Significant Variation In Treatment Research Articles

Disparities in pediatric drug-resistant epilepsy care

IntroductionEpilepsy affects millions of children worldwide, with 20–40% experiencing drug-resistant epilepsy (DRE) who are recommended for epilepsy surgery evaluation and may benefit from surgical management. However, many patients live with DRE for multiple years prior to surgical epilepsy referral or treatment or are never referred at all.ObjectiveWe aimed to describe factors associated with referral for epilepsy surgery in the USA, in order to identify disparities in DRE, characterize why they may exist, and recognize areas for improvement.MethodsPediatric patients diagnosed with DRE between January 1, 2004 and December 31, 2020 were identified from the Pediatric Health Information System (PHIS) Database. Patients treated with antiseizure medications (ASMs) only, ASMs plus vagus nerve stimulation (VNS), and ASMs plus cranial epilepsy surgery were studied regarding access to epilepsy surgery and disparities in care. This study used chi-square tests to determine associations between treatment time and preoperative factors. Preoperative factors studied included epilepsy treatment type, age, sex, race/ethnicity, insurance type, geographic region, patient type, epilepsy type, and presence of pediatric complex chronic conditions (PCCCs).ResultsA total of 18,292 patients were identified; 10,240 treated with ASMs, 5019 treated with ASMs + VNS, and 3033 treated with ASMs + cranial epilepsy surgery. Sex was not found to significantly vary among groups. There was significant variation in age, census region, race/ethnicity, patient type, presence of PCCCs, diagnosis, and insurance (p < 0.001). Those treated surgically, either with VNS or cranial epilepsy surgery, were 2 years older than those medically treated. Additionally, those medically treated were less likely to be living in the Midwest (25.46%), identified as non-Hispanic white (51.78%), have a focal/partial epilepsy diagnosis (8.74%), and be privately insured (35.82%).ConclusionsWe studied a large administrative US database examining variables associated with surgical epilepsy evaluation and management. We found significant variation in treatment associated with age, US census region, race/ethnicity, patient type, presence of PCCCs, diagnosis, and health insurance type. We believe that these disparities in care are related to access and social determinants of health, and we encourage focused outreach strategies to mitigate these disparities to broaden access and improve outcomes in children in the USA with DRE.

Clinical characteristics of patients requiring lung transplantation referral in national cystic fibrosis registry data.

We aimed to determine the number of cystic fibrosis (CF) patients recorded in the Cystic Fibrosis Registry of Türkiye (CFRT) who were in need of lung transplantation (LT) referral and examine clinical differences between patients who were LT candidates due to rapid forced expiratory volume in one second (FEV₁) decline and LT candidates without rapid FEV₁ decline in the last year to identify a preventable cause in patients with such rapid FEV₁ decline. All CF patients recorded in the CFRT in 2018 were evaluated in terms of LT. Patients were divided into those with FEV₁ below 50% and in need of LT due to a decrease of 20% or more in the previous year (Group 1) and those who did not have FEV₁ decline of more than 20% in the previous year but had other indications for LT (Group 2). Demographic and clinical features were compared between the two groups. Of 1488 patients registered in CFRT, 58 had a need for LT. Twenty patients were included in Group 1 and others in Group 2. Our findings did not reveal any significant variations in treatment, chronic infection status, or complications between the two groups. The average weight z-score was significantly higher in Group 1. Positive correlations were detected between weight z-score and FEV₁ in 2017 in Group 1 and between FEV₁ values in 2017 and 2018 in Group 2. There appears to be a relationship between the nutritional status and weight z-scores of CF patients and pulmonary function, which may indirectly affect the need for lung transplantation referral.

Fortification of diets with omega-3 long-chain polyunsaturated fatty acids enhances feedlot performance, intramuscular fat content, fat melting point, and carcass characteristics of Tattykeel Australian White MARGRA lambs.

