Variation In Practice Patterns Research Articles

Variability in practice patterns among emergency physicians in the evaluation of patients with a suspected diagnosis of pulmonary embolism.

To describe the inter-physician variability in the utilisation rate and diagnostic yield of computed tomography pulmonary angiography (CTPA) among a group of emergency department (ED) physicians working in a similar clinical environment. We collected data on all CTPA studies ordered by ED physicians at three affiliated sites during a 2-year period between January 1, 2016, and December 31, 2017. For each physician, we calculated individual CTPA utilisation rate (total number of CTPAs ordered per 1000 ED visits) and diagnostic yield (percentage of CTPAs that were positive for PE). Additional analysis was carried out in order to identify the highest orderers of CTPA and their diagnostic yield. Seventy-seven ED physicians who collectively ordered a total of 2788 CTPAs were included in the study. Utilisation rates ranged from 1.1 to 22.2 CTPA per 1000 ED visits (median: 5.2 CTPA/1000 ED visits; 25%ile: 3.6 CTPA/1000 ED visits; 75%ile: 7.9 CTPA/1000 ED visits) and the CTPA diagnostic yields ranged from 0% to 33% (median: 9.1%; 25%ile: 5.2%; 75%ile: 16.1%). Those physicians in the lower quartile for ordering rate had a higher mean diagnostic yield when compared to the higher quartiles. The findings of this study demonstrate variability in CTPA ordering patterns and diagnostic yields among physicians working within the same clinical environment. There is some suggestion that those physicians who order disproportionately higher numbers of CTPAs have lower diagnostic yields.

Clinical Outcomes in Cyclin-dependent Kinase 12 Mutant Advanced Prostate Cancer

BackgroundCyclin-dependent kinase 12 (CDK12) loss occurs in 3–7% of metastatic prostate cancer patients and is characterized by a genomic instability signature, but the clinical implications of CDK12 loss are not well established. ObjectiveTo determine the clinical course of patients with CDK12 mutant advanced prostate cancer compared with other genomic subtypes. Design, setting, and participantsA retrospective analysis of data from three academic medical centers, including 317 patients with advanced prostate cancer and prior next-generation sequencing from tumor tissue (n = 172) or circulating tumor DNA (n = 145), was performed. Forty-six patients had CDK12 mutations; 34 had biallelic CDK12 loss (79%). Outcome measurements and statistical analysisPatients were stratified by mutation status (CDK12, homologous recombination deficiency [HRD; BRCA1/2 and ATM], TP53, and other cohort). The Kaplan-Meier method was used to evaluate time to event outcomes: time to development of metastatic disease, time to development of castration resistance, and time to prostate-specific antigen (PSA) progression after first-line androgen receptor pathway inhibitor (ARPI) therapy in a patient subset. Results and limitationsThe median follow-up was 66.6 mo. Patients with CDK12 mutant prostate cancer exhibited shorter time to metastasis (median = 34.9 mo, p = 0.004) and development of castration-resistant disease (median = 32.7 mo, p < 0.001), compared with other genomic subtypes, with shorter time to PSA progression on first-line ARPI treatment of metastatic castration-resistant disease (median = 3.6 mo, p = 0.0219). CDK12 mutant patients did not have overall shorter time on treatment compared with other mutation subgroups, and CDK12 status did not demonstrate statistical significance in multivariate analysis. Limitations include variable center-dependent practice patterns and heterogeneity due to combining tumor and liquid biopsy data. ConclusionsOur data suggest that advanced prostate cancers harboring CDK12 mutations display aggressive clinical behavior, underscoring the need to fully delineate the molecular and clinical characteristics, and appropriate therapeutic approaches for distinct subtypes of advanced prostate cancers. Patient summaryIn this report, we evaluate the clinical characteristics and outcomes of patients with prostate cancer and CDK12 mutation in their tumors. These patients seem to have more aggressive disease, with more high-grade Gleason ≥8 cancers and shorter time to developing metastatic cancer. Cases of advanced CDK12-mutated prostate cancer may warrant consideration of therapy intensification or combination approaches.

Current Practice Patterns in the Diagnosis and Management of Sleep-Disordered Breathing in Infants.

Currently, there are no universally accepted guidelines for diagnosis and management of sleep-disordered breathing (SDB) in infants. The purpose of this study was to survey pediatric sleep medicine providers regarding their current practice patterns for diagnosis and management of SDB in infants. An anonymous, web-based survey with 71 questions was distributed via the PEDSLEEP and Ped-Lung listserv, which serve as a hub of communication for pediatric sleep and pulmonary medicine providers worldwide. Fifty-four providers from eight countries completed the survey. Ninety-six percent of providers reported performing sleep studies in infants with 53% performing more than 30 studies per year. There was no consensus on the definition of obstructive sleep apnea (OSA) in infants when using an obstructive apnea-hypopnea index (AHIo) cutoff: AHIo > 1 (30%), AHIo > 2 (35%), AHIo > 5 (24%), AHIo > 10 (2%) and other (9.3%). Thirty-six percent did not use pediatric criteria to define severity of OSA in infants. Opinions regarding management of five typical SDB cases were solicited and the results varied among respondents. Most of the providers (89%) thought that more research is needed to gather normative sleep data in infants and that their practice would benefit from evidence- based guidelines for diagnosis and management of SDB in infants (98%). These results demonstrate substantial variability in practice patterns for diagnosis and management of SDB in infants. Further research and consensus guidelines are needed to ensure optimal care for infants with SDB.

