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Background The COVID-19 pandemic has driven primary healthcare (PHC) providers to use telehealth as an alternative to traditional face-to-face consultations. Providing telehealth that meets the needs of patients in a pandemic has presented many challenges for PHC providers. The aim of this study was to describe the positive and negative implications of using telehealth in one Canadian (Quebec) and one American (Massachusetts) PHC setting during the COVID-19 pandemic as reported by physicians. Methods We conducted 42 individual semi-structured video interviews with physicians in Quebec (N = 20) and Massachusetts (N = 22) in 2020. Topics covered included their practice history, changes brought by the COVID-19 pandemic, and the advantages and challenges of telehealth. An inductive and deductive thematic analysis was carried out to identify implications of delivering care via telehealth. Results Four key themes were identified, each with positive and negative implications: 1) access for patients; 2) efficiency of care delivery; 3) professional impacts; and 4) relational dimensions of care. For patients’ access, positive implications referred to increased availability of services; negative implications involved barriers due to difficulties with access to and use of technologies. Positive implications for efficiency were related to improved follow-up care; negative implications involved difficulties in diagnosing in the absence of direct physical examination and non-verbal cues. For professional impacts, positive implications were related to flexibility (teleworking, more availability for patients) and reimbursement, while negative implications were related to technological limitations experienced by both patients and practitioners. For relational dimensions, positive implications included improved communication, as patients were more at ease at home, and the possibility of gathering information from what could be seen of the patient’s environment; negative implications were related to concerns around maintaining the therapeutic relationship and changes in patients’ engagement and expectations. Conclusion Ensuring that health services provision meets patients’ needs at all times calls for flexibility in care delivery modalities, role shifting to adapt to virtual care, sustained relationships with patients, and interprofessional collaboration. To succeed, these efforts require guidelines and training, as well as careful attention to technological barriers and interpersonal relationship needs.

Background Vaccine receipt among mid-adults remains low, with only one quarter of adults being up to date for all recommended vaccines. It is important to understand the myriad factors that influence vaccine receipt among mid-adult women to address these low rates. Methods We conducted a cross-sectional analysis of data from women ages 24–45 years collected as part of an ongoing case-control study of the effectiveness of HPV vaccine. We examined associations between demographic characteristics and healthcare utilization and receipt of individual vaccines and combinations of multiple vaccines using logistic regression analyses for three routinely recommended vaccines: tetanus, influenza and HPV. Results Among the 309 women enrolled in the study, only 19 (6.2%) were up to date for all three recommended vaccines and 41 (13.3%) had not received any of the recommended vaccines. A greater number of health care visits in the past year was associated with receipt of influenza (aOR = 6.37, 95% CI = 2.53, 16.1) and tetanus (aOR = 2.17, 95% CI = 1.14, 4.12) vaccines. White women were more likely to have received HPV vaccine (aOR = 2.39, 95% CI = 1.07, 5.36). Conclusions Uptake of recommended vaccines is low among young and mid-adult women. There is a need for greater understanding of the underlying factors influencing vaccine receipt in this population.

Increasing regionalization of pediatric care has led to interfacility transfer of children with general pediatric conditions at rates similar to those of high-risk adults, which may delay appropriate treatment. We sought to identify common medical diagnoses that did not require significant advanced intervention and that had high rates of discharge within 1 day of interfacility transfer. Using the Pediatric Health Information System (PHIS) database, we identified all transfers into PHIS-participating children’s hospitals in 2019. We excluded encounters for mental health, labor/maternity, primary newborn diagnoses, and direct admissions to an intensive care unit. Eligible encounters were categorized by duration of hospitalization and basic vs advanced intervention after transfer. Of 286,905 transfers, 197,386 (68.6%) met inclusion criteria. Cough, febrile seizures, croup, and allergic reactions required advanced interventions

Background and Objectives: Despite recent improvements in access to health care, many Americans still lack access to dental care. There has been a national focus on interprofessional education and team-based care to work toward the integration of services including dental care into primary care. The purpose of this systematic review is to understand the impact of implementing oral health curricula in primary care training on measurable changes in primary care practice. Methods: Researchers utilized a two-step process, first a scoping review and then using the PRISMA systematic review method to develop inclusion and exclusion criteria around audience, curricula, and outcomes to identify practice change due to oral health education curricula delivered in primary care clinician training. Researchers assessed titles, abstracts, and full texts and abstracted data for the review. Results: Researchers reviewed 2,749 articles and found 12 meeting the systematic review criteria. The reported outcomes and evaluations differed for each of the 12 studies identified. Over 40% utilized self-reporting. Seven of the included studies tracked outcomes by checklists embedded in electronic health records changes to well-child visit forms, or chart audits, one of which also tracked billing reimbursements. Conclusions: Oral health curricula for primary care clinicians are too heterogeneous to determine the effects on practice behavior. Future research should focus on developing a clear evaluation framework for measuring practice level changes in primary care settings as a result of implementing an oral health curriculum.

With a rapid shift to telehealth during the coronavirus disease 2019 (COVID-19) pandemic, clinicians, health care organizations, and policy makers must consider and address patients' evolving needs, concerns, and expectations.

The COVID-19 pandemic burdens health-care workers (HCWs) worldwide. Amid high-stress conditions and unprecedented needs for crisis management, organizations face the grand challenge of supporting the mental health and well-being of their HCWs. The current literature on mental health and well-being primarily focuses on improving personal resilience among HCWs. However, this puts the responsibility for coping with COVID-19-related stress almost fully on the individual. This chapter discusses an important alternative framing of this issue - how health-care organizations (HCOs) can facilitate recovery from work processes (i.e., returning to a baseline level by engaging in nonwork activities after work) for their workers. Based on a narrative review of the occupational health psychology literature, we provide practical strategies for supporting the four key recovery experiences of detachment, control, mastery, and relaxation, as well as present general recommendations about how to promote recovery. These strategies can help HCOs facing the grand challenge of sustaining worker well-being and functioning during the COVID-19 pandemic, as well as during future pandemics and for workers facing high work pressure in general.

Importance With the approval of avapritinib for adults with unresectable or metastatic gastrointestinal stromal tumors (GISTs) harboring a platelet-derived growth factor receptor alpha (PDGFRA) exon 18 variant, including PDGFRA D842V variants, and National Comprehensive Cancer Network guideline recommendations as an option for patients with GIST after third-line treatment, it is important to estimate the potential financial implications of avapritinib on a payer's budget. Objective To estimate the budget impact associated with the introduction of avapritinib to a formulary for metastatic or unresectable GISTs in patients with a PDGFRA exon 18 variant or after 3 or more previous treatments from the perspective of a US health plan. Design, setting, and participants For this economic evaluation, a 3-year budget impact model was developed in March 2020, incorporating costs for drug acquisition, testing, monitoring, adverse events, and postprogression treatment. The model assumed that avapritinib introduction would be associated with increased PDGFRA testing rates from the current 49% to 69%. The health plan population was assumed to be mixed 69% commercial, 22% Medicare, and 9% Medicaid. Base case assumptions included a GIST incidence rate of 9.6 diagnoses per million people, a metastatic PDGFRA exon 18 mutation rate of 1.9%, and progression rate from first-line to fourth-line treatment of 17%. Exposures The model compared scenarios with and without avapritinib in a formulary. Main outcomes and measures Annual, total, and per member per month (PMPM) budget impact. Results In a hypothetical 1-million member plan, fewer than 0.1 new patients with a PDGFRA exon 18 variant per year and 1.2 patients receiving fourth-line therapy per year were eligible for treatment. With avapritinib available, the total increase in costs in year 3 for all eligible adult patients with a PDGFRA exon 18 variant was $46 875, or $0.004 PMPM. For patients undergoing fourth-line treatment, the total increase in costs in year 3 was $69 182, or $0.006 PMPM. The combined total budget impact in year 3 was $115 604, or $0.010 PMPM, including an offset of $3607 in postprogression costs avoided or delayed. The higher rates of molecular testing resulted in a minimal incremental testing cost of $453 in year 3. Conclusions and relevance These results suggest that adoption of avapritinib as a treatment option would have a minimal budget impact to a hypothetical US health plan. This would be primarily attributable to the small eligible patient population and cost offsets from reduced or delayed postprogression costs.

