Variation In Practice Patterns Research Articles

Microfracture for the Treatment of Symptomatic Cartilage Lesions of the Knee: A Survey of International Cartilage Regeneration & Joint Preservation Society

The purpose of this study was to describe the current practice trends for managing symptomatic cartilage lesions of the knee with microfracture among ICRS (International Cartilage Regeneration & Joint Repair Society) members. A 42-item electronic questionnaire was sent to all ICRS members, which explored indications, surgical technique, postoperative management, and outcomes of the microfracture procedure for the treatment of symptomatic, full thickness chondral and osteochondral defects of the knee. Responses were compared between surgeons from different regions and years of practice. A total of 385 surgeons answered the questionnaire. There was a significant difference noted in the use of microfracture among surgeons by region (P < 0.001). There was no association between the number of years in practice and the self-reported proportion of microfracture cases performed (P = 0.37). Fifty-eight subjects (15%) indicated that they do not perform microfracture at all. Regarding indication for surgery, 56% of surgeons would limit their indication of microfracture to lesions measuring 2 cm2 or less. Half of the surgeons reported no upper age or body mass index limit. Regarding surgical technique, 90% of surgeons would recommend a formal debridement of the calcified layer and 91% believe it is important to create stable vertical walls. Overall, 47% of surgeons use biologic augmentation, with no significant difference between regions (P = 0.35) or years of practice (P = 0.67). Rehabilitation protocols varied widely among surgeons. Indications, operative technique, and rehabilitation protocols utilized for patients undergoing microfracture procedures vary widely among ICRS members. Regional differences and resources likely contribute to these practice pattern variations.

Radiotherapy Remains Underutilized in the Treatment of Soft-Tissue Sarcomas: Disparities in Practice Patterns in the United States

Practice patterns in the use of radiation therapy (RT) for soft tissue sarcoma (STS) remains quite variable, despite national guidelines recommending the addition of radiotherapy to surgery for patients with high grade STS. Furthermore, treatment with neoadjuvant RT can reduce many late RT toxicities. Likewise, the use of intensity modulated radiation therapy (IMRT) can reduce both early and late radiation-induced toxicities. Using the National Cancer Database (NCDB), we assessed patterns of care in regards to variations in overall radiotherapy use, preoperative versus postoperative treatment, and specific RT modalities in this population. Patients aged 18 years or older with stage II/III STS treated with limb-sparing surgery and radiation therapy from 2004 through 2015 were identified from the NCDB. Patterns of care were assessed using multivariable logistic regression analysis. Of 27,426 total patients, 11,654 (42%) were treated with surgery alone versus 15,772 (58%) with RT in addition to surgery, with no overall increase in RT use noted over the study period. Notable predictors of receipt of RT include larger tumor size (>5 cm), Grade III tumors, and tumors located in the extremity. Conversely, female gender, older age (≥ 70), African American race, insurance status, farther distance to treatment, and poor performance status were negative predictors of perioperative radiotherapy use. Of those receiving RT, 27% were treated neoadjuvantly and 73% were treated adjuvantly. The proportion of those receiving neoadjuvant vs. adjuvant RT increased over time. Relevant factors associated with neoadjuvant radiation include treatment at academic centers, larger tumors, and tumors located in the extremity. In addition, of those who received RT with modality specified as IMRT or 3D conformal RT (3DCRT), 61% were treated with IMRT and 39% were treated with 3DCRT. The proportion of those treated with IMRT increased with time. Relevant factors associated with IMRT use include treatment at academic centers, commercial insurance, larger tumors, and tumors arising in non-extremity locations (head and neck, thorax, and abdomen/pelvis). In this observational cohort study using the NCDB, we noted that a significant number of patients are not receiving guideline-concordant care. Our findings also note potential sociodemographic disparities that may be contributing to variations in practice patterns and highlight the concern that not all patients may be equally benefiting from available therapies for STS.

