Provider Practice Patterns Research Articles

Influence of Geography on Prostate Cancer Treatment

Several definitive treatment options are available for prostate cancer, but geographic access to those options is not uniform. We created maps illustrating provider practice patterns relation to patients and assessed the influence of distance to treatment receipt. The patient cohort was created by searching the National Medicare Database for patients diagnosed and treated for prostate cancer from 2011 to 2014. The provider cohort was created by querying the American Medical Association Physician Masterfile to identify physicians who had treated patients with prostatectomy, intensity modulated radiation therapy (IMRT), brachytherapy, stereotactic body radiation therapy (SBRT), or proton therapy. Maps detailing the location of providers were created for each modality. Multivariate multinomial logistic regressions were used to assess the association between patient-provider distance and probability of treatment. Cohorts consisted of 89,902 patients treated by 5518 physicians. Substantial numbers of providers practicing established modalities (IMRT, prostatectomy, and brachytherapy) were noted in major urban centers, whereas provider numbers were reduced in rural areas, most notably for brachytherapy. Ninety percent of prostate cancer patients lived within 35.1, 28.9, and 55.6 miles of a practitioner of prostatectomy, IMRT, and brachytherapy, respectively. Practitioners of emerging modalities (SBRT and proton therapy) were predominantly concentrated in urban locations, with 90% of patients living within 128 miles (SBRT) and 374.5 miles (proton). Greater distance was associated with decreased probability of treatment (IMRT -3.8% per 10 miles; prostatectomy -2.1%; brachytherapy -2%; proton therapy -1.6%; and SBRT -1.1%). Geographic disparities were noted for analyzed treatment modalities, and these disparities influenced delivery.

Improving Obstetric Provider Congenital Cytomegalovirus Knowledge and Practices.

Background Congenital cytomegalovirus infection (cCMV) is the most common congenital infection. Antenatal education is proven to reduce cCMV risk. Little is known about obstetric provider knowledge and practice patterns around cCMV. Objectives To evaluate obstetric provider knowledge and practice patterns regarding cCMV at baseline and again after a brief educational intervention. Methods Obstetric providers (N = 53) at a US academic community hospital were invited to complete a survey regarding their knowledge and practice patterns around cCMV. Providers attended a brief presentation about cCMV and later were invited to repeat the same survey. Univariate statistics were calculated for baseline data, and prepost intervention comparison analyses were conducted. Results Baseline cCMV knowledge was low at 49% (M = 17.54 out of a possible 36, SD 6.4), with most providers (51%) reporting never counseling pregnant patients about cCMV. Post intervention, overall cCMV knowledge increased to 80% (M = 29.33, SD 4.1, p < .001); provider intention to counsel about cCMV prevention increased to 100%. Conclusions Obstetric provider knowledge about cCMV is low, which likely impacts their antenatal counseling. Educational initiatives to increase awareness about cCMV may increase antenatal education and thereby decrease the risk of cCMV.

A survey of adult and pediatric urologists on current practice in antibiotic prophylaxis for ureteral stent removal

Recommendations for antibiotic prophylaxis prior to cystourethroscopy with manipulation are based on limited evidence and may not be applicable to procedures without tissue resection such as ureteral stent removal. Our objectives were to investigate and compare practice patterns among adult and pediatric urologists on antibiotic prophylaxis for stent removal. An online survey was distributed to members of the Endourological Society (EUS) and Societies for Pediatric Urology (SPU) including questions about provider demographics and practice patterns. Adult urologists were defined as EUS member respondents and pediatric urologists were defined as SPU member respondents. Comparisons were made using Pearson's Chi-Square analysis. Of 2544 adult urologists surveyed, 258 (10%) completed the survey and of 714 pediatric urologists surveyed, 180 (25%) completed the survey (Table 1). Pediatric urologists report using antibiotic prophylaxis "most of the time" (i.e.≥75% of the time) more often than adult urologist when removing stents by string or operating room cystoscopy but less often when removing stents by office cystoscopy. Pediatric urologists report using antibiotic prophylaxis "most of the time" more often than adult urologists after pyeloplasty, ureteroscopy and ureteral reimplantation. There is no difference in reported duration of prophylaxis between adult and pediatric urologists, with 64% giving a single dose. Pediatric urologists report obtaining a urine culture (UC) "most of the time" more often than adult urologists (32% vs 15%, p<0.001), but there is no difference in reported use of antibiotic treatment by UC result. Sixty-four percent of survey respondents report giving patients with negative UC antibiotic treatment, and 93% of survey respondents report treating patients with asymptomatic bacteriuria (defined as patients with a positive urine culture but no symptoms) with antibiotics. There is variation in reported practice among surveyed adult and pediatric urologists regarding antibiotic prophylaxis prior to stent removal. Overall, pediatric urologists report using antibiotic prophylaxis prior to stent removal more often than adult urologists. This variation in practice combined with lack of evidence to support the use of antibiotic prophylaxis prior to ureteral stent removal underscores the need for additional research to guide the development of evidence-driven guidelines for both adult and pediatric patients.

