Variation In Practice Patterns Research Articles

International practice patterns and perspectives on endovascular therapy for the treatment of cerebral venous thrombosis.

Cerebral venous thrombosis (CVT) accounts for 0.5-1% of all strokes. The role of endovascular therapy (EVT) in the management of CVT remains controversial and variations in practice patterns are not well known. Here, we present a comprehensive, international characterization of practice patterns and perspectives on the use of EVT for CVT.Methods A comprehensive 42-question survey was distributed to stroke clinicians globally from May-October 2023, asking about practice patterns and perspectives on the use of EVT for CVT. The overall response rate was 31% (863 respondents of 2744 invited) across 61 countries. The majority of respondents (74%) supported the use of EVT for CVT in certain clinical situations. Key considerations for decision-making in using EVT favored clinical over radiographic/procedural factors and included worsening level of consciousness (86%) and worsening neurological deficits (76%). In the past three years, 56% of respondents used EVT for the treatment of CVT, with most (49.5%) involved in 2-5 cases. Among interventionalists, significant variability existed in the techniques used for EVT (p<0.001), with aspiration thrombectomy (56%) and stent retriever (51%) being the most used overall. Regionally, interventionalists from China predominately used intra-sinus heparin (56%), while this technique was most commonly ranked as "never indicated" throughout the rest of the world (23%). Post-procedure, low molecular weight heparin was the most used anticoagulant (83%), although North American respondents favored unfractionated heparin (37%), while imaging was primarily split between magnetic resonance (71.8%) and computed tomography (65.9%) arteriography or venography. Our survey reveals significant heterogeneity in approaches to EVT for CVT, and provides a comprehensive characterization of indications, techniques and long-term management used by clinicians internationally. This resource will aid in optimizing patient selection and endovascular treatments for future trials.

Stereotactic ablative radiotherapy for primary kidney cancer – An international patterns of practice survey

PurposeTo conduct an international survey of radiation oncologists treating primary renal cell carcinoma (RCC) with SABR to ascertain the general patterns of SABR use, common dose/treatment/follow-up details, and expected outcomes. Materials and methodsA 51-question survey was created containing the following themes: prevalence and clinical scenarios in which RCC SABR is used, dose-fractionation schedules, treatment delivery details, follow-up/outcome assessments, and implementation barriers. The survey was distributed widely across multiple influential radiation oncology societies and social media, and ran from January to April 2023. ResultsA total of 255 respondents participated, mostly from academic centers within Europe/North America. Of these, 40 % (n = 102) currently offer SABR (50 % having begun within the last 3 years). Common barriers in non-users included lack of referrals by urologists and lack of supportive practice guidelines. Of respondents who do offer SABR, 77 % treat both small (4 cm or less) and large (>4 cm) renal masses. Dose-fractionation strategies varied from 27-52 Gy (3–5 fractions) for multifraction regimens, and 15–34 Gy for single fractions. Apart from treatment for medically inoperable disease, scenarios in which SABR was likely to be offered were for recurrence post surgery/thermal ablation and for oligometastatic kidney lesions. Uncommon scenarios included RCC with renal vein/inferior vena cava thrombosis, and as cytoreductive therapy in metastatic RCC. Expected local control outcomes were generally above 70 %, higher for small versus large renal masses. ConclusionsSABR is a relatively newer indication for primary RCC, offered by less than 50% of respondents, with both consistent and variable practice patterns observed.

Institution-level Patterns of Care for Early-stage Oropharynx Cancers in the United States.

The adoption of transoral robotic surgery and shifting epidemiology in oropharyngeal squamous cell cancer have stimulated debate over upfront and adjuvant treatment. Institutional variation in practice patterns can be obscured in patient-level analyses. We aimed to characterize institutional patterns of care as well as identify potential associations between patterns of care and survival. This was a retrospective cohort study of patients identified from 2004-2015 in the National Cancer Database. We analyzed 42,803 cases of oropharyngeal squamous cell cancer Stage cT1-2N0-2bM0 (AJCC 7th edition) treated with curative intent surgery and/or radiotherapy. We defined facility-4-year periods to account for changing institutional practice patterns. The 42,803 patients were treated within 2578 facility-4-year periods. We assessed institutional practice patterns, including the ratio of upfront surgery to definitive radiotherapy, case volumes, use of adjuvant therapies (radiotherapy or chemoradiotherapy), and margin positivity rates. Survival associations with institutional practice patterns were estimated with Cox regression. The ratio of upfront surgery to definitive radiotherapy ranged from 80-to-1 to 1-to-23. The institution-level median rate of adjuvant radiotherapy was 69% (IQR 50%-100%), adjuvant chemoradiotherapy was 44% (IQR 0%-67%), and margin-positive resection was 33% (IQR 0%-50%). On patient-level MVA, worse overall survival was not significantly associated with institutional case volume, adjuvant radiotherapy, or adjuvant chemoradiotherapy utilization. High rates of multimodal therapy and positive margins underscore the importance of multidisciplinary care and highlight variable patterns of care across institutions. Further work is warranted to explore indicators of high-quality care and to optimize adjuvant therapy in the HPV era.