Comparative Trends in Percutaneous Coronary Intervention in Japan and the United States, 2013 to 2017

BackgroundAdoption of the results of large-scale randomized controlled trials in percutaneous coronary intervention (PCI) may differ internationally, yet few studies have described the potential variations in PCI practice patterns. ObjectivesUsing representative national registries, we compared temporal trends in procedural volume, patient characteristics, pre-procedural testing, procedural characteristics, and quality metrics in the United States and Japan. MethodsThe National Cardiovascular Data Registry CathPCI was used to describe care in the United States, and the J-PCI was used to assess practice patterns in Japan (numbers of participating hospitals: 1,752 in the United States and 1,108 in Japan). Both registries were summarized between 2013 and 2017. ResultsPCI volume increased by 15.8% in the United States from 550,872 in 2013 to 637,650 in 2017, primarily because of an increase in nonelective PCIs (p for trend <0.001). In Japan, the volume of PCIs increased by 36%, from 181,750 in 2013 to 247,274 in 2017, primarily because of an increase in elective PCIs (p for trend <0.001). The proportion of PCI cases for elective conditions was >2-fold greater in Japan (72.7%) than in the United States (33.8%; p < 0.001). Overall, the ratio of nonelective PCI (vs. elective PCI; 27.3% vs. 66.2%; p < 0.001) and the performance of noninvasive stress testing in patients with stable disease (15.2% vs. 55.3%; p < 0.001) was lower in Japan than in the United States. Computed tomography angiography was more commonly used in Japan (22.3% vs. 2.0%; p < 0.001). ConclusionsElective PCI is more than twice as common in Japan as in the United States in contemporary practice. Computed tomography angiography is much more frequently used pre-procedurally in Japan than in the United States.

Landscape of Lipid Management Following an Acute Coronary Syndrome Event: Survey of Canadian Specialists

BackgroundFollowing the occurrence of an acute coronary syndrome (ACS), patients are at high risk for subsequent cardiovascular events. Therapies to lower the level of low-density lipoprotein (LDL) cholesterol remain a pillar in secondary prevention approaches following ACS. Significant variability remains in the application of therapies to lower cholesterol level in clinical practice. MethodsA cross-sectional, online survey was conducted of 200 cardiovascular and lipid specialists across Canada who routinely care for patients following the occurrence of ACSs. The survey consisted of 50 multiple-choice questions with opportunities for free-text entry exploring knowledge of lipid guidelines and recent clinical trials, and in-hospital and outpatient management of lipids and familial hypercholesterolemia. ResultsA total of 67.5% (n = 135) of participants stated that a lipid panel would routinely be obtained during the first 24 hours of an admission for an ACS, and 68.5% (n = 137) stated that their hospitals had standing orders for statin initiation at ACS presentation. In high-risk patients, the majority (75.5%; n = 151) of participants indicated that they target an LDL cholesterol level of <1.8 mmol/L. However, a subset (22%; n = 44) would target lower LDL cholesterol levels ranging from 0.5 to 1.7 mmol/L. Only 32.0% (n = 64) of participants stated that >70% of their ACS patients were at or below guideline-recommended LDL cholesterol levels. Respondents generally underappreciated the prevalence of familial hypercholesterolemia in both the general population and ACS patients. ConclusionsThere is significant variation in practice patterns involving therapies to lower LDL cholesterol level in the post–ACS onset period. To improve management of lipids in this high-risk population, changes to institutional policies, shared responsibility of lipid management across multiple disciplines, and physician education are required.

83 Electrocardiogram in Syncope: An old habit or clinically helpful?

Abstract Background Syncope affects up to 50% of individuals by age 21 years and accounts for 1% of presentations to the emergency department (ED). Cardiac causes of syncope, including structural heart defects and rhythm disorders, cannot always be ruled out by an electrocardiogram (ECG) as this test lacks sensitivity and specificity. Conflicting recommendations for the role of ECG in evaluation of pediatric syncope underscore the clinical equipoise of how ECG findings influence physicians’ clinical decisions. Objectives The primary objective of this study is to determine how ECG findings affect ED physicians’ management of children presenting with vasovagal syncope. Our secondary objective is to document the practice pattern variation among ED physicians regarding their decision to obtain an ECG for the evaluation of vasovagal syncope in children. Design/Methods We conducted a prospective cross-sectional survey study using the REDCap platform. Our sample frame consisted of practicing emergency physicians enrolled in the Pediatric Emergency Research Canada (PERC) network. Outcome measures included frequency investigations, specialist consultation, and disposition stratified by type of syncope presentation (low/high risk). We also evaluated which specific ECG findings were likely to change physicians’ management and explored factors influencing the decision to perform or not perform the ECG. Results We obtained data from 105/225 (47%) potential respondents. In a clinical scenario presenting a vasovagal syncope, 52% of respondents would order an ECG. Forty-five percent changed their management if the ECG interpretation was anything other than “Normal ECG”. In a high-risk syncope scenario, an ECG was performed by 96% of respondents. Cardiology referral was requested by 93% of respondents, despite normal ECG findings. Borderline ECG findings led to significant practice variation in management, for both low and high-risk presentations scenarios. Overall, 66% of respondents stated that performing an ECG is not important to rule out a cardiac etiology in a typical vasovagal syncope presentation, but 64% stated that performing an ECG is important to reassure the patient. Conclusion There is substantial practice pattern variation among emergency physicians with regards to the frequency and motivations to order ECGs, and how ECG findings impact the management of pediatric syncope in the ED. Information provided by an ECG can lead to unnecessary change to clinical management, additional testing, and referrals to specialists for typical vasovagal syncope. This reinforces the importance of better knowledge translation surrounding evidence-based management of vasovagal syncope among ED physicians.

