Variation In Practice Patterns Research Articles

Local regional management of the axilla after positive sentinel node biopsy in breast cancer patients clinically downstaged with neoadjuvant therapy: A population-based, real-world analysis.

e12578 Background: The optimal local regional management of the positive axilla in patients who convert to clinical negative nodal status after neoadjuvant chemotherapy (NAC) remains unclear. Specifically, the benefit of completion axillary node dissection (cALND) remains in question, particularly given the associated morbidity. With results of the A11202 trial pending, we noted regional variation in the management of the axilla in this population. We therefore aimed to describe the current management of women with positive SNB after NAC, describe recurrence patterns and identify predictors of cALND in a large, population-based, real-world setting. Methods: We identified all patients who had biopsy-proven nodal disease on presentation, underwent NAC and were then clinically downstaged allowing SNB as part of their index surgery from our Synoptec provincial operative database, from January 2016 to September 2021. Pre and post NAC tumour characteristics, patient demographics, treatments and final pathology were abstracted and conveyed using descriptive statistics. Primary outcome measures were treatment with cALND and recurrence. A Cox regression model was utilized to determine predictors of both outcomes. Results: A total of 850 patients had biopsy-proven axillary disease at presentation and subsequently underwent NAC. Of these, 364 patients converted to clinically-negative node status and had a SNB, of which 175 (48%) had persistent nodal disease. Median age of this group was 50 (IQR 43-60) and 143 patients (81.7%) were treated by a high-volume breast surgeon. Most patients had clinical T1/2 tumours (73.1%) before NAC, of which 21.1% were HER2 positive, and 12.6% were triple-negative. Post NAC, 95 patients (54.3%) underwent mastectomy. A total of 39/175 patients (22.3%) underwent a cALND. Median number of sentinel nodes was 4 (IQR 3, 5); the proportion of positive sentinel nodes did not differ in those who had cALND (0.59 vs. 0.59, p = 0.95). Almost all patients (96.6%) had regional radiation. After a median of 17 months of follow-up, 33 (18.8%) SNB positive patients recurred; the majority (29 (87.9%)) had a distant recurrence, 3 (9.1%) had an isolated local breast/chest wall recurrence, and only 1 (3.0%) had an isolated regional recurrence. As far as local control, in patients with any regional recurrence, 4/7 (57.1%) had undergone cALND. Treatment site was the only significant predictor of cALND on multivariable analysis. Predictors of recurrence were low BMI, triple-negative status and clinical T3/4 disease before NAC. Conclusions: The lack of definitive data for patients with persistent pathologic nodal disease after NAC has led to variable practice patterns, with lower than expected rates of cALND. Within our cohort, there was not a significant association between omission of cALND and regional recurrence.

A Clinical Severity Index for Eosinophilic Esophagitis: Development, Consensus, and Future Directions

Disease activity and severity of eosinophilic esophagitis (EoE) dictate therapeutic options and management, but the decision-making process for determining severity varies among practitioners. To reduce variability in practice patterns and help clinicians monitor the clinical course of the disease in an office setting, we aimed to create an international consensus severity scoring index for EoE. A multidisciplinary international group of adult and pediatric EoE researchers and clinicians, as well as non-EoE allergy immunology and gastroenterology experts, formed 3 teams to review the existing literature on histology, endoscopy, and symptoms of EoE in the context of progression and severity. A steering committee convened a 1-day virtual meeting to reach consensus on each team's opinion on salient features of severity across key clinicopathologic domains and distill features that would allow providers to categorize disease severity. Symptom features and complications and inflammatory and fibrostenotic features on both endoscopic and histologic examination were collated into a simplified scoring system-the Index of Severity for Eosinophilic Esophagitis (I-SEE)-that can be completed at routine clinic visits to assess disease severity using a point scale of 0-6 for mild, 7-14 for moderate, and ≥15 for severe EoE. A multidisciplinary team of experts iteratively created a clinically usable EoE severity scoring system denominated "I-SEE" to guide practitioners in EoE management by standardizing disease components reflecting disease severity beyond eosinophil counts. I-SEE should be validated and refined using data from future clinical trials and routine clinical practice to increase its utilization and functionality.

