Predictors of kidney function recovery among incident ESRD patients.

BACKGROUND: ESRD is considered an irreversible loss of renal function, yet some patients will recover kidney function sufficiently to come off dialysis. Potentially modifiable predictors of kidney recovery, such as dialysis prescription, have not been fully examined. METHODS: Retrospective cohort study using United States Renal Data System (USRDS) data to identify incident hemodialysis (HD) patients between 2012 and 2016, the first 4 years for which dialysis treatment data is available. The primary outcome was kidney recovery within 1 year of ESRD and HD initiation, defined by a specific recovery code and survival off dialysis for at least 30 days. Patient and treatment characteristics were compared between those that recovered versus those that remained dialysis-dependent. A time-dependent survival model was used to identify independent predictors of kidney recovery. RESULTS: During the study period, there were 372,387 incident HD patients with available data, among whom 16,930 (4.5%) recovered to dialysis-independence. Compared to non-recovery, a higher proportion of patients with kidney recovery were of white race, and non-Hispanic ethnicity. Both groups had a similar age distribution. Patients with an acute kidney injury diagnosis as primary cause of ESRD were most likely to recover, but the most common ESRD diagnosis among recovering patients was type 2 diabetes (29.8% of recovery cases). Higher eGFR and lower albumin at ESRD initiation were associated with increased likelihood of recovery. When examining HD ultrafiltration rate (UFR), each quintile above the first quintile was associated with a progressively lower likelihood of recovery (HR 0.45, 95% CI 0.43-0.48 for highest versus lowest quintile, p < 0.001). CONCLUSIONS: We identified non-modifiable and potentially modifiable factors associated with kidney recovery which may assist clinicians in counseling and monitoring incident ESRD patients with a greater chance to gain dialysis-independence. Clinical trials are warranted to examine the impact of dialysis prescription on subsequent kidney function recovery.

Postoperative Complications and Long-Term Survival After Complex Cancer Resection.

BACKGROUND: Recent attention has focused on the ability to rescue patients from postoperative complications and prevent short-term mortality. However, it is unknown whether patients rescued from complications after complex cancer resections have long-term survival outcomes similar to those of patients without complications. METHODS: From 2005 to 2009 Surveillance, Epidemiology, and End Results (SEER)-Medicare data, the study identified elderly patients who underwent resection for cancers of the esophagus, lung, or pancreas. The association of risk-adjusted long-term survival with serious complications, minor complications, and no complications was analyzed. RESULTS: The study included 905 patients with esophageal cancer, 12,395 patients with lung cancer, and 1966 patients with pancreatic cancer. The serious complication rates were respectively 17.4, 9.5 and 11.8 %. The patients with serious complications had lower 5-year survival rates than those with no complications even if they were rescued and survived 30 days (20 vs 43 % for esophagus, 29 vs 54 % for lung, and 10 vs 21 % for pancreas cancer). Even after patients who died within 180 days after surgery were excluded from the analysis, a decrement in risk-adjusted long-term survival was observed among the patients with serious complications after all three procedures. The association between complications and long-term survival was not explained by differences in receipt of adjuvant chemotherapy CONCLUSION: Patients who undergo complex cancer resection and experience serious complications have diminished long-term survival, even if they are "rescued" from their complications. This finding persists even when deaths within 6 months after surgery are excluded from the analysis. Metrics of surgical success should consider terms beyond 30 and even 90 days as well as the long-term consequences of surgical complications.

Multimodal cancer care in poor prognosis cancers: Resection drives long-term outcomes.