Practice Patterns in Hospitalized Adult Patients with Hemophilia: A Survey Study of US Hemophilia Centers

Introduction:The care of patients with hemophilia (PwH) is rapidly evolving, with novel uses for existing clotting factor concentrates (CFC) and the introduction of non-CFC hemostatic agents (e.g. emicizumab) recently approved by the Food and Drug Administration. However, inpatient care of PwH hospitalized for elective surgery or major bleeds does not follow standardized protocols, and the manner and extent to which novel therapeutic strategies are applied is unknown. Objective:We performed a nationwide survey to obtain information on the practice patterns of adult hematology providers practicing at accredited U.S. hemophilia treatment centers (HTC) in the inpatient care of PwH in the perioperative setting. Methods:Using a publicly available list of accredited HTC adult providers, 59 providers were contacted by email with the option to participate in a phone call or online survey. We aimed to collect information regarding the perioperative management of patients on emicizumab, postoperative factor level monitoring, type of CFCs routinely utilized in the inpatient setting, hospital length of stay, and use of venous thromboembolism (VTE) prophylaxis in the postoperative setting. All non-categorizable responses were excluded. Results: Providers from 10 out of 59 hemophilia centers contacted across the U.S. participated in a phone survey (n=5) or online survey (n=5). Responses were collected from providers practicing in the Mountain States (n=2), Southeast (n=2), Mid-Atlantic (n=2), New England (n=2), Northern States (n=1), and undisclosed (n=1). Of the participating providers, 80% had experience managing patients on emicizumab who had undergone elective surgery or experienced major bleeding. Perioperative management of patients undergoing elective surgery on emicizumab by center was as follows: a single pre-operative bolus of FVIII (n=1), unmonitored weight-based CFC for the same duration as patients not on emicizumab (n=5), and monitored weight-based CFC using a bovine chromogenic assay for the same duration as patients not on emicizumab (n=2). One provider who had not yet cared for patient on emicizumab undergoing elective surgery anticipated that they would preemptively discontinue emicizumab and treat with CFC alone perioperatively. Ninety percent of providers monitored factor levels in hospitalized PwH after elective surgeries; length of monitoring varied between 1-2 days (n=3), 4-5 days (n=1), daily or every other day while inpatient (n=4), or through utilization of surgical site dependent monitoring (n=1). Of those who monitored factor levels, 67% measured both peaks and troughs, while 33% monitored troughs alone. For postoperative inpatient CFC infusion, 60% of providers used standard half-life products alone, while 30% used both standard and extended half-life (EHL) products for hospitalized PwH, generally with the EHL product given preoperatively. Forty percent of providers employed bolus CFC delivery alone while 60% used a combination of bolus and continuous infusions in their practice. Mean length of hospital stay after elective surgery varied between centers and ranged from 1-2 days up to 5-7 days depending on factor levels, pain management, and/or physical therapy needs. Length of stay was highly variable for major bleeds and non-elective surgeries depending on severity of illness and location of bleed. VTE prophylaxis was not given postoperatively by 70% of providers, another 20% of providers reported they may conditionally consider it, and the remaining 10% prescribed either enoxaparin or apixaban to all PwH on CFCs getting elective surgery while hospitalized. Conclusions:Practice patterns of medical providers caring for PwH hospitalized for elective surgery or major bleeding are highly variable across institutions. While the majority of participating providers reported monitoring factor levels in inpatients, the length of monitoring and measurements of peaks/troughs varied. EHL products are being used occasionally in hospitalized patients. The majority of providers do not prescribe VTE prophylaxis inpatient. Additional studies are required to clarify the optimal management strategy in this complex patient population. Disclosures Shatzel: Aronora, Inc.:Consultancy.

