Significant Increase In Utilization Research Articles

Retrospective analysis of perioperative transfusion requirements in living donor renal transplantation

BackgroundExtensive bleeding in solid organ transplantation is a major challenge faced by transplant surgeons. Our aim was to audit the peri-operative transfusion requirements in our patients. Materials and methodsA retrospective analysis of living donor renal transplant surgeries performed from 1st May 2014 to 31st December 2014 was done. The blood/blood component usage during the peri-operative period was obtained. Univariate analysis was performed and the significant factors identified were further analyzed through multivariate regression analysis. ResultsA total of 510 patients (398 males: 78%, and 112 females: 22%) ranging from 18 to 77 years in age were included in the study. Of these, 269 (52.7%) patients were not transfused, while 241 (47.3%) patients received a total of 845 units of blood/blood components. The mean pre-operative hemoglobin in the transfused group was 8.7g/dl while in the non-transfused group it was 10.3g/dl. Leukoreduced packed red blood cell (PRBC) was the major blood component transfused during the peri-operative period. Multivariate regression analysis revealed that pre-operative hemoglobin was a major predictor of intra-operative PRBC transfusion (p = <0.001). Average post-operative length of stay (PLOS) was 10 ± 6 days. There was no significant difference in the PLOS between the transfused and non-transfused groups of patients; however, a statistical significant increase in utilization for both PRBC (p = 0.044) and fresh frozen plasma (p = 0.002) was observed with increased PLOS. ConclusionNearly 47.3% of patients undergoing living donor renal transplant received transfusion. PRBC was the most common product transfused and pre-operative hemoglobin was identified as strong predictor of blood consumption.

The Impact of a Preauthorization Policy on the After-hours Utilization of Emergency Department Computed Tomography Imaging

We evaluated the effects of a streamlined emergency department (ED) policy for CT ordering, pre- and postimplementation, on the completed imaging study rates of all after-hours computed tomography (CT) studies. The study hypothesis was that a streamlined CT ordering process would increase the utilization rates of ED CT. A prospective cohort study was used to estimate the effect of enhancing a preauthorization policy for after-hours CT studies requested through the ED, performed between January 1 and June 30, 2013, and the postimplementation period, performed between January 1 and June 30, 2014. Inclusion criteria were all CT chest, CT abdomen/pelvis, musculoskeletal, neurological, and neuroangiographic examinations performed by ED physicians on adult patients. Pre- and postintervention examination imaging study rates were compared. The period following implementation of the preauthorization policy was associated with a statistically significant increase in utilization for most subtypes of CT examinations (CT chest, CT abdomen/pelvis, and musculoskeletal CT studies), with the exception of neurological examinations, which showed a significant decrease. This study demonstrates a trend toward increased utilization of CT resources after implementation of an ED preauthorization policy with most study types showing significantly increased utilization. In the case of neurological examinations, a potential "substitution effect" was observed, whereby the rates of neuroangiographic studies showed a marked increase, offsetting the decrease in general neurological examinations performed. Departments considering implementation of preauthorization policies should weigh carefully the benefits of ED workflow efficiencies against the potential harms of increased CT use.

Investigating parents/caregivers financial burden of care for children with non-communicable diseases in Ghana.

