Practice Size Research Articles

Overdiagnosis of dental caries in South Korea: a pseudo-patient study

BackgroundTo evaluates the tendency of South Korean dentists to over-diagnose clinically healthy teeth in pseudo-patients.MethodsWe conducted a pseudo-patient, cross-sectional study in 196 private dental clinics with 58 pseudo-patients in South Korea between August and December 2018. Trained pseudo-patients with no previous oral diseases, including dental caries, diagnosed by two experienced dentists, were sent to each dental clinic. Before visiting each private dental clinic, participants were instructed to state, “I have no symptoms, but I would like to have a dental caries examination”. The oral examination was performed using visual and tactile inspection methods only. The interactions between the dental clinic staff and the pseudo-patient were documented on a data collection form shortly after each visit.ResultsIn 33.2% (65/196) of these interactions, the pseudo-patients were diagnosed as having no dental caries. 11.7% (23/196), 12.8% (25/196), 10.7% (21/196), and 10.7% (21/196) of the sample were diagnosed with dental caries in one, two, three, and four teeth, respectively. Dentists diagnosed five or more dental caries in 20.9% (41/196) of the sample. 196 dental clinics diagnosed a total of 503 dental caries. Of these, 392 were in molars. Small solo practice dentists diagnosed 3.54 dental caries and large group practice dentists 1.57, but the difference was not significant (p = 0.07). The recommendation rate for dental caries treatment was highest among 43 (55.1%) large solo practices, and lowest in 7 (33.3%) large group practices. However, small solo practices had the lowest rate of preventive care recommendations at 12 (30.8%) and 10 (47.6%) in large group practices. The data shows that preventive care recommendations increased as the practice size increased.ConclusionThe study findings indicate that Korean dentists tend to over-diagnose dental caries, which could pose a threat to public health both in Korea and worldwide. Therefore, it is important to carefully consider strategies to improve the correct diagnosis and standard of care for dental caries by private dentists.

Differences in Use of a Patient Portal Across Sociodemographic Groups: Observational Study of the NHS App in England.

The adoption of patient portals, such as the National Health Service (NHS) App in England, may improve patient engagement in health care. However, concerns remain regarding differences across sociodemographic groups in the uptake and use of various patient portal features, which have not been fully explored. Understanding the use of various functions across diverse populations is essential to ensure any benefits are equally distributed across the population. This study aims to explore differences in the use of NHS App features across age, sex, deprivation, ethnicity, long-term health care needs, and general practice (GP) size categories. We used weekly NHS App use data from the NHS App dashboard for 6386 GPs in England from March 2020 to June 2022. Negative binomial regression models explored variations in weekly rates of NHS App features used (registrations, log-ins, prescriptions ordered, medical record views, and appointments booked). Outcomes were measured as weekly rates per 1000 GP-registered patients, and we conducted separate models for each outcome. Regression models included all covariates mentioned above and produced incident rate ratios, which we present here as relative percentages for ease of interpretation. GP-level covariate data on sociodemographic variables were used as categorical variables in 5 groups for deprivation (Q1=least deprived practices and Q5=most deprived practices) and 4 groups for all other variables (Q1=least deprived practices and Q4=most deprived practices). We found variations in the use of different features overall and across sociodemographic categories. Fully adjusted regression models found lower use of features overall in more deprived practices (eg, Q5 vs Q1: registrations=-34%, log-ins=-34.9%, appointments booked=-39.7%, medical record views=-32.3%, and prescriptions ordered=-9.9%; P<.001). Practices with greater proportions of male patients also had lower levels of NHS App use (eg, Q4 vs Q1: registration=-7.1%, log-in=-10.4%, and appointments booked=-36.4%; P<.001). Larger practices had an overall higher use of some NHS App features (eg, Q4 vs Q1: registration=3.2%, log-ins=11.7%, appointments booked=73.4%, medical record views=23.9%, and prescriptions ordered=20.7%; P<.001), as well as those with greater proportions of White patients (eg, Q4 vs Q1: registration=1.9%, log-ins=9.1%, appointments booked=14.1%, medical record views=28.7%, and prescriptions ordered=130.4%; P<.001). Use patterns varied for practices with greater proportions of patients with long-term health care needs (eg, Q4 vs Q1: registrations=-3.6%, appointments booked=-20%, and medical record views=6%; P≤.001). This study highlights that the use of the NHS App features varied across sociodemographic groups. In particular, it is used less by people living in more deprived areas. Tailored interventions and patient support are required to ensure that any benefits from the NHS App are spread equally throughout the population.

