Variation In Practice Patterns Research Articles

Low grade serous ovarian carcinoma: identifying variations in practice patterns.

Low grade serous ovarian carcinoma is a rare subtype of ovarian cancer with an indolent and chemorefractory course. As such, treatment strategies among practitioners are not uniformly known. The primary objective of this study was to identify differences in practice patterns among physicians who treat low grade serous carcinoma. A de novo survey was distributed to members of the Society of Gynecologic Oncology. Questions about demographics, management of primary and recurrent disease, and use of consolidation therapy were included. Statistical analyses were performed using χ2 and Fisher's exact tests. 194 gynecologic oncologists completed the survey. Approximately two-thirds of respondents practiced in a university based setting and treated a high volume of ovarian cancers, including low grade serous carcinoma. 82% recommended somatic testing during treatment and 84% routinely sent patients for genetic counseling. Treatment preferences for primary disease varied by debulking status. 48% of practitioners used hormone antagonism as consolidation after primary treatment. Secondary cytoreduction was preferred for patients with platinum sensitive recurrence and a long disease free interval following primary treatment (P<0.001). Hormone antagonism was the preferred treatment for the first platinum resistant recurrence (54%), while a BRAF inhibitor was the preferred agent in platinum resistant recurrence in the presence of a known BRAF mutation (56%). There was significant variation in the preferred management of low grade serous carcinoma among practitioners. Further efforts to improve knowledge of this disease, identify optimal treatment modalities, and provide guidelines for management should be encouraged.

Fiducial marker placement with electromagnetic navigation bronchoscopy: a subgroup analysis of the prospective, multicenter NAVIGATE study.

Background:Fiducial markers (FMs) help direct stereotactic body radiation therapy (SBRT) and localization for surgical resection in lung cancer management. We report the safety, accuracy, and practice patterns of FM placement utilizing electromagnetic navigation bronchoscopy (ENB).Methods:NAVIGATE is a global, prospective, multicenter, observational cohort study of ENB using the superDimension™ navigation system. This prospectively collected subgroup analysis presents the patient demographics, procedural characteristics, and 1-month outcomes in patients undergoing ENB-guided FM placement. Follow up through 24 months is ongoing.Results:Two-hundred fifty-eight patients from 21 centers in the United States were included. General anesthesia was used in 68.2%. Lesion location was confirmed by radial endobronchial ultrasound in 34.5% of procedures. The median ENB procedure time was 31.0 min. Concurrent lung lesion biopsy was conducted in 82.6% (213/258) of patients. A mean of 2.2 ± 1.7 FMs (median 1.0 FMs) were placed per patient and 99.2% were accurately positioned based on subjective operator assessment. Follow-up imaging showed that 94.1% (239/254) of markers remained in place. The procedure-related pneumothorax rate was 5.4% (14/258) overall and 3.1% (8/258) grade ⩾ 2 based on the Common Terminology Criteria for Adverse Events scale. The procedure-related grade ⩾ 4 respiratory failure rate was 1.6% (4/258). There were no bronchopulmonary hemorrhages.Conclusion:ENB is an accurate and versatile tool to place FMs for SBRT and localization for surgical resection with low complication rates. The ability to perform a biopsy safely in the same procedure can also increase efficiency. The impact of practice pattern variations on therapeutic effectiveness requires further study.Trial registration:ClinicalTrials.gov identifier: NCT02410837.

Treatment of vaginal vault prolapse in The Netherlands: a clinical practice survey.