BACKGROUND AND OBJECTIVES: Hospitals with high complex oncologic surgical volume have improved short-term outcomes. However, for long-term outcomes, the influence of other therapies must be considered. We compared effects of resection with other therapies on long-term outcomes across U.S. hospitals. METHODS: We examined claims in the Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset for patients with esophageal (EC) and pancreatic (PC) cancers between 2005-2009, with follow-up through 2011, performing multivariable Cox proportional hazards analyses. We stratified hospitals by volume and compared rates of treatments in the context of survival. RESULTS: We studied 905 EC and 3,293 PC patients at 138 and 375 hospitals, respectively. For EC, resection rates were significantly higher (32.9% vs. 9.5%, P < 0.001) in the highest versus lowest volume hospitals. Adjusted survival was also statistically significantly better (48.5% vs. 43.1%, P < 0.001). For PC, resection rates were also statistically significantly higher (30.1% vs. 12.0%, P < 0.001) with higher adjusted survival (21.5% vs. 19.9%, P = 0.01). We did not find variation in rates of other cancer treatments across hospitals. CONCLUSIONS: A significant association exists between long-term survival and rates of cancer-directed surgery across hospitals, without variation in rates of other therapies. Access to resection appears to be key to reducing variation in long-term survival. J. Surg. Oncol. 2016;113:599-604. © 2016 Wiley Periodicals, Inc.

Variation in hospital mortality rates with inpatient cancer surgery.

OBJECTIVE: To elucidate clinical mechanisms underlying variation in hospital mortality after cancer surgery BACKGROUND: : Thousands of Americans die every year undergoing elective cancer surgery. Wide variation in hospital mortality rates suggest opportunities for improvement, but these efforts are limited by uncertainty about why some hospitals have poorer outcomes than others. METHODS: Using data from the 2006-2007 National Cancer Data Base, we ranked 1279 hospitals according to a composite measure of perioperative mortality after operations for bladder, esophagus, colon, lung, pancreas, and stomach cancers. We then conducted detailed medical record review of 5632 patients at 1 of 19 hospitals with low mortality rates (2.1%) or 30 hospitals with high mortality rates (9.1%). Hierarchical logistic regression analyses were used to compare risk-adjusted complication incidence and case-fatality rates among patients experiencing serious complications. RESULTS: The 7.0% absolute mortality difference between the 2 hospital groups could be attributed to higher mortality from surgical site, pulmonary, thromboembolic, and other complications. The overall incidence of complications was not different between hospital groups [21.2% vs 17.8%; adjusted odds ratio (OR) = 1.34, 95% confidence interval (CI): 0.93-1.94]. In contrast, case-fatality after complications was more than threefold higher at high mortality hospitals than at low mortality hospitals (25.9% vs 13.6%; adjusted OR = 3.23, 95% CI: 1.56-6.69). CONCLUSIONS: Low mortality and high mortality hospitals are distinguished less by their complication rates than by how frequently patients die after a complication. Strategies for ensuring the timely recognition and effective management of postoperative complications will be essential in reducing mortality after cancer surgery.

Comparing perioperative processes of care in high and low mortality centers performing pancreatic surgery.

BACKGROUND: Pancreatic surgery outcomes vary widely. We hypothesize that by comparing high and low mortality hospitals, we may identify differences in patient care impacting safety. METHODS: We sampled hospitals with very-low and very-high mortality (LMH; HMH) and conducted on-site chart reviews evaluating perioperative care practices for pancreatic operations. RESULTS: HMHs had an 11.6% mortality rate; LMHs 1.5%. Patients in HMHs had worse ASA classification (20.9% ASA Class 4/5 vs. 2.0%, P < 0.001) and comorbidity burden (55.3% with ≥ 1 comorbidity vs. 39.6%, P = 0.037). At HMHs, operations took longer (353.9 min vs. 313.7 min, P = 0.05), had higher blood loss (1,203.7 ml vs. 881.6 ml, P = 0.04), and patients underwent more transfusions (70.2% vs. 41.1%, P < 0.001). There were differences in anesthetic care: less invasive monitoring (76.1% vs. 93.1%, P < 0.001) and epidural pain management (22.5% vs. 62.9%, P < 0.001). Both cohorts had similar rates of VTE prophylaxis and SSI prevention compliance. CONCLUSION: High and low mortality hospitals both have high compliance with common quality measures; however, HMHs performed worse in other areas of perioperative care, indicating possible targets for quality improvement efforts.

N-heterocyclic carbene-palladium(II)-1-methylimidazole complex catalyzed α-arylation reactions of tetralones with aryl chlorides and further transformation of the products.

