Practice Size Research Articles

Understanding how context and culture in six communities can shape implementation of a complex intervention: a comparative case study

BackgroundContextual factors can act as barriers or facilitators to scaling-up health care interventions, but there is limited understanding of how context and local culture can lead to differences in implementation of complex interventions with multiple stakeholder groups. This study aimed to explore and describe the nature of and differences between communities implementing Health TAPESTRY, a complex primary care intervention aiming to keep older adults healthier in their homes for longer, as it was scaled beyond its initial effectiveness trial.MethodsWe conducted a comparative case study with six communities in Ontario, Canada implementing Health TAPESTRY. We focused on differences between three key elements: interprofessional primary care teams, volunteer program coordination, and the client experience. Sources of data included semi-structured focus groups and interviews. Data were analyzed through the steps of thematic analysis. We then created matrices in NVivo by splitting the qualitative data by community and comparing across the key elements of the Health TAPESTRY intervention.ResultsOverall 135 people participated (39 clients, 8 clinical managers, 59 health providers, 6 volunteer coordinators, and 23 volunteers). The six communities had differences in size and composition of both their primary care practices and communities, and how the volunteer program and Health TAPESTRY were implemented. Distinctions between communities relating to the work of the interprofessional teams included characteristics of the huddle lead, involvement of physicians and the volunteer coordinator, and clarity of providers’ role with Health TAPESTRY. Key differences between communities relating to volunteer program coordination included the relationship between the volunteers and primary care practices, volunteer coordinator characteristics, volunteer training, and connections with the community. Differences regarding the client experience between communities included differing approaches used in implementation, such as recruitment methods.ConclusionsAlthough all six communities had the same key program elements, implementation differed community-by-community. Key aspects that seemed to lead to differences across categories included the size and spread of communities, size of primary care practices, and linkages between program elements. We suggest future programs engaging stakeholders from the beginning and provide clear roles; target the most appropriate clients; and consider the size of communities and practices in implementation.Trial registrationClinicalTrials.gov: NCT03397836.

Low-value pharmaceutical care among Dutch GPs: a retrospective cohort study.

Low-value pharmaceutical care exists in general practice. However, the extent among Dutch GPs remains unknown. To assess the prevalence of low-value pharmaceutical care among Dutch GPs. Retrospective cohort study using data from patient records. The prevalence of three types of pharmaceutical care prescribed by GPs between 2016 and 2019 were examined: topical antibiotics for conjunctivitis, benzodiazepines for non-specific lower back pain, and chronic acid-reducing medication (ARM) prescriptions. Multilevel logistic regression analysis was performed to assess prescribing variation and the influence of patient characteristics on receiving a low-value prescription. Large variation in prevalence as well as practice variation was observed among the types of low-value pharmaceutical GP care examined. Between 53% and 61% of patients received an inappropriate antibiotics prescription for conjunctivitis, around 3% of patients with lower back pain received an inappropriate benzodiazepine prescription, and 88% received an inappropriate chronic ARM prescription during the years examined. The odds of receiving an inappropriate antibiotic or benzodiazepine prescription increased with age (P<0.001), but decreased for chronic inappropriate ARM prescriptions (P<0.001). Sex affected only the odds of receiving a non-indicated chronic ARM, with males being at higher risk (P<0.001). The odds of receiving an inappropriate ARM increased with increasing neighbourhood socioeconomic status (P<0.05). Increasing practice size decreased the odds of inappropriate antibiotic and benzodiazepine prescriptions (P<0.001). The results show that the prevalence of low-value pharmaceutical GP care varies among these three clinical problems. Significant variation in inappropriate prescribing exists between different types of pharmaceutical care - and GP practices.

Practice cost and size differences in invasive plant management strategies: An empirical analysis of US Great Plains states

Grassland conservation of the Conservation Stewardship Program in the United States (US) is one of the largest cost-sharing initiatives for protecting grazing land from invasive and woody plants. The practice cost and unit size of various invasive and woody plant management strategies, such as mulching, brush management, and prescribed burning, are different from state to state. We aimed to compare and examine the association between practice cost ($/acre[ac]) and standard unit size of practice (acre) of mulching, brush management, and prescribed burning strategies in nine US Great Plains states, including Kansas, Montana, Nebraska, New Mexico, North Dakota, Oklahoma, South Dakota, Texas, and Wyoming. We estimated state-level average practice cost and unit size of mulching, brush management, and prescribed burning strategies using the conservation payment data of the Natural Resources Conservation Service (NRCS) to determine a cost-minimizing management strategy. A linear regression model was used to understand the association between practice cost and unit size of different management strategies and states. Practice cost and unit size differ by invasive and woody plant management strategy and Great Plains state. In the nine US Great Plains states, prescribed burning costs less on average ($29/ac) than mulching ($222/ac) and brush management ($152/ac) but covers a larger area on average (239 acres/unit) than mulching (3.19 acres/unit) and brush management (132 acres/unit). From the regression results, we also find a significantly negative association between practice cost and unit size (Coef. = -0.18, p<0.05). For prescribed burning, the practice cost is significantly lower (Coef. = -148.70, p<0.00) than the reference category of mulching. Our findings imply a policy idea that prescribed burning could be a cost-minimizing and high-coverage strategy than brush management in managing woody invasion under existing cost-unit size framework. Alternatively, expanding the typical unit sizes of a small covering strategy such as mulching could be another policy option for further assessment.