Meat eating quality indices such as intramuscular fat content (IMF) and fat melting point (FMP) of the Longissimus thoracis et lumborum muscle and the feedlot performance, carcass traits, and commercial wholesale cuts of lot-fed Tattykeel Australian White (TAW) MARGRA lambs as a result of dietary fortification of the diet with omega-3 long-chain polyunsaturated fatty acids (n-3 LC-PUFA) were evaluated. A total of 75 TAW MARGRA lambs at 6 months of age with an average liveweight of 30 ± 1.2 kg were used. The lambs were randomly allocated to the following three dietary treatments of 25 lambs each in a 47-day feeding trial using a completely randomized experimental design: (1) control diet of hay plus pellets without omega-3 oil, (2) hay plus commercial whole grain pellets (MSM) without omega-3 oil, and (3) hay plus pellets fortified with omega-3 oil. It was hypothesized that dietary supplementation with omega-3 fortified pellets will improve feedlot performance, meat-eating quality indices of IMF, FMP, and carcass characteristics. Lot-fed lambs on the MSM whole grain had the highest feed intake of 1.69 kg/day, followed by the control at 1.57 kg/day and the lowest in the omega-3 diet at 1.01 kg/day (p = 0.0001). However, the omega-3 diet had the highest average daily gain of 230 g/head/day (p = 0.0001), indicating the greatest feed efficiency since it had the best growth response with minimal feed intake. Post-slaughter evaluation of the Longissimus thoracis et lumborum muscle revealed significant treatment variations in IMF (p = 0.0001), FMP (p = 0.0001), pH (p = 0.0380), and wholesale French rack primal cut (p = 0.0001). Strong correlations (p < 0.05) between liveweight, temperature, pH, FMP, and IMF were observed. Similarly, significant correlations between carcass characteristics of total saleable meat yield, lean trim, fat trims, bones, and leg shank were evident (p < 0.05). However, there were no treatment differences in the final liveweight, GR fat depth, hot standard carcass weight, or dressing percentage. The findings indicate that feedlot performance, meat-eating quality traits such as IMF and FMP, and commercial wholesale French rack cuts can be further improved during feedlot finishing of TAW MARGRA lambs through dietary supplementation with omega-3 oils, and hence the tested hypothesis of improved meat quality attributes is partially confirmed.

Clinical Practice Guidelines on the Treatment of Patients with Cleft Lip, Alveolus, and Palate: An Executive Summary.

Significant treatment variation exists in the Netherlands between teams treating patients with cleft lip, alveolus, and/or palate, resulting in a confusing and undesirable situation for patients, parents, and practitioners. Therefore, to optimize cleft care, clinical practice guidelines (CPGs) were developed. The aim of this report is to describe CPG development, share the main recommendations, and indicate knowledge gaps regarding cleft care. Together with patients and parents, a multidisciplinary working group of representatives from all relevant disciplines assisted by two experienced epidemiologists identified the topics to be addressed in the CPGs. Searching the Medline, Embase, and Cochrane Library databases identified 5157 articles, 60 of which remained after applying inclusion and exclusion criteria. We rated the quality of the evidence from moderate to very low. The working group formulated 71 recommendations regarding genetic testing, feeding, lip and palate closure, hearing, hypernasality, bone grafting, orthodontics, psychosocial guidance, dentistry, osteotomy versus distraction, and rhinoplasty. The final CPGs were obtained after review by all stakeholders and allow cleft teams to base their treatment on current knowledge. With high-quality evidence lacking, the need for additional high-quality studies has become apparent.

Variation in Treatment of Children Hospitalized With New-Onset Systemic Juvenile Idiopathic Arthritis in the US.