A Clinical Severity Index for Eosinophilic Esophagitis: Development, Consensus, and Future Directions

Disease activity and severity of eosinophilic esophagitis (EoE) dictate therapeutic options and management, but the decision-making process for determining severity varies among practitioners. To reduce variability in practice patterns and help clinicians monitor the clinical course of the disease in an office setting, we aimed to create an international consensus severity scoring index for EoE. A multidisciplinary international group of adult and pediatric EoE researchers and clinicians, as well as non-EoE allergy immunology and gastroenterology experts, formed 3 teams to review the existing literature on histology, endoscopy, and symptoms of EoE in the context of progression and severity. Asteering committee convened a 1-day virtual meeting to reach consensus on each team's opinion on salient features of severity across key clinicopathologic domains and distill features that would allow providers to categorize disease severity. Symptom features and complications and inflammatory and fibrostenotic features on both endoscopic and histologic examination were collated into a simplified scoring system-the Index of Severity for Eosinophilic Esophagitis (I-SEE)-that can be completed at routine clinic visits to assess disease severity using a point scale of 0-6 for mild, 7-14 for moderate, and ≥15 for severe EoE. A multidisciplinary team of experts iteratively created a clinically usable EoE severity scoring system denominated "I-SEE" to guide practitioners in EoE management by standardizing disease components reflecting disease severity beyond eosinophil counts. I-SEE should be validated and refined using data from future clinical trials and routine clinical practice to increase its utilization and functionality.

Lost potential and missed opportunities for DCD liver transplantation in the United States

BackgroundDonation after cardiac death(DCD) has been proposed as an avenue to expand the liver donor pool. MethodsWe examined factors associated with nonrecovery of DCD livers using UNOS data from 2015 to 2019. ResultsThere 265 non-recovered potential(NRP) DCD livers. Blood type AB (7.8% vs. 1.1%) and B (16.9% vs. 9.8%) were more frequent in the NRP versus actual donors (p < 0.001). The median driving time between donor hospital and transplant center was similar for NRP and actual donors (30.1 min vs. 30.0 min; p = 0.689), as was the percentage located within a transplant hospital (20.8% vs. 20.9%; p = 0.984).The donation service area(DSA) of a donor hospital explained 27.9% (p = 0.001) of the variability in whether a DCD liver was recovered. ConclusionA number of potentially high quality DCD donor livers go unrecovered each year, which may be partially explained by donor blood type and variation in regional and DSA level practice patterns.

Department of Defense Trauma Registry Infectious Disease Module Impact on Clinical Practice.

The Joint Trauma System (JTS) is a DoD Center of Excellence for Military Health System trauma care delivery and the DoD's reference body for trauma care in accordance with National Defense Authorization Act for Fiscal Year 2017. Through the JTS, evidence-based clinical practice guidelines (CPGs) have been developed and subsequently refined to standardize and improve combat casualty care. Data are amassed through a single, centralized DoD Trauma Registry to support process improvement measures with specialty modules established as the registry evolved. Herein, we review the implementation of the JTS DoD Trauma Registry specialty Infectious Disease Module and the development of infection-related CPGs and summarize published findings on the subsequent impact of the Infectious Disease Module on combat casualty care clinical practice and guidelines. The DoD Trauma Registry Infectious Disease Module was developed in collaboration with the Infectious Disease Clinical Research Program (IDCRP) Trauma Infectious Disease Outcomes Study (TIDOS). Infection-related information (e.g., syndromes, antibiotic management, and microbiology) were collected from military personnel wounded during deployment June 1, 2009 through December 31, 2014 and medevac'd to Landstuhl Regional Medical Center in Germany before transitioning to participating military hospitals in the USA. To support process improvements and reduce variation in practice patterns, data collected through the Infectious Disease Module have been utilized in TIDOS analyses focused on assessing compliance with post-trauma antibiotic prophylaxis recommendations detailed in JTS CPGs. Analyses examined compliance over three time periods: 6 months, one-year, and 5 years. The five-year analysis demonstrated significantly improved adherence to recommendations following the dissemination of the 2011 JTS CPG, particularly with open fractures (34% compliance compared to 73% in 2013-2014). Due to conflicting recommendations regarding use of expanded Gram-negative coverage with open fractures, infectious outcomes among patients with open fractures who received cefazolin or expanded Gram-negative coverage (cefazolin plus fluoroquinolones and/or aminoglycosides) were also examined in a TIDOS analysis. The lack of a difference in the proportion of osteomyelitis (8% in both groups) and the significantly greater recovery of Gram-negative organisms resistant to aminoglycosides or fluoroquinolones among patients who received expanded Gram-negative coverage supported JTS recommendations regarding the use of cefazolin with open fractures. Following recognition of the outbreak of invasive fungal wound infections (IFIs) among blast casualties injured in Afghanistan, the ID Module was refined to capture data (e.g., fungal culture and histopathology findings, wound necrosis, and antifungal management) needed for the TIDOS team to lead the DoD outbreak investigation. These data captured through the Infectious Disease Module provided support for the development of a JTS CPG for the prevention and management of IFIs, which was later refined based on subsequent TIDOS IFI analyses. To improve combat casualty care outcomes and mitigate high-consequence infections in future conflicts, particularly in the event of prolonged field care, expansion, refinement, and a mechanism for sustainability of the DoD Trauma Registry Infectious Disease Module is needed to include real-time surveillance of infectious disease trends and outcomes.