The Current State of Mohs Surgery for the Treatment of Melanoma: A Nationwide Cross-Sectional Survey of Mohs Surgeons.

The increased use of Mohs micrographic surgery (MMS) to treat melanoma has been accompanied by wide variations in practice patterns and a lack of best practice guidelines. The present study was a nationwide cross-sectional survey of Mohs surgeons to elucidate commonalities and variations in their use of MMS to treat melanoma. A cross-sectional analysis was performed using survey responses of Mohs surgeons with membership in the American College of Mohs Surgery. A total of 210/513 (40.9%) participants used MMS to treat melanoma of any subtype and 123/210 (58.6%) participants within this group treated invasive T1 melanoma (AJCC Eighth Edition) with MMS. A total of 172/210 (81.9%) participants debulked melanoma in situ (MIS). Average margin size of the first Mohs stage for MIS was 4.96 ± 1.74 mm. A total of 149/210 (71.0%) participants used immunohistochemical stains, with 145/149 (97.3%) using melanoma antigen recognized by T-cells 1 (MART-1) in 96.5% of melanoma cases treated with MMS. Over half of surveyed Mohs surgeons treating melanoma with MMS are treating early invasive melanoma with MMS. Most Mohs surgeons treating melanoma with MMS debulk MIS and virtually all use MART-1 when excising invasive melanoma with MMS.

Practice Patterns of Vascular Surgery's “1%”

Public focus on health care spending has increased attention on variation in practice patterns and overutilization of high-cost services. Mainstream news reports have revealed that a small number of providers account for a disproportionate amount of total Medicare payments. Here, we explore variation in Medicare payments among vascular surgeons and compare practice patterns of the most highly reimbursed surgeons to the rest of the workforce. 2016 Medicare Provider Utilization Data were queried to identify procedure, charge, and payment data to vascular surgeons, identified by National Provider Identification taxonomy. Commonly performed services (>10/year) were stratified into categories (endovascular, open surgery, varicose vein, evaluation and management, etc.). Practice patterns of vascular surgeons comprising the top 1% Medicare payments (n=31) were compared with the remainder of the workforce (n=3,104). In 2016, Medicare payments to vascular surgeons totaled $589 M. 31 vascular surgeons-1% of the workforce-received $91 million (15% of total payments). Practice patterns of the 1% differed significantly from the remainder of vascular surgeons (P<0.05), with endovascular procedures accounting for 85% of their reimbursement. Specifically, the 1% received 49% of total Medicare payments for atherectomy ($121 M), 98% of which were performed in the office setting. One percentage of vascular surgeons receive an inordinate amount of total Medicare payments to the specialty. This discrepancy is due to variations in volume, utilization, and site of service. Disproportionate use of outpatient atherectomy in a small number of providers, for example, raises concerns regarding appropriateness and overutilization. Given current scrutiny over health care spending, these findings should prompt serious discussion regarding the utility of personal and societal self-regulation.

Benchmarking Perioperative Outcomes of Cytoreductive Surgery for Cancer: Implications for Quality Measurement.

