Physician Choices Research Articles

Randomized Clinical Trial of Surgical vs. Percutaneous vs. Hybrid Revascularization in Multivessel Coronary Artery Disease: Residual Myocardial Ischemia and Clinical Outcomes at One Year-Hybrid coronary REvascularization Versus Stenting or Surgery (HREVS).

Aim Optimal revascularization strategy in multivessel (MV) coronary artery disease (CAD) eligible for percutaneous management (PCI) and surgery remains unresolved. We evaluated, in a randomized clinical trial, residual myocardial ischemia (RI) and clinical outcomes of MV-CAD revascularization using coronary artery bypass grafting (CABG), hybrid coronary revascularization (HCR), or MV-PCI. Methods Consecutive MV-CAD patients (n = 155) were randomized (1 : 1 : 1) to conventional CABG (LIMA-LAD plus venous grafts) or HCR (MIDCAB LIMA-LAD followed by PCI for remaining vessels) or MV-PCI (everolimus-eluting CoCr stents) under Heart Team agreement on equal technical and clinical feasibility of each strategy. SPECT at 12 months (primary endpoint of RI that the trial was powered for; a measure of revascularization midterm efficacy and an independent predictor of long-term prognosis) preceded routine angiographic control. Results Data are given, respectively, for the CABG, HCR, and MV-PCI arms. Incomplete revascularization rate was 8.0% vs. 7.7% vs. 5.7% (p=0.71). Hospital stay was 13.8 vs. 13.5 vs. 4.5 days (p < 0.001), and sick-leave duration was 23 vs. 16 vs. 8 weeks (p < 0.001). At 12 months, RI was 5 (2, 9)% vs. 5 (3, 7)% vs. 6 (3, 10)% (median; Q1, Q3) with noninferiority p values of 0.0006 (HCR vs. CABG) and 0.016 (MV-PCI vs. CABG). Rates of angiographic graft stenosis/occlusion or in-segment restenosis were 20.4% vs. 8.2% vs. 5.9% (p=0.05). Clinical target vessel/graft failure occurred in 12.0% vs. 11.5% vs. 11.3% (p=0.62). Major adverse cardiac and cerebral event (MACCE) rate was similar (12% vs. 13.4% vs. 13.2%; p=0.83). Conclusion In this first randomized controlled study comparing CABG, HCR, and MV-PCI, residual myocardial ischemia and MACCE were similar at 12 months. There was no midterm indication of any added value of HCR. Hospital stay and sick-leave duration were shortest with MV-PCI. While longer-term follow-up is warranted, these findings may impact patient and physician choices and healthcare resources utilization. This trial is registered with NCT01699048.

Adherence to Clinical Guidelines, Electronic Health Record Use, and Online Reviews

To increase transparency of healthcare quality, the Centers for Medicare and Medicaid Services (CMS) initiated the Physician Quality Reporting System (PQRS). However, the impact of PQRS on physicians is unclear, particularly as related to their online reputation. Is there an association between a physician’s online reputation and her adherence to clinical guidelines stipulated in the PQRS? Is online reputation associated with use of electronic health records (EHR)? To investigate these questions, we combine data on online physician reviews with the PQRS data on clinical guideline adherence and EHR use. Unlike prior research, which primarily uses clinical outcomes as proxies for care quality, our study uses adherence to clinical guidelines, a process measure that reflects physician conformance with evidence-based clinical practices. In addition, we focus on EHR use at the physician level, in contrast to the usual approach of examining it at the aggregate institutional level. Consistent with the economic theory of credence goods, we observe no significant relationship between physicians’ adherence to clinical guidelines and their online reviews. Although there is some evidence of association between EHR use and their overall rating, similar relationships are not consistently observed for individual dimensional ratings. Overall, the online reputation of a physician exhibits minimal association with her actual clinical activities — and is mostly driven by latent topics in the textual reviews — implying that the ability of online reviews to inform prospective patients of care quality might be quite limited. Therefore, patients should be cautious when using online physician reviews, and policymakers should increase the accessibility of PQRS and other similar data to help patients make informed physician choices.