Variations in the management of pediatric cerebral vasospasm.

Pediatric cerebral vasospasm (PCV) is associated with aneurysmal subarachnoid hemorrhage (aSAH), but aSAH is uncommon in children. No universal guidelines exist for PCV management. The authors sought to assess variations in practice patterns in pediatric aSAH and PCV management. A REDCap survey was circulated by the AANS/CNS Pediatric Section and the Pediatric Neurocritical Care Research Group assessing PCV management practices. A total of 58 responses were received. The proportion of responses received from each region ranged from 19% in the Northeast to 28% in the Midwest. Of all respondents, 88% reported practicing at academic institutions. Neurosurgeons constituted 79% of respondents, and intensivists 17%; 85% primarily managed children. Most providers treated 1-3 aSAHs annually and a minority (21%) reported protocolized aSAH management at their centers. PCV prevention used permissive hypertension (90%), chemoprophylaxis (86%), and strict fluid-volume management (83%). PCV was typically assessed using serial neurological examination (60%) and transcranial Doppler (TCD) studies (72%). Treatment of PCV included permissive hypertension (50%) and endovascular interventions (81% intraarterial verapamil, 35% nitroprusside, and 67% angioplasty). Balloon angioplasty was more common than stent retriever-plasty. Pediatric PCV is rare and primarily treated by specialists at academic institutions. Although some elements of management are commonly used, wide variability exists in the strategies used for PCV prevention, detection, and treatment. Management strategies for pediatric PCV may be extrapolations from adult paradigms, but standardized guidelines are lacking. Prioritization should be given to the development of such guidance to enable the development of more robust evidence-based practices in the future.

Practice Pattern Variations in the Use of Neuromonitoring, Image Guidance, and Robotics for Lumbar Pedicle Screw Placement Based on a Nationwide Neurosurgery Survey

Lumbar pedicle screw placement surgery involves various assistive technologies, including fluoroscopic, stereotactic, or robotic navigation and intraoperative neuromonitoring (IONM). We aimed to discern neurosurgeons' preferences for screw placement techniques and IONM utility, while also considering the influence of experience. A survey was distributed to members of the Congress of Neurological Surgeons using REDCap software, collecting demographic data and querying preferred techniques for screw placement and IONM modalities. Opinions on IONM use during stereotactic or robotic navigation were also obtained. Responses were analyzed using Pearson's Chi-square and analysis of variance tests via R software. Of 188 responses, 35.5% (n= 67) reported 1-10years of experience and 64.5% (n= 121) reported ≥ 11years. Less experienced neurosurgeons used stereotactic navigation more than those with greater experience (P < 0.001). Seasoned neurosurgeons used fluoroscopic guidance more often (P= 0.038). Less experienced neurosurgeons employed 1.69 (± 0.11) techniques for their fixation surgeries compared to 1.50 (± 0.0.8) for more experienced neurosurgeons. Robotic navigation utilization was low and comparable between the groups. Surgeons employing multiple techniques used triggered electromyography the most (62.1%, P= 0.024). No strong opinions emerged on the necessity of multimodality IONM with robotic or stereotactic navigation. This national survey shows that stereotactic navigation is the predominant technique for pedicle screw placement among less experienced neurosurgeons, with seasoned neurosurgeons leaning toward fluoroscopic guidance. Robotic guidance was the least used technique with no observed difference based on experience. Neurosurgeons employing multiple techniques use IONM the most, compared with surgeons who only use stereotactic navigation and/or robotic guidance.

Increasing Utilization of Intratympanic Injections among Medicare Fee-for-Service Providers.

