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ObjectiveTo examine initial treatments given to men with newly diagnosed lower urinary tract dysfunction (LUTD) within a large integrated health care system in the United States.MethodsWe used data from 2003 to 2009 from the Veteran's Health Administration to identify newly diagnosed cases of LUTD using established ICD-9CM codes. Our primary outcome was initial LUTD treatment (3 months), categorized as watchful waiting (WW), medical therapy (MT), or surgical therapy (ST); our secondary outcome was pharmacotherapy class received. We used logistic regression models to examine patient, provider, and health system factors associated with receiving MT or ST when compared with WW.ResultsThere were 393,901 incident cases of LUTD, of which 58.0% initially received WW, 41.8% MT, and 0.2% ST. Of the MT men, 79.8% received an alpha-blocker, 7.7% a 5-alpha reductase inhibitor, 3.3% an anticholinergic, and 7.3% combined therapy (alpha-blocker and 5-alpha reductase inhibitor). In our regression models, we found that age (higher), race (white/black), income (low), region (northeast/south), comorbidities (greater), prostate-specific antigen (lower), and provider (nonurologist) were associated with an increased odds of receiving MT. We found that age (higher), race (white), income (low), region (northeast/south), initial provider (urologist), and prostate-specific antigen (higher) increased the odds of receiving ST.ConclusionMost men with newly diagnosed LUTD in the Veteran's Health Administration receive WW, and initial surgical treatment is rare. A large number of men receiving MT were treated with monotherapy, despite evidence that combination therapy is potentially more effective in the long-term, suggesting opportunities for improvement in initial LUTD management within this population.

IntroductionColonic volvulus is a rare entity associated with high mortality rates. Most studies come from areas of high endemicity and are limited by small numbers. No studies have investigated trends, outcomes, and predictors of mortality at the national level.MethodsThe Nationwide Inpatient Sample 2002-2010 was retrospectively reviewed for colonic volvulus cases admitted emergently. Patients' demographics, hospital factors, and outcomes of the different procedures were analyzed. The LASSO algorithm for logistic regression was used to build a predictive model for mortality in cases of sigmoid (SV) and cecal volvulus (CV) taking into account preoperative and operative variables.ResultsAn estimated 3,351,152 cases of bowel obstruction were admitted in the United States over the study period. Colonic volvulus was found to be the cause in 63,749 cases (1.90%). The incidence of CV increased by 5.53% per year whereas the incidence of SV remained stable. SV was more common in elderly males (aged 70 years), African Americans, and patients with diabetes and neuropsychiatric disorders. In contrast, CV was more common in younger females. Nonsurgical decompression alone was used in 17% of cases. Among cases managed surgically, resective procedures were performed in 89% of cases, whereas operative detorsion with or without fixation procedures remained uncommon. Mortality rates were 9.44% for SV, 6.64% for CV, 17% for synchronous CV and SV, and 18% for transverse colon volvulus. The LASSO algorithm identified bowel gangrene and peritonitis, coagulopathy, age, the use of stoma, and chronic kidney disease as strong predictors of mortality.ConclusionsColonic volvulus is a rare cause of bowel obstruction in the United States and is associated with high mortality rates. CV and SV affect different populations and the incidence of CV is on the rise. The presence of bowel gangrene and coagulopathy strongly predicts mortality, suggesting that prompt diagnosis and management are essential.

Objective To analyze industry payments to pain medicine physicians in the United States. Design Retrospective cohort study using publicly available databases. Subjects The study includes U.S. pain medicine physicians (PMPs) with reports in the Open Payments program from 2013 to 2018. Methods The Centers for Medicare and Medicaid Services Open Payments program was analyzed for general, investment, and ownership payments to PMPs reported from 2013 to 2018. The nature, type, and geographic variation of payments were analyzed. Results The main findings of the study are as follows: 1) Payments made to PMPs constituted a small proportion of the payments made to all physicians in the United States, and the number of transactions and the total dollar amount seem to have decreased from 2016 to 2018. 2) The median number of payments among physicians with reported payments was around 4 (interquartile range: 18), and the majority of them were under $20. 3) The majority of payments were for in-kind items and services (85%) and were made for food and beverages (91%), travel and lodging (5.5%). 4) Some of the ownership and investment interest payments exceeded $500,000. 5) The top five drugs associated with physician payments included medications with opioids. 6) A very small minority of payments were made for entertainment or gifts. 7) A third of PMPs with reports had payments reported under more than one taxonomy. Conclusions Overall payments made to PMPs seem to be decreasing since 2016. The majority of the payments are made for the food, beverage, and travel categories. Public and physician awareness of the Open Payments system reports is essential to promote transparency and to minimize adverse effects of financial relationships on patient care. [ABSTRACT FROM AUTHOR]

BackgroundLimited information is available on the contemporary and potentially changing trends in the incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction (STEMI).Methods and resultsWe queried the 2003-2010 Nationwide Inpatient Sample databases to identify all patients ≥ 40 years of age with STEMI and cardiogenic shock. Overall and age-, sex-, and race/ethnicity-specific trends in incidence of cardiogenic shock, early mechanical revascularization, and intra-aortic balloon pump use, and inhospital mortality were analyzed. From 2003 to 2010, among 1 990 486 patients aged ≥ 40 years with STEMI, 157 892 (7.9%) had cardiogenic shock. The overall incidence rate of cardiogenic shock in patients with STEMI increased from 6.5% in 2003 to 10.1% in 2010 (P(trend)

PurposeRural-urban disparities in provision of preventive services exist, but there is sparse research on how rural, suburban, or urban differences impact physician adherence to clinical preventive service guidelines. We aimed to identify factors that may cause differences in adherence to preventive service guidelines among rural, suburban, and urban primary care physicians.MethodsThis qualitative study involved in-depth semistructured interviews with 29 purposively sampled primary care physicians (10 rural, 10 suburban, 9 urban) in Missouri. Physicians were asked to describe barriers and facilitators to clinical preventive service guideline adherence. Using techniques from grounded theory analysis, 2 coders first independently conducted content analysis then reconciled differences in coding to ensure agreement on intended meaning of transcripts.FindingsPatient epidemiologic differences, distance to health care services, and care coordination were reported as prominent factors that produced differences in preventive service guideline adherence among rural, suburban, and urban physicians. Epidemiologic differences impacted all physicians, but rural physicians highlighted the importance of occupational risk factors in their patients. Greater distance to health care services reduced visit frequency and was a prominent barrier for rural physicians. Care coordination among health care providers was problematic for suburban and urban physicians. Patient resistance to medical care and inadequate access to resources and specialists were identified as barriers by some rural physicians.ConclusionsThe rural, suburban, or urban context impacts whether a physician will adhere to clinical preventive service guidelines. Efforts to increase guideline adherence should consider the barriers and facilitators unique to rural, suburban, or urban areas.