Influence of nurse’s involvement on practices during end-of-life decisions within stroke units

ObjectivesDecision-making processes concerning end-of-life decisions are not well understood for patients admitted into stroke units with severe stroke. To assess the influence of nurses on the medical perspectives and approaches that lead to withholding and/or withdrawing treatments related to end-of-life (EOL) decisions. Patients and methodsThis secondary analysis nested within the TELOS French national survey was based on a physicians' self-report questionnaire and on a I-Score which was linked to nurses' involvement. Physician's responses were evaluated to assess the potential influence of nurse's involvement on physician's choices during an end-of-life decision. ResultsAmong the 120 questionnaires analyzed, end-of-life decisions were more often made during a round-table discussion (58% vs. 35%, p = 0.004) when physicians declare to involve nurses in the decision process. Neurologists involved with nurses in decision making were more likely to withhold a treatment (98% vs. 88%, p = 0.04), to withdraw artificial feeding and hydration (59% vs. 39%, p = 0.04), and more frequently prescribed analgesics and hypnotics at a potentially lethal dose (70% vs. 48%, p = 0.03). ConclusionThe involvement of nurses during end-of-life decisions for patients with acute stroke in stroke units seemed to influence neurologists' intensivist practices and behaviors. Nurses supported the physicians' decisions related to forgoing life sustaining treatment for patients with acute stroke and may positively impact on the family's choice to participate in end-of-life decisions.

A Review on Traditional Ayurveda Formulations and their Therapeutic Importance

Ayurveda the therapeutic system of Indian medicine utilizes various types of dosage forms for health benefits including Vati, Churna, Kwatha, Asava, Arishta, Kalka and Avaleha, etc. The different formulations possess different Virya (potency) therefore they act in different way. Ayurveda specified uses of various formulation for different health benefits and some formulation meant for specified uses through different route of administration like; oral, topical and nasal formulations, etc. Ayurveda also recommended use of various formulations with in specified age group say for example Bhasma not very popular in children. The availability of large number of formulation options not only enhances patient compliance but also increases physician choices. The liquid, solid, semisolid and Dhupan (smoke) are some ayurveda drug formulations based on their appearance, these all formulations having their specific characteristics differ from each other. Present article explored the concept and importance of diversified ayurveda formulations used for various therapeutic purposes. Keywords: Ayurveda, formulations, dosage forms, Virya.

Adherence of cardiologist physicians to the American Heart Association guideline in approach to risk factors of cardiovascular diseases: An experience from a teaching hospital.

BACKGROUNDCardiovascular disease (CVD) is the leading cause of death globally and has enormous costs for healthcare systems. This disease has a strong association with lifestyle behaviors. Therefore, applying reliable and effective strategies for prevention and treatment of CVD is important. In this study, we aimed to evaluate the adherence of cardiologist physicians to the American Heart Association (AHA) guideline for prevention of CVD.METHODSUsing a cross-sectional study, data were gathered for 208 patients using their medical records in the cardiology ward of a general teaching hospital. A physician systematically reviewed the medical records and completed the checklist in each domain. Adherence to the AHA guideline was evaluated in treating physician's choices and recommendations regarding these eight variables: hypertension (HTN), dietary intake, weight management, diabetes management, physical activity, blood lipid management, smoking, and aspirin prescription.RESULTSMedical records of 208 patients (109 men and 99 women) with the mean age of 62 ± 14 years were reviewed. The frequency of CVDs was 5.3% for coronary heart failure (HF) and 67.8% for the acute coronary syndrome (ACS). Cardiovascular risk factors of patients were HTN (53.8%), diabetes (34.6%), hyperlipidemia (17.3%), smoking (17.8%), and obesity (31.7%). We found a proportion of 59%, 15%, and 26% for high, moderate, and low adherence to AHA guideline, respectively.CONCLUSIONOur study showed almost 60% high adherence to the AHA guideline by physicians in a teaching hospital. The most and the least adherence to the AHA guideline were for obesity and diabetes recommendations, respectively. More studies are needed to evaluate preventive guideline adherence in Iran. Establishing national preventive and therapeutic guidelines may increase the physicians' adherence to them.

Better Doctor-Patient Relationships Are Associated with Men Choosing More Active Depression Treatment.