To characterize national practice patterns and geographic variations in intratympanic injections among Medicare providers. Retrospective cross-sectional analysis of intratympanic injections performed in the Medicare fee-for-service population from 2013 to 2021. Center for Medicare & Medicaid Services Physician and Other Practitioners database. Providers performing outpatient intratympanic injections, documented by Current Procedural Terminology code 69801. Intratympanic injections. The number of intratympanic injections performed by individual providers, states, and geographic regions, as well as reimbursements, was analyzed annually. A total of 159,236 in-office intratympanic injections were performed. The Center for Medicare & Medicaid Services reimbursed $25,407,086; out-of-pocket patient costs were $6,591,514. The mean Medicare reimbursement rate and out-of-pocket cost per injection were $159.56 and $41.38, respectively. From 2013 to 2021, the number of intratympanic injections increased from 13,117 to 20,711 injections, representing a 57.9% increase. On linear regression, an additional 989.9 injections were performed each year (95% CI 766.4-1,213.4, p < 0.001). The number of providers performing injections also increased from 1,828 to 2,834 from 2013 to 2021 ( b = 125.6 [95% CI 111.3-140.0], p < 0.001). The population-controlled annual mean number of injections varied substantially across the United States, ranging from 12.0 injections per 100,000 beneficiaries in Oklahoma to 255.2 injections per 100,000 beneficiaries in Alabama. The number of intratympanic injections administered in the Medicare population has increased from 2013 to 2021. There is variability in practice patterns and utilization of intratympanic injections among otolaryngologists in the United States.

A survey of dysphagia services practice in China.

Dysphagia services have only recently been formalised within Chinese health services. There has been no comprehensive evaluation of all aspects of dysphagia services practice in China. To provide a profile for the dysphagia practice in China by assessing various facets of dysphagia services. This is a survey study carried out from December 2022 to May 2023 online in China. One hundred fifty-nine respondents comprising doctors, nurses or therapists involved in the field of dysphagia rehabilitation completed a questionnaire via Sojump. The questionnaire included dichotomous (e.g., yes/no) and multiple-choice questions related to participants' general information and their provision of dysphagia management services. Results were analysed descriptively and the differences among different levels of hospitals were analysed. Approximately two-thirds of hospitals (67.9%) started dysphagia services within the last 5 years. A significant difference in the initiation of dysphagia rehabilitation was observed across different hospital levels (χ2=32.70;p<0.001). Routine dysphagia screening was a standard practice in most hospitals (71.7%), with the most frequently employed screening method being the water swallow test (95.6%). Clinical swallowing evaluation emerged as the preferred initial assessment method (80.5%) and the most utilised assessment method (91.8%). Video fluoroscopic swallow study and flexible endoscopic evaluation swallowing were used by 22.7% and 12.6% of respondents. A significant difference was observed in the choice of assessment methods across hospitals of different levels (χ2=43.397; p < 0.001). The majority of respondents (53.5%) primarily employed rehabilitation as the main intervention method (76%-100%). Most respondents indicated that they would reevaluate patients after treatment (74.8%) and reported routine follow-up with patients (60.4%). Despite the relatively recent development of dysphagia management in China, the practice patterns uncovered in this study are broadly consistent with Chinese guidelines and consensus. However, the use of instrumental assessments remains low, resulting in a lack of objective evaluation of patient conditions and outcomes. There is a need for policy and resource support in the field of dysphagia rehabilitation in China. What is already known on this subject Assessment and treatment methods for dysphagia are various across different patients, medical facilities and settings. There has been no comprehensive evaluation of all aspects of dysphagia rehabilitation practice in China. What this study adds to existing knowledge The study assessed various facets of dysphagia rehabilitation in China through an online survey. We found that the relatively recent development of dysphagia management in China, but the practice patterns uncovered in this study are broadly consistent with Chinese guidelines and consensus. Variations in practice patterns between hospitals of different levels may be attributed to resource constraints and patient needs. Besides, while rehabilitation exercises are the primary intervention method for dysphagia in China, the assessment largely centres on clinical swallowing evaluation. The use of instrumental assessments remains low, resulting in a lack of objective evaluation of patient conditions and outcomes. What are the clinical implications of this work? The study assessed various facets of dysphagia rehabilitation in China, and the results indicate that the use of instrumental assessments needs to be improved and there is a need for policy and resource support in the field of dysphagia rehabilitation in China.

6511 Provider Opinions on Holding Antiplatelet and Anticoagulant Drugs Prior to Thyroid Nodules FNA Biopsy: A Survey Study