A great variety of conservative and surgical procedures to correct vaginal vault prolapse have been reported. The aim of this study was to describe practice pattern variation-the difference in care that cannot be explained by the underlying medical condition-among Dutch gynecologists regarding treatment of vaginal vault prolapse. A clinical practice survey was conducted from March to April 2017. The questionnaire was developed to evaluate treatment of vaginal vault prolapse. All members of the Dutch Society for Urogynaecology were invited to participate in a web-based survey. One hundred four Dutch gynecologists with special interest in urogynecology responded to the survey (response rate, 44%). As first-choice therapy for vaginal vault prolapse, 78% of the respondents chose pessary treatment, whereas sacrospinous fixation was the second most common therapy choice according to 64% of the respondents. Preferences on how to approach vaginal vault prolapse surgically are conflicting. Overall, the most performed surgery for vaginal vault prolapse is sacrospinous fixation, followed by laparoscopic and robotic sacrocolpopexy. Gynecologists in The Netherlands manage vaginal vault prolapse very differently. No standardized method could be determined for the treatment of vaginal vault prolapse in The Netherlands, and we observed practice pattern variations.

Large variations in the practice patterns of surgical antiseptic preparation solutions in patients with open and closed extremity fractures: a cross-sectional survey

BackgroundSurgically-managed fractures, particularly open fractures, are associated with high rates of surgical site infections (SSIs). To reduce the risk of an SSI, orthopaedic surgeons routinely clean open fracture wounds in the emergency department (ED) and then apply a bandage to the open wound. Prior to the surgical incision, it is standard practice to prepare the fracture region with an antiseptic skin solution as an additional SSI prevention strategy. Multiple antiseptic solutions are available.ObjectivesTo explore the variation in practice patterns among orthopaedic surgeons regarding antiseptic solution use in the ED and antiseptic preparatory techniques for fracture surgery.MethodsWe developed a 27-item survey and surveyed members of several orthopaedic associations.ResultsTwo hundred and-ten surveys were completed. 71.0% of respondents irrigate the open wound and skin in the ED, primarily with saline alone (59.7%) or iodine-based solutions (32.9%). 90.5% of responders indicated that they dress the open wound in the ED, with 41.0% applying a saline-soaked bandage and 33.7% applying an iodine-soaked dressing (33.7%). In their surgical preparation of open fractures, 41.0% of respondents used an iodine-based solution, 26.7% used a chlorhexidine gluconate (CHG)-based solution, and 31.4% used a combination of the two. In closed fractures, 43.8% of respondents used a CHG-based solution, 28.1% used an iodine-based solution, and 27.1% used a combination. Despite theoretical concerns about the use of alcohol in open wounds, 51.4% used alcohol-based solutions or alcohol alone during skin preparation of open fractures.ConclusionsA lack of consensus exists regarding use of antiseptic surgical preparation solutions for fractures. High-quality clinical research is needed to assess the effectiveness of different surgical antiseptic preparation solutions on patient outcomes in fracture populations.

Pneumocystis jirovecii prophylaxis in patients treated for high-grade gliomas: a survey among neuro-oncologists.

Pneumocystis jirovecii pneumonia (PJP) is a known complication in patients with high-grade gliomas (HGGs) who are treated with radiation and chemotherapy. PJP prophylaxis is commonly recommended, but there are currently no clear guidelines regarding duration of treatment and choice of drugs. This study aimed to assess current practice patterns of PJP prophylaxis among neuro-oncologists. An online survey of 14 multiple choice questions was sent to 207 neuro-oncologists and medical oncologists treating brain cancers at all National Cancer Institute-designated cancer centers in the United States. Recipients were identified via a search of the cancer centers' websites. Sixty-one invited experts completed the survey (response rate 29%; of these, 72% were neuro-oncologists, 18% were medical oncologists, and 10% were pediatric neuro- or medical oncologists). Seventy percent of respondents stated that they routinely prescribe PJP prophylaxis, while 7% do not provide prophylaxis. Eighty-one percent of respondents use absolute lymphocyte count (ALC) to assess lymphopenia and 13% also monitor CD4 lymphocyte counts during prophylaxis. The most commonly used first-line agent is trimethoprim-sulfamethoxazole (88% of respondents), followed by pentamidine (6%). Discontinuation of PJP prophylaxis is determined by the following: count recovery (33% by ALC; 18% by CD4 lymphocyte counts), radiation completion (23%), and chemotherapy completion (7%). Glucose-6-phosphate dehydrogenase levels were routinely checked by only 13% of respondents. PJP prophylaxis is commonly used in HGG patients, but there are large variations in practice patterns, including the duration of prophylaxis. As consideration for PJP prophylaxis affects all patients with HGG, standardization of prophylaxis should be formally addressed.