Men tend to have low rates of treatment uptake for depression. The quality of the relationship with their family physician may be a factor influencing attitudes toward treatment. The present study was developed to explore this issue in a nationally representative sample of Canadian men. An online survey of 1000 Canadian men was conducted to inquire about men's relationship with their family physician and hypothetical treatment choices for depression. Main analyses were conducted among 819 men who indicated having a regular primary care physician. Two thirds of men with a family physician (n = 534; 65%) indicated they would pursue treatment if they were suffering from depression. Multinomial logistic regression, controlling for age, employment, education level, and current depressive symptoms indicated that positive perceptions of the patient-doctor relationship were associated with men being more likely to opt for pharmacotherapy (n = 183; odds ratio [OR], 1.06; P < .001), and individual psychotherapy (n = 277; OR, 1.04; P < .001), compared with a wait-and-see/no treatment approach (n = 285). The quality of the doctor-patient relationship is an important element in helping men choose active treatment for depression.

CJEM Debate Series: #ChoosingWisely - The Choosing Wisely campaign will not impact physician behaviour and choices - CORRIGENDUM.

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Trust in Physician and Health Agency Impact Postpartum Choices in Women with Gestational Diabetes [20N

INTRODUCTION: Trust in physicians and health agency have been associated with adherence in primary care, but have not been evaluated in the postpartum setting. We assessed the role of these constructs in adherence to postpartum best-practices among women with gestational diabetes mellitus (GDM). METHODS: A prospective cohort of 300 women with GDM completed the validated Trust in Physician Scale (Cronbach alpha 0.81) during their postpartum hospitalization. Participants rated health agency with a 4-point Likert scale evaluating the statement, “I feel that I have little control over risks to my health”. Chart review determined postpartum visit attendance, glucose testing, and sustained breastfeeding. Contraceptive use was collected via telephone interview at 3 months postpartum. Trust and agency were compared with Kruskal-Wallis and Wilcoxon rank sum tests respectively. Confounders were accounted for in multivariable models. RESULTS: By 12 weeks postpartum, 83% of participants had attended postpartum visits, 61% of whom were breastfeeding, and 42% had completed postpartum glucose testing. Of 226 participants who completed telephone interviews, 66% reported using contraception. Trust did not differ by demographics or pregnancy outcome. Health agency differed by income and race/ethnicity. Trust and health agency were not associated with postpartum visit adherence, but greater trust was associated with postpartum glucose testing adherence (P&lt;.01), and contraception use (P&lt;.01). Increased health agency was associated with sustained breastfeeding (P&lt;.01). This association persisted after adjusting for income and race/ethnicity. CONCLUSION: Strategies that foster trust between clinicians and patients may improve adherence with postpartum glucose testing and contraception use in women with GDM.

P088: Procedural sedation in Canadian emergency departments a national survey of airway management, patient monitoring, and adverse events

Introduction: Emergency department (ED) physicians strive to provide analgesia, amnesia and sedation for patients undergoing painful procedures through the use of procedural sedation (PS). While, PS is generally safe and effective in the ED, there is institutional variability and clinician disagreement with respect to the bedside equipment required for airway management and the monitoring of adverse events. The primary goal of this research project was to describe the variability of the bedside setup utilized by Canadian ED physicians preforming PS in conjunction with self-reported adverse events. Methods: An electronic survey was distributed through the Canadian Association of Emergency Physicians (CAEP). Practicing physician members of CAEP were invited to complete the survey. The 20 question survey encompassed various aspects of PS including physician choices regarding bedside setup of airway equipment, and prevalence of self-reported adverse events. The primary outcome was the quantification of variability among ED physicians with respect to the above listed aspects of PS. Data was presented with simple descriptive statistics. Results: 278 ED physicians responded to our survey (response rate 20.9%). Respondents were primarily academic (53.2%) or community hospital based (38.2%). With emergency medicine training as: CCFP-EM (55.2%), FRCPC (30.1%), and CCFP (9.0%). The ED area in which PS was carried out varied; bedside (30.5%), procedure room (37.1%), resuscitation area (31.2%). The basic equipment set utilized appears to be a bag valve mask, suction, and an oral airway. These 3 items were present 95.4%, 95.9%, and 86.3% of the time respectively. The preparation of other items such as capnography and difficult airway equipment is highly variable and appears to be physician specific rather than clinical situation specific. The most common physician self-reported adverse events associated with PS appear to be hypoxia (Spo2&lt;90%), hypotension (sBP&lt;90), and prolonged sedation which occurred in 10.7%, 8.3%, and 8.1% of PS performed. Conclusion: There appears to be significant practice variability with respect to the clinical setting as well as the equipment ED physicians prefer when administering PS. Given that causal relationships cannot be inferred between airway/monitoring equipment preferences and adverse events, future studies should be targeted at identifying optimal bedside set ups which minimize adverse events.