Learning ballet technique modulates the stretch reflex in students with cerebral palsy: case series

BackgroundCerebral palsy (CP) is considered the most prevalent developmental motor disorder in children. There is a need for training programs that enhance motor abilities and normalize function from an early age. Previous studies report improved motor outcomes in dance interventions for CP. Investigating the neurophysiological mechanisms underlying such improvements is necessary for efficient and safe intervention design. This study reports changes in stretch reflex responses as the primary neurophysiological motor outcome of a targeted ballet class intervention.ResultsA case series of participants with mixed spastic and dyskinetic CP (n = 4, mean age = 12.5 years, SD = 6.9S years, three female, one male) who learned ballet technique in a course of one-hour classes twice per week for six weeks is presented. Changes in stretch reflex responses and in clinical motor tests as secondary outcomes were observed after the course and at one-month follow-up. Quantitative measures of elbow or ankle stretch reflex were obtained using electromyography and electrogoniometry. The joint angle of the stretch reflex onset varied across velocities of stretch, and its variability decreased after the intervention. Within-subject tests of the central tendency of stretch reflex angle coefficients of variation and frequency distribution demonstrated significant changes (p-values < 0.05). Secondary outcomes included the Quality of Upper Extremity Skills Test (QUEST), Pediatric Balance Scale (PBS), Modified Tardieu Scale (MTS), Dyskinesia Impairment Scale (DIS), and Selective Control Assessment of the Lower Extremity (SCALE). All the participants demonstrated improvements larger than the minimal clinical important difference (MCID) or the smallest detectable difference (SDD), as applicable.ConclusionsEvidence of changes in the stretch reflex responses in these four cases of mixed CP was observed. The observed variability in the stretch reflex responses may be due to the dyskinetic component of the mixed CP presentations. More studies with a larger sample size and longer duration of learning and practice of ballet technique are necessary to establish the extent of possible modulation and adaptation of the stretch reflex response as a neurophysiological basis for observed improvements in clinical measures.Trial registration: This study was registered in the Clinical Trials Protocol Registration and Results System (NCT04237506, January 17, 2020).

Recent Trends in Academic Vs Non-academic Radiologist Compensation and Clinical Productivity.

Recent radiologist compensation and clinical productivity trends have not been well characterized, especially across academic vs. non-academic practice settings. To assess recent trends in in financial compensation and clinical productivity between academic and non-academic settings in diagnostic (DR) and interventional radiology (IR). We studied deidentified data from the Medical Group Management Association (MGMA) for both DR and IR radiologists in academic and non-academic practices from 2014 to 2023. Median, 25th and 75th percentile, and mean values were analyzed for compensation, collections and work relative-value-units (wRVUs). Compensation and productivity data were compared by radiology subspecialty (DR vs IR), practice type (academic vs non-academic provider), geographical region of the US, and practice size. Trends in absolute changes were analyzed with linear regression. The MGMA Survey data for 2023 included responses for 3769 radiologists (2883 in DR and 886 in IR). In 2023, non-academic radiologists had greater total median compensation than academic faculty in both DR (by 27%) and IR (by 32%). From 2014 to 2023, median compensation increased faster for academic DRs (3.2% annually) than for non-academic DRs (1.9% annually). In 2023, DRs produced greater median wRVUs than IRs (by 53 % for non-academic and 46 % for academic radiologists) with higher collections, but IRs had higher compensation (by 16% in non-academic and 10% in academic settings). Over the last decade, IR physician compensation increased by 3.9% and 3.4% annually for non-academic and academic IR physicians respectively while median work RVUs trended downward (by -1.5 % for non-academic and -2.4 % for academic physicians) with declining collections (by -4.4 % annually for non-academic and -2.1 % for academic physicians). Over the last decade, the salary gap between academic and non-academic radiologists has narrowed. Physician compensation has increased at a faster pace in IR, despite relatively lower clinical productivity and declining collections.

Increasing medication assisted treatment in rural primary care practice: a qualitative comparative analysis from IT MATTTRs Colorado.