1636. Variation in Clinical Practice Patterns Among Infectious Diseases Faculty at a Large Academic Institution

BackgroundClinical practice patterns vary between providers, but few studies have examined this variation among infectious disease (ID) physicians. Characterizing these differences in practice can help identify areas where targeted educational interventions or further research are needed to improve clinical decision-making. We describe a faculty survey conducted at our institution designed to identify clinical practice variation within a large academic ID division.MethodsIn January 2017, an electronic survey was distributed to all clinical ID faculty at our institution. The survey collected baseline demographic information as well as responses to 28 common clinical dilemmas encountered in routine practice. Descriptive statistics were performed.ResultsTwenty-four (44%) of 54 active clinical ID faculty (12 assistant professors, 6 associate professors, and 6 professors) completed the survey. Examples of clinical dilemmas with >80% agreement among faculty included: (1) S. aureus bacteremia should be a mandatory ID consult (88%) and (2) lumbar puncture should be performed for all patients with suspected ocular syphilis (88%). The majority of clinical dilemmas had less than 80% agreement, and these spanned the range of routine ID practice. Examples included: (1) use of ceftriaxone for outpatient antibiotic therapy for nonbacteremic invasive methicillin-susceptible S. aureus infections (58% agree), (2) length of treatment for guideline-defined uncomplicated S. aureus bacteremia (50% 2 weeks, 50% 4 weeks), (3) use of fixed-dose dolutegravir/abacavir/lamivudine as a single-drug regimen for an HIV-infected patient with an M184V mutation (42% agree), and (4) benefit of routine anal Pap smears among HIV-infected men who have sex with men (50% agree).ConclusionPractice patterns vary between ID physicians within our institution, particularly for clinical dilemmas for which there is insufficient or conflicting published data. Further studies to examine practice pattern variation among ID physicians across institutions and geographic regions could identify areas where further research or educational interventions are needed to enhance clinical care.Disclosures All authors: No reported disclosures.

The Clinical Significance of Crohn Disease Activity at Resection Margins.

Conflicting data about the clinical significance of microscopic Crohn disease (CD) activity at resection margins have led to varying practice patterns for routine reporting by pathologists. To characterize the association between active disease at resection margins with postoperative CD recurrence and time-to-recurrence in the era of anti-tumor necrosis factor therapy. We performed a multicenter retrospective cohort study of 101 consecutive CD bowel resections during 10 years. Margin slides were reviewed, and CD activity at the margins was graded as none, mild, moderate, or severe. The association between microscopic CD activity at the margin with postoperative recurrence and time-to-recurrence were evaluated with logistic regression and Cox regression analyses, respectively. Crohn disease activity at resection margins was reported in 43% of pathology reports. Resection margins had CD involvement in 39.6% of cases, 20 of which were classified as mild, 6 as moderate, and 12 with severe CD activity. Although patients with mild (odds ratio, 1.14; 95% CI, 0.40-3.20) and moderate to severe (odds ratio, 1.97; 95% CI, 0.62-6.35) activity were at increased risk of disease recurrence, the differences were not statistically significant. Patients with mild (hazard ratio, 0.97; 95% CI, 0.50-1.91) and moderate to severe (hazard ratio, 1.29; 95% CI, 0.65-2.55) disease activity at margins did not have significantly different time-to-recurrence compared with those without disease activity. Our study suggests CD activity at resection margins is not significantly associated with postoperative CD recurrence.