Practice Patterns in Reporting Tertiary Grades at Radical Prostatectomy: Survey of a Large Group of Experienced Urologic Pathologists.

In prostate cancer, "tertiary" higher-grade patterns (TPs) have been associated with biochemical recurrence after radical prostatectomy. To determine variation regarding definition and application of TPs. Online survey regarding TPs in a range of grading scenarios circulated to 105 experienced urologic pathologists. Among 95 respondents, 40 of 95 (42%) defined TPs as "third most common pattern" and 55 (58%) as "minor pattern/less than 5% of tumor." In a tumor with pattern 3 and less than 5% pattern 4, of the 95 respondents, 35 (37%) assigned 3 + 3 = 6 with TP4, while 56 (59%) assigned 3 + 4 = 7. In a tumor with pattern 4 and less than 5% pattern 5, of the 95 respondents, 51 (54%) assigned 4 + 4 = 8 with TP5, while 43 (45%) assigned 4 + 5 = 9. Six scenarios were presented in which the order of most common patterns was 3, 4, and 5 (Group 1) or 4, 3, and 5 (Group 2) with varying percentages. In both groups, when pattern 5 was less than 5%, we found that 98% and 93% of respondents would assign 3 + 4 = 7 or 4 + 3 = 7 with TP5. In scenarios with 15% or 25% pattern 5, most respondents (70% and 80%, respectively) would include pattern 5 as the secondary grade, that is, 3 + 5 = 8 (Group 1) or 4 + 5 = 9 (Group 2). For 85 of 95 (89%), a TP would not impact Grade Group assignment. This survey highlights substantial variation in practice patterns regarding definition and application of "tertiary" grading in radical prostatectomy specimens. High consistency was observed in 3 + 4 = 7/4 + 3 = 7 scenarios with truly minor pattern 5. These findings should inform future studies assessing the standardization and predictive value of "tertiary" patterns.

Paediatric anterior cruciate ligament tears: management and growth disturbances. A survey of EPOS and POSNA membership.

PurposeThe therapeutic algorithm of paediatric anterior cruciate ligament (ACL) tears remains controversial. The primary aim of the study was to describe variations in practice patterns among European Paediatric Orthopaedic Society (EPOS) and Pediatric Orthopaedic Society of North America (POSNA) members with respect to management of ACL tears in skeletally immature patients. The secondary objective was to determine the number, type and severity of growth disturbances associated with ACL reconstruction (ACLR).MethodsAn email invitation to complete a 52-question survey was sent to all members of POSNA and EPOS. Data were collected automatically. Descriptive statistics were applied.ResultsIn all, 305 (25.4%) surgeon members responded. Only 182 (60%) of the participants treated ACL injuries in skeletally immature patients and completed the survey. A total of 17% of EPOS and 70% of POSNA members recommended ACLR within three months for a prepubescent paediatric ACL tear. In total, 61% of POSNA and 83% of EPOS members recommended ACLR within three months for a pubescent paediatric ACL tear. Epiphyseal tunnels were the preferred technique in prepubescent children (43% at the tibia and 49% at the femur), while transphyseal tunnels were recommended preferentially in pubescent children (85% at the tibia and 63% at the femur). In all, 5.5% of participants reported growth disturbances after ACLR.ConclusionCurrent practice patterns across the Atlantic remain varied and controversial. Consensus remains elusive; as such, research collaboration among societies will be important to develop an evidence-based treatment algorithm. The use of transphyseal tunnels has been reinforced. The number of cases of significant growth disturbance is minimal, yet worrisome.Level of EvidenceII

PREDICTORS OF DAPT USE IN PATIENTS BEYOND 1 YEAR POST MYOCARDIAL INFARCTION: INSIGHTS FROM THE TIGRIS OBSERVATIONAL STUDY