Opioid dependence and use disorders (OUDs) are serious public health crises resulting in a rising number of opioid-related deaths. Medication assisted treatment (MAT), in this case treatment with buprenorphine, is an evidence-based solution to combatting OUD; however, MAT has been largely unavailable in rural areas. This study investigated what it took to increase MAT in rural Colorado primary care practices. Mixed methods study using qualitative and quantitative data collected from interviews, observations, surveys, and practice-reported data. Participants were staff members from 35 rural primary care practices in Colorado, United States. We qualitatively analyzed the data, then transformed the data, then analyzed it using qualitative comparative analysis (QCA). Having a MAT waivered prescribing clinician on staff and a MAT system in place were necessary conditions to providing MAT (consistency = 1.0; coverage = 0.53 & 0.39 respectively). Practice size (number of providers) was associated with differences in conditions that provided sufficient aspects for MAT provision. Small (1-2 medical providers), non-private practices benefited from the presence of behavioral health and a clinician with MAT experience. Medium sized practices (3-5 providers) whether private or not benefited from behavioral health, often in combination with a clinician with MAT experience. In large practices (6 or more providers), behavioral health was not a factor while having a clinician with MAT experience mattered half of the time. Implementation of MAT in rural primary care is a complex task that may benefit from the resources of behavioral health and a clinician with prior MAT experience.

Provider and facility factors in relation to receipt of dose-reduced chemotherapy among patients with breast cancer.

310 Background: Little is known about how provider and facility factors relate to patients’ receipt of dose-reduced adjuvant chemotherapy. Methods: In a cohort of 8,581 stage I-IIIA women with breast cancer treated with chemotherapy at Kaiser Permanente Northern California between 2006 and 2019, we evaluated the associations between provider- and facility-level factors related to chemotherapy dosing with a primary interest in the first cycle dose reduction (FCDR). Here, FCDR is defined as a first cycle dose proportion &lt;90% of that expected based on the intended regimen, reflecting clinician intent at the outset of chemotherapy. Provider-level factors examined included provider gender, age, race, Hispanic ethnicity, years since completion of medical school, volume of breast cancer patients treated per year, and patient-provider racial concordance; we also examined practice size and rurality. Prevalence ratios (PR) were calculated using generalized linear models of the Poisson family with a log-link function and robust standard errors, accounting for significant patient factors and clustering at the provider level. Results were further mutually-adjusted for significant provider- and facility-level factors to ensure independence of associations. Results: Patients treated by providers practicing for longer (30+ years since medical school vs &lt;10 years) were more likely to be dose-reduced at the outset of chemotherapy (PR: 1.94; 95% CI: 1.15-3.25; p-trend: 0.02). Patients treated by providers in a larger practice (10+ vs ≤5 oncologists) were less likely to be dose reduced (PR: 0.53; 95% CI: 0.34-0.84; p-trend: 0.03) as were patients treated by providers treating a higher volume of breast cancer patients (30+ vs ≤15 patients/year: PR 0.64 (95% CI: 0.41-0.99; p-trend: 0.03). Other factors examined were not significantly associated with use of FCDR. Conclusions: These results indicate provider years of experience, as well as practice size and the volume of breast cancer patients treated per year are significantly associated with first cycle dose reductions in chemotherapy. This is a complex, multi-factorial issue, and these results indicate that provider- and provider- and facility-level factors should be considered when evaluating sources of heterogeneity in chemotherapy delivery.

Evolving Trainee Participation in Radiologists’ Workload: A National Medicare-Focused Analysis From 2008 to 2020

PurposeIncreasing volumes and productivity expectations, along with practice type consolidation, may be impacting trainees’ roles in the work effort of radiologists involved in education. We assessed temporal shifts in trainee participation in radiologists’ workload nationally. MethodsAll US radiologists interpreting noninvasive diagnostic imaging for Medicare fee-for-service beneficiaries were identified from annual 5% Research Identifiable Files from 2008 to 2020 (n = 35,595). Teaching radiologists were defined as those billing services using Medicare’s GC modifier, indicating trainee supervision. Billed work relative value units were used to determine the percentage of teaching radiologists’ total workload with trainee participation. Mean trainee participation in workload was calculated for teaching radiologists overall and stratified by radiologist and practice characteristics determined using National Downloadable Files. ResultsThe percentage of radiologists involved in teaching increased from 13.6% (2008) to 20.4% (2020). Among teaching radiologists, mean total workload increased 7% from 2008 to 2019 and decreased in 2020 to 2% below 2008’s level; mean teaching workload decreased 19% from 2008 to 2019 and decreased in 2020 to 31% below 2008’s level. Mean trainee participation in teaching radiologists’ total workload decreased from 35.3% (2008) to 26.3% (2019) and 24.5% (2020). Teaching radiologists showed decreased mean trainee participation when stratified by gender, experience, subspecialty, geography, practice type, and practice size. ConclusionsThe percentage of US radiologists involved in resident teaching has increased, likely reflecting academic practice expansion and academic-community practice consolidation. However, a declining percentage of teaching radiologists’ total workload involves trainees; this dispersion effect could have implications for education quality.