Practice Variation in Umbilical Hernia Repair Demonstrates a Need for Best Practice Guidelines

To evaluate and better understand variations in practice patterns, we analyzed ambulatory surgery claims data from 3 demographically diverse states to assess the relationship between age at umbilical hernia repair and patient, hospital, and geographic characteristics. We performed a cross-sectional descriptive study of uncomplicated hernia repairs performed as a single procedure in 2012-2014, using the State Ambulatory Surgery and Services Database for Wisconsin, New York, and Florida. Age and demographic characteristics of umbilical hernia repair patients are described. The State Ambulatory Surgery and Services Database analysis included 6551 patients. Across 3 states, 8.2% of hernia repairs were performed in children <2 years, 18.7% in children age 2-3 years, and 73.0% in children age ≥4 years, but there was significant variability (P < .001) in practice patterns by state. In regression analysis, race, Medicaid insurance and rural residence were predictive of early repair, with African American patients less likely to have a repair before age 2 (OR 0.62, P = .046) and rural children (OR 1.53, P = .009) and Medicaid patients (OR 2.01, P < .001) more likely to do so. State of residence predicted early repair even when holding these variables constant. The age of pediatric umbilical hernia repair varies widely. As hernias may resolve over time and can be safely monitored with watchful waiting, formal guidelines are needed to support delayed repair and prevent unnecessary operations.

Treatment strategies and clinical outcomes of locally advanced pancreatic cancer patients treated at high-volume facilities and academic centers

PurposeLocally advanced pancreatic cancer (LAPC) treatment has varying practice patterns with poor outcomes. We investigated treatment using single-agent chemotherapy and multiagent chemotherapy (MAC) with or without radiation therapy (RT) at high-volume facilities (HVFs) and academic centers (ACs). Methods and MaterialsThe National Cancer Database was used to obtain data on 10,139 patients with LAPC. HVF was defined as the top 5% of facilities per number of patients treated at each facility. Univariate and multivariable (MVA) analysis Cox regressions were performed to identify the impact of HVF, AC, MAC, and RT on overall survival (OS). ResultsThe median age of patients was 66 years (range, 22-90); 50.1% were male and 49.9% female. Of the patients, 46.1% received MAC, 53.8% received single-agent chemotherapy, 45.7% received RT, 54.3% did not receive RT, and 5% underwent surgical resection. The median follow-up was 48.8 months. On MVA, treatment at HVFs and ACs remained significantly associated with improved OS, with a hazard ratio (HR) of 0.84 (P < .001) and 0.94 (P = .004), respectively. The median OS for HVF treatment compared with low-volume facilities was 14.3 versus 11.2 months, respectively (P < .001). The median OS for AC treatment versus non-AC was 12.1 versus 10.8 months, respectively (P < .001). Additionally, on MVA, receipt of RT and MAC remained significantly associated with improved OS (HR: 0.76; P < .001; and HR: 0.73; P < .001, respectively). MVA for receipt of surgery showed that MAC is a significant predictor for receiving surgery (odds ratio: 1.29; P = .009). ConclusionsOur results build on a growing literature supporting RT and MAC in treating LAPC. Additionally, we believe that—in the absence of prospective data—this makes a strong case for considering MAC with RT at ACs and HVFs for treating LAPC.

Technique Failure in a Multicenter Canadian Home Hemodialysis Cohort

Increasing uptake of home hemodialysis (HD) has led to interest in characteristics that predict discontinuation of home HD therapy for reasons other than death or transplantation. Recent reports of practice pattern variability led to the hypothesis that there are patient- and center-specific factors that influence these discontinuations. Retrospective cohort study. Incident home HD patients at 7 centers in Canada between 2000 and2010. Treatment center, case-mix, and process-of-care variables. Technique failure (defined as discontinuation of home HD therapy for any reason other than training failure, death, or transplantation) and mortality. Regression modeling of technique failure using Cox proportional hazard models adjusting for treatment center and modifiable and nonmodifiable patient-level variables, censored for death and transplantation. The cohort consisted of 579 patients. Mean age was 49.9±14.1 years, 74% were of European ancestry, median dialysis vintage was 1.9 (IQR, 0.6-5.2) years, and 68% used an arteriovenous access. Mean duration of dialysis was 31.2±12.6 hours per week. Unadjusted 1- and 2-year technique survival and overall survival were 90% and 83% and 94% and 87%, respectively. Treating center was a strong predictor of technique failure and mortality, with HRs ranging from 0.37 to 5.11 for technique failure (1 of 6 centers with P<0.05 relative to the reference) and 0.17 to 8.73 for mortality (3 of 6 centers with P<0.05 relative to the reference). With baseline adjustment for center, only older age and more than 3 treatments per week remained significant predictors of technique failure, while no individual-level variables remained as significant predictors of survival. Limited statistical power. Home HD treating centers may influence technique failure and patient mortality independent of case-mix. The relationship between processes of care and patient outcomes requires further investigation.