International guidelines vary in their recommendations for dual antiplatelet therapy (DAPT) use beyond 1 year post-myocardial infarction (MI). In the current analysis, we sought to identify predictors of DAPT use in patients ≥1 year post-MI prior to publication of the DAPT score and the most recent iterations of international guidelines for the use of DAPT in the management of patients with MI. TIGRIS (NCT01866904) was a prospective, multi-center (369 centers in 25 countries), observational study of patients 1 to 3 years post-MI between June 2013 and November 2014. We performed a multivariable logistic regression analysis to identify independent predictors of DAPT use at 396 days post-MI (365 days plus a 31-day overrun period to allow intended DAPT discontinuation at 1 year). Patients on oral anticoagulation or on treatment with ticagrelor were excluded. Of 8464 patients enrolled (mean age 66 years, women 24%, ST-elevation MI 53%, prior MI 10%, multivessel disease 66%), the index MI was managed with a percutaneous coronary intervention in 82% of patients, coronary artery bypass grafting in 7%, and medically in 11%. The prevalence of DAPT use was 78% at the time of hospital discharge and 40% at 396 days post-MI. There was significant variability in practice patterns of DAPT use post-MI across the different geographical regions (Figure). In the subset of patients on DAPT at 396 days post-MI, aspirin was combined with clopidogrel in 84%, prasugrel in 12%, and other antiplatelet agents in 4%. DAPT use at 396 days post-MI was independently associated with geographic region, age, use of PCI for the index MI, and a history of multivessel disease or angina (Table). Several variables included in the DAPT score and addressed in international guideline recommendations for the use of antiplatelet therapies (e.g. diabetes, second prior MI, hypertension, peripheral artery disease, heart failure, smoking, and renal insufficiency) were not independent predictors of DAPT use at 396 days. DAPT use declined from hospital discharge to 1 year post-MI. Overall, DAPT use ≥1 year post-MI was prevalent and appeared to be influenced by regional practices. Further research is needed to determine how the DAPT score and international guidelines have affected long-term DAPT use practice patterns.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

2895 Recurrent Bleeding in Patients With LVADs: Endoscopic Yield and Impact of Endoscopic Intervention

INTRODUCTION: Patients with LVADs are at increased risk for gastrointestinal bleeds (GIBs) because of chronic anticoagulation and high flow states. A prior retrospective study at our institution confirmed that 22% of patients with LVADs had a GIB after implantation, consistent with prior literature. There are no evidence-based guidelines regarding the role of repeat endoscopic procedures for recurrent GIB, resulting in varying practice patterns among Cardiology and GI teams. It is unknown how often repeat inpatient endoscopic examinations during hospitalizations result in intervention or reduction in future GIB episodes. We sought to assess the proportion of endoscopic intervention and impact on recurrent GIB. METHODS: We conducted a retrospective cohort study of all patients at one academic institution who underwent LVAD implantation between March 2016 through February 2018. For each patient, we assessed post implant hospital encounters for GIBs through May 2019. The primary outcome was the odds ratio for a future GIB based on the occurrence of endoscopic intervention versus none (endoscopy with no intervention or no procedure). Secondary outcomes included endoscopic intervention based on overt versus occult GIB. RESULTS: The cohort included 105 patients who had LVADs implanted during the stated time. 34 patients (32%) presented for GIBs during the study period, with a total of 71 encounters. A third or higher encounter occurred in 26% of patients (9/34) and accounted for 27% (19/71) of encounters. 79% of all encounters (56/71) included at least one invasive endoscopic evaluation; an endoscopic intervention was performed in 41% (23/56). The odds ratio for future GIB after endoscopic intervention during the first GIB (34/71) was 0.2 (95% CI 0.04-0.97, P = 0.046) but was not statistically significant if the intervention was during a recurrent GIB (37/71) (0.33, 95% CI 0.08 - 1.41, P = 0.14). The odds ratio of performing an intervention during endoscopic procedure for overt versus occult GIB was 3.4 (95% CI 0.98-11.7231, P = 0.053), trending towards significant. CONCLUSION: Patients with LVADs who have recurrent GIBs experience repeat admissions and endoscopic procedures. In our cohort, endoscopic interventions for repeat GIB did not have an impact on future episodes of GIB. Our data suggest that the endoscopic yield is likely lower with occult GIB.There is a clinical need to identify characteristics of LVAD patients at risk and to develop guidelines for the management of patients with recurrent GIB.