EoE Down Under Is Still EoE: Variability in Provider Practice Patterns in Australia and New Zealand Among Pediatric Gastroenterologists.

There is likely variation in approach and management of patient with EoE due to lack of standardized care and variation in guidelines. We aimed to identify current practices regarding diagnosis and treatment in children with eosinophillic esophagitis (EoE) in Australia and New Zealand (ANZ). Information on current diagnostic and management approaches for pediatric EoE was collected via an online survey sent to pediatric gastroenterologists (pGE) in ANZ. We performed a cross-sectional study of pGE using a 49-question instrument regarding evaluation, diagnostic, and therapeutic aspects of EoE between October 2019 and December 2019. Eighty-five percent of the survey responders were from Australia, and 66% were academic. 30% pGE perform > 3 esophageal biopsies for diagnosis of EoE, 40% involve an allergist, 30% use a twice daily PPI trial, and 70% do not exclude other cause of esophageal eosinophilia. For management, only 3% use dietary elimination as an initial therapy, and 24% use less than the recommended doses of swallowed fluticasone. Forty-nine percent were likely to stop treatment in after remission is achieved for 12months. The EoE endoscopic reference score (EREFS) was not routinely used (49%). Two-thirds of pGE are concerned about long-term effects of recurrent need of general anesthesia. Diagnostic and management strategies for EoE differed widely among pGE in ANZ, including in diagnostic biopsies, assessing competing causes of esophageal eosinophilia, initials selection of treatments, and maintenance strategies. This variability likely reflects continued uncertainty regarding optimal management strategies and stresses the need for pediatric-specific ANZ guidelines to standardize EoE care.

Impact of Health Insurance, Poverty, and Comorbidities on Colorectal Cancer Screening: Insights from the Medical Expenditure Panel Survey.

Despite national campaigns and other efforts to improve colorectal cancer (CRC) screening, participation rates remain below targets set by expert panels. We hypothesized that availability and practice patterns of healthcare providers may contribute to this gap. Using data of the Medical Expenditure Panel Survey for the years between 2000 and 2016, we extracted demographic, socioeconomic, and health-related data as well as reported experiences about barriers to care, correlating results with answers about recent participation in colorectal cancer screening. As CRC screening guidelines recommend initiation of testing at age 50, we focused on adults 50years or older. We included responses of 163,564 participants for the period studied. There was a significant increase in CRC screening rates over time. Comorbidity burden, poverty, race, and ethnicity independently predicted participation in screening. Lack of insurance coverage and cost of care played an important role as reported barrier. Convenient access to care, represented by availability of appointments beyond typical business hours, and frequency of provider interactions, correlated with higher rates of screening. Our data show a positive effect of educational efforts and healthcare reform with coverage of screening. Easy and more frequent access to individual providers predicted a higher likelihood of completed screening tests. This finding could translate into more widespread implementation of screening programs, as the increasingly common virtual care delivery offers a new and convenient option to patients.

Abstract 5739: Caring through the controversy: Primary care provider practice patterns and attitudes towards PSA based prostate cancer screening in a high risk area