BackgroundHepatitis B (HBV) is prevalent in certain US populations and regular HBV disease monitoring is critical to reducing associated morbidity and mortality. Adherence to established HBV monitoring guidelines among primary care providers is unknown.AimsThe purpose of this study was to evaluate HBV disease monitoring patterns and factors associated with adherence to HBV management guidelines in the primary care setting.MethodsPrimary providers within the San Francisco safety net healthcare system were surveyed for HBV management practices, knowledge, attitudes, and barriers to HBV care. Medical records from 1,727 HBV-infected patients were also reviewed retrospectively.ResultsOf 148 (45 %) responding providers, 79 % reported ALT and 44 % reported HBV viral load testing every 6-12 months. Most providers were knowledgeable about HBV but 43 % were unfamiliar with HBV management guidelines. Patient characteristics included: mean age 51 years, 54 % male and 67 % Asian. Within the past year, 75 % had ALT, 24 % viral load, 21 % HBeAg tested, and 40 % of at-risk patients had abdominal imaging for HCC. Provider familiarity with guidelines (OR 1.02, 95 % CI 1.00-1.03), Asian patient race (OR 4.18, 95 % CI 2.40-7.27), and patient age were associated with recommended HBV monitoring. Provider HBV knowledge and attitudes were positively associated, while provider age and perceived barriers were negatively associated with HCC surveillance.ConclusionsComprehensive HBV disease monitoring including HCC screening with imaging were suboptimal. While familiarity with AASLD guidelines and patient factors were associated with HBV monitoring, only provider and practice factors were associated with HCC surveillance. These findings highlight the importance of targeted provider education to improve HBV care.

BackgroundPrimary care provides most of the evidence-based chronic disease prevention and screening services offered by the healthcare system. However, there remains a gap between recommended preventive services and actual practice. This trial (the BETTER Trial) aimed to improve preventive care of heart disease, diabetes, colorectal, breast and cervical cancers, and relevant lifestyle factors through a practice facilitation intervention set in primary care.MethodsPragmatic two-way factorial cluster RCT with Primary Care Physicians' practices as the unit of allocation and individual patients as the unit of analysis. The setting was urban Primary Care Team practices in two Canadian provinces. Eight Primary Care Team practices were randomly assigned to receive the practice-level intervention or wait-list control; 4 physicians in each team (32 physicians) were randomly assigned to receive the patient-level intervention or wait-list control. Patients randomly selected from physicians' rosters were stratified into two groups: 1) general and 2) moderate mental illness. The interventions involved a multifaceted, evidence-based, tailored practice-level intervention with a Practice Facilitator, and a patient-level intervention involving a one-hour visit with a Prevention Practitioner where patients received a tailored 'prevention prescription'. The primary outcome was a composite Summary Quality Index of 28 evidence-based chronic disease prevention and screening actions with pre-defined targets, expressed as the ratio of eligible actions at baseline that were met at follow-up. A cost-effectiveness analysis was conducted.Results789 of 1,260 (63%) eligible patients participated. On average, patients were eligible for 8.96 (SD 3.2) actions at baseline. In the adjusted analysis, control patients met 23.1% (95% CI: 19.2% to 27.1%) of target actions, compared to 28.5% (95% CI: 20.9% to 36.0%) receiving the practice-level intervention, 55.6% (95% CI: 49.0% to 62.1%) receiving the patient-level intervention, and 58.9% (95% CI: 54.7% to 63.1%) receiving both practice- and patient-level interventions (patient-level intervention versus control, P < 0.001). The benefit of the patient-level intervention was seen in both strata. The extra cost of the intervention was $26.43CAN (95% CI: $16 to $44) per additional action met.ConclusionsA Prevention Practitioner can improve the implementation of clinically important prevention and screening for chronic diseases in a cost-effective manner.

ObjectiveTo determine the impact on referral patterns of using a Multivariate Index Assay, CA125, modified-American College of Obstetricians and Gynecologists referral guidelines, and clinical assessment among patients undergoing surgery for an adnexal mass after initial evaluation by nongynecologic oncologists.Study designOverall, 770 patients were enrolled by nongynecologic oncologists from 2 related, multiinstitutional, prospective trials and analyzed retrospectively. All patients had preoperative imaging and biomarker analysis. The subset of patients enrolled by nongynecologic oncologists was analyzed to determine the projected referral patterns and sensitivity for malignancy based on multivariate index assay (MIA), CA125, modified-American College of Obstetricians and Gynecologists (ACOG) guidelines, and clinical assessment compared with actual practice.ResultsThe prevalence of malignancy was 21.3% (n = 164). In clinical practice, 462/770 patients (60.0%) were referred to a gynecologic oncologist for surgery. Triage based on CA125 predicted referral of 157/770 patients (20.4%) with sensitivity of 68.3% (95% confidence interval [CI], 60.8-74.9). Triage based on modified-ACOG guidelines would have resulted in referral of 256/770 patients (33.2%) with a sensitivity of 79.3% (95% CI, 72.4-84.8). Clinical assessment predicted referral of 184/763 patients (24.1%) with a sensitivity of 73.2% (95% CI, 65.9-79.4). Risk stratification using multivariate index assay would have resulted in referral of 429/770 (55.7%) patients, with sensitivity of 90.2% (95% CI, 84.7-93.9). MIA demonstrated statistically significant higher sensitivity (P < .0001) and lower specificity (P < .0001) for detecting malignancy compared with clinical assessment, CA125, and modified-ACOG guidelines.ConclusionIn this study population, use of MIA as a risk stratification test was associated with referral patterns by nongynecologic oncologists comparable to actual clinical practice and higher sensitivity for malignancy than other adnexal mass triage algorithms.

BackgroundDabigatran is a novel oral anticoagulant approved for thromboprophylaxis in atrial fibrillation. Adoption patterns of this new agent in community practice are unknown.Methods and resultsWe studied patterns of dabigatran use among patients enrolled in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) Registry between June 2010 and August 2011 and followed for 12 months. Among 9974 atrial fibrillation patients included, 1217 (12%) were treated with dabigatran during the study. Overall, patients receiving dabigatran were younger (median age 72 versus 75 years, P

BackgroundLittle is known regarding clinicians' attitudes about or the extent to which the recommendation to offer same-day insertions for long-acting reversible contraception (LARC) is applied in practice.Study designSince 2006, 47 family planning agencies in Colorado and Iowa participated in two initiatives to reduce unintended pregnancy by increasing LARC provision. Clinic directors (n = 45) and clinicians (n = 114) participating in these initiatives were interviewed and surveyed regarding their LARC provision practices and attitudes.ResultsAgencies required fewer visits for the contraceptive implant than for the intrauterine device (IUD). Only 18% of agencies typically offered an IUD, and 36% typically offered an implant in one visit. Years of experience and professional title significantly predicted attitudes about the number of visits required to get LARC.DiscussionBarriers must be overcome for full implementation of professional LARC guidelines and for more women to receive chosen methods without the extra burden of multiple visits.

PurposeTo describe recruitment, enrollment, and participation in a study of US radiologists invited to participate in a randomized controlled trial of two continuing medical education (CME) interventions designed to improve interpretation of screening mammography.MethodsWe collected recruitment, consent, and intervention-completion information as part of a large study involving radiologists in California, Oregon, Washington, New Mexico, New Hampshire, North Carolina, and Vermont. Consenting radiologists were randomized to receive either a 1-day live, expert-led educational session; to receive a self-paced DVD with similar content; or to a control group (delayed intervention). The impact of the interventions was assessed using a preintervention-postintervention test set design. All activities were institutional review board approved and HIPAA compliant.ResultsOf 403 eligible radiologists, 151 of 403 (37.5%) consented to participate in the trial and 119 of 151 (78.8%) completed the preintervention test set, leaving 119 available for randomization to one of the two intervention groups or to controls. Female radiologists were more likely than male radiologists to consent to and complete the study (P = .03). Consenting radiologists who completed all study activities were more likely to have been interpreting mammography for 10 years or less compared to radiologists who consented and did not complete all study activities or did not consent at all. The live intervention group was more likely to report their intent to change their clinical practice as a result of the intervention compared to those who received the DVD (50% versus 17.6%, P = .02). The majority of participants in both interventions groups felt the interventions were a useful way to receive CME mammography credits.ConclusionsCommunity radiologists found interactive interventions designed to improve interpretative mammography performance acceptable and useful for clinical practice. This suggests CME credits for radiologists should, in part, be for examining practice skills.