P087: Procedural sedation in Canadian emergency departments a national survey of pharmacological agent selection and practice variation

Introduction: Emergency department (ED) physicians strive to provide analgesia, amnesia and sedation for patients when performing painful procedures through the use of procedural sedation (PS). Examination of the literature suggests that the application of PS appears to be variable with institutional influences and clinician disagreement on pharmacology, airway management, and monitoring. The primary goal of this research project was to describe the variability of practice with respect to pharmacologic choices and clinical applications of PS among Canadian ED physicians. Methods: An electronic survey was distributed through the Canadian Association of Emergency Physicians (CAEP). Practicing physician members of CAEP were invited to complete the survey. The 20 question survey encompassed various aspects of PS including physician choices regarding PS indications and pharmacology. The primary outcome was the quantification of practice variability among ED physicians with respect to the above listed aspects of PS. The data was presented with simple descriptive statistics. Results: To date, 278 ED physicians responded to our survey (response rate 20.3%). Respondents were primarily academic hospital (53.2%) or community hospital based (38.2%). With emergency medicine training as: CCFP-EM (55.2%), FRCPC (30.1%), and CCFP (9.0%). There was relative agreement on the following interventions requiring PS: 98.4% applied PS for electrical cardioversion and 98.1% for brief (&lt;10 mins) orthopedic manipulations. However, only 36.3% utilized PS for burn debridement in the ED. PS was utilized less frequently (78.1%) for prolonged (&gt;10mins) orthopedic manipulations than brief manipulations. For all procedures aggregated, in hemodynamically stable patients with an American Society of Anesthesiology (ASA) score of 1, ED physicians utilized propofol 76.3% of the time. Additional agents were utilized at the following rates: fentanyl-propofol (7.6%), ketamine (7.6%), and fentanyl (4%). This inclination towards propofol alone appears to be consistent across modality of ER training, type of ER setting (rural vs academic), and volume of PS performed. Conclusion: This study demonstrates that Canadian ED physicians have a clear preference for propofol as a first line pharmacologic agent when administering PS in hemodynamically stable, ASA1 patients. Conversely, there appears to be more variation amongst ED physicians with respect to second line pharmaceutical choices for PS.

CJEM Debate Series: #ChoosingWisely - The Choosing Wisely campaign will not impact physician behaviour and choices.

CJEM Debate Series: #ChoosingWisely - The Choosing Wisely campaign will not impact physician behaviour and choices.

MP77-18 WHAT FALSE NEGATIVE RATE OF NON-INVASIVE TESTING ARE ACTIVE SURVEILLANCE PATIENTS AND URO-ONCOLOGISTS WILLING TO ACCEPT IN ORDER TO AVOID PROSTATE BIOPSY?