Understanding variation and heterogeneity in practice patterns allows programs to develop effective strategies to improve patient outcomes. Cytoreductive surgery is a potentially highly morbid operation that could benefit from systematic assessments directed towards quality improvement. We describe the hospital-level variation and benchmarks for programs performing cytoreductive surgery. Cytoreductive and tumor debulking operations with or without hyperthermic intraperitoneal chemotherapy performed for cancer between January 1, 2013 and June 30, 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Risk-adjusted hospital-level variation in 30-day death, serious morbidity, reoperation, readmission, and a composite of death or serious morbidity (DSM) were evaluated using hierarchical models. National Cancer Institute (NCI)-designated cancer center (NCI-CC) status was also explored. A total of 6203 operations across 589 hospitals were included, of which 56 were at NCI-CCs. Unadjusted rates of death, serious morbidity, reoperation, readmission, and DSM were 1.4%, 12.9%, 3.6%, 8.6%, and 13.4%, respectively. The coefficients of variation for hospital-level performance were 4.7%, 2.1%, 4.6%, 14.4%, and 1.0% for DSM, death, serious morbidity, unplanned reoperation, and unplanned readmissions, respectively. When compared with other hospitals, NCI-CCs had better risk-adjusted 30-day mortality (median odds ratio 0.984 versus 0.998, p < 0.001), but not for the other outcomes studied. Hospital-level variation was modestly detected using the usual measures of perioperative outcomes. Given the increasing interest in cytoreductive surgery, we demonstrate a clear opportunity to not only improve the quality of our care but to also better improve the way quality is measured for these patients.

Variations in bariatric surgical practice patterns between general and bariatric surgeons: a matched analysis of the 2017 MBSAQIP database.

While general surgeons (GSs) perform metabolic and bariatric surgery (MABS), these procedures are increasingly performed by metabolic and bariatric surgeons (MBSs). Because MABS is an evolving practice with changing surgical platforms and approaches, it is important to evaluate outcomes between different specialists performing these procedures. To compare perioperative practice pattern variations and outcomes of MABS performed by GSs versus MBSs. University Hospital, United States. Using the 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, we identified Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) cases and stratified them by specialization (GSs versus MBSs). Patient characteristics, practice patterns and outcomes, complications, and 30-day outcomes were compared between cohorts. Matched procedure-specific analyses were performed. Of 172,430 MABS procedures, 4394 (2.5%) were performed by GSs and 168,036 (97.4%) by MBSs. At baseline, patients of GSs had fewer co-morbidities. GSs more commonly used the robotic platform for SG cases and performed interventions such as staple line reinforcement and staple line check with provocative testing. MBSs more commonly performed robotic (versus laparoscopic) RYGB. Overall complications were low in both study cohorts. After propensity matching, transfusion and venous thromboembolism were higher in SG performed by GSs, while surgical site infection was higher in SG and RYGB performed by MBSs. These findings were not reproduced after case-control matching. In matched analyses, there were no mortality or morbidity differences between study cohorts. MABS is performed safely by both GSs and MBSs, with no difference in morbidity andmortality.

Assessment and management of coronary artery disease in patients undergoing transcatheter aortic valve replacement.

Coronary artery disease (CAD) is commonly observed in patients undergoing transcatheter aortic valve replacement (TAVR). Significant variability exists across institutions for strategies used for CAD diagnosis and its management. The heart team often relies upon traditional practice patterns and the decision for revascularization by percutaneous coronary intervention (PCI) is influenced by patient, angiographic, operator, and system-related factors. Contemporary coronary tomography angiography (CTA) shows significant promise for detection of clinically important CAD and preliminary data support CTA use for TAVR patients. The prognostic implications of CAD in a TAVR population remain unclear with studies showing conflicting data for the benefits of PCI. Recent trials show that medical management is an effective initial treatment strategy for stable CAD, a finding likely also applicable for asymptomatic and stable TAVR patients. In addition, PCI performed pre-TAVR, concomitant with TAVR or after TAVR has been shown to produce similar outcomes. Dual antiplatelet therapy (DAPT) is mandated after PCI but associated with increased risk of bleeding in TAVR population with accumulating evidence for single antiplatelet therapy (SAPT) post-TAVR unless DAPT or anticoagulation is indicated for another reason. Although coronary angiography remains the predominant modality for CAD assessment, CTA is increasingly being used in TAVR patients. There is limited evidence to guide CAD management in TAVR patients with significant variability in practice patterns. Medical therapy is recommended for asymptomatic and stable CAD patients with applicability for TAVR population. Despite prior concerns, recent studies suggest successful coronary access post-TAVR and similar outcomes for PCI offered pre-TAVR, concomitant with TAVR and post-TAVR settings. Safety of DAPT should be an important consideration for PCI in TAVR patients. Ongoing studies will determine the preferred testing for CAD diagnosis, benefit of revascularization, timing of PCI, and optimum antithrombotic therapy for TAVR populations.

