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The purpose of this study was to examine temporal nationwide utilization patterns and predictors for use of positron emission tomography/computed tomography (PET/CT) in comparison with magnetic resonance imaging (MRI) and computed tomography (CT) among patients diagnosed with bladder cancer. A total of 36,855 patients aged 66 years or older diagnosed with clinical stage TI-IV, N0M0 bladder cancer from 2004 to 2011 were analyzed. We used multivariable logistic regression analyses to discern factors associated with receipt of imaging within 12 months from diagnosis. The Cochran-Armitage test for trend was used to determine changes in the proportion of patients receiving imaging after cancer diagnosis. Independent of clinical stage, there was marked increase in use of PET/CT throughout the study period (2011 vs. 2004: odds ratio, 17.55; 95% confidence interval, 10.14-30.38; P < .001). Although use of CT imaging remained stable during the study period, there was significantly decreased utilization of MRI (odds ratio, 0.60; 95% confidence interval, 0.49-0.75; P < .001) in 2011 versus 2004. The mean incremental cost of PET/CT versus CT and MRI was $1040 and $612 (in 2016 dollars), respectively. Extrapolating these findings to the patients with bladder cancer in the United States results in excess spending of $11.6 million for PET/CT imaging. We identified rapid adoption of PET/CT imaging independent of clinical stage, resulting in excess national spending of $11.6 million for this imaging modality alone. Further value-based research discerning the clinical versus economic benefits of advanced imaging among patients with bladder cancer are needed.

Objectives. We sought to assess appropriateness of medication prescribing for older Texas prisoners. Methods. In this 12-month cross-sectional study of 13117 prisoners (aged [greater than or equal to]55 years), we assessed medication use with Zhan criteria and compared our results to prior studies of community prescribing. We assessed use of indicated medications with 6 Assessing Care of Vulnerable Elders indicators. Results. Inappropriate medications were prescribed to a third of older prisoners; half of inappropriate use was attributable to over-the-counter antihistamines. When these antihistamines were excluded, inappropriate use dropped to 14% ([greater than or equal to]55 years) and 17% ([greater than or equal to]65 years), equivalent to rates in a Department of Veterans Affairs study (17%) and lower than rates in a health maintenance organization study (26%). Median rate of indicated medication use for the 6 indicators was 80% (range=12%-95%); gastrointestinal prophylaxis for patients on nonsteroidal anti-inflammatories at high risk for gastrointestinal bleed constituted the lowest rate. Conclusions. Medication prescribing for older prisoners in Texas was similar to that for older community adults. However, overuse of antihistamines and underuse of gastrointestinal prophylaxis suggests a need for education of prison health care providers in appropriate prescribing practices for older adults. (Am J Public Health. 2010;100:756-761. doi: 10.2105/AJPH.2008.154591)

Objective. Current guidelines of the Accreditation Council for Graduate Medical Education have restricted the amount of intensive care experience obtained during pediatric residency. The impact on performing procedures has not been evaluated. To determine the current level of competency in 1 common procedure, we investigated the proficiency of pediatric residents in performing neonatal endotracheal intubation during the academic years 1998-1999 and 2000-2001. Methods. Indication for intubation, number of attempts, and achievement of success were recorded by the respiratory therapist present for the procedure. Each intubation was scored according to the attempt on which intubation was successful. Indications for intubation were categorized as respiratory failure, delivery room resuscitation, and meconium-stained amniotic fluid. Competency was defined as a successful intubation occurring on the first or second attempt [greater than or equal to]80% of the time. Intubation scores were compared between residents at various stages of training and analyzed by multivariate logistic regression analysis for significance. Comparisons were then performed to determine percentage success with confidence intervals. We also surveyed previous graduates of the training program not included in the observations for this study and asked them to indicate how frequently they perform intubation in current practice and to assess their own competence in the procedure. Results. A total of 449 resident procedures were observed during the study periods: 192 by postgraduate year I (PGY-1) residents, 126 by PGY-2 residents, and 131 by PGY-3 residents. A total of 35% (160 of 449) of intubation procedures were never successful by pediatric house officers. Intubation was successful on the first or second attempt for 50% of PGY-1 residents (95% confidence interval [CI]: 42.6-56.8), 55% of PGY-2 residents (95% CI: 46-63.5), and 62% of PGY-3 residents (95% CI: 53.9-70.7). The third-year residents exhibited a significantly higher likelihood of performing a successful intubation compared with first-year residents. The first-year residents in 1998-1999 showed no improvement by their third year in 2000-2001. Surveys were sent to 56 graduates of our residency program (1998-2000). Completed surveys were received from 31 (66%) of 47. A total of 71% of the respondents are practicing general pediatrics, and 36% attend deliveries or perform intubations. A total of 87% reported that their level of confidence with endotracheal intubation was good or excellent after completion of residency training. Conclusions. We provide objective and subjective data concerning the proficiency of pediatric residents in performing neonatal endotracheal intubation. None of our resident groups met the specified definition of technical competence, although there was improvement with advancing training level in bivariate analyses. However, graduates of our training program felt confident with their intubation skills in contrast to our objective findings. As exposure to these important skills becomes limited, methods to ensure attainment of technical competency during training may need to be redefined. Pediatrics 2003;112:1242-1247; residency education, intubation, neonatal resuscitation., ABBREVIATIONS. NRP, neonatal resuscitation program; RRC, Residency Review Committee; NICU, neonatal intensive care unit; PGY, postgraduate year; MSAF, meconium-stained amniotic fluid; CI, confidence interval; OR, odds ratio. Guidelines of the [...]