Abstract Disclosure: M.D. Lundholm: None. P.P. Rao: None. Objective: It is thought that anticoagulant (AC) or antiplatelet (AP) therapy at the time of thyroid nodule fine needle aspiration biopsy (TNFNAB) may increase the risk of non-diagnostic results and post-procedure hematomas. However, interrupting a patient’s AC or AP can lead to procedural delays or have thrombotic consequences. Since there is currently no consensus on whether or not to hold these medications, this study aims to survey the expertise of our providers across multiple specialties. Methods: A survey was sent out to Cleveland Clinic providers who have performed TNFNABs for patients with an active prescription for AC or AP since 2010. Providers were asked if they routinely held a number of blood thinner medication classes and included a free response section for open-ended comments. Results: The survey responses represented 60 providers (of 68 invited, 88% response rate). Respondents were 51.7% medical endocrinologists, 30% interventional radiologists, 13% surgical endocrinologists, and 5% ENTs. Of respondents, 13.3% held aspirin 81 mg, 15.0% held aspirin 325 mg, 41.7% held other antiplatelet agents, 73.3% held warfarin, 43.3% held direct oral anticoagulants (DOACs), and 43.3% held heparin. No department was uniform in practice, with the least agreement (responses closest to 50%) amongst medical endocrinologists. In a subset of 15 providers who have performed ≥100 TNFNABs on patients with AC/AP, a consensus emerged not to hold aspirin at any dose, but there was no agreement in any other AC/AP categories (hold rates ranging 53.5-66.6%). Free response themes reiterated that the main concerns for continuing blood thinners are hematomas and non-diagnostic results. Other comments included consideration of the nodule features such as location as well as strategies used to lower risk for hematomas (i.e., small-gauge needles, ice, holding pressure). A couple responses referred to the Society of Interventional Radiology (SIR) and the International Society on Thrombosis and Haemostasis (ISTH) guidelines which offer INR and platelet goal recommendations prior to any procedure with a low bleeding risk. Discussion: A survey of Cleveland Clinic providers demonstrated that ≥85% continue aspirin therapies prior to TNFNAB. However, there is no such agreement in any other category of AC/AP medication, even amongst the most experienced providers. The closest guidelines available come from SIR and ISTH and rely on recent platelet and/or INR information, which may not be available in routine endocrinology practice. The caveat is that these recommendations are not specific to TNFNAB and do not take into account the nuances of this procedure. Conclusion: There is wide variation in provider opinions and practice patterns regarding AC and AP medications prior to TNFNAB. This highlights the need for further study into the safety and adequacy of TNFNAB performed on uninterrupted AC or AP therapy. Presentation: 6/3/2024

Variable practice patterns in the surgical management of renal hyperparathyroidism

BackgroundHyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The American Association for Endocrine Surgery published clinical practice guidelines that address the surgical treatment of secondary and tertiary hyperparathyroidism. The purpose of this study is to determine practice patterns for the surgical management of secondary and tertiary hyperparathyroidism prior to guideline publication. MethodsWith the approval of the American Association for Endocrine Surgery, a Qualtrics email survey was sent to the Association’s membership in 2022 about current clinical decision making for surgical treatment of secondary and tertiary hyperparathyroidism. Respondents were divided into groups based on surgical subspecialty (endocrine surgery versus non-endocrine surgery), yearly parathyroidectomy volume, and yearly parathyroidectomy volume for surgical treatment of secondary and tertiary hyperparathyroidism. Descriptive statistics were performed; the role of volume was evaluated. ResultsThere were 142 responses from 795 solicited email addresses (18% response rate); 114 (84%) identified as endocrine surgeons. The majority (62%) perform >50 parathyroidectomies yearly, but most perform <10 parathyroidectomies for surgical treatment of secondary and tertiary hyperparathyroidism per year (<10/y, 53.7%; 10–30/y, 41.9%; >30/y, 4.4%). Subtotal parathyroidectomy is most commonly performed for surgical treatment of secondary (83%) and tertiary (52%) hyperparathyroidism, but transcervical thymectomy variably performed for both. There was no consensus regarding starting calcitriol preoperatively (always 43%, never 25%, depends on vitamin D levels 24%) or stopping cinacalcet (2 weeks prior 28%, day of surgery 29%, postoperatively 20%). Surgeons who perform >10 parathyroidectomies per year for surgical treatment of secondary and tertiary hyperparathyroidism were less likely to consider the patient's preoperative vitamin D levels to inform their decision to start calcitriol before surgery (<10 cases/year, 34%; ≥10 cases/year 15%; P = .023), were more likely to have a postoperative hypocalcemia protocol managed by the surgical team (<10 cases/year, 49%; ≥10 cases/year, 58%; P = .029), and were more likely to use intraoperative parathyroid hormone monitoring for tertiary hyperparathyroidism (<10 cases/year, 70%; ≥10 cases/year, 87%; P = .046). ConclusionThe majority of respondents perform <10 parathyroidectomies yearly for surgical treatment of secondary and tertiary hyperparathyroidism. Subtotal parathyroidectomy was most commonly performed, but there was little other consensus regarding preoperative management, intraoperative decision-making, and postoperative care. Opportunity exists through guideline dissemination to improve heterogeneity of care provided to surgical treatment of secondary and tertiary hyperparathyroidism patients.