Peritoneal dialysis (PD) and in-center hemodialysis (HD) are accepted as clinically equivalent dialysis modalities, yet in-center HD is the predominant renal replacement therapy (RRT) modality offered to new end-stage renal disease (ESRD) patients in the United States and most other industrialized nations. This predominance has little to do with clinical outcomes, patient choice, cost, or quality of life. It has been driven by ease of HD initiation, physician experience and training, inadequate pre-ESRD patient education, ample in-center HD capacity, and lack of adequate infrastructure for PD-related care. As compared with in-center HD, PD is a widely applicable, yet underutilized modality of RRT that provides comparable clinical outcomes, superior quality of life measures, significant cost savings, and many other unmeasured advantages. A "PD First" approach not only has advantages for patients but also physicians, healthcare systems, and society. In this review, we will summarize evidence demonstrating that PD should be the default modality when new ESRD patients are transitioning to dialysis therapy when preemptive transplantation is not an option and highlight the essential infrastructural requirements to allow for a "PD First" model.

Nearly a half-century ago, the thrice-weekly hemodialysis schedule was empirically established as a means to provide an adequate dialysis dose while also treating the greatest number of end-stage renal disease (ESRD) patients using limited resources. Landmark trials of hemodialysis adequacy have historically been anchored to thrice-weekly regimens, but a recent randomized controlled trial demonstrated that frequent hemodialysis (six times per week) confers cardiovascular and survival benefits. Based on these collective data and experience, clinical practice guidelines advise against a less than thrice-weekly treatment schedule in patients without residual renal function, yet provide limited guidance on the optimal treatment frequency when substantial native kidney function is present. Thus, during the transition from Stage 5 chronic kidney disease to ESRD, the current paradigm is to initiate hemodialysis on a "full-dose" thrice-weekly regimen even among patients with substantial residual renal function. However, emerging data suggest that frequent hemodialysis accelerates residual renal function decline, and infrequent regimens may provide better preservation of native kidney function. Given the high mortality rates during the first 6 months of hemodialysis and the survival benefits of preserved native kidney function, initiation with twice-weekly treatment schedules ("infrequent hemodialysis") with an incremental increase in frequency over time may provide an opportunity to optimize patient survival. This review outlines the clinical benefits of post-hemodialysis residual renal function, studies of twice-weekly treatment regimens, and the potential risks and benefits of infrequent hemodialysis.

ObjectiveThe purpose of this study was to characterize the performance of the Neuroradiology Second Opinion Consultation Service (NSOCS) at our institution to establish the rate, causes, and implications of requests for repeat imaging.Materials and methodsWe queried 11,753 complete reports of all NSOCS studies for calendar year 2010 for the words "repeat" and "follow-up." We categorized study limitations described in these reports into poor image quality, missing or inadequate MR sequences or CT reformats, lack of IV contrast administration where otherwise deemed appropriate, an "other" category for miscellaneous items, and a "clarification" category for indeterminate findings or recommendations for more advanced protocols. The corresponding available electronic medical records were reviewed. An estimated financial analysis of the NSOCS was additionally performed.ResultsRepeat imaging studies were recommended in 1.5% of cases. In 0.3% of all cases, a subsequent repeat examination was documented in the electronic medical records. Study limitations were most commonly due to poor image quality (77.5%), followed by missing or inadequate MR sequences or CT reformats (20.3%). The additional estimated cost of repeat imaging was calculated at $14,019.34, with an overall per-patient cost of $2.12 for the service.ConclusionReviewing outside studies generates a very low rate of requests for and performance of repeat studies, and is not a major additional health care expense.

BackgroundSurvivorship care plans (SCPs), including a treatment summary and follow-up plan, intend to promote coordination of posttreatment cancer care; yet, little is known about the provision of these documents by oncologists to primary care physicians (PCPs). This study compared self-reported oncologist provision and PCP receipt of treatment summaries and follow-up plans, characterized oncologists who reported consistent provision of these documents to PCPs, and examined associations between PCP receipt of these documents and survivorship care.MethodsA nationally representative sample of medical oncologists (n = 1130) and PCPs (n = 1020) were surveyed regarding follow-up care for breast and colon cancer survivors. All statistical tests were two-sided. Multivariable regression models identified factors associated with oncologist provision of treatment summaries and SCPs to PCPs (always/almost always vs less frequent).ResultsNearly half of oncologists reported always/almost always providing treatment summaries, whereas 20.2% reported always/almost always providing SCPs (treatment summary + follow-up plan). Approximately one-third of PCPs indicated always/almost always receiving treatment summaries; 13.4% reported always/almost always receiving SCPs. Oncologists who reported training in late- and long-term effects of cancer and use of electronic medical records were more likely to report SCP provision (P < .05). PCP receipt of SCPs was associated with better PCP-reported care coordination, physician-physician communication, and confidence in survivorship care knowledge compared to receipt of neither treatment summaries nor SCPs (P < .05).ConclusionsProviding SCPs to PCPs may enhance survivorship care coordination, physician-physician communication, and PCP confidence. However, considerable progress will be necessary to achieve implementation of sharing SCPs among oncologists and PCPs.

BackgroundWe evaluated how computerized clinical decision support (CDS) affects the counseling women receive when primary care physicians (PCPs) prescribe potential teratogens and how this counseling affects women's behavior.MethodsBetween October 2008 and April 2010, all women aged 18-50 years visiting one of three community-based family practice clinics or an academic general internal medicine clinic were invited to complete a survey 5-30 days after their clinic visit. Women who received prescriptions were asked if they were counseled about teratogenic risks or contraception and if they used contraception at last intercourse.ResultsEight hundred one women completed surveys; 27% received a prescription for a potential teratogen. With or without CDS, women prescribed potential teratogens were more likely than women prescribed safer medications to report counseling about teratogenic risks. However, even with CDS 43% of women prescribed potential teratogens reported no counseling. In multivariable models, women were more likely to report counseling if they saw a female PCP (odds ratio: 1.97; 95% confidence interval: 1.26-3.09). Women were least likely to report counseling if they received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Women who were pregnant or trying to conceive were not more likely to report counseling. Nonetheless, women who received counseling about contraception or teratogenic risks were more likely to use contraception after being prescribed potential teratogens than women who received no counseling.ConclusionsPhysician counseling can reduce risk of medication-induced birth defects. However, efforts are needed to ensure that PCPs consistently inform women of teratogenic risks and provide access to highly effective contraception.

BackgroundLittle is known about how often contextual factors such as patient preferences and competing priorities impact prescribing of guideline-recommended medications, or about the extent to which these factors are documented in medical records and available to performance measurement systems.MethodsMixed-methods study of 295 veterans aged 50 years and older in 4 VA health care systems who had systolic heart failure and were not prescribed a β-blocker and/or an angiotensin converting enzyme inhibitor or angiotensin-receptor blocker. Reasons for nontreatment were identified from clinic notes and from interviews with 62 primary care clinicians caring for these patients. These reasons were classified using a published taxonomy.ResultsAmong 295 patients not receiving guideline-recommended drugs for heart failure, chart review identified biomedical reasons for nonprescribing in 42%-58% of patients and contextual reasons in 11%-17%. Clinician interviews identified twice as many reasons for nonprescribing as chart review (mean 1.6 vs. 0.8 reasons per patient, P

