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Background: Physician burnout is associated with deleterious effects for physicians and their patients and might be exacerbated by practice transformation.Objective: Assess the effect of the Comprehensive Primary Care (CPC) initiative on primary care physician experience.Design: Prospective cohort study conducted with about 500 CPC and 900 matched comparison practices. Mail surveys of primary care physicians, selected using cross-sectional stratified random selection 11 months into CPC, and a longitudinal design with sample replacement 44 months into CPC.Participants: Primary care physicians in study practices.Intervention: A multipayer primary care transformation initiative (October 2012-December 2016) that required care delivery changes and provided enhanced payment, data feedback, and learning support.Main Measures: Burnout, control over work, job satisfaction, likelihood of leaving current practice within 2 years.Key Results: More than 1000 physicians responded (over 630 of these in CPC practices) in each round (response rates 70-81%, depending on round and research group). Physician experience outcomes were similar for physicians in CPC and comparison practices. About one third of physician respondents in CPC and comparison practices reported high levels of burnout in each round (32 and 29% in 2013 [P = 0.59], and 34 and 36% in 2016 [P = 0.63]). Physicians in CPC and comparison practices reported some to moderate control over work, with an average score from 0.50 to 0.55 out of 1 in 2013 and 2016 (CPC-comparison differences of - 0.04 in 2013 [95% CI - 0.08-0.00, P = 0.07], and - 0.03 in 2016 [95% CI - 0.03-0.02, P = 0.19]). In 2016, roughly three quarters of CPC and comparison physicians were satisfied with their current job (77 and 74%, P = 0.77) and about 15% planned to leave their practice within 2 years (14 and 15%, P = 0.17).Conclusions: Despite requiring substantial practice transformation, CPC did not affect physician experience. Research should track effects of other transformation initiatives on physicians and test new ways to address burnout.Trial Registration: ClinicalTrials.gov number, NCT02320591. [ABSTRACT FROM AUTHOR]

The article focuses on the national interest and ethical obligations of the U.S. in relation to its climate change policy. It also examines the important role to be played by religious groups in the definition of ethical principles in terms of the debate on global warming. The Catholic and evangelical perspectives towards environmental issues are discussed in which both groups are said to have the voting power to enact solutions for climate change. It is concluded that the U.S. possesses an ethical obligation to lead others in addressing global warming.

It costs about $1.2 billion to bring a single new drug to market in the U.S. today. With a combination of high latestage failure rates and the high cost of drug trials, the number of new drugs being approved by the FDA has flatlined at historically low levels, falling from 53 in 1996 to just 19 in 2009. If the cost of drug trials doesn't come down, we will see far fewer new drugs on pharmacy shelves. [ABSTRACT FROM AUTHOR]

The article discusses the study on the revisions to the second edition of the occupational medicine practice guidelines of the American College of Occupational and Environmental Medicine (ACOEM) in the U.S. It revealed that ACOEM Guideline Methodology Committee (GMC) developed a rigorous, standardized process to ensure the reproducibility and transparency of the guideline development process that serves as the criteria in identifying and evaluating relevant scientific evidence of the published literature based on generally accepted principles and methodologies.

ABSTRACT Objectives: While controversial, the use of prostate specific antigen (PSA) testing is common and may reduce the morbidity and mortality associated with prostate cancer. The use of age-specific reference ranges (ASRRs) has been suggested to increase the sensitivity of the PSA test in younger men. The objective of this study was to determine the normal age-specific reference ranges for a large group of clinically cancer-free men and to compare these findings with similar studies. Materials and Methods: A retrospective chart review of PSA values was conducted on 1199 students from the National Defense University, Fort McNair, Washington, DC, who were matriculating between 1994 and July 1999. The AsXYM system using MEIA technology with monoclonal antibodies from Abbott laboratories was used to determine the PSA values. The mean, median, 95th percentile, 99th percentile, and range were calculated for each decade. Results: A total of 1123 students between the ages of 30 and 59 were included in the study (1105 with PSA levels ≤ 4.0 ng/ml). The largest number of students (67.4%) fell in the 40–49-year-old group. The median PSA level was 0.74 ng/ml. There was a significant correlation between age and PSA level for the 40–59-year-old age group (r = 0.06, p = 0.044). There was no significant correlation between age and PSA for the 40–49-year-old age group (r = 0.048, p = 0.192). The median PSA value and the 95th percentile increased from 0.7 and 2.3, respectively, in the 40–49-year-old age group to 0.8 and 2.7, respectively, in the 50–59-year-old age group. Conclusions: The results of this study indicate that PSA values in young men are quite low. The 95th percentile of PSA levels for men in their 40s and 50s was 2.3 and 2.7 ng/ml, respectively, which is significantly lower than the traditional normal value of 4.0 ng/ml. Although further prospective studies are needed, our data suggest that a lower PSA value threshold of... [ABSTRACT FROM AUTHOR]