CRITICAL CARE ULTRASONOGRAPHY USE AT ACADEMIC TRAINING PROGRAMS: A SURVEY OF CRITICAL CARE FELLOWS

SESSION TITLE: PCCM - The Next Generation or Building the Skills of Tomorrow SESSION TYPE: Original Investigations PRESENTED ON: 10/21/2019 1:30 PM - 2:30 PM PURPOSE: Although in widespread use, data regarding the training and practice of critical care fellows in critical care ultrasonography (CCUS) are limited. We hypothesized that significant variation exists in critical care training programs in relation to accessibility to expert faculty, number of dedicated ultrasonography machines for teaching and patient care, methods of instruction, and modes of application. METHODS: An anonymous online survey was sent to program directors (PD) of all ACGME accredited critical care training programs (n = 453). PD were asked to forward the survey to their critical care fellows. The 22-question survey consisted of questions related to training by expert faculty, modalities of ultrasonography used, and methods of instruction. Data was collected over a three-month period. RESULTS: There were 73 respondents, from the critical care fields of pulmonary (n = 31), pediatrics (n = 21), surgery (n = 9), internal medicine (n = 8) and anesthesia (n = 4). The response rate was not calculated as the total number of critical care fellows is not known. The majority of respondents reported having faculty with expertise in CCUS (73%). Methods of learning included mandatory rotation (14%), national course attendance (25%), elective rotation (29%), local course attendance (40%), simulation (53%), lectures (53%), hands-on lectures (67%), and informal bedside teaching (85%). More expert faculty was associated with participation in institutional-based CCUS training and through local, national, or international courses (78%). Although >80% of respondents utilize CCUS for vascular access, lung ultrasonography, and volume responsiveness, While the majority of critical care fellows reported having an ultrasound machine for learning (95%), agree that CCUS is clinically useful (99%) and can result in a change in patient management (80%), < 50% use CCUS daily. Only 13% of respondents were actively engaged in CCUS research, and fewer than 30% are required to submit CCUS studies and interpretations to expert faculty for review. Low response rates in this study make generalization of this data problematic. CONCLUSIONS: Critical care fellows report widespread use of CCUS; however, there exists a disconnect between its use and the allotment of necessary resources and attention to ensure the modality is correctly taught and used. Further research is needed to confirm the generalizability of this study. CLINICAL IMPLICATIONS: The widespread use of CCUS amongst critical care fellows without formal standardization of training has resulted in widespread variation in fellow training and overall practice patterns with varied emphasis on allotment of resources to ensure safe and successful CCUS programs. DISCLOSURES: No relevant relationships by Andrew Berman, source=Web Response No relevant relationships by Sunil Chulani, source=Web Response No relevant relationships by Yonatan Greenstein, source=Web Response No relevant relationships by Keith Guevarra, source=Web Response No relevant relationships by Amee Patrawalla, source=Web Response

Comparison of the Inpatient Complications and Health Care Costs of Anterior versus Posterior Cervical Decompression and Fusion in Patients with Multilevel Degenerative Cervical Myelopathy: A Retrospective Propensity Score–Matched Analysis

The optimal surgical approach for multilevel degenerative cervical myelopathy (DCM) is unclear, and there is significant variation in practice patterns. We sought to compare inpatient complications and costs of anterior (ACDF) versus posterior cervical decompression and fusion (PCDF). Patients who underwent multilevel ACDF or PCDF for DCM were identified from the National Inpatient Sample for 2004-2014 using ICD-9-CM codes. Propensity score matching was performed with age, sex, comorbidities, hospital bed size, and use of intraoperative monitoring as covariates. Hospitalization charges/costs, length of stay (LOS), discharge disposition, and inpatient morbidity/mortality were compared between matched ACDF and PCDF groups. Propensity score matching generated a cohort of 13,884 patients (n= 6,942 ACDF; n= 6,942 PCDF). PCDF was associated with greater LOS (mean difference [MD]+1.7 days, P < 0.001) and less frequent routine discharge home (odds ratio [OR] 0.26, P < 0.01). With regard to complications, PCDF had a higher rate of myocardial infarction (OR 1.6, P= 0.007), pulmonary embolism (OR 2.6, P= 0.009), deep vein thrombosis (OR 3.7, P < 0.001), neurological complications (OR 1.7, P= 0.037), hardware-related complications (OR 2.7, P < 0.001), wound infection/breakdown (OR 6.8, P < 0.001), and cerebrospinal fluid leak (OR 1.7, P= 0.011). By contrast, rates of postoperative hematoma (OR 0.61, P= 0.007), hoarseness (OR 0.13, P < 0.001), and dysphagia (OR 0.20, P < 0.001) were higher after ACDF. Mortality was comparable. Hospital charges (MD+$26,259, P < 0.001) and costs (MD+$7,728, P < 0.001) were significantly higher for PCDF. At a national level, for multilevel DCM, we found PCDF to be associated with greater LOS, in-hospital costs, and general medical and surgical complications. ACDF carried higher risk of postoperative hematoma, hoarseness, and dysphagia.

Geographic Variation in the Availability of Deceased Donor Kidneys per Wait-Listed Candidate in the United States

Geographic Variation in the Availability of Deceased Donor Kidneys per Wait-Listed Candidate in the United States

Care management and contemporary challenges in spina bifida: a practice preference survey of the American Society of Pediatric Neurosurgeons.