ProblemThere is a lack of leadership training in health care despite it being an essential competency for providers to deliver accessible, high quality healthcare and navigate a continually changing system. The barriers to adding leadership development to the various stages of medical training are numerous. A specific barrier is the lack of access to resources for this training. This group aimed to tackle this barrier within post-graduate medical education and training through their e- Leadership Academy.ApproachThe e-Leadership Academy was developed as a partnership between the Harvard Medical School Center for Primary Care and Clinical Directors Network, Inc. (CDN). The result of the collaboration was a virtual leadership academy, offered over a 10-month period that covered the fundamental concepts and skills for leading within a clinical practice. The audience for this program were clinicians and staff of community health centers and health departments in the United States.OutcomesFor the results of this article, primary outcome analysis was of participant responses to both formative and summative evaluations that took place throughout and at the end of the course. Results were used to assess course quality, participant satisfaction, participant engagement, and provide data about future offerings that would be useful to the target audience.Next StepsThe group proposes future training programs could measure the changes in the behavior of teams and clinical outcomes utilizing expanded evaluations. Proposed plans for expansion of the e- Leadership Academy include developing additional modules and the potential integration of an in- person component.

To detail common comorbidities and procedures performed to evaluate functional nausea in children.In total, 63 children age 7-18 years seen in a tertiary care pediatric clinic who met Rome IV criteria for functional nausea prospectively completed an Intake Questionnaire, the Pediatric and Parent-Proxy PROMIS-25 Profile v 2.0, the Pediatric and Parent-Proxy Pediatric Sleep Disturbance-Short Form 4a, and the COMPASS 31 orthostatic intolerance scale to assess comorbidities. Medical records were reviewed for diagnostic tests performed to evaluate nausea and for additional comorbidities. Summary statistics were used to determine the most common comorbidities and diagnostic yield of the procedures. Intraclass correlation coefficients assessed agreement between parent and child reports on the PROMIS scales.Patients with functional nausea experienced multisystem comorbidities. A majority reported abdominal pain, headache, orthostatic intolerance, fatigue, disturbed sleep, anxiety, constipation, allergies, and vomiting. Agreement between parent-proxy and child report of symptoms on PROMIS scales was good to excellent (intraclass correlation coefficients = .78-.83; all P .001). Patients underwent extensive diagnostic testing: 96 endoscopic procedures, 199 radiologic tests, and 4 cholecystectomies. Most of the procedures were not diagnostically informative.Children with functional nausea have comorbidities outside the gastrointestinal tract that warrant evaluation. Gastrointestinal diagnostic tests were of low-yield in identifying a cause. Understanding the relationship with comorbidities may provide insight into etiologies for the nausea and define clinical phenotypes to better tailor care.

BACKGROUND Morphea is an inflammatory and fibrosing condition that affects the skin and subcutaneous structures. Morphea is managed by dermatologists, rheumatologists, or both. Prior studies have suggested there is significant variability in approach to treatment. In 2012, the Childhood Arthritis and Rheumatology Research Alliance (CARRA) published consensus treatment plans (CTPs) for pediatric morphea to develop more standardized treatment plans for patients requiring systemic therapy. We aimed to assess whether the publication of CTPs has impacted care of patients with morphea at our institution. METHODS Data were collected via a retrospective review of medical records of 61 pediatric patients diagnosed with morphea at Seattle Children's Hospital (SCH) from January 1, 2005, to December 12,2017. RESULTS Prior to the publication of CTPs, 2 out of 24 patients (8.3%) were treated with a regimen that matched a subsequent CTP. After publication of CTPs, 29 out of 37 patients (78.4%) were treated with a regimen that matched a CTP (P

Prior to the COVID-19 pandemic, studies demonstrated an alarming prevalence of burnout in primary care. In the midst of the pandemic, primary care clinician wellbeing deteriorated and burnout rates increased, yet many organizational efforts to reduce burnout were put on hold due to the urgency of the pandemic. In this article, we present the “Reducing Burnout Driver Diagram” as a tool that clinical leaders and policy makers can use to address and mitigate primary care clinician burnout.

Systemic mastocytosis (SM) is a rare mast cell disease driven by the KIT D816V mutation in which mast cells accumulate in ≥1 tissues or organs resulting from clonal proliferation of abnormal mast cells in one or more extracutaneous organs. Most forms of SM are non-advanced (non-AdvSM). To date, the economic burden of non-AdvSM has not been well-studied among Medicare patients. This study compared direct healthcare resource utilization (HCRU) and healthcare costs in Medicare beneficiaries with non-AdvSM and a matched cohort without SM. This study used Centers for Medicare and Medicaid Services-sourced 100% Medicare Fee for Service (FFS) claims (Parts A/B/D) and identified newly diagnosed non-AdvSM patients who had ≥2 medical claims for SM (ICD-10-CM Dx codes: D47.02 OR C94.30 OR C94.31 OR C94.32 OR C96.21) between 1/1/2017 and 12/31/2018. Patients were classified as non-AdvSM using a claims-based algorithm. The index date was the date of first observed SM diagnosis. Continuous enrollment in Medicare Parts A/B/D for 12 months pre- and post-index was required. Non-AdvSM patients were direct matched (1:1) on age, sex, race, index year, Medicare-Medicaid dual eligibility, and Charlson Comorbidity Index score to a non-SM control cohort. HCRU and costs were assessed during the 12 months pre- and post-index. Medical costs are reported in 2021 US dollars. Post match, there were 333 non-AdvSM and 333 non-SM patients. Mean [SD] age of the non-AdvSM cohort was 67.3 [11.7] and 67.8 [13.3] years for the control cohort. Over 25% of patients were Total (Parts A/B/D) healthcare costs in the 12-month follow up period were almost one-third higher for non-AdvSM patients than for non-SM controls (mean [SD]: $40,250, [$54,563] vs. $30,013 [$51,235]; p=0.0128). Pharmacy (Part D only) expenditures were also significantly higher ($13,938[$38,367] vs. $5,745 [$17,213], p=0.0004) and accounted for a greater proportion (34.6% vs. 19.1%) of total costs for non-AdvSM patients vs. non-SM patients. Non-AdvSM patients were high utilizers of physician office visits post-index compared to non-SM controls; more non-AdvSM patients had ≥1 oncology/hematology visit (36.9% vs. 12.9%; p Compared to a matched cohort of non-SM Medicare FFS patients, non-AdvSM Medicare patients had 30% higher mean per patient total healthcare expenditures ($40,250 vs. $30,013), driven by more prescription drug use and higher utilization of outpatient resources, specifically visits to oncologists/hematologists and allergists/immunologists. Notably, this analysis does not represent the HCRU and costs of the most severe SM patients. Further research to understand the basis of the higher proportion of non-AdvSM patient in this analysis who were Disclosures Sullivan: Blueprint Medicines: Current Employment, Current equity holder in publicly-traded company, Divested equity in a private or publicly-traded company in the past 24 months. Cohen: Blueprint Medicines: Current Employment, Current equity holder in publicly-traded company, Divested equity in a private or publicly-traded company in the past 24 months. Norregaard: Blueprint Medicines: Current Employment, Current equity holder in publicly-traded company. Nguyen: Blueprint Medicines: Current Employment. Sloan: Blueprint Medicines: Current Employment, Current equity holder in publicly-traded company, Current holder of individual stocks in a privately-held company, Current holder of stock options in a privately-held company. Petrilla: Blueprint Medicines: Other: Allison Petrilla is an employee of Avalere Health, which received consulting fees from Blueprint Medicines for this study.. Silverstein: Blueprint Medicines: Other: Alison Silverstein is an employee of Avalere Health, which received consulting fees from Blueprint Medicines for this study.. Murunga: Blueprint Medicines: Other: Anne Murunga is an employee of Avalere Health, which received consulting fees from Blueprint Medicines for this study.. Schinkel: Blueprint Medicines: Other: Jill Schinkel is an employee of Avalere Health, which received consulting fees from Blueprint Medicines for this study..