Telemedicine Use During the COVID-19 Pandemic by Office-based Physicians and Long-term Care Providers.

This report examines telemedicine use by office-based physicians and long-term care providers in the United States, stratified by electronic health record use and by provider or practice size. Further, it examines differences in telemedicine use before and after the COVID-19 pandemic onset among office-based physicians and assesses telemedicine use during the first year of the COVID-19 pandemic for long-term care providers. Nationally representative estimates in this report are derived from data collected in the 2019 and 2021 National Electronic Health Records Survey, which assesses characteristics of office-based physicians, and the 2020 National Post-acute and Long-term Care Study, which assesses characteristics of adult day services centers and residential care communities. Measures include telemedicine using audio with video or web videoconference for patient care, electronic health record use for more than accounting or billing purposes, and size of physician practices and long-term care providers. In 2021, 80.5% of physicians in office-based settings used telemedicine for patient care, up from 16.0% in 2019. In 2020, 20.5% of adult day services centers and 44.5% of residential care communities used telemedicine to care for users with COVID-19. Office-based physicians, adult day services centers, and residential care communities that used electronic health record systems were more likely to also use telemedicine compared with those not using electronic health records. Large practices and providers were more likely to use telemedicine compared with small practices and providers. Findings from this report describe telemedicine use among office-based physicians and long-term care providers. Practices and providers that used electronic health records and were larger were more likely to also use telemedicine for patient care during the COVID-19 pandemic.

Examining the expansion of agroforestry practices and their management practices in the central highlands of Ethiopia

Agroforestry is an emerging livelihood strategy for meeting the fundamental requirements of millions of rural households, yet quantifying its expansion and management practices in Ethiopia remains limited. This study investigated the trends, extents and drivers of agroforestry expansion and related management practices in the central highlands of Ethiopia. A two-stage sampling method was employed to select 160 rural households that engaged in home garden and woodlot agroforestry practices. The data were collected via semi-structured questionnaires, key informant interviews, and focus group discussions and analyzed using descriptive statistics, content analysis, the Kruskal-Wallis test, and the Mann‒Whitney U test. The results demonstrated that there was a significant difference in the mean size (in hectares) of home gardens and woodlot agroforestry practices (p<0.05). There has been an increasing trend in the adoption and expansion of agroforestry practices, both in home gardens and woodlots. The rate of agroforestry expansion increased from 0.23 % before the 1980s to 3.95 % between 2011 and 2022. The expansion of agroforestry practices, particularly the increase in home garden size and woodlot establishment, was positively influenced by increased market demand, increased seedling availability, increased availability of labor, improved knowledge of agroforestry benefits, and increased proximity to homes and roads. Furthermore, the findings demonstrated that rural households implemented weeding, pruning, thinning, looping, pollarding, fertilizer application, watering, coppicing, fencing, and mulching to maintain and optimize the productivity of their agroforestry systems. Policymakers and stakeholders should consider developing targeted programs and incentives to further encourage the expansion of both home gardens and woodlot agroforestry practices.

Trends in urine sampling rates of general practice patients with suspected lower urinary tract infections in England, 2015–2022: a population-based study

ObjectivesInappropriate prescribing of antibiotics is a key driver of antimicrobial resistance. This study aimed to describe urine sampling rates and antibiotic prescribing for patients with lower urinary tract infections (UTIs)...

Prevalence of technology and connectivity issues in general practices in rural New South Wales and their impact on staff capability to perform their job.

To identify the technology and connectivity issues in rural and remote general practices, and the factors independently associated with these issues that negatively impact staff's capability to perform their job. An annual cross-sectional survey of rural and remote general practice managers. Dependent variables included demographic data, practice size, geographic location, connection type and frequency of connectivity issues. Descriptive statistics are presented, and bivariate logistic regression was undertaken to determine factors independently associated with connectivity issues that negatively impact staff's capability to perform their job. One hundred sixty-eight general practice managers from rural and remote New South Wales. The majority of respondents (87%, n = 146) indicated that technology and connectivity issues had impacted staff's capability to perform their job. Internet problems were the most frequently reported issue (36%, n = 61). In bivariate analysis, practices that had a total clinical staff headcount between 5 and 7 (OR 0.27; 95% CI 0.10-0.67; p = 0.005) or between 8 and 11 (OR 0.39; 95% CI 0.16-0.95; p = 0.038) were significantly less likely to report technology and connectivity issues that negatively impact staff's capability to perform their job, compared with practices with a total clinical headcount of less than five. Technology and connectivity issues persist in rural and remote general practices. This is the first study to demonstrate that technology and connectivity issues impact on rural staff's capability to perform their job. Furthermore, smaller practices face more technology and connectivity issues that negatively impact staff's capability to do their job than larger practices. Further research is required to find solutions to address these challenges.