Survey of international pediatric nutritional supportive care practices: a report from the Pediatric Study Group of the Multinational Association of Supportive Care in Cancer (MASCC)

PurposeMalnutrition is common in children with cancer. While multiple validated malnutrition screens exist, there is no universal, standardized approach to screen or diagnose malnutrition. The Multinational Association of Supportive Care in Cancer (MASCC) Pediatric Study Group is focused on oncologic supportive care for children and young adults. This subgroup designed and administered a pilot study to characterize global malnutrition screening, diagnosis, and treatment practices for pediatric patients with cancer after identifying variations in malnutrition practice patterns within its members.MethodsA novel, exploratory survey was iteratively developed and distributed in early 2020 to 45 MASCC Pediatric Study Group members. The survey included multiple questions with standard patient presentations and nutritional scenarios, and the respondents selected the answer that best reflected the care patients would receive at their institution.ResultsA validated screening tool to assess for malnutrition was routinely used by 15 of 26 respondents (58%). No single validated screen was used by more than 24% of responders, and 11 of 26 (42%) reported not having a standard malnutrition treatment screen. When the same patient was presented with the survey using different malnutrition indicators, patient care plans varied greatly. This was particularly true for z-scores compared to weight percentiles.ConclusionsDevelopment of consensus recommendations for screening practices, preferred malnutrition indicators, and treatment guidelines could help reduce the underdiagnosis of malnutrition and subsequent variation in its management and ought to be a focus of the global pediatric cancer supportive care community.

Practice variation using the hybrid stage I procedure in congenital heart disease: Results from a national survey

ObjectivesHybrid stage I palliation has been used in many clinical scenarios including initial palliation in single ventricle heart disease, a bridge to biventricular repair, a bridge to transplant, and as a destination therapy. There is considerable hybrid stage I palliation practice variation, which we aimed to better understand in this study. MethodsSurvey-based assessment of practice variation related to hybrid stage I palliation was sent to congenital heart centers across the United States and Canada. ResultsOf the 106 centers surveyed, responses were received from 54 centers (50.9%). Of respondents, 45 centers perform hybrid stage I palliation. Centers most commonly (97.7%) perform hybrid stage I palliation on “high-risk” patients with single ventricle heart disease. Regarding the technical aspects of hybrid stage I palliation, most centers (95.3%) accomplish restrictive pulmonary blood flow using pulmonary artery bands and primarily use changes in oxygen saturation (34.1%) to identify appropriate restriction. Ductal stents are most often used (67.4%) to maintain ductal patency. Only 10 centers (23.3%) routinely enlarge the atrial septal defect. Indications for atrial septal defect intervention varied widely. Most centers (71.9%) discharge patients home to follow with a formal “interstage” program. ConclusionsThere is significant variation in practice patterns for hybrid stage I palliation indications, technical aspects, and postoperative care. Therefore, generalizability of single-center studies on outcomes after hybrid stage I palliation is limited. Future multicenter studies are needed to best delineate which patients benefit most from hybrid stage I palliation and to further define optimal approaches to caring for these patients.

Management of Psychiatric Diagnoses in Reversible Cerebral Vasoconstriction Syndrome: The Dangers of Worsening Pathology with Serotonergic Medications: A Case Report and Literature Review.

Reversible cerebral vasoconstriction syndrome (RCVS) represents a group of conditions that show reversible multifocal narrowing or constriction of the cerebral arteries that supply blood to the brain. The initial manifestation of RCVS often includes a "thunderclap" headache that is sudden, severe, and often disabling. Stimulants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and antipsychotics with serotonergic activity can alter the cerebral arterial tone, trigger vasoconstriction, and place patients at risk of a cerebrovascular accident. Thus, psychiatric medications are commonly discontinued on admission for RCVS, and psychiatry is often consulted for input on acute medication management and longitudinal treatment options. Currently, there is a dearth of literature on managing psychiatric medications in RCVS, resulting in variable practice patterns that place patients at risk of withdrawal, decompensation, and relapse. In this article, we provide a case example and aim to consolidate the limited data surrounding the management of psychiatric illness with comorbid RCVS in our discussion. There is a clear concern about worsening and even potentially lethal consequences due to serotonin or stimulant-induced vasospasm both during an acute episode and in long-term management of RCVS. We discuss the underlying pathophysiologic mechanisms proposed for serotonergic-, noradrenergic-, and dopaminergic-induced cerebral vasospasm and how this correlates with the clinical management of patients on psychiatric medications. These data will then be organized to create a risks versus benefits outline to equip psychiatrists to make decisions about when to stop and when to restart psychiatric medications in the setting of RCVS.