Neurosurgical management preferences related to myelomeningocele (MMC) care demonstrate significant variability. The authors sought to evaluate variability in practice patterns across a group of senior pediatric neurosurgeons. The purpose of this study was to identify the extent of variability and of consensus with regard to neurosurgical management of MMC and associated hydrocephalus, Chiari II malformation, and tethered spinal cord. A 43-question survey was distributed electronically to the members of the American Society of Pediatric Neurosurgeons (ASPN). The survey covered domains such as clinic case volume, newborn management, hydrocephalus management, transition to adulthood, clinical indications for shunt revision, Chiari II malformation decompression (C2MD), and tethered cord release (TCR). Ninety responses were received from 200 active ASPN members, for an overall response rate of 45%. The majority (58%) of respondents closed 5-15 new cases of open MMC per year. Nearly all (98%) respondents perform back closure within 48 hours of birth, with the majority imbricating the placode and striving for a 3- to 4-layer closure. The most consistent indications for surgical intervention in early hydrocephalus were CSF leak from the back (92%), progressive ventricular enlargement (89%), and brainstem symptoms, including apnea/bradycardia (81%), stridor (81%), and dysphagia (81%). Eighty percent of respondents indicated that spina bifida care is delivered through multidisciplinary clinics, with neurosurgery, orthopedic surgery, urology, physical therapy, and social work as the most common disciplines included. One-third of clinics see both pediatric and adult patients, one-third offer a formal transition program to adult care, and one-third have no transition program. The vast majority of respondents offer prenatal counseling (95%), referral for in utero closure (66%), and endoscopic third ventriculostomy/choroid plexus cauterization (72%). Respondents were more willing to perform shunt revision for symptoms alone than for image changes alone. An asymptomatic broken shunt without ventricular enlargement produced responses evenly divided between observation, intervention, and further investigation. Operative shunt exploration was always performed before C2MD by 56% of respondents and performed sometimes by 40% of respondents. Symptoms of brainstem dysfunction were the strongest clinical triggers reported for C2MD, while declines in urinary continence, leg strength or sensation, or ambulation were the most consistent thresholds for TCR. Significant disparities exist surrounding key areas of decision making regarding treatment for patients with MMC, though there are central areas of agreement among ASPN members. Additionally, there is significant variation in the clinical management of chronic hydrocephalus, C2MD, and TCR, underscoring the need for further research into these specific areas.

Evolution of Excisional Surgery Practices for Melanoma in the United States

National Comprehensive Cancer Network guidelines for melanoma have consistently recommended wide local excision as the standard of care since their inception. Although surgery with more comprehensive margin assessment (eg, Mohs surgery) has been advocated for certain subsets of melanoma, how often these techniques are used in clinical practice is uncertain. To examine trends in the use of comprehensive margin assessment surgery for melanoma by tracking claims data for Mohs surgery. This national cross-sectional analysis examined claims data from the Optum Clinformatics Data Mart, a nationally representative database. The study cohort consisted of 79 108 patients undergoing surgical excision for melanoma from January 1, 2001, through December 31, 2016. Data were analyzed from January 1, 2001, through December 31, 2016. The primary outcome was the likelihood of a melanoma being treated with Mohs surgery over time, evaluated by multivariable logistic regression and expressed as the odds of treatment per additional calendar year. Among 79 108 patients with melanoma (median age, 63 years [interquartile range {IQR}, 51-73]; 47 407 men [59.9%]), 75 047 were treated with conventional excision (median age, 62 years [IQR, 50-73 years]; 44 786 men [59.7%]) and 4061 with Mohs surgery (median age, 67 years [IQR, 56-76 years]; 2621 men [64.5%]). Mohs surgery was used in 5.1% of all surgical cases, with the rate of Mohs surgery increasing 304% from 2.6% in 2001 to 7.9% in 2016. Odds of receiving Mohs surgery for melanoma increased significantly in more recent calendar years (odds ratio [OR], 1.02 per calendar year; 95% CI, 1.01-1.03; P < .001). Immunohistochemistry (IHC) use was only coded with Mohs surgery in 1087 cases (26.8%), and the odds of receiving Mohs surgery with IHC increased in more recent calendar years (OR, 1.13 per calendar year; 95% CI, 1.10-1.15; P < .001). Use of Mohs surgery and Mohs surgery with IHC for melanoma differed widely across geographic census divisions with greater than 3-fold variation between the regions with highest and lowest use in every period (eg, for 2013 through 2016, the East South Central region used Mohs surgery in 8.8% of melanoma excisions compared with 2.6 in the New England region). Despite stable guidelines for melanoma surgery, the results of this study suggest that surgical practices for melanoma are evolving. Wide variations in surgical practice patterns for melanoma are present in the United States. This study's findings suggest that the effect of variations in surgical techniques on outcomes requires scrutiny and further study.

Practice pattern variability in the management of acute severe colitis: a UK provider survey

IntroductionLack of comparative trial data on dosing regimens of infliximab in patients with acute severe ulcerative colitis (ASUC) failing intravenous corticosteroids has resulted in variability of rescue regimes in ASUC...