Integrating meta-analysis and experts’ knowledge for prioritizing climate-smart agricultural practices in Ethiopian

Various climate-smart agricultural (CSA) practices are being advocated in different agroecological zones of Ethiopia to enhance the sustainability, resilience, and productivity of the agricultural sector in response to climate change. Prioritizing and packaging these CSA practices are essential to amplify the impact of climate change mitigation efforts. By strategically selecting and prioritizing these practices and technologies, resources can be allocated effectively to activities with the highest potential for reducing greenhouse gas emissions, bolstering resilience, and fostering sustainable development. However, identifying and prioritizing climate-smart practices that cater to the needs of vulnerable farmers and are tailored to specific local contexts remains challenging, often hindered by subjective assessments and limited awareness. The objective of this paper was to enhance the precision and objectivity of prioritizing CSA practices by leveraging a combination of research findings and expert knowledge. The steps included the following: i) a CSA prioritization assessment framework was used to identify and prioritize CSA practices across various agro-ecologies based on the CSA pillars (productivity, adaptation, and mitigation); ii), a meta-analysis approach was employed to determine the effect size of various CSA practices on the three pillars of CSA practices; iii), the effect size values were rescaled and ranked based on effect size categories; and iv), correlation was performed to assess the relationship between the two approaches, and finally, average values were taken to integrate and determine the final rank of CSA practices. Overall, we found out that there were weak correlations between the ranks of the two approaches, resulted in a mismatch between the ranks of CSA practices by experts and meta-analysis results. Using the meta-analysis approach, only 35% of the CSA practices were equally ranked by both approaches, 40% of the CSA practices were more likely ranked by experts, while 25% of the CSA practices were more likely ranked by the meta-analysis approach. This implies that experts overestimated the effect of various CSA practices on various indicators of productivity, soil loss, and run-off and soil organic matter. Integrating the ranks of the two approaches helped to target CSA practices across various agro-ecological zones. According to the combined ranking, several CSA practices were targeted to six major agro-ecological zones in the country. These various CSA practices increase productivity, enhance adaptation, and sequester carbon dioxide from the atmosphere. Based on the availability of these CSA practices, it is possible to package various combinations of these practices.

Case managers within general practices in 11 Western countries: repeat cross-sectional studies.

In the context of an ageing population and increasing health needs, primary care reform is needed and several new models have emerged, including the introduction of case managers in general practitioner practices. To describe the frequency of case managers in general practices in eleven Western countries between 2012 and 2019 and to investigate the characteristics of general practitioners and their practices associated with case manager frequency. A secondary analysis of the Commonwealth Fund International Health Policy Surveys of Primary Care Physicians, which were international cross-sectional studies conducted in 2012, 2015 and 2019. Random samples of general practitioners were selected in 11 Western countries (2012: n = 9776; 2015: n = 12,049; 2019: n = 13,200). The use of case managers in general practitioner practices was determined with the question "Does your practice use personnel, such as nurses or case managers, to monitor and manage care for patients with chronic conditions that need regular follow-up care?", with possible answers "Yes, within the practice", "Yes, outside the practice", "Yes, both within and outside the practice" or "No". Other variables characterising general practitioners and their practices were considered. Mixed-effects logistic regression was performed. The frequency of case managers within general practitioner practices varied greatly by country, with an overall trend towards an increase from 2012 to 2019. In the multivariate analysis, more case managers were found in practices located in small towns (odds ratio [OR] 1.4; 95% confidence interval [CI] 1.2-1.7) and in rural areas (OR 1.9; 95% CI 1.5-2.4) compared to cities. The frequency of case managers was higher in larger practices, as shown in comparisons of practices in the second, third and fourth quartile of full-time equivalent employee counts compared to those in the first quartile (Q2: OR 1.7, 95% CI 1.4-1.9; Q3: OR 2.1, 95% CI 1.6-2.9; Q4: OR 3.8, 95% CI 3.0-4.9). There was no significant difference in frequency with respect to the age and sex of the general practitioners. The use of case managers in general practitioner practices is a promising approach, but its practice varies greatly. This practice has been developing in Western countries and is tending to increase. The implementation of case managers seems to be associated with certain characteristics linked to general practitioner practices (practice location, practice size), whereas it does not seem to depend on the personal characteristics of general practitioners, such as age or sex.