BackgroundThe introduction of the Ghana national health insurance scheme (NHIS) has led to progressive and significant increase in utilization of health services. However, the financial burden of caring for children with non-communicable diseases (NCDs) under the dispensation of the NHIS, especially during hospitalization, is less researched. This paper therefore sought to assess the financial burden parents/caregivers face in caring for children hospitalized with NCDs in Ghana, in the era of the Ghana NHIS.MethodsWe conducted a cross-sectional survey of 225 parents or caregivers of children with NCDS hospitalized in three hospitals. Convenience sampling was used to select those whose children were discharged from hospital after hospitalization. Descriptive statistics such as frequencies and chi-square and logistic regression were used in data analysis. The main outcome variable was financial burden of care, proxied by cost of hospitalization. The independent variable included socio-economic and other indicators such as age, sex, income levels and financial difficulties faced by parents/caregivers.ResultsThe study found that over 30 % of parents/caregivers spend more than Gh¢50 (25$) as cost of treatment of children hospitalized with NCDs; and over 40 % of parents/caregivers also face financial difficulties in providing health care to their wards. It was also found that even though many children hospitalized with NCDs have been covered by the NHIS, and that the NHIS indeed, provides significant financial relief to parents in the care of children with NCDs, children who are insured still pay out-of-pocket for health care, in spite of their insurance status. It was also found that there is less support from relatives and friends in the care of children hospitalized with NCDs, thus exacerbating parents/caregivers financial burden of caring for the children.ConclusionsEven though health insurance has proven to be of significant relief to the financial burden of caring for children with NCDs, parents/caregivers still face significant financial burden in the care of their wards. Stakeholders in health care delivery should therefore ensure that all children with NCDs including those excluded from the NHIS should be covered by NHIS. A special effort focusing on identifying children with NCDs within the lower income groups, especially from rural areas, in order to exempt them from any form of payment for their health care is recommended.

Demographic Trends of Adults in New York City Opioid Treatment Programs—An Aging Population

Background: The population of adults accessing opioid treatment is growing older, but exact estimates vary widely, and little is known about the characteristics of the aging treatment population. Further, there has been little research regarding the epidemiology, healt h status, and functional impairments in this population. Objectives: To determine the utilization of opioid treatment services by older adults in New York City. Methods: This study used administrative data from New York State licensed drug treatment programs to examine overall age trends and characteristics of older adults in opioid treatment programs in New York City from 1996 to 2012. Results: We found significant increases in utilization of opioid treatment programs by older adults in New York City. By 2012, those aged 50–59 made up the largest age group in opioid treatment programs. Among older adults there were notable shifts in demographic background including gender and ethnicity, and an increase in self-reported impairments. Conclusions/Importance: More research is needed to fully understand the specific characteristics and needs of older adults with opioid dependence.

Gene-Expression-Based Predictors for Breast Cancer.

An important and often complicated management decision in early stage hormone receptor (HR)-positive breast cancer relates to the use of adjuvant systemic chemotherapy. Although traditional clinicopathologic markers exist, tremendous progress has been achieved in the field of predictive biomarkers and genomics with both prognostic and predictive capabilities to identify patients who will potentially benefit from additional therapy. The use of these genomic tests in the neoadjuvant setting is also being studied and may lead to these tests providing clinical benefit even earlier in the disease course. Landmark articles published in the last few years have expanded our knowledge of breast cancer genomics to an unprecedented level, and mutational analysis via next-generation sequencing methods allows the identification of molecular targets for novel targeted therapeutic agents and clinical trials testing efficacy of targeted therapies, such as PI3K inhibitors, in addition to endocrine therapy for HR-positive breast cancer, are ongoing. We provide an in-depth review on the role of gene expression-based predictors in early stage breast cancer and an overview of future directions, including next-generation sequencing. Over the coming years, we anticipate a significant increase in utilization of genomic-based predictors for individualized selection and duration of endocrine therapy with and without genotype-driven targeted therapy, and a major decrease in the use of chemotherapy, possibly even leading to a chemotherapy-free road for early stage HR-positive breast cancer.

A step toward next-generation nanoimprint lithography: extending productivity and applicability

Because of its unique principle based on mechanical deformation, nanoimprint lithography (NIL) has been playing an important role for nanopatterning and nanofabrication beyond the limit of conventional optical lithography. Many diverse fields involving electronics, photonics, and energy engineering have all shown significant increase in utilization of nanopattern structures, particularly in large areas and at submicron scales. To meet this demand, expanding the realm of NIL toward more scalable and versatile patterning technology is in high demand. In this feature article, we give an overview of how NIL can extend productivity and applicability by addressing three key issues: continuous NIL for more scalable nanopatterning, large-area mold fabrications, and novel resist engineering.

Mortality of acute mesenteric ischemia remains unchanged despite significant increase in utilization of endovascular techniques.