Exploring HbA1c variation between Australian diabetes centres: The impact of centre-level and patient-level factors.

Increasing global diabetes incidence has profound implications for health systems and for people living with diabetes. Guidelines have established clinical targets but there may be variation in clinical outcomes including HbA1c, based on location and practice size. Investigating this variation may help identify factors amenable to systemic improvement interventions. The aims of this study were to identify centre-specific and patient-specific factors associated with variation in HbA1c levels and to determine how these associations contribute to variation in performance across diabetes centres. This cross-sectional study analysed data for 5,872 people with type 1 (n = 1,729) or type 2 (n = 4,143) diabetes mellitus collected through the Australian National Diabetes Audit (ANDA). A linear mixed-effects model examined centre-level and patient-level factors associated with variation in HbA1c levels. Mean age was: 43±17 years (type 1), 64±13 (type 2); median disease duration: 18 years (10,29) (type 1), 12 years (6,20) (type 2); female: 52% (type 1), 45% (type 2). For people with type 1 diabetes, volume of patients was associated with increases in HbA1c (p = 0.019). For people with type 2 diabetes, type of centre was associated with reduction in HbA1c (p <0.001), but location and patient volume were not. Associated patient-level factors associated with increases in HbA1c included past hyperglycaemic emergencies (type 1 and type 2, p<0.001) and Aboriginal and Torres Strait Islander status (type 2, p<0.001). Being a non-smoker was associated with reductions in HbA1c (type 1 and type 2, p<0.001). Centre-level and patient-level factors were associated with variation in HbA1c, but patient-level factors had greater impact. Interventions targeting patient-level factors conducted at a centre level including sick-day management, smoking cessation programs and culturally appropriate diabetes education for and Aboriginal and Torres Strait Islander peoples may be more important for improving glycaemic control than targeting factors related to the Centre itself.

Practice Billing for Medicare Advance Care Planning Across the USA.

Medicare introduced billing codes in 2016 to encourage clinicians to engage in advance care planning (ACP) and promote goal-concordantend-of-life care, but uptake has been modest. While prior research examined individual-level factors in ACP billing, organization-level factors associated with physician practices billing for ACP remain unknown. Examine the role of practices in ACP billing. Retrospective cohort study analyzing 2016-2018 national Medicare data. A total of 53,926 practices with at least 10 attributed Medicare beneficiaries. Outcomes were practice-level ACP billing (any use by the practice) and ACP use rate by practice-attributed beneficiaries. Practice characteristics were number of beneficiaries attributed to the practice; percentage of beneficiaries by race, Medicare-Medicaid dual enrollment, sex, and age; practice size; and specialty mix. Fifteen percent of practices billed for ACP. In adjusted models, we found higher odds of ACP billing and higher ACP use rates among practices with more primary care physicians (billing AOR: 10.01, 95%CI: 8.81-11.38 for practices with 75-100% (vs 0) primary care physicians), and those serving more Medicare beneficiaries (billing AOR: 4.55, 95%CI 4.08-5.08 for practices with highest (vs lowest) quintile of beneficiaries), and larger shares of female beneficiaries (billing AOR: 3.06, 95% CI 2.01-4.67 for 75-100% (vs <25%) female ). Several years after Medicare introduced ACP reimbursements for physicians, relatively few practices bill for ACP. ACP billing was more likely in large practices with a greater percentage of primary care physicians. To increase ACP billing uptake, policymakers and health system leaders might target interventions to larger practices where a small number of physicians already bill for ACP and to specialty practices that serve as the primary source of care for seriously ill patients.