Variable Practice Patterns and Variation Among Orthopaedic Surgeons Specializing in Pediatric Sports Medicine

Introduction:Pediatric sports medicine is a growing subspecialty within orthopedic surgery. However, there is very limited literature on the practice of pediatric sports medicine in North America.Purpose:To evaluate and describe the current practice patterns of orthopedic surgeons specializing in pediatric sports medicine via survey of PRiSM (Pediatric Research in Sports Medicine Society) members.Methods:An online survey was distributed to orthopaedic surgeons specializing in pediatric sports medicine through PRiSM in April 2021. The survey was designed to (1) characterize respondent demographics (practice focus on pediatric vs. adult, fellowship training, years in practice, location), (2) characterize the breakdown of different joint specialization, and (3) determine the most common procedures across different joints that the respondent specializes in. Specialization was defined as composing ≥ 25% of a respondent’s practice. Commonly operated joints were defined as composing ≥5% of their practice.Results:Responses from 55 orthopedic surgeons were collected and analyzed. The majority of respondents considered pediatric sports medicine as the primary focus of their practice (89.1%, n=49/55). The number of fellowships completed was almost evenly split between either a single fellowship (52.7%, 29/55) or two or more (47.3%, 26/55). The most common combination of fellowships was pediatric orthopaedics and adult sports medicine (32.7%, 18/55). The majority of survey respondents have been in practice for <10 years (69.0%, 38/55), were affiliated with an academic center (61.8%, 34/55), and utilized non-operative providers as a part of their practice (66.6%, 36/54). On average, 77.5% of patients treated were skeletally immature. Overall, 54.5% of respondents reported specializing in one joint and 41.8% specialized in two. Surgeons commonly operated on a mean of 3 joints. The knee was the most commonly specialized joint (composing a mean of 52.1% of an overall practice), followed by the shoulder (15.2%), hip (13.9%), ankle (7.5%), elbow (7.1%), and wrist (4.2%) (Table 1). Interestingly, 87.3% (48/55) commonly operate on the shoulder but only 21.8% (12/55) were specialists. Conversely, the hip had a similar amount of specialization (23.6%, 13/55) but 56.3% (31/55) reported that they rarely operated on the hip.Conclusions:Pediatric sports medicine practices in orthopaedic surgery are quite variable. The majority of surgeons are <10 years into practice, affiliated with academic centers and have typically completed either 1 or 2 fellowships after residency. The majority of patients are skeletally immature. Most surgeons specialize in one or two joints, most commonly the knee, followed by hip and then shoulder.Table 1.Distribution of joints that make up individuals’ practice (n=55).Figure 1:Number of joints commonly operated on. Joint options were the knee, shoulder, hip, andkle, elbow and wrist. Commonly operated on was defined as composing >5% of total practice.

