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This sequential, cross-sectional study examines the prevalence of perforated appendicitis in children in the United States in relation to access to health care from 2001 to 2015.

Biykem Bozkurt, MD, PhD, FACC, FAHA, Chair H. Vernon Anderson, MD, FACC, FAHA Garth N. Graham, MD, FACC Hani Jneid, MD, FACC, FAHA Gail K. Jones, MD David Kao, MD, FAHA Michael Kutcher, MD, FACC Leo Lopez, MD, FACC Gregory Marcus, MD, FACC, FAHA Jennifer Rymer, MD James E. Tcheng, MD

As sepsis hospitalizations have increased, in-hospital sepsis deaths have declined. However, reported rates may remain higher among racial/ethnic minorities. Most previous studies have adjusted primarily for age and sex. The effect of other patient and hospital characteristics on disparities in sepsis mortality is not yet well-known. Furthermore, coding practices in claims data may influence findings. The objective of this study was to use a broad method of capturing sepsis cases to estimate 2004-2013 trends in risk-adjusted in-hospital sepsis mortality rates by race/ethnicity to inform efforts to reduce disparities in sepsis deaths.Retrospective, repeated cross-sectional study.Acute care hospitals in the Healthcare Cost and Utilization Project State Inpatient Databases for 18 states with consistent race/ethnicity reporting.Patients diagnosed with septicemia, sepsis, organ dysfunction plus infection, severe sepsis, or septic shock.In-hospital sepsis mortality rates adjusted for patient and hospital factors by race/ethnicity were calculated. From 2004 to 2013, sepsis hospitalizations for all racial/ethnic groups increased, and mortality rates decreased by 5-7% annually. Mortality rates adjusted for patient characteristics were higher for all minority groups than for white patients. After adjusting for hospital characteristics, sepsis mortality rates in 2013 were similar for white (92.0 per 1,000 sepsis hospitalizations), black (94.0), and Hispanic (93.5) patients but remained elevated for Asian/Pacific Islander (106.4) and "other" (104.7; p0.001) racial/ethnic patients.Our results indicate that hospital characteristics contribute to higher rates of sepsis mortality for blacks and Hispanics. These findings underscore the importance of ensuring that improved sepsis identification and management is implemented across all hospitals, especially those serving diverse populations.

The American College of Cardiology (ACC) and the American Heart Association (AHA) support their members’ goal to improve the care of patients with cardiovascular disease through professional education, research, and development of guidelines and standards and by fostering policies that support optimal patient outcomes. The ACC and AHA recognize the importance of the use of clinical data standards for patient management, assessment of outcomes, and conduct of research, and the importance of defining the processes and outcomes of clinical care, whether in randomized trials, observational studies, registries, or quality improvement initiatives. Clinical data standards strive to define and standardize data relevant to clinical concepts, with the primary goal of facilitating uniform data collection by providing a platform of clinical terms with corresponding definitions and data elements. Broad agreement on a …

Background: Congenital heart defects (CHDs) occur in approximately 8 per 1000 live births. Improvements in detection and treatment have increased survival. Few national estimates of the healthcare costs for infants, children and adolescents with CHDs are available. Methods: We estimated hospital costs for hospitalizations using pediatric (0–20 years) hospital discharge data from the 2009 Healthcare Cost and Utilization Project Kids' Inpatient Database (KID) for hospitalizations with CHD diagnoses. Estimates were up-weighted to be nationally representative. Mean costs were compared by demographic factors and presence of critical CHDs (CCHDs). Results: Up-weighting of the KID generated an estimated 4,461,615 pediatric hospitalizations nationwide, excluding normal newborn births. The 163,980 (3.7%) pediatric hospitalizations with CHDs accounted for approximately $5.6 billion in hospital costs, representing 15.1% of costs for all pediatric hospitalizations in 2009. Approximately 17% of CHD hospitalizations had a CCHD, but it varied by age: approximately 14% of hospitalizations of infants, 30% of hospitalizations of patients aged 1 to 10 years, and 25% of hospitalizations of patients aged 11 to 20 years. Mean costs of CHD hospitalizations were higher in infancy ($36,601) than at older ages and were higher for hospitalizations with a CCHD diagnosis ($52,899). Hospitalizations with CCHDs accounted for 26.7% of all costs for CHD hospitalizations, with hypoplastic left heart syndrome, coarctation of the aorta, and tetralogy of Fallot having the highest total costs. Conclusion: Hospitalizations for children with CHDs have disproportionately high hospital costs compared with other pediatric hospitalizations, and the 17% of hospitalizations with CCHD diagnoses accounted for 27% of CHD hospital costs. Birth Defects Research (Part A) 100:934–943, 2014. © 2014 Wiley Periodicals, Inc.

Objective Children and adolescents are known to experience poor health care quality; some groups of children have poorer health care than others. We sought to examine trends over time in health care quality and disparities by race, Hispanic ethnicity, income, insurance, gender, rurality, and special health care needs. Methods Source data were extracted from the 2011 National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR) database, which contains aggregated data from many government and private sources for the years 2000 through 2009. The NHQR and NHDR approaches to calculating disparities and trends in quality and disparities were used. Within each quality measure with available data, results for demographic subgroups of children characterized by race/ethnicity, income, insurance, residence, special health care need, and gender were compared to those of a reference group to determine whether disparities existed and whether disparities had changed over time. Results Of 68 measures with data for calculating potential disparities, 50 showed disparities in quality for at least 1 comparison subgroup in the most recent year of data available, while 18 measures showed no such disparities. Of the 50 measures with current disparities, 39 measures had sufficient data to calculate trends. Among the 137 comparisons made within these 39 measures, there was no change in disparities over time for 126 comparisons, 3 comparisons worsened, and 8 comparisons improved. Conclusions There was some progress in health care quality and reducing disparities in children's health care quality from 2000 to 2009; opportunities for targeting improvement strategies remain.

BACKGROUND Differences in quality of care may contribute to racial variation in outcomes of bladder cancer (BCa). Quality indicators in patients undergoing surgery for BCa include the use of high-volume surgeons and high-volume hospitals, and, when clinically indicated, receipt of pelvic lymphadenectomy, receipt of continent urinary diversion, and undergoing radical cystectomy instead of partial cystectomy. The authors compared these quality indicators as well as adverse perioperative outcomes in black patients and white patients with BCa. METHODS The Healthcare Cost and Utilization Project State Inpatient Databases for New York, Florida, and Maryland (1996-2009) were used, because they consistently included race, surgeon, and hospital identifiers. Quality indicators were compared across racial groups using regression models adjusting for age, sex, Elixhauser comorbidity sum, insurance, state, and year of surgery, accounting for clustering within hospital. RESULTS Black patients were treated more often by lower volume surgeons and hospitals, they had significantly lower receipt of pelvic lymphadenectomy and continent diversion, and they experienced higher rates of adverse outcomes compared with white patients. These associations remained significant for black patients who received treatment from surgeons and at hospitals in the top volume decile. CONCLUSIONS Black patients with BCa had lower use of experienced providers and institutions for BCa surgery. In addition, the quality of care for black patients was lower than that for whites even if they received treatment in a high-volume setting. This gap in quality of care requires further investigation. Cancer 2014;120:1018–1025. © 2013 American Cancer Society.