A Canadian national survey: understanding the differences in management of cryptorchidism among pediatric surgeons and pediatric urologists

BackgroundThis investigation aims to assess the variability in practice patterns regarding management of children with cryptorchidism (UDT) among pediatric urologists (U) and pediatric surgeons (S) practicing in Canada. MethodsAll active members of Pediatric Urologists of Canada (PUC) and Canadian Association of Pediatric Surgery (CAPS) were invited to participate in an online multiple-choice type questionnaire with clinical scenarios in management of UDT. Responses were compared between U and S using Fisher's exact test. ResultsThe response rates were 74% and 79% among CAPS members (54/73) and PUC members (27/34) respectively. CAPS members were more likely to order diagnostic ultrasounds prior to surgery (44.4% vs 18.5%, p = 0.027). For palpable testis, most (80%) CAPS members favored the classic inguinal approach, while most PUC members did not demonstrate a clear preference, and were flexible with their approach depending on the position of the palpated testes (55%; p < 0.001). There was no statistically significant difference in preferred approach to unilateral or bilateral nonpalpable testis. However, for both palpable and nonpalpable bilateral UDT, more CAPS members preferred metachronous correction, compared to PUC members who opted to approach them synchronously (p = 0.008, 0.002, respectively). ConclusionPreferences with regard to use of diagnostic tools such as US, surgical approach for palpable testes and bilateral UDTs were not consistent between the two surgical specialties who perform orchidopexy across Canada. Both groups were compliant with guideline recommendations, with the exception of utilizing preoperative ultrasounds, which is uniformly not recommended by the most recent guidelines. Level of evidenceThis is a level II evidence study.

Practice Pattern Variation in Test Ordering for Low-Acuity Pediatric Emergency Department Patients.

Rising costs in healthcare have focused attention on interventions to optimize efficiency of patient care, including decreasing unnecessary diagnostic testing. The primary objective of this study was to determine the variability of laboratory and radiology testing among licensed independent providers (LIPs) with different training backgrounds treating low-acuity patients in a pediatric emergency department (PED). We performed a retrospective review of the electronic health records of all encounters with patients 21 years or younger, triaged as low-acuity, visiting 2 urban, academic PEDs from January 2012 to December 2013. We calculated frequency of orders for specific tests, including complete blood counts, aerobic blood cultures, urine cultures, and chest radiographs. Bivariable analyses were used to measure associations of test ordering between these LIP dyad groups: physician versus nurse practitioner (NP); physicians with pediatric emergency medicine fellowship training (PEM) versus physicians without PEM training and physicians with at least 5 years since residency graduation versus less than 5 years. We used multivariable logistic regression to adjust for potential confounders, including ED location, trainee co-management, and patient characteristics. We also performed sensitivity analyses by location. There were 148,570 total encounters treated by 12 NPs and 144 physicians, of whom 60 were PEM physicians. Seventy-three physicians had 5 or more years of experience. Testing rates per patient encounter ranged from 0% to 40% for individual providers. In bivariable analyses, testing was more likely when the LIP was a physician (odds ratio [OR] = 1.2, 95% confidence interval = 1.1-1.2) or PEM trained (OR = 1.3, 1.2-1.3). In multivariable analyses, testing was more likely for encounters with PEM providers (adjusted OR [AdjOR] = 1.2, 1.1-1.3). A sensitivity analysis on a subset of encounters seen exclusively at our PED-based urgent care revealed that testing was also more likely for encounters seen by PEM physicians (AdjOR = 1.5, 1.4-1.7) and with NPs (AdjOR = 1.2, 1.1-1.4) compared with physicians. Our study identified substantial variation in test ordering patterns for LIPs treating low-acuity patients. There were significant differences in ordering practices between providers from different training backgrounds, most significantly when comparing PEM with non-PEM providers. Further research should examine interventions to standardize practice across disciplines.