MP04-09 TRENDS IN HOLMIUM LASER ENUCLEATION OF THE PROSTATE FOR TREATMENT OF BENIGN PROSTATIC HYPERPLASIA

You have accessJournal of UrologyCME1 May 2022MP04-09 TRENDS IN HOLMIUM LASER ENUCLEATION OF THE PROSTATE FOR TREATMENT OF BENIGN PROSTATIC HYPERPLASIA Tenny R. Zhang, Mary O. Strasser, Samantha L. Thorogood, Christina Sze, Bilal Chughtai, Alexis Te, Richard K. Lee, and Jim C. Hu Tenny R. ZhangTenny R. Zhang More articles by this author , Mary O. StrasserMary O. Strasser More articles by this author , Samantha L. ThorogoodSamantha L. Thorogood More articles by this author , Christina SzeChristina Sze More articles by this author , Bilal ChughtaiBilal Chughtai More articles by this author , Alexis TeAlexis Te More articles by this author , Richard K. LeeRichard K. Lee More articles by this author , and Jim C. HuJim C. Hu More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002521.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Compared to traditional treatment options for benign prostatic hyperplasia (BPH), holmium laser enucleation of the prostate (HoLEP) has demonstrated improved outcomes in hemostasis, urinary symptoms, and immediate complication rates. We investigated practice patterns associated with the use of HoLEP. METHODS: We obtained de-identified, self-reported American Board of Urology (ABU) certification/recertification case log data from 2008-2021. We identified 6,632 urologists who performed 73,884 surgeries with an indication for BPH. Current Procedural Terminology (CPT) codes distinguished HoLEP, transurethral resection of prostate (TURP), laser TURP, simple prostatectomy, prostatic urethral lift, transurethral incision of the prostate, and microwave and radiofrequency ablation. We identified 548 urologists (8.3%) who performed 7,386 HoLEP surgeries. Forty-three urologists (0.7%) performed HOLEP exclusively (no other BPH surgical approaches). A logistic regression model was used to determine factors independently associated with using HoLEP. RESULTS: The annual number of HoLEP procedures performed ranged from 3 to 1276, comprising 0.06% to 17.3% of total BPH surgeries annually. Highest HoLEP volumes were logged in 2019, representing 17.3% of total BPH cases. In adjusted analyses (table) factors associated with lower odds of performing HoLEP include surgeon age (odds ratio [OR] 0.93); government (OR 0.06), private practice group (OR 0.44), managed care (OR 0.14), salaried hospital (OR 0.38) vs. academic employment; and Mid-Atlantic (OR 0.28) and New England (0.45) regions vs. South Central (referent). Factors associated with higher odds of performing HoLEP include higher BPH surgical volume (OR 1.02) and endourology (OR 2.41) vs. general urology subspecialty. CONCLUSIONS: HoLEP is more likely to be performed by younger urologists, urologists in academic practice, endourology subspecialists, and those with higher BPH volume. HoLEP was less likely to be performed in Mid-Atlantic and New England regions. Additional studies are needed to elucidate practice pattern variations. Despite evidence demonstrating improved perioperative outcomes compared to competing BPH surgical approaches, HoLEP dissemination over time has been limited, possibly due to prolonged learning curve. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e60 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tenny R. Zhang More articles by this author Mary O. Strasser More articles by this author Samantha L. Thorogood More articles by this author Christina Sze More articles by this author Bilal Chughtai More articles by this author Alexis Te More articles by this author Richard K. Lee More articles by this author Jim C. Hu More articles by this author Expand All Advertisement PDF DownloadLoading ...

AGA Institute Quality Measure Development for the Management of Gastric Intestinal Metaplasia With Helicobacter pylori

AGA Institute Quality Measure Development for the Management of Gastric Intestinal Metaplasia With Helicobacter pylori

Survey of Pediatric Otolaryngology Frenotomy Practice Patterns.

Assess current frenotomy practice patterns of pediatric otolaryngologists via a cross-sectional survey. Survey study. A 31-question electronic survey assessing frenotomy practice patterns was distributed to all American Society of Pediatric Otolaryngology (ASPO) members. Descriptive statistics were used to summarize responses and demographics of respondents. Of all ASPO members, 41% (240/588) completed the survey. Most respondents, 185 (77%), reported increased frenotomy referrals over the last 5 years and 144 (60%) described the current number of referrals as "too many." The two primary lingual frenotomy indications identified in infants were: breastfeeding/nipple pain (92%) and inability to latch (83%). For older children, speech difficulty (87%) was the primary indication. Maxillary frenotomy indications in infants varied amongst respondents. For analgesia during in-office frenotomy procedures, respondents used glucose/sucrose drops (48%), topical lidocaine (29%), or no pain control measure (27%). For post-procedure care, respondents recommended continuing lactation support (45%), massaging/stretching the wound (38%), or none (40%). Most respondents, 143 (60%), reported having seen a complication from frenotomy, and the most reported frenotomy complications were frenulum re-attachment and excessive bleeding. In the last 5 years, otolaryngologists have seen an increase in referrals for frenotomy. Pediatric otolaryngologists have varying practice patterns with regards to ankyloglossia diagnosis and treatment. The reported indications for frenotomy varied amongst pediatric otolaryngologists especially with respect to maxillary frenotomy. Practice patterns also varied with respect to procedural pain control and frenotomy aftercare recommendations. More frenotomy research is needed to establish a standard of care for patients with ankyloglossia. 4 Laryngoscope, 132:2505-2512, 2022.

A survey of use of mTOR inhibitors in patients with lymphangioleiomyomatosis listed for lung transplant

BackgroundLymphangioleiomyomatosis (LAM) is an uncommon indication for lung transplantation. The use of mechanistic target of rapamycin (mTOR) inhibitors, which are the mainstay of treatment in progressive LAM, in patients awaiting lung transplant is controversial. We sought to examine worldwide practice patterns in use of mTOR inhibitors in LAM patients on the lung transplant waiting list. MethodsWe designed and disseminated an online survey about institution-specific practice patterns, particularly regarding listing LAM patients for lung transplant and use of mTOR inhibitors in those patients on the transplant waitlist. ResultsOf the 49 unique respondent programs, 83.6% had previously listed a LAM patient for lung transplant. Thirteen centers allowed patients to continue on mTOR inhibitor until time of lung transplant. None of those centers reported any complications or deaths attributable to mTOR inhibitor adverse effects. ConclusionThere exists significant variability in practice patterns concerning the use of mTOR inhibitors in LAM patients on the lung transplant waiting list. Our survey suggests favorable outcomes for those patients that did continue mTOR inhibitor up to time of transplant. Further data regarding the risk of anastomotic complication with use of mTOR inhibitors in the pre-transplant period would help provide clarity in this debate.