The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) support their members’ goal to improve the prevention and care of cardiovascular diseases through professional education, research, and development of guidelines and standards and by fostering policy that supports optimal patient outcomes. The ACCF and AHA recognize the importance of the use of clinical data standards for patient management, assessment of outcomes, and conduct of research, and the importance of defining the processes and outcomes of clinical care, whether in randomized trials, observational studies, registries, or quality-improvement initiatives. Hence, clinical data standards strive to define and standardize data relevant to clinical topics in cardiology, with the primary goal of assisting data collection by providing a platform of data elements and definitions applicable to various conditions. Broad agreement on a common vocabulary with reliable definitions used by all is vital to pool and/or compare data across studies to promote interoperability of electronic health records (EHRs) …

The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) support their members’ goal to improve the prevention and care of cardiovascular diseases through professional education, research, and development of guidelines and standards and by fostering policy that supports optimal patient outcomes. The ACCF and AHA recognize the importance of the use of clinical data standards for patient management, assessment of outcomes, and conduct of research, and the importance of defining the processes and outcomes of clinical care, whether in randomized trials, observational studies, registries, or quality-improvement initiatives. Hence, clinical data standards strive to define and standardize data relevant to clinical topics in cardiology, with the primary goal of assisting data collection by providing a platform of data elements and definitions applicable to various conditions. Broad agreement on a common vocabulary with reliable definitions used by all is vital to pool and/or compare data across studies to promote interoperability of electronic health records (EHRs) …

Difference in the quality of care may contribute to the less optimal prostate cancer treatment outcomes among black men compared with white men. We determined whether a racial quality of care gap exists in surgical care for prostate cancer, as evidenced by racial variation in the use of high volume surgeons and facilities, and in the quality of certain outcome measures of care.We performed cross-sectional and cohort analyses of administrative data from the Healthcare Cost and Utilization Project all-payer State Inpatient Databases, encompassing all nonfederal hospitals in Florida, Maryland and New York State from 1996 to 2007. Included in analysis were men 18 years old or older with a diagnosis of prostate cancer who underwent radical prostatectomy. We compared the use of surgeons and/or hospitals in the top quartile of annual volume for this procedure, inpatient blood transfusion, complications, mortality and length of stay between black and white patients.Of 105,972 patients 81,112 (76.5%) were white, 14,006 (13.2%) were black, 6,999 (6.6%) were Hispanic and 3,855 (3.6%) were all other. In mixed effects multivariate models, black men had markedly lower use of high volume hospitals (OR 0.73, 95% CI 0.70-0.76) and surgeons (OR 0.67, 95% CI 0.64-0.70) compared to white men. Black men also had higher odds of blood transfusion (OR 1.08, 95% CI 1.01-1.14), longer length of stay (OR 1.07, 95% CI 1.06-1.07) and inpatient mortality (OR 1.73, 95% CI 1.02-2.92).Using an all-payer data set, we identified concerning potential quality of care gaps between black and white men undergoing radical prostatectomy for prostate cancer.

Study Design. Sequential cross-sectional analysis. Objective. To document vertebroplasty rates and costs. Summary of Background Data. Little is known about interstate variation in rates or about nation-wide costs associated with the growing use of percutaneous vertebroplasty. Methods. Using specific CPT-4 billing codes, we reviewed aggregate Medicare Part B fee-for-service claims data (cross-stratified by physician specialty and treatment setting) on thoracolumbar vertebroplasties performed from 2001-2005. Vertebroplasty rates for individual states were expressed per 100,000 Part B fee-for-service enrollees. Nation-wide facility and physician charges (combining expected contributions from all sources) allowed by Medicare for vertebroplasties and associated imaging guidance procedures were applied to observed vertebroplasty volumes. These charges (reflecting direct medical costs from an all-payer perspective) were expressed in 2005 dollars using the Producer Price Index. Results. Vertebroplasty rates for individual states rose but varied considerably, ranging from 0.0 to 515.6/ 100,000 Medicare Part B fee-for-service enrollees in 2001 (median state rate 35.4), and from 9.8 to 849.5 in 2005 (median state rate = 75.0). On average, 1.3 vertebral levels were treated per procedure, varying by treatment site and physician specialty. Fluoroscopic rather than computed tomography guidance was used in 98.7% of cases. Total nation-wide inflation-adjusted charges rose from $76.0 million for 14,142 cases performed in 2001 to $152.3 million for 29,090 cases in 2005. While vertebroplasty was predominantly an outpatient procedure, inpatient cases generated most of the charges. Increasing volumes and costs were associated with cases performed in ambulatory surgery centers and physicians' offices. Conclusion. Nation-wide vertebroplasty volumes and inflation-adjusted charges doubled from 2001 to 2005 in this Medicare population. Procedure rates varied considerablyby state. Almost all cases involved fluoroscopic guidance; procedures treating multiple vertebral levels were not uncommon. Procedures performed in free-standing facilities are of growing importance. Given the issues surrounding appropriate vertebroplasty use, future practice patterns and outcomes should be closely tracked.

STUDY DESIGN Retrospective cohort study using a hospital discharge registry of all nonfederal acute care hospitals in Washington state. OBJECTIVES To determine the cumulative incidence of reoperation following lumbar surgery for degenerative disease and, for specific diagnoses, to compare the frequency of reoperation following fusion with that following decompression alone. SUMMARY OF BACKGROUND DATA Repeat lumbar spine operations are generally undesirable, implying persistent symptoms, progression of degenerative changes, or treatment complications. Compared to decompression alone, spine fusion is commonly viewed as a stabilizing treatment that may reduce the need for additional surgery. However, indications for fusion surgery in degenerative spine disorders remain controversial, and the effects of fusion on reoperation rates are unclear. METHODS Adults who underwent inpatient lumbar surgery for degenerative spine disorders in 1990-1993 (n = 24,882) were identified from International Classification of Diseases ninth Revision, Clinical Modification codes and then categorized as having either a lumbar decompression surgery or lumbar fusion surgery. We then compared the subsequent incidence of lumbar spine surgery between these groups. RESULTS Patients who had surgery in 1990-93 had a 19% cumulative incidence of reoperation during the subsequent 11 years. Patients with spondylolisthesis had a lower cumulative incidence of reoperation after fusion surgery than after decompression alone (17.1% vs. 28.0%, P = 0.002). For other diagnoses combined, the cumulative incidence of reoperation was higher following fusion than following decompression alone (21.5% vs. 18.8%, P = 0.008). After fusion surgery, 62.5% of reoperations were associated with a diagnosis suggesting device complication or pseudarthrosis. CONCLUSION Patients should be informed that the likelihood of reoperation following a lumbar spine operation is substantial. For spondylolisthesis, reoperation is less likely following fusion than following decompression alone. For other degenerative spine conditions, the cumulative incidence of reoperation is higher or unimproved after a fusion procedure compared to decompression alone.