Increasing evidence supports the conclusion that early initiation of biologics may dramatically improve disease course and reduce glucocorticoid exposure for children with systemic juvenile idiopathic arthritis (JIA). The present study was undertaken to characterize variation in the use of first-line biologic and glucocorticoid therapy and to identify drivers of variation in children hospitalized with new-onset systemic JIA. We conducted a retrospective cohort study of children hospitalized with new-onset systemic JIA from 2008 to 2019 utilizing a comparative pediatric database from 52 tertiary care children's hospitals. Subjects and treatment receipt were identified using International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 discharge diagnosis codes, pharmacy billing data, and clinical transaction classification codes. Mixed-effects logistic regression was used to identify patient- and hospital-level factors associated with receipt of glucocorticoids and biologics. In total, 534 children with new-onset systemic JIA hospitalized during the study period met inclusion criteria. Twenty-nine percent received biologics, and 58% received glucocorticoids. Biologic use increased over time (P < 0.001), methotrexate use decreased (P < 0.01), and glucocorticoid use remained unchanged. Biologics and glucocorticoid use varied significantly between hospitals. High annual hospital volume, intensive care unit stay, and later discharge year were significantly associated with biologic exposure. Medium-high and high annual hospital volume were significantly associated with less glucocorticoid exposure. Despite increasing evidence demonstrating improved outcomes with first-line treatment with biologics, we found significant treatment variation across hospitals with many children not receiving biologics and a persistent high rate of glucocorticoid exposure. These results underscore the need for comparative efficacy studies and improved treatment standardization.

Report of a Large Cohort of Intermediate-Risk Prostate Cancer Patients Treated with Cs-131 Brachytherapy

The intermediate-risk (IR) group of prostate cancer patients is extremely heterogenous. Patients are sub-classified into favorable-IR (FIR) and unfavorable-IR (UIR) groups due to variable prognoses, leading to significant treatment variations. We sought to evaluate our institutional outcomes utilizing Cs-131 prostate brachytherapy (PB) for IR patients and elucidate which factors are important for driving more aggressive treatment. We reviewed a prospectively collected database of men treated with Cs-131 PB between 2006-2019. Patients with less than 24-months follow-up were excluded. Patients were classified as IR if they had one of the following factors: Gleason Score 7, prostate specific antigen (PSA) >10 but < 20 ng/mL, or T2b-c on clinical exam. We defined UIR patients as having either Grade Group (GG) 3 or >1 IR factors. Our general treatment schema was to treat FIR with PB alone (115 Gy) and UIR with combined external beam radiation therapy (EBRT) to 45 Gy + PB boost (85 Gy), though this was somewhat variable. The Kaplan-Meier method was used to estimate actuarial event-time probabilities for biochemical failure (BF). BF was defined as a serum PSA at least 2 ng/mL greater than posttreatment nadir PSA. Cox regression analysis was performed to identify predictors for BF. These factors included: GG, UIR subgroup, treatment (PB alone vs combined modality), ADT use, age (≤67 vs >67), clinical T-stage, PSA (<10 vs ≥10-20), and >1 IR factors. A total of 327 patients with a median follow-up of 70.6 months (IQR 45.9-102.7 months) were identified. Median age was 67 (IQR 62-72). ADT was used in 12.5% of patients. Most patients (57.5%) were classified as FIR. Of the 139 patients in the UIR subgroup, 69.1% met UIR criteria by virtue of GG 3 only and 30.9% by having >1 IR factor. Twenty-eight patients (20.1%) had a GG 3 and >1 IR factor. FIR patients had a 5-year BF rate (BFR) of 2.5% (SE 0.012). The 5-year BFRs for FIR patients treated with PB alone (81.4%) and combined modality (18.6%) were 1.7% (SE 0.012) and 5.0% (SE 0.035), respectively (p = 0.18). UIR patients had a 5-year BFR of 10.9% (SE 0.030) and were most commonly treated with EBRT+PB (61.9%). Five-year BFRs were 14.0% (SE 0.078) and 10.1% (SE 0.032) for UIR patients treated with PB alone and combined modality, respectively (p = 0.91). UIR patients by virtue of GG 3 only (n = 68) had a 5-year BFR of 13.0% (SE 0.047). The 5-year BFR for UIR due to >1 IR factors (n = 71) was 8.9% (SE 0.038). Six patients had 3 IR factors with a 5-year BFR of 50% (SE 0.25). On multivariate analysis, UIR subgroup was the only significant predictor for BF (p = 0.02; HR 2.49, 95% CI 1.15-5.41). The FIR subgroup is a distinct entity from the UIR subgroup with excellent outcomes when treated with Cs-131 PB alone. UIR patients have excellent outcomes with combined EBRT + PB. The majority of UIR patients do not require ADT, though the group that would benefit still needs to be defined.