High-Flow Nasal Cannula Practice Patterns Reported by Neonatologists and Neonatal Nurse Practitioners in the United States.

High-flow nasal cannula (HFNC) is widely used to treat neonatal respiratory conditions. Significant evidence emerged in recent years to guide practice, yet current practice patterns and their alignment with the evidence remain unknown. To examine current HFNC practice patterns and availability of clinical practice guidelines used in neonatal intensive care units in the United States. A nonexperimental, descriptive study was designed using a web-based survey to elicit a convenience sample of US neonatal providers. Quantitative data were analyzed using descriptive statistics, χ tests were used to test for differences among the categories, and post hoc comparisons among each combination of categories were conducted using a Bonferroni-corrected α of .05 to determine significance as appropriate. A total of 947 responses were analyzed (626 neonatologists and 321 neonatal nurse practitioners). Univariate analyses suggested wide variations in practice patterns. One-third of the respondents used clinical guidelines, the majority utilized HFNC devices in conjunction with nasal continuous positive airway pressure, more than two-thirds used HFNC as a primary respiratory support treatment, and among all respondents, significant differences related to HFNC device types were reported. US providers revealed wide practice variations related to HFNC therapy. In addition, type of device used appears to impact practice patterns and approaches. Use of standardized guidelines was reported by one third of the respondents, and as such may be the contributing factor for wide practice variations. Future Research is needed to target aspects of practice where practice variations exist, or practice is not supported by evidence. Significant practice differences related to the device types should be considered in future research design.

Comparing Current Practice Patterns and Practice Guidelines for the Diagnosis and Management of Eosinophilic Esophagitis in the United States

Introduction: While guidelines exist for the diagnosis and management of EoE, the current real-world practice patterns among gastroenterologists are not well-described. The aim is to assess practice patterns of EoE diagnosis and management among gastroenterologists in the United States and whether practice is concordant with EoE consensus guidelines. Methods: We conducted a cross-sectional online survey of academic and community gastroenterologists in the United States. The survey was designed using QualtricsTM and comprised of 35 questions over four categories: EoE symptoms & endoscopic findings, EoE diagnosis, EoE treatment, and respondent characteristics. The survey was dispersed through the North Carolina Society of Gastroenterology (NCSG) and American College of Gastroenterology (ACG) member listserves. A similar survey was sent to NCSG members in 2010 and responses were compared in a sub-analysis. Results: Of 240 respondents, 239 (99.6%) reported having cared for a EoE patient, 37% (n=80) worked in a community practice, and 63% (n=138) in an academic setting. Providers saw a median of 18 (IQR 2-100) EoE patients per month. Of the group, 24% (n=52) reported being “very familiar” with EoE consensus guidelines. A proton-pump inhibitor (PPI) trial was required by only 37% of providers prior to making a definitive EoE diagnosis (Figure). 60% used a ≥15 eos/hpf cut-point for EoE diagnosis and 62% biopsied from the proximal and distal esophagus on initial exam. Only 12% (n=28) followed guideline recommendations for EoE diagnosis. For first-line treatment, 7% used dietary therapy, 32% used topical steroids, and 61% used PPIs; 67% used fluticasone as first-line steroid; 41% used maintenance steroid treatment in responders. 63% dilated critical/symptomatic strictures and 54% used balloon dilation. There were significant differences in practice patterns between those working in academic vs. community settings in EoE diagnosis and treatment (Table 1). In the NCSG cohort, a higher proportion in 2017 followed guideline recommendations for diagnosis compared to 2010 (14% vs. 3%; p=0.03) and used dietary therapy as first-line treatment (13% vs 3%; p=0.046) (Table 2). Conclusion: There is variability in practice patterns for both diagnosis and treatment of EoE that differ from consensus guidelines, and between gastroenterologists practicing in academic versus community practices. Further education and guideline dissemination is needed to standardize practice for EoE.376_A Figure 1 No Caption available.376_B Figure 2 No Caption available.376_C Figure 3 No Caption available.