The Emergency Classification of Hand Injuries: Analyzing Urgency Assessment among German Hand Surgeons

Emergency capacities in the operating theatre are limited and often need to be split among surgical departments. Hand injuries often have to compete with other surgical disciplines for the availability of operating capacity. For this reason, an emergency classification was introduced to define a timespan in which the injury should be taken care of in the OR in order to enable the prioritizing of emergency cases in an interdisciplinary approach when capacities are scarce. However, neither valid data nor specific recommendations concerning the medical urgency of treatment or the forensic background of different hand injuries exist to this date. This work describes how emergency classifications in Germany are applied to hand surgical cases and how certain hand injuries are prioritized among different hand surgeons. An online survey was sent to all members of the German Society for Hand Surgery twice during a time span of several months. The survey featured questions on size and type of clinic or practice and requested an assessment of urgency levels for various hand injuries (immediately - within 2 h - within 6 h - within 12 h - within 24 h or elective care). The analysis of the questionnaire and graphic presentation was carried out using Excel. 172 (25 %) out of 700 active members filled in the survey. Among the participants were members of university clinics, hospitals run by the German Statutory Accident Insurance, specialized clinics and primary care clinics. 15 % of participants work in a practice that offers hand-surgical treatment. First and foremost, maximum care hospitals with a hand surgical department participate in the treatment of hand injuries. 64 % of the hospitals use an emergency classification to enable the interdisciplinary prioritizing of surgical emergencies. The categorization of limb-threatening hand injuries appears to be very homogenous among participants whereas non-threatening injuries are assessed rather inconsistently. Emergency treatment of hand injuries primarily depends on available resources and surgical capacities. The assessment of urgency and severity of injuries additionally depends on experience and education. In order to maintain the ability to compete with other surgical disciplines for surgical capacities, a standard classification of hand surgical urgencies needs to be established. As valid data on the treatment of hand injuries are still missing, further studies need to evaluate possible outcomes in order to define the timespan in which surgery should take place.

Measuring the effectiveness of online problem solving for improving academic performance in a probability course

Research on impact in student achievement of online homework systems compared to traditional methods is ambivalent. Methodological issues in the study design, besides of technological diversity, can account for this uncertainty. Hypothesis This study aims to estimate the effect size of homework practice with exercises automatically provided by the ‘e-status’ platform, in students from five Engineering programs. Instead of comparing students using the platform with others not using it, we distributed the subject topics into two blocks, and created nine probability problems for each block. After that, the students were randomly assigned to one block and could solve the related exercises through e-status. Teachers and evaluators were masked to the assignation. Five weeks after the assignment, all students answered a written test with questions regarding all topics. The study outcome was the difference between both blocks’ scores obtained from the test. The two groups comprised 163 and 166 students. Of these, 103 and 107 respectively attended the test, while the remainder were imputed with 0. Those assigned to the first block obtained an average outcome of −1.85, while the average in the second block was −3.29 (95% confidence interval of difference, −2.46 to −0.43). During the period in which they had access to the platform before the test, the average total time spent solving problems was less than three hours. Our findings provide evidence that a small amount of active online work can positively impact on student performance.

Practice Consolidation in Otolaryngology: The Decline of the Single-Provider Practice.

ObjectiveTo observe trends in practice consolidation within otolaryngology by analyzing changes in size and geographic distribution of practices within the United States from 2014 to 2021.Study DesignRetrospective analysis based on the Physician Compare National Database from the US Centers for Medicare and Medicaid Services.SettingUnited States.MethodsAnnual files from the Physician Compare National Database between 2014 and 2021 were filtered for all providers that listed “otolaryngology” as their primary specialty. Organization affiliations were sorted by size of practice and categorized into quantiles (1 or 2 providers, 3-9, 10-24, 25-49, and ≥50). Both the number of practices and the number of surgeons within a practice were collected annually for each quantile. Providers were also stratified geographically within the 9 US Census Bureau divisions. Chi-square analysis was conducted to test significance for the change in surgeon and practice distributions between 2014 and 2021.ResultsOver the study period, the number of active otolaryngology providers increased from 7763 to 9150, while the number of practices fell from 3584 to 3152 in that time span. Practices with just 1 or 2 otolaryngology providers accounted for 80.2% of all practices in 2014 and fell to 73.1% in 2021. Similar trends were observed at the individual provider level. Regional analysis revealed that New England had the largest percentage decrease in otolaryngologists employed by practices of 1 or 2 active providers at 45.7% and the Mountain region had the lowest percentage decrease at 17.4%.ConclusionThe otolaryngology practice marketplace has demonstrated a global trend toward practice consolidation.