You have accessJournal of UrologyProstate Cancer: Detection & Screening VII1 Apr 2017MP77-18 WHAT FALSE NEGATIVE RATE OF NON-INVASIVE TESTING ARE ACTIVE SURVEILLANCE PATIENTS AND URO-ONCOLOGISTS WILLING TO ACCEPT IN ORDER TO AVOID PROSTATE BIOPSY? Rashid Sayyid, Dharmendra Dingar, Katherine Fleshner, Taylor Thorburn, Joshua Diamond, Erik Yao, Karen Hersey, Karen Chadwick, Nathan Perlis, Laurence Klotz, Antonio Finelli, Alexandre Zlotta, Robert Hamilton, Girish Kulkarni, and Neil Fleshner Rashid SayyidRashid Sayyid More articles by this author , Dharmendra DingarDharmendra Dingar More articles by this author , Katherine FleshnerKatherine Fleshner More articles by this author , Taylor ThorburnTaylor Thorburn More articles by this author , Joshua DiamondJoshua Diamond More articles by this author , Erik YaoErik Yao More articles by this author , Karen HerseyKaren Hersey More articles by this author , Karen ChadwickKaren Chadwick More articles by this author , Nathan PerlisNathan Perlis More articles by this author , Laurence KlotzLaurence Klotz More articles by this author , Antonio FinelliAntonio Finelli More articles by this author , Alexandre ZlottaAlexandre Zlotta More articles by this author , Robert HamiltonRobert Hamilton More articles by this author , Girish KulkarniGirish Kulkarni More articles by this author , and Neil FleshnerNeil Fleshner More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2126AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Repeat prostate biopsies in active surveillance patients are associated with significant complications. Novel imaging and blood/urine based non-invasive tests are being developed to better predict disease grade and volume progression. We conducted a theoretical study to determine what test performance characteristics and costs would a non-invasive test(s) require in order for patients and their physicians to comfortably avoid biopsy. METHODS Surveys were administered to two populations to determine an acceptable false-negative rate and cost for such test(s). AS patients were recruited at time of visit to the prostate cancer clinic at Princess Margaret Cancer Centre, beginning August 2015 for a period of four months. Responses from urologic oncologists worldwide were obtained in March 2016 by circulating an online survey via the Society of Urologic Oncology. Participants were questioned about their demographics and other characteristics that might influence chosen error rates and cost. Differences between patient and physician choices were tested using the Chi-square test. RESULTS 136 patients and 670 physicians were surveyed, with 130 (96%) and 104 (16%) responses obtained, respectively. 90.6% of patients were comfortable with a non-invasive test(s) in place of biopsy, with 64.8% accepting a false-negative rate of 5% or worse. 25.8% of patients requested a FN rate of 1% or lower. 93.3% of physicians were comfortable with a non-invasive test, with 77.9% accepting a rate of 5% or worse. 15.4% of physicians requested a FN rate of 1% or lower. 75% of patients and 77% of physicians felt that a cost of less than $1,000, per administration, would be reasonable. No significant differences existed between patient and physicians choices for FN rate or costs (p>0.05). CONCLUSIONS Most patients/physicians are comfortable with a non-invasive test(s). Although a 5% error rate seems acceptable to many, a substantial subset feels that 99% or higher negative predictive value is required. Thus, a personalized approach with shared-decision making between patients and physicians is essential to optimize patient care in such situations. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1028-e1029 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Rashid Sayyid More articles by this author Dharmendra Dingar More articles by this author Katherine Fleshner More articles by this author Taylor Thorburn More articles by this author Joshua Diamond More articles by this author Erik Yao More articles by this author Karen Hersey More articles by this author Karen Chadwick More articles by this author Nathan Perlis More articles by this author Laurence Klotz More articles by this author Antonio Finelli More articles by this author Alexandre Zlotta More articles by this author Robert Hamilton More articles by this author Girish Kulkarni More articles by this author Neil Fleshner More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

‘Medical Necessity’ in Psychiatry: Whose Definition Is It Anyway?

‘Medical Necessity’ in Psychiatry: Whose Definition Is It Anyway?

Pain Medicine Ethics Forum: Key Opinion Leaders with Industry Conflicts of Interest Should Be Able to Hold Leadership Positions in Professional Medical Associations.

Disclosure: Depomed, Advisory Board; Spinal Modulations, Data Safety and Monitoring Board; Boston Scientific, Consultant; Jazz Pharmaceutical, Advisory Board and Speaker; Jansen, Advisory Board; Zynerba, Advisory Board; Daiichi Sankyo, Advisory Board and Coronado Biosciences, Advisory Board. In 2009, the Journal of the American Medical Association published a proposal for controlling conflicts of interest between Professional Medical Associations (PMAs) and industry [1]. The proposal recommended $0 thresholds for presidents, officers, and board members. It also recommended $0 funding of any PMA activities. The premise for this recommendation was based on research showing the power of gifts to bias physician choices. However, it was not based on research on the effects of payments made to consulting physicians, those serving on scientific advisory boards for …