Introduction: Social determinants of health such as race, ethnicity, and socioeconomic status (SES) are associated with inferior outcomes in patients with B-cell acute lymphoblastic leukemia (B-ALL). Latinx patients have worse event-free survival and are at increased risk of relapse when compared to non-Latinx peers; given that low SES is also an independent predictor of relapse, some of this disparity is likely the result of structural racism. Chimeric antigen receptor T-cell therapy (CAR-T) is a promising approach to improve survival for patients with relapsed/refractory (r/r) B-ALL. However, given the limited number of cellular therapy centers, these therapies may not be equally accessible to patients of low SES or patients from historically disadvantaged populations. The sociodemographic characteristics of pediatric and young adult patients referred for CAR-T have not been well-described. We aimed to evaluate how sociodemographic characteristics of patients referred for CAR-T from outside institutions (referred CAR-T) differed from r/r patients referred for CAR-T at their home institution (local CAR-T), r/r patients not referred for CAR-T at their home institution (other relapse), and patients without r/r disease (without relapse). We hypothesized that there would be a higher proportion of non-Latinx White patients and patients with higher SES among referred CAR-T patients. Methods: We conducted a multicenter, retrospective cohort study of children and young adults with B-ALL treated at five large pediatric hospitals between 2012-2018. Patients diagnosed with B-ALL between age 0 and 29 were included. Clinical and demographic data (including race/ethnicity, insurance, and primary language) were collected from the electronic health record and analyzed using descriptive statistics. For patients residing within the United States, ArcGIS NSES Index software was used to assign SES score by census tract (0-100, with 50 as the national average). Results: Our cohort included 1374 patients with B-ALL, of which 372 (27%) had r/r disease (Table 1). Among 372 r/r patients, 142 were referred CAR-T patients and 230 were treated for r/r leukemia at their home institution (35% local CAR-T and 65% other relapse). Median distance traveled to CAR-T therapy was 824 miles among referred patients and 20.5 miles among local CAR-T patients. The majority of patients (76% of the overall cohort and 79% of those receiving CAR-T) were either White or Latinx. A higher proportion of local CAR-T patients were Latinx compared to referred CAR-T patients (56% vs. 29%; p Conclusions: In a large multicenter cohort of B-ALL pediatric and young adult patients, the demographics of referred CAR-T patients were notably different than local CAR-T patients. Latinx patients are at increased risk of relapse, making access to CAR-T all the more essential; however, we found less than one-third of patients referred from outside institutions for CAR-T cell therapy were Latinx, while a majority of patients receiving CAR-T cell therapy locally were Latinx. This association suggests that barriers to access such as distance and need for travel may differentially impact Latinx patients due to structural racism. Spanish-speaking patients and patients with public insurance were also underrepresented in referrals from outside institutions. However, these observational differences may be in part due to regional variations in the demographics of the population. Preliminary analysis by site is underway and indicates that center level demographic variation may be driving some of the observed differences. Very few Black and Asian patients received CAR-T within our cohort making any assessments of patterns of care difficult. Future work will involve additional analysis to identify non-clinical factors that may influence referral and enrollment rates on CAR-T clinical trials as well as qualitative work to understand these factors from the patient and provider perspectives. Figure 1 Figure 1. Disclosures Walters: AllCells, Inc: Consultancy; BioLabs, Inc: Consultancy; Vertex pharmaceuticals: Consultancy; Ensoma, Inc.: Consultancy. Ramsey: Vertex Pharmaceuticals: Consultancy; Cystetics Medicines: Consultancy.

Systemic mastocytosis (SM) is a rare mast cell neoplasm driven by KIT D816V mutation. Advanced SM (AdvSM) includes three disease subtypes: aggressive SM, SM with associated hematological neoplasm, and mast cell leukemia. 1 Advanced disease onset often develops in patients above the age of 60. 1 Patients with AdvSM experience a range of severe symptoms including organ damage and shortened survival. 2 There is limited research quantifying the impact of AdvSM on healthcare resource utilization (HCRU) and costs, particularly within the Medicare population. This retrospective study compared direct HCRU and costs in Medicare beneficiaries with AdvSM to a matched cohort of beneficiaries without SM. This study used Centers for Medicare and Medicaid Services-sourced 100% Medicare Fee for Service (FFS) claims (Parts A/B/D) to identify newly diagnosed SM patients with >2 medical claims for SM (ICD-10-CM Dx codes: D47.02 OR C94.30 OR C94.31 OR C94.32 OR C96.21) between 01/01/2017 and 12/31/2018. The index date was the date of first observed SM diagnosis code. A claims-based algorithm was used to determine AdvSM subtype. Patients were required to have continuous enrollment in Medicare Parts A/B/D for 12 months pre- and post-index. AdvSM patients were direct matched (1:1) to a non-SM control cohort on age, sex, race, index year, Medicare-Medicaid dual eligibility, and Charlson Comorbidity Index score. HCRU and costs were assessed pre- and post-index. Chi-square and t-tests were used to evaluate differences in outcomes between AdvSM and non-SM patients. Medical costs are reported in 2021 USD. After matching, there were 339 AdvSM and 339 non-SM patients. Mean [SD] age was 68.2 [13.2] among AdvSM and 68.5 [13.9] among non-SM patients. More than 25% of patients were During the 12 months post-index, all cause total healthcare expenditures (Parts A/B/D) were significantly higher for AdvSM patients than for non-SM comparator patients (mean [SD]: $123,412 [$180,386] vs. $47,988 [$64,693]; p AdvSM Medicare FFS patients were more resource intensive and had 2.5 times higher per-patient healthcare costs in the 12 months following SM diagnosis compared to a matched cohort of non-SM patients. These costs were driven by significantly higher rates of inpatient stays, more frequent ED and physician outpatient visits, and higher utilization of multiple medications. Notably, AdvSM patients in this analysis included a larger proportion of patients Disclosures Sullivan: Blueprint Medicines: Current Employment, Current equity holder in publicly-traded company, Divested equity in a private or publicly-traded company in the past 24 months. Cohen: Blueprint Medicines: Current Employment, Current equity holder in publicly-traded company, Divested equity in a private or publicly-traded company in the past 24 months. Norregaard: Blueprint Medicines: Current Employment, Current equity holder in publicly-traded company. Nguyen: Blueprint Medicines: Current Employment. Sloan: Blueprint Medicines: Current Employment, Current equity holder in publicly-traded company, Current holder of individual stocks in a privately-held company, Current holder of stock options in a privately-held company. Petrilla: Blueprint Medicines: Other: Allison Petrilla is an employee of Avalere Health, which received consulting fees from Blueprint Medicines for this study.. Silverstein: Blueprint Medicines: Other: Alison Silverstein is an employee of Avalere Health, which received consulting fees from Blueprint Medicines for this study.. Murunga: Blueprint Medicines: Other: Anne Murunga is an employee of Avalere Health, which received consulting fees from Blueprint Medicines for this study.. Schinkel: Blueprint Medicines: Other: Jill Schinkel is an employee of Avalere Health, which received consulting fees from Blueprint Medicines for this study..