Institutional variation in recovery after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: An opportunity for enhanced recovery pathways.

Variations in care have been demonstrated both within and among institutions in many clinical settings. By standardizing perioperative practices, Enhanced Recovery After Surgery (ERAS) pathways reduce variation in perioperative care. We sought to characterize the variation in cytoreductive surgery (CRS)/heated intraperitoneal chemotherapy (HIPEC) perioperative practices among experienced US medical centers. Data from the US HIPEC Collaborative represents a retrospective multi-institutional cohort study of CRS and CRS/HIPEC procedures performed from 12 major academic institutions. Patient characteristics and perioperative practices were reported and compared. Institutional variation was analyzed using hierarchical mixed-effects linear (continuous outcomes) or logistic (binary outcomes) regression models. A total of 2372 operations were included. CRS/HIPEC was performed most commonly for appendiceal histologies (64.2%). The rate of complications (overall 56.3%, range: 31.8-70.9) and readmissions (overall 20.6%, range: 8.9-33.3) varied by institution (P < .001). Institution-level variation in perioperative practice patterns existed among measured ERAS pathway process/outcomes (P < .001). The percentages of variation with each process/outcome measure attributable solely to institutional practices ranged from 0.6% to 66.6%. Significant variation exists in the perioperative care of patients undergoing CRS/HIPEC at major US academic institutions. These findings provide a strong rationale for the investigation of best practices in CRS/HIPEC patients.

Double trouble? Clinic-specific risk factors for monozygotic twinning

To investigate clinic-specific risk factors for monozygotic twinning (MZT) using a large, electronic database. Retrospective case-control study. Infertility clinics. Using an electronic medical record system, viable clinical pregnancy (confirmation of a gestational sac(s) and presence of at least one fetal pole with a heartbeat on first trimester ultrasound), data were obtained from homologous invitro fertilization (IVF) cycles after single ET from June 1, 2004, to December 31, 2016. Monozygotic twinning was defined as a pregnancy with two fetal heartbeats on ultrasound with sex concordance at birth. None. Risk factors for MZT including cycle type, method of insemination, and method of cryopreservation. Of the 28,265 IVF cycles that met inclusion criteria over the study period, 8,749 (31.0%) resulted in a viable intrauterine clinical pregnancy. There were 102 (2.7%) MZT in the fresh cycle cohort and 133 (2.7%) in the frozen cycle cohort. Neither cryopreservation nor the method of cryopreservation was a significant risk factor for MZT. However, the use of sequential media was an independent risk factor for MZT in fresh, but not frozen, ETs (odds ratio = 1.72, 95% confidence interval, 1.10-2.68). Significant differences were seen in the incidence of MZT between clinics, and this difference persisted after controlling for known risk factors (clinic 0, reference; clinic 2, odds ratio = 2.22; 95% confidence interval, 1.48-3.32; clinic 3, odds ratio = 1.93; 95% confidence interval, 1.30-2.87). Differences in MZT rates exist between individual IVF clinics, suggesting that variations in practice patterns may contribute to this event. The present study noted the use of sequential media was an independent risk factor for fresh but not frozen cycles.

Variation in Prescribing and Factors Associated With the Use of Prophylactic Antibiotics for Mohs Surgery: A Single-Institution Retrospective Study.

Antibiotic use associated with Mohs surgery is increasing. To understand variation in practice patterns and factors associated with antibiotic use. The authors conducted a retrospective cohort study of antibiotic use among patients treated with Mohs micrographic surgery between July 1, 2013, and June 30, 2017, at an academic medical center. Multivariate logistic regression was used to evaluate for associations between antibiotic prescribing and the surgeon, site, reconstruction, and patient characteristics. The odds of prescribing antibiotics differed significantly between each surgeon evaluated; 3.35-fold variation in postoperative antibiotic use was observed. Increasing number of surgical sites (odds ratio [OR] 1.24; 95% confidence interval [CI] 1.09-1.41), number of Mohs stages required (OR 1.18; 95% CI 1.08-1.28), and defect area (OR 1.31; 95% CI 1.25-1.37), as well as patient female sex (OR 1.14; 95% CI 1.03-1.27), were associated with increased postoperative antibiotic use, whereas age >80 was associated with decreased use (OR 0.75; 95% CI 0.64-0.87) compared with age <60. Antibiotics are more commonly prescribed for repairs that are considered higher risk for infection. However, significant variation exists between surgeons, even within a single institution, suggesting a need for prospective trials and consensus guideline development.