Geographic variation in surgical practice patterns and outcomes for resected nonmetastatic gastric cancer in Ontario.

Gastrectomy with negative resection margins and adequate lymph node dissection is the cornerstone of curative treatment for gastric cancer (gc). However, gastrectomy is a complex and invasive operation with significant morbidity and mortality. Little is known about surgical practice patterns or short- and long-term outcomes in early-stage gc in Canada. We undertook a population-based retrospective cohort study of patients with gc diagnosed between 1 April 2005 and 31 March 2008. Chart review provided clinical and operative details such as disease stage, primary tumour location, surgical approach, operation, lymph nodes, and resection margins. Administrative data provided patient demographics, geography, and vital status. Variations in treatment and outcomes were compared for 14 local health integration networks. Descriptive statistics and log-rank tests were used to examine geographic variation. We identified 722 patients with nonmetastatic resected gc. We documented significant provincial variation in case mix, including primary tumour location, stage at diagnosis, and tumour grade. Short-term surgical outcomes varied across the province. The percentage of patients with 15 or fewer lymph nodes removed and examined varied from 41.8% to 73.8% (p = 0.02), and the rate of positive surgical margins ranged from 15.2% to 50.0% (p = 0.002). The 30-day surgical mortality rates did not vary statistically significantly across the province (p = 0.13); however, rates ranged from 0% to 16.7%. Overall 5-year survival was 44% and ranged from 31% to 55% across the province. This cohort of patients with resected stages i-iii gc is the largest analyzed in Canada, providing important historical information about treatment outcomes. Understanding the causes of regional variation will support interventions aiming to improve gc operative outcomes in the cancer system.

Assessing practice pattern differences in the treatment of acute low back pain in the United States Military Health System

BackgroundAcute low back pain is one of the most common reasons for individuals to seek medical care in the United States. The US Military Health System provides medical care to approximately 9.4 million beneficiaries annually. These patients also routinely suffer from acute low back pain. Within this health system, patients can receive care and treatment from physicians, or physician extenders including physician assistants and nurse practitioners. Given the diversity of provider types and their respective training programs, it would be informative to evaluate variation in care delivery, adherence to clinical guidelines, and differences within the MHS among a complex mix of provider types.MethodsThis study was a retrospective, cross-sectional quantitative analysis that examined variations in treatment between provider types within the Military Health System in 2015 for treatment of acute low back pain using administrative data. In addition to descriptive and summary statistics, binomial logistic regression models were used to assess variation in practice patterns among physicians and mid-level practitioners for prescribing of non-steroidal anti-inflammatory, opioids, plain radiography, computed tomography, and magnetic resonance imaging.ResultsWith regard to prescribing practices, results indicated that the odds of receiving non-steroidal anti-inflammatory prescriptions increased significantly for both physician assistants and nurse practitioners when compared to physicians. For basic radiological referrals, odds increased significantly for ordering plain radiography for physician assistants and nurse practitioners when compared to physicians. For more advanced imaging, odds significantly decreased for ordering computed tomography (CT) and slightly decreased for magnetic resonance for physician assistants, nurse practitioners and physician residents compared to the physician group. Additionally this study discovered differences in the prescribing patterns between provider categories. Both contractors and civilians had higher odds of prescribing opioids compared to active duty providers.ConclusionsAs physician assistants and nurse practitioners continue to gain popularity as physician extenders in the US and in addressing provider shortages for the Military Health System, further research should be conducted to determine what impact, if any, the differences found in this study have on patient outcomes. In addition, provider type warrants further investigation to determine if labor mix and outsourcing decisions within a single payer system impacts health delivery and value based care.