Purpose: To describe the impact of fractionation scheme and tumor location on toxicities in stereotactic body radiation therapy (SBRT) for ≥5-cm non-small cell lung cancer (NSCLC), as part of a multi-institutional analysis.Methods: Patients with primary ≥5-cm N0 M0 NSCLC who underwent ≤5-fraction SBRT were examined across multiple high-volume SBRT centers. Collected data included clinical/treatment parameters; toxicities were prospectively assessed at each institution according to the Common Terminology Criteria for Adverse Events. Patients treated daily were compared with those treated every other day (QOD)/other nondaily regimens. Stratification between central and peripheral tumors was also performed.Results: Ninety-two patients from 12 institutions were evaluated (2004-2016), with median follow-up of 12 months. In total there were 23 (25%) and 6 (7%) grade ≥2 and grade ≥3 toxicities, respectively. Grades 2 and 3 pulmonary toxicities occurred in 9% and 4%, respectively; 1 patient treated daily experienced grade 5 radiation pneumonitis. Of the entire cohort, 46 patients underwent daily SBRT, and 46 received QOD (n=40)/other nondaily (n=6) regimens. Clinical/treatment parameters were similar between groups; the QOD/other group was more likely to receive 3-/4-fraction schemas. Patients treated QOD/other experienced significantly fewer grade ≥2 toxicities as compared with daily treatment (7% vs 43%, P<.001). Patients treated daily also had higher rates of grade ≥2 pulmonary toxicities (P=.014). Patients with peripheral tumors (n=66) were more likely to receive 3-/4-fraction regimens than those with central tumors (n=26). No significant differences in grade ≥2 toxicities were identified according to tumor location (P>.05).Conclusions: From this multi-institutional study, toxicity of SBRT for ≥5-cm lesions is acceptable, and daily treatment was associated with a higher rate of toxicities. [ABSTRACT FROM AUTHOR]

: PurposeTo compare CT and transrectal ultrasound (TRUS)-measured prostate volumes in patients with untreated prostate cancer.: Methods and materialsBetween 1995 and 1999, 48 consecutive patients at the Portland Veterans Affairs Medical Center were treated with external beam radiotherapy. In 36 of these patients, TRUS and CT measurements of the prostate volume were obtained before treatment and <6 months apart. The TRUS volume was calculated using the prolate ellipsoid formula. The CT volume was calculated from the contours of the prostate drawn by one physician, who was unaware of the TRUS volume calculation, on axial CT images.: ResultsThe TRUS and CT prostate volume measurements correlated strongly (Pearson’s correlation coefficient = 0.925, 95% confidence interval 0.856–0.961, p < 0.0001). The CT volume was consistently larger than the TRUS volume by a factor of approximately 1.5. In men with a TRUS prostate volume less than the median (<28 cm3), the CT/TRUS volume ratio was 1.7, and it was 1.4 for men whose volume was greater than the median. The CT volumes were correlated similarly with the TRUS volumes regardless of the CT slice interval.: ConclusionA strong correlation was found between CT scan and TRUS measurement of the prostate volume; however, CT consistently overestimated the prostate volume by approximately 50% compared with TRUS. [Copyright &y& Elsevier]