Assessing the state of care for Huntington disease in the United States: Results from a survey of practices treating Huntington disease patients

BackgroundNo study to date has thoroughly examined US Huntington disease (HD) care delivery in a variety of clinic settings by HD specialists and non-specialists. ObjectiveTo obtain a clearer understanding of current care structure and delivery of care through a survey of representative US physicians treating HD patients. MethodsWe designed and fielded a survey of 40 closed-ended evaluative items and one open-ended item to a sample of 339 US practices. Unique to this survey was the inclusion of non-specialists. ResultsResponses were received from 156 practices (overall response rate 46.02 %), with 52.6 % from academic sites, 35.3 % from private practices, and 12.2 % from the VA. More than half (63.5 %) of the practice leads were movement disorder trained or Directors of HDSA Centers of Excellence and 58.3 % had an HD or multidisciplinary care clinic. However, 48.7 % of the practices saw 1–25 HD patients, 28.2 % saw 26–100 HD patients, and 23.1 % served over 100 HD patients annually. Most practices (>69 %) reported having difficulty providing social work, genetic counseling, care coordination and psychologists/psychiatrists. Increased HD practice size was associated with higher rates of pre-visit screenings, care navigator/care coordinators, routine monitoring of weight, and provision of genetic counseling by genetic counselors. ConclusionsNot surprisingly, we found that HD care was inconsistently applied across the US. Practices led by neurologists trained in movement disorders, and higher HD volume practices, tended to be better equipped to provide multi-disciplinary staffing and procedures as compared to those with fewer numbers of HD patients.

Technical efficiency evaluation of colorectal cancer care for older patients in Dutch hospitals.

Preoperative colorectal cancer care pathways for older patients show considerable practice variation between Dutch hospitals due to differences in interpretation and implementation of guideline-based recommendations. This study aims to report this practice variation in preoperative care between Dutch hospitals in terms of technical efficiency and identifying associated factors. Data on preoperative involvement of geriatricians, physical therapists and dieticians and the clinicians' judgement on prehabilitation implementation were collected using quality indicators and questionnaires among colorectal cancer surgeons and specialized nurses. These data were combined with registry-based data on postoperative outcomes obtained from the Dutch Surgical Colorectal Audit for patients aged ≥75 years. A two-stage data envelopment analysis (DEA) approach was used to calculate bias-corrected DEA technical efficiency scores, reflecting the extent to which a hospital invests in multidisciplinary preoperative care (input) in relation to postoperative outcomes (output). In the second stage, hospital care characteristics were used in a bootstrap truncated regression to explain variations in measured efficiency scores. Data of 25 Dutch hospitals were analyzed. There was relevant practice variation in bias-corrected technical efficiency scores (ranging from 0.416 to 0.968) regarding preoperative colorectal cancer surgery. The average efficiency score of hospitals was significantly different from the efficient frontier (p = <0.001). After case-mix correction, higher technical efficiency was associated with larger practice size (p = <0.001), surgery performed in a general hospital versus a university hospital (p = <0.001) and implementation of prehabilitation (p = <0.001). This study showed considerable variation in technical efficiency of preoperative colorectal cancer care for older patients as provided by Dutch hospitals. In addition to higher technical efficiency in high-volume hospitals and general hospitals, offering a care pathway that includes prehabilitation was positively related to technical efficiency of hospitals offering colorectal cancer care.

Impact of COVID-19 on Primary Care Practice Sites and Their Vulnerable Patients.

Purpose: While COVID-19 has upended lives, it has also catalyzed innovation with potential to advance health delivery. Yet, we know little about how the delivery system, and primary care in particular, has responded and how this has impacted vulnerable patients. We aimed to understand the impact of COVID-19 on primary care practice sites and their vulnerable patients and to identify explanations for variation. Approach: We developed and administered a survey to practice managers and physician leaders from 173 primary care practice sites, October-November 2020. We report and graphically depict results from univariate analysis and examine potential explanations for variation in practices' process innovations in response to COVID-19 by assessing bivariate relationships between seven dependent variables and four independent variables. Findings: Among 96 (55.5%) respondents, primary care practice sites on average took more safety (8.5 of 12) than financial (2.5 of 17) precautions in response to COVID-19. Practice sites varied in their efforts to protect patients with vulnerabilities, providing care initially postponed, and experience with virtual visits. Financial risk, practice size, practitioner age, and emergency preparedness explained variation in primary care practices' process innovations. Many practice sites plan to sustain virtual visits, dependent mostly on patient and provider preference and continued reimbursement. Value: While findings indicate rapid and substantial innovation, conditions must enable primary care practice sites to build on and sustain innovations, to support care for vulnerable populations, including those with multiple chronic conditions and socio-economic barriers to health, and to prepare primary care for future emergencies.