ObjectiveTo analyse the current provision of long-acting reversible contraception (LARC) and clinician training needs in HIV-prevalent settings.DesignNationally representative survey of clinicians.SettingHIV-prevalent settings in South Africa and Zimbabwe.PopulationClinicians in South Africa and Zimbabwe.MethodsNationally representative surveys of clinicians were conducted in South Africa and Zimbabwe (n = 1444) to assess current clinical practice in the provision of LARC in HIV-prevalent settings. Multivariable logistic regression was used to analyse contraceptive provision and clinician training needs.Main outcome measureMultivariable logistic regression of contraceptive provision and clinician training needs.ResultsProvision of the most effective reversible contraceptives is limited: only 14% of clinicians provide copper intrauterine devices (IUDs), 4% levonorgestrel-releasing IUDs and 16% contraceptive implants. Clinicians' perceptions of patient eligibility for IUD use were overly restrictive, especially related to HIV risks. Less than 5% reported that IUDs were appropriate for women at high risk of HIV or for HIV-positive women, contrary to evidence-based guidelines. Only 15% viewed implants as appropriate for women at risk of HIV. Most clinicians (82%), however, felt that IUDs were underused by patients, and over half desired additional training on LARC methods. Logistic regression analysis showed that LARC provision was largely restricted to physicians, hospital settings and urban areas. Results also showed that clinicians in rural areas and clinics, including nurses, were especially interested in training.ConclusionsClinician competency in LARC provision is important in southern Africa, given the low use of methods and high rates of unintended pregnancy among HIV-positive and at-risk women. Despite low provision, clinician interest is high, suggesting the need for increased evidence-based training in LARC to reduce unintended pregnancy and associated morbidities.

BackgroundElderly patients are frequently undertriaged. However, the associations between triage patterns and outcomes from a population perspective are unknown. We hypothesized that triage patterns would be associated with differences in outcomes.Study designThis is a population-based, retrospective, cohort study of all injured adults aged 55 years or older, from 3 counties in California and 4 in Utah (2006 to 2007). Prehospital data were linked to trauma registry data, state-level discharge data, emergency department records, and death files. The primary outcome was 60-day mortality. Patients treated at trauma centers were compared with those treated at nontrauma centers. Undertriage was defined as an Injury Severity Score (ISS) >15, with transport to a nontrauma center.ResultsThere were 6,015 patients in the analysis. Patients who were taken to nontrauma centers were, on average, older (79.4 vs 70.7 years, p < 0.001), more often female (68.6% vs 50.2%, p < 0.01), and less often had an ISS >15 (2.2% vs 6.7%, p < 0.01). There were 244 patients with an ISS >15 and the undertriage rate was 32.8% (n = 80). Overall 60-day mortality for patients with an ISS >15 was 17%, with no difference between trauma and nontrauma centers in unadjusted or adjusted analyses. However, the median per-patient costs were $21,000 higher for severely injured patients taken to trauma centers.ConclusionsThis is the first population-based analysis of triage patterns and outcomes in the elderly. We have shown high rates of undertriage that are not associated with higher mortality, but are associated with higher costs. Future work should focus on determining how to improve outcomes for this population.

ImportanceBack pain treatment is costly and frequently includes overuse of treatments that are unsupported by clinical guidelines. Few studies have evaluated recent national trends in guideline adherence of spine-related care.ObjectiveTo characterize the treatment of back pain from January 1, 1999, through December 26, 2010.Design, setting, and patientsUsing nationally representative data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, we studied outpatient visits with a chief symptom and/or primary diagnosis of back or neck pain, as well as those with secondary symptoms and diagnoses of back or neck pain. We excluded visits with concomitant "red flags," including fever, neurologic symptoms, or cancer. Results were analyzed using logistic regression adjusted for patient and health care professional characteristics and weighted to reflect national estimates. We also present adjusted results stratified by symptom duration and whether the health care professional was the primary care physician (PCP).Main outcomes and measuresWe assessed imaging, narcotics, and referrals to physicians (guideline discordant indicators). In addition, we evaluated use of nonsteroidal anti-inflammatory drugs or acetaminophen and referrals to physical therapy (guideline concordant indicators).ResultsWe identified 23,918 visits for spine problems, representing an estimated 440 million visits. Approximately 58% of patients were female. Mean age increased from 49 to 53 years (P

ImportancePay for performance is intended to align incentives to promote high-quality care, but results have been contradictory.ObjectiveTo test the effect of explicit financial incentives to reward guideline-recommended hypertension care.Design, setting, and participantsCluster randomized trial of 12 Veterans Affairs outpatient clinics with 5 performance periods and a 12-month washout that enrolled 83 primary care physicians and 42 nonphysician personnel (eg, nurses, pharmacists).InterventionsPhysician-level (individual) incentives, practice-level incentives, both, or none. Intervention participants received up to 5 payments every 4 months; all participants could access feedback reports.Main outcomes and measuresAmong a random sample, number of patients achieving guideline-recommended blood pressure thresholds or receiving an appropriate response to uncontrolled blood pressure, number of patients prescribed guideline-recommended medications, and number who developed hypotension.ResultsMean (SD) total payments over the study were $4270 ($459), $2672 ($153), and $1648 ($248) for the combined, individual, and practice-level interventions, respectively. The unadjusted baseline and final percentages and the adjusted absolute change over the study in patients meeting the combined blood pressure/appropriate response measure were 75% to 84% and 8.84% (95% CI, 4.20% to 11.80%) for the individual group, 80% to 85% and 3.70% (95% CI, 0.24% to 7.68%) for the practice-level group, 79% to 88% and 5.54% (95% CI, 1.92% to 9.52%) for the combined group, and 86% to 86% and 0.47% (95% CI, -3.12% to 4.04%) for the control group. The adjusted absolute estimated difference in the change between the proportion of patients with blood pressure control/appropriate response for individual incentive and control groups was 8.36% (95% CI, 2.40% to 13.00%; P=.005). The other incentive groups did not show a significant change compared with controls for this outcome. For medications, the unadjusted baseline and final percentages and the adjusted absolute change were 61% to 73% and 9.07% (95% CI, 4.52% to 13.44%), 56% to 65% and 4.98% (95% CI, 0.64% to 10.08%), 65% to 80% and 7.26% (95% CI, 2.92% to 12.48%), and 63% to 72% and 4.35% (95% CI, -0.28% to 9.28%), respectively. These changes in the use of guideline-recommended medications were not significant in any of the incentive groups compared with controls, nor was the incidence of hypotension. The effect of the incentive was not sustained after a washout.Conclusions and relevanceIndividual financial incentives, but not practice-level or combined incentives, resulted in greater blood pressure control or appropriate response to uncontrolled blood pressure; none of the incentives resulted in greater use of guideline-recommended medications or increased incidence of hypotension compared with controls. Further research is needed on the factors that contributed to these findings.Trial registrationclinicaltrials.gov Identifier: NCT00302718.