Introduction: While cause and treatment vary for ISs, SAHs and OHSs, their results are often combined in reported statistics. Hypothesis: ISs, SAHs and OHSs differ in frequency and outcomes. Methods: ICD-9-CM principal discharge (D/C) diagnosis codes of 430 (SAH), 431-432 (OHS) and 433-434 (IS) were used to obtain US nationwide estimates of stroke frequency and outcomes for 2006-2012 from HCUPnet, the on-line query system of the Healthcare Cost and Utilization Project (HCUP). HCUP's sampling frame captured ~90% of D/Cs from non-Federal acute care hospitals for 2006, and >95% of such D/Cs as of 2012. Data came from HCUP's Nationwide Inpatient Sample, which captures 100% of D/Cs from a stratified sample of 20% of HCUP hospitals. Results: There were 2,005 cases (2.7/100,000) seen in 0-17 year-olds (YOs) in both 2006 and 2012. While 33.9 vs 34.2% were ISs, 19.5 vs 17.0% were SAHs, and 46.6 vs 48.9% were OHSs. Analyses focused on 18+ YOs estimated that there were 653,429 such cases (290.1/100,000) in 2006. Among ISs (82.0% of cases), 4.4% died as inpatients, 49.3% were routine D/Cs and the rest (46.3%) were D/Cd to other care settings. Mean length of stay (MLOS) was 4.8 days. Mean hospital costs (not charges) were $10,059/case (in 2012 US $). Among SAHs (4.1%), inpatient mortality was 23.1% and 35.2% were routine D/Cs. MLOS was 12.3 days. Mean costs were $41,941. Among OHSs (13.9%), 24.3% died as inpatients and 24.3% were routine D/Cs. MLOS was 7.8 days. Mean costs were $17,456. Some 680,980 adult cases (283.5/100,000) were seen in 2012. Among ISs (82.5%), 3.7% died as inpatients; 45.7% were routine D/Cs. MLOS was 4.5 days. Mean costs were $11,651. Among SAHs (3.6 %), mortality was 19.6%; 37.2% were routine D/Cs. MLOS was 11.7 days. Mean costs were $50,372. Among OHSs (13.9 %), mortality was 21.7%; 23.3% were routine D/Cs. MLOS was 7.4 days. Mean costs were $19,871. Discussion: While pediatric and adult stroke D/C rates were stable from 2006-12, they were much more common in adults. Subtype distributions differed. Adult inpatient mortality fell while LOS varied. Overall adult inflation-adjusted acute care hospital costs rose from $8 to 10 trillion/ year. Lower rates, worse outcomes and higher resource use seen in SAHs and OHSs relative to ISs argue for separate tracking of subtype results.

Study design Sequential cross-sectional study. Objectives To quantify patterns of outpatient lumbar spine surgery. Summary of background data Outpatient lumbar spine surgery patterns are undocumented. Methods We used CPT-4 and ICD-9-CM diagnosis/procedure codes to identify lumbar spine operations in 20+ year olds. We combined sample volume estimates from the National Hospital Discharge Survey (NHDS), the National Survey of Ambulatory Surgery (NSAS), and the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) with complete case counts from HCUP's State Inpatient Databases (SIDs) and State Ambulatory Surgery Databases (SASDs) for four geographically diverse states. We excluded pregnant patients and those with vertebral fractures, cancer, trauma, or infection. We calculated age- and sex-adjusted rates. Results Ambulatory cases comprised 4% to 13% of procedures performed from 1994 to 1996 (NHDS/NSAS data), versus 9% to 17% for 1997 to 2000 (SID/SASD data). Discectomies comprised 70% to 90% of outpatient cases. Conversely, proportions of discectomies performed on outpatients rose from 4% in 1994 to 26% in 2000. Outpatient fusions and laminectomies were uncommon. NIS data indicate that nationwide inpatient surgery rates were stable (159 cases/100,000 in 1994 vs. 162/100,000 in 2000). However, combined data from all sources suggest that inpatient and outpatient rates rose from 164 cases/100,000 in 1994 to 201/100,000 in 2000. Conclusions While inpatient lumbar surgery rates remained relatively stable for 1994 to 2000, outpatient surgery increased over time.

C or surgical removal of the penile foreskin, is the subject of a cost-utility analysis appearing in this issue of Medical Decision Making. In an Egyptian bas-relief dating back to roughly 4000 BC, one patient appears willing to undergo the procedure. His more reluctant companion seems to require physical restraint, and this divergence of opinion presages the controversies still surrounding this procedure. It is not known to what degree routine circumcision (performed as a preventive rather than a therapeutic measure) favorably or unfavorably affects the risks of mechanical, inflammatory, infectious, and neoplastic processes, not to mention sexual sensation in males and their partners. The most serious potential complications of circumcision can be tragic but are fortunately rare. The advisability of this procedure has been addressed in countless letters, case reports, and, of necessity, observational studies of variable methodological rigor. These discussions are far too numerous to even begin recounting here. However, the volume of ink and effort devoted to them affirms that “the history of these few millimeters of skin is utterly epochal and fascinating.” Most reviewers concede that there is no conclusive medical evidence of either net benefit or net harm. Neither the American Academy of Pediatrics (AAP) nor the Canadian Paediatric Society (CPS) still recommends circumcision as a routine procedure, with CPS being a bit less enthusiastic. Both bodies recommend that parents be provided with balanced information on the procedure’s potential benefits and risks, and both acknowledge that there are religious, ethnic, and sociocultural considerations that tend to drive the final decision anyway. If circumcision is performed, it has been recommended that the procedure be accompanied by documented informed consent, as well as by adequate analgesia. Multistate administrative data from the Federal Healthcare Cost and Utilization Project (HCUP) indicate that 1.2 million males (59% of all US male newborns and 86% of those without a complicating diagnosis) were circumcised at birth in 2000. Figures are felt to be somewhat lower in Canada, and considerably lower elsewhere in the world. It is difficult to isolate costs specifically attributable to circumcisions performed during the birth admission. Nonetheless, the volumes of procedures performed make the aggregate “up front” and potential “downstream” costs (so to speak) of various circumcision strategies an important area to study. This discussion of Van Howe’s article may be prefaced with a review of the few formal cost analyses of circumcision that preceded it. A 1984 Canadian study estimated the mean costs of neonatal circumcision at Can$38.32 per case. Through compounding at 4% annually, this amount would have been worth $272 at age 50. Neonatal circumcision was assumed to prevent the 2 penile cancer cases estimated to occur otherwise per 100,000 50-year-old men per year. The modeled cost was Can$13.6 million per cancer case averted, and the authors concluded that “until demonstrated otherwise, prophylactic neonatal circumcision should be regarded as cosmetic surgery, paid for directly by parents wishing it.” A 1991 cost-utility analysis arbitrarily assigned utilities to death (0), penile cancer (0.5), other penile problems such as phimosis (0.99), and survival without such problems (1.0). No disutilities were assigned