Introduction: SM is a rare, mast cell neoplasm characterized by uncontrolled proliferation, accumulation, and activation of abnormal mast cells (MCs). Approximately 95% of patients with SM harbor the D816V mutation, which results in constitutive activation of the KIT receptor, causing debilitating symptoms across all SM subtypes such as pruritus, headaches, bone pain, nausea, vomiting, diarrhea, brain fog, and anaphylaxis. Patients with SM are managed across specialties depending on symptom severity and organ involvement. Hematologists/oncologists and allergists/immunologists both play key roles in the management of disease. With few multidisciplinary SM practices in the US, more information is needed across specialties to enable optimal SM care. Here we report findings from the TouchStone SM survey of healthcare providers (HCPs) in the US to inform perceptions of disease and disease management strategies. Methods: HCPs completed an online survey containing 47 items covering a range of concepts related to diagnosis (how made, how long it takes), symptoms (how assessed, what symptoms patients experience, how HCPs discuss symptoms with patients, treatment and management), perceived impact on daily life, treatment received (prescription and over-the-counter, treatment goals, unmet needs) and satisfaction (symptom management, overall treatment and disease management). The focus of these analyses are HCP perceptions of disease severity, treatment goals, and disease management. Practicing hematologists/oncologists and allergists/immunologists were eligible if caring for ≥4 SM patients and in practice ≥3 years post fellowship. HCPs were recruited through double-blinded market research survey panels, with individual responses kept confidential. Descriptive analyses were performed on survey responses. Results: Of 304 HCPs contacted, 60 allergists/immunologists and 59 hematologists/oncologists were enrolled with an average of 14 years of practice experience. On average, participating HCPs had 25 SM patients (range: 4-100) under their care. HCPs reported perceived prevalence of the KIT D816V mutation at 46% of patients (range 0-100), substantially lower than published prevalence rates of up to 95%.1 Among HCPs, the average perceived time from patient symptom onset to diagnosis was 8 months, in contrast to 7 years as reported by patients.2 Allergist/immunologists reported primarily seeing patients with non-advanced disease (80%), while hematologists/oncologists reported managing both non-advanced (50%) and advanced patients (50%). Participating HCPs reported that 58% of their patients have moderate-severe SM. HCP treatment goals for SM patients were consistent across specialties. The 2 most important treatment goals for non-advanced patients were improved quality of life (QoL) (40%; 48/120) and improvement of symptoms (24%; 29/119), while the 2 most important treatment goals for advanced patients were improved progression-free survival /improved overall survival (34%, 35/104) and improved QoL (25%, 26/104). Conclusions: Allergists/immunologists co-manage SM care with hematologists/oncologists, particularly in non-advanced SM, and have similar treatment goals for this patient population, including improvement in QoL and symptom control. In this sample of HCPs, the perceived prevalence of the KIT D816V mutation as well as the perceived time from symptom onset to diagnosis were substantially lower than published estimates. These gaps identified suggest a need to improve HCP awareness of SM symptoms and diagnostic tools to help facilitate earlier patient diagnosis. 1. Garcia-Montero et al. Blood. 2006;108(7):2366-2372. 2. Jennings SV et al. Immuno Allergy Clin North Am. 2018;38(3):505-525. Disclosures Mesa: Promedior: Research Funding; Incyte: Research Funding; Genetech: Research Funding; CTI: Research Funding; Celgene: Research Funding; Abbvie: Research Funding; Sierra Onc: Consultancy; Novartis: Consultancy; LaJolla Pharma: Consultancy; Samus: Research Funding. Sullivan:Blueprint Medicines Corporation: Current Employment, Current equity holder in publicly-traded company. Dubinsky:Blueprint Medicines Corporation: Current Employment, Current equity holder in publicly-traded company. Carroll:Blueprint Medicines Corporation: Consultancy, Current equity holder in publicly-traded company. Mathias:Blueprint Medicines Corporation: Other: employed by Health Outcomes Solutions, which received funding Blueprint for providing assistance in developing the Touchstone survey. Castells:Blueprint Medicines Corporation: Consultancy, Other: Clinical trials: Principle Investigator; UpToDate: Other: Author fee; Annals of Allergy, Asthma & Immunology: Other: Editorial Board.

The mind and the body are clearly intertwined in ways that are only now being discovered. In the orthopaedic world, injuries and diseases are often classified and described in a very organized, discrete fashion-The radius is fractured, the ACL or meniscus or rotator cuff is torn, the ankle is sprained, and/or the lumbar spine has a disc herniation. Although it is, in many ways, almost comforting to think about injuries or orthopaedic issues in this manner, what about the many patients who fail to fall into this classification? What about the thousands of patients with severe unexplained chronic pain or patients who just are not improving with the typical treatment algorithm. What about patients who present with multiple overlapping symptoms that do not fall into any of the classic diagnosis patterns? The mismatch between the actual health needs of typical patients and the standard acute medical response produces an immense waste of medical resources and incredible frustration for both the patient and the provider and creates a real risk that acute conditions will go untreated and become chronic. After more than a decade of traditional orthopaedic and musculoskeletal practice, its tremendous benefits as well as its limitations have become apparent. These limitations have sparked a search for integration of mind-body considerations to fill some of these gaps. Although this can prove to be quite challenging in today's healthcare world of maximizing volume and decreasing costs, it has proven to be an invaluable resource for both personal growth and patient and family satisfaction. The goals of this 2-part article are to dissect the relatively new concept of the mind-body connection in orthopaedics. The article aims to provide a framework that illustrates how the mind will predictably create objective observable phenomena in the body. The central focus of this framework is the role of the sympathetic nervous system and its effect on the chemistry, biomechanics, and appearance of various tissues in the body. Further identified are factors contributing to the aberrant emotional response as a means to empower practitioners and patients in recognizing the link between negative perception and observable symptoms. Our hope is to ultimately introduce a model of empowerment that when presented to a patient/family can produce a proactive response and, in turn, enhance current orthopaedic and pain management practices.

As the US transitions to value-based healthcare, physicians and payers are incentivized to change healthcare delivery to improve quality of care while controlling costs. By assisting with the management of common chronic conditions, community health workers (CHWs) may improve healthcare quality, but physicians and payers who are making choices about care delivery also need to understand their effects on healthcare spending.We searched PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PsycINFO, Embase, and Web of Science from the inception of each database to 22 June 2015. We included US-based studies that evaluated a CHW intervention for patients with at least one chronic health condition and reported cost or healthcare utilization outcomes. We evaluated studies using tools specific to study design.Our search yielded 2,941 studies after removing duplicates. Thirty-four met inclusion and methodological criteria. Sixteen studies (47%) were randomized controlled trials (RCTs). RCTs typically had less positive outcomes than other study designs. Of the 16 RCTs, 12 reported utilization outcomes, of which 5 showed a significant reduction in one or more of ED visits, hospitalizations and/or urgent care visits. Significant reductions reported in ED visits ranged from 23%-51% and in hospitalizations ranged from 21%-50%, and the one significant reduction in urgent care visits was recorded at 60% (p 0.05 for all).Our results suggest that CHW interventions have variable effects, but some may reduce costs and preventable utilization. These findings suggest that it is possible to achieve reductions in care utilization and cost savings by integrating CHWs into chronic care management. However, variations in cost and utilization outcomes suggest that CHWs alone do not make an intervention successful. The paucity of rigorous studies and heterogeneity of study designs limited conclusions about factors associated with reduced utilization.

INTRODUCTIONT he need for accessible, efficient, cost-effective, and quality primary care is a recurring theme in the literature. The 15-minute physician visit model fails to provide acute, chronic, and preventive care and does not enable providers to build lasting relationships with patients or manage multiple diagnoses in line with evidence-based recommendations (Bodenheimer & Laing, 2007). These problems have caused a resurgence of interest in team-based primary care among key stakeholders, including government officials, providers, policy analysts, and researchers (Institute of Medicine, 2011; Iglehart, 2009). The rise of integrated models, such as accountable care organizations and patient-centered medical homes (PCMI Is), the critical shortage of primary care physicians, the increasing number of patients covered by insurance since passage of the Affordable Care Act, the prioritization of interprofessional training, and the call for payment reform all suggest a solution that includes implementation of team-based primary care (Iglehart, 2009). By incorporating team-based frameworks and lessons from management, stakeholders can create innovative and holistic solutions for primary care that enable teams to achieve goals (Hackman, 1990). The purpose of this literature review is to examine the extensive management literature on this topic, as well as current trends and recommendations in the healthcare literature. T his review focuses on applying this knowledge to primary care and considers the preliminary research conducted on primary care teams.METHODSStudy DesignWe conducted an extensive, semistructured review of management and healthcare literature to identify research on teams. We identified articles in the Business Source Complete (Premier, Elite, and Main Edition), Academic Search Complete (Premier, Elite, and Main Edition), Coogle Scholar, and PubMed databases, and we also identified relevant reports and white papers on prominent healthcare websites, including-but not limited to-The Commonwealth Fund, The Robert Wood Johnson Foundation, and T he Johns I Jopkins Primary Care Consortium. In addition, we examined cited works and references to discover additional publications. The following key search terms, as well as stems, variants, and synonyms, were used in combination across the databases: "management," "teams," "teamwork," "interprofessional teams," "cross-functional teams," "highfunctioning, " "high-performing," "health care," and "primary care." Additionally, the MeSH (Medical Subject Headings) headings "primary health care" and "patient care team" were used in PubMed to focus results. We queried databases and collected articles dating from 1979 to 2015.Inclusion Criteria and Articles IdentifiedAll articles identified in the preliminary searches were selected because of their interdisciplinarity and potential applicability to healthcare. "Management" searches yielded results from the fields of general management, service management, operations management, crisis management, organizational behavior, and strategy. We excluded articles from the field of information services because we determined that their technologyfocused team structure was too narrow and did not directly apply to healthcare. Our search for "teams" and "teamwork" included, but was not limited to, literature detailing members of a team and their behavior, planning, and execution of teamwork, situations requiring teams, and benefits and challenges of teams. We also included seminal literature on "interprofessional" and "cross-functional" teams. For the terms "high functioning and high performing," we included literature pertaining to the distinction between successful and unsuccessful teams. When searching for the term "health care," we included only literature relevant to the field in general; with the exception of primary care, subspecialties were excluded. Within primary care, we included existing models and evidence of team-based care for adults from internal medicine, family medicine, pediatrics, and geriatrics; literature focusing on mental health was excluded because of its lack of integration with primary care. …