Abstract Prostate cancer remains the leading cancer diagnosis among men in the United States and the second leading cause of cancer-related mortality. Furthermore, the incidence and mortality of prostate cancer in the Bronx, NY is in the highest quintile in New York State. Prostate cancer screening is accomplished mainly through measurement of serum prostate specific antigen (PSA). However, most prostate cancers detected by screening are not aggressive, and can be monitored under active surveillance, with no interventions required. Unfortunately, many men diagnosed with prostate cancer experience anxiety and pressure to seek treatment, resulting in overtreatment of clinically insignificant disease. Guidelines for prostate cancer screening with PSA measurement have changed several times in the past 10 years, with the leading recommending groups frequently disagreeing on recommendations. National data suggests that this has resulted in inconsistent prostate cancer screening practices and current screening rates at our institution are low (23%). Current recommendations are to screen healthy men aged 55-69 with an emphasis on shared decision making with the patient. The authors administered an anonymous, voluntary paper survey to medical providers in the Departments of Family and Internal Medicine at BronxCare. In total, 91 anonymous surveys were collected. 50% of respondents had ordered a PSA in the past 2 years, most frequently because of patient age (34%), urological symptoms (26%) or because the patient had asked (27%). They most frequently decided against PSA testing in certain patients because of patient age (25%) or health status (23%). 46% of medical practitioners stated that they at least occasionally screen their healthy patients for prostate cancer and they screen patients at all age ranges from 35-80+ years, even though 73% say that they intend to follow current USPSTF guidelines. Notably, in response to questions about comfort with PSA testing, feelings about the scientific validity and importance of PSA testing, medical provider responses were nearly evenly distributed across the Likert Scale, while most (68%) were comfortable with shared decision making with there patients. Importantly, the majority (79%) felt that they wanted more information on prostate cancer screening. Regardless of demographics or training level, primary care providers at BronxCare approach PSA testing in many ways. The majority intend to follow USPSTF guidelines while most are not actually in practice. Given the high need for prostate cancer screening among our patients, and the desire of PCPs for additional information on PSA testing, a Quality Improvement project is underway. The intervention will include an educational module developed in conjunction with the Departments of Internal Medicine, Urology and the BronxCare Cancer Center and changes to the electronic medical record to spur prostate cancer screening discussions and guide PCPs and patients through the shared decision making process are being developed. Citation Format: Asona Lui, Jose Tiburcio, Douglas Reich. Caring through the controversy: Primary care provider practice patterns and attitudes towards PSA based prostate cancer screening in a high risk area [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5739.

Trends in Breast Cancer Treatment De-Implementation in Older Patients with Hormone Receptor-Positive Breast Cancer: A Mixed Methods Study.

Guidelines allow for the omission of sentinel lymph node biopsy (SLNB) and post-lumpectomy radiotherapy in women ≥ 70years of age with hormone receptor-positive (HR +) breast cancer. Despite this, national data suggest these procedures have not been widely de-implemented. Our objectives were to evaluate trends in SLNB and post-lumpectomy radiotherapy utilization in patients who are eligible for omission, and evaluate patient preferences as a target for de-implementation of low-value care. We performed a sequential explanatory mixed-methods study by first analyzing an institutional database of patients ≥ 70years of age with HR + breast cancer who received surgical treatment from 2014 to 2018. Based on the quantitative data, we conducted semi-structured interviews with women identified as high or low utilizers of breast cancer treatments to elicit patient perspectives on de-implementation. SLNB and post-lumpectomy radiotherapy were performed in 68% and 43% of patients, respectively, who met the criteria for omission. There was a significant decrease in SLNB rates from 2014 to 2018. Forty-nine percent of patients were classified as high utilizers and 26% were classified as low utilizers. Qualitative analysis found that the most important factors influencing decision making regarding SLNB and post-lumpectomy radiotherapy omission for both high and low utilizers were trust in their provider and a desire for peace of mind. Despite efforts to de-implement low-value care, older women with HR + breast cancer remain at risk of overtreatment. Patient perspectives suggest that multi-level de-implementation strategies will need to target provider practice patterns and patient-provider communication to promote high-quality decision making and reduction in breast cancer overtreatment.

Increased opioid use following rotator cuff repair associated with prior opioid use and surgeon prescription patterns