Background: Physician burnout is associated with deleterious effects for physicians and their patients and might be exacerbated by practice transformation., Objective: Assess the effect of the Comprehensive Primary Care (CPC) initiative on primary care physician experience., Design: Prospective cohort study conducted with about 500 CPC and 900 matched comparison practices. Mail surveys of primary care physicians, selected using cross-sectional stratified random selection 11 months into CPC, and a longitudinal design with sample replacement 44 months into CPC., Participants: Primary care physicians in study practices., Intervention: A multipayer primary care transformation initiative (October 2012-December 2016) that required care delivery changes and provided enhanced payment, data feedback, and learning support., Main Measures: Burnout, control over work, job satisfaction, likelihood of leaving current practice within 2 years., Key Results: More than 1000 physicians responded (over 630 of these in CPC practices) in each round (response rates 70-81%, depending on round and research group). Physician experience outcomes were similar for physicians in CPC and comparison practices. About one third of physician respondents in CPC and comparison practices reported high levels of burnout in each round (32 and 29% in 2013 [P = 0.59], and 34 and 36% in 2016 [P = 0.63]). Physicians in CPC and comparison practices reported some to moderate control over work, with an average score from 0.50 to 0.55 out of 1 in 2013 and 2016 (CPC-comparison differences of - 0.04 in 2013 [95% CI - 0.08-0.00, P = 0.07], and - 0.03 in 2016 [95% CI - 0.03-0.02, P = 0.19]). In 2016, roughly three quarters of CPC and comparison physicians were satisfied with their current job (77 and 74%, P = 0.77) and about 15% planned to leave their practice within 2 years (14 and 15%, P = 0.17)., Conclusions: Despite requiring substantial practice transformation, CPC did not affect physician experience. Research should track effects of other transformation initiatives on physicians and test new ways to address burnout., Trial Registration: ClinicalTrials.gov number, NCT02320591.

Background: Thoracic radiotherapy (TRT) with concurrent chemotherapy is standard for limited-stage small-cell lung cancer (LS-SCLC). However, the optimal dosing and fractionation remain unclear. The National Comprehensive Cancer Network guidelines have recommended either 45 Gy delivered twice daily (BID) or 60 to 70 Gy delivered once daily (QD). However, the current practice patterns among US radiation oncologists are unknown., Materials and Methods: We surveyed US radiation oncologists using an institutional review board-approved questionnaire. The questions covered demographic data, self-rated knowledge of key trials, and treatment recommendations., Results: We received 309 responses from radiation oncologists. Of the 309 radiation oncologists, 60% preferred TRT QD and 76% acknowledged QD to be more common in their practice. The respondents in academic settings were more likely to endorse BID treatment by both preference (P = .001) and actual practice (P = .009). The concordance between preferring QD and administering QD in practice was 100%. In contrast, 40% of respondents who preferred BID actually administered QD more often. Also, 15% of physicians would be unwilling to switch from QD to BID and 3% would be unwilling to switch from BID to QD, even on patient request. Most respondents (88%) recommended a dose of 45 Gy for BID treatment. For QD treatment, the division was greater, with 54% recommending 60 Gy, 30% recommending 63 to 66 Gy, and 10% recommending 70 Gy., Conclusion: Substantial variation exists in how US radiation oncologists approach TRT dosing and fractionation for LS-SCLC. Three quarters of our respondents reported administering TRT QD most often. The most common doses were 60 Gy QD and 45 Gy BID. The results of the present survey have provided the most up-to-date information on US practice patterns for LS-SCLC., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: To determine how the multipayer Comprehensive Primary Care (CPC) initiative that transformed primary care delivery affected patient experience of Medicare fee-for-service beneficiaries. The study examines whether patient experience changed during the 4-year initiative, whether ratings of CPC practices changed relative to ratings of comparison practices, and areas in which practices still have an opportunity to improve patient experience., Study Design: Prospective study using 2 cross-sectional samples of more than 25,000 Medicare fee-for-service beneficiaries attributed to 490 CPC practices and more than 8000 beneficiaries attributed to 736 comparison practices., Methods: We analyzed patient experience 8 to 12 months and 45 to 48 months after CPC began, measured using 5 domains of the Consumer Assessment of Healthcare Providers and Systems Clinician and Group survey with Patient-Centered Medical Home items, version 2.0. A regression-adjusted analysis compared differences in the proportion of beneficiaries giving the best responses (and, as a sensitivity test, mean responses) to survey questions over time and between CPC and comparison practices., Results: Patient ratings of care over time were generally comparable for CPC and comparison practices. CPC had favorable effects on measures of follow-up care after hospitalizations and emergency department visits., Conclusions: Practice transformation did not alter patient experience. The lack of favorable findings raises questions about how future efforts in primary care can succeed in improving patient experience.