Regional variation in vestibular schwannoma management and patient support group participation across the United States.

The Acoustic Neuroma Association (ANA) represents the largest existing patient support organization for those diagnosed with vestibular schwannoma (VS) in the United States. Yet, the degree to which the ANA is actually utilized across the country is unknown. Moreover, evidence suggests that there may exist significant regional variation in management practices of VS across the United States. Patient participation in the ANA by state and geographical region, as well as their management approach, was reviewed through a cross-sectional survey performed from February 2017 through January 2019, patients diagnosed with sporadic VS. Among 878 patients studied, the District of Columbia had the largest proportion of ANA patients relative to state population (0.85 per 100,000 persons), followed by New Hampshire (0.74), Maine (0.60), and New Jersey (0.42). Comparatively, Mississippi (0.03), Hawaii (0.07), and Rhode Island (0.09) harbored significantly lower participation rates (p=0.001). Significant treatment variations were observed across the United States: in Maine, Iowa, Missouri, Kansas, and New Hampshire, an average of 73% (range, 70-75) of patients underwent microsurgery, whereas only 24% (range, 0-35) of patients in Colorado, New York, Massachusetts, Connecticut, and West Virginia underwent microsurgery (p<0.001). After controlling for patient age and tumor size, patients were significantly more likely to undergo a retrosigmoid approach than the translabyrinthine approach for medium- to large-sized tumors in the Northeast (OR=4.18; p=0.001) and Western United States (OR=2.94; p=0.009). Large regional variation exists surrounding patient participation in the ANA as well as management practices across the United States.

Updated leg ulcer pathway: improving healing times and reducing costs

Regardless of the amount of literature and evidence on leg ulcer management, there are still significant variations in treatment. Implementing a standardised leg ulcer pathway to ensure patients are appropriately and timely assessed could help reduce nursing time and overall costs, while improving healing outcomes and patients' quality of life. Such a pathway was introduced in Lincolnshire and Leicestershire, UK, to treat venous leg ulcers (VLUs). The results showed improved healing times, reduced costs and fewer nurse visits, among other findings.

Lack of Data-driven Treatment Guidelines and Wide Variation in Management of Chronic Pelvic Pain in Adolescents and Young Adults.

Current literature lacks data-driven guidelines for surgical treatment of adolescent and young adult (AYA) patients with chronic pelvic pain. We hypothesized that there is a significant variation in treatment of these patients, which might be an indicator of over- or undertreatment by some providers. We completed a retrospective population-based analysis of the Nationwide Inpatient Sample from 1998 to2016. We included AYA patients aged 9-25years whose primary diagnosis was adenomyosis, endometriosis, or chronic pelvic pain. Patients who might have undergone pelvic or abdominal procedures for other primary diagnoses were excluded. Trends of inpatient surgical intervention were calculated. Logistic regression was performed to determine the likelihood of undergoing an intervention, adjusted for patient demographic characteristics. A total of 13,111 AYA patients were analyzed. Median age at diagnosis was 22 (interquartile range, 20-24) years. The overall inpatient intervention rate was 5879/13111 (45.0%) (2445/5897 (18.6%) for excision/ablation, 2057/5897 (15.7%) for hysterectomy, 1239/5897 (9.5%) for diagnostic laparoscopy, and 156/5897 (1.2%) for biopsy). Rate of hysterectomy increased in the late 2000s while rates of all other interventions decreased. Patients in the northeast were less likely to undergo an intervention than patients in the rest of the country. Rates of intervention also differed according to race, insurance status, and type of hospital. There is wide variation in the use of surgical treatment for chronic pelvic pain in AYA patients across the country and between types of institutions. Of concern, the rate of hysterectomy has increased over time. There is a need for data-directed treatment guidelines for the management of AYA patients with chronic pelvic pain to ensure appropriate application of surgical treatments and expand high-value surgical care.