NHC-Pd(II)-Im complex 1 has proven to be an efficient catalyst in the reaction between tetralones 2 and aryl chlorides 3, giving the α-arylated tetralones 4 in good to high yields. In addition, if the above reaction mixture was exposed to air at room temperature for another 3 h, the normal α-arylated products 4 can be fully oxidized to 2-aryl-2'-hydroxytetralones 6 in good yields in a one-pot procedure. Furthermore, if the reaction mixture containing the oxidized products 6 was treated with TsOH/toluene solution under reflux for 19 h, the final aromatized products, 2-aryl-naphthalen-1-ols 5 can be achieved in acceptable to moderate yields. All reactions can tolerate various substituents on the tetralones 2 and aryl chlorides 3, thus giving an efficient method for the α-arylation of tetralones and further transformation of the products, and also enriching the applications of NHC-Pd(II) complexes in organic synthesis.

Differences in perioperative care at low- and high-mortality hospitals with cancer surgery.

OBJECTIVE: To evaluate adherence to perioperative processes of care associated with major cancer resections. BACKGROUND: Mortality rates associated with major cancer resections vary across hospitals. Because mechanisms underlying such variations are not well-established, we studied adherence to perioperative care processes. METHODS: There were 1,279 hospitals participating in the National Cancer DataBase (2005-2006) ranked on a composite measure of mortality for bladder, colon, esophagus, stomach, lung, and pancreas cancer operations. We sampled hospitals from among those with the lowest and highest mortality rates, with 19 low-mortality hospitals [(LMHs), risk-adjusted mortality rate of 2.84 %] and 30 high-mortality hospitals [(HMHs), risk-adjusted mortality rate of 7.37 %]. We then conducted onsite chart reviews. Using logistic regression, we examined differences in perioperative care, adjusting for patient and tumor characteristics. RESULTS: Compared to LMHs, HMHs were less likely to use prophylaxis against venous thromboembolism, either preoperative or postoperatively [adjusted relative risk (aRR) 0.74, 95 % CI 0.50-0.92 and aRR 0.80, 95 % CI 0.56-0.93, respectively]. The two hospital groups were indistinguishable with respect to processes aimed at preventing surgical site infections, such as the use of antibiotics prior to incision (aRR, 0.99, 95 % CI 0.90-1.04), and processes intended to prevent cardiac events, including the use of ß-blockers (1.00, 95 % CI 0.81-1.14). HMHs were significantly less likely to use epidurals (aRR, 0.57, 95 % CI 0.32-0.93). CONCLUSIONS: HMHs and LMHs differ in several aspects of perioperative care. These areas may represent opportunities for improving cancer surgery quality at hospitals with high mortality.

Assessing the responses of ecosystem patterns, structures and functions to drought under climate change in the Yellow River Basin, China.

Understanding how ecosystems respond and adapt to drought has become an urgent issue as drought stress intensifies under climate change, yet this topic is not fully understood. Currently, conclusions on the response of ecosystems in different regions to drought disturbance are inconsistent. Based on long MODIS data and observed data, this study systematically explored the relationships between ecosystem patterns, structures and functions and drought, taking a typical climate change-sensitive area and an ecologically fragile area-the Yellow River Basin-as a case study. Drought assessment results revealed that the Yellow River Basin has experienced meteorological and hydrological drought during most of the last two decades, predominantly characterized by medium and slight droughts. The ecosystem patterns and structures changed dramatically as the grassland decreased and the landscape fragmentation index (F) increased with increasing wetness. The annual gross primary productivity (GPP) increased, the water use efficiency (WUE) declined and ecosystem service value (ESV) exhibited a W-shaped increase at the watershed scale, but there were significant regional differences. There were positive correlations between F, GPP, ESV and drought indices, while there was a negative correlation between WUE and drought indices at the watershed scale. Under drought stress, the ecosystem structure in the basin was disrupted, the GPP and ESV decreased, but the WUE increased. Notably, approximately 106 %, 20 %, and 1 % of the maximum reductions in F, GPP, and ESV, respectively, were caused by drought, while the maximum 4 % of WUE increased. Responses of some functions in the wetland and grassland to drought vary from those in other ecosystems. The mechanisms underlying ecosystem responses to drought were further investigated. This study enhances the understanding of these responses and will help stakeholders formulate drought mitigation policies and protect ecosystem health.