Practice Variation in the Surgical Management of Children With Acute Hematogenous Osteomyelitis.

The surgical indications to manage children with acute hematogenous osteomyelitis (AHO) remain poorly defined. The purpose of this study was to identify if practice pattern variation exists in the surgical management of pediatric AHO among tertiary pediatric medical centers across the United States. A secondary purpose was to evaluate variables that may impact the rate of surgical intervention among these institutions. Children with AHO were retrospectively analyzed between January 1, 2010, and December 31, 2016, from 18 pediatric medical centers throughout the United States. The rates of surgery were identified. Admission vitals, labs, weight-bearing status, length of stay, and readmission rates were compared between those who did and did not undergo surgery. Multivariate regression and classification and regression tree analyses were performed to identify the variables that were associated with surgical intervention. Of the 1003 children identified with AHO in this retrospective, multicenter database, 619/1003 (62%) were treated surgically. Multivariate analysis revealed institution, inability to ambulate, presence of multifocal infection, elevated admission C-reactive protein, increased admission platelet count, and location of the osteomyelitis were significant predictors of surgery (P<0.01). Patients who underwent surgery were more than twice as likely to have a recurrence or readmission and stayed a median of 2 days longer than those who did not have surgery. In the classification and regression tree analysis, 2 distinct patterns of surgical intervention were identified based on institution, with 12 institutions operating in most cases (72%), regardless of clinical factors. A second cohort of 6 institutions operated less routinely, with 47% receiving surgery overall. At these 6 institutions, patients without multifocal infection only received surgery 26% of the time, which increased to 74% with multifocal infection and admission erythrocyte sedimentation rate >37.5 mm/h. This study is the first to objectively identify significant differences in the rates of surgical management of pediatric AHO across the United States. Variation in the surgical management of AHO appears to be driven primarily based on institutional practice. Twelve institutions operated on 72% of patients, regardless of the severity of disease, indicating that the institution custom or dogma may drive the surgical indications. Six institutions relied more on clinical judgment with significant variability in rates of surgical intervention (26% vs. 74%), depending on the severity of the disease. Surgical intervention is associated with increased recurrence, readmission, and hospital length of stay. As a result of these findings, it is essential to prospectively study the appropriate surgical indications and measure the outcomes in children with pediatric AHO. Level III.

Rural-urban differences in secular trends of locoregional treatment for ductal carcinoma in situ: A patterns of care analysis.

PrecisOmission of PORT following BCS remains high among rural patients despite evidence that PORT leads to a significant reduction in the risk of local recurrence. Further research is needed to examine the impact of rural residence on treatment choices and develop methods to ensure equitable care among all breast cancer patients.BackgroundDespite national guidelines, debate exists among clinicians regarding the optimal approach to treatment for patients diagnosed with ductal carcinoma in situ (DCIS). While regional variation in practice patterns has been well documented, population‐based information on rural–urban treatment differences is lacking.MethodsData from the SEER Patterns of Care studies were used to identify women diagnosed with histologically confirmed DCIS who underwent cancer‐directed surgery in the years 1991, 1995, 2000, 2005, 2010, and 2015. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using weighted multivariable logistic regression to evaluate cancer‐directed surgery and use of post‐operative radiation therapy (PORT).ResultsOf the 3337 patients who met inclusion criteria, 27% underwent mastectomy, 26% underwent breast‐conserving surgery (BCS) without PORT, and 47% underwent BCS with PORT. After adjustment for other covariates, there was no difference in the likelihood of receiving mastectomy between rural and urban patients (aOR = 0.65; 95% CI 0.37–1.14). However, rural residents were more likely than urban residents to have mastectomy during 1991/1995 (aOR = 1.78; 95% CI 1.09–2.91; p interaction = 0.022). Across all diagnosis years, patients residing in rural areas were less likely to receive PORT following BCS compared to urban patients (aOR = 0.35; 95% CI 0.18–0.67).ConclusionsOmission of PORT following BCS remains high among rural patients despite evidence that PORT leads to a significant reduction in the risk of local recurrence. Further research is needed to examine the impact of rural residence on treatment choices and develop methods to ensure equitable care among all breast cancer patients.

Split course palliative radiotherapy for advanced lung cancer with 3D planning based analysis of outcome: a retrospective review.

