Substance Use Among Patients With Incident Crohn's Disease in the United States, 2010 to 2019: A Medicaid Observational Study.

BACKGROUND AND AIMS: Substance use among persons with Crohn's disease (CD) is associated with symptomatic exacerbation and poorer quality of life. However, data on the prevalence of substance use among individuals with CD are limited. Therefore, our study aimed to estimate the burden of alcohol and drug use among individuals with incident CD in the United States. We also assessed the associations between CD-related interventions and substance use after CD diagnosis. METHODS: Our retrospective cohort study of the national Medicaid databases from 2010 to 2019 identified participants with newly diagnosed CD and defined substance use (ie, alcohol, opioids, cocaine, amphetamine, and cannabis) using diagnosis codes. Multivariable logistic regression models assessed the associations between CD-related interventions and substance use after CD diagnosis. RESULTS: Overall, 16.3% of Medicaid enrollees with incident CD had substance ever-use, most commonly alcohol or opioids (each 8.0%). Any substance use saw an absolute decrease of 3.8% after CD diagnosis, but changes were less than 1% in either direction for each substance. CD-related hospitalization was associated with increased alcohol or opioid use post-CD diagnosis. Surgery was associated with lower use post-CD of opioids but not alcohol. CD medications (except steroids) were generally associated with decreased post-CD alcohol or opioid use. CONCLUSION: Among Medicaid enrollees with incident CD, alcohol and opioid use were more frequent than previously published estimates for the general US population (6% and 4%, respectively, in 2019). Consequently, medical communities must be more aware of substance use by patients with CD to provide quality patient-centered care.

Tobacco use in Crohn's disease patients and association with disease outcomes in the United States Medicaid population, 2010-2019.

Background and Aim: To identify demographic factors associated with tobacco use in Crohn's disease (CD) patients in the US Medicaid population and examine how tobacco use affects disease outcomes. Methods: We included Medicaid-eligible patients who had ≥1 ICD code for CD, and 1 year of eligibility before and after the initial encounter. We used ICD codes to identify tobacco use with respect to the time of diagnosis and used logistic regression to identify the association between age, sex, and race with tobacco use at any point before diagnosis and after diagnosis, and determine the association of tobacco use before and after diagnosis on disease outcomes. Results: We identified 98 176 eligible patients; 74.5% had no documented use of tobacco and 25.5% used tobacco at some point; 21.1% had used tobacco before their CD diagnosis and 11.8% had used tobacco after diagnosis. The population that used tobacco had a higher proportion of women, those who were White, non-Hispanic, and those in their middle ages (21-60) than the group that did not use tobacco. Tobacco use before diagnosis resulted in higher risk of hospitalization and surgery (OR: 1.85 and 1.36, respectively). Conclusion: Within the CD Medicaid population, tobacco use is more common in women than men, which differs from the general population, which is possibly a result of using diagnostic codes rather than survey data. Smoking cessation efforts should especially be directed at younger people who are at risk for CD, due to increased risk for more adverse outcomes among those who use tobacco before diagnosis.

The burden of gastrointestinal diseases in Japan, 1990-2019, and projections for 2035.

Background and Aim: Disease burden estimation allows clinicians and policymakers to plan for future healthcare needs. Although advances have been made in gastroenterology, as Japan has an aging population, disease burden assessment is important. We aimed to report gastrointestinal disease burden in Japan since 1990 and project changes through to 2035. Methods: This descriptive study examined the crude and age-standardized rates of prevalence, mortality, and disability-adjusted life years (DALYs) of 22 gastrointestinal diseases between 1990 and 2019. We used data from the Global Burden of Disease study 2019. We calculated the expected disease burden of gastrointestinal diseases by 2035 using an autoregressive integrated moving average. Results: Since 1990, cancer has accounted for most gastrointestinal disease-related causes of mortality and DALYs in Japan (77.1% and 71.2% in 1990, 79.2% and 73.7% in 2019, respectively). Although cancer-associated age-standardized mortality rates and DALYs have shown a decreasing trend, the crude rates have increased, suggesting that an aging society has a significant impact on the disease burden in Japan. Therefore, the overall gastrointestinal disease burden is expected to increase by 2035. Noncancerous chronic diseases with a high burden included cirrhosis, biliary disease, ileus, gastroesophageal reflux disorder, hernia, inflammatory bowel disease, enteric infections, and vascular intestinal disorders. In cirrhosis, the DALYs for hepatitis C decreased and the prevalence of non-alcoholic steatohepatitis increased. Conclusion: In the super-aging Japanese society, the burden of gastrointestinal diseases is expected to increase in the coming years. Colorectal, gastric, pancreatic, and liver cancers are the focus of early detection and treatment.

Human-Centered Design of a Clinical Decision Support for Anemia Screening in Children with Inflammatory Bowel Disease.

