosure: Mr Deniz is an employee and stock holder of Vertex Pharmaceuticals, Dr. Brogan, Mr. Miller, Ms. Talbird and Mr. Thompson are employees of RTI Health Solutions. This research was performed by RTI Health Solutions and funded by Vertex Pharmaceuticals Incorporated.

Tod an behandlungsbedürftiger Tuberkulose oder an Begleitkrankheiten?

Tuberculosis (TB) is a curable disease. Nevertheless, patients in Germany also die of TB. Although mortality is decreasing, there are indications for an increase in lethality. This observation provided the impetus for a detailed analysis that sought to investigate the validity of the statistics on deaths caused by TB. The study population consists of the 926 fatal cases that were classified either as "death from TB" or as "death due to other causes" out of the 6044 TB patients in the DZK study. For the analysis, health authorities were asked to provide additional information and such documents as the death certificate, the autopsy protocol and the final medical report. In 778 cases, there was at least one additional piece of information available. Three teams of two experts each conducted independent evaluations of the documents. Based on the findings of the experts, every second death caused by TB in 1997 and 1998 was not recorded correctly during the post-mortem examination. Every third TB death was not diagnosed during the patient's lifetime. Patients who died due to TB were, on average, older and more likely to be born in Germany. This indicates that age-related comorbidity among the native German population plays a relevant role. Yet, the unicausal death registration did not acknowledge comorbidity as a contributing factor to the fatal outcome. Pulmonary TB with positive microscopy and culture, miliary TB and meningeal TB were more common among the deaths due to TB than among the general study population, and led more often to a fatal outcome than other organ manifestations. However, the two groups did not differ with regard to multi-drug resistant TB. Alcohol abuse was a leading risk factor for death caused by TB in patients under 65 years. Patient's delay ranged from six to 34 days, and doctor's delay from eight to 46 days. For example, alcohol abusers, on average, visited a physician much later, but were diagnosed more rapidly after the first visit than patients who were not alcohol-dependent. A period of 32 - 200 days elapsed between diagnosis and death caused by TB. The post-mortem examination often missed TB as the cause of death. Many native German TB patients showed age-related comorbidity. Pulmonary TB with positive microscopy, miliary TB and meningeal TB led more often to a fatal outcome than other organ manifestations. Alcohol abuse was a leading risk factor for TB deaths in patients younger the 65 years. The average period between the onset of symptoms and the diagnosis was significantly longer than the one month generally considered acceptable. The experts could not confirm an increase in lethality for the period under investigation.

Health Reform: A Community Experience Using Design Research as a Guide

Meaningful health reform in the United States must improve the health of the population while lowering costs. In an effort to provide a framework for doing so, the Institute of Health Care Improvement created the triple aim, which encompasses the goals of (1) improving individual health and experience with the health care system, (2) improving population health, and (3) decreasing the rate of per capita health care costs. Current reform efforts have focused on the development of Patient-Centered Medical Homes (an innovative team-based model of care that facilitates a partnership between the patient's personal physician coordinating care throughout a patient's lifetime to maximize health outcomes), but these relatively narrow efforts are focused on office practice and payment methods and are not generally oriented toward community needs. We sought to apply design research in assessing a community opportunity to apply the triple aim as a strategy to transform health care delivery. Mixed methodology provides greater insight into the unexpressed health needs of individuals and into the creation of delivery systems more likely to achieve the triple aim. In a small, midwestern town, a mixed methods approach was used to assess community health needs to facilitate design and implementation of care delivery systems. The research findings suggest that health system design concepts should focus on the creation of health, not health care; foster simplicity; create nurturing relationships; eliminate user fear; and contain costs. These observations can be helpful to health care professionals who are developing new methods of care delivery and policymakers and payers contemplating new payment systems to achieve the goals of the triple aim.

All-Arthroscopic Biologic Total Shoulder Resurfacing

The treatment of advanced, bipolar glenohumeral osteoarthritis in the young patient is particularly challenging because of the expected failure of a traditional shoulder arthroplasty within the patient's lifetime. We have had early success performing osteochondral allograft resurfacing of the humeral head articular surface and glenoid articular surface, and we describe a new all-arthroscopic technique for performing this procedure. In the context of our new procedure, we have reviewed the available literature on the topic of biologic resurfacing with osteochondral allograft and have provided an overview of the relevant findings. Although only short-term follow-up data are available, our results in young patients have been promising in terms of regained motion, minimal pain, and accelerated rehabilitation. We believe that this new arthroscopic biologic shoulder resurfacing technique has the potential to be superior to other available treatments for this patient population because it preserves bone stock, limits damage to surrounding structures, and allows for early rehabilitation. Although longer-term follow-up is needed, early results have been greatly encouraging.