The directed sperm donor: an SREI study of physician attitudes and practice pattern variations

The directed sperm donor: an SREI study of physician attitudes and practice pattern variations

Enhanced Recovery After Surgery in Community Hospitals.

Multidisciplinary collaboration and administrative support are essential to enhanced recovery program (ERP) success. The key tenets for ERP are opiate-sparing pain regimen, decreased fasting, and minimizing intravenous fluids. Getting buy-in from community surgeons may be difficult due to varied practice patterns and clinical fragmentation. Prospective tracking of ERP outcomes will allow for more targeted interventions.

Practice Pattern Variation in the Use of Transesophageal Echocardiography for Open Valve Cardiac Surgery

The authors sought to assess for the presence of practice variation in the use of intraoperative transesophageal echocardiography (TEE) for open cardiac valve surgery. This study was a retrospective cohort analysis. The administrative claims data used for this investigation were multi-institutional and a representative sample of commercially insured patients in the United States between 2010 and 2015. The cohort consisted of adult patients, aged 18 years or older, undergoing open mitral valve (MV) or aortic valve (AV) surgery. This was an observational analysis without interventions. Of 19,386 valve surgeries, 12,313 (64%) underwent AV replacement, 6,192 (32%) underwent MV repair or replacement, and 881 (<5%) underwent both MV and AV surgery. The overall rate of intraoperative TEE was 82% (95% confidence interval [CI]: 81%-82%), less frequently observed in AV procedures compared to MV or combined MV-AV procedures (80% v 85%, p < 0.001). Rates of intraoperative TEE claims varied markedly across U.S. states. After adjustment, the relative odds of an intraoperative TEE claim ranged across states from 0.26 (Louisiana, 95% CI: 0.18-0.36; p < 0.001) to 2.10 (North Carolina, 95% CI: 1.57-2.82; p < 0.001). Among adult patients undergoing open AV or MV surgery in the United States, 82% had a claim for an intraoperative TEE with marked variability across U.S. states. Increasing adherence to intraoperative TEE guidelines for valve surgery may represent an unrecognized opportunity to improve the quality of cardiac surgical care.

Pediatric Vascular Surgical Practice Patterns

Vascular surgeons infrequently care for pediatric patients. As such, variability in operative management and available hospital resources at free-standing children's hospitals (CHs) may exist. The study aims were (1) to determine vascular surgeon comfort level with pediatric vascular surgery and (2) to determine variations in pediatric vascular surgery practice patterns. A survey composed of clinical vignettes emailed to all members of Vascular and Endovascular Surgery Society was designed to assess operative management of pediatric vascular conditions and hospital resources. Comparisons of surgeon satisfaction between free-standing CHs and a CH within an adult general hospital were made using Wilcoxon rank-sum tests. Comparison of surgeon comfort between hospital types was made using a McNemar's test. P-values less than or equal to 0.05 indicated statistical significance. Response rate was 18% (93/525) with 96% (89/93) indicating completion of a 2year vascular fellowship. Surgeon satisfaction with operative equipment (P=0.002), support staff (P<0.001), and vascular laboratory availability (P=0.01) was significantly lower at CHs. Eighty-seven percent of surgeons operated on fewer than 2 children over the preceding 3 months. For the different clinical vignettes, there was a wide variation in practice patterns with a range of 50-89% of the surgeons performing fewer than 5 cases over the preceding 10 years. There was a significant decrease in surgeon's comfort level with elective pediatric vascular operations compared to the operative management of pediatric vascular trauma (P=0.0025). Most vascular surgeons do not feel comfortable in the operative management of pediatric vascular disease, and optimal resource availability within pediatric CHs may be lacking. Centralized care of this patient population may be warranted.