Durable palliation of advanced lung cancer is a common objective for radiation oncologists. However, there is no consensus on how to deliver the radiation course. Herein we report our experience of using split course radiotherapy and our assessment of outcomes based on planning from three-dimensional (3D) simulation before each treatment course. All lung cancer patients from 2006-2020 were identified. Of these, 52 patients received a split course treatment of 50-60 Gy in 18-25 fractions intended to provide durable palliation for disease not amenable to curative therapy. Treatment involved 3D planning with repeat computed tomography (CT) simulation prior to the second course. Survival and symptomatic response were analyzed via chart review. We categorized rapid responders versus non-rapid responders from the initial radiation course based on ≥30% gross tumor volume (GTV) reduction at the second CT simulation. We evaluated the impact of response on overall survival and palliative response. Among our cohort treated with split course palliative radiotherapy, 33 (63%) had a rapid response to initial treatment. There was no difference in survival between groups [hazard ratio (HR) =1.30, P=0.47]. There was no significant difference in palliative response rates between rapid and non-rapid responders. On multivariable analysis, only female sex (HR =0.26, P<0.01) and receipt of systemic therapy following radiotherapy (HR =0.19, P<0.01) were associated with improved survival. There is currently significant practice pattern variability for palliative lung radiotherapy. Split course palliative radiation of 50-60 Gy in 18-25 fractions represents an option to consider for patients with advanced lung cancer who do not undergo definitive therapy and may benefit from a higher dose regimen. Our retrospective review suggests that rapid tumor response in a split course model does not predict survival or symptomatic response. Prospective studies are needed to further define which lung cancer patients may benefit from higher dose regimens.

Physician Practice Pattern Variations in Common Clinical Scenarios Within 5 US Metropolitan Areas

While variations in quality of care have been described between US regions, physician-level practice pattern variations within regions remain poorly understood, notably among specialists. To examine within-area physician-level variations in decision-making in common clinical scenarios where guidelines specifying appropriateness or quality of care exist. This cross-sectional study used 2016 through 2019 data from a large nationwide network of commercial insurers, provided by Health Intelligence Company, LLC, within 5 metropolitan statistical areas (MSAs). Physician-level variations in appropriateness and quality of care were measured using 14 common clinical scenarios involving 7 specialties. The measures were constructed using public quality measure definitions, clinical guidelines, and appropriateness criteria from the clinical literature. Physician performance was calculated using a multilevel model adjusted for patient age, sex, risk score, and socioeconomic status with physician random effects. Measure reliability for each physician was calculated using the signal-to-noise approach. Within-MSA variation was calculated between physician quintiles adjusted for patient attributes, with the first quintile denoting highest quality or appropriateness and the fifth quintile reflecting the opposite. Data were analyzed March through October 2021. Fourteen measures of quality or appropriateness of care, with 2 measures each in the domains of cardiology, endocrinology, gastroenterology, pulmonology, obstetrics, orthopedics, and neurosurgery. A total of 8788 physicians were included across the 5 MSAs, and about 2.5 million unique patient-physician pairs were included in the measures. Within the 5 MSAs, on average, patients in the measures were 34.7 to 40.7 years old, 49.1% to 52.3% female, had a mean risk score of 0.8 to 1.0, and more likely to have an employer-sponsored insurance plan that was either self-insured or fully insured (59.8% to 97.6%). Within MSAs, physician-level variations were qualitatively similar across measures. For example, statin therapy in patients with coronary artery disease ranged from 54.3% to 70.9% in the first quintile of cardiologists to 30.5% to 42.6% in the fifth quintile. Upper endoscopy in patients with gastroesophageal reflux disease without alarm symptoms spanned 14.6% to 16.9% in the first quintile of gastroenterologists to 28.2% to 33.8% in the fifth quintile. Among patients with new knee or hip osteoarthritis, 2.1% to 3.4% received arthroscopy in the first quintile of orthopedic surgeons, whereas 25.5% to 30.7% did in the fifth quintile. Appropriate prenatal screening among pregnant patients ranged from 82.6% to 93.6% in the first quintile of obstetricians to 30.9% to 65.7% in the fifth quintile. Within MSAs, adjusted differences between quintiles approximated unadjusted differences. Measure reliability, which can reflect consistency and reproducibility, exceeded 70.0% across nearly all measures in all MSAs. In this cross-sectional study of 5 US metropolitan areas, sizeable physician-level practice variations were found across common clinical scenarios and specialties. Understanding the sources of these variations may inform efforts to improve the value of care.

Influence of rurality on lymph node assessment among women diagnosed with ductal carcinoma in situ and treated with mastectomy, SEER 2000-2015.