Introduction: For limited-stage small-cell lung cancer (LS-SCLC), National Comprehensive Cancer Network guidelines recommend that thoracic radiotherapy (TRT) be delivered concurrently with chemotherapy and early in the regimen, with cycle 1 or 2. Evidence is conflicting regarding the benefit of early timing of TRT. A Korean randomized trial did not see a survival difference between early (cycle 1) and late (cycle 3) TRT. Current United States (US) practice patterns are unknown., Materials and Methods: We surveyed US radiation oncologists using an institutional review board-approved online questionnaire. Questions covered treatment recommendations, self-rated knowledge of trials, and demographics., Results: We received 309 responses from radiation oncologists. Ninety-eight percent recommend concurrent chemoradiotherapy over sequential. Seventy-one percent recommend starting TRT in cycle 1 of chemotherapy, and 25% recommend starting in cycle 2. In actual practice, TRT is started most commonly in cycle 2 (48%) and cycle 1 (44%). One-half of respondents (54%) believe starting in cycle 1 improves survival compared with starting in cycle 3. Knowledge of the Korean trial was associated with flexibility in delaying TRT to cycle 2 or 3 (P = .02). Over one-third (38%) treat based on pre-chemotherapy volume., Conclusion: US radiation oncologists strongly align with National Comprehensive Cancer Network guidelines, which recommend early concurrent chemoradiotherapy. Nearly three-quarters of respondents prefer starting TRT with cycle 1 of chemotherapy. However, knowledge of a trial supporting a later start was associated with flexibility in delaying TRT. Treating based on pre-chemotherapy volume-endorsed by over one-third of respondents-may add unnecessary toxicity. This survey can inform development of future trials., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Treatment of head and neck cancer is complex, and a multidisciplinary clinic may improve the coordination of care. The value of a head and neck multidisciplinary clinic has not yet been established in oropharyngeal squamous cell carcinoma (SCC)., Methods: A retrospective review was conducted of Veterans Affairs patients with oropharyngeal SCC undergoing concurrent chemoradiation before and after implementation of the head and neck multidisciplinary clinic., Results: Fifty-two patients before and 54 patients after multidisciplinary clinic were included in this study. Age, tobacco use, and p16+ status were similar between groups. With multidisciplinary clinic, time to treatment decreased, and utilization of supportive services, including speech pathology, dentistry, and nutrition increased. The 5-year disease-specific survival rate increased from 63% to 81% (p = .043) after implementation of the multidisciplinary clinic. Multivariate analysis showed that disease stage (p = .016), p16 status (p = .006), and multidisciplinary clinic participation (p = .042) were predictors of disease-specific survival., Conclusion: Implementation of a multidisciplinary clinic improved care coordination and disease-specific survival in patients with oropharyngeal SCC. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1106-1112, 2017., (© 2017 Wiley Periodicals, Inc.)

A growing number of employed persons in the United States live and work with potentially complex chronic conditions such as rheumatoid arthritis, multiple sclerosis, and cancer. Increasingly, many of the medications used to treat these serious conditions are costly, primarily because many of the newest drugs are high-cost biotechnology derived pharmaceuticals, referred to in this report as biotech drugs. The rapidly increasing use of new biotech medications for an expanding number of chronic and potentially disabling conditions of working-age adults has significant implications for US employers in the anticipated effect on worker productivity, human capital preservation, and health care costs. However, new approaches, including sophisticated modeling techniques, are providing employers with the insights and guidance necessary to make the benefit design decisions that will provide optimal outcomes to employees while managing employer costs effectively.