Variation in Practice Patterns and Reimbursements Between Female and Male Urologists for Medicare Beneficiaries

Previous assessments of practice patterns and reimbursements for female urologists relied on surveys or board certification logs. A current evaluation of the geographic distribution and practice patterns by female urologists would reveal contemporary patterns of access for Medicare beneficiaries. To characterize the variation in practice patterns and reimbursements by urologist sex and the regional deficiencies in care provided by female urologists. This population-based cohort study used the publicly available Centers for Medicare & Medicaid Services Provider Payment database to evaluate payments for US urologists. The cohort (n = 8665) included urologists who provided and were paid for 11 or more services to Medicare beneficiaries in 2016. Data collection and analysis were performed from October 3, 2018, through June 19, 2019. Proportion of female-specific services, payments per beneficiary, and payments per work relative value unit (wRVU) by urologist sex were assessed. Density of female urologists across hospital markets was also identified. Among the 8665 urologists who received payments in 2016, 7944 (91.7%) were men and 721 (8.3%) were women. Female urologists, compared with male urologists, saw a lower proportion of patients with cancer (mean [SD], 16.3% [9.2%] vs 22.7% [8.8%]; P < .001) and a greater proportion of female Medicare beneficiaries (mean [SD], 52.8% [23.2%] vs 24.4% [10.3%]; P < .001). Female urologists generated a greater proportion of wRVU from urodynamics (median [IQR], 2.88% [1.26%-4.84%] vs 1.07% [0.31%-2.26%]; P < .001) and gynecological operations (median [IQR], 0.68% [0.45%-1.07%] vs 0.41% [0.20%-0.81%]; P < .001) than male urologists. In addition, female urologists, compared with their male counterparts, received lower median payments per beneficiary seen ($70.12 [interquartile range (IQR), $60.00-$84.81] vs $72.37 [IQR, $59.63-$89.29]; P = .03) and lower payments per wRVU ($58.25 [IQR, $48.39-65.26] vs $60.04 [IQR, $51.93-$67.88]; P < .001). One-third (103 [33.7%]) of 306 hospital referral regions had 0 female urologists, and 80 (26.1%) had only 1 female urologist. Female urologists were more likely to provide care for female Medicare beneficiaries, to receive lower payments per wRVU generated and beneficiaries seen, and to be difficult to access in certain geographic areas; these findings have policy-related implications and highlight the regional deficiencies in urological care and reimbursement discrepancies according to urologist sex.

Variations in actual practice patterns and their deviations from the clinical practice guidelines for nephrotic syndrome in Japan: certified nephrologists' questionnaire survey.

Few good-quality clinical trials on adults with nephrotic syndrome exist. Thus, there are discrepancies between real-world practice and clinical practice guidelines. We conducted a questionnaire-based survey to investigate potential discrepancies and the factors associated with variations in clinical practice. A questionnaire was administered electronically to all board-certified nephrologists in Japan. To examine clinical practice variations in relation to physician characteristics, we estimated the ratio of the mean duration of steroid therapy using a generalized linear model, and the odds ratio of higher level ordinal variables using an ordered logistic regression model. Responses of the 116 participants showed some variation for the majority of questions. Most participants (94.8%) indicated that screening for malignant tumors was "Conducted for almost all patients". The duration of steroid therapy was found to be longer among physicians seeing ≥ 30 patients with nephrotic syndrome per month, both for minimal-change disease (ratio of mean 1.69; 95% CI 1.07-2.66) and membranous nephropathy (ratio of mean 1.71; 95% CI 1.09-2.69). We identified practice patterns for nephrotic syndrome and discrepancies between clinical practice guidelines and actual practice. Defining the standard therapy for nephrotic syndrome may be necessary to generate high-quality evidence and develop clinical guidelines.

Social Determinants of Appropriate Treatment for Muscle-Invasive Bladder Cancer.

Racial disparities in guideline-based, appropriate treatment (ApT) may be a significant driving force for differences in survival for people with nonmetastatic muscle-invasive bladder cancer (MIBC). We hypothesize that receipt of ApT is influenced by factors such as race and socioeconomic status, irrespective of neighborhood-level differences in healthcare, variations in practice patterns, and clinical characteristics of patients with nonmetastatic MIBC. Within the National Cancer Database, we identified individuals diagnosed with MIBC between 2004 and 2013. Multivariable logistic regression and mixed effects modelling was used to examine predictors of ApT, clustered within institutions. A total of 51,350 individuals had clinically staged nonmetastatic, lymph node-negative MIBC. Black individuals comprised 6.4% of the cohort. Mean age was 72.6 years (SD 11.6) with a male predominance (71.4%). Less than half received ApT (42.6%). Fewer black individuals received ApT compared with white individuals (37% vs. 43%, P < 0.001). When clustered by institution, the odds of ApT were 21% lower for black individuals [odds ratio (OR), 0.79; 95% confidence interval (CI), 0.73-0.87] compared with white individuals with nonmetastatic MIBC. When restricted to higher volume centers with more diverse populations, black individuals had 25% lower odds of ApT (OR, 0.75; 95% CI, 0.61-0.91; P < 0.01), compared with white counterparts. Racial disparities in treatment persisted after accounting for various clinical factors and social determinants of health. Future efforts should focus on addressing racial bias to improve disparities in bladder cancer treatment. If we are not delivering evidence-based care due to these biases (after accounting for access and biology), then it is expected that patients will experience inferior outcomes.