Updated leg ulcer pathway: improving healing times and reducing costs.

Regardless of the amount of literature and evidence on leg ulcer management, there are still significant variations in treatment. Implementing a standardised leg ulcer pathway to ensure patients are appropriately and timely assessed could help reduce nursing time and overall costs, while improving healing outcomes and patients' quality of life. Such a pathway was introduced in Lincolnshire and Leicestershire, UK, to treat venous leg ulcers (VLUs). The results showed improved healing times, reduced costs and fewer nurse visits, among other findings.

Real-World Outpatient Prescription Patterns for Atopic Dermatitis in the United States.

Atopic dermatitis (AD) often requires combination treatment regimens. However, little is known about treatment combinations and polypharmacy in AD. We sought to characterize patterns of outpatient prescriptions and polypharmacy among US children and adults with AD. Data from the 1993-2015 National Ambulatory Medical Care Survey were analyzed, including 128,300 pediatric and 623,935 adult outpatient visits. Among AD visits, dermatologists prescribed more topical corticosteroids (TCSs, P = 0.01) than any other clinicians, particularly multiple TCSs (P < 0.0001), topical calcineurin inhibitors (TCI, P = 0.009), combination TCIs with TCSs (P = 0.004), and systemic immunosuppressants (P = 0.003). Prescriptions for multiple TCSs increased from ages 0 to 19 years, 20 to 39 years, and peaked at 40 to 59 years (P = 0.0002). Prescriptions for prednisone peaked at ages of 40 to 59 years (P = 0.003). A subset of AD patients was prescribed oral antibiotics (7.1%), although fewer than half had a diagnosis of bacterial infection (42.1%). The proportion of patients receiving multiple prescriptions was higher in visits to primary care practitioners versus dermatologists, those with private versus public insurance, and 50 years or older versus 20 to 49 years versus 0 to 19 years. Visits with 4 or more prescriptions by dermatologists increased between 1993-2000 (10%) and 2011-2015 (29%, P = 0.0001). In conclusion, significant treatment variation exists among specialists managing AD, with increasing polypharmacy over time.

Intrastate Variation in Treatment and Outcomes of Out-of-Hospital Cardiac Arrest

Objective: Our objective was to analyze and compare out-of-hospital cardiac arrest (OHCA) system of care performance and outcomes at the Medical Control Authority (MCA) level in the state of Michigan. We hypothesized that clinically and statistically significant variations in treatment and outcomes of OHCA exists within a single U.S. state. Methods: We performed a retrospective, observational study of all non-traumatic EMS-treated OHCA from the state of Michigan CARES registry for 2014–2015. Geocoding of the OHCA incident address was used to assign records to individual MCAs. MCA-based demographics, arrest characteristics, system of care performance and outcomes were quantified and compared. Associations between demographics, system of care parameters, and outcomes were examined at the MCA level. Results: A total of 8,115 records with complete data were available for analysis. Eleven MCAs met study inclusion criteria of >100 cases, producing a final sample size of 7,788 records (96%). Statistically significant variations in survival to hospital discharge ranged from 4.5% to 15% (p < 0.001) (Adjusted odds ratio [AOR] range 0.6–2.0) and survival with good neurologic outcome 2.7–12.5% (p < 0.001; AOR range 0.5–2.2,) were observed across MCAs. Bystander CPR ranged from 32% to 53% (p < 0.001) and bystander AED application ranged from 3.5% 11.5% (p < 0.05). Of patients admitted to the hospital alive, 29–68% received targeted temperature management. In hospital mortality ranged from 53.1% to 73.9% (p < 0.05). Conclusion: Significant intrastate variability in OHCA system of care performance and outcomes currently exist and are similar to what has been previously reported across North America almost a decade ago. This degree of variability highlights the opportunity to optimize modifiable factors within local systems of care to improve OHCA outcomes.