Factors associated with acute esophagitis during radiation therapy for lung cancer.

INTRODUCTION: Limiting acute esophagitis remains a clinical challenge during the treatment of locally advanced non-small cell lung cancer (NSCLC). METHODS: Demographic, dosimetric, and acute toxicity data were prospectively collected for patients undergoing definitive radiation therapy +/- chemotherapy for stage II-III NSCLC from 2012 to 2022 across a statewide consortium. Logistic regression models were used to characterize the risk of grade 2 + and 3 + esophagitis as a function of dosimetric and clinical covariates. Multivariate regression models were fitted to predict the 50 % risk of grade 2 esophagitis and 3 % risk of grade 3 esophagitis. RESULTS: Of 1760 patients, 84.2 % had stage III disease and 85.3 % received concurrent chemotherapy. 79.2 % of patients had an ECOG performance status ≤ 1. Overall rates of acute grade 2 + and 3 + esophagitis were 48.4 % and 2.2 %, respectively. On multivariate analyses, performance status, mean esophageal dose (MED) and minimum dose to the 2 cc of esophagus receiving the highest dose (D2cc) were significantly associated with grade 2 + and 3 + esophagitis. Concurrent chemotherapy was associated with grade 2 + but not grade 3 + esophagitis. For all patients, MED of 29 Gy and D2cc of 61 Gy corresponded to a 3 % risk of acute grade 3 + esophagitis. For patients receiving chemotherapy, MED of 22 Gy and D2cc of 50 Gy corresponded to a 50 % risk of acute grade 2 + esophagitis. CONCLUSIONS: Performance status, concurrent chemotherapy, MED and D2cc are associated with acute esophagitis during definitive treatment of NSCLC. Models that quantitatively account for these factors can be useful in individualizing radiation plans.

Variation in Androgen Deprivation Therapy Use Among Men With Intermediate-Risk Prostate Cancer: Results From a Statewide Radiation Oncology Quality Consortium.

PURPOSE: For men with intermediate-risk prostate cancer treated with definitive therapy, the addition of androgen deprivation therapy (ADT) reduces the risk of distant metastasis and cancer-related mortality. However, the absolute benefit of ADT varies by baseline cancer risk. Estimates of prognosis have improved over time, and little is known about ADT decision making in the modern era. We sought to characterize variability and identify factors associated with intended ADT use within the Michigan Radiation Oncology Quality Consoritum (MROQC). MATERIALS AND METHODS: Patients with localized prostate cancer undergoing definitive radiation therapy were enrolled from June 9, 2020, to June 26, 2023 (n = 815). Prospective data were collected using standardized patient, physician, and physicist forms. Intended ADT use was prospectively defined and was the primary outcome. Associations with patient, tumor, and practice-related factors were tested with multivariable analyses. Random intercept modeling was used to estimate facility-level variability. RESULTS: Five hundred seventy patients across 26 facilities were enrolled with intermediate-risk disease. ADT was intended for 46% of men (n = 262/570), which differed by National Comprehensive Cancer Network favorable intermediate-risk (23.5%, n = 38/172) versus unfavorable intermediate-risk disease (56.3%, n = 224/398; P < .001). After adjusting for the statewide case mix, the predicted probability of intended ADT use varied significantly across facilities, ranging from 15.4% (95% CI, 5.4%-37.0%) to 71.7% (95% CI, 57.0%-82.9%), with P < .01. Multivariable analyses showed that grade group 3 (OR, 4.60 [3.20-6.67]), ≥50% positive cores (OR, 2.15 [1.43-3.25]), and prostate-specific antigen 10 to 20 (OR, 1.87 [1.24-2.84]) were associated with ADT use. Area under the curve was improved when incorporating MRI adverse features (0.76) or radiation treatment variables (0.76), but there remained significant facility-level heterogeneity in all models evaluated (P < .05). CONCLUSIONS: Within a state-wide consortium, there is substantial facility-level heterogeneity in intended ADT use for men with intermediate-risk prostate cancer. Future efforts are necessary to identify patients who will benefit most from ADT and to develop strategies to standardize appropriate use.