The Treatment of Anterior Dental Trauma

Avulsed frontal teeth often cannot be saved because of improper or lack of initial treatment. The result is a need for multiple interventions over the patient's lifetime, which also carry a high financial cost. We explored the subject of lost anterior teeth in young patients with a PubMed search based on the term "prevalence of traumatic dental injuries" over the time period 2000-2010. In this article, we selectively review the publications retrieved by the search and give case examples to illustrate the proper initial treatment of children and adolescents (ages 6 to 17) with broken anterior teeth. The search retrieved 138 articles. Here, we review retrospective clinical studies of dental trauma between the ages of 6 and 17: only 6 adequately designed studies of this type were found. The estimated prevalence of anterior dental trauma in this age group ranged from 6.4% to 37.9%. The recommended initial steps for the preservation of traumatized teeth are easy to take. Avulsed teeth can and should be replanted at once. If there is no time, or if the patient simultaneously has other, life-threatening injuries, the avulsed teeth can be stored in a special nutrient medium until they can be replanted. Commercially available tooth rescue boxes enable replantation to be performed up to 24 hours after the injury. The authors of the selected studies agree that dental trauma is often improperly treated. Timely treatment of injured anterior teeth prevents much further damage and expensive treatment for the affected young patients.

Radiation therapy for ductal carcinoma in situ: a decision analysis.

The benefit of adding radiation therapy after excision of ductal carcinoma in situ (DCIS) is widely debated. Randomized clinical trials are underpowered to delineate long-term outcomes after radiation. The authors of this report constructed a Markov decision model to simulate the clinical course of DCIS in a woman aged 60 years who received treatment with either of 2 breast-conserving strategies: excision alone or excision plus radiation therapy. Sensitivity analyses were used to study the influence of risk of local recurrence, likelihood of invasive disease at recurrence, surgical choice at recurrence, and patient age at diagnosis on treatment outcomes. The addition of radiation therapy was associated with slight improvements in invasive disease-free and overall survival. However, radiation therapy decreased the chance of having both breasts intact over a patient's lifetime. Radiation therapy improved survival by 2.1 months for women who were diagnosed with DCIS at age 60 years but decreased the chance of having both breasts by 8.6% relative to excision alone. The differences in outcomes between the treatment strategies became smaller with increasing age at diagnosis. Sensitivity analyses revealed a greater benefit for radiation with an increased likelihood of invasive recurrence. The decrement in breast preservation with radiation therapy was mitigated by an increased likelihood of mastectomy at the time of recurrence or new breast cancer diagnosis. The current analysis quantified the benefits of radiation after excision of DCIS but also revealed that radiation therapy may increase the likelihood of eventual mastectomy. Therefore, the authors concluded that patient age and preferences should be considered when making the decision to add or forgo radiation for DCIS.

Low lifetime recreational activity is a risk factor for peripheral arterial disease

The relationship between lifetime physical activity and the risk of developing peripheral arterial disease (PAD) is not known. We studied 1381 patients referred for elective coronary angiography in a point prevalence analysis. PAD was defined as ankle-brachial index (ABI) <0.9 at the time or a history of revascularization of the lower extremities regardless of ABI measure. We used a validated physical activity questionnaire to retrospectively measure each patient's lifetime recreational activity (LRA). Multivariate and logistic regression analyses were used to assess the independent association of LRA to ABI and the presence of PAD. PAD was present in 19% (n = 258) of all subjects. Subjects reporting no regular LRA had greater diastolic blood pressure and were more likely to be female. They had lower average ABI, and a higher proportion had PAD (25.6%). In a regression model, including traditional risk factors and LRA, multivariate analysis showed that age (P < .001), female gender (P < .001), systolic blood pressure (P = .014), fasting glucose (P < .001), serum triglycerides (P = .02), and cumulative pack years (P < .001) were independent negative predictors of ABI, and LRA was a positive predictor of ABI (P < .001). History of sedentary lifestyle independently increased the odds ratio for PAD (odds ratio, 0.46; 95% confidence interval, 1.01-2.10) when assessed by logistic regression. Intriguingly, there is a correlation between physical activity and gender, such that women with low LRA are at greatest risk. Recalled LRA is positively correlated to ABI and associated with PAD. Whereas the mechanism for this effect is not clear, LRA may be a useful clinical screening tool for PAD risk, and strategies to increase adult recreational activity may reduce the burden of PAD later in life.