Impact of carboplatin and cisplatin shortages on treatment patterns in patients with metastatic solid tumors.

11149 Background: The United States experienced cisplatin (CP) and carboplatin (CB) shortages in 2023, leading to potential rationing or switching to alternative therapies in multiple cancers. Using a US nationwide, real-world oncology dataset, we assessed changes in the use of CP and CB in 7 cancers during the shortage period. Methods: All patients (pts) from the Flatiron Health electronic health record-derived de-identified database (~280 cancer clinics, ~800 sites of care) with a machine learning-extracted metastatic (met) diagnosis of a cancer of interest between March 2022 and June 2023 and evidence of first-line (1L) therapy, were selected. Pts with multiple primaries were excluded. Platinum of interest was identified based on frequency of pre-period 1L use for a given cancer. The pre-period was June 2022 through first month of reported shortage (February 2023 for CP; April 2023 for CB); data cutoff was June 2023. Clinical characteristics of platinum-treated pts stratified by pre- vs post-period by disease were assessed. 1L platinum utilization rates (UR), calculated as the proportion of 1L-treated pts initiating CB/CP within 30 days of met diagnosis, were plotted by month. Cohort-level impact was evaluated with an interrupted time series analysis—overall and stratified by practice type, practice size, and socioeconomic status (SES). Multiple testing was controlled using the Benjamini-Hochberg procedure. Results: 10,983 pts received 1L therapy in the study period. Monthly platinum UR were stable across diseases in the pre-period. However, there was a significant post-period decrease in CB usage for non-small cell lung (NSCLC) and endometrial cancers (EC), and a decreasing trend in UR for CB in bladder (BC), ovarian (OC), and small cell lung cancers (SCLC). We also observed a decreasing trend in CP usage for cholangiocarcinoma (CC). Post-period monthly UR were stable for CB and CP in head and neck cancer (HNC), and for CP in BC. Odds ratios (OR) representing the month-over-month change in the odds of receiving platinum therapy during both pre- and post-periods are shown (table). OR trends varied by practice type and disease; no notable trends were seen by practice size or SES. UR with additional follow-up times will be presented. Conclusions: We observed decreased platinum use across multiple cancers during the shortage period, most notably for met NSCLC and EC, suggesting shortages led oncologists to seek alternatives to standard 1L platinum-based regimens. Further study of how treatment changes due to platinum shortages impacted pt outcomes is warranted. [Table: see text]

Primary Care Organizational Support for Nurse Practitioner Practice and Emotional Health Care Delivery.

Nurse practitioners (NPs) are key to delivery of primary care services. However, poor organizational support for independent NP practice, such as lack of access to clinic resources, may lead to prioritizing patient physical health over emotional health. We investigated the relationship between organizational support for independent NP practice and emotional health care delivery. This was a secondary analysis of cross-sectional survey data collected from 397 NPs in 2017. We measured organizational support for independent NP practice using the independent practice and support subscale of the NP Primary Care Organizational Climate Questionnaire. Emotional health care delivery was measured by asking NPs how frequently they addressed emotional concerns of patients. We utilized multilevel mixed effects linear regression models, adjusting for NP and practice covariates. Controlling for NP age, gender, marital status, race, and ethnicity, along with practice setting and size, as the independent practice and support score increased, NPs reported addressing emotional concerns of patients more frequently (beta = 0.34, 95% confidence interval = 0.02-0.66, P = 0.04). This indicates that as organizations provided more support for independent NP practice, NPs were able to more frequently address emotional concerns of patients. Organizational support for independent NP practice is associated with addressing emotional concerns of patients. To support NP practice, primary care organizations should ensure that NPs manage patients independently and have access to ancillary staff and support for care management.