Marginal treatment benefit in anaplastic thyroid cancer.

BACKGROUND: Because anaplastic thyroid cancer is a rare malignancy with a high mortality rate, the benefit of multimodality treatment was evaluated. METHODS: Overall survival was determined in the 2742 patients captured by the National Cancer Database who were diagnosed with anaplastic thyroid cancer between 1998 and 2008. Kaplan-Meier analysis and then Cox proportional hazard regression was performed, controlling for patient characteristics and treatment. RESULTS: Only older age (adjusted hazard ratio [AHR] for ≥ 85 years = 3.43, 95% confidence interval [CI] = 2.34-5.03; for 75-84 years, AHR = 2.85, 95% CI = 1.97-4.11; for 65-74 years, AHR = 2.20, 95% CI = 1.53-3.15; for 45-64 years, AHR = 2.08, 95% CI = 1.47-2.95) and omission of treatment were associated with greater mortality (omission of surgery: AHR = 1.79, 95% CI = 1.61-1.99; omission of radiation therapy: AHR = 1.56; 95% CI = 1.41-1.73; and omission of chemotherapy: AHR = 1.28, 95% CI = 1.15-1.43). In subgroup analysis of patients with American Joint Committee on Cancer stage IVA, IVB, and IVC anaplastic thyroid cancer, combination therapy with surgery, radiation, and chemotherapy was associated a difference in median survival of months. CONCLUSIONS: Multimodality management of anaplastic thyroid cancer results in a marginal treatment benefit. The poor overall survival of all anaplastic thyroid cancer patients, regardless of treatment, emphasizes the need for informed patients whose preferences are incorporated into treatment decision-making.

Cardiac and Pulmonary Dosimetric Parameters in Patients With Lung Cancer Undergoing Postoperative Radiation Therapy Across a Statewide Consortium.

PURPOSE: The recently published Lung Adjuvant Radiotherapy Trial (Lung ART) reported increased rates of cardiac and pulmonary toxic effects in the postoperative radiation therapy (PORT) arm. It remains unknown whether the dosimetric parameters reported in Lung ART are representative of contemporary real-world practice, which remains relevant for patients undergoing PORT for positive surgical margins. The purpose of this study was to examine heart and lung dose exposure in patients receiving PORT for non-small cell lung cancer across a statewide consortium. METHODS AND MATERIALS: From 2012 to 2022, demographic and dosimetric data were prospectively collected for 377 patients at 27 academic and community centers within the Michigan Radiation Oncology Quality Consortium undergoing PORT for nonmetastatic non-small cell lung cancer. Dosimetric parameters for target coverage and organ-at-risk exposure were calculated using data from dose-volume histograms, and rates of 3-dimensional conformal radiation therapy (3D-CRT) and intensity modulated radiation therapy (IMRT) utilization were assessed. RESULTS: Fifty-one percent of patients in this cohort had N2 disease at the time of surgery, and 25% had a positive margin. Sixty-six percent of patients were treated with IMRT compared with 32% with 3D-CRT. The planning target volume was significantly smaller in patients treated with 3D-CRT (149.2 vs 265.4 cm3; P < .0001). The median mean heart dose for all patients was 8.7 Gy (interquartile range [IQR], 3.5-15.3 Gy), the median heart volume receiving at least 5 Gy (V5) was 35.2% (IQR, 18.5%-60.2%), and the median heart volume receiving at least 35 Gy (V35) was 9% (IQR, 3.2%-17.7%). The median mean lung dose was 11.4 Gy (IQR, 8.1-14.3 Gy), and the median lung volume receiving at least 20 Gy (V20) was 19.6% (IQR, 12.7%-25.4%). These dosimetric parameters did not significantly differ by treatment modality (IMRT vs 3D-CRT) or in patients with positive versus negative surgical margins. CONCLUSIONS: With increased rates of IMRT use, cardiac and lung dosimetric parameters in this statewide consortium were slightly lower than those reported in Lung ART. These data provide useful benchmarks for treatment planning in patients undergoing PORT for positive surgical margins.