Despite recommendations from national organizations supporting the use of lymph node assessment (LNA) among patients with ductal carcinoma in situ (DCIS) at time of mastectomy, variation in practice patterns across the United States has been observed. However, few studies have evaluated LNA differences and rurality. Data from the SEER Patterns of Care studies were used to identify women who underwent mastectomy for newly diagnosed DCIS during 2000, 2005, 2010, and 2015. Weighted multivariate logistic regression was used to evaluate the association between rural-urban residence and the use of LNA. A subgroup analysis was performed comparing the use of axillary lymph node dissection (ALND) versus sentinel lymph node biopsy (SLNB). Of the 504 patients included in the analysis, approximately 81% underwent LNA at time of mastectomy with lower rates of use observed among rural patients (66%) versus urban patients (82%). In multivariate analysis, LNA increased over time (p < 0.0001), and rural patients were less likely to receive LNA compared to urban patients [adjusted odds ratio (aOR) = 0.19; 95% confidence interval (CI) 0.06-0.66]. However, the likelihood of undergoing ALND relative to SLNB was lower among rural compared to urban patients (aOR = 0.16; 95% CI 0.03-0.73). Over time, the use of LNA with mastectomy has increased among DCIS patients. However, significant rural-urban differences in the use and type of LNA persist. The findings of this study highlight the importance of continued research aimed at examining the impact of rurality on the receipt of high-quality cancer care.

A modified-delphi study establishing consensus in the therapeutic management of posttrauamtic elbow stiffness

Study Design: Web-based modified Delphi study. Background: Therapy is widely considered the first choice of treatment for posttraumatic stiffness of the elbow since loss of motion is a common sequela following traumatic elbow injuries. There is high variability in practice patterns for the management of the posttraumtic elbow. Purpose: The aim of this study is to identify the current therapeutic management of posttraumatic elbow stiffness using expert consensus. Methods: This study surveyed experts using a web-based 3 round modified Delphi method. Quantitative data and comments were collected during the first round. Questions with Likert scaling were used to identify consensus (defined as 75% agreement) with each statement and comment boxes enabled open-ended responses to gather expert opinion. Lack of consensus and data from comments guided the second-round of the survey. This process was repeated after Round 2 to develop the Round 3 survey. Consensus was achieved at Round 3 and no further rounds were needed. Results: Round 1 included 34 experts (response rate 20%), not all experts were able to continue through all rounds. Round 2 included 18 experts and Round 3 included 15 experts. Survey items were categorized as follows: examination procedures, therapeutic interventions, orthotic intervention considerations, contributing patient factors, and clinical decisions and rehabilitation challenges. Twenty-five percent of items achieved consensus after Round 1, 30% after Round 2 and 52% after Round 3. Although most participants agreed that orthotic intervention is critical to patient outcomes, there were conflicting thoughts about the orthotic design and wearing schedule. Conclusions: The findings of this web-based modified Delphi study helped to establish a current body of knowledge using expert consensus to guide practice and identify specific questions that can be studied in future clinical studies on posttraumatic elbow stiffness.

Perioperative Considerations for Antithrombotic Therapy in Oculofacial Surgery: A Review of Current Evidence and Practice Guidelines.

Purpose:Recent survey studies have demonstrated wide variability in practice patterns regarding the management of antithrombotic medications in oculofacial plastic surgery. Current evidence and consensus guidelines are reviewed to guide perioperative management of antithrombotic medications.Methods:Comprehensive literature review of PubMed database on perioperative use of antithrombotic medication.Results/Conclusions:Perioperative antithrombotic management is largely guided by retrospective studies, consensus recommendations, and trials in other surgical fields due to the limited number of studies in oculoplastic surgery. This review summarizes evidence-based recommendations from related medical specialties and provides context for surgeons to tailor antithrombotic medication management based on patient’s individual risk. The decision to continue or cease antithrombotic medications prior to surgery requires a careful understanding of risk: risk of intraoperative or postoperative bleeding versus risk of a perioperative thromboembolic event. Cessation and resumption of antithrombotic medications after surgery should always be individualized based on the patient’s thrombotic risk, surgical and postoperative risk of bleeding, and the particular drugs involved, in conjunction with the prescribing doctors. In general, we recommend that high thromboembolic risk patients undergoing high bleeding risk procedures (orbital or lacrimal surgery) may stop antiplatelet agents, direct oral anticoagulants, and warfarin including bridging warfarin with low-molecular weight heparin. Low-risk patients, regardless of type of procedure performed, may stop all agents. Decision on perioperative management of antithrombotic medications should be made in conjunction with patient’s internist, cardiologist, hematologist, or other involved physicians which may limit the role of guidelines depending on patient risk and should be used on a case-by-case basis. Further studies are needed to provide oculofacial-specific evidence-based guidelines.