Clinical and economic burden associated with stage III to IV triple-negative breast cancer: A SEER-Medicare historical cohort study in elderly women in the United States.

The current study was performed to describe patient characteristics, treatment patterns, survival, health care resource use (HRU), and costs among older women in the United States with advanced (American Joint Committee on Cancer stage III/IV) triple-negative breast cancer (TNBC) in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Women who were aged ≥66 years at the time of diagnosis and diagnosed with advanced TNBC between January 1, 2007, and January 1, 2011, in the SEER-Medicare database and who were followed for survival through December 31, 2013, were eligible. Patient demographic and clinical characteristics at the time of diagnosis, subsequent treatment patterns, and survival outcomes were analyzed. HRU and costs for the first 3 months after diagnosis, the last 3 months of life, and the time in between are summarized. All analyses were stratified by American Joint Committee on Cancer stage of disease. There were 1244 patients newly diagnosed with advanced TNBC; the majority were aged ≥75 years (61% with stage III disease and 57.4% with stage IV disease) and white (>70% of patients in both disease stage groups). The most common treatment approaches were surgery combined with chemotherapy for patients for stage III disease (50.6%) and chemotherapy alone or with radiotherapy for patients with stage IV disease (31.3%). Diverse chemotherapy regimens were administered for each line of therapy; nevertheless, the medications used were consistent with national guidelines. Patients with stage III and stage IV disease were found to have a similar mean number of hospitalizations and outpatient visits, but mean monthly costs were greater for patients with stage IV disease at all 3 time points. The mean cost per patient-month (in 2013 US dollars) was $4810 for patients with stage III disease and $9159 for patients with stage IV disease. Among older women with advanced TNBC, significant treatment variations and considerable HRU and costs exist. Further research is needed to find effective treatments with which to reduce the clinical and economic burden of this disease. Cancer 2018;124:2104-14. © 2018 American Cancer Society.

Do Lower-Risk Thyroid Cancer Patients Who Live in Regions with More Aggressive Treatments Have Better Outcomes?

The management of differentiated thyroid cancer has traditionally consisted of total thyroidectomy with or without adjuvant radioactive iodine. However, in the last two decades, this approach has been challenged, with the consideration of more conservative approaches such as less radical surgery and deferring adjuvant treatment, especially in lower-risk patients. The objective of this study was to consider the effectiveness of current treatment options by comparing the survival outcomes from different geographic regions with different treatment philosophies. This study design was based on the concept of natural experiments in patient care that occur when physicians in different regions treat the spectrum of typical patients with varying treatments. This population-based retrospective cohort study investigated 2444 patients with differentiated thyroid cancer ≤4 cm between 1990 and 2001 from Ontario, Canada. Extent of disease and extent of surgery were abstracted from pathology reports and were linked to downstream administrative medical information on treatments and outcomes. Patient demographics, tumor characteristics, treatments, and outcomes were compared between those geographic regions with more aggressive treatments and those regions with less aggressive treatments. Treatment varied across the province. When comparing outcomes in regions where patients had more extensive treatment to those in regions where patients had less extensive therapy, similar rates were found for 15-year survival, recurrence, and survival after recurrence. There were significant variations in treatment but no differences in outcomes for regions with more versus less aggressive approaches. These findings support the trend toward more conservative management approaches in the treatment of thyroid cancer.

Variation in Locoregional Prostate Cancer Care and Treatment Trends at Commission on Cancer Designated Facilities: A National Cancer Data Base Analysis 2004 to 2013.