Pediatric Type II Tibial Spine Fractures: Addressing the Treatment Controversy With a Mixed-Effects Model.

Background:Tibial spine fractures, although relatively rare, account for a substantial proportion of pediatric knee injuries with effusions and can have significant complications. Meyers and McKeever type II fractures are displaced anteriorly with an intact posterior hinge. Whether this subtype of pediatric tibial spine fracture should be treated operatively or nonoperatively remains controversial. Surgical delay is associated with an increased risk of arthrofibrosis; thus, prompt treatment decision making is imperative.Purpose:To assess for variability among pediatric orthopaedic surgeons when treating pediatric type II tibial spine fractures.Study Design:Cross-sectional study.Methods:A discrete choice experiment was conducted to determine the patient and injury attributes that influence the management choice. A convenience sample of 20 pediatric orthopaedic surgeons reviewed 40 case vignettes, including physis-blinded radiographs displaying displaced fractures and a description of the patient’s sex, age, mechanism of injury, and predominant sport. Surgeons were asked whether they would treat the fracture operatively or nonoperatively. A mixed-effects model was then used to determine the patient attributes most likely to influence the surgeon’s decision, as well as surgeon training background, years in practice, and risk-taking behavior.Results:The majority of respondents selected operative treatment for 85% of the presented cases. The degree of fracture displacement was the only attribute significantly associated with treatment choice (P < .001). Surgeons were 28% more likely to treat the fracture operatively with each additional millimeter of displacement of fracture fragment. Over 64% of surgeons chose to treat operatively when the fracture fragment was displaced by ≥3.5 mm. Significant variation in surgeon’s propensity for operative treatment of this fracture was observed (P = .01). Surgeon training, years in practice, and risk-taking scores were not associated with the respondent’s preference for surgical treatment.Conclusion:There was substantial variation among pediatric orthopaedic surgeons when treating type II tibial spine fractures. The decision to operate was based on the degree of fracture displacement. Identifying current treatment preferences among surgeons given different patient factors can highlight current variation in practice patterns and direct efforts toward promoting the most optimal treatment strategies for controversial type II tibial spine fractures.

Provider Attitudes and Practice Patterns for Direct-Acting Antiviral Therapy for Patients With Hepatocellular Carcinoma

Direct-acting antivirals (DAAs) are effective against hepatitis C virus and sustained virologic response is associated with reduced incidence of hepatocellular carcinoma (HCC). However, there is controversy over the use of DAAs in patients with active or treated HCC and uncertainty about optimal management of these patients. We aimed to characterize attitudes and practice patterns of hepatology practitioners in the United States regarding the use of DAAs in patients with HCC. We conducted a survey of hepatology providers at 47 tertiary care centers in 25 states. Surveys were sent to 476 providers and we received 279 responses (58.6%). Provider beliefs about risk of HCC recurrence after DAA therapy varied: 48% responded that DAAs reduce risk, 36% responded that DAAs do not change risk, and 16% responded that DAAs increase risk of HCC recurrence. However, most providers believed DAAs to be beneficial to and reduce mortality of patients with complete response to HCC treatment. Accordingly, nearly all providers (94.9%) reported recommending DAA therapy to patients with early-stage HCC who received curative treatment. However, fewer providers recommended DAA therapy for patients with intermediate (72.9%) or advanced (57.5%) HCC undergoing palliative therapies. Timing of DAA initiation varied among providers based on HCC treatment modality: 49.1% of providers reported they would initiate DAA therapy within 3 months of surgical resection whereas 45.9% and 5.0% would delay DAA initiation for 3-12 months and >1 year post-surgery, respectively. For patients undergoing transarterial chemoembolization (TACE), 42.0% of providers would provide DAAs within 3 months of the procedure, 46.7% would delay DAAs until 3-12 months afterward, and 11.3% would delay DAAs more than 1 year after TACE. Based on a survey sent to hepatology providers, there is variation in provider attitudes and practice patterns regarding use and timing of DAAs for patients with HCC. Further studies are needed to characterize the risks and benefits of DAA therapy in this patient population.

Professionalism and performance issues during neurosurgical training and job satisfaction after training: a single training center 50-year experience.