Plans to reduce from four to two the number of hospitals performing paediatric cardiac surgery in Sweden prompted an inter-institutional comparison of risk-adjusted 30-day post-operative mortality. Pre-operative, intra-operative and follow-up data were abstracted from medical records of all patients listed by the hospitals as having undergone ‘complex' paediatric cardiac surgery in 1992, based on previously established criteria. Surgeon-investigators abstracted clinical data to place all cases meeting these criteria into four preoperative risk categories. Discrepancies were resolved by consensus. Odds ratios were used to compare mortality in three hospitals relative to the fourth hospital, before and after adjusting for risk group distribution. Of 320 admission records submitted by the hospitals, 284 admissions involving 261 patients were considered complex procedures by criteria that included some re-operations but excluded heart transplants. Mortality risks and odds ratios increased in higher-risk groups, indicating the validity of the risk grouping. One-stage procedures or the initial components of multi-stage interventions were performed in 196 patients. Mortality odds ratios unadjusted for pre-operative risk in three other centres relative to the centre with the most patients were 0.72, 0.37 and 0.32, respectively ( P =0.2750 by log-likelihood Chi-square). Risk-adjusted mortality odds ratios among the three centres (relative to the baseline hospital and the lowest risk category) were 0.44, 0.17 and 0.30, respectively ( P =0.0001). For all 261 patients, unadjusted odds ratios for the three centres were 0.44, 0.27 and 0.39 ( P =0.1130), while risk-adjusted odds ratios were 0.24, 0.12 and 0.32, respectively ( P =0.0001). In this study, higher institutional volumes of complex procedures were not consistently associated with increased survival. Adjusting for preoperative risk did significantly alter institutional mortality odds ratios. Formal approaches for comparing specific–specific mortality following paediatric cardiac surgery are evolving, and adjusting for risk may enhance the validity of inter-institutional comparisons. Independent review of risk classification and mortality data submitted by hospitals may enhance the consistency of such analyses.

Background:Outcomes and costs of inpatient versus outpatient pediatric cardiac catheterization have not been extensively evaluated.Methods:For a cost-consequence analysis, we reviewed the medical records and cost data in a Swiss pediatric hospital. We compared outcomes and costs of observed inpatient management versus hypothetical planned same-day discharge for patients meeting the outpatient catheterization criterions for an American pediatric hospital.Results:Among 346 catheterization admissions occurring from January, 1998 through December, 1999, 179 met the American criterions for outpatient catheterization. Complications observed, and/or nursing interventions begun within 5 hours of catheterization, might have required overnight observation in 41 of the 179 admissions (22.9%). The remaining 138 patients were stable at five hours, and presumably could have been discharged the day of the procedure. Routine pre-discharge imaging detected significant complications following three interventional procedures. Postulated costs from the perspective of the provider, counting hospital and physician expenditure were calculated for the Swiss franc in 2000 at a rate of 1.69 francs for each American dollar, averaged 10,946 francs per inpatient, versus 9790 francs for outpatient treatment (p < 0.001 by paired t-test). Estimated revenue deficits, calculated as costs minus reimbursement, averaged 8565 francs per inpatient versus 1756 francs per patient treated as an outpatient.Conclusions:Half the patients being catheterized in the Swiss hospital met the external criterions for attempted outpatient catheterization. Most might have been safely discharged on the same day, with modest savings in costs, and reduced deficits in terms of revenue. Routine pre-discharge imaging may be more important than overnight observation. Outpatient catheterization merits prospective evaluation in Switzerland.

Objective: This study was undertaken to assess the degree to which published cost comparisons of minimally invasive direct coronary artery bypass through a thoracotomy versus conventional coronary artery bypass grafting, off-pump bypass surgery through a sternotomy, or angioplasty with or without stenting adhered to existing guidelines for performing economic analyses. Methods: We used minimally invasive direct coronary artery bypass (MIDCAB), off-pump bypass surgery, cost-effectiveness, economic analysis, and related keywords to search MEDLINE, other literature databases and article reference lists for English-language economic analyses of minimally invasive direct coronary artery bypass procedures versus other procedures that were published from 1990 to February 2002. We critically appraised article adherence to a 10-item methodologic checklist modified to address issues particularly relevant to minimally invasive direct coronary artery bypass evaluations. Assessment discordance was reconciled by consensus. Results: Ten articles published from June 1997 to March 2001 compared costs and (generally) outcomes of minimally invasive direct coronary artery bypass with those of other procedures. All were nonrandomized comparisons, generally of concurrent intrainstitutional clinical series. Stated results generally favored minimally invasive direct coronary artery bypass, angioplasty, or off-pump bypass surgery through a sternotomy relative to conventional coronary artery bypass grafting. Studies adequately addressed an average of only 24% of applicable checklist items (range 0%-67%). Few studies adequately ensured the comparability of treatment groups, clearly performed intent-to-treat analyses, comprehensively and credibly measured costs that were considered, or clearly addressed costs and results of preprocedural angiography or postprocedural imaging. Only 1 study compared success of revascularization between minimally invasive direct coronary artery bypass and competing alternatives. No studies specified the cost-analysis perspective or included costs of physician or physician assistant care. Conclusions: Most published comparative economic analyses of minimally invasive direct coronary artery bypass have failed to adequately address issues crucial to such evaluations. Future studies should more closely follow well-described principles of clinical epidemiology and cost-effectiveness analysis. J Thorac Cardiovasc Surg 2003;125:618-24

The current healthcare environment requires the evaluation of both the costs and benefits of alternative interventions for a given clinical problem. Given the increased interest in the economic evaluation of healthcare interventions, this article briefly defines various forms of economic evaluations and describes some useful steps for conducting appraisals of cost-effectiveness analyses. Studies of competing methods of treatment of abdominal aortic aneurysms greater than 5 cm are used as a clinical example of interest to the readers of this Journal. Rather than actually conducting such an analysis with existing data, we describe the principles for conducting or reviewing an economic analysis with factitious data. (J Vasc Surg 2003;37:226-34.)