ImportanceMost evaluations of pay-for-performance (P4P) incentives have focused on large-group practices. Thus, the effect of P4P in small practices, where many US residents receive care, is largely unknown. Furthermore, whether electronic health records (EHRs) with chronic disease management capabilities support small-practice response to P4P has not been studied.ObjectiveTo assess the effect of P4P incentives on quality in EHR-enabled small practices in the context of an established quality improvement initiative.Design, setting, and participantsA cluster-randomized trial of small (

BackgroundA doctor's ability to communicate effectively is key to establishing and maintaining positive doctor-patient relationships. The Consumer Assessment of Healthcare Providers and System (CAHPS(®)) Clinician and Group Survey is the standard for collecting and reporting information about patients' experiences of care in the USA.ObjectiveTo evaluate how well CAHPS(®) Clinician and Group 2.0 core and supplemental survey items (CG-CAHPS) with a 12-month reference capture doctor-patient communication.Data sources/study settingEleven of the 40 highest-rated physicians on the CG-CAHPS survey treating patients in a Midwest commercial health plan.Study designData were obtained via semi-structured interviews. Specific behaviors, practices, and opinions about doctor communication were coded and compared to the CG-CAHPS items.Principal findingsCG-CAHPS fully captures six of the nine behaviors most commonly mentioned by high-performing physicians: employing office staff with good people skills; involving office staff in communication with patients; spending enough time with patients; listening carefully; providing clear, simple explanations; and devising an action plan with each patient. Three physician behaviors identified as key were not captured in CG-CAHPS items: use of nonverbal communication; greeting patients and introducing oneself; and tracking personal information about patients.ConclusionsCG-CAHPS survey items capture many of the most commonly mentioned doctor-patient communication behaviors and practices identified by high-performing physicians. Nonverbal communication, greeting patients, and tracking personal information about patients were identified as key aspects of doctor-patient communication, but are not captured by the current CG-CAHPS. We recommend further research to assess patients' perceptions of specific verbal and nonverbal behaviors (such as leaning forward in a chair, casually asking about other family members), followed by the development of new items (if needed) that aim to capture what these specific behaviors represent to patients (e.g., listens attentively, seems to care about me as a person, empathy). We also recommend including items about greeting and tracking personal information about patients in future CAHPS item sets addressing doctor-patient communication. Enriching the content of the CAHPS communication measure can help health-care organizations improve doctor-patient communication and interactions.

Hyperinsulinemia euglycemia (HIE) and intravenous fat emulsion (IFE) may be beneficial in the treatment of calcium channel (CCB) and beta receptor (BB) antagonist toxicity. Many poison control centers (PCC) now recommend use. Healthcare providers may be unfamiliar with these treatments and may not institute them despite recommendations. We sought to determine how often HIE and IFE are recommended by a statewide PCC in CCB and BB toxicity, how often those recommendations are implemented, and whether a faxable information sheet increased adherence. All cases of CCB and BB exposure from January 2005-July 2011 where insulin or "other therapy" was coded were reviewed. Exclusion criteria included an incomplete PCC record, miscoding, and insulin administration as other than cardiovascular drug antidotal therapy. There were 215 CCB or BB exposures initially identified using the search criteria. HIE was recommended in 71 cases and started in one case prior to PCC recommendation. HIE was subsequently used in 30 cases after PCC recommendation (42 %). IFE was recommended by the PCC in 30 cases and implemented 10 times (33 %). In six cases, both HIE and IFE were implemented after recommendation. There was no statistical difference when recommendation was made via telephone or by faxable information sheet for HIE or IFE. HIE and IFE are two therapies that are potentially beneficial in the treatment of BB and CCB toxicity. Current national organization guidelines for use are limited. Exploration of reasons for not following recommendations and additional efforts to improve clinician education regarding HIE and IFE may be required to increase the utilization of these potentially lifesaving antidotes.

PurposeNew strategies for delivering cancer follow-up care are needed. We surveyed primary care providers (PCPs) and oncologists to assess how physician attitudes toward and self-efficacy with cancer follow-up affect preferences for different cancer survivorship models.MethodsThe survey of physician attitudes regarding the care of cancer survivors was mailed to a randomly selected national sample of PCPs and oncologists to evaluate their perspectives regarding physician roles, knowledge about survivorship care processes, and views on cancer surveillance. Multinomial logistic regression models were constructed to examine how physician attitudes towards, and self-efficacy with, their own skills affected preferences for different cancer survivorship care models.ResultsOf 3,434 physicians identified, a total of 2,026 participants provided eligible responses: 938 PCPs and 1,088 oncologists. Most PCPs (51 %) supported a PCP/shared care model; whereas, the majority of specialists (59 %) strongly endorsed an oncologist-based model (p

BackgroundHydralazine-isosorbide dinitrate (H-ISDN) therapy is recommended for African American patients with moderate to severe heart failure with reduced ejection fraction (

ObjectiveWe sought to determine the extent to which adoption of health information technology (HIT) by physician practices may differ from the extent of use by individual physicians, and to examine factors associated with adoption and use.Materials and methodsUsing cross-sectional survey data from the National Study of Small and Medium-Sized Physician Practices (July 2007-March 2009), we examined the extent to which organizational capabilities and external incentives were associated with the adoption of five key HIT functionalities by physician practices and with use of those functionalities by individual physicians.ResultsThe rate of physician practices adopting any of the five HIT functionalities was 34.1%. When practices adopted HIT functionalities, on average, about one in seven physicians did not use those functionalities. One physician in five did not use prompts and reminders following adoption by their practice. After controlling for other factors, both adoption of HIT by practices and use of HIT by individual physicians were higher in primary care practices and larger practices. Practices reporting an emphasis on patient-centered management were not more likely than others to adopt, but their physicians were more likely to use HIT.DiscussionLarger practices were most likely to have adopted HIT, but other factors, including specialty mix and self-reported patient-centered management, had a stronger influence on the use of HIT once adopted.ConclusionsAdoption of HIT by practices does not mean that physicians will use the HIT.

BackgroundTelemedicine can facilitate communication between primary care clinicians and specialists. Generalists who use telemedicine for consultation (teleconsultation) may be able to practice more independently and reduce the number of formal referrals to specialists. In the United States, a federally funded human immunodeficiency virus (HIV) teleconsultation service (HIV Warmline) offers clinicians live telephone access to HIV specialists; however, its impact on clinicians' self-perceived clinical competence and referral rates has not been studied.ObjectiveTo determine if primary care clinicians who used the HIV Warmline felt more capable of managing HIV in their own practices.DesignOnline survey.ParticipantsPrimary care physicians and mid-level practitioners who used the HIV Warmline for teleconsultation between 1/2008 and 3/2010.Main measuresParticipants compared the HIV Warmline to other methods of obtaining HIV clinical support, and then rated its impact on their confidence in their HIV skills and their referral patterns.Key resultsRespondents (N = 191, 59% response rate) found the HIV Warmline to be quicker (65%), more applicable (70%), and more trustworthy (57%) than other sources of HIV information. After using the HIV Warmline, 90% had improved confidence about caring for HIV, 67% stated it changed the way they managed HIV, and 74% were able to avoid referring patients to specialists. All valued the availability of live, free consultation.ConclusionsPrimary care clinicians who called the HIV Warmline reported increased confidence in their HIV care and less need to refer patients to specialists. Teleconsultation may be a powerful tool to help consolidate HIV care in the primary care setting, and could be adapted for use with a variety of other medical conditions. The direct impact of teleconsultation on actual referral rates, quality of care and clinical outcomes needs to be studied.

BackgroundGuidelines advise testing for ischemia, such as with stress testing, before elective percutaneous coronary intervention (PCI). However, pre-PCI stress testing is not always done; the implications of this practice are not known. Our objective was to evaluate whether receipt of stress testing before elective PCI predicts mortality.Methods and resultsUsing claims data from a 20% random sample of Medicare beneficiaries, we identified patients who had elective PCI in 2004 and followed them for a median of 3.4 years (n=23 887). Cox proportional hazards models were used to test the relationship of pre-PCI stress testing to survival. Population-based rates of elective PCI and stress testing were calculated for 306 hospital referral regions and categorized into 4 groups: high stress test/high PCI, low stress test/low PCI, low stress test/high PCI, and high stress/low PCI regions. Cox modeling was used to test whether category of hospital referral regions is related to survival. Patients who underwent pre-PCI stress testing had a 13% lower risk of mortality than those who did not (adjusted hazard ratio, 0.87; 95% confidence interval, 0.81-0.92) after median follow-up of 3.4 years. Patients in low stress test/high PCI regions had a 14% higher risk of mortality than those in high stress test/high PCI regions (adjusted hazard ratio, 1.14; 95% confidence interval, 1.03-1.26).ConclusionsPre-PCI stress testing is associated with lower mortality in patients undergoing elective PCI. Greater adherence to guidelines with respect to documenting ischemia before elective PCI may result in improved outcomes for patients.