Prospective Evaluation of Limited-Stage Small Cell Lung Cancer Radiotherapy Fractionation Regimen Usage and Acute Toxicity in a Large Statewide Quality Collaborative.

PURPOSE: National guidelines on limited-stage small cell lung cancer (LS-SCLC) treatment give preference to a hyperfractionated regimen of 45 Gy in 30 fractions delivered twice daily; however, use of this regimen is uncommon compared with once-daily regimens. The purpose of this study was to characterize the LS-SCLC fractionation regimens used throughout a statewide collaborative, analyze patient and treatment factors associated with these regimens, and describe real-world acute toxicity profiles of once- and twice-daily radiation therapy (RT) regimens. METHODS AND MATERIALS: Demographic, clinical, and treatment data along with physician-assessed toxicity and patient-reported outcomes were prospectively collected by 29 institutions within the Michigan Radiation Oncology Quality Consortium between 2012 and 2021 for patients with LS-SCLC. We modeled the influence of RT fractionation and other patient-level variables clustered by treatment site on the odds of a treatment break specifically due to toxicity with multilevel logistic regression. National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0, incident grade 2 or worse toxicity was longitudinally compared between regimens. RESULTS: There were 78 patients (15.6% overall) treated with twice-daily RT and 421 patients treated with once-daily RT. Patients receiving twice-daily RT were more likely to be married or living with someone (65% vs 51%; P = .019) and to have no major comorbidities (24% vs 10%; P = .017). Once-daily RT fractionation toxicity peaked during RT, and twice-daily toxicity peaked within 1 month after RT. After stratifying by treatment site and adjusting for patient-level variables, once-daily treated patients had 4.11 (95% confidence interval, 1.31-12.87) higher odds of treatment break specifically due to toxicity than twice-daily treated patients. CONCLUSIONS: Hyperfractionation for LS-SCLC remains infrequently prescribed despite the lack of evidence demonstrating superior efficacy or lower toxicity of once-daily RT. With peak acute toxicity after RT and lower likelihood of a treatment break with twice-daily fractionation in real-word practice, providers may start using hyperfractionated RT more frequently.

Generalizability of an acute kidney injury prediction model across health systems.

Delays in the identification of acute kidney injury (AKI) in hospitalized patients are a major barrier to the development of effective interventions to treat AKI. A recent study by Tomasev and colleagues at DeepMind described a model that achieved a state-of-the-art performance in predicting AKI up to 48 hours in advance.1 Because this model was trained in a population of US Veterans that was 94% male, questions have arisen about its reproducibility and generalizability. In this study, we aimed to reproduce key aspects of this model, trained and evaluated it in a similar population of US Veterans, and evaluated its generalizability in a large academic hospital setting. We found that the model performed worse in predicting AKI in females in both populations, with miscalibration in lower stages of AKI and worse discrimination (a lower area under the curve) in higher stages of AKI. We demonstrate that while this discrepancy in performance can be largely corrected in non-Veterans by updating the original model using data from a sex-balanced academic hospital cohort, the worse model performance persists in Veterans. Our study sheds light on the importance of reproducing artificial intelligence studies, and on the complexity of discrepancies in model performance in subgroups that cannot be explained simply on the basis of sample size.

In-Hospital and 1-Year Mortality Trends in a National Cohort of US Veterans with Acute Kidney Injury.