Heparin as a therapy for COVID-19: current evidence and future possibilities.

Coronavirus disease 2019 (COVID-19), the clinical syndrome associated with infection by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has impacted nearly every country in the world. Despite an unprecedented focus of scientific investigation, there is a paucity of evidence-based pharmacotherapies against this disease. Because of this lack of data-driven treatment strategies, broad variations in practice patterns have emerged. Observed hypercoagulability in patients with COVID-19 has created debate within the critical care community on the therapeutic utility of heparin. We seek to provide an overview of the data supporting the therapeutic use of heparin, both unfractionated and low molecular weight, as an anticoagulant for the treatment of SARS-CoV-2 infection. Additionally, we review preclinical evidence establishing biological plausibility for heparin and synthetic heparin-like drugs as therapies for COVID-19 through antiviral and anti-inflammatory effects. Finally, we discuss known adverse effects and theoretical off-target effects that may temper enthusiasm for the adoption of heparin as a therapy in COVID-19 without confirmatory prospective randomized controlled trials. Despite previous failures of anticoagulants in critical illness, plausibility of heparin for COVID-19 is sufficiently robust to justify urgent randomized controlled trials to determine the safety and effectiveness of this therapy.

Practice patterns of preoperative hormonal stimulation in pediatric penile surgeries—A survey of Nigerian pediatric surgeons

Variable practice patterns exist in the use of Preoperative Hormonal Stimulation (PHS) prior to penile surgeries and there seems to be no generally agreed standards. To assess the current practice patterns of PHS before penile surgeries among Nigerian pediatric surgeons and compare with literature. Self-administered questionnaires were distributed amongst consultants and senior registrars in Pediatric surgery during the 2019 Association of Pediatric Surgeons of Nigeria (APSON) national conference. SPSS version 20 was used for data entry and analysis and results presented as ranges, percentages, tables. Test for association was done using chi square test and a p-value of <0.05 was deemed significant. All fifty respondents comprising 43 males, 7 females; 31 consultants and 19 senior registrars have managed hypospadias, with eighty-six percent managing less than 50 per year. Seventy-six percent practice PHS and more proportion of males use PHS than females (p=0.027).Only 15.8% and 7.9% respectively estimated serum testosterone before and after PHS. Majority (92.1%) gave PHS because of small-appearing penis and 86.8% have used it in proximal hypospadias. Most commonly used form of PHS was intramuscular testosterone (76.3%) while 2mg/kg testosterone was commonest dose (65.7%). Ninety-one percent give intramuscular testosterone at 2-4 weeks intervals; ninety-four percent give 2-3 doses of intramuscular testosterone preoperatively with last dose given 2-4 weeks before surgery in 57.9%. Ninety-two percent thought PHS will not increase postoperative complications and pubic hair was most common complication of PHS (63%). There is diversity in PHS practices among Nigerian pediatric surgeons. Though mainly low-volume surgeons, majority use PHS before penile surgeries especially in proximal hypospadias and small-appearing penis. Males tend to practice PHS more than females and most commonly used form of PHS is 2-3 doses of 2mg/kg intramuscular testosterone at 2-4 weekly intervals with last dose given 2-4 weeks before surgery. This study may be limited by bias inherent in self-reported practices and outcomes as seen in surveys, though surveys help to evaluate practices of professionals. Majority of Pediatric surgeons in Nigeria use PHS in form of intramuscular testosterone mainly for small appearing penis and proximal hypospadias. Most common dosing is 2mg/kg at 2-4 weeks intervals and 2-3 doses preoperatively with the last dose 2-4 weeks preoperatively. Serum testosterone estimation is not common before PHS. Many believe that PHS does not increase complications following penile surgeries. Current diversity in practice suggests the need for further studies to encourage standardization or guidelines for practice in Nigeria.