In this study, we evaluated if increase in utilization of endovascular surgery has affected in-hospital mortality rates among patients with acute mesenteric ischemia. The National Inpatient Sample (2003-2011) was queried for acute mesenteric ischemia using ICD-9 code for acute mesenteric ischemia (557.1). This cohort was divided into patients treated with open vascular surgery (open vascular group) and by endovascular therapies (endovascular group) based on the ICD-9CM procedure codes. Multivariable logistic regression was used to determine temporal trend for mortality while adjusting for confounding variables. There was 1.45-fold increase in utilization of endovascular techniques in this study. In-hospital mortality rate, total median charges and length of stay were significantly lower among the endovascular group than the open vascular group despite having significantly higher Elixhauser comorbidities index (3 ± 0.1 vs. 2.7 ± 0.1, p = .003). Over the course of the study period, there was no change in the overall mortality rate despite higher endovascular utilization. Factors associated with increased mortality included age, open surgical repair (Odds ratio: 1.45, 95% Confidence Interval: 1.10-1.91, p = .016) and bowel resection Odds ratio: 2.88, 95% Confidence Interval: 2.01-4.12). The mortality rate for acute mesenteric ischemia remains unchanged throughout this contemporary study. Open surgical intervention, bowel resection and age were associated with increased mortality. Endovascular group patients had better survival despite higher morbidity indices.

A single 80 mg intravenous gentamicin dose prior to prostate needle biopsy does not reduce procedural infectious complications.

IntroductionRates of infectious complications continue to increase following transrectal ultrasound guided prostate needle biopsy (TRUS PNB). Administration of a parenteral antibiotic at time of procedure represents one potential prophylaxis strategy. The efficacy of this practice remains incompletely defined.Material and methodsOur institutional TRUS PNB database was reviewed to identify consecutive men undergoing a biopsy over a 48-month period. The peri-operative intravenous antibiotic regimen (when used) included gentamicin 80 mg administered intravenously (IV) 30 minutes prior to biopsy. The incidence of infections post-biopsy was compared between patients receiving oral alone versus IV plus oral antibiotic prophylaxis.Results182 of 522 men (34.9%) included in this study received peri-procedural IV gentamicin at time of TRUS PNB, with a significant increase in utilization during the study time period (p <0.001). In total, 39 patients (7.5%) developed an infectious complication post-biopsy. No differences in infection rates were observed between patients receiving only oral prophylaxis (27 of 340, 7.9%) versus those receiving oral with IV gentamicin (12 of 182, 6.6%) (p = 0.73).ConclusionsIn this 4-year cohort analysis, a single peri-procedural dose of 80 mg of intravenous gentamicin failed to confer a reduction in infectious complications following prostate needle biopsy. Such data underscore the need to better understand the dose, route, and type of antimicrobial therapy to limit procedural infections.

Abstract 13861: Trends in Utilization of Mechanical Circulatory Assist Devices in Patients Presenting with ST Elevation Myocardial Infarction

Despite significant controversy about the efficacy, mechanical circulatory support (MCS) is often utilized in patients with cardiogenic shock after ST elevation myocardial infarction (STEMI). We aimed to characterize the trends and outcomes following the use of MCS devices in patients presenting with STEMI. Methods: We used the 2003-2011 US Nationwide Inpatient Sample for this study. All admissions with a principal diagnosis of STEMI were identified using standard ICD codes. MCS devices included intra aortic balloon pump or Impella and were identified using ICD procedure codes. Results: Of a total of 372984 admissions with STEMI, we identified 35685 (9.3%) cases that required MCS. Over the study duration, there was a significant increase in the utilization of MCS from 7.6% in 2003 to 10.5% in 2011 (Panel A). This increase in the use of MCS was accompanied by a significant increase in the incidence of cardiogenic shock in the study population (Panel A). Despite an increase in the overall cardiogenic shock incidence, there was a significant increase in the relative utilization of MCS in cardiogenic shock (Panel B) during the study duration. Of all the cardiogenic shock cases, utilization of MCS increased from 48.6% in 2003 to 57.4% in 2009, followed by a small decline to 54.7% in 2011. Among patients with cardiogenic shock, in-hospital mortality rate was 31.5% in patients with MCS as compared to 42.4% in those treated without MCS (p&lt;0.001). Using multivariable hierarchical regression modeling, we found a significant reduction in adjusted in-hospital mortality with MCS, among patients with cardiogenic shock [OR (95% CI): 0.82 (0.77-0.88), p&lt;0.001]. Conclusions: Over the last decade, there has been a significant increase in the utilization of MCS in patients with STEMI. In contrast to the results of the IABP trial, the use of MCS was associated with a significant reduction in in-hospital mortality in this real world nationwide experience.