Abstract PO3-03-10: Race and neoadjuvant treatment of triple negative breast cancer (TNBC) in the US community oncology setting

Abstract Background: TNBC is an aggressive subtype of breast cancer with limited targeted therapies. Black women have twice the incidence of TNBC compared to White women and within TNBC, Black women have worse outcomes than White women. Differences in both tumor biology of TNBC and social determinants of health (SDOH) play a role in observed disparities. The focus of this study is to evaluate SDOH factors associated to differences in the use of neoadjuvant chemotherapy (NC) in Black and White women in the US community oncology setting. Methods: This study was a retrospective, observational, cross-sectional design and used iKnowMed SM EHR data from the The US Oncology Network. Patients diagnosed with TNBC between 03/31/2017 and 09/30/2021 with stages II-III disease of tumor size ≥ 2cm (T2 or higher) were included. The index date was date of TNBC diagnosis and records were assessed from 6 months pre- to 6 months post-diagnosis for NC initiation. Univariable and multivariable logistic regression was conducted to evaluate impact of self-reported race on NC. Age, stage, BMI, insurance, area deprivation index (ADI), size of practice represented by physician count and geographical region, were studied in their mediating and moderating effects1 on the relationship between race and NC treatment. Results: Of the 3321 patients with TNBC identified in this study, 1969 self-reported white and 494 self-reported black (80% and 20% respectively). In multivariable regression accounting for all variables, Black race (OR = 1.57, 95% CI [ 1.02, 2.44], p=0.04), younger age, more advanced stage, obesity, non-Medicaid insurance, and West region, were all found to be positively associated with use of NC. Higher physician count was nominally associated, (p = 0.07). ADI was not found to be associated to NC. Mediator and moderator analysis for the relationship between race and NC showed that only stage and ADI variable inclusion in the model are required for the positive association between black race and NC. This is driven by a significant interaction between ADI and stage (p = 0.027) which differed for Black and White women. Mainly, for Black women ADI is positively associated to NC treatment in stage IIA, but negatively associated in all other stages (interaction term, p = 0.033). For White women, ADI is negatively associated to NC treatment in all stages. Only Black women with stage IIA tend to be treated more instead of less with NC in areas of greater deprivation (greater ADI). BMI presents nominal interactions with both race and stage, where obesity was more strongly associated with NC treatment in Black women (p = 0.088) and in stage IIA (p = 0.086). All other variables presented association to NC treatment without mediation or moderation of the race effect and without detectable differences across stages. Conclusions: Black women with stage IIA appear to be a special subgroup of TNBC patients for whom treatment with NC increases with ADI. Increased ADI generally results in less standard of care treatment; this is observed in this study for White women overall and for Black women in stages &amp;gt; IIA. Black women in areas of greater deprivation with stage IIA disease, may be perceived to be presenting with more aggressive disease and thus offered NC preferentially. This result lends support to the hypothesis that young black women present with a distinct, more aggressive subtype of TNBC in the early stages. Mediator and moderator analyses are important tools in elucidating the relationships between factors underlying racial disparities in both care and outcomes. 1. Hayes AF, Rockwood NJ. Regression-based statistical mediation and moderation analysis in clinical research: Observations, recommendations, and implementation. Behav Res Ther. 2017 Nov;98:39-57. Odds ratios for multivariable analysis –insert figure image– Race, stage and ADI –insert figure image– Race and BMI in stage IIA –insert figure image– Citation Format: Paola Raska, Joseph Dye, Nicholas J Robert, Angel Kidd, Michael Danso. Race and neoadjuvant treatment of triple negative breast cancer (TNBC) in the US community oncology setting [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-03-10.

Factors Associated with Missing Sociodemographic Data in the IRIS® (Intelligent Research in Sight) Registry

PurposeTo describe the prevalence of missing sociodemographic data in the IRIS® Registry (Intelligent Research for Sight) and to identify practice-level characteristics associated with missing sociodemographic data. DesignCross-sectional study ParticipantsAll patients with clinical encounters at practices participating in the IRIS Registry prior to 12/31/2020. MethodsWe describe geographic and temporal trends in the prevalence of missing data for each sociodemographic variable (age, sex, race, ethnicity, geographic location, insurance type, and smoking status). Each practice contributing data to the registry was categorized based on the number of patients, number of physicians, geographic location, patient visit frequency, and patient population demographics. Main outcome measureMultivariable linear regression was used to describe the association of practice-level characteristics with missing patient-level sociodemographic data. ResultsThis study included the electronic health records of 66,477,365 patients receiving care at 3306 practices participating in the IRIS Registry. The median number of patients per practice was 11,415 (IQR: 5,849-24,148) and the median number of physicians per practice was 3 (IQR: 1-7). The prevalence of missing patient sociodemographic data was 0.1% for age, 0.4% for sex, 24.8% for race, 30.2% for ethnicity, 2.3% for 3-digit zip code, 14.8% for state, 5.5% for smoking status, and 17.0% for insurance type. The prevalence of missing data increased over time and varied at the state-level. Missing race data was associated with practices that had fewer visits per patient (p<0.001), cared for a larger non-privately insured patient population (p=0.001), and were located in urban areas (p<0.001). Frequent patient visits were associated with a lower prevalence of missing race (p<0.001), ethnicity (p<0.001), and insurance (p<0.001), but a higher prevalence of missing smoking status (p<0.001). ConclusionsThere are geographic and temporal trends in missing race, ethnicity, and insurance type data in the IRIS Registry. Several practice-level characteristics, including practice size, geographic location, and patient population are associated with missing sociodemographic data. While the prevalence and patterns of missing data may change in future versions of the IRIS registry, there will remain a need to develop standardized approaches for minimizing potential sources of bias and ensure reproducibility across research studies.