Purpose: To determine the population-based incidence and cause of cranial nerve palsies affecting ocular motility in children in the circumscribed population of Olmsted County, Minnesota. MethodsM: The Rochester Epidemiology Project medical records linkage system captures virtually all medical care provided to Olmsted County residents. By means of this database, all cases of third, fourth, and sixth cranial nerve palsy were identified among county residents less than 18 years of age from 1978 through 1992. Medical records were reviewed to confirm the diagnosis, determine the cause, and document county residency. Incidence rates were adjusted to the age and sex distribution of the 1990 white population in the United States. Results: Over this 15-year period, 36 incidence cases of cranial nerve palsy were identified in 35 children in this defined population. The age-adjusted and sex- adjusted annual incidence of third, fourth, and sixth nerve palsies combined was 7.6 per 100,000 (95% confidence interval, 5.1 to 10.1). The most commonly affected nerve was the fourth (36%), followed by the sixth (33%), the third (22%), and multiple nerve palsies (9%). The most common cause was congenital for third and fourth nerve palsy, undetermined for sixth, and trauma for multiple nerve palsies. Although three cases were associated with neoplasia, a cranial nerve palsy was not present at the time of diagnosis in any case. Conclusions: Unlike many institutionally based referral series, our population-based study provides data on the incidence and cause of third, fourth, and sixth nerve palsies in a geographically defined population. In contrast to previous institutionally based series, nearly half the cases were congenital in origin, and in no case did intracranial neoplasia present as an isolated nerve palsy.

Objective To estimate the incidence of rhegmatogenous retinal detachment (RD) in a geographically defined population and to compare the probability of RD in residents after cataract extraction with the probability of RD in residents who did not have cataract extraction. Design Rochester Epidemiology Project databases were used to perform a retrospective population-based incidence study of RD diagnosed between 1976 and 1995 with cohort analyses of the influence of risk factors on the occurrence of RD. Participants The population of Olmsted County, Minnesota, participated. Main outcome measure Incidence rates of RD adjusted to the age and gender distribution of the 1990 U.S. white population were measured. Results Three hundred eleven incident cases of rhegmatogenous RD were identified. The mean annual age- and gender-adjusted incidence rate of rhegmatogenous RD was 17.9 per 100,000 persons (95% confidence interval [CI], 15.9–19.9). For idiopathic rhegmatogenous RD alone, the mean annual age- and gender-adjusted incidence rate was 12.6 (95% CI, 10.9–14.3) per 100,000 persons. Ten years after phacoemulsification and extracapsular cataract extraction, the estimated cumulative probability of RD was 5.5 (95% CI, 3.4–7.6) times as high as would have been expected in a similar group of county residents not undergoing cataract surgery. Conclusions Cataract surgery is associated with a significantly elevated long-term cumulative probability of retinal detachment.

The prognostic value of exercise thallium-201 imaging has been well established in referral patient populations at tertiary care centers, but these results may be influenced by referral bias.This study was performed to evaluate the prognostic value of thallium imaging in a community-based population of 446 residents of Olmsted County, Minn. Eleven variables were prospectively selected and tested for their associations with outcome end points.Four variables (age, history of myocardial infarction, number of abnormal thallium segments on the postexercise images, and increased thallium lung uptake) contained the most independent prognostic information. For the end point overall mortality rate, the multivariate chi-square values were 17.2 (p0.0001) for age and 20.9 (p0.0001) for the number of abnormal thallium segments on the postexercise images. Five-year survival rate for patients older than the median age of 59 years with an abnormal scan was 84% versus 97% for patientsor = 59 years of age with a normal scan.Exercise thallium imaging was useful for prognostic purposes in this relatively low-risk community population, confirming the findings of referral population studies.

The randomized controlled clinical trial is generally acknowledged to provide the most scientifically valid evidence of the efficacy of therapeutic interventions compared to results of specified alternatives. While this approach represents the top of a hierarchy of levels of evidence, other study designs may also be appropriate at various stages in the evaluation of therapy. This article describes other study designs which may be used to assess clinical outcomes, namely case reports, case series, intra- and inter-institutional non-randomized cohort comparisons with historical or concurrent controls, and case-control studies. The relative advantages and disadvantages of each approach are reviewed, and illustrations are provided from the literature in pediatric cardiology and related fields.

While the options available for treatment of congenital heart disease continues to expand, rigorous evaluation of outcome has not always accompanied the introduction of new therapeutic modalities. For example, transcatheter implantation of the Rashkind double-umbrella occluder for persistent patent ductus arteriosus had not previously been compared to conventional surgery in a rigorous fashion. Consequently, a 14-center retrospective study compared outcomes of 631 prognostically similar patients treated concurrently with these two modalities. Particular efforts were made to reduce the bias and confounding that often plague nonrandomized comparisons. The study's design is described in detail as an example of the use of epidemiologic methods to enhance the rigor of observational studies of outcomes of cardiology interventions.

Differences in quality of care may contribute to racial variation in outcomes of bladder cancer (BCa). Quality indicators in patients undergoing surgery for BCa include the use of high-volume surgeons and high-volume hospitals, and, when clinically indicated, receipt of pelvic lymphadenectomy, receipt of continent urinary diversion, and undergoing radical cystectomy instead of partial cystectomy. The authors compared these quality indicators as well as adverse perioperative outcomes in black patients and white patients with BCa.The Healthcare Cost and Utilization Project State Inpatient Databases for New York, Florida, and Maryland (1996-2009) were used, because they consistently included race, surgeon, and hospital identifiers. Quality indicators were compared across racial groups using regression models adjusting for age, sex, Elixhauser comorbidity sum, insurance, state, and year of surgery, accounting for clustering within hospital.Black patients were treated more often by lower volume surgeons and hospitals, they had significantly lower receipt of pelvic lymphadenectomy and continent diversion, and they experienced higher rates of adverse outcomes compared with white patients. These associations remained significant for black patients who received treatment from surgeons and at hospitals in the top volume decile.Black patients with BCa had lower use of experienced providers and institutions for BCa surgery. In addition, the quality of care for black patients was lower than that for whites even if they received treatment in a high-volume setting. This gap in quality of care requires further investigation.

Expansion of the options available for the treatment of congenital heart disease has been accompanied by an increasing realization of the limits of our available health care resources. Cost-effectiveness analysis is one of several analytic approaches that can improve decisions about the appropriate use of technology in interventional pediatric cardiology and other fields. In this article, cost-effectiveness analysis is distinguished from related approaches, such as cost-benefit analysis. Then, basic principles of cost-effectiveness analysis are described. Next, the application of these principles is illustrated, using a recently published comparison of transcatheter versus surgical closure of patent ductus arteriosus. Finally, potential research implications of the surprising findings of this study are discussed.