Prescription opioids are standard of care for postoperative pain management after musculoskeletal surgery, but there is no guidelineor consensus on best practices. Variability in the intensity of opioids prescribed for postoperative recovery has been documented, but it is unclear whether this variability is clinically motivated or associated with provider practice patterns, or how this variation is associated with patient outcomes. This study described variation in the intensity of opioids prescribed for patients undergoing rotator cuff repair (RCR)and examined associations with provider prescribing patterns and patients' long-term opioid use outcomes. Medicare data from 2010 to 2012 were used to identify 16,043 RCRs for patients with new shoulder complaints in 2011. Two measures of perioperative opioid use were created: (1) any opioid fill occurring 3 days before to 7 days after RCR and (2) total morphine milligram equivalents (MMEs) of all opioid fills during that period. Patient outcomes for persistent opioid use after RCR included (1) any opioid fill from 90 to 180 days after RCR and (2) the lack of any 30-day gap in opioid availability during that period. Generalized linear regression models were used to estimate associations between provider characteristics and opioid use for RCR, and between opioid use and outcomes. All models adjusted for patient clinical and demographic characteristics. Separate analyses were done for patients with and without opioid use in the 180 days before RCR. In this sample, 54% of patients undergoing RCR were opioid naive at the time of RCR. Relative to prior users, a greater proportion of opioid naive users had any opioid fill (85.7% vs. 75.4%), but prior users received more MMEs than naive users (565 vs. 451 MMEs). Providers' opioid prescribing for other patients was associated with the intensity of perioperative opioids received for RCR. Total MMEs received for RCR were associated with higher odds of persistent opioid use 90-180 days after RCR. The intensity of opioids received by patients for postoperative pain appears to be partially determined by the prescribing habits of their providers. Greater intensity of opioids received is, in turn, associated with greater odds of patterns of chronic opioid use after surgery. More comprehensive, patient-centered guidance on opioid prescribing is needed to help surgeons provide optimal postoperative pain management plans, balancing needs for short-term symptom relief and risks for long-term outcomes.

Results of a deep-dive survey on practice patterns of oncologists and advanced practice providers utilizing PARP inhibitors as maintenance therapy for patients with ovarian cancer.

e18044 Background: Often diagnosed at an advanced stage, most patients with ovarian cancer will relapse. As several PARP inhibitors (PARPi) have recently been approved as maintenance, patients are presented with treatment options that extend the interval of disease remission. However, novel challenges exist as oncology teams are apprehensive of integrating PARPi in practice. Emphasis on building this competence is essential for patients to obtain the maximum benefit of maintenance PARP therapy. Methods: Oncology teams were invited to participate in a 1-hour live and online education activity broadcast from 2018-2019 at OMedLive.com for 12 months. The activity addressed clinical data on the use of PARPi as maintenance therapy, management of adverse events, and emerging strategies utilizing PARP inhibition. A deep-dive survey, including structured and open-ended questions, was conducted 2 to 4 months after participation and focused on changes in practice, barriers to change, and observed patient outcomes. Results: In total, 915 clinicians participated in the video-based activity. Sixty physicians and advanced practitioners opted to complete the deep-dive survey, 70% of whom have used PARP inhibitors as maintenance therapy. Practice improvements were reported for identifying patients likely to benefit from PARPi (90%), differentiating among approved PARPi (86%), counseling patients (85%), and team-based side effect management (95%). The top 3 barriers to utilization of PARPi were lack of reimbursement (23%), inability to anticipate patient outcomes (15%), and unfamiliarity with clinical guidelines (15%). Variations in responses to open-ended questions included persistent questions (n = 47) in need of responses before adopting PARPi, data needed to better inform decision-making (n = 49), major concerns about PARPi (n = 55), and the most challenging aspects of current patient management with PARPi (n = 39). Conclusions: Patient education yielded improvements in practical application and management of PARP inhibitors for patients with ovarian cancer. The thematic variations in open-ended responses may inform the design of tailored interventions to improve clinical integration of PARP inhibitors as maintenance therapy and different lines of treatment.

Improving provider practice patterns in ordering FDG PET/CT for breast cancer patients at a safety-net hospital.

e14027 Background: Accurate staging is critical in determining treatment strategies in the management of breast cancer (BC) patients. FDG PET/CT is used to identify the presence of metastatic disease. The criteria for FDG PET/CT utilization is variable, including in any patient with nodal positivity, any patients with systemic symptoms, to those with Stage III disease or higher.. This practice variation has results in different patterns of ordering FDG PET/CT. The preliminary results of a Quality Oncology Practice Initiative (QOPI) audit performed in our Cancer Center in 2017 prompted concern for the over utilization of FDG PET/CT in our BC patients. We performed an initial audit of these practices in 2017 and confirmed these findings. The goal of this study was to re-measure our adherence to NCCN guidelines in 2019 after an educational session complimented by use of a checklist. Methods: A retrospective review was conducted for all BC patients who had FDG PET/CT ordered as initial treatment planning from 1/2017-12/2017. This revealed a 33% rate of failure to meet NCCN guidelines. We then educated our team about the NCCN guidelines for initial PET/CT ordering during our weekly multi-disciplinary conferences, created a test ordering checklist and compared the effect of this education on the use of PET/CT in patients treated at our institution from 1/2019-12/2019. Results: 65 female BC patients had an FDG PET/CT ordered to assist in initial treatment recommendation in 2017. Overall, 66.2% (n = 43) of patients met NCCN indications while 33.8% (n = 22) did not. In comparison to 2017 data, 71 female breast cancer patients had an FDG PET/CT ordered in 2019. Overall, 67 patients (94.4%) met NCCN criteria indications for undergoing FDG PET/CT while only 5 patients (5.6%) did not. Conclusions: Review of FDG PET/CT scans ordered for initial treatment in 2017 revealed that about one third of scans were ordered outside of NCCN guideline recommendations. After an educational session and implementation of a test ordering checklist, we found a marked reduction in the use of FDG PET/CT outside of NCCN guideline recommendations. Although our study is limited by small sample sizes, we identified a practice area that deviated from national recommendations and were able to improve our internal compliance in national guidelines through education and system modification.