Tu1151 QUALITY OF RECOMMENDATIONS AFTER SURVEILLANCE COLONOSCOPY IN OLDER ADULTS

Current guidelines for surveillance colonoscopy in adults age ≥75 recommend that decisions be individualized, which may lead to wide variation in practice patterns. We evaluated the content and clarity of endoscopist-written recommendations after surveillance colonoscopy in older adults. We performed a single center, retrospective, chart review of adults age ≥75 who underwent surveillance colonoscopy. We developed a data collection tool to facilitate data abstraction and minimize inter-observer variability. Kappa scores for recommendation assessments showed substantial agreement. Patient age and gender, endoscopist recommendations for follow-up, and follow-up letters after review of pathology were collected. Recommendations for follow-up were categorized based on content (continue vs. stop surveillance), definitiveness of the recommendation (definitive [e.g., “should,” “recommend”] vs. not definitive [e.g., “could,” “consider”]), and if/what rationale was provided (e.g. “because of your age…”). Differences in recommendations were evaluated using Fisher’s exact test at the 0.05 level of significance. Between 2012-2019, 4453 colonoscopies were performed in adults age ≥75, of which 1324 were for surveillance. We evaluated a subset of these (n=165) using stratified sampling to get a range of patient ages and findings for each endoscopist (n=11). 21.8% of reports contained no recommendation, ranging from 0% to 60.0% by endoscopist. There was a significant difference in the proportion of “stop” versus “continue” recommendation given across all endoscopists (p = 0.001) (Figure 1). There were no discrepancies between colonoscopy reports and post-pathology follow-up letters (Table 1). Among reports that included a recommendation, 69.0% were to continue surveillance, 69.0% were definitive, and 72.1% provided a rationale. There was no significant difference in the definitiveness of the recommendation based on stopping or continuing (p = 0.89). Exams that recommended stopping included a rationale 65.0% of the time, citing: age (57.5%), the current exam being normal (12.5%), overall health (7.5%), and the patient’s history of polyps (7.5%). Exams that recommended continuing included a rationale 76.4% of the time, citing the malignant potential of polyps (34.8%), the patient’s history of polyps (32.6%), and overall health (10.1%). There is considerable variation in the content and clarity of endoscopist recommendations after surveillance colonoscopy in older adults. Over a fifth lacked any recommendation. This study highlights opportunities for quality improvement targeted at standardizing endoscopist written post-colonoscopy recommendations. Next steps include understanding patient and referring provider interpretation of written recommendations and how variation in recommendations affects follow-up and clinical outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Variation in acute fluid resuscitation among pediatric burn centers

BackgroundAccurate resuscitation of pediatric patients with large thermal injury is critical to achieving optimal outcomes. The goal of this project was to describe the degree of variability in resuscitation guidelines among pediatric burn centers and the impact on fluid estimates. MethodsFive pediatric burn centers in the Pediatric Injury Quality Improvement Collaborative (PIQIC) contributed data from patients with ≥15% total body surface area (TBSA) burns treated from 2014 to 2018. Each center's resuscitation guidelines and guidelines from the American Burn Association were used to calculate estimated 24-h fluid requirements and compare these values to the actual fluid received. ResultsDifferences in the TBSA burn at which fluid resuscitation was initiated, coefficients related to the Parkland formula, criteria to initiate dextrose containing fluids, and urine output goals were observed. Three of the five centers’ resuscitation guidelines produced statistically significant lower mean fluid estimates when compared with the actual mean fluid received for all patients across centers (4.53 versus 6.35ml/kg/% TBSA, p<0.001), (4.90 versus 6.35ml/kg/TBSA, p=0.002) and (3.38 versus 6.35ml/kg/TBSA, p<0.0001). ConclusionsThis variation in practice patterns led to statistically significant differences in fluid estimates. One center chose to modify its resuscitation guidelines at the conclusion of this study.

P140: Variability in practice patterns in the emergency department treatment of hyperkalemia