Scaling up safe motherhood program at Dang district: Impact of programmatic intervention

Introduction: Safe motherhood has been a national priority programme and this article highlights the impact of a good programmatic approach to improve safe motherhood services in a district of mid west region of Nepal. Method: Interventions included strengthening of program- Emergency Obstetric Care Services (EmOC) at district hospital and Primary Health Care Center level (basic and comprehensive), Skilled Birth Attendance (SBA) at Health Post level and Community Based Safe Motherhood interventions at community level. In addition, improved family/community practices for birth preparedness and referral of mothers through building the capacity of individuals and families to demand and utilize health services were also implemented. Results: Met need of Emergency Obstetric Care increased from 2% in 2000 to 27.58 % in 2005/06. Number of births increased in hospital from 1078 (2003/2004) to 1753 (2005/2006). Number of caesarean sections was 10 in 2003/04 whereas it has risen to 174 in 2005/06. Similar trends were noticed in other obstetric procedures such as instrumental deliveries and manual removal of placenta. There has also been a significant increase in utilization of EmOC services among the poorest castes- Dalits and Janjatis (from 6.3% in 2000/01 to 12.7% in 2003/04). Twenty four hours blood transfusion services are made available at district hospital. EmOC fund has saved the life of 676 women who utilized EmOC fund and watch group has referred total 559 women to health facilities. Conclusion: Data from Dang district suggests that if interventions are delivered simultaneously and effectively at community level and health facility level, there is definite impact on various indicators of safe motherhood program. However, frequent turnover of staff, vacant post, lack of provision of 24 hours SBA services, limited budget for construction, training and equipment supports, lack of transportation and communication in remote Village Development Committees are barriers of effective safe motherhood program. DOI: http://dx.doi.org/10.3126/njog.v3i2.10827 Nepal Journal of Obstetrics and Gynaecology Vol.3(2) 2008; 21-25

Utility of Postoperative Radiographs for Pediatric Scoliosis: Association Between History and Physical Examination Findings and Radiographic Findings.

Postoperative radiographs are routinely obtained following surgery for the correction of scoliosis in pediatric patients. The purpose of this study was to comprehensively evaluate the utility of obtaining routine postoperative radiographs in the management of these patients. A total of 1969 clinic notes and corresponding radiographs regarding 451 consecutive patients with scoliosis (age range, ten to eighteen years) who had surgical correction over a ten-year period at a single institution were retrospectively reviewed. Curve etiology, preoperative curve characteristics, and surgical procedures performed were recorded. All postoperative clinic notes and radiographs were reviewed for abnormalities and changes in treatment course. It was then determined whether clinical signs and symptoms and/or abnormal radiographic findings led to a change in treatment course, which was defined as a therapeutic intervention or further diagnostic testing. Of the 451 patients in this study (average age [and standard deviation], 14.7 ± 2.4 years), 72.5% had adolescent idiopathic scoliosis, 23.3% had neuromuscular scoliosis, and 4.2% had other underlying causes of scoliosis. A change in treatment course occurred in the cases of forty-two patients, all of whom had symptomatic findings on postoperative history and physical examination and only fifteen of whom had supportive abnormal findings on postoperative radiographs. Curve etiology and surgical procedures performed had no impact on radiographic utility. A significant increase in utility was seen for radiographs obtained at visits one year or more following surgery compared with those obtained at visits less than one year following surgery (1.7% compared with 0.3%, p = 0.001). The overall sensitivity, specificity, positive predictive value, and negative predictive value of routine postoperative radiographs in guiding treatment course were 35.7%, 98.1%, 28.8%, and 98.6%, respectively. Routine radiographs provide low utility in guiding the course of treatment for asymptomatic pediatric patients following surgery for scoliosis. The results of this study suggest that patient or caregiver complaints, comorbidities, and clinical suspicion should be considered before obtaining radiographs at postoperative visits in order to minimize radiation exposure in pediatric patients and reduce medical costs without compromising care. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