STUDY DESIGN: A retrospective analysis of population-based hospital discharge registry from all nonfederal acute care hospitals in Washington State. OBJECTIVE: We examined the cumulative incidence of second lumbar spine operation following an initial lumbar operation for degenerative conditions. We aimed to determine if the cumulative incidence of a second lumbar spine operation decreased in the 1990s following an increase in the rate of fusion surgery and the introduction of several newer fusion technologies. SUMMARY OF BACKGROUND DATA: Repeat lumbar spine operations are generally undesirable, implying persistent symptoms, progression of degenerative changes, or treatment complications. Improved technology is expected to improve alignment, healing, and instability, and to reduce repeat operations. METHODS: Among the patients who had an inpatient lumbar decompression or lumbar fusion surgery for degenerative spine disorders in 1990 to 1993 (n = 24,882) or in 1997 to 2000 (n = 25,209), we examined rates of subsequent lumbar spine surgery during a 4-year follow-up. We performed a Cox proportional hazards regression to compare the probability of a reoperation between the 2 cohorts, adjusting for age, sex, primary diagnosis, type of insurance, and comorbidity. RESULTS: Among patients who underwent surgery for lumbar degenerative disease, more than twice as many had a fusion procedure in the 1997 to 2000 cohort (19.1%) compared with the 1990 to 1993 cohort (9.4%). However, the 4-year cumulative incidence of reoperation was higher in the 1997 to 2000 cohort compared with the 1990 to 1993 cohort (14.0% vs. 12.4%; hazard ratio, 1.16; 95% confidence interval, 1.11-1.22, P < 0.001). Among fusion patients, those in the 1997 to 2000 cohort were approximately 40% more likely to undergo a reoperation within the first year when compared with fusion patients in the 1990 to 1993 cohort. There was no difference in reoperation probability beyond 1 year. CONCLUSION: A higher proportion of fusion procedures and the introduction of new spinal implants between 1993 and 1997 did not reduce reoperation rates. Patients who had lumbar surgery for degenerative disease in the late 1990s were more likely to undergo a repeat operation within 4 years than patients who had surgery in the early 1990s.

Study design Retrospective cohort study using national sample administrative data. Objectives To determine if lumbar fusion rates increased in the 1990s and to compare lumbar fusion rates with those of other major musculoskeletal procedures. Summary of background data Previous studies found that lumbar fusion rates rose more rapidly during the 1980s than did other types of lumbar surgery. Methods We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1988 through 2001 to examine trends. U.S. Census data were used for calculating age and sex-adjusted population-based rates. We excluded patients with vertebral fractures, cancer, or infection. Results In 2001, over 122,000 lumbar fusions were performed nationwide for degenerative conditions. This represented a 220% increase from 1990 in fusions per 100,000. The increase accelerated after 1996, when fusion cages were approved. From 1996 to 2001, the number of lumbar fusions increased 113%, compared with 13 to 15% for hip replacement and knee arthroplasty. Rates of lumbar fusion rose most rapidly among patients aged 60 and above. The proportion of lumbar operations involving a fusion increased for all diagnoses. Conclusions Lumbar fusion rates rose even more rapidly in the 90s than in the 80s. The most rapid increases followed the approval of new surgical implants and were much greater than increases in other major orthopedic procedures. The most rapid increases in fusion rates were among adults aged 60 and above. These increases were not associated with reports of clarified indications or improved efficacy, suggesting a need for better data on the efficacy of various fusion techniques for various indications.

ContextFaster magnetic resonance imaging (MRI) scanning has made MRI a potential cost-effective replacement for radiographs for patients with low back pain. However, whether rapid MRI scanning results in better patient outcomes than radiographic evaluation or a cost-effective alternative is unknown.ObjectiveTo determine the clinical and economic consequences of replacing spine radiographs with rapid MRI for primary care patients.Design, Setting, and PatientsRandomized controlled trial of 380 patients aged 18 years or older whose primary physicians had ordered that their low back pain be evaluated by radiographs. The patients were recruited between November 1998 and June 2000 from 1 of 4 imaging centers in the Seattle, Wash, area: a university-based teaching program, a nonuniversity-based teaching program, and 2 private clinics.InterventionPatients were randomly assigned to receive lumbar spine evaluation by rapid MRI or by radiograph.Main Outcome MeasuresBack-related disability measured by the modified Roland questionnaire. Secondary outcomes included Medical Outcomes Study 36-Item Short Form Health Survey (SF-36), pain, preference scores, satisfaction, and costs.ResultsAt 12 months, primary outcomes of functional disability were obtained from 337 (89%) of the 380 patients enrolled. The mean back-related disability modified Roland score for the 170 patients assigned to the radiograph evaluation group was 8.75 vs 9.34 for the 167 patients assigned the rapid MRI evaluation group (mean difference, −0.59; 95% CI, −1.69 to 0.87). The mean differences in the secondary outcomes were not statistically significant : pain bothersomeness (0.07; 95% CI −0.88 to 1.22), pain frequency (0.12; 95% CI, −0.69 to 1.37), and SF-36 subscales of bodily pain (1.25; 95% CI, −4.46 to 4.96), and physical functioning (2.73, 95% CI −4.09 to 6.22). Ten patients in the rapid MRI group vs 4 in the radiograph group had lumbar spine operations (risk difference, 0.34; 95% CI, −0.06 to 0.73). The rapid MRI strategy had a mean cost of $2380 vs $2059 for the radiograph strategy (mean difference, $321; 95% CI, −1100 to 458).ConclusionsRapid MRIs and radiographs resulted in nearly identical outcomes for primary care patients with low back pain. Although physicians and patients preferred the rapid MRI, substituting rapid MRI for radiographic evaluations in the primary care setting may offer little additional benefit to patients, and it may increase the costs of care because of the increased number of spine operations that patients are likely to undergo.

To incorporate personnel and equipment use time in an activity-based cost comparison of conventional radiography and conventional and rapid magnetic resonance (MR) imaging for low back pain (LBP).At each of four Seattle Lumbar Imaging Project (SLIP) sites, patients were randomized to undergo conventional radiography or rapid MR imaging of the lumbar spine. For sample SLIP patients and for similar non-SLIP patients undergoing conventional lumbar spine MR imaging as usual care in calendar year 2000, measured imaging room use and technologist and radiologist times were multiplied by costs per minute of standard equipment acquisition, personnel compensation, and related expenses. Resulting provider-perspective costs and Seattle area Medicare reimbursements for conventional MR imaging and radiography for calendar year 2001 were used to estimate future "normative" reimbursement for rapid MR imaging.For 23 conventional radiography, 27 rapid MR imaging, and 38 conventional MR imaging examinations timed in calendar year 2000, all rapid MR imaging times exceeded those of conventional radiography but were less than those of conventional MR imaging. All 0.3- and 0.35-T MR imaging room and technologist times exceeded those for 1.5-T MR imaging. Average costs (in 2001 dollars) were $44 for conventional radiography, 126 US dollars for 1.5-T rapid MR imaging, 128 US dollars for 0.3-0.35-T rapid MR imaging, 267 US dollars for 1.5-T conventional MR imaging, and 264 US dollars for 0.3-0.35-T conventional MR imaging. Conclusions regarding cost differences between conventional radiography and rapid MR imaging were robust to plausible parameter value changes evaluated in sensitivity analyses. Conventional radiography reimbursement was 44 US dollars. Applying the ratio of reimbursement (620 US dollars) to costs (264-267 US dollars) for conventional MR imaging to rapid MR imaging costs predicted reimbursement of 292-300 US dollars for the new modality.Times and costs for rapid MR imaging are roughly three times those for conventional radiography but about half those for conventional MR imaging for LBP. While current conventional radiography costs exceed reimbursement, current conventional MR and projected rapid MR imaging reimbursements exceed costs.