Determinants of Nurse Practitioner Independent Panel Management in Primary Care

In this study, we examine nurse practitioner (NP) practice and regulatory factors associated with NP independent panel management. We use survey data from 1,244 NPs from 6 states. Independent panel management was not associated with NP demographic characteristics. NP work environments, practice type, and practice size were associated with independent practice management. NPs practicing in states with more restrictive regulatory environments had less independent panel management. NP workforce can play an important role in increasing access to primary care, but facilitators and barriers to NP independence must be scrutinized to develop more efficient models of primary care delivery.

OP321 The Scale And Variation Of The Impact Of COVID-19 On Prescribing Of Medicines In Primary Care In Wales

IntroductionPrescribing of medicines in primary care in Wales has been exceptional in 2020 due to COVID-19 and the associated changes to the delivery of health services. The changes are likely to have harmful, albeit unintended, consequences, including disruption of pharmacy stock management; unpredictable changes in prescribing; and interruption to patients’ supply of medicines and reduced medication adherence. Changes in prescribing are unlikely to be distributed evenly across the country or population. Therefore, this study aimed to identify changes in GP prescribing compared with previous years, the variation of these changes, and factors related to the variation in changes, to identify patient subgroups for whom the impact is disproportionate.MethodsWe identified medicines of interest where concerns around prescribing have been raised and, for each of these medicines, retrieved monthly prescribing data for each GP practice in Wales (N = 492). We then linked these data with other publicly available data (for example, practice size, indices of multiple deprivation, disease prevalence).We developed a novel approach to measure the impact of COVID-19 on GP prescribing. We compared observed with expected prescribing volume projected via time series modelling and differences were related to patient and practice characteristics using general estimating equations.ResultsThere was evidence of stockpiling of medicines during March 2020 (for example, oral-contraceptives and oral-anticoagulants with 11.6 and 18.5 percent increases from March 2019), followed by a short-term reduction in prescribing for oral-contraceptives (a reduction of 12.9 percent), but not oral-anticoagulants (an increase of 6.5 percent). However, GP level data show considerable deviation from the national trend for several GPs, which may be due to health and socio-demographic factors.ConclusionsCOVID-19 has had a major impact on primary care prescribing in Wales. The distribution of changes in prescribing will not be even across the country or the population. Identification of systematic variation in impacts on prescribing could identify geographical areas or patients in need of additional support to ensure uninterrupted and appropriate access to medicines.

A critical review of surgical strategies to minimise venous stenosis in arteriovenous grafts.

It is inevitable that complications arising from surgical procedures are ascribed to surgical technique, and this applies to venous stenosis (VS) in arteriovenous grafts. However, despite a wide range of cellular studies, computer modelling, observational series and clinical trials, there remains uncertainty on whether surgical technique contributes to VS. This article reviews evidence from basic science, fluid dynamics and clinical data to try and rationalise the main surgical options to modify the occurrence of venous stenosis. There is sufficient data from diverse sources to make recommendations on clinical practice (size of target vein, shape of anastomosis, angle of approach, distance from venous needling, trauma to the target vein) whilst at the same time this emphasises the need to carefully report the practical aspects of surgical technique in future clinical trials.

National Survey of Pediatric Sickle Cell Providers on Their Contraceptive Practices for Female Patients

