Universal Healthcare Coverage Does Not Ensure Adherence to Initial Colorectal Cancer Screening Guidelines.

INTRODUCTION: Colorectal cancer is the second leading cause of cancer deaths in the USA, and screening tests are underutilized. The aim of this study was to determine the proportion of individuals at average risk who utilized a recommended initial screening test in a universal healthcare coverage system. MATERIALS AND METHODS: This is a retrospective cohort study of active duty and retired military members as well as civilian beneficiaries of the Military Health System. Individuals born from 1960 to 1962 and eligible for full benefits on their 50th birthday were evaluated. Military rank or rank of benefits sponsor was used to determine socioeconomic status. Adherence to the U.S. Preventive Services Task Force guidelines for initial colorectal cancer screening was determined using "Current Procedural Terminology" and "Healthcare Common Procedure Coding System" codes for colonoscopy, sigmoidoscopy, fecal occult blood test, and fecal immunohistochemistry test. Average risk individuals who obtained early screening ages 47 to 49 were also identified. RESULTS: This study identified 275,665 individuals at average risk. Of these, 105,957 (38.4%) adhered to screening guidelines. An additional 19,806 (7.2%) individuals were screened early. Colonoscopy (82.7%) was the most common screening procedure. Highest odds of screening were associated with being active duty military (odds ratio [OR] 3.63, 95% confidence interval [CI] 3.43 to 3.85), having highest socioeconomic status (OR 2.37, 95% CI 2.31 to 2.44), and having managed care insurance (OR 4.36, 95% CI 4.28 to 4.44). CONCLUSIONS: Universal healthcare coverage does not ensure initial colorectal cancer screening utilization consistent with guidelines no does it eliminate disparities.

Bursting strength evaluation in an experimental model of incisional hernia.

Incisional hernias occur in up to 11 per cent of patients undergoing abdominal surgery. Up to 50 per cent of these patients with hernias will require repeat operative procedures. Management of these hernias have focused primarily on tensile strength of the mesh material, have not addressed currently used materials, and have not compared the strength of these repairs with each other. Forty-nine adult Sprague-Dawley rats had an incisional hernia created by removing a portion of their abdominal wall that was then repaired primarily, using either a composite mesh, Dual mesh (Gore-Tex), or polypropylene mesh. Six weeks after the repair, the rats were euthanized. Hydrostatic distension of the abdominal cavity was performed to compare bursting strength of each repair. Wound tensile strength was assessed and compared. Tissue samples were also taken to compare repair types for incorporation of prosthetic materials. The gross weight of the animals subjected to hydrostatic distention was equivalent between groups, as was the volume required prior to failure of the repair. There was a trend toward improved tensile strength of the Prolene mesh repair, which had a lower average inflammatory and fibrosis score on histology. Overall, the type of mesh used for repair does not seem to impact significantly the strength of the repair when assessed 6 weeks postoperatively. Choice of prosthetic material to repair the hernia should be made based on economics and handling characteristics alone. Prolene mesh has satisfactory strength with the least amount of inflammation and fibrosis.

The economic impact of laparoscopic inguinal hernia repair: results of a double-blinded, prospective, randomized trial.

For this study, 66 patients with a preoperative diagnosis of unilateral primary inguinal hernia were randomized to undergo laparoscopic totally extra peritoneal (TEP), laparoscopic transabdominal (TAPP), or open inguinal hernia repair with polypropylene mesh (Lichtenstein type). Both the operative team caring for the patient postoperatively and the patient were blinded to the operative approach by placement of a large dressing covering the abdomen, which was not removed until postoperative day 3. The patients recorded their pain level on a visual analog pain scale daily. Medication usage also was recorded. All patients were seen at 7-day intervals until they returned to work. The patients were interviewed during their postoperative visits by an investigator blinded to the operative approach and questioned regarding their ability to return to work and their pain levels. The average number of lost work days in all the groups was 12, and there was no significant difference between the three groups (p = 0.074). The average operating time for the TAPP procedure was 59 min, less than the time required to complete either the TEP or the Lichtenstein approach, which had equivalent operative times (p = 0.027). The material cost was significantly lower for the Lichtenstein repair (1,200 dollars less) than for either of the laparoscopic approaches, a saving primarily related to consumable operating room supplies. The TEP repair costs were minimally higher than those for the TAPP repair (125 dollars more). No significant differences were noted in the postoperative pain scales, and the use of postoperative oral analgesics was equivalent. The higher operative costs noted for the laparoscopic hernia repairs were not offset by a shortened convalescence. Postoperative pain appears to be equivalent regardless of the operative approach chosen and is easily managed with oral analgesics.