This study compared the relative efficiency of lumbar x-ray and rapid magnetic resonance (MR) imaging for diagnosing cancer-related low back pain (LBP) in primary care patients.We developed a decision model with Markov state transitions to calculate the cost per case detected and cost per quality-adjusted life year (QALY) of rapid MR imaging. Model parameters were estimated from the medical literature. The costs of x-ray and rapid MR were calculated in an activity-based costing study.A hypothetical cohort of primary care patients with LBP referred for imaging to exclude cancer as the cause of their pain.The rapid MR strategy was more expensive due to higher initial imaging costs and larger numbers of patients requiring conventional MR and biopsy. The overall sensitivity of the rapid MR strategy was higher than that of the x-ray strategy (62% vs 55%). However, because of low pre-imaging prevalence of cancer-related LBP, this generates1 extra case per 1,000 patients imaged. Therefore, the incremental cost per case detected using rapid MR was high ($213,927). The rapid MR strategy resulted in a small increase in quality-adjusted survival (0.00043 QALYs). The estimated incremental cost per QALY for the rapid MR strategy was $296,176.There is currently not enough evidence to support the routine use of rapid MR to detect cancer as a cause of LBP in primary care patients.

Recent research has derived preference scores from the SF-36. We compare the practicality and construct validity of SF-36 derived preference scores with directly elicited time trade off (TTO) and visual analogue scale (VAS) scores. In this observational study, low back pain (LBP), patients were asked to complete disease specific, generic (SF-36), and health state preference (VAS and TTO) instruments. Baseline SF-36 responses were converted to preference scores using six published algorithms. Response rates for the SF-36 derived and TTO preference values were 354 of 379 (93%) and 303 of 379 (80%), respectively. Thirty patients were excluded from the TTO exercise because of difficulties comprehending the scaling task. Choice based methods (standard gamble, TTO) yielded higher and more uniform estimates of preference (0.77–0.79) than non-choice based methods (VAS) (0.42–0.70). Directly elicited TTO values were variable and had less power to distinguish among patients with differing severity of LBP. All SF-36 derived preferences exhibited a minimum threshold implying a potential floor effect for severely ill patients. SF-36 derived preferences demonstrated good practicality and construct validity in this setting, however different methods will yield disparate estimates of marginal benefit. This emphasises the need for a standardised algorithm for deriving SF-36 preference scores. Copyright © 2001 John Wiley & Sons, Ltd.

Introduction Differences in quality of care may contribute to racial variation in outcomes of bladder cancer (BC). Quality indicators in BC surgery include use of high-volume surgeons (HVSs) and hospitals (HVHs), receipt of pelvic lymphadenectomy (PLND) and undergoing radical cystectomy (RC) instead of partial cystectomy (PC) when clinically indicated. We compared these quality indicators across racial groups. Methods We used public-access versions of the Healthcare Cost and Utilization Project's State Inpatient Databases, selecting NY, FL, and MD (1996-2007), because they included race, surgeon and hospital identifiers. We identified cases by ICD-9-CM codes. We defined HVS / HVH as top volume decile surgeons / hospitals. Quality indicators were compared across racial groups using mixed-effects models, adjusting for age, Elixhauser comorbidity sum, insurance, and year, with random effects for state. Results There were 16,631 cases, 13,917 (83.7%) RCs and 2,713 (16.3%) PCs. The cohort was 87.0% Caucasian, 5.3% African-American (AA) and 7.8% Other. Compared with Whites, AA patients were younger (65.3 SD [11.6] vs. 69.4 [10.3] years, p Conclusions As indicators of surgical quality among BC patients, utilization of RC compared to PC, and use of PLND, HVSs and HVHs among patients undergoing RC, varied by race. Assuming that these findings do not reflect differences in surgical indications, they may identify a quality gap, which could influence important outcomes.

Objective This study aimed to determine the probability of a patient developing legal blindness in either one or both eyes from newly diagnosed and treated open-angle glaucoma (OAG) after starting medical or surgical therapy or both. Design The study design was a retrospective, community-based descriptive study. Participants Two hundred ninety-five residents of Olmsted County, Minnesota, newly diagnosed with, and treated for, OAG between 1965 and 1980 with a mean follow-up of 15 years (standard deviation ± 8 years) participated. Intervention Kaplan-Meier cumulative probability of blindness was estimated for patients treated and followed for OAG. Main outcome measures Legal blindness, defined as a corrected visual acuity of 20/200 or worse, and/or visual field constricted to 20° or less in its widest diameter with the Goldmann III4e test object or its equivalent on automated perimetry, secondary to glaucomatous loss, was measured. Results At 20-years’ follow-up, the Kaplan-Meier cumulative probability of glaucoma-related blindness in at least one eye was estimated to be 27% (95% confidence interval, 20%–33%), and for both eyes, it was estimated to be 9% (95% confidence interval, 5%–14%). At the time of diagnosis, 15 patients were blind in at least 1 eye from OAG. Conclusion A retrospective study of a white population determined that the risk of blindness from newly diagnosed and treated OAG may be considerable.

Decision and cost-utility analyses considered the tradeoffs of treating patent ductus arteriosus (PDA) using conventional surgery versus transcatheter implantation of the Rashkind occluder. Physicians and informed lay parents assigned utility scores to procedure success/complications combinations seen in prognostically similar pediatric patients with isolated PDA treated from 1982 to 1987. Utility scores multiplied by outcome frequencies from a comparative study generated expected utility values for the two approaches. Cost-utility analyses combined these results with simulated provider cost estimates from 1989. On a 0-100 scale (worst to best observed outcome), the median expected utility for surgery was 99.96, versus 98.88 for the occluder. Results of most sensitivity analyses also slightly favored surgery. Expected utility differences based on 1987 data were minimal. With a mean overall simulated cost of $8,838 vs $12,466 for the occluder, surgery was favored in most cost-utility analyses. Use of the inherently less invasive but less successful, more risky, and more costly occluder approach conferred no apparent net advantage in this study. Analyses of comparable current data would be informative.