Distribution and Practice Patterns of Retina Providers in the United States

Abstract Synthesis of multiple national databases reveal significant differences in the distribution and practice patterns of retina specialists compared to non-retina specialists who provide retina care. The clinical significance of these differences is yet unclear.

Comparing Provider-Led Sexual Health Counseling of Male and Female Patients Undergoing Radical Cystectomy

BackgroundSexual dysfunction is a common quality-of-life issue among patients undergoing radical cystectomy (RC) for bladder cancer, but patients report deficiencies in sexual health counseling. AimWe sought to characterize provider-led sexual health counseling of patients undergoing RC and whether provider practice differs by patient gender. MethodsWe conducted a cross-sectional survey of members of the Society of Urologic Oncology to assess topics included in provider-led sexual health counseling and barriers to counseling. OutcomesNonroutine counseling regarding each sexual health topic was compared for female vs male patients using chi-squared tests. Modified Poisson regression was used to examine associations between provider characteristics and nonroutine counseling of female patients. ResultsAmong 140 urologists, the majority did not routinely counsel patients about sexual orientation, partner sexual dysfunction, or referral options to sexual health services. Providers were significantly more likely to not provide routine counseling to female patients compared to male patients about the following topics: baseline sexual activity (20.6% vs 9.7%, respectively, P = 0.04), baseline sexual dysfunction (60.8% vs 20.2%, respectively, P < 0.05), the risk of sexual dysfunction after RC (20.0% vs 6.5%, respectively, P = 0.006), the potential for nerve-sparing RC (70.8% vs 35.5%, respectively, P = 0.002), and postoperative sexual health and dysfunction (42.6% vs 21.1%, respectively, P = 0.01). Overall, 41.2% of providers did not routinely discuss the potential for pelvic organ-preserving RC with sexually active female patients. Provider sex, age, practice type, urologic oncology fellowship training, years in practice, or female RC volume were not predictive of nonroutine or disparate counseling of female patients. The most common barriers to counseling female patients were older patient age (50.7%), inadequate time (47.1%), and uncertainty about baseline sexual function (37.1%). Clinical ImplicationsUrologists acknowledge key deficiencies and gender disparities in sexual health counseling of patients undergoing RC. Strengths and LimitationsAlthough cross-sectional, to our knowledge, this is the first study to examine provider practice patterns regarding sexual health counseling of patients undergoing RC. ConclusionFuture efforts should be directed towards reducing barriers to sexual health counseling of patients undergoing RC to improve deficiencies and gender disparities.Gupta N, Kucirka LM, Semerjian A, et al. Comparing Provider-Led Sexual Health Counseling of Male and Female Patients Undergoing Radical Cystectomy. J Sex Med 2020;17:949–956.

PERCEPTIONS AND PRACTICES OF CARDIOLOGY FELLOWS REGARDING CORONARY ARTERY CALCIUM SCORING

CAC (coronary artery calcium) scoring is a noninvasive imaging modality which can be used to assess cardiovascular risk in asymptomatic patients and as a guide for initiating preventive therapy. While CAC scoring has gained wider acceptability, perceptions and practice patterns of providers

Fertility preservation options for transgender individuals.