Contemporary treatment trends for prostate cancer show increased rates of active surveillance. However, nationwide applicability of these reports is limited. Additionally, the effect of Commission on Cancer facility type on prostate cancer treatment patterns is unknown. We used the National Cancer Data Base to identify men diagnosed with prostate cancer, between 2004 and 2013. Our cohort was stratified on the basis of the National Comprehensive Cancer Network prostate cancer risk classes. Cochran-Armitage tests were used to evaluate temporal trends. Random effects hierarchical logit models were used to assess treatment variation at Commission on Cancer facility and institution level. In 825,707 men, utilization of radiation therapy declined and utilization of radical prostatectomy increased for all prostate cancer risk groups between 2004 and 2013 (P< .0001). Observation for low-risk prostate cancer increased from 16.3% in 2004 to 2005 to 32.0% in 2012 to 2013 (P< .0001). Significant treatment variation was observed on the basis of Commission on Cancer facility type. Across all risk groups, the lowest rates of radical prostatectomy and highest rates of external beam radiation therapy were observed in community cancer programs. The highest rates of observation for low-risk disease were observed in academic centers. Treatment variation according to institution ranged from 14% (95% confidence interval, 0.12-0.15) for androgen deprivation therapy up to 59% (95% confidence interval, 0.45-0.73) for cryotherapy. The increased utilization of observation in low-risk prostate cancer is an encouraging finding, which appears to be mainly derived by a decrease in radiotherapy utilization in this risk group. Regardless of tumor characteristics, significant variations in treatment modality exist among different facility types and institutions.

Variations in the medical treatment of inflammatory bowel disease among gastroenterologists.

Background and aimsWith expanding available treatment options and evolving understanding of the risks and benefits of medical therapies for inflammatory bowel disease (IBD), there is the possibility of significant variations in treatment and outcomes. Little is known about the variation in treatment between IBD specialists and other gastroenterology (GI) physicians. Evaluating possible variations is an important first step to help address standardized care and optimize treatment. We studied the differences in use of biologics and immunomodulators in the management of IBD patients at a tertiary care hospital between IBD-trained physicians and other gastroenterologists.MethodsA total of 325 IBD patients were included in the analysis. Of these, 216 patients received care with an IBD physician and 109 had other GI/non-IBD physicians as their main caregivers.ResultsThe unadjusted use of immunomodulators (35.6% vs 16.5%, p = 0.001), biologics (45.8% vs 22.9%, p =0.001) and dual therapy (biologics and immunomodulator) (14.4% vs 3.7%, p =0.001) was significantly higher in the IBD-physician group. These differences in therapy between the two groups remained after adjusting for patient and disease characteristics.ConclusionThere are significant variations in the treatment of patients with IBD by GI physicians. The use of biologics and immunomodulators is higher in GI physicians with dedicated IBD interest and training.

Variations in gastric cancer care

Race is associated with patterns of presentation and survival outcomes of gastric cancer in the United States. However, the impact of race on the receipt of guideline-recommended care is not well characterized. By using current recommendations, the authors examined the association between race and guideline-recommended treatments and identified factors that are predictive of variations in gastric cancer care. By using the National Cancer Database for 1998 through 2005, 106,002 patients with gastric adenocarcinoma were identified. Multivariate analysis techniques were used to examine the association between race, the receipt of guideline-recommended care, and survival after adjusting for covariates. Although African-American and Hispanic patients were more likely to undergo adequate lymphadenectomy (> or =15 lymph nodes) and to receive care at comprehensive cancer centers and high-volume facilities (for all, P < or = .001), they were less likely to receive adjuvant multimodality therapy for American Joint Committee on Cancer stage IB through IV, lymph node-negative (M0) disease. Up to 60% of all patients who underwent gastrectomy failed to receive adequate lymphadenectomy and adjuvant multimodality therapy. The delivery of multimodality therapy varied significantly by stage and lymph node evaluation (P < or = .001). These findings persisted on our multivariate analyses, indicating that African-American and Hispanic patients received adequate lymph node evaluation (P < or = .001), whereas they were associated with receiving no adjuvant multimodality therapy (P < or = .025). There were significant variations in treatment for gastric cancer among ethnic groups in the United States. It was noteworthy that, although nonwhite race was associated with improved surgical care, gastric cancer care remained suboptimal overall. Cancer programs need to identify procedures to maximize the delivery of adequate gastric cancer care to all patients.