Agreement on the processes of health care that are necessary to achieve health care quality goals is the foundation of performance measurement. In addition, standardization of performance measures themselves is essential to avoid confusion and undue burden among those whose performance is being

Objective: To analyze population-based trends in cataract extraction. Design: Rochester Epidemiology Project databases, which capture virtually all health care services provided to residents of Olmsted County, Minnesota, were used to perform retrospective cohort analyses of rates of primary cataract extractions performed between 1980 and 1994. Participants: The population of Olmsted County, Minnesota. Main Outcome Measures: Incidence rates adjusted to the age and sex distribution of the 1990 US white population were analyzed using Poisson regression. Results: The 4257 procedures performed on 3176 patients of all ages represented overall annual age-adjusted rates of 404 procedures per 100 000 females and 320 per 100 000 males. Annual age- and sex-adjusted rates for both sexes combined rose from 133 procedures per 100 000 in 1980 to a peak of 507 per 100 000 in 1992. The rates fell to 470 per 100 000 in 1994. Manual review of a random sample of records estimated case overascertainment at 0.9%. Conclusions: With the exception of 1988 and 1989, rates of cataract surgery in this geographically circumscribed population increased every year between 1980 and 1992. Data from 1993-1994 indicate that rates may have plateaued and possibly declined slightly. If sustained, these patterns could have major implications for future utilization of ophthalmologic resources.

The authors assessed concordance of local Medicare health care utilization data on cataract surgery and estimates generated using the databases of the Rochester Epidemiology Project, which capture virtually all medical care received by residents of Olmsted County, Minnesota. The Rochester Project databases identified 1,353 primary cataract extractions performed in Olmsted County between October 1989 and December 1993 among county residents aged > or = 65 years. Medicare data identified 1,148 claims-84.8% of the number of procedures identified by the Rochester Project. Ratios of numbers of encounters (Medicare/Rochester Project) were 189/350 (0.540) for 1992 versus 959/1,003 (0.956) for the other years combined. Changes in Medicare data file transfer procedures may have produced the 1992 data shortfall. Medicare data should periodically be compared with source data to assess concordance.

Purpose Nonarteritic anterior ischemic optic neuropathy is the most common acute optic nerve disease of adults over age 50 years. This study determined the incidence of acute nonarteritic anterior ischemic optic neuropathy in the circumscribed population of Olmsted County, Minnesota. Methods This was a retrospective study of the incidence of acute nonarteritic anterior ischemic optic neuropathy between 1981 and 1990. The Rochester Epidemiology Project medical records linkage system facilitates identification of the medical records of virtually all Olmsted County residents with a given diagnosis. All cases of acute nonarteritic anterior ischemic optic neuropathy that fulfilled certain inclusion and exclusion criteria were identified. Results Twenty-two cases in 21 patients (11 men and 10 women) were recorded. The crude annual incidence rate was 10.3 per 100,000 individuals (95% confidence interval [CI] = 5.1 to 18.4). When adjusted to the age and sex distribution of the 1990 United States white population, the incidence rate was 10.2 per 100,000 (95% CI=6.5 to 15.6). At diagnosis, the median age was 72 years, mean visual acuity was 20/200 in the affected eye, and the most common visual field defect was an altitudinal deficit (10 cases). Conclusions Although results of this small study should be interpreted cautiously, extrapolation of our findings to the United States white population indicates that nearly 5,700 new cases of acute nonarteritic anterior ischemic optic neuropathy may be expected to occur each year in this group.

Background: Limited population-based data are available on trends in the incidence of arterial surgery, balloon angioplasty, and amputation for arterial occlusive disease of the legs over the past two decades. Methods: We identified all elective and emergency arterial operations, balloon angioplasty procedures, and amputations performed for all residents of a defined community, Olmsted County, Minn., between 1973 and 1992. We focused on gender mix, type of procedure, and secular trends in utilization. Results: A total of 1155 procedures were performed, including 733 arterial surgical procedures, 59 balloon angioplasty procedures, and 363 amputations (288 major and 75 minor). Emergency procedures were performed in 12%. Suprainguinal inflow procedures were the most common arterial reconstruction (60%) compared with infrainguinal procedures (40%). The incidence of all revascularization procedures increased in the first decade but reached a plateau after 1985. Utilization rates of revascularization procedures from 1988 to 1992 were higher for men (141.9/100,000 person-years [p-yr]) than women (57.4/100,000 p-yr.). Angioplasty (17.0/100,000 p-yr) rates lagged behind surgery until 1985, but tripled in the past 10 years and have not yet reached a plateau. Although minor amputation rates remain unchanged in 20 years, major amputation rates have been reduced by 50% from 36.7/100,000 p-yr between 1973 and 1977 to 19.0/100,000 p-yr from 1988 to 1992. Conclusions: From this long-term population-based analysis (1973 to 1992), we conclude that increased vascular surgery and balloon angioplasty rates have coincided with a significant reduction in major amputation rates in the past 10 years. (J Vasc Surg 1997;25:29-38.)

In medical technology assessment, randomized control trials (RCTs) play an important role in determining the relative efficacy of compared treatments. As scarce resources necessitate choosing among options for care, comparing costs of alternative tests, treatments, or programs also becomes important. This study assessed the prevalence and completeness of economic analyses in RCTs published from January 1966 through June 1988. It was found that only 121 of over 50,000 published randomized trials (0.2%) included economic analyses. For a random sample of 51 of these 121 studies, results revealed a mean quality of research score of 0.32 (SD of measurement = 0.14) and a mean economic analysis completeness score of 0.52 (SD = 0.13) on scales of 0 to 1. It was also found that higher economic completeness scores were positively correlated with later dates of publication (r = 0.28, P = 0.046) and with the presence of a statement of study perspective (r = 0.38, P = 0.006). A near-zero correlation between the economic completeness and the quality of research scores was revealed. Also noted were several deficiencies among the economic analyses, including improper allocation of overhead costs, absence of sensitivity analyses, and the fact that only 28% of the 51 studies included some form of aggregation of treatment costs and consequences. Progress in health care depends on accurate assessments of both relative efficacy and costs. The quality of both needs improvement.

Objective To estimate the incidence of rhegmatogenous retinal detachment (RD) in a geographically defined population and to compare the probability of RD in residents after cataract extraction with the probability of RD in residents who did not have cataract extraction. Design Rochester Epidemiology Project databases were used to perform a retrospective population-based incidence study of RD diagnosed between 1976 and 1995 with cohort analyses of the influence of risk factors on the occurrence of RD. Participants The population of Olmsted County, Minnesota, participated. Main outcome measure Incidence rates of RD adjusted to the age and gender distribution of the 1990 U.S. white population were measured. Results Three hundred eleven incident cases of rhegmatogenous RD were identified. The mean annual age- and gender-adjusted incidence rate of rhegmatogenous RD was 17.9 per 100,000 persons (95% confidence interval [CI], 15.9–19.9). For idiopathic rhegmatogenous RD alone, the mean annual age- and gender-adjusted incidence rate was 12.6 (95% CI, 10.9–14.3) per 100,000 persons. Ten years after phacoemulsification and extracapsular cataract extraction, the estimated cumulative probability of RD was 5.5 (95% CI, 3.4–7.6) times as high as would have been expected in a similar group of county residents not undergoing cataract surgery. Conclusions Cataract surgery is associated with a significantly elevated long-term cumulative probability of retinal detachment.