Introduction: Pregnancies of women with sickle cell disease (SCD) have increased risk of morbidity and mortality, with potential additional complications due to uncertain teratogenicity of hydroxyurea and the newer medications. Unintended pregnancy is common among adolescents and young adults (AYA). We aimed to assess the beliefs, practices and barriers of U.S. pediatric hematology providers related to contraception for female AYA with SCD, as little is known about this topic.Methods: We developed a 25-question, web-based survey guided by the Health Belief Model to assess pediatric SCD providers' contraceptive perspectives and practices. Most questions were adapted from published surveys assessing provider views and practices on contraception for general AYA care or patients with other chronic health conditions. The survey was distributed from December 2020-April 2021 to licensed U.S. prescribers who provided care to female SCD AYAs ages 12-21 years within the prior two years. The anonymous survey was distributed by two methods: (1) a list of 526 pediatric SCD and/or general hematology providers from the HRSA SCD Treatment Demonstration Program Regional Collaborative, cross-referenced for reminder emails to 126 providers using a list from the HRSA Regional Genetics Collaborative (https://www.hrsa.gov); (2) directors from all 74 U.S. ACGME-accredited Pediatric Hematology-Oncology fellowship programs, asking then to forward the survey to their SCD providers. Surveys with >50% completion were analyzed using descriptive statistics and chi square analyses.Results: Of 177 respondents, 160 surveys met inclusion criteria and were analyzed: 73 (45.6%) contacted by emails and 87 (54.4%) contacted via the fellowship directors (Table 1). Respondents recruited via fellowship program directors were more frequently NP/PAs (total of 30 (18.7%)), of younger age (total 103 (64.4%) and had fewer years in practice compared to those contacted directly. The majority of providers reported counseling (76.9%) and/or referring patients for contraception (90.9%), but not prescribing (41.8%). Practices regarding contraception differed by provider characteristics (Table 2). Trainees vs. established providers less frequently reported counseling about contraception (54.1% vs. 84.6%, p<0.001). Overall however, younger vs. older providers (<45 years), did not differ in contraceptive counseling (75.7% vs. 80.7%, p=0.7). Motivators for providing counseling differed by certain demographics (data not shown): female providers more frequently counseled about contraception when patients disclosed being sexually active (87.0% vs 66.7%, p=0.046); NPs/PAs more frequently counseled if standards for counseling were in place (45.5% vs 22.0%, p=0.03); and providers with more years in practice when they had concerns about SCD patients' increased pregnancy risks (43.1% vs 23.9%, p=0.03). Provider practices did not differ by region or size of SCD practice. Providers who believed that hydroxyurea causes increased risk of pregnancy complications more frequently reported prescribing contraception (48.8% vs. 31.7%, p=0.04), but did not differ by counseling or referral practices. Concerns about teratogenic risk of hydroxyurea was not significantly associated with provider practices. The most frequently reported barriers for counseling (>30% respondents) were insufficiencies in time, patient/parent willingness, formal training, knowledge/ability and/or professional guidelines. Concerns about side effects was a barrier to prescribing (34.2%), while lack of access to providers with contraceptive expertise was the most common barrier to patient referral (34.9%). Multivariate analyses are ongoing.Conclusions: To our knowledge, this is the first national report of pediatric hematology providers' beliefs and practices regarding contraception for female AYA with SCD. While providers generally felt responsible for offering counseling and referral but not prescribing, practices varied based on certain provider characteristics, beliefs and perceived barriers. Clinical guidelines, improved provider education and training, and patient/parent decision [Display omitted] DisclosuresSmith-Whitley: Global Blood Therapeutics: Current Employment. Strouse: Takeda: Consultancy.

Use of Thromboprophylaxis for Central Venous Access Devices in Patients with Sickle Cell Disease: A Survey of Canadian Providers

Background: Sickle cell disease (SCD) induces a chronic prothrombotic state, with a cumulative incidence of venous thromboembolism (VTE) reported to be 11% by age 40. Central venous access devices (CVAD) are commonly used for chronic transfusions and iron chelation in this patient population.The presence of a CVAD is an additional risk factor for venous thromboembolism (VTE), with a catheter related thrombosis rate of 24%. Despite this high risk of VTE, the role of thromboprophylaxis in this setting is uncertain due to a lack of high quality data.Methods: A survey was administered in March 2021 to physicians caring for adult sickle cell disease patients via the Canadian Haemoglobinopathy Association (CanHaem), covering nine SCD comprehensive care centers in Canada. One reminder email was distributed after 3 weeks to encourage participation. Questions were directed at characterizing the practice size, number of patients with CVADs, and the role of thromboprophylaxis for CVADs. Physicians were also surveyed about their willingness to enroll their SCD patients with CVADs in a randomized trial of thromboprophylaxis versus placebo. Items were generated and selected based on face and content validity. Results are reported in medians and percentages, where applicable.Results: Responses were collected from 14 physicians who care for a median of 100 (IQR 185) adult sickle cell disease patients in practices across Canada. Physicians reported approximately 5% of their patients currently require a CVAD, and physicians estimated no CVAD patients are lost to follow up. Respondents use a variety of CVADs, including port-a-caths (75%), followed by PICC lines (58%), tunneled (25%) and non-tunneled CVCs (25%) (Figure 1). Duration of venous access was reported to be <1 month (17%), 1-3 months (8%), 3-6 months (0%), 6-12 months (8%), and >12 months (67%). Fifty percent of respondents indicated they do not use thromboprophylaxis for CVADs. Responses varied with respect to choice and dose of antiplatelet or anticoagulant in cases where thromboprophylaxis is used (Figure 2). Forty-two percent of physicians indicated they were not very confident or not at all confident in choice of prophylaxis. Past history of VTE was the most cited factor influencing the choice to use thromboprophylaxis. Physicians were generally in favour of enrolling patients in an RCT using thromboprophylaxis for CVADs. The exception was that 69% answered “No” when asked about enrolling patients with a prior history of VTE who are not currently on anticoagulation. One-hundred percent of physicians agreed that an RCT would improve their confidence in decision-making around thromboprophylaxis in their patients with CVADs.Conclusions: While there is evidence for an increased risk of VTE for SCD patients with CVADs, our results suggest there remains clinical equipoise with respect to the use of thromboprophylaxis. Thromboprophylaxis options were variable when physicians chose to use them, as there is no evidence to support specific antithrombotic regimens. All physicians surveyed are supportive of an RCT to clarify this management approach, and many would enroll their patients. As a result of this survey, a Canadian multicenter pilot RCT addressing this question is currently underway. [Display omitted] DisclosuresForte: Pfizer: Research Funding; Canadian Hematology Society: Research Funding; Novartis: Honoraria. Verhovsek: Vertex: Consultancy. Kuo: Alexion: Consultancy, Honoraria; Celgene: Consultancy; Bluebird Bio: Consultancy; Bioverativ: Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy, Research Funding; Agios: Consultancy, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Honoraria; Apellis: Consultancy. OffLabel Disclosure:This survey explored the use of LMWH, direct oral anticoagulants, warfarin and ASA for prophylaxis among patients with sickle cell disease using a central venous access device.