Resident Physicians Choices of Anticoagulation for Stroke Prevention in Patients With Nonvalvular Atrial Fibrillation

Atrial fibrillation (AF) is a common cardiac arrhythmia and is associated with an increased risk of ischemic stroke. The aim of this study was to identify practice patterns of Canadian resident physicians pertaining to stroke prevention in nonvalvular AF according to the Canadian Cardiovascular Society guidelines. A Web-based survey consisting of 16 multiple-choice questions was distributed to 11 academic centres. Questions involved identification of risks of stroke, bleeding, and selection of appropriate therapy in clinical scenarios that involve a patient with AF with a Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack (CHADS2) score of 3 and no absolute contraindications to anticoagulation. There were 1014 total respondents, of whom 570 were internal, 247 family, 137 emergency medicine, and 60 adult cardiology residents. For a patient with a new diagnosis of AF, warfarin was chosen by 80.3%, novel oral anticoagulants (NOACs) by 60.3%, and acetylsalicylic acid (ASA) by 7.2% of residents. To a patient with a history of gastrointestinal bleed during ASA treatment, warfarin was recommended by 75.1%, NOACs by 36.1%, ASA by 12.1%, and 4% were unsure. For a patient with a history of an intracranial bleed, warfarin was recommended by 38.8%, NOACs by 23%, ASA by 24.8%, and 18.2% were unsure. For a patient taking warfarin who had a labile international normalized ratio, 89% would switch to a NOAC and 29.5% would continue warfarin. This study revealed that, across a wide sampling of disciplines and centres, resident physician choices of anticoagulation in nonvalvular AF differ significantly from contemporary Canadian Cardiovascular Society guidelines.

Factors influencing the geographic distribution of physicians in Iran: a qualitative study

Introduction: The uneven geographic distribution of physicians has been a longstanding important issue worldwide. Different policies have been recently employed in Iran, with the aim of bridging the gap. This study aimed to explore factors influencing the distribution of specialist physicians in Iran and investigate the effects of newly established policies on attracting and retaining physicians in rural and remote areas. Methods: This qualitative study was conducted in 2012. Qualitative data were obtained through an open-ended questionnaire and by reviewing relevant documents. Participants were 82 key officials from medical universities, who were directly involved in the distribution of physicians across the country, including vice chancellors for treatment affairs, managers for treatment affairs, and human resources experts. Thematic analysis was used to analyse qualitative data. Results: Four main factors influencing the distribution of physicians were explored, namely external, contextual, individual, and organizational factors. The decision to practice in rural areas was mainly influenced by socioeconomic characteristics of the designated areas and personal attributes of physicians, including sex, income expectations, and rural background. Participants also asserted that the implemented policies had a major positive influence on the distribution of physicians. In addition, participants believed that the improvement in the distribution of physicians had both positive economic and health impacts in underdeveloped areas. Conclusions: It seems that the regional distribution and supply of physicians have been improved in the light of the implemented policies in recent years. The study also revealed that a number of factors influence physician choices to stay and practice in rural and

Comparison Between Related T-Cell Depleted HLA-Haploidentical Stem Cell Transplantation (TCD-Haplo) and Umbilical Cord Blood Transplantation (UCBT) in Pediatric Patients with Acute Leukemia, a Eurocord, PDWP-EBMT Study