Assessment and management of dysphagia in the neonatal intensive care units in India: A survey report

BackgroundEvidence-based assessment and management of dysphagia in neonates, especially those in the neonatal intensive care unit (NICU), are limited. Understanding existing clinical practices may be the first step toward developing a consensus. The current study aimed to identify clinical practice patterns of speech-language pathologists (SLPs) in India towards facilitating the development of feeding skills and assessment and management of dysphagia among neonates. MethodAn electronic survey questionnaire comprising 46 questions categorized into two main sections (demographics and a hypothetical case scenario) was emailed to 35 SLPs practicing in the NICU. The hypothetical clinical case was created to include considerations of assessment and management of dysphagia in the NICU, and the participants answered questions about clinical decision-making. ResultsAs many as 22 individuals completed the survey. The responses were analyzed descriptively to identify themes and trends in practice patterns. Our results revealed varied practice patterns in the clinical swallowing assessment and management approaches for neonatal dysphagia. ConclusionThere is a need to develop a consensus statement and standard guidelines for the assessment and intervention for dysphagia by the SLP in the NICU. Translation of current evidence-based research into clinical practice is critical to patient care.

Do Prophylactic Postoperative Antibiotics Prevent Sacral Neuromodulation Infections?

There are no definitive guidelines for use of postoperative antibiotics after sacral neuromodulation (SNM) leading to practice pattern variation among health care professionals. The objectives of this study were to determine if additional antibiotics beyond preoperative intravenous antibiotics and surgical preparation decrease postoperative infections and to determine if additional antibiotics are associated with other postoperative complications. This was a single-center, retrospective cohort study of all SNM procedures from 2014 to 2023 performed by 12 surgeons. Cohorts were stratified between patients who received preoperative antibiotics only (OnlyPreAbx) and patients who received both preoperative antibiotics and postoperative antibiotics (PrePostAbx) after either insertion of tined lead and/or after insertion of a neurostimulator. There were 212 patients included in this study: 70 (33.0%) in the OnlyPreAbx group and 142 (67.0%) in the PrePostAbx group. Of patients receiving postoperative antibiotics, 76 (53.5%) received cephalexin, 49 (34.5%) received sulfamethoxazole-trimethoprim, and 17 (12.0%) received alternative antibiotics. Six patients overall (2.8%) experienced infections after SNM. There was no difference in the rates of infection between groups (4 [1.9%] PrePostAbx vs 2 [0.9%] OnlyPreAbx, P = 0.99). Of the 4 patients with postoperative infections in the PrePostAbx group, 2 had cellulitis requiring antibiotics and 2 required full explantation. Of the 2 patients with postoperative infections in the OnlyPreAbx group, both patients required explantation. In a subanalysis comparing infected and noninfected patients, infected patients (n = 6) had higher rates of hypertension (n = 6, 100%; P = 0.02) and diabetes mellitus (n = 3, 50%; P = 0.05). Additional postoperative antibiotics did not decrease infection rates in patients undergoing SNM. Similar comparative analyses should be performed with larger sample sizes.

Gender-Based Variations in Medicare Reimbursements Among Different Surgical Subspecialties

Gender inequities and limited representation are an obstacle to surgical workforce diversification. There has been limited examination of gender-based disparities in billing practices among surgeons. To evaluate variations in practice metrics and billing practices among female and male surgeons and identify factors associated with gender disparities in Medicare reimbursements. This retrospective cross-sectional study used publicly available Medicare Fee-for-Service Provider Utilization and Payment data from January to December 31, 2021, to identify demographics, annual services provided, and financial payments and charges for general surgeons, surgical oncologists, and colorectal surgeons. Data were analyzed from November 2023 to February 2024. The primary exposure of interest was surgeon gender (ie, female or male). The annual total submitted charges and payments submitted in 2021 by female and male surgeons were assessed. Additionally, the total number and types of services provided each year and the number of beneficiaries treated were examined. Multivariable linear regression models were used to evaluate the association of surgeon gender with payments, number of services, and beneficiaries. A total of 20 549 general surgeons (5036 [24.5%] female; 15 513 [75.5%] male), 1065 surgical oncologists (450 [42.3%] female; 615 [57.7%] male), and 1601 colorectal surgeons (432 [27.0%] female; 1169 [73.0%] male) were included. Across all surgical subspecialties, female surgeons billed fewer mean (SE) Medicare charges (general surgeons: 30.1% difference; $224 934.80 [$3846.97] vs $321 868.50 [$3933.57]; surgical oncologists: 27.5% difference; $277 901.70 [$22 857.37] vs $382 882.90 [$19 566.06]; colorectal surgeons: 21.7% difference; $274 091.70 [$10 468.48] vs $350 146.10 [$8741.66]; all P < .001) and received significantly lower mean (SE) reimbursements (general surgeons: 29.0% difference; $51 787.61 [$917.91] vs $72 903.12 [$890.35]; surgical oncologists: 23.6% difference; $57 945.18 [$3853.28] vs $75 778.22 [$2622.75]; colorectal surgeons: 24.5% difference; $63 117.01 [$2248.10] vs $83 598.53 [$1934.77]; all P < .001). On multivariable analysis, a reimbursement gap remained across all 3 surgical subspecialties (general surgeons: -$14 963.46 [95% CI, -$18 822.27 to -$11 104.64] [P < .001]; surgical oncologists: -$8354.69 [95% CI, -$15 018.12 to -$1691.25] [P = .01]; colorectal surgeons: -$4346.73 [95% CI, -$7660.15 to -$1033.32] [P = .01]). In this cross-sectional study, there was considerable gender-based variation in practice patterns and reimbursement among different surgical subspecialties serving the Medicare population. Differences in mean payment per service were associated with variations in billing and coding strategies among female and male surgeons.