The Decline of Small Practice in Colorectal Surgery: Practice Consolidation From 2015-2022

IntroductionPhysicians have gravitated toward larger group practice arrangements in recent years. However, consolidation trends in colorectal surgery have yet to be well described. Our objective was to assess current trends in practice consolidation within colorectal surgery and evaluate underlying demographic trends including age, gender, and geography. MethodsWe performed a retrospective cross-sectional study using the Center for Medicare Services National Downloadable File from 2015 to 2022. Colorectal surgeons were categorized by practice size and by region, gender, and age. ResultsFrom 2015 to 2022, the number of colorectal surgeons in the United States increased from 1369 to 1621 (+18.4%), while the practices with which they were affiliated remained relatively stable (693-721, +4.0%). The proportion of colorectal surgeons in groups of 1-2 members fell from 18.9% to 10.7%. Conversely, those in groups of 500+ members grew from 26.5% to 45.2% (linear trend P < 0.001). The midwest region demonstrated the highest degree of consolidation. Affiliations with group practices of 500+ members saw large increases from both female and male surgeons (+148.9% and +86.9%, respectively). New surgeons joining the field since 2015 overwhelmingly practice in larger groups (5.3% in groups of 1-2, 50.1% in groups of 500+). ConclusionsColorectal surgeons are shifting toward larger practice affiliations. Although this change is happening across all demographic groups, it appears unevenly distributed across geography, gender, and age. New surgeons are preferentially joining large group practices.

Impact on the performance of esg indices: a comparative study in Brazil and international markets

ABSTRACT The frequent use of Socially Responsible Investment (SRI) indices by market in developed countries has motivated the investigation of the performance of portfolios using SRI indices in Brazil, where no research has been identified comparing relative performance of portfolios composed of companies with and without properly documented Environment, Social and Governance (ESG) practices. In this work we compared the performance of ESG and traditional indices for Brazil and for some reference markets in the United States, Europe and Asia through a panel data analysis for a period from May 2014 to June 2021. The results indicated that there was no significant difference in performance between the traditional and ESG indices for all the markets analysed. In addition, in order to identify the factors that could influence the performance of the ESG index portfolio in Brazil, we control for companies’ ESG practice scores, leverage, size and sector of activities in both additive and interactive models. It was found that the performance of the ESG index was positively influenced by the size and leverage of these companies. The study also shows that the industry of basic materials have a significantly effect on the ESG index.

Postresidency Practice Setting and Clinical Care Features According to 3 Versus 4 Years of Training in Family Medicine: A Length of Training Pilot Study.

Factors associated with physician practice choice include residency location, training experiences, and financial incentives. How length of training affects practice setting and clinical care features postgraduation is unknown. In this Length of Training Pilot (LoTP) study, we surveyed 366 graduates of 3-year (3YR) and 434 graduates of 4-year (4YR) programs 1 year after completion of training between 2013 and 2021. Variables assessed included reasons for practice setting choice, practice type, location, practice and community size, specialty mix, and clinical care delivery features (eg, integrated behavioral health, risk stratified care management). We compared different length of training models using χ2 or Fisher's exact tests for categorical variables and independent samples, and t test (unequal variances) for continuous variables. Response rates ranged from 50% to 88% for 3YR graduates and 68% to 95% for 4YR graduates. Scope of practice was a predominant reason for graduates choosing their eventual practice, and salary was a less likely reason for those completing 4 years versus 3 years of training (scope, 72% vs 55%, P=.001; salary, 15% vs 22%, P=.028). Community size, practice size, practice type, specialty mix, and practice in a federally designated underserved site did not differ between the two groups. We found no differences in patient-centered medical home features when comparing the practices of 3YR to 4YR graduates. Training length did not affect practice setting or practice features for graduates of LoTP programs. Future LoTP analyses will examine how length of training affects scope of practice and clinical preparedness, which may elucidate other elements associated with practice choice.