Gender affirming medical and surgical treatments affect the reproductive potential of transgender individuals. Prior to the development of assisted reproductive technologies (ART), genital gender-affirming surgery frequently eliminated a patient’s reproductive potential. Today, all patients should be counseled on their fertility preservation (FP) options before medical and surgical transition, yet this appears to seldom occur in practice. The following review is the result of a systematic literature search of PubMed, Medline and Google Scholar to identify current and future FP options, barriers to treatment patients face, practice patterns of transgender health care providers, and if there were any standardized counseling protocols. Options for transwomen at any point in their transition range from simply providing a semen sample to be used with assistive reproductive techniques to experimental techniques involving testicular cryopreservation followed by in vitro initiation of spermatogenesis. Transmen before and after starting hormone therapy can pursue any assistive reproductive techniques available for ciswomen. Future options currently under investigation include ovarian tissue cryopreservation (OTC) with in vitro oocyte maturation. In addition to counseling about their FP options, patients should be advised prospectively about the requirements, process details, the total costs associated with achieving pregnancy, and the inherent risks associated with using preserved genetic material including risk of failure, and maternal and fetal health risks. Transgender patients report using assistive reproductive services difficult, due to a lack of dialogue about fertility and the lack of information offered to them- presumably because their circumstances do not fit into a traditional narrative familiar to providers. Physicians and health care providers would benefit from better educational tools to help transgender patients make informed decisions and better training about transgender patients in general, and FP options available to them.

Practice patterns of board-certified sleep medicine providers: a national analysis among older adult Medicare beneficiaries.

To examine the proportion of Medicare beneficiaries with sleep disorders who were evaluated by board-certified sleep medicine providers (BCSMPs). Using a random 5% sample of Medicare administrative claims data (2007-2011), BCSMPs were identified by employing a novel cross-matching approach based on National Provider Identifiers available within the Medicare database. Sleep disorders were included based partially on the International Classification of Sleep Disorders, Third Edition (insomnia, sleep-related breathing disorders, hypersomnias, circadian rhythm sleep-wake disorders, parasomnias, and restless legs syndrome), and operationalized as International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes. The proportion of beneficiaries with each disorder who were seen by BCSMPs and nonspecialists was computed. Among older adult Medicare beneficiaries with sleep disorders, the most common sleep disorder was insomnia (n = 65,033), and the least common sleep disorder was narcolepsy (n = 784). Individuals with central sleep apnea (n = 1,561) were most likely to be treated by a BCSMP (63.9% of beneficiaries with central sleep apnea), and individuals diagnosed with insomnia were least likely to be treated by a BCSMP (16.4% of beneficiaries with insomnia). Most BCSMPs treated beneficiaries with obstructive sleep apnea (84.9% of BCSMPs) and insomnia (75.8% of BCSMPs). BCSMPs are involved in the care of a substantial proportion of Medicare beneficiaries with sleep disorders.

Provider Attitudes and Practice Patterns for Direct-Acting Antiviral Therapy for Patients With Hepatocellular Carcinoma

Provider Attitudes and Practice Patterns for Direct-Acting Antiviral Therapy for Patients With Hepatocellular Carcinoma

Primary care providers’ awareness, knowledge, and practice with regard to cardiovascular risk in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is a systemic auto-inflammatory disease associated with increased cardiovascular risk. Early identification and aggressive cardiovascular risk factor modification are critical for improvement in morbidity and mortality in patients with RA. This study is a cross-sectional survey with the purpose of evaluating primary care providers' awareness, practice patterns, and satisfaction with continuing medical education on cardiovascular risk in patients with RA. Our study showed that 71% of clinicians felt that the CME on RA patient management regarding CV risk factors is inadequate. Only 37% of providers reported feeling well prepared to manage CV risk for RA patients. Only 15% of participants were actively initiating a discussion regarding CV risk with RA patients. A better understanding of the educational needs and practice patterns of primary care providers may warrant the development of strategies for cardiovascular risk management in patients with RA.

Deployment Infectious Disease Threats: IDCRP Initiatives and Vision Forward.