Trends in Patient Complexity, Practice Setting, and Surgeon Reimbursement for Urolithiasis: Do Rural Urologists Pay the Price?

ObjectivesTo evaluate the relationship between patient complexity, practice setting, and surgeon reimbursement for ureteroscopy and percutaneous nephrolithotomy (PCNL). MethodsThe “2021 Medicare Physician and Other Provider” file was used to collect Rural-Urban Commuting Area (RUCA) codes and hierarchical condition category (HCC) scores of urologists. Higher HCC score corresponds to higher medical complexity and higher RUCA code corresponds to a more rural area. Medicare reimbursement for ureteroscopy and PCNL were collected. Linear regressions were performed to predict change in reimbursement based on RUCA and HCC scores. ResultsIn 2021, 52,816 procedures under CPT code 52356 (ureteroscopy) and 1649 procedures under 50080 or 50081 (PCNL) were billed to Medicare. Mean reimbursement was $338.24 for ureteroscopy and $957.89 for PCNL. For ureteroscopy, higher HCC score predicted lower reimbursement (p<0.001). Higher HCC score predicted higher reimbursement for PCNL (p<0.01). Average RUCA for ureteroscopy was higher than for PCNL (p=0.02). Rural location predicted lower reimbursement for ureteroscopy (p<0.001), however there was no association for PCNL. ConclusionsFor ureteroscopy, higher-risk patients are associated with lower reimbursement while the opposite holds true for PCNL. Rural practices were associated with lower reimbursement for ureteroscopy, but there was no association between location and PCNL reimbursement. Together, these findings suggest practice pattern variation between ureteroscopy and PCNL and highlight gaps in reimbursement policy. Risk-adjusted reimbursement should be considered to incentivize urologists to treat complex patients within their practice scope.

Trends and Factors Associated With Peripheral Vascular Interventions for the Treatment of Claudication From 2011 to 2022: A National Medicare Cohort Study.

Previous cross-sectional studies have identified wide practice pattern variations in the use of peripheral vascular interventions (PVIs) for the treatment of claudication. However, there are limited data on longitudinal practice patterns. We aimed to describe the temporal trends and charges associated with PVI use for claudication over the past 12 years in the United States. We conducted a retrospective analysis using 100% Medicare fee-for-service claims data to identify all patients who underwent a PVI for claudication between January 2011 and December 2022. We evaluated the trends in utilizationand Medicare-allowed charges of PVI according to anatomic level, procedure type, and intervention settings using generalized linear models. Multinomial logistic regressions were used to evaluate factors associated with different levels and types of PVI. We identified 599 197 PVIs performed for claudication. The proportional use of tibial PVI increased 1.0% per year, and atherectomy increased by 1.6% per year over the study period. The proportion of PVIs performed in ambulatory surgical centers/office-based laboratories grew at 4% per year from 12.4% in 2011 to 55.7% in 2022. Total Medicare-allowed charges increased by $11 980 035 USD/year. Multinomial logistic regression identified significant associations between race and ethnicity and treatment setting with use of both atherectomy and tibial PVI. The use of tibial PVI and atherectomy for the treatment of claudication has increased dramatically in in ambulatory surgical center/office-based laboratory settings, non-White patients, and resulting in a significant increase in health care charges. There is a critical need to improve the delivery of value-based care for the treatment of claudication.