BACKGROUND AND OBJECTIVES: AKI, a frequent complication among hospitalized patients, confers excess short- and long-term mortality. We sought to determine trends in in-hospital and 1-year mortality associated with AKI as defined by Kidney Disease Improving Global Outcomes consensus criteria. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This retrospective cohort study used data from the national Veterans Health Administration on all patients hospitalized from October 1, 2008 to September 31, 2017. AKI was defined by Kidney Disease Improving Global Outcomes serum creatinine criteria. In-hospital and 1-year mortality trends were analyzed in patients with and without AKI using Cox regression with year as a continuous variable. RESULTS: We identified 1,688,457 patients and 2,689,093 hospitalizations across the study period. Among patients with AKI, 6% died in hospital, and 28% died within 1 year. In contrast, in-hospital and 1-year mortality rates were 0.8% and 14%, respectively, among non-AKI hospitalizations. During the study period, there was a slight decline in crude in-hospital AKI-associated mortality (hazard ratio, 0.98 per year; 95% confidence interval, 0.98 to 0.99) that was attenuated after accounting for patient demographics, comorbid conditions, and acute hospitalization characteristics (adjusted hazard ratio, 0.99 per year; 95% confidence interval, 0.99 to 1.00). This stable temporal trend in mortality persisted at 1 year (adjusted hazard ratio, 1.00 per year; 95% confidence interval, 0.99 to 1.00). CONCLUSIONS: AKI associated mortality remains high, as greater than one in four patients with AKI died within 1 year of hospitalization. Over the past decade, there seems to have been no significant progress toward improving in-hospital or long-term AKI survivorship.

Uptake of Adjuvant Durvalumab After Definitive Concurrent Chemoradiotherapy for Stage III Nonsmall-cell Lung Cancer.

OBJECTIVES: The addition of adjuvant durvalumab improves overall survival in locally advanced nonsmall-cell lung cancer (NSCLC) patients treated with definitive chemoradiation, but the real-world uptake of adjuvant durvalumab is unknown. MATERIALS AND METHODS: We identified patients with stage III NSCLC treated with definitive concurrent chemoradiation from January 2018 to October 2020 from a statewide radiation oncology quality consortium, representing a mix of community (n=22 centers) and academic (n=5) across the state of Michigan. Use of adjuvant durvalumab was ascertained at the time of routine 3-month or 6-month follow-up after completion of chemoradiation. RESULTS: Of 421 patients with stage III NSCLC who completed chemoradiation, 322 (76.5%) initiated adjuvant durvalumab. The percentage of patients initiating adjuvant durvalumab increased over time from 66% early in the study period to 92% at the end of the study period. There was substantial heterogeneity by treatment center, ranging from 53% to 90%. In multivariable logistic regression, independent predictors of durvalumab initiation included more recent month (odds ratio [OR]: 1.05 per month, 95% confidence interval [CI]: 1.02-1.08, P=0.003), lower Eastern Cooperative Oncology Group score (OR: 4.02 for ECOG 0 vs. 2+, 95% CI: 1.67-9.64, P=0.002), and a trend toward significance for female sex (OR: 1.66, 95% CI: 0.98-2.82, P=0.06). CONCLUSION: Adjuvant durvalumab for stage III NSCLC treated with definitive chemoradiation was rapidly and successfully incorporated into clinical care across a range of community and academic settings in the state of Michigan, with over 90% of potentially eligible patients starting durvalumab in more recent months.

Effect of Education and Standardization of Cardiac Dose Constraints on Heart Dose in Patients With Lung Cancer Receiving Definitive Radiation Therapy Across a Statewide Consortium.