Introduction: Hyperkalemia is a common electrolyte disturbance associated with morbidity and mortality. Commonly used therapies for hyperkalemia include IV calcium, sodium bicarbonate, insulin, beta-adrenergic agents, ion-exchange resins, diuretics and hemodialysis. This study aims to evaluate which treatments are more commonly used to treat hyperkalemia and to examine factors which influence those clinical decisions. Methods: This is a retrospective chart review of all cases of hyperkalemia encountered in 2017 at a Canadian adult ED. Potassium values were classified as mild (5.5 - 6.5 mEq/L), moderate (&gt;6.5 - 7.5 mEq/L) and severe (&gt;7.5 mEq/L). Treatment choices were then recorded and matched to hemodynamic stability, degree of hyperkalemia and ECG findings. More statistical methods to test correlation between treatment and specific variables will be performed over the next 2 months, including logistic regression to highlight potential determinants of treatment and Chi-square tests to verify randomness and to construct 95% confidence intervals. Results: 1867 ED visits were identified, of which 479 met the inclusion criteria. 89.1% of hyperkalemia cases were mild, 8.2% were moderate, and 2.7% were severe. IV insulin was used in 22.1% of cases, followed by Kayexalate in 20.5%, sodium bicarbonate in 12.3%, IV calcium in 9.4%, frusemide in 7.3%, salbutamol in 2.7%, and dialysis in 1.9%. Moderate and severe hyperkalemia were associated with higher use of insulin (79.5% and 64.3% respectively), IV calcium (41% and 64.3% respectively), sodium bicarbonate (56.4% and 85.7% respectively). Bradycardia was associated with higher insulin and IV calcium use (46.7% and 33.3% respectively). Hypotension was associated with a similar increase in use of insulin and IV calcium (34.2% and 23.7% respectively). There were only 15 cases of cardiac arrest in which sodium bicarbonate and IV calcium were more frequently used (80% and 60% respectively). Conclusion: This study demonstrates variability in the ED management of hyperkalemia. We found that Insulin and Kayexalate were the 2 most common interventions, with degree of hyperkalemia, bradycardia and hypotension influencing rates of treatment. Overuse of kayexalate for emergent treatment of hyperkalemia is evident despite weak supporting evidence. Paradoxically, beta adrenergic agents were underutilized despite their rapid effect and safer profile. The development of a widely accepted guideline may help narrow the differences in practice and potentially improve outcomes.

Current Trends in Unilateral Cleft Lip Care: A 10-Year Update on Practice Patterns.

The care of unilateral cleft lip (UCL) patients is extremely variable. Historical benchmarks for perioperative and intraoperative choices by cleft surgeons were produced by Sitzman et al (Plast Reconstr Surg. 2008;121:261e-270e) in 2005. However, emerging data and cleft lip repair methods around this period were not captured by this study. The aim of this study was to update the current practice patterns of cleft lip surgeons. An electronic survey was distributed to surgeons in the American Cleft Palate Association. Demographic data about the surgeon were collected as well as their choices regarding perioperative and intraoperative cleft lip care. Eighty-six surgeons responded to the survey. Nearly 40% of surgeons have changed their technique for UCL repair with Fisher anatomical subunit repair gaining significant popularity. Nasoalveolar molding is also being used more frequently (41% vs 22%). At the time of the cleft lip repair, closure of the nasal floor is occurring in 83.1% of patients and primary cleft rhinoplasty is being performed routinely 57% of the time. Over the last 10 years, there has been an increase in the use of modified rotation advancement repairs and Fisher anatomic subunit approximation technique for treatment of UCL. There continues to be a lack of evidence regarding superiority of specific repair techniques or the benefits of adjunct procedures, which results in varying practice patterns. Educating all cleft surgeons on practices that are well supported is important to improve care to cleft patients.

National Utilization of Surgery and Outcomes for Primary Tracheal Cancer in the United States

Tracheal cancer (TC) is a rare disease, and surgical treatment requires a high level of expertise. We sought to determine the treatment patterns and surgical outcomes of TC in the United States. The National Cancer Database was queried for all cases of primary invasive TC without distant metastatic disease between 2004 and 2015. Primary surgical treatment and outcomes were analyzed. Factors associated with utilization of surgery and overall survival were tested using regression analysis. Of 1379 identified TC patients, 338 patients (25%) were treated surgically. Among resected patients, most had adenoid cystic (48%) or squamous cell (28%) carcinoma. Median length of hospital stay after resection was 7 days (interquartile range, 3-8), and 30-day mortality was 1.4%. Most nonsurgically managed patients underwent radiation (63%). Factors associated with surgical resection were younger age, higher education level, tumor size, and adenoid cystic histology. On multivariate analysis patients were also more likely to undergo surgery if they traveled a farther distance for treatment (>45 km; odds ratio, 1.53; 95% confidence interval, 1.09-2.13) or were treated at academic centers (odds ratio, 1.68; 95% confidence interval, 1.25-2.26). Five-year overall survival was 71% after resection, 39% after surgical debulking, and 31% without surgery (P < .001). National surgical outcomes for resection of TC demonstrate low perioperative mortality and excellent long-term prognosis. However, few nonmetastatic TC patients underwent surgery, indicating disparities in access to optimal surgical care and variability in practice patterns at a national level.