Both TCD-Haplo and UCBT are used for treating children with either acute lymphoblastic (ALL) or myeloid (AML) leukemia in need of an allograft and lacking a suitable donor. Although both these types of HSCT have been shown to be effective in curing children with acute leukemia, to date, no study has compared the outcomes of these two types of transplant.We performed a retrospective registry-based study on children (less than 18 years) with either ALL or AML, receiving, after a myeloablative conditioning regimen, a TCD-Haplo (CD34+ cell positive selection, CD3+ negative or TCR alpha/beta+ cell depletion) or single unit UCBT. Patients given pharmacological graft-versus-host disease (GVHD) prophylaxis after graft infusion in haplo HSCT were excluded.Transplants were performed from 2001 to 2012 in EBMT centers; 1067 patients received single UCBT and 266 TCD-Haplo for AML (n=478) or ALL (n=855). Median follow up was 28 (range 1-150) and 20 (range 1-152) months for UCBT and TCD-Haplo, respectively.Compared to TCD-Haplo, UCBT recipients were younger (median age 5.96 years vs 9.6 years, p=<0.0001), were transplanted more frequently in CR1 (42% vs 24%, p=<0.001), less frequently in advanced disease (10% vs 21%, p=<0.001) and had more often negative cytomegalovirus (CMV) serology (45% vs 31%, p=<0.001).Conditioning regimen was mainly total body irradiation (TBI)-based, 56% versus 50% for TCD-Haplo and UCBT, respectively. For UCBT, patients CSA+steroids was the most commonly used (72%) GVHD prophylaxis. A higher proportion of patients transplanted with TCD-Haplo received ATG in the conditioning regimen (90% vs 74%, p=<0.001).Acute GVHD (grade II-IV) incidence was 16% and 28% (p<0.001) while that of chronic GVHD was 14% and 16%, (p=0.40) for TCD-Haplo and UCBT respectively. Since diagnosis was the most important factor influencing outcome, the analysis was performed separately for patients with ALL and AML.For ALL (n=855) in univariate analysis, the 2-year probability of leukemia-free survival (LFS) was 35% and 43% (p=0.08), for TCD-Haplo and UCBT, respectively. The cumulative incidence (CI) of non-relapse mortality (NRM) was 28% and 29% (p=0.57), and relapse incidence (RI) was 36% and 28% (p=0.01) for TCD-Haplo and UCBT, respectively.According to disease status, for patients in CR1 (n=300), 2-year RI was 21% versus 20%, p=0.75; NRM 30% versus 24%, p=0.59; and 2- year LFS 49% versus 56%, p=0.87; for TCD-Haplo and UCBT, respectively.For patients in CR2 (n=478), 2-year RI was 34% versus 29%, p=0.75; NRM 28% versus 32%, p=0.29; and 2- year LFS 38% versus 39%, p=0.63, for TCD-Haplo and UCBT, respectively. For patients in advanced disease (n=77), 2-year LFS was 5% versus 8%, p=0.08 for TCD-Haplo and UCBT, respectively.For patients with AML (n=478), 2-year probability of LFS was 21% and 58% (p=<0.0001), for TCD-Haplo and UCBT, respectively. CI of NRM was 43% and 19% (p=<0.001), and RI was 36% and 23% (p=0.01) for TCD-Haplo and UCBT, respectively.According to disease status, for patients in CR1 (n=207), 2-year RI was 31% versus 14%, p=0.06; NRM 45% versus 16%, p=0.002; and 2-year LFS 24% versus 69%, p=<0.001; for TCD-Haplo and UCBT, respectively.For patients in CR2 (n=180), 2-year RI was 28% versus 24%, p=0.49; NRM 44% versus 21%, p=0.004; and 2- year LFS 28% versus 55%, p=0.0005, for TCD-Haplo and UCBT, respectively. For patients in advanced disease status (n=91), 2-year LFS was 10% versus 22%, p=0.44 for TCD-Haplo and UCBT, respectively.In multivariate analysis adjusted for differences between the 2 groups, for patients with ALL, no statistically significant differences were observed according to the graft source. Disease status was the only factor associated with better LFS (HR 4.84, p<0.0001). TCD-Haplo was associated with greater risk of RI (HR 1.58, p=0.01).For AML, in multivariate analysis, TCD-Haplo was associated with greater risk of relapse (HR 1.67, p=0.05) and of NRM (HR= 1.94; p=<0.001), and worse LFS (HR 1.94, p=<0.001) when compared to UCBT. Advanced disease at transplantation (HR 2.89, p=<0.001) was the other factor associated with LFS and RI.This retrospective analysis demonstrates that children with ALL have comparable probability of LFS after either UCBT or TCD-Haplo. By contrast, in children with AML, UCBT is associated with lower risk of relapse and NRM than TCD-Haplo, this translating into better LFS. These results may help guide physician choices for transplanting children with acute leukemia. DisclosuresNo relevant conflicts of interest to declare.