PurposeMedication safety is a critical concern for older adults. Regional variation in potentially inappropriate prescribing practices may reflect important differences in health care quality. Therefore, the objectives of this study were to characterize prescribing quality variation among older adults across geographic region, and to compare prescribing quality across rural versus urban residence.MethodsCross-sectional study of 1,549,824 older adult veterans with regular Veterans Affairs (VA) primary care and medication use during fiscal year 2007. Prescribing quality was measured by 4 indicators of potentially inappropriate prescribing: Zhan criteria drugs to avoid, Fick criteria drugs to avoid, therapeutic duplication, and drug-drug interactions. Frequency differences across region and rural-urban residence were compared using adjusted odds-ratios.FindingsSignificant regional variation was observed for all indicators. Zhan criteria frequencies ranged from 13.2% in the Northeast to 21.2% in the South. Nationally, rural veterans had a significantly increased risk for inappropriate prescribing according to all quality indicators. However, regional analyses revealed this effect was limited to the South and Northeast, whereas rural residence was neutral in the Midwest and protective in the West.ConclusionsSignificant regional variation in prescribing quality was observed among older adult veterans, mirroring recent findings among Medicare beneficiaries. The association between rurality and prescribing quality is heterogeneous, and relying solely on national estimates may yield misleading conclusions. Although we documented important variations in prescribing quality, the underlying factors driving these trends remain unknown, and they are a vital area for future research affecting older adults in both VA and non-VA health systems.

BackgroundNational quality indicators show little change in the overuse of antibiotics for uncomplicated acute bronchitis. We compared the effect of 2 decision support strategies on antibiotic treatment of uncomplicated acute bronchitis.MethodsWe conducted a 3-arm cluster randomized trial among 33 primary care practices belonging to an integrated health care system in central Pennsylvania. The printed decision support intervention sites (11 practices) received decision support for acute cough illness through a print-based strategy, the computer-assisted decision support intervention sites (11 practices) received decision support through an electronic medical record-based strategy, and the control sites (11 practices) served as a control arm. Both intervention sites also received clinician education and feedback on prescribing practices, as well as patient education brochures at check-in. Antibiotic prescription rates for uncomplicated acute bronchitis in the winter period (October 1, 2009, through March 31, 2010) following introduction of the intervention were compared with the previous 3 winter periods in an intent-to-treat analysis.ResultsCompared with the baseline period, the percentage of adolescents and adults prescribed antibiotics during the intervention period decreased at the printed decision support intervention sites (from 80.0% to 68.3%) and at the computer-assisted decision support intervention sites (from 74.0% to 60.7%) but increased slightly at the control sites (from 72.5% to 74.3%). After controlling for patient and clinician characteristics, as well as clustering of observations by clinician and practice site, the differences for the intervention sites were statistically significant from the control sites (P = .003 for control sites vs printed decision support intervention sites and P = .01 for control sites vs computer-assisted decision support intervention sites) but not between themselves (P = .67 for printed decision support intervention sites vs computer-assisted decision support intervention sites). Changes in total visits, 30-day return visit rates, and proportion diagnosed as having uncomplicated acute bronchitis were similar among the study sites.ConclusionsImplementation of a decision support strategy for acute bronchitis can help reduce the overuse of antibiotics in primary care settings. The effect of printed vs computer-assisted decision support strategies for providing decision support was equivalent.Trial registrationclinicaltrials.gov Identifier: NCT00981994.

ObjectiveLess-than-annual cervical cancer screening is now recommended for most US women, raising questions about the need for routine annual bimanual pelvic examinations. Little is known about clinicians' bimanual pelvic examination practices, their beliefs about its importance, or the reasoning underlying its performance in asymptomatic women.Study designWe conducted a nationwide survey of US obstetrician-gynecologists. Respondents (n = 521) reported their examination practices and beliefs based on vignettes for asymptomatic women across the lifespan.ResultsNearly all obstetrician-gynecologists perform bimanual pelvic examinations in asymptomatic women across the lifespan, although it is viewed as less important for a newly sexually active 18-year-old. Reasons cited as very important included adherence to standard medical practices (45%), patient reassurance (49%), detection of ovarian cancer (47%), and identification of benign uterine (59%) and ovarian (54%) conditions.ConclusionObstetrician-gynecologists perform bimanual pelvic examinations in the vast majority of asymptomatic women, but the importance placed on the examinations and reasons for conducting them vary.

ObjectivesTo determine which older adults tend to receive potentially inappropriate medications (PIMs), how this may differ according to cognitive status, and how the trajectories of PIM use change over time.DesignTen-year longitudinal cohort study.SettingThree clinical sites in the United States.ParticipantsOne thousand four hundred eighty-four community-dwelling women aged 75 and older.MeasurementsAt follow-up, cognitive status was ascertained and classified as normal, mild cognitive impairment (MCI), or dementia. Beers 2003 criteria and other literature were used to identify PIMs from detailed medication inventory performed at three time points. Anticholinergic load was measured using the Anticholinergic Cognitive Burden Scale (ACB), which assigns medications a value from 0 to 3 depending on anticholinergic properties.ResultsAt baseline, 23.9% of women were taking at least one PIM and the mean ± SD ACB score was 1.41 ± 1.69. The most frequently reported PIMs were anticholinergics (15.2%), benzodiazepines (8.6%), and antispasmodics (8.0%). Over 10 years, PIM use increased for women with dementia (24.9-33.1%; P = .02) but remained fairly constant for women with MCI (23.9-23.0%; P = .84) and normal cognitive status (22.2-19.8%; P = .17). Mean ACB score increased significantly (P < .001) over time for all groups (dementia: 1.28-2.05; MCI: 0.98-1.66; normal: 0.99-1.48).ConclusionPIM use and anticholinergic load in a community-dwelling population of older women was high, especially in women who later developed dementia. Future guidelines should limit PIM use and seek safer alternatives.

Traditionally, patients presenting to primary care with severe eczema would be referred to a dermatology clinic for an in-person specialist appointment. With the rise of teledermatology, dermatologists are instead dispensing tailored written advice based on information provided in the referral. However, there is currently minimal literature assessing whether this advice translates into relevant prescriptions. This clinical audit examines GP prescribing practices and how they correlate to dermatologist recommendations with the objective of assessing whether this form of teledermatology is a viable method of providing care to paediatric eczema patients., (© 2024 The Authors. Australasian Journal of Dermatology published by John Wiley & Sons Australia, Ltd on behalf of Australasian College of Dermatologists.)