(105) - Single Lung Transplantation in the United States: What Happens To the Other Lung?

(105) - Single Lung Transplantation in the United States: What Happens To the Other Lung?

Significant increase in utilization of donor sperm by lesbian couples after the ligalization of same sex marriages in ontario, canada

Despite of the advances in the field of ART, utilization of donor sperm remains an effective option to achieve pregnancy in certain patients; including some couples with male infertility, single women or lesbian couples. Literature on the demographics of donor semen recipients is limited. The objective of this our study was to better understand temporal changes in the demographics of patients utilizing donor sperm in our patient population.

Abstract 159: Comparing Blood Pressure Control in Diabetic vs Non-Diabetic Veterans following Percutaneous Coronary Intervention

Background As per the US Joint National Committee VII (JNC-7) recommendations, patients with known underlying coronary artery disease and diabetes should have goal blood pressures (BP) of systolic (SBP) &lt;130 and diastolic (DBP) &lt;80 to decrease morbidity and mortality associated with cardiovascular disease. In addition to lifestyle modification, these goals can be attained by use of multiple classes of drugs including beta-blockers (BB), angiotensin agonists (ACE-I/ARB), calcium channel blockers (CCB), diuretics and nitrates. Methods We conducted a retrospective cohort study focusing on the attainment of the JNC-7 guidelines, comparing outcomes between 415 diabetic to 637 non-diabetic patients undergoing PCI between September 2004 and December 2012 at the Jesse Brown Veterans Administration Hospital in Chicago, IL. Blood pressure (BP) measurements and antihypertensive medications pre and post PCI at 6-month follow-up were documented. Results Among the diabetic population, the mean SBP decreased from 136 to 131 mmHg (p &lt; 0.0001) and mean DBP decreased from 73 to 70 mmHg (p &lt; 0.0001). In the non-diabetics, the mean SBP decreased from 133 to 127 mmHg (p &lt; 0.0001) and the mean DBP decreased from 74 to 71 mmHg (p &lt; 0.0001). With regards to JNC-7 guidelines, the percent of diabetics at SBP goal increased from 42% to 49% (p = 0.047) and percent at DBP goal increased from 74% to 82% (p = 0.008). In non-diabetics, percent at goal for SBP increased from 46% to 57% (p &lt; 0.0001) and percent at DBP goal increased from 68% to 76% (p = 0.003). Among diabetics, there was a statistically significant (p &lt;0.0001) increase in use of BB from 77% to 90%. In non-diabetics, there was a statistically significant (p &lt;0.0001) increase in use of BB from 64% to 86% and ACE-I/ARB from 51% to 70%. Conclusions In both groups (diabetics and non-diabetics) undergoing PCI, both systolic and diastolic blood pressure improved with more patients achieving JNC-7 targets. Among diabetics, there was a significant increase in utilization of BB. Among non-diabetics, there was a significant increase in utilization of BB and ACE-I/ARB.