Background: Given concerns about suboptimal pain management for actively treated cancer patients following the 2014 federal reclassification of hydrocodone, we examined changes in patterns of opioid prescribing among surgical breast cancer patients. Materials and Methods: Data from a large nationally representative commercial health insurance program from 2009 to 2017 were used to identify women aged 18 years and older who were diagnosed with carcinoma in‐situ or malignant breast cancer and received breast‐conserving surgery or mastectomy from 2010 to 2016. Generalized linear mixed models were used to estimate the adjusted odds ratio (aOR) for receipt of ≥1‐day, >30‐day, or ≥ 90‐day supply of opioids in the 12 months following surgery adjusting for demographics, cancer treatment–related characteristics, and preoperative opioid use. Results: A total of 60,080 patients were included in the study. Surgically treated breast cancer patients in 2015 (aOR = 0.90, 0.84–0.97) and 2016 (aOR = 0.80, 0.74–0.86) were less likely to receive ≥1‐day supply of opioid prescriptions when compared with patients in 2013. Patients who had surgery in 2015 (aOR = 0.89, 0.81–0.98) and 2016 (aOR = 0.80, 0.73–0.87) were also less likely to receive >30‐day supply of prescription opioids in the 12 months following surgery. However, only surgical breast cancer patients in 2016 were less likely to receive ≥90‐day supply (aOR = 0.86, 0.76–0.98). Conclusion: Surgically treated breast cancer patients are less likely to receive short‐ and long‐term opioid prescriptions following the implementation of hydrocodone rescheduling. Further studies on the potential impact of federal policy on cancer patient pain management are needed. Implications for Practice: Clinicians and researchers with diverse perspectives should be included as stakeholders during policy development for restricting opioid prescriptions. Stakeholders can identify potential unintended consequences early and help identify methods to mitigate concerns, specifically as it relates to policy that influences how providers manage pain for actively treated cancer patients. This work shows how federal policy may have led to declines in opioid prescribing for breast cancer patients who underwent mastectomy or breast‐conserving surgery. This article addresses the effect of federal regulation of opioids, with a goal of improving understanding of the unintended effects of policy on quality of pain management for patients undergoing cancer‐related surgery. [ABSTRACT FROM AUTHOR]

The article presents a study which aims at evaluating presumably therapeutic components within a therapeutic community in terms of received helpfulness by patients and staff of an alcohol treatment unit. Eighteen male patients and 18 staff members participated. A nonparametric statistic was used as an index of treatment philosophy articulation or degree of value-sharing. A core of activities valued congruently by patients and staff was identified. A decision was made on the basis of all the information at hand to modify the activity to make it psychologically therapeutic. Art therapy, with a structured format and individualized feedback, was substituted for art classes. Patients recognize its value as one component in the overall program, and so there is better attendance and less dissatisfaction.