Introduction: SM is a rare, clonal mast cell neoplasm characterized by uncontrolled proliferation and activation of mast cells driven by the KIT D816V mutation, which leads to severe and unpredictable symptoms. This study evaluated disease and healthcare system burden of SM in a real-world treatment setting in the US. Methods: In this cross-sectional study, SM patients recruited through the Mast Cell Connect Registry completed an online survey. The 100-item survey consists of symptom assessments using the ISM-SAF© and widely used patient-reported outcomes (PRO) measures including the Short Form (SF)-12, Work Productivity and Activity Impairment (WPAI), and questions regarding SM-related medication and physician and emergency department (ED) visits during the past year. Patients ≥18 years with a self-reported diagnosis were included after providing informed consent. Established PRO measures were scored using established scoring algorithms. Data from the first 30 patients enrolled were analyzed using descriptive statistics. Results: Thirty patients completed the survey: 87% female; mean age of 54 years; mean time since diagnosis of 8 years; mean time from symptom onset to diagnosis of 7 years; 80% reported indolent SM, 10% reported aggressive SM, 3% reported smoldering SM, and the remainder (7%) were uncertain of their type. Ninety percent reported ≥10 symptoms during the past year, the most bothersome being abdominal/stomach pain (17%), anaphylactic episodes (13%), diarrhea/loose stools (13%), and fatigue (10%). Most patients indicated they have moderate (43%) or severe (33%) disease. Symptom Burden and Quality of Life (QoL) Impact Mean ± SD mental and physical component summary scores from the SF-12 were 44 ± 1.8 and 43 ± 2.5, respectively, indicating below average health and mental well-being. The mean total symptom score (TSS) from the ISM-SAF was 50, with >28 indicating moderate-severe SM. Nearly all (27/30) patients reported that they strongly agreed (27%), agreed (40%) or somewhat agreed (23%) that SM had a negative impact on their QoL, and 50% (15/30) reported feeling a great deal (17%), quite a bit (10%), or somewhat (23%) depressed or discouraged due to their disease. Use of Healthcare Services & Medications Patients reported encounters with multiple physicians over the course of 1 year (Table). Most patients (90%) reported taking ≥2 over-the-counter (OTC) medications, and 40% of patients reported taking >3 prescription medications to manage SM. Twenty percent of survey respondents visited the ED due to anaphylaxis, with 50% of these patients requiring ED care for anaphylaxis on 3 different occasions. Fifty-seven percent (17/30) of patients reported managing at least 1 anaphylactic episode at home without visiting the ED, with 4 of these patients reporting ≥12 anaphylactic episodes within the past year. Work Impairment Limited activities due to pain attributed to SM were reported by 60% (18/30) of patients, and 56% (17/30) of patients indicated that pain interfered with their ability to work. 17% of respondents reported they were unable to work for pay, 46% of patients reported having to reduce work hours because of SM, and 20% of patients had filed for disability, all due to SM. Conclusions: Despite close management by healthcare providers, and taking prescription and OTC medications, early findings from the TouchStone survey show that the majority of SM patients continue to report significant burden of disease, including inadequate symptom control, negative effects on QoL, reduced ability to work, frequent physician visits to manage SM and multiple, potentially costly, ED visits. These findings suggest high unmet medical need underscoring the value of more effective therapeutic interventions. Disclosures Mesa: LaJolla Pharma: Consultancy; Novartis: Consultancy; Sierra Onc: Consultancy; Abbvie: Research Funding; Celgene: Research Funding; CTI: Research Funding; Genetech: Research Funding; Incyte: Research Funding; Promedior: Research Funding; Samus: Research Funding. Sullivan:Blueprint Medicines Corporation: Current Employment, Current equity holder in publicly-traded company. Dubinsky:Blueprint Medicines Corporation: Current Employment, Current equity holder in publicly-traded company. Carroll:Blueprint Medicines Corporation: Consultancy, Current equity holder in publicly-traded company. Mathias:Blueprint Medicines Corporation: Other: employed by Health Outcomes Solutions, which received funding Blueprint for providing assistance in developing the Touchstone survey. Castells:Annals of Allergy, Asthma & Immunology: Other: Editorial Board; UpToDate: Other: Author fee; Blueprint Medicines Corporation: Consultancy, Other: Clinical trials: Principle Investigator.

Background Ascertaining history of prior immunization with human papillomavirus (HPV) vaccine can be challenging and resource-intensive. Computer-assisted self-interviewing instruments have the potential to address some of the challenges of self-reporting, and may also reduce the time, costs, and efforts associated with ascertaining immunization status. Objective This study assesses both the feasibility and the accuracy of a computer-assisted self-interviewing instrument to ascertain a patient’s history of immunization with the HPV vaccine. Methods We developed both a survey and a Web-based data collection system using computer-assisted self-interviewing to ascertain self-reported HPV vaccine immunization history. We implemented the instrument in a sample of adult women enrolled in an ongoing study of the HPV vaccine. Vaccine records from prior sources of care were reviewed to verify reported immunization history. Results Among the 312 participants who provided HPV vaccine immunization history by self-report, almost all (99%) were able to do so using the computer-assisted self-interviewing instrument. The median survey completion time was 10 minutes (IQR 7-17). The accuracy of self-report was 84%, sensitivity was 89%, specificity was 80%, and the negative predictive value was 92%. Conclusions We found that it is feasible to collect a history of immunization with the HPV vaccine using a computer-assisted self-interviewing instrument. This approach is likely to be acceptable to adult women and is reasonably accurate in a clinical research setting.

BACKGROUND: Research in treatment-naïve, first episode patients with severe mental illnesses (SMIs) suggest a pre-diabetic condition at the onset of illness. However, we have limited knowledge on glucose metabolism differences across diagnostic categories of SMIs. AIMS: To compare the differences of glucose metabolism outcomes between treatment-naïve, patients with first episode psychosis (FEP) and mood disorders. METHOD: We conducted a systematic review and meta-analysis of glucose intolerance in treatment-naïve, first episode patients with SMIs. RESULTS: We identified 31 eligible studies. Compared to healthy controls, FEP group have higher insulin and insulin resistance levels, and both groups have higher glucose tolerance test results. No significant differences were found in glucose metabolism outcomes between FEP and mood disorder groups. CONCLUSIONS: Our results highlight impaired glucose metabolism at the onset of SMIs, suggesting both patients with psychosis and mood disorders are high-risk groups for diabetes development.

The present study focuses on current efforts underway in one western US state to prepare educators’ for meaningful participation with families. Directors and faculty from 43 accredited Institutions of Higher Education (IHEs) preparing pre-service teachers, administrators, and student support personnel were asked to complete an online survey regarding current family–school partnering coursework, practice requirements, and resources. Responses were obtained from 63% of the identified programs. Similar to prior studies, our results indicate that current course offerings and field practice requirements may not match prevailing views regarding the need for and importance of family engagement in promoting student success. Specific recommendations include refocusing coursework, providing alternative field experiences, offering interdisciplinary coursework and projects, and developing ongoing avenues for continued professional development to improve the preparation of future educators to partner with families.