Determining factors in the treatment choice of patients with hypertension with complications and secondary hypertension

The purpose of this article is to analyze the effects patients' socioeconomic characteristics, along with hospital size and location, had on the initial treatment choice for individuals with hypertension with complications and secondary hypertension. The analysis uses retrospective data and binary logistic regression to analyze treatment choice determinants. Initial diagnostic and/or therapeutic procedures were categorized as invasive or non-invasive, which served as the dependent variable. Uninsured people were more likely to get less expensive non-invasive treatment. Medicare patients were approximately twice as likely to receive an invasive procedure as individuals with private insurance, even after controlling for age and other socioeconomic characteristics. Minorities and males were also more likely to receive an invasive primary procedure. Significant treatment variations across States were also found. There were insufficient observations to look at variability within patients treated by a single physician. Future research could tie this information into a simultaneous equation system in order to determine whether patients who received one treatment type versus another were better off. Finding that characteristics other than morbidity affect the type of treatment received indicates that public policy could improve care. Most important, the ability to pay, type of insurance, geographic location and race influence whether patients receive invasive or non-invasive treatment upon hospitalization for hypertension, indicating that policies prescribing treatment alternatives that remove non-medical issues from calculation may improve overall outcomes. Comprehensive treatment-choice analyzes have been largely overlooked in the hypertension literature. Additionally, few studies analyze choice using data from such a diverse array of geographic areas and socio-economic strata.

Cost of illness: An international comparison

To assess international comparability of general cost of illness (COI) studies and to examine the extent to which COI estimates differ and why. Five general COI studies were examined. COI estimates were classified by health provider using the system of health accounts (SHA). Provider groups fully included in all studies and matching SHA estimates were selected to create a common data set. In order to explain cost differences descriptive analyses were carried out on a number of determinants. In general similar COI patterns emerged for these countries, despite their health care system differences. In addition to these similarities, certain significant disease-specific differences were found. Comparisons of nursing and residential care expenditure by disease showed major variation. Epidemiological explanations of differences were hardly found, whereas demographic differences were influential. Significant treatment variation appeared from hospital data. A systematic analysis of COI data from different countries may assist in comparing health expenditure internationally. All cost data dimensions shed greater light on the effects of health care system differences within various aspects of health care. Still, the study's objectives can only be reached by a further improvement of the SHA, by international use of the SHA in COI studies and by a standardized methodology.

Effects of breed and nutrition on the productive traits of beef cattle in South East Brazil: Part 2—Tissue distribution and carcase composition

This paper is the second in a series recording the effects of breed and nutrition on the productive traits of Nelore, Guzerá, Charolais and Canchim cattle in south-east Brazil. Significant treatment variations were recorded in carcase bone weights but differences in meat to bone ratios were not sufficiently marked to demonstrate that bone might grow at the expense of muscle when animals are maintained on particularly severe nutritional regimes. A simple carcase weight to length ratio was shown to be highly correlated with total bone proportion but not with yield of saleable meat. Recovery of total saleable meat was only marginally and not significantly affected by breed but was significantly affected by treatment. The increased levels of fatness in the carcases of the zebu and, in particular, all animals finished in feedlot, that affected the yield of saleable meat, was also thought to be responsible for the decreased recovery of first quality meat in these carcases. In general, tissue differences were more noticeable between treatments than between breeds and reflected the varying nutritional status of the animals pre-slaughter.