Provision of infertility care for the underserved in reproductive endocrinology and infertility practices associated with obstetrics and gynecology residency training programs in the United States

ObjectiveTo survey practice patterns designed to increase access to infertility care and evaluate the exposure of obstetrics and gynecology residents to infertility care for the underserved.DesignCross-sectional.SettingReproductive endocrinology and infertility (REI) practices associated with Accreditation Council for Graduate Medical Education-accredited obstetrics and gynecology residency training programs.Patient(s)None.Intervention(s)Questionnaire survey.Main Outcome Measure(s)Presence of clinical programs designed to improve access to REI care, resident involvement in such programs, and perceived barriers to expanding access to care.Result(s)Clinical initiatives to expand access included discounted infertility services (38%, n = 30), utilization of a low-cost in vitro fertilization (IVF) program (28%, n = 22), and utilization of a resident- and/or fellow-staffed clinic to provide infertility care (39%, n = 31). The most commonly discounted infertility services were IVF (73%, n = 22), clinical consultation (70%, n = 21), and intrauterine insemination (53%, n = 16). The provision of discounted prices was correlated with the increasing practice size (odds ratio [OR], 2.29; 95% confidence interval [CI], 1.23–4.24) and number of assisted reproductive technology cycles performed annually (OR, 3.65; 95% CI, 1.48–9.02). Academic REI practices (OR, 3.6; 95% CI, 0.98–13.25) were more likely to have a low-cost IVF program. Less than half of obstetrics and gynecology residency programs (39%, n = 31) had an associated REI clinic in which obstetrics and gynecology residents provide direct infertility care to the medically underserved. Frequency and services offered in trainee clinics varied. Multiple barriers to expanding access to care were reported.Conclusion(s)Reproductive endocrinology and infertility practices associated with obstetrics and gynecology residency programs utilize a diverse range of approaches to provide infertility care to the underserved in the backdrop of considerable challenges and barriers, but significant gaps persist.

Orthopaedic Group Practice Size Is Increasing

PurposeTo analyze recent trends in orthopaedic surgery consolidation and quantify these changes temporally and geographically from 2012 to 2020.MethodsWe performed a retrospective cross-sectional analysis of orthopaedic surgeon practice size in the United States using 2012 and 2020 data obtained from the Physician Compare database.ResultsAlthough we observed an increase from 21,216 unique orthopaedic surgeons in 2012 to 21,553 in 2020 (1.6% increase), the number of practices experienced a large decrease from 7,299 practices in 2012 to 5,829 in 2020 (20.1% decrease). The proportion of orthopaedic surgeons working in solo practices decreased from 13.2% (2,790) in 2012 to 7.4% (1,595) in 2020, and the proportion of orthopaedic surgeons working in groups sized 2 to 24 decreased from 35.3% (7,482) in 2012 to 22.2% (4,775) in 2020. In contrast, groups sized 25 to 99 have grown from 20.7% (4,387) of all orthopaedic surgeons to 23.4% (5,048) in 2020. Groups sized 100 to 499 have increased from 16.9% (3,593) in 2012 to 24.1% (5,190) in 2020, whereas groups sized 500 or greater have grown from 14% (2,964) in 2012 to 22.9% (4,945) in 2020. The number of unique group practices showed a significant decrease in the number of solo groups, which comprised 43.8% (3,200) of the total number of individual practices in 2012, decreasing to 32% (1,886) in 2020. All other groups increased in number and proportionally from 2012 to 2020.ConclusionsThis study shows that over the period from 2012 to 2020, there has been a substantial trend of orthopaedic surgeons shifting to increasing practice sizes, potentially indicating that more orthopaedic surgeons are working for large health care organizations rather than small independent practices.Clinical RelevanceThe impact of these changes should be examined to determine large-scale effects on patient care, payment models, access, and outcomes, along with physician compensation, lifestyle, and satisfaction.