Epidemiology and treatment of mood disorders in a day hospital setting from 1996 to 2007: an Italian study

Background:The present study aimed: to assess prescribing patterns in the treatment of major depression, bipolar disorder type I, cyclothymia, and dysthymia from 1996 to 2007 in a day hospital setting; to evaluate the prevalence of the above-mentioned mood disorders and gender distribution; and to relate familiality, comorbidity, and marital status to each diagnosis.Methods:Medical records for 777 day hospital patients with a diagnosis of major depression, bipolar disorder type I, cyclothymia, or dysthymia were grouped into two 6-year periods so as to compare the prescribing patterns of tricyclic antidepressants, selective serotonin reuptake inhibitors, noradrenergic reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, noradrenergic and specific serotonergic antidepressants, first-generation antipsychotics, second-generation antipsychotics, and mood stabilizers. Gender, prevalence, familiality, comorbidity, and marital status were related to each diagnosis.Results:The most common mood disorder, with a female preponderance, was major depression, regardless of marital status. High percentages of familiality and comorbidity were found for major depression, while a reduction was found in the utilization of tricyclic antidepressants. There was no statistically significant difference in rates of prescription of selective serotonin reuptake inhibitors and noradrenergic reuptake inhibitors, but some irregularities were found upon evaluating each diagnosis (eg, increased utilization of these agents in dysthymia and major depression, respectively). There was an increase in prescriptions for serotonin and norepinephrine reuptake inhibitors, but no marked differences in utilization of noradrenergic and specific serotonergic antidepressants, which remained basically low. There was no significant difference in prescribing of first-generation antipsychotic agents, although a reduction was found. There was a significant increase in utilization of second-generation antipsychotics and mood stabilizers.Conclusion:Our epidemiological findings are consistent with data reported in the literature regarding the high prevalence of major depression among the mood disorders, as well as the impact of familiality and comorbidity. Analysis of prescribing patterns for antidepressants, antipsychotics, and mood stabilizers in the treatment of mood disorders shows a shift from older to newer drugs, and wider use of mood stabilizers.

From omics and etics to policy and ethics: regulating evolution

Few technologies have experienced such an explosive development and significant increase in utility as the study, description and manipulation of the genes that spell out many of the functions of human life—it almost seems as if the science of our genes is autopoietic in terms of generating innovation. Genetic information is used to address large-scale problems, for example where whole genome and exome sequencing advances the understanding of rare diseases. It is used to tailor individualised health interventions, such as where the identification of a HER2 mutation may open the therapeutic pathway to a treatment with Herceptin or where evidence of a BRCA mutation may trigger potentionally life-saving surgery. From Sir Alec Jeffrey's discovery of DNA similarities, used to identify perpetrators of crime and family relations in immigration cases, to direct-to-consumer genetic testing, used to identify a child's father (or possibly more frequently—establishing the fact that the putative father is not the genetic father) and an individual's genetic disease probability (relative to some nebulous population), genetics and -omics are becoming all-pervasive and, above all, affordable. The cost of whole genome sequencing has decreased dramatically in little more than 10 years—Figure 1 (Wetterstrand, 2013) shows the decreasing cost of sequencing a genome at NHGRI: from just under $100 m in 2001 to just over $5000 in 2013. 23 and Me, a prominent provider of direct-to-consumer genetic testing for disease probability and ancestry, started in 2007 at a cost of $999 per test and now only charges $99 for its service.1 This is the mainstreaming of high-impact technologies: similar to the development and impact of the internet—once available to the specialised privileged few, with limited features and at great expense only—the genetic revolution has taken powerful information out of the hands of the few and made it available to many. This increase in density and availability of meaningful information leads to a perceivable public trend in seeing privacy merely as a symptom of an informational deficiency, i.e., there is a plausible argument that the perceived explosion in information sharing online may well lead to a desensitization, rather than an increased fear for privacy. At the same time, regulatory sciences and the disciplines looking at ethical, legal, and social implications of this type of technology doggedly adhere to their time-honored, heterogeneous and siloed methodological traditions: bar some notable exceptions, lawyers speak to lawyers, ethicists speak to ethicists, sociologists speak to sociologists. Where debate transcends disciplinary boundaries, it is often received with suspicion of the other discipline's (or country's) scholarly conventions, language, and style.