Physician Approaches to Imaging and Revascularization for Acutely Symptomatic Carotid Stenosis: Insights from the Hot Carotid Qualitative Study

Background Evidence informing the choice between carotid endarterectomy and carotid artery stenting for acutely symptomatic carotid stenosis (“hot carotid”) is dated and does not factor in contemporary therapies or techniques. The optimal imaging modality is also uncertain. We explored the attitudes of stroke physicians regarding imaging and revascularization of patients with acute symptomatic carotid stenosis. Methods We used a qualitative descriptive methodology to examine decision‐making approaches and opinions of physicians regarding the choice of imaging and revascularization procedures for hot carotids. We conducted semistructured interviews with purposive sampling of 22 stroke physicians from 16 centers in 6 world regions and various specialties: 11 neurologists, 3 geriatricians, 5 interventional neuroradiologists, and 3 neurovascular surgeons. Results Qualitative analysis revealed several themes regarding clinical decision‐making for hot carotids. Whereas CT angiography was favored by most participants, timely imaging availability, breadth of information gained, and surgeon/interventionalist preferences were important themes influencing the choice of imaging modality. Carotid endarterectomy was generally favored over carotid artery stenting, but participants’ choice of intervention was influenced by healthcare system factors such as use of multidisciplinary vascular teams and operating room or angiography suite availability, and patient factors like age and infarct size. Areas of uncertainty included choice of imaging modality for borderline stenosis, utility of carotid plaque imaging, timing of revascularization, and the role of intervention with borderline stenosis or intraluminal thrombus. Conclusions This qualitative study highlights practice patterns common in different centers around the world, such as the general preference for CT angiography imaging and carotid endarterectomy over carotid artery stenting but also identified important differences in availability, selection, and timing of imaging and revascularization options. To gain widespread support, future carotid trials will need to accommodate identified variations in practice patterns and address areas of uncertainty, such as optimal timing of revascularization with modern best medical management and risk‐stratification with imaging features other than just degree of stenosis.

Residency Training and Hand Surgery Practice Patterns: A National Surgical Quality Improvement Program Database Analysis

Introduction Fellowship-trained hand surgeons may have residency training in either orthopedic, plastic, or general surgery, generating significant variability in education background. To study the effect of different training backgrounds on practice pattern variations, we utilized the NSQIP (National Surgical Quality Improvement Database) database to assess hand surgery volumes and case variety by specialty.Materials and Methods NSQIP years 2008 to 2017 was queried with hand surgery current procedural terminology codes defined by the American Board of Orthopedic Surgery. Procedures were grouped according to type and specialty, and relative rates calculated. Hand society membership data were used to determine if procedural volume for each specialty in each category and overall contribution to the volume of hand surgery performed nationally was distributed in accordance with membership data.Results A total of 145,015 hand surgeries were performed; 13,267 (9.1%) by general surgeons, 28,402 (19.6%) by plastic surgeons, and 103,346 (71.3%) by orthopedic surgeons. Orthopedic surgeons performed significantly more bone, fracture, joint, and tendon cases. General surgeons and plastic surgeons performed higher than expected numbers of soft tissue coverage and cases overall with respective excesses of 183 and 22%.Conclusion Hand surgery is an available fellowship pathway from multiple residencies. Fellowship training does not level the field of real-world practice patterns. Residency training experiences significantly impact practice.

Trauma Surgeons' Perceptions of Resuscitating Lethally Injured Patients for Organ Preservation.

Trauma surgeons face a challenge when deciding whether to resuscitate lethally injured patients whose organ donor status is unknown. Data suggests practice pattern variability in this setting, but little is known about why. We conducted semi-structured interviews with trauma surgeons practicing in Level 1 or 2 trauma centers in Tennessee. Interviews focused on ethical dilemmas and resource constraints. Analysis was performed using inductive thematic analysis. Response rate was 73% (11/15). Four key themes emerged. All described resuscitating patients to buy time to collect more definitive clinical information and to identify family. Some acknowledged this served the secondary purpose of organ preservation. 11/11 participants felt a primacy of obligation to the patient in front of them even after it became apparent, they could not personally benefit. For 9/11 (82%), the moral obligation to consider organ preservation was secondary/balancing; 2/11 (18%) felt it was irrelevant/immoral. Resource allocation was commonly considered. All participants expressed some limitation to resources they would allocate. All participants conveyed clear moral agency in determining resuscitation extent when the goal was to save the patient's life, however this was less clear when resuscitating for organ preservation. Across themes, perceptions of a "standard practice" existed but the described practices were not consistent across interviewees. Widely ranging perceptions regarding ethical and resource considerations underlie practices resuscitating toward organ preservation. Common themes suggest a lack of consensus. Despite expressed beliefs, there is no identifiable standard of practice amongst trauma surgeons resuscitating in this setting.