Understanding multidisciplinary care for people with rheumatic disease in British Columbia, Canada, through patients, nurses and physicians voices: a qualitative policy evaluation

BackgroundIn 2011, the province of British Columbia (BC) moved to allow patients with complex rheumatic disease to be seen by nurses along with their rheumatologist by introducing a ‘Multidisciplinary Care Assessments’ (MCA) billing code (G31060).ObjectiveTo describe multidisciplinary care introduced as part of MCAs across BC and investigate the perceived impact of this intervention, the addition of nurses to the care team, on patient care from the perspective of patients, nurses, and rheumatologists.MethodsWe conducted semi-structured interviews, informed by a qualitative evaluation approach with patients, nurses, and rheumatologists from September 2019 – August 2020. Interviews investigated 1) the experiences of all stakeholders with adopting the multidisciplinary care billing code, 2) the perceived role of the nurse in the care team, and 3) the perceived impact of multidisciplinary care on patient experience and outcomes. We purposefully sampled practices for maximum variation of geographical location (rural vs. urban), size of practice (i.e., patient caseload), and number of nurses employed.ResultsWe interviewed 21 patients, 13 nurses, and 12 rheumatologists from across BC. Our analysis identified variation in the way rheumatologists adopted multidisciplinary care across BC. Our analysis showed some heterogeneity in the way the MCA was delivered in rheumatology practices; however, patient education was identified as the core role of nurses across practices. We identified six core themes describing the impact of this model of care, all representing improvements in the way practices functioned, from improved efficiency to access, patient experience, time management, clinician experience, and patient health outcomes. Contextual factors that influenced the presence of these themes were related to the time the nurses spent with patients and the professional roles they performed.ConclusionOur results suggest nurse care can complement physician care by extending contact time for patients and promoting the efficient use of health care professionals’ skills, time, and resources. These data may encourage future uptake of the billing code to help ensure the policy delivers maximum benefits to patients given the wide range of perceived benefits described by clinicians and patients.

Trends in Fractionation in Radiation Oncology Over the Past Decade

Advances in radiation oncology have allowed for more accurate targeting of treatment areas allowing for safer hypofractionation. Additionally, many trials have been published supporting the use of hypofractionation as an alternative to longer courses of radiation. In the United States most reimbursement models are currently based on a fee for service model which increases payment based on the number of treatments delivered. Our goal was to analyze available Medicare billing data in order to evaluate trends in fractionation in the United States.Medicare Provider Utilization and Payment Data was accessed from the CMS.gov website for years 2012 - 2018. Radiation Oncology specific providers (ROP) and only data corresponding to the billing code for status checks (77427), were extracted. Status checks (SC) were used as a surrogate for length of fractionation. Only ROP's that were practicing every year between 2012 through 2018 were included and those with less than 100 status checks in a year at any single practice setting were excluded. Providers were classified as hospital-based practices versus independent clinics and academic versus private practice. ROP's were separated into four regions based on Census classifications: Northeast, Midwest, South, and West.Amongst ROP's with at least 100 SC per year, there was an overall decrease in average number of SC per patient from 2012 to 2018 (3.96 to 3.64, respectively) or an overall 8% decrease in fractions delivered per patient. This holds true for those based in hospitals (3.85 to 3.45) and independent clinic (4.07 to 3.73) locations from 2012 to 2018, respectively. The number of patients per year each provider treated has decreased from 172 (2012) to 163 (2018). The total number of providers seeing at least 100 SC/year has decreased from 2012 to 2018 (2,353 to 2,011). A decrease in fractionation was experienced in all regions of the country with the largest overall decrease in the Northeast (13% vs 8.8% in the South). Large practices (greater than 10 ROP's) treated less fractions per patient than smaller practices. A larger decrease in fractions per patient was seen in academic practices with a 14% drop in status checks per patient vs 9.9% in private practices from 2012-2018. In 2018, academic physicians treated each patient with 15% less fractions than private practice.Trends in fractionation confirm that as a specialty, we are moving more towards hypofractionation with an overall decrease in fractions per patient over the past decade. This is seen in all settings regardless of practice setting, location, and size of practice. Academic ROP's have decreased the rate of fractions per patient at a slightly higher rate than private practice ROP's. Given the reduced number of visits for the patient, this is a positive for improving the cost-effectiveness of medicine as well as reducing the financial and logistical burden for the patient.