External cues to action and influenza vaccination among post-graduate trainee physicians in Toronto, Canada

BackgroundUnderstanding factors affecting trainee physician choices about vaccination may permit the design of more effective vaccination programmes. MethodsTo identify factors associated with seasonal and pandemic influenza vaccination, an online questionnaire based on the health belief model was sent to trainee physicians registered at the post-graduate medical education office at the University of Toronto in September 2011. Results963 complete responses were received from 1884 trainee physicians (51%); 28 (2.9%) reported an allergy to vaccine components and were excluded from further analysis. Reported seasonal influenza vaccination rates in 2008, 2009 and 2010 were 69% (648/935), 75% (708/935) and 76% (703/935), respectively; 788 (84%) reported receiving the A(H1N1)pdm09 vaccine. In multivariable analysis, number of years of post-graduate training (OR for 4+ versus 1–3 post-graduate years 2.2 (95% CL 1.3, 3.8)) was associated with receipt of the 2009 pandemic vaccine, as were four components of the health belief model: odds ratios were 4.7 (95% CL 3.0, 7.5) for perceived severity, 1.9 (95% CL 1.2, 2.9) for perceived benefits, .35 (95% CL .21, .59) for perceived barriers, and 5.8 (95% CLI 3.6, 9.1) for external cues to action. Both vaccinated and unvaccinated respondents reported that their decisions were significantly influenced by encouragement from their colleagues, families and employers. ConclusionSelf-reported vaccination coverage among trainee physicians was high. External cues to action appear to be particularly important in trainee physician vaccination decisions: active institutional promotion may increase influenza vaccination rates in trainees.

Physician and patient willingness to pay for electronic cardiovascular disease management

ObjectivesCardiovascular disease (CVD) is an important target for electronic decision support. We examined the potential sustainability of an electronic CVD management program using a discrete choice experiment (DCE). Our objective was to estimate physician and patient willingness-to-pay (WTP) for the current and enhanced programs. MethodsFocus groups, expert input and literature searches decided the attributes to be evaluated for the physician and patient DCEs, which were carried out using a Web-based program. Hierarchical Bayes analysis estimated preference coefficients for each respondent and latent class analysis segmented each sample. Simulations were used to estimate WTP for each of the attributes individually and for an enhanced vascular management system. Results144 participants (70 physicians, 74 patients) completed the DCE. Overall, access speed to updated records and monthly payments for a nurse coordinator were the main determinants of physician choices. Two distinctly different segments of physicians were identified – one very sensitive to monthly subscription fee and speed of updating the tracker with new patient data and the other very sensitive to the monthly cost of the nurse coordinator and government billing incentives. Patient choices were most significantly influenced by the yearly subscription cost. The estimated physician WTP was slightly above the estimated threshold for sustainability while the patient WTP was below. ConclusionCurrent willingness to pay for electronic cardiovascular disease management should encourage innovation to provide economies of scale in program development, delivery and maintenance to meet sustainability thresholds.

The Impact of Public Information and FDA Issued Warnings on the Use of Antidepressants in Primary Care

Context: This article explores the relative impact of marketing information and FDA regulatory actions in the market for prescription drugs. We examine how direct to consumer advertising (DTCA) and FDA issued precautions and boxed warnings together affect young patients' visits with physicians and active prescriptions for anti-depressants. Methods: We aggregate 10 years (1998-2006) of detailed electronic medical record data on 9344 patients (254,810 patient-months) between the ages of 5 and 25, to the physician practice level. We then estimate monthly visit rates and active prescription rates using random and fixed effects models on the resulting unbalanced panel of practice months (N=1702). Findings: Results indicate that DTCA, FDA mandated changes to drug labels and media coverage affects the flow of patients into the physician practice and the rate of prescribing antidepressants. The FDA-issued boxed warning had a statistically significant effect only on prescribing rates for the under-18 year old population and only for the drugs explicitly mentioned in the boxed warning announcement. Conclusions: Since the policy goal of the boxed warning was to impact physician choices for all antidepressants our findings suggest there is room for improvement in the way boxed warnings – or indeed any FDA warning information – are released.