Background : In 2013, the Harvard Medical School Center for Primary Care established the Abundance Agents of Change (AoC) program to promote interprofessional learning and innovation, increase partnership between 15 academic and community health centers (CHCs) in Boston’s most under-served communities, and increase medical student interest in primary care careers. Methods : The AoC is modeled in the form of a ‘grants challenge’, offering $20,000 to interprofessional student teams to develop an innovative solution that addresses a healthcare delivery need identified by CHCs. The program’s initial two years were characterized by a four-stage process which included working with CHCs and crafting a request for proposals, forming interprofessional 20 student teams comprising students from across and outside of Harvard University, training students using a systems-based innovation curriculum, and performing program evaluation. Results : Our evaluation data from cohorts 1 and 2 of the AoC program demonstrate that we succeeded in training students as innovators and members of interprofessional teams. We also learned valuable lessons regarding creating better alignment with CHC priorities, extending the program cycle from 12 to 18 months, and changing the way funding is disbursed to 25 students, which will be incorporated in later versions of the program. Conclusions : Based on our experience and evaluation data, we believe that this program is a replicable way to train students as innovators and members of interprofessional teams to address the current complex healthcare environment. Keywords: leadership; innovation; community health centers; interprofessional; teams (Published: 14 June 2016) Citation: Med Educ Online 2016, 21: 30662 - http://dx.doi.org/10.3402/meo.v21.30662

Investments in global health have more than doubled over the past decade, generating a cadre of new institutions. To date, most of the funded research in global health has focused on discovery, and, more recently, on the development of new tools, which has tightened the implementation bottleneck. This article introduces the concept of global health delivery and the need to catalog and analyze current implementation efforts to bridge gaps in delivery. Global health delivery is complex and context-dependent and requires an interdisciplinary effort, including the application of strategic principles. Furthermore, delivery is necessary to ensure that the investments in research, discovery, and development generate value for patients and populations. This article discusses the application of value-based delivery to global health. It provides some examples of approaches to aggregating implicit knowledge to inform practice. With global health delivery, the aim is to transform global health scale-up from a series of well-intentioned but often disconnected efforts to a value-based movement based upon 21st-century technology, standards, and efficiency. Mt Sinai J Med 78:458–469, 2011 © 2011 Mount Sinai School of Medicine

End-stage liver disease with severe portopulmonary hypertension (PPHTN), which is refractory to vasodilator therapies, is a contraindication for isolated liver transplantation (LT) because of the high mortality rate. Combined heart, lung, and liver transplantation (CHLLT) and combined lung and liver transplantation (CLLT) can be lifesaving options for these patients; however, these procedures have rarely been performed. A 52-year-old man had end-stage liver disease due to hepatitis C and PPHTN; the latter showed a suboptimal response to pulmonary vasodilator therapy with continuous intravenous treprostinil sodium and oral sildenafil citrate and was considered a contraindication to isolated LT. His preoperative left ventricular function was normal, and he had mild to moderate right ventricular dysfunction. He underwent CLLT, which consisted of sequential double-lung transplantation under cardiopulmonary bypass followed by standard LT under venovenous bypass. Re-exploration of the chest cavity was necessary because of bleeding, and respiratory failure developed; however, the patient recovered, was discharged home on day 26, and remained well 1 year after CLLT with the standard immunosuppressants (similar to those used for heart and lung transplantation). For PPHTN, combined thoracic organ and liver transplantation has been reported in only 10 patients. Six of these patients, including our case, underwent CLLT, whereas 4 patients underwent CHLLT. Notably, 2 of the 6 CLLT patients expired within 24 hours of transplantation because of acute right heart failure. CHLLT should be considered for patients with refractory PPHTN. The assessment of preoperative cardiac function is a vital part of the decision to include heart transplantation in CLLT.

Evidence has accumulated since the Alma Ata declaration (1978) that health care systems with a greater primary care orientation achieve better outcomes at lower cost. Yet, little progress has been ...

Objectives This study was conducted to evaluate the safety and efficacy of high-dose tranexamic acid (TA) compared with aprotinin in patients who underwent thoracic aortic surgery with deep hypothermic circulatory arrest (DHCA). Design A retrospective study. Participants Eighty-four patients underwent thoracic aortic surgery with DHCA arrest between July 2006 and December 2007. Antifibrinolytic efficacy and perioperative outcomes were compared between the groups by appropriate statistical tests. Measurements and Main Results Demographic data, comorbid conditions, aortic pathology, surgical procedures, and operative data were comparable between groups. The use of blood products tended to be more in the TA group, despite the fact that the aprotinin group had longer CPB duration. Thirty-day mortality was 5 of 48 (10.4%) in the aprotinin group versus 5 of 36 (13.9%) in the TA group (p = 0.44). Neurologic, cardiac, and respiratory dysfunctions were comparable as well as intensive care unit and hospital stay. Serum creatinine increased significantly postoperatively in both groups, with more patients in the aprotinin group developing stage 1 postoperative renal dysfunction based on Acute Kidney Insufficiency Network criteria. Multivariate logistic regression analysis identified risk factors for postoperative renal dysfunction including preoperative creatinine clearance, blood transfusion, and sepsis. Throughout the study, both drugs were available for use, allowing selective bias for providers. Conclusions Aprotinin appeared more effective in reducing blood product use after thoracic aortic surgery in this limited cohort. Aprotinin use also appeared to be associated with postoperative renal dysfunction. The choice of antifibrinolytic appeared to not be associated with cardiac, neurologic, or respiratory outcomes or survival after thoracic aortic surgery requiring DHCA.

Background CT scan measures of emphysema and airway disease have been correlated with lung function in cohorts of subjects with a range of COPD severity. The contribution of CT scan-assessed airway disease to objective measures of lung function and respiratory symptoms such as dyspnea in severe emphysema is less clear. Methods Using data from 338 subjects in the National Emphysema Treatment Trial (NETT) Genetics Ancillary Study, densitometric measures of emphysema using a threshold of −950 Hounsfield units (%LAA-950) and airway wall phenotypes of the wall thickness (WT) and the square root of wall area (SRWA) of a 10-mm luminal perimeter airway were calculated for each subject. Linear regression analysis was performed for outcome variables FEV 1 and percent predicted value of FEV 1 with CT scan measures of emphysema and airway disease. Results In univariate analysis, there were significant negative correlations between %LAA-950 and both the WT ( r = −0.28, p = 0.0001) and SRWA ( r = −0.19, p = 0.0008). Airway wall thickness was weakly but significantly correlated with postbronchodilator FEV 1 % predicted (R = −0.12, p = 0.02). Multivariate analysis showed significant associations between either WT or SRWA (β = −5.2, p = 0.009; β = −2.6, p = 0.008, respectively) and %LAA-950 (β = −10.6, p = 0.03) with the postbronchodilator FEV 1 % predicted. Male subjects exhibited significantly thicker airway wall phenotypes (p = 0.007 for WT and p = 0.0006 for SRWA). Conclusions Airway disease and emphysema detected by CT scanning are inversely related in patients with severe COPD. Airway wall phenotypes were influenced by gender and associated with lung function in subjects with severe emphysema.

Challenged by demands to reduce costs and improve service delivery, the U.S. health care system requires transformational change. Health systems innovation is defined broadly as novel ideas, products, services, and processes-including new ways to promote healthy behaviors and better integrate health services with public health and other social services-which achieve better health outcomes and/or patient experience at equal or lower cost. Academic health centers (AHCs) have an opportunity to focus their considerable influence and expertise on health systems innovation to create new approaches to service delivery and to nurture leaders of transformation. AHCs have traditionally used their promotions criteria to signal their values; creating a health systems innovator promotion track could be a critical step towards creating opportunities for innovators in academic medicine. In this Perspective, the authors review publicly available promotions materials at top-ranked medical schools and find that while criteria for advancement increasingly recognize systems innovation, there is a lack of specificity on metrics beyond the traditional yardstick of peer-reviewed publications. In addition to new promotions pathways and alternative evidence for the impact of scholarship, other approaches to fostering health systems innovation at AHCs include more robust funding for career development in health systems innovation, new curricula to enable trainees to develop skills in health systems innovation, and new ways for innovators to disseminate their work. AHCs that foster health systems innovation could meet a critical need to contribute both to the sustainability of our health care system and to AHCs' continued leadership role within it.