Increasing Use of Total Knee Replacement and Revision Surgery

IN THIS ISSUE OF JAMA, CRAM AND COLLEAGUES 1 report detailed analysis of primary and revision total knee replacement (TKR) performed on more than 3.2 million Medicare beneficiaries from 1991 to 2010. This analysis confirms and quantifies several important findings. First, the use of primary and revision TKRs in Medicare beneficiaries has increased both in absolute volume from 93 230 procedures in 1991 to 226 177 procedures in 2010 and in per capita usage. Second, the pattern of care has changed substantially. Between 1991 and 2010, length of hospital stay for primary TKR decreased from 7.9 to 3.5 days and revision TKR from 8.9 to 5.0 days. However, 30-day all-cause readmission rates after primary TKR increased from 4.2% in the years 1991-1994 to 5.0% in the years 2007-2010 and after revision TKR increased from 6.1% in the years 1991-1994 to 8.9% in the years 2007-2010. A clear change in the pattern of discharge status also occurred with a shift initially to a more institutionalized setting, and recently to a discharge to home with home care services (ie, discharges to patients’ homes decreased from 67.5% in the years 19911994 to 39.9% in the years 1999-2001 then increased to 56.2% in years 2007-2010). In addition to the increase in readmissions, the data demonstrated an important increase in infection rates for revision cases, increasing from 1.4% in the years 1991-1994 to 3.0% in the years 2007-2010. The first question to consider is what is driving the increased utilization. While there are different contributing factors, more importantly this report may be describing only the surface of what is expected to be a profound increase in knee arthroplasty over the next 30 years. By 2030, the demand for TKR in the United States is projected to be as high as 3.48 million procedures annually. Cram et al address only Medicare beneficiaries, but the number of younger individuals (and those without Medicare) undergoing knee replacement is also expected to continue to increase. This is particularly true considering the development of newer arthroplasty procedures used to treat degenerative arthritis in younger patients, such as bicompartmental and unicondylar knee replacements, which have been shown in select studies to be the most rapidly increasing arthroplasty treatment in this younger population. These projections will make TKR a key driver of health care cost, which makes this procedure worthy of careful consideration. This is particularly challenging given the magnitude of the predicted increase and because, as the authors discuss, many studies have demonstrated that TKR is a cost-effective procedure that may improve patients’ activity and health-related quality of life. Although health benefits are difficult to quantify, this expenditure could potentially decrease the allocation of health care resources used by patients having knee replacement over the remainder of their lifetime. Consequently, the ideal number of knee replacements that should be performed per capita is unknown. Although the study by Cram et al suggests that recent stabilization in rates of TKR procedures appears to have occurred, the authors suggest several explanations for the per capita increase, including expansion of indications and the increased prevalence of obesity, which combined with the increase in the number of patients eligible for Medicare has led to the significant increases in utilization reported. Another factor is the increased demand for an active lifestyle in this age group. Furthermore, increased efforts are needed to identify and address predisposing modifiable factors, such as obesity that lead to the need for knee replacement, and to advance efforts at early intervention strategies to treat mild arthritis and to prevent progression of the disease obviating the need for eventual arthroplasty. The cost of TKR over the next 20 years will be driven by the absolute number of primary procedures performed, the increasing number of more costly revision procedures, and

Abstract 137: Comparing Blood Pressure Control in Diabetic Versis Nondiabetic Veterans Following Percutaneous Coronary Intervention