Purpose: 'Low-value' clinical care and medical services are 'questionable' activities, being more likely to cause harm than good or with disproportionately low benefit relative to cost. This study examined the predictive ability of the QUestionable In Training Clinical Activities Index (QUIT-CAI) for general practice (GP) registrars' (trainees') performance in Australian GP Fellowship examinations (licensure/certification examinations for independent GP)., Methods: The study was nested in ReCEnT, an ongoing cohort study in which Australian GP registrars document their in-consultation clinical practice. Outcome factors in analyses were individual registrars' scores on the three Fellowship examinations ('AKT', 'KFP', and 'OSCE' examinations) and pass/fail rates during 2012-21. Analyses used univariable and multivariable regression (linear or logistic, as appropriate). The study factor in each analysis was 'QUIT-CAI score percentage'-the percentage of times a registrar performed a QUIT-CAI clinical activity when 'at risk' (i.e. when managing a problem where performing a QUIT-CAI activity was a plausible option)., Results: A total of 1265, 1145, and 553 registrars sat Applied Knowledge Test, Key Features Problem, and Objective Structured Clinical Exam examinations, respectively. On multivariable analysis, higher QUIT-CAI score percentages (more questionable activities) were significantly associated with poorer Applied Knowledge Test scores (P = .001), poorer Key Features Problem scores (P = .003), and poorer Objective Structured Clinical Exam scores (P = .005). QUIT-CAI score percentages predicted Royal Australian College of General Practitioner exam failure [odds ratio 1.06 (95% CI 1.00, 1.12) per 1% increase in QUIT-CAI, P = .043]., Conclusion: Performing questionable clinical activities predicted poorer performance in the summative Fellowship examinations, thereby validating these examinations as measures of actual clinical performance (by our measure of clinical performance, which is relevant for a licensure/certification examination)., (© The Author(s) 2024. Published by Oxford University Press on behalf of Fellowship of Postgraduate Medicine.)

Objectives: We aimed to assess HIV symptoms from the perspective of both patients and HIV specialists and the impact of discontinuing antiretroviral treatment (ART) on symptomology. We gathered opinions from HIV specialists and people living with HIV about ideal ART parameters and treatment satisfaction., Methods: Ex post-facto cross-sectional surveys were administered to 502 people living with HIV and 101 HIV clinicians in Spain (18 sites)., Results: The median age of participants with HIV was 43.2 years, 74.5% were male, and 91.6% had an undetectable viral load. The mean time since initiation of ART was 10.2 years. Between 54% and 67% of people living with HIV reported experiencing nervousness or anxiety, sadness, fatigue, sleep problems, or muscle/joint pain during the preceding 4 weeks. However, only 22%-27% of specialists acknowledged the presence of these symptoms. The most bothersome symptoms were related to mental health or the central nervous system. There were significant differences between the burden of symptoms reported by people living with HIV and those acknowledged by specialists. The symptoms that more frequently caused ART discontinuation were depression, dizziness, and sleep problems. Both people living with HIV and specialists prioritized ART efficacy and low toxicity, but their importance ratings differed for 5 of the 11 ART characteristics assessed. People living with HIV rated their satisfaction with ART at a mean (± standard deviation) of 8.9 ± 1.5 out of 10, whereas HIV specialists rated it lower, at 8.3 ± 0.7 (p < 0.001)., Conclusions: Despite advances in HIV care and treatment, a large proportion of patients still experience symptoms. HIV specialists may not be fully aware of these. People living with HIV and HIV specialists are, overall, satisfied with ART. However, the importance they place on different ART characteristics may vary., (© 2024 British HIV Association.)

Hospital physicians care for most seriously ill patients in the United States. We employed dimensional analysis to describe communication about death and dying in audio-recorded admission encounters between seriously ill patients and hospitalists. Acknowledging or not acknowledging the possibility of dying emerged as a key process. Acknowledgment was rare, and depended on synergistic communication behaviors between patient and physician. Facilitators included patients cuing for information and disclosing emotional distress, and physicians exploring the patient's understanding of his or her illness and emotional distress. When hospitalists focused on acute issues, stated that they were awaiting test results, and deferred to other physicians, discussion moved away from acknowledgment. Meaningful discussion of end-of-life issues, including goals and values, fears about death and dying, prognosis, and options for palliative care followed open acknowledgment. This acknowledgment process can serve as a guide for providers to sensitively and honestly discuss essential end-of-life issues.

ObjectiveTo characterize population-level surgical treatment patterns for cervical carcinoma in situ (CIS) reported to the Michigan Cancer Surveillance Program (MCSP), and to inform data collection strategies.MethodsAll cases of cervical carcinoma in situ (CIS) (including cervical intraepithelial neoplasia grade 3 and adenocarcinoma in situ [AIS]) reported to the MCSP during 1998-2003 were identified. First course of treatment (ablative procedure, cone biopsy, loop electrosurgical excisional procedure [LEEP], hysterectomy, unspecified surgical treatment, no surgical treatment, unknown if surgically treated) was described by histology, race, and age at diagnosis.ResultsOf 17,022 cases of cervical CIS, 82.8 percent were squamous CIS, 3 percent AIS/adenosquamous CIS, and 14.2 percent unspecified/other CIS. Over half (54.7 percent) of cases were diagnosed in women under age 30. Excisional treatments (LEEP, 32.3 percent and cone biopsy, 17.3 percent) were most common, though substantial proportions had no reported treatment (17.8 percent) or unknown treatment (21.1 percent). Less common were hysterectomy (7.2 percent) and ablative procedures (2.6 percent). LEEP was the most common treatment for squamous cases, while hysterectomy was the most treatment for AIS/adenosquamous CIS cases. Across histologic types, a sizeable proportion of women diagnosed ≤30 years of age underwent excision, either LEEP (20 percent-38.7 percent) or cone biopsy (13.7 percent-44 percent).ConclusionDespite evidence suggesting it may be safer and equally effective as excision, ablation was rarely used for treating cervical squamous CIS. These population-based data indicate some notable differences in treatment by histology and age at diagnosis, with observed patterns appearing consistent with consensus guidelines in place at the time of study, but favoring more aggressive procedures. Future data collection strategies may need to validate treatment information, including the large proportion of no or unknown treatment.

ObjectiveThe objectives of this study were to describe inpatient anticoagulation and bridging in patients with non-valvular atrial fibrillation (NVAF) and to identify whether differences exist in length of stay (LOS) among bridged versus non-bridged NVAF patients.DesignAdministrative claims data were used to select patients ≥18 years with a primary or secondary discharge diagnosis of NVAF and inpatient warfarin use from 1 July 2004 to 30 September 2009. Patients with valvular or transient causes of NVAF or pregnancy were excluded. Inpatient bridging was defined as receipt of an anticoagulant in addition to warfarin during the hospitalization. LOS was reported for non-bridged patients (warfarin only) and compared with three bridging regimens: low molecular weight heparin/pentasaccharide (LMWH/PS); unfractionated heparin (UFH); and two-agent bridging (LMWH/PS and UFH). Multivariate analyses were performed to evaluate the association between bridging and LOS, adjusting for demographic and clinical variables.ResultsOf 6340 NVAF patients, 48% received inpatient warfarin (mean LOS 5.5 days); among them, 64% received bridging therapy (mean LOS 6.3 days) [LMWH/PS 45% (mean LOS 5.6 days), UFH 36% (mean LOS 6.0 days), two-agent bridging 18% (mean LOS 8.4 days)]. Following multivariate analysis, relative to patients who received inpatient warfarin only, LOS was significantly higher for patients with UFH (19.3%) and patients with two-agent bridging (45.1%). Patients with pre-period warfarin, cancer, or diabetes mellitus who received bridging agents had significantly longer LOS than patients with those conditions who were not bridged.ConclusionLOS was longer for bridged than non-bridged patients. Further studies are needed to identify predictors of bridging and to explain why bridged NVAF patients had longer LOS.