Significant advances have been achieved in surgical and anesthetic techniques for the treatment of patients presenting with a variety of complex intrathoracic lesions. Despite the technologic advances, these patients continue to pose a challenge for anesthesiologists to provide safe and effective clinical care. A thorough understanding of the patient's underlying pathology inclusive of a detailed preoperative evaluation and effective communication between the surgical and anesthesia teams would help to ensure a favorable outcome.

To evaluate the cost effectiveness of minimally invasive therapy relative to medical (alpha-blocker) therapy and transurethral resection (TURP) for patients with moderate to severe symptoms of benign prostatic hyperplasia (BPH).We constructed a decision-analytic Markov model for a hypothetical cohort of 65-year-old men with moderate to severe BPH symptoms. Microwave thermotherapy was selected to represent minimally invasive treatment. Cost-effectiveness analysis was performed with 25 health states using the 3 treatments, 5 short-term clinical events, and 17 possible long-term outcomes. Each health state had an associated cost and utility. Quality of life (QoL) and utility estimates were obtained by interviewing 13 men with BPH symptoms using the standard gamble reference methods. Patients were classified as risk averse (RA) or non-risk averse (NRA) on the basis of their attitudes to risk. We calculated the incremental cost effectiveness of microwave thermotherapy relative to medical therapy and TURP over 5 years after treatment initiation. Event probabilities were obtained from the literature, a consensus panel, and published randomized clinical trials.The utility values generated were internally consistent and externally valid for a hypothetical cohort of 10,000 RA patients. Microwave thermotherapy was preferred by the NRA group, while medical therapy was preferred by the RA group. Surgery was least preferred by both groups. Microwave thermotherapy had a small incremental cost but improved QoL in comparison with medical therapy. Microwave thermotherapy had a higher utility and lower cost than TURP and thus was dominant over TURP. This analytical method can be applied to evaluate the cost effectiveness of any BPH therapy.

Objective. To identify costs among rheumatoid arthritis (RA) patients receiving alternative disease-modifying antirheumatic drug (DMARD) therapies. Methods. Using managed care organization data, we identified members who (a) were prescribed any DMARD therapy for two consecutive months between July 1993 and February 1998, (b) were aged ≥18 years, (c) had ≥6 months of DMARD-free enrollment prior to the first DMARD, and (d) had a diagnosis of RA. Results. The average age of the cohort (n = 571) was 51 years, and 70% were women. Mean duration of enrollment following initiation of DMARD therapy (observation period) was 19.5 months; 28.8% of patients switched DMARD regimens. The average monthly cost of care was $853, of which $294 (34%) was for RA-coded medical services. Monthly RA-coded costs varied by DMARD: hydroxychloroquine $227 (n = 252), methotrexate $340 (n = 185); sulfasalazine $233 (n = 49), and other mono/combination therapy $425 (n = 85) (P = 0.001). Conclusion. Costs of RA-coded care in patients receiving DMARDs are low and vary by DMARD.

Background: We compared patterns of medical resource utilization and costs among patients receiving a serotonin-norepinephrine reuptake inhibitor (venlafaxine), one of the selective serotonin reuptake inhibitors (SSRIs), one of the tricyclic agents (TCAs), or 1 of 3 other second-line therapies for depression. Method: Using claims data from a national managed care organization, we identified patients diagnosed with depression (ICD-9-CM criteria) who received second-line antidepressant therapy between 1993 and 1997. Second-line therapy was defined as a switch from the first class of antidepressant therapy observed in the data set within 1 year of a diagnosis of depression to a different class of antidepressant therapy. Patients with psychiatric comorbidities were excluded. Results: Of 981 patients included in the study, 21% (N = 208) received venlafaxine, 34% (N = 332) received an SSRI, 19% (N = 191) received a TCA, and 25% (N = 250) received other second- line antidepressant therapy. Mean age was 43 years, and 72% of patients were women. Age, prescriber of second-line therapy, and prior 6-month expenditures all differed significantly among the 4 therapy groups. Total, depression- coded, and non-depression-coded 1-year expenditures were, respectively, $6945, $2064, and $4881 for venlafaxine; $7237, $1682, and $5555 for SSRIs; $7925, $1335, and $6590 for TCAs; and $7371, $2222, and $5149 for other antidepressants. In bivariate analyses, compared with TCA-treated patients, venlafaxine- and SSRI-treated patients had significantly higher depression- coded but significantly lower non-depression-coded expenditures. Venlafaxine was associated with significantly higher depression-coded expenditures than SSRIs. However, after adjustment for potential confounding covariables in multivariate analyses, only the difference in depression-coded expenditures between SSRI and TCA therapy remained significant. Conclusion: After adjustment for confounding patient characteristics, 1-year medical expenditures were generally similar among patients receiving venlafaxine, SSRIs, TCAs, and other second-line therapies for depression. Observed differences in patient characteristics and unadjusted expenditures raise questions as to how different types of patients are selected to receive alternative second-line thera pies for depression.

The coronary arterial bed is diffusely and heavily innervated by the sympathetic nervous system. The anatomical arrangements of both the vagal and the sympathetic at the level of the cardiac plexus and below are also sufficiently complex to make clear distinctions between these nerves difficult. At the level of the coronary artery, however, the situation seems clearer. The normal arterial smooth muscle responds to sympathetic stimulation with vasodilation; however, the atherosclerotic coronary bed responds with vasoconstriction. The exact aetiology of this response is either a reflection of the loss of endothelial cell integrity and hence vasodilatory capacity or the release of mediators which are not normally found at sympathetic terminals. The latter response is probably related to the release of serotonin. The source for the serotonin is thought to follow its non-specific uptake at platelet activation sites. These sites are typically found at areas of high turbulence and constriction in the coronary bed. The successful ablation of this sympathetic constriction is accomplished most thoroughly with the use of thoracic epidural blockade or anaesthesia (TEA). There is extensive experience in both animals and humans with the use of TEA around the time of myocardial ischaemia. In animals the use of TEA is capable of decreasing the incidence and type of ventricular arrythmias following an ischaemic insult. In humans the use of TEA can reduce in most patients and totally supplant in many the need for anti-ischaemic medications during unstable anginal episodes. Further the outcome of these patients may be improved when compared with cohorts not receiving TEA. The use of TEA for cardiac surgery is associated with an improvement in pulmonary and myocardial function following surgery. While the release of catecholamines is reduced during surgery, glucocorticoid response remains unimpaired. The incidence of ischaemia is reduced by 50% in the post-operative period following TEA activation. Finally, patients receiving TEA resume normal body temperatures more rapidly and are extubated more quickly than their conventionally treated counterparts. While there is much we do not know about the use of TEA during cardiac surgery, we do know that the risk of neuraxial haematoma formation is not excessively high. As of this writing almost 4000 patients world wide have received TEA during cardiopulmonary bypass and there are no reports of haematoma formation. This suggests that the previously postulated mechanisms for haematoma formation may be in error.

Amyotrophic lateral sclerosis (ALS) is a fatal, degenerative neuromuscular disease characterised by a progressive loss of voluntary motor activity. Recombinant human insulin-like growth factor I (rhIGF-I) has been shown to be useful in treating ALS. The purpose of this study was to examine the cost effectiveness of rhIGF-I therapy in patients who have ALS.We performed a cost-effectiveness analysis from the societal perspective on 177 patients who received treatment with rhIGF-I or placebo in a North American randomised clinical trial. We estimated the incremental cost-effectiveness ratio of rhIGF-I using resource utilisation and functional status measurements from the clinical trial. Costs were estimated from 1996 US Medicare reimbursement schedules. Utility weights were elicited from ALS healthcare providers using the standard gamble technique.The overall cost per quality-adjusted life-year (QALY) gained for rhIGF-I therapy compared with placebo was $US67,440. For the subgroups of patients who were progressing rapidly or were in earlier stages of disease at enrolment, rhIGF-I cost $US52,823 and $US43,197 per QALY gained, respectively.Treatment with rhIGF-I is most cost effective in ALS patients who are either in earlier stages of the disease or progressing rapidly. The cost effectiveness of rhIGF-I therapy compares favourably with treatments for other chronic progressive diseases.