Neurosurgery is often self-selecting. Concern has been raised that residents in the millennial era (born between 1982 and 2004) may have more serious professionalism and performance issues (PPIs) during training compared to prior trainees. Serious PPIs were defined as concerns that led to specific resident disciplinary actions ranging from initial warnings to termination. In order to evaluate this concern, the authors retrospectively reviewed a 50-year experience at a single training center. They then prospectively surveyed living graduates of the program to assess variations in practice patterns and job satisfaction over 5 decades. The PPIs of 141 residents admitted for training at the University of Pittsburgh (subsequently UPMC) Department of Neurological Surgery were reviewed by decade starting in 1971 when the first department chair was appointed. The review was conducted by the senior author, who served from 1975 to 1980 as a resident, as a faculty member since 1980, and as the resident director since 1986. A review of resident PPIs between 1971 and 1974 was performed in consultation with a senior faculty member active at that time. During the last decade, electronic reporting of PPIs was performed by entry into an electronic reporting system. In order to further evaluate whether the frequency of PPIs affected subsequent job satisfaction and practice patterns after completion of training, the authors surveyed living graduates. There was no statistically significant difference by decade in serious PPIs. Although millennial residents had no significant increase in the reporting of serious PPIs, the increased use of electronic event reporting over the most recent 2 decades coincided with a trend of increased reporting of all levels of suspected PPIs (p < 0.05). Residents surveyed after completion of training showed no difference by decade in types of practice or satisfaction-based metrics (p > 0.05) but reported increasing concerns related to the impact of their profession on their own lifestyle as well as their family's. There was no statistically significant difference in the incidence of serious PPIs over 5 decades of training neurosurgery residents at the authors' institution. During the millennial era, serious PPIs have not been increasing. However, reporting of all levels of PPIs is increasing coincident with the ease of electronic reporting. There was remarkably little variance in satisfaction metrics or type of practice over the 5 decades studied.

Standardizing the Care of Acute Severe Ulcerative Colitis Inpatients at an Inflammatory Bowel Disease Referral Hospital

Patients who present with acute severe ulcerative colitis (ASUC) are at high risk for short-term colectomy. Despite consensus guidelines on the management of inpatient ASUC, variations in practice exist that can delay time-sensitive therapy. The variability in practice patterns at our institution has previously been published. The aim of this project is to implement a standardized care pathway for patients who present with ASUC, leveraging our EMR to decrease time to IV steroid and infliximab administration with the goal of decreasing colectomy rate and length of stay. Process mapping was used to evaluate current institutional ASUC care and to identify variation and delays in care. AGA, ACG, ECCO, and Toronto consensus guidelines were used to critically evaluate the process map. Causal factor analysis was used to identify the root cause of delays. Stakeholder meetings were held with gastroenterology, Emergency Department (ED), nursing, and colorectal surgery leadership. An ED Severe Ulcerative Colitis Order Set was designed and implemented, featuring 6 time-sensitive orders to initiate the pathway (see Figure). Review of 10 baseline pre-intervention charts and all 19 post-intervention charts focused on the following outcomes: (a) C. Diff ordering in ED, (b) time to C. Diff order, (c) time to C. diff collection, (d) C Diff collection in ED, (e) abdominal x-ray in ED, (f) time to IV steroids, (g) time to infliximab (f) hospital length of stay. Chi-squared test was used to determine significance for binary data. Mann-Whitney test was used for non-parametric time data. With use of the ED order set, time to C. Diff ordering and time to infliximab administration were significantly reduced (2.9 hours to 1 hour, P=0.02 and 111 hours to 57.5 hours, P=0.004 respectively). Post-intervention, there were non-significant trends towards improvement in the ordering and successful collection of C. Diff stool, time to C. Diff stool collection, completion of abdominal X-rays and decrease in hospital length of stay (see Table). The care processes for patients with ASUC were critically evaluated using process mapping and causal factor analysis. A successful Epic based Order Set was implemented in the ED with significant improvement in the rapidity of ordering C. Diff testing and decreased time to infliximab administration. Current efforts are focused on implementation of an inpatient admission order set. Future outcomes of interest include colectomy rate and time to colectomy.TablePre-InterventionPost-InterventionP-ValueC Diff Ordered in ED8 of 10= 80%19 of 19= 100%P=0.05Time Until C Diff Ordered (Median)2.9 hours1 hourP=0.02Time Until C Diff Collected (Median)7.9 hours5.7 hoursP=0.25# of C Diff Collected in ED3 of 8 = 38%14 of 19 = 74%P=0.08Abdominal X-rays done in ED5 of 10 = 50%16 of 19 = 84%P=0.06Time to IV Steroids (Median)6.6 hours10.8 hoursP=0.80Time to Infliximab (Median)111.6 hours57.5 hoursP=0.004Length of Stay for Patients Receiving Infliximab (Median)163.5 hours137.9 hoursP=0.18 Open table in a new tab