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Purpose Health care systems increasingly demand health professionals who can lead interdisciplinary teams. While physicians recognize the importance of leadership skills, few receive formal instruction in this area. This paper aims to describe how the Student Leadership Committee (SLC) at the Harvard Medical School Center for Primary Care responded to this need by creating a leadership curriculum for health professions students. Design/methodology/approach The SLC designed an applied longitudinal leadership curriculum and taught it to medical, dentistry, nursing, public health and business students during monthly meetings over two academic years. The perceptions of the curriculum were assessed via a retrospective survey and an assessment of team functioning. Findings Most teams met their project goals and students felt that their teams were effective. The participants reported increased confidence that they could create change in healthcare and an enhanced desire to hold leadership positions. The sessions that focused on operational skills were especially valued by the students. Practical implications This case study presents an effective approach to delivering leadership training to health professions students, which can be replicated by other institutions. Social implications Applied leadership training empowers health professions students to improve the health-care system and prepares them to be more effective leaders of the future health-care teams. The potential benefits of improved health-care leadership are numerous, including better patient care and improved job satisfaction among health-care workers. Originality/value Leadership skills are often taught as abstract didactics. In contrast, the approach described here is applied to ongoing projects in an interdisciplinary setting, thereby preparing students for real-world leadership positions.

STUDY DESIGN Structured key informant interviews with follow-up. OBJECTIVE The aim of the study was to describe innovative reimbursement models in spine care and gather perspectives on the future of spine care reimbursement. SUMMARY OF BACKGROUND DATA The United States spends $90 billion annually on medical expenses for low back pain. One approach to promoting high-quality, cost-effective care is through bundled payments and other reimbursement models wherein physicians are held accountable for costs and utilization. Little data exist on innovative payment models in spine care. METHODS Through literature review and discussions with leaders in the field, we identified organizations that were engaged in bundled payment initiatives for spine care and surgery. These included healthcare systems, physician groups, organizations helping to set up bundles, and a large employer. We conducted interviews to understand the background and specific features of each initiative, generalizable success factors and challenges, and perspectives on the future of spine reimbursement. RESULTS We interviewed 24 stakeholders across 18 organizations that collectively perform approximately 12,000 inpatient spine surgeries annually. Fee-for-service reimbursement accounts for a majority of revenue, but several organizations expect 30% to 45% of their spine volume to be covered under bundled payments within 3 years and cite new patient volume, increased surgical yield, and financial benefits from efficiency improvements as reasons for adopting bundled payments. Current initiatives are heterogeneous, but share similar success factors and challenges. Institutions are more hesitant to adopt risk-based payment models for chronic back care, citing difficulty modeling risk, patient heterogeneity, and difficulty aligning incentives. CONCLUSION Payment models outside of the traditional fee-for-service paradigm are emerging in spine care. Providers that preemptively adopt bundled payments can increase patient volumes from payers seeking cost-effective care. Going forward, organizations should begin considering reimbursement models that focus on noninterventional spine care. Finally, developments in spine reimbursement may apply to other procedure-based specialties, including orthopedics and cardiology. LEVEL OF EVIDENCE 5.

STUDY DESIGN Retrospective analysis of billing data, medical records, and hospital cost data. OBJECTIVE To quantify intersurgeon variation for hospital costs of four spine procedures while adjusting for patient comorbidities and demographic factors. SUMMARY OF BACKGROUND DATA Spine care accounts for $90 billion in health care expenditures in the United States. Past findings demonstrate regional variation in surgery rates and high intersurgeon variation for anterior cervical discectomies/fusions. However, less has been done to examine intersurgeon variation in resource use across multiple procedures while adjusting for patient characteristics outside of a surgeon's control. METHODS We examined intersurgeon variation for 1241 elective spine procedures at one facility for 3 years. The procedures included 1 to 2 level cases of anterior cervical discectomies/fusions, posterior lumbar decompressions/fusions, posterior laminectomies, and lumbar discectomies. We isolated mean and median costs by surgeon and adjusted for patient demographics, comorbidities, and procedure types. Finally, we examined variation in subcategories such as instrumentation and inpatient stay costs to determine which contribute to total cost variation. RESULTS Unadjusted costs per surgeon varied by a factor of 1.32 to 1.81 between lowest and highest cost surgeon depending on procedure. After adjusting for patient features and procedure, variation was reduced to 1.31x. Of the seven surgeons who had sufficient patient volume, one was significantly less costly (-$1,462 per procedure) whereas three were significantly more costly than mean (+$685, +$839, +$702 per procedure). Intersurgeon differences in supply and operating room costs largely accounted for total variation, though actual drivers of variation were surgeon-specific. CONCLUSION Surgeons vary in average cost for spine procedures, though variation is more modest once adjusted for patient characteristics. Data on procedure-level variation should be discussed with individual surgeons to shift practice patterns. Finally, the comparison methodology can be applied to other procedures and specialties. LEVEL OF EVIDENCE 4.