Background: As per the US Joint National Committee VII (JNC-7) recommendations, patients with known underlying coronary artery disease and diabetes should have goal blood pressures (BP) of systolic (SBP) &lt;130 and diastolic (DBP) &lt;80 to decrease morbidity and mortality associated with cardiovascular disease. In addition to lifestyle modification, these goals can be attained by use of multiple classes of drugs including beta-blockers (BB), angiotensin-converting-enzyme inhibitors/angiotensin receptor blockers (ACE-I/ARB), calcium channel blockers (CCB), diuretics and nitrates. Methods: We conducted a retrospective cohort study focusing on the attainment of the JNC-7 guidelines, comparing outcomes between 355 diabetic to 580 non-diabetic patients undergoing PCI between September 2004 and January 2011 at the Jesse Brown Veterans Affairs Hospital in Chicago, IL. BP measurements and antihypertensive medications pre and post PCI at 6-month follow-up were documented. Results: Among the diabetic population, the mean SBP decreased from 136 to 131 mmHg (p = 0.0007) and mean DBP decreased from 73 to 70 mmHg (p = 0.0005). In the non-diabetics, the mean SBP decreased from 133 to 127 mmHg (p &lt; 0.0001) and the mean DBP decreased from 73 to 70 mmHg (p &lt; 0.0001). With regards to JNC-7 guidelines, the percent of diabetics at SBP goal increased from 39% to 49% (p = 0.0053) and percent at DBP goal increased from 73% to 82% (p = 0.0098). In non-diabetics, percent at goal for SBP increased from 45% to 57% (p &lt; 0.0001) and percent at DBP goal increased from 68% to 76% (p = 0.0009). Among diabetics, there was a statistically significant (p &lt;0.0001) increase in use of BB from 79% to 92%. In non-diabetics, there was a statistically significant (p &lt;0.0001) increase in use of BB from 66% to 87% and ACE-I/ARB from 51% to 70%. Conclusions: In both groups undergoing PCI, SBP and DBP improved with more patients achieving JNC-7 targets. Among diabetics, there was a significant increase in utilization of BB. Among non-diabetics, there was a significant increase in utilization of BB and ACE-I/ARB.

Abstract 188: Blood Pressure Control in Veterans following Percutaneous Coronary Intervention

Background: As per the US Joint National Committee VII (JNC-7) recommendations, patients with known underlying CAD and percutaneous coronary intervention (PCI) should have goal blood pressures of systolic &lt;130 and diastolic &lt;80. In addition to lifestyle modification, these goals can be attained by use of multiple classes of drugs including beta-blockers (BB), angiotensin agonists (ACE-I/ARB), calcium channel blockers (CCB), diuretics and nitrates. Methods: We conducted a retrospective cohort study in 935 consecutive patients undergoing PCI between September 2004 and January 2011 at the Jesse Brown Veterans Administration Hospital in Chicago, IL. Blood pressure (BP) measurements and antihypertensive medications pre and post PCI at 6-month follow-up were documented. Results: Over the 6-month follow-up period, mean systolic blood pressure (SBP) decreased from 134 to 129 mmHg (p &lt; 0.0001) and mean diastolic blood pressure (DBP) decreased from 73 to 70mmHg (p &lt; 0.0001). As per JNC-7 guidelines, the percent of patients who reached SBP goals increased from 43 to 52% (403 to 485 of 935) and with DBP goals rose from 70 to 76% (655 to 706 of 935). At 6-month follow-up, there was a statistically significant increase in the utilization of beta-blockers, ACE-I/ARBs, and nitrates. (TABLE) Conclusions: In this group of patients undergoing PCI, both systolic and diastolic blood pressure improved with more patients achieving JNC-7 targets. There was a significant increase in utilization in evidence-based medication.

Behind‐the‐Counter Statins: A Silver Bullet for Reducing Costs and Increasing Access?

To examine how the 2004 introduction of behind-the-counter (BTC) simvastatin in the United Kingdom affected utilization, prices, and expenditures. Secondary data on simvastatin utilization, prices, and expenditures between 1997 and 2007 in the United Kingdom and four other countries. We used a difference-in-differences approach to estimate how the introduction of BTC simvastatin affected utilization, prices, and expenditures. This approach compares outcomes in the United Kingdom before and after the introduction of BTC simvastatin, using outcomes in countries where the drug remained prescription only to control for possible confounders. Data on simvastain utilization, prices, and expenditures between 1997 and 2007 in the United Kingdom and four other countries were obtained from an outside vendor. The introduction of BTC simvastatin in the United Kingdom led to a significant increase in utilization of simvastatin and a significant decline in expenditures for simvastatin purchases. Our results are robust to alternate model specifications. Behind-the-counter statins have the potential to simultaneously increase use of statins and lower expenditures.