Infectious diseases pose a significant threat to health and readiness of military personnel deployed globally during wartime and peacekeeping activities. Surveillance and improvement in mitigation through research of infectious disease threats remain an integral part of Force Health Protection. Herein, we review research efforts of the Infectious Disease Clinical Research Program related to deployment and travel-related infections. The objectives of the Deployment and Travel-Related Infections Research Area are to (1) provide epidemiologic and clinical data, including pathogen-specific estimates of disease incidence among deployed troops, (2) execute clinical trials and effectiveness studies to improve recommendations regarding prevention and treatment of infections during deployment, and (3) evaluate the knowledge and practice patterns of health care providers engaged in deployment/travel medicine and the impact on outcomes. The centerpiece protocol of the research area is the Deployment and Travel-Related Infectious Disease Risk Assessment, Outcomes, and Prevention Strategies cohort study (TravMil), which was initiated in 2010 and collects data on a broad range of deployment-related infections. To date, 4,154 deployed military personnel and traveling Department of Defense (DoD) beneficiaries have been enrolled in TravMil. Surveillance data collected through the TravMil study provide assessment of deployment and travel-related infectious disease threats, and the effectiveness of mitigation strategies. The incidence of travelers' diarrhea, influenza-like illness, and undifferentiated febrile illness is 20.48%, 9.34%, and 6.16%, respectively. The cohort study also provides necessary infrastructure to execute clinical trials. The TrEAT TD clinical trial evaluated the effectiveness of single-dose antibiotic therapy for travelers' diarrhea in the deployed setting. When compared to levofloxacin, azithromycin was not inferior; however, inferiority was not demonstrated with use of single dose of rifaximin. The trial findings supported the development of a deployment-related health guideline for the management of acute diarrheal disease. A clinical trial evaluating the effectiveness of rifaximin for prevention for travelers' diarrhea (Prevent TD) is underway. The research area has proven its ability to conduct impactful research, including the development of field-expedient diagnostics, the largest DoD multi-site travelers' diarrhea randomized control trial in peacetime and combat settings, and informed Force Health Protection guidance. The research area continues to provide surveillance data to military commands via an established collaborative network of military treatment facilities, DoD laboratories (both within and outside the continental United States), foreign militaries, and academia. The conduct of clinical and translational research in a deployment setting presents significant challenges, most notably in recruitment/enrollment and compliance with study-related procedures during deployment.

An Examination of Multilevel Factors Influencing Colorectal Cancer Screening in Primary Care Accountable Care Organization Settings: A Mixed-Methods Study

To identify patient, provider, and delivery system-level factors associated with colorectal cancer (CRC) screening and validate findings across multiple data sets. A concurrent mixed-methods design using electronic health records, provider survey, and provider interview. Eight primary care accountable care organization clinics in Nebraska. Patients' demographic/social characteristics, health utilization behaviors, and perceptions toward CRC screening; provider demographics and practice patterns; and clinics' delivery systems (eg, reminder system). Quantitative (frequencies, logistic regression, and t tests) and qualitative analyses (thematic coding). At the patient level, being 65 years of age and older (odds ratio [OR] = 1.34, P < .001), being non-Hispanic white (OR = 1.93, P < .001), having insurance (OR = 1.90, P = .01), having an annual physical examination (OR = 2.36, P < .001), and having chronic conditions (OR = 1.65 for 1-2 conditions, P < .001) were associated positively with screening, compared with their counterparts. The top 5 patient-level barriers included discomfort/pain of the procedure (60.3%), finance/cost (57.4%), other priority health issues (39.7%), lack of awareness (36.8%), and health literacy (26.5%). At the provider level, being female (OR = 1.88, P < .001), having medical doctor credentials (OR = 3.05, P < .001), and having a daily patient load less than 15 (OR = 1.50, P = .01) were positively related to CRC screening. None of the delivery system factors were significant except the reminder system. Interview data provided in-depth information on how these factors help or hinder CRC screening. Discrepancies in findings were observed in chronic condition, colonoscopy performed by primary doctors, and the clinic-level system factors. This study informs practitioners and policy makers on the effective multilevel strategies to promote CRC screening in primary care accountable care organization or equivalent settings. Some inconsistent findings between data sources require additional prospective cohort studies to validate those identified factors in question. The strategies may include (1) developing programs targeting relatively younger age groups or racial/ethnic minorities, (2) adapting multilevel/multicomponent interventions to address low demands and access of local population, (3) promoting annual physical examination as a cost-effective strategy, and (4) supporting organizational capacity and infrastructure (eg, IT system) to facilitate implementation of evidence-based interventions.