BACKGROUND: Treatment of small intestinal neuroendocrine tumors (SINETs) with mammalian target of rapamycin (mTOR) inhibitors alone or with somatostatin analogs has been proposed as effective therapy, because both agents have been reported to exhibit antiproliferative activity. Because adenocarcinomas escape mTOR inhibition, we examined whether the escape phenomenon occurred in SINETs and whether usage of somatostatin analogs with mTOR inhibitors surmounted loss of inhibition. METHODS: The effects of the somatostatin analog octreotide (OCT), the mTOR inhibitor RAD001 (RAD), or the combination were evaluated in SINET cell lines (KRJ-I, H-STS) using cell viability assays, western blotting, enzyme-linked immunosorbent assay, and reverse-transcription polymerase chain reaction to assess antiproliferative signaling pathways and feedback regulation. RESULTS: RAD (10 � 9 M) incompletely decreased cell viability (� 40% to þ15%); growth escape (P < .001) was noted at 72 hours in both cell lines. Phosphorylated (p)mTOR/mTOR and pp70S6K/p70S6K ratios were decreased but were associated with increases in phosphorylated extracellular signal-regulated kinase (pERK)/ERK and pAKT/AKT in both cell lines, whereas phosphorylated insulin-like growth factor 1 receptor (pIGF-1R)/IGF-1R levels were elevated only in H-STS cells. Increased (P < .05) transcript levels for AKT1, MAPK, mTOR, IGF-1R, IGF-1, and TGFb1 were evident. OCT (10 � 6 M) itself had no significant effect on growth signaling in either cell line. An antiproliferative effect (66 � 5%) using OCTþRAD was only noted in the KRJ-I cells (P < .05). CONCLUSIONS: SINET treatment with the mTOR inhibitor RAD had no antiproliferative effect based on activation of pAKT and pERK1/2. A combinatorial approach using OCT and RAD failed to overcome this escape phenomenon. However, differences in RAD response rates in individual NET cell lines suggested that pretreatment identification of different tumor sensitivity to mTOR inhibitors could provide the basis for individualized treatment. Cancer 2011;117:4141–54. V C 2011 American Cancer Society.

Study design Retrospective review of medical records and administrative data. Objective Validate a claims-based algorithm for classifying surgical indication and operative features in lumbar surgery. Summary of background data Administrative data are valuable to study rates, safety, outcomes, and costs in spine surgery. Previous research evaluates outcomes by procedure, not indications and operative features. One previous study validated a coding algorithm for classifying surgical indication. Few studies examined claims data for classifying patients by operative features. Methods Patients undergoing lumbar decompression or fusion at a single institution in 2009 for back pain, herniated disc, stenosis, spondylolisthesis, or scoliosis were included. Sensitivity and specificity of a claims-based algorithm for indication and operative features were examined versus medical record abstraction. Results A total of 477 patients, including 246 (52%) undergoing fusion and 231 (48%) undergoing decompression were included in this study. Sensitivity of the claims-based coding algorithm for classifying the indication for the procedure was 71.9% for degenerative disc disease, 81.9% for disc herniation, 32.7% for spinal stenosis, 90.4% for degenerative spondylolisthesis, and 93.8% for scoliosis. Specificity was 87.9% for degenerative disc, 85.6% for disc herniation, 90.7% for spinal stenosis, 95.0% for degenerative spondylolisthesis, and 97.3% for scoliosis. Sensitivity and specificity of claims data for identifying the type of procedure for fusion cases was 97.6% and 99.1%, respectively. Sensitivity of claims data for characterizing key operative features was 81.7%, 96.4%, and 53.0% for use of instrumentation, combined (anterior and posterior) surgical approach, and 3 or more disc levels fused, respectively. Specificity was 57.1% for instrumentation, 94.5% for combined approaches, and 71.9% for 3 or more disc levels fused. Conclusion Claims data accurately reflected certain diagnoses and type of procedures, but were less accurate at characterizing operative features other than the surgical approach. This study highlights both the potential and current limitations of claims-based analysis for spine surgery.

Platelet‐derived serotonin (5‐HT) is involved in liver regeneration. The liver is also the metastatic site for malignant enterochromaffin (EC) cell “carcinoid” (neuroendocrine) neoplasms, the principal cellular source of 5‐HT. We hypothesized that 5‐HT produced by metastatic EC cells played a role in the hepatic tumor‐microenvironment principally via 5‐HT (7) receptor‐mediated activation of hepatocyte IGF‐1 synthesis and secretion. Using isolated rat hepatocytes, we evaluated 5‐HT(7) receptor expression (using PCR, sequencing and western blot). ELISA, cell transfection and western blots delineated 5‐HT‐mediated signaling pathways (pCREB, AKT and ERK). IGF‐1 synthesis/secretion was evaluated using QPCR and ELISA. IGF‐1 was tested on small intestinal neuroendocrine neoplasm proliferation, while IGF‐1 production and 5‐HT (7) expression were examined in an in vivo SCID metastasis model. Our results demonstrated evidence for a functional 5‐HT (7) receptor. 5‐HT activated cAMP/PKA activity, pCREB (130–205%, P