We assessed the frequency and costs of hospitalizations in patients receiving tacrolimus (FK506) compared with patients receiving cyclosporine A for immunosuppression during 1 year after kidney transplantation. Four hundred twelve cadaveric kidney transplant recipients were randomized onto a phase III, prospective, multicenter, clinical trial. Hospital billing data were collected for 1 year posttransplantation. Total inpatient costs were calculated from billed charges and standardized to 1995 US dollars. Medical resource utilization rates and inpatient costs were compared between treatment groups using unpaired Student's t-tests. Complete billing data (transplantation and all posttransplantation hospitalizations) were available for 65% (268 of 412) of the study patients. Among tacrolimus and cyclosporine patients with complete billing data, the rates of allograft rejection were 32% and 47%, respectively (P=0.009), and the rates of rehospitalization during the year after transplantation were 53% and 63%, respectively (P=0.080). The mean per-episode rehospitalization costs were significantly lower among tacrolimus-treated patients compared with cyclosporine-treated patients ($7,495 v $11,497; P=0.031), and the mean total rehospitalization costs were significantly lower in the tacrolimus group compared with the cyclosporine group ($8,550 v $14,869; P=0.029). In addition, the total 1-year hospitalization costs (including transplantation and posttransplantation hospitalizations) were significantly lower in the tacrolimus group compared with the cyclosporine group ($53,435 v $61,191; P=0.046). Compared with cyclosporine-based immunosuppression, tacrolimus-based immunosuppression for kidney transplant recipients was associated with a significantly lower rate of rejection, which was associated with significantly lower per-episode rehospitalization costs, lower total 1-year rehospitalization costs, and lower total 1-year hospitalization costs.

Summary Cardiovascular morbidity continues to represent the single most important contributor to surgical mortality. The impact of postoperative interventions in potentially improving cardiovascular morbidity and mortality is extremely difficult to separate from the influence of the intra-operative technique. It is most likely that the combination of techniques used intra-operatively and postoperatively have a combined impact on cardiovascular outcome. A thorough preoperative assessment of the patient to determine the probability of risk for coronary artery disease and whether further workup will improve patient outcome is essential. Perioperative interventions such as coronary artery bypass grafting have not always shown a subsequent reduction in patient morbidity before noncardiac surgery. Other perioperative interventions such as percutaneous transluminal coronary angioplasty and the insertion of an intraaortic balloon pump may provide more patient benefit with less risk than coronary artery bypass graft. Intra-operative monitoring devices are only helpful if clinicians can interpret and extrapolate meaningful data that will assist them in achieving an end-point (detection and prevention of myocardial ischemia) for their patient's management. A familiarity of the sensitivity and specificity of a particular monitoring device is helpful to determine the best method for detecting myocardial ischemia. A smooth transition from the intraoperative to the postoperative period is desirable. Attenuation of the neurohumeral stress response through adequate pain management may reduce the incidence of postoperative morbid cardiac events. Regional techniques may hold the greatest promise for effecting significant improvements in cardiovascular outcome. Yeager's study is conclusive in showing that epidural anesthesia and analgesia results in decreased morbidity and mortality for major vascular surgery patients. Tuman 55 showed decreased hypercoagulability with epidural anesthesia that may be a critical physiological benefit in reducing the incidence of vascular graft occlusion, coronary artery occlusion, and deep venous thromboses. Blomberg's studies in patients with severe coronary artery disease provide insight into the mechanisms by which epidural anesthesia may be a therapeutic measure in preventing and treating myocardial ischemia. Perhaps we should consider using thoracic epidural anesthesia for patients with coronary artery disease scheduled for noncardiac surgery to reduce the incidence or even the occurrence of perioperative myocardial infarction. Perhaps thoracic epidural anesthesia will replace our conventional therapies for myocardial ischemia. Only further investigation of this hypothesis will elucidate the answer.

Lung volume reduction surgery (LVRS) is a viable option for a select group of emphysema patients. Effective preoperative pulmonary rehabilitation and careful patient selection criteria promote favorable outcomes. Effective perioperative pain management and early extubation are significant factors that minimize postoperative complications and lead to better outcome. LVRS improves dyspnea, exercise tolerance, and increases potential for patient survival in appropriately selected patients.

Objective.— To prospectively evaluate the diagnosis of menstrual migraine (MM) by comparing 2 diagnostic systems. Methods.— Female migraineurs self-reporting a substantial relationship between migraine and menses were evaluated with 3 consecutive months of daily headache recording diaries. A relationship between menses and migraine was evaluated using International Classification of Headache Disorders (ICHD-II) criteria and a probability model called Probability MM. Results.— Three months of pretreatment prospective diaries were completed by 126 women. ICHD-II menstrually related migraine was diagnosed in 73.8% with pure MM in 7.1%. ICHD-II and Probability diagnoses agreed for all cases of ICHD-II non-MM and pure MM, with disagreement among women diagnosed with ICHD-II menstrually related migraine, only half of whom were identified as having a relationship with menses greater than chance alone using the Probability model. Interestingly, 20% of those women self-reporting a substantial relationship between migraine and menses were not prospectively diagnosed with MM using either diagnostic system. Differences in menstrual vs nonmenstrual headaches were greater when using the Probability model. Conclusions.— Prospective headache diaries are needed to diagnose MM. A probability-based method, which considers the chance occurrence of headaches during the menstrual cycle, identifies fewer women as having menstrually related migraine compared with the diary-based methods recommended by the current ICHD-II candidate criteria. (Headache 2010;50:539-550)

Objective.— To prospectively evaluate the efficacy of perimenstrual prophylaxis with eletriptan to reduce headaches in women identified with menstrual migraine (MM). Methods.— Female migraineurs self-reporting a substantial relationship between migraine and menses were evaluated with 3 consecutive months of daily headache recording diaries. A relationship between menses and migraine was evaluated using International Classification of Headache Disorders (ICHD-II) criteria and a probability model called Probability MM. Women prospectively diagnosed with ICHD-II MM were treated for 3 consecutive months with perimenstrual eletriptan 20 mg 3 times daily starting 2 days prior to the expected onset of menstruation and continued for a total of 6 days. Headache activity was compared during the 3 months of recording prior to eletriptan therapy and 3 months with eletriptan perimenstrual prevention therapy. Results.— Three months of pretreatment prospective diaries were completed by 126 women. ICHD-II menstrually related migraine was diagnosed in 74%, with pure MM in 7%. Among those women diagnosed with ICHD-II MM, 61 completed at least 1 treatment month. Overall change in headache activity was a 46% decrease. The mean percentage of treated menses without migraine occurring during the 6 days of treatment was 71%. The percentage of subjects with 1, 2, and 3 migraine-free menstrual periods (no migraines occurring 2 days before menses through the first 3 days of menstruation) with eletriptan, respectively, were 14%, 19%, and 53%. Among those subjects who remained headache-free during the 6 days of eletriptan treatment, migraine occurred during the 3 days immediately after discontinuing eletriptan for 9%. Perimenstrual eletriptan was generally tolerated and no abnormalities were identified on the 6th day of treatment using either blood pressure recording or electrocardiogram. Conclusions.— Among patients with prospectively identified MM, eletriptan 20 mg 3 times daily effectively reduced MM. A significant reduction in headache activity occurred for 53% of patients. (Headache 2010;50:551-562)

Research on talented women who have achieved eminence in a variety of domains illustrates that no one formula leads to success. Some successful women marry and have children; some do not. Some work and live at high speed; others move more calmly through the world and achieve at similar or even higher levels. The current chapter draws from two decades of research pertaining to the lives of women who have successfully navigated the obstacles that often prevent high achievement in women, offering a new theory of female talent development. Issues explored include the spheres in which women express their talents, factors that may promote or inhibit the development of gifts, and gender differences in experiences that contribute to the unique nature of female achievement.