ContextThe federal Title X grant program provides funding for family planning services for low-income women and men. In California, all clinics receiving Title X funds participate in the state's family planning program, Family PACT, along with other public and private providers. The relative extent to which Title X-funded clinics and other Family PACT providers have incorporated enhancements beyond their core medical services has never been studied.MethodsIn 2010, a survey was sent to public- and private-sector Family PACT clinicians to assess whether funding streams were associated with the availability of special services: extended clinic hours, outreach to vulnerable populations, services for clients not proficient in English and use of advanced clinic-based technologies. Bivariate and logistic regression analyses controlling for potentially confounding factors were conducted.ResultsGreater proportions of Title X-funded clinics than of other public and private providers had Spanish-speaking unlicensed clinical staff (89% vs. 71% and 58%, respectively) and Spanish-language signs (95% vs. 85% and 82%). Title X-funded providers were more likely than other public providers to offer extended clinic hours, provide outreach to at least three vulnerable or hard-to-reach populations, and use three or more advanced technologies (odds ratios, 2.0-2.9).ConclusionsCompared with other Family PACT providers, clinics that receive Title X funding have implemented greater infrastructure enhancements to promote access and improve the quality of service for underserved populations. This may be because Title X-funded providers have more financial opportunities to provide the array of services that best respond to their clients' needs.

ContextThe federal Title X grant program provides funding for family planning services for low-income women and men. In California, all clinics receiving Title X funds participate in the state's family planning program, Family PACT, along with other public and private providers. The relative extent to which Title X-funded clinics and other Family PACT providers have incorporated enhancements beyond their core medical services has never been studied.MethodsIn 2010, a survey was sent to public- and private-sector Family PACT clinicians to assess whether funding streams were associated with the availability of special services: extended clinic hours, outreach to vulnerable populations, services for clients not proficient in English and use of advanced clinic-based technologies. Bivariate and logistic regression analyses controlling for potentially confounding factors were conducted.ResultsGreater proportions of Title X-funded clinics than of other public and private providers had Spanish-speaking unlicensed clinical staff (89% vs. 71% and 58%, respectively) and Spanish-language signs (95% vs. 85% and 82%). Title X-funded providers were more likely than other public providers to offer extended clinic hours, provide outreach to at least three vulnerable or hard-to-reach populations, and use three or more advanced technologies (odds ratios, 2.0-2.9).ConclusionsCompared with other Family PACT providers, clinics that receive Title X funding have implemented greater infrastructure enhancements to promote access and improve the quality of service for underserved populations. This may be because Title X-funded providers have more financial opportunities to provide the array of services that best respond to their clients' needs.

PurposeRoutine assessment of women's pregnancy intentions and contraceptive use-a so-called contraceptive vital sign-may help primary care physicians identify patients who need preconception or contraceptive counseling and be of particular benefit when teratogenic medications are prescribed.MethodsWe conducted a cluster-randomized controlled trial to evaluate the effect of a contraceptive vital sign on primary care documentation of contraceptive use and change in primary care physicians' provision of family planning services. Academic internists in the intervention group (n = 26) were provided with information on their female patients' pregnancy intentions and contraceptive use immediately before visits; internists in the control group (n = 27) received only standard intake information. Data were abstracted from the electronic health record for 5,371 visits by 2,304 women aged 18 to 50 years.ResultsDocumentation of contraception increased from baseline, from 23% to 57% in the intervention group, but remained 28% in the control group, a change of +77.4 (95% confidence interval [CI], 70.7 to 84.1) adjusted percentage points in the former vs +3.1 (95% CI, 1.2 to 5.0) in the latter (P

BackgroundConsequences of antibiotic overuse are substantial, especially among older adults, who are more susceptible to adverse reactions. Findings about variation in antibiotic prescribing can target policy efforts to focused areas; however, little is known about these patterns among older adults.MethodsUsing Medicare Part D data from January 1, 2007, through December 31, 2009 (comprising 1.0-1.1 million patients per year), we examined geographic variation in antibiotic use among older adults in 306 Dartmouth Atlas of Health Care hospital referral regions, 50 states and the District of Columbia, and 4 national regions (South, West, Midwest, and Northeast). In addition, we examined the quarterly change in antibiotic use across the 4 regions. Differences in patient demographics, insurance status, and clinical characteristics were adjusted for across regions.ResultsSubstantial geographic and quarterly variation in outpatient antibiotic prescribing existed across regions after adjusting for population characteristics. This variation could not be explained by differences in the prevalences of the underlying conditions. For example, the ratios of the 75th percentile to the 25th percentile of adjusted annual antibiotic spending were 1.31 across states and 1.32 across regions. The highest antibiotic use was in the South, where 21.4% of patients per quarter used an antibiotic, whereas the lowest antibiotic use was in the West, where 17.4% of patients per quarter used an antibiotic (P < .01). Regardless of region, the rate of antibiotic use was highest in the first quarter (20.9% in January through March) and was lowest in the third quarter (16.9% in July through September) (P < .01).ConclusionsAreas with high rates of antibiotic use may benefit from targeted programs to reduce unnecessary prescription. Quality improvement programs can set attainable targets using the low-prescribing areas as a reference, particularly targeting older adults.

Despite the importance of measuring weight and height at well-child visits, there are limited data on frequency of anthropometric documentation. The authors aimed to identify characteristics associated with missing weight and height documentation at preventive visits for children. Among preventive visits for children from birth to 18 years old, recorded in the National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Surveys for 2005-2009, the authors found that 20.8% had missing weight and/or height (n = 19,033) documentation. Compared with infants younger than 2 years, school-age children (odds ratio [OR] = 1.30; 95% confidence interval [CI] = 1.03-1.64), and adolescents (OR = 1.61; 95% CI = 1.26-2.04) were more likely to lack documentation. Missing documentation was also more likely for visits with nonphysicians (OR = 4.53; 95% CI = 3.17-6.48) and nonpediatricians (OR = 2.63; 95% CI = 2.02-3.41) compared with pediatricians. Efforts to improve weight and height surveillance should be directed to clinics in which midlevel providers and nonpediatric physicians are caring for school-age children and adolescents.

ObjectiveWe examined chronic pain management practices and confidence and satisfaction levels in treating chronic pain among primary care providers (PCPs) who cared for high-risk patients in safety net health settings.DesignWe recruited PCPs (N = 61) through their HIV-infected patients who were enrolled in a longitudinal study on pain, use, and misuse of opioid analgesics (Pain Study). We asked PCPs to complete a questionnaire about all of their patients in their practice on the prevalence of chronic pain and illicit substance use, use of opioid analgesics, confidence and satisfaction levels in treating chronic pain, and likelihood of prescribing opioid analgesics in response to clinical vignettes.ResultsAll PCPs cared for at least some patients with chronic pain, and the majority prescribed opioid analgesics for its treatment. All PCPs cared for at least some patients who used illicit substances. PCPs reported low confidence and satisfaction levels in treating chronic pain. The majority (73.8%) of PCPs were highly likely to prescribe opioid analgesics to a patient without a history of substance use who had chronic pain. The majority (88.5%) were somewhat to highly likely to prescribe opioid analgesics to a patient with a prior history of substance use but not active use. Most (67.2%) were somewhat to highly likely to prescribe opioids to a patient with active substance use.ConclusionIn order to improve PCPs' confidence and satisfaction in managing chronic pain, further work should explore the root causes of low confidence and satisfaction and also explore possible remedies.

BackgroundThe 2010 Affordable Care Act relies on Federally Qualified Health Centers (FQHCs) and FQHC look-alikes (look-alikes) to provide care for newly insured patients, but ties increased funding to demonstrated quality and efficiency.PurposeTo compare FQHC and look-alike physician performance with private practice primary care physicians (PCPs) on ambulatory care quality measures.MethodsThe study was a cross-sectional analysis of visits in the 2006-2008 National Ambulatory Medical Care Survey. Performance of FQHCs and look-alikes on 18 quality measures was compared with private practice PCPs. Data analysis was completed in 2011.ResultsCompared to private practice PCPs, FQHCs and look-alikes performed better on six measures (p