PURPOSE: Cardiac radiation exposure is associated with an increased rate of adverse cardiac events in patients receiving radiation therapy for locally advanced non-small cell lung carcinoma (NSCLC). Previous analysis of practice patterns within the Michigan Radiation Oncology Quality Consortium (MROQC) revealed 1 in 4 patients received a mean heart dose >20 Gy and significant heterogeneity existed among treatment centers in using cardiac dose constraints. The purpose of this study is to analyze the effect of education and initiation of standardized cardiac dose constraints on heart dose across a statewide consortium. METHODS AND MATERIALS: From 2012 to 2020, 1681 patients from 27 academic and community centers who received radiation therapy for locally advanced NSCLC were included in this analysis. Dosimetric endpoints including mean heart dose (MHD), mean lung dose, and mean esophagus dose were calculated using data from dose-volume histograms. These dose metrics were grouped by year of treatment initiation for all patients. Education regarding data for cardiac dose constraints first occurred in small lung cancer working group meetings and then consortium-wide starting in 2016. In 2018, a quality metric requiring mean heart dose <20 Gy while maintaining dose coverage (D95) to the target was implemented. Dose metrics were compared before (2012-2016) versus after (2017-2020) initiation of interventions targeting cardiac constraints. Statistical analysis was performed using the Wilcoxon rank sum test. RESULTS: After education and implementation of the heart dose performance metric, mean MHD declined from an average of 12.2 Gy preintervention to 10.4 Gy postintervention (P < .0001), and the percentage of patients receiving MHD >20 Gy was reduced from 21.1% to 10.3% (P < .0001). Mean lung dose and mean esophagus dose did not increase, and target coverage remained unchanged. CONCLUSIONS: Education and implementation of a standardized cardiac dose quality measure across a statewide consortium was associated with a reduction of mean heart dose in patients receiving radiation therapy for locally advanced NSCLC. These dose reductions were achieved without sacrificing target coverage, increasing mean lung dose, or increasing mean esophagus dose. Analysis of the clinical ramifications of the reduction in cardiac doses is ongoing.

The relationship between ASSH membership and the treatment of distal radius fracture in the United States Medicare population.

PURPOSE: Internal fixation for distal radius fractures (DRFs) in the elderly has increased from 3% in 1997 to 17% in 2007. This increase has been uneven across regions of the United States. There is some evidence that patients treated by hand surgeons receive internal fixation at an increased rate and that hand surgeons might be driving the increased usage in regions where their presence is greatest. The specific aim of this study was to explore this relationship by analyzing Medicare beneficiaries treated by members of the American Society for Surgery of the Hand (ASSH). METHODS: Surgeons who were members of ASSH in 2007 were matched with surgeons treating Medicare beneficiaries for DRFs in the same year. We then fit a series of multilevel models to estimate the proportion of total variance in internal fixation usage explained by ASSH membership status, patient demographic data, patient comorbidity, and/or type of fracture diagnosed. RESULTS: Beneficiaries treated by ASSH members received internal fixation significantly more often than beneficiaries who were treated by surgeons who were not ASSH members. ASSH member status accounts for 12% of the total variance in internal fixation utilization. CONCLUSIONS: Medicare beneficiaries who were treated by ASSH member surgeons receive internal fixation at a significantly higher rate than do patients of other physicians. When there is uncertainty about the optimal treatment for a condition, there is the possibility for specialty-related disparities. This specialty effect contributes to the national variations in the treatment of DRFs in the Medicare population.

Current and future national costs to medicare for the treatment of distal radius fracture in the elderly.

PURPOSE: Distal radius fractures (DRFs) are the second most common fracture experienced by elderly individuals. In 2005, 16% of DRFs in the Medicare population were being treated with internal fixation, up from 3% in 1997. This shift in treatment strategy can have substantial financial impact on Medicare and the health care system in general. The specific aims of this project were to quantify the current and future Medicare expenditures attributable to DRF and to compare Medicare payments for the 4 treatment options for elderly DRF. METHODS: We analyzed the 100% 2007 Medicare dataset for annual DRF-attributable spending. Payments were obtained for claims that were identified as attributable to DRF by International Classification of Diseases, 9th Revision, Clinical Modification codes for DRF in conjunction with a Current Procedural Technology code for relevant treatment or service. We projected annual payments based on increasing internal fixation treatment. All payments are reported in 2007 U.S. dollars. RESULTS: In 2007, Medicare made $170 million in DRF-attributable payments. If the usage of internal fixation were to reach 50%, DRF-attributable payments could be nearly $240 million. The mean attributable payment made for each patient in 2007 was $1,983. Most of this is due to facility and staffing cost for the treatment procedure. CONCLUSIONS: This analysis provides an accurate quantification of Medicare DRF-attributable expenditure. Use of 100% Medicare data allows for the summation of actual patient experience rather than modeling or estimation. The burden of DRF is going to grow as the U.S. population ages and as internal fixation becomes more widely used. The Medicare payment data can help in allocating resources nationally to address the increasing disease burden of DRF.