Impact of Patient Age on Management of Hypothyroidism: A Survey of Physicians from Three Developing Regions

Abstract Background The thyroid-stimulating hormone (TSH) levels increase with age, and aiming for the same TSH target applicable in a younger population in older patients who are on replacement with thyroid hormones. Methods We assessed practice patterns regarding TSH goals and explored factors influencing physicians' decision-making when managing hypothyroidism. Multiple-choice questions in a case-based survey of a convenience sample of physicians practicing in relevant disciplines in three developing regions. Results Of the total 286, senior physicians represented 63% and mid-grades represented 27% of the respondents. Forty-one percent were endocrinologists, 19% were internists with endocrine interests, and 16% were family physicians. Over half (52%) practiced at a tertiary level and 42% had been in practice for over 20 years. Fifty percent of respondents had more than 20% of their patients over 65 years.Several attributes were factored into decision-making when managing hypothyroidism. Respondents took into account age (75%), preceded by the presence of cardiac arrhythmias (80%), pregnancy (79%), heart disease (78%), and patient symptoms (77%) when determining the treatment strategy. When presented with scenarios differing in patients' age, around 90% of physicians targeted a TSH ≤ 3.0 mIU/L in 30-year-old patients. Fifteen percent of respondents targeted a TSH of 1.6 to 3.0 mIU/L in octogenarians, but 78% targeted a TSH &gt; 3.1 to 5.0 mIU/L in this group. Regardless of sex, physician-reported TSH goal ranges (0.1–0.5, 0.6–1.5, 1.6–3.0, and 3.1–5.0 mIU/L) increased directly to patient age. Overall, respondents were less inclined to start treatment in 85-year-olds than in 70-year-old females with TSH of 6 mU/L (20% vs. 11%). Females with a TSH of 15 mU/L were more likely to get treated than those with a 6 mU/L TSH. Vital persons are more likely to be treated with thyroxine than vulnerable persons for the same TSH levels. Multivariate analysis showed that compared with endocrinologists, family physicians and other specialties were less likely to consider age in their clinical decisions, odds ratio (OR) 0.2 (95% confidence interval [CI] 0.1–0.7), p = 0.018, and OR 0.3 (95% CI 0.1–0.8), p = 0.013, respectively. Conclusion A consensus is needed on the role of patients' age in hypothyroidism management, the complexity of managing hypothyroidism in an older adult patient, and the variability in practice patterns among physicians. Addressing these challenges demands ongoing dialogue and collaboration among health care providers to improve patient care and outcomes in hypothyroidism management across different age groups.

The role of routine cardiac investigations before hyperbaric oxygen treatment.

Cardiac complications are a rare but potentially serious consequence of hyperbaric oxygen treatment (HBOT), resulting from increased blood pressure and decreased heart rate and cardiac output associated with treatment. These physiologic changes are generally well-tolerated by patients without preexisting cardiac conditions, although those with known or undetected cardiac disease may be more vulnerable to treatment complications. Currently, there are no universally accepted guidelines for pre-HBOT cardiac screening to identify these patients at heightened risk, leading to variability in practice patterns. In the absence of HBOT-specific evidence, screening protocols might be adapted from the diving medicine community; however, given the important differences in physiological stressors, these may not be entirely applicable to patients undergoing HBOT. Traditional cardiac investigations such as electro- and echo-cardiograms are limited in their ability to detect relevant risk modifying states in the pre-HBOT patient, stymieing their cost-effectiveness as routine tests. In the absence of strong evidence to support routine cardiac investigation, we argue that a comprehensive history and physical exam - tailored to identify high-risk patients based on clinical parameters - may serve as a more practical screening tool. While certain unique patient groups such as those undergoing dialysis or with implanted cardiac devices may warrant specialised assessment, thorough evaluation may be sufficient to identify many patients unlikely to benefit from cardiac investigation in the pre-HBOT setting. A clinical decision-making tool based on suggested low-risk and high-risk features is offered to guide the use of targeted cardiac investigation prior to HBOT.

Prophylactic somatostatin analogs for postoperative pancreatic fistulas: a cross-sectional survey of AHPBA surgeons

BackgroundPostoperative pancreatic fistulas lead to substantially increased morbidity, mortality, and healthcare costs after pancreatectomy. Studies have reported conflicting data on the role of prophylactic somatostatin analogs in the reduction of postoperative pancreatic fistula. Current practice patterns, surgeon beliefs, and barriers to using these drugs in the Americas is not known. MethodsAn online 26-question cross-sectional survey was distributed via email to the members of the Americas Hepato-Pancreato-Biliary Association in April 2023. ResultsOne hundred and two surgeons responded in spring 2023. 48.0% of respondents reported using prophylactic SSAs during their surgical training, however, only 29.4% do so in their current practice, most commonly when performing Whipple procedures. Octreotide was the most frequently used SSA (34.3%), followed by octreotide LAR (12.7%) and pasireotide (11.8%). Reasons for not prescribing included a lack of high-quality data (62.7%), perception of limited efficacy (34.3%) and high cost (30.4%). ConclusionThese results highlight key areas for future study including understanding surgeon rationale for patient and drug selection. Variable practice patterns amongst surgeons also underscore the importance of generalizability in the design of future clinical trials in order to maximize impact.