BACKGROUND: Inflammatory bowel disease (IBD) commonly leads to iron deficiency anemia (IDA). Rates of screening and treatment of IDA are often low. A clinical decision support system (CDSS) embedded in an electronic health record could improve adherence to evidence-based care. Rates of CDSS adoption are often low due to poor usability and fit with work processes. One solution is to use human-centered design (HCD), which designs CDSS based on identified user needs and context of use and evaluates prototypes for usefulness and usability. OBJECTIVES: this study aimed to use HCD to design a CDSS tool called the IBD Anemia Diagnosis Tool, IADx. METHODS: Interviews with IBD practitioners informed creation of a process map of anemia care that was used by an interdisciplinary team that used HCD principles to create a prototype CDSS. The prototype was iteratively tested with "Think Aloud" usability evaluation with clinicians as well as semi-structured interviews, a survey, and observations. Feedback was coded and informed redesign. RESULTS: Process mapping showed that IADx should function at in-person encounters and asynchronous laboratory review. Clinicians desired full automation of clinical information acquisition such as laboratory trends and analysis such as calculation of iron deficit, less automation of clinical decision selection such as laboratory ordering, and no automation of action implementation such as signing medication orders. Providers preferred an interruptive alert over a noninterruptive reminder. CONCLUSION: Providers preferred an interruptive alert, perhaps due to the low likelihood of noticing a noninterruptive advisory. High levels of desire for automation of information acquisition and analysis with less automation of decision selection and action may be generalizable to other CDSSs designed for chronic disease management. This underlines the ways in which CDSSs have the potential to augment rather than replace provider cognitive work.

A Systematic Review of Crohn's Disease Case Definitions in Administrative or Claims Databases.

BACKGROUND: We sought to review Crohn's disease (CD) case definitions that use diagnosis, procedure, and medication claims. METHODS: We searched PubMed and Embase from inception through January 31, 2022, using terms related to CD, inflammatory bowel disease, administrative claims, or validity. Each article was scrutinized by 2 authors independently screening and abstracting data. Collected data included participant characteristics, case definition characteristics, and case definition validity. When diagnostic accuracy was provided for multiple case definitions, we extracted the case definition selected by the authors. All diagnostic accuracy characteristics were captured. RESULTS: We identified 30 studies that evaluated a case definition using claims data to identify CD patients. The most common case definition included counts of diagnosis codes (57%) followed by a combination of diagnosis codes and medications (20%). All but 1 study validated the case definition with a medical chart review. In 2 studies, the patient's primary care provider completed a survey to confirm disease status. The positive predictive value of the case definitions ranged from 18% (≥1 code at a single U.S. health plan) to 100% (≥1 code plus a relevant prescription at a U.S. hospital). More complex case definitions (eg, ≥1 code + prescription or ≥2 codes) had lower variability in positive predictive value (≥80%) and specificity (≥85%) than the ≥1 code requirement. CONCLUSIONS: Health services researchers should validate case definitions in their research cohorts. When such validation cannot be performed, we recommend using a more complex case definition. Studies without a validated CD case definition should use sensitivity analyses to confirm the robustness of their results.

This systematic review of Crohn's disease (CD) case definitions identified that complex case definitions such as ≥1 diagnosis code + ≥1 prescription had desirable diagnostic accuracy properties.

Pre-existing Thyroid Autoimmunity and Risk of Papillary Thyroid Cancer: A Nested Case-Control Study of US Active-Duty Personnel.

PURPOSE: Thyroid autoimmunity has been associated with differentiated thyroid cancer although multiple potential biases might have influenced the results of previous studies. METHODS: We conducted a case-control study nested within the cohort of US active-duty personnel 1996-2014 to assess the association between thyroid autoimmunity, defined by serology, and thyroid cancer diagnosis. The primary exposure was thyroid peroxidase (TPO) antibody status 7-10 years before the thyroid cancer index date. We also assessed whether diagnosis of thyroid autoimmunity mediated any associations identified and if thyroid cancer features differed by autoimmunity status. RESULTS: Among 451 incident cases of papillary thyroid cancer and matched controls (median age 36 years, 61.4% men), TPO antibody positivity (v negative) 7-10 years prediagnosis was associated with thyroid cancer (odds ratio [OR] 1.90 [95% CI, 1.33 to 2.70]). Exploratory analyses suggested an increasing risk of thyroid cancer with higher TPO antibody titer (TPO antibody 550-1,399 IU/mL: OR 2.95 [95% CI, 1.37 to 6.36]; and ≥ 1,400 IU/mL: OR 3.91 [95% CI, 1.66 to 9.24]). Positive TPO antibody status remained associated with thyroid cancer after those with diagnosed autoimmunity were excluded, and the association was not mediated by diagnosis of thyroid autoimmunity. Among the cases with diagnosed autoimmunity, 58% thyroid cancers were ≤ 10 mm diameter. CONCLUSION: Longstanding prior thyroid autoimmunity up to 10 years before thyroid cancer diagnosis was associated with papillary thyroid cancer risk. The results could not be fully explained by diagnosis of thyroid autoimmunity although when autoimmunity had been identified, thyroid cancers were diagnosed at a very early stage.

A micro-costing analysis of outpatient flexible cystoscopy: implications for adoption of single-use flexible cystoscopes.

PURPOSE: To evaluate the total cost of outpatient flexible cystoscopy associated with reusable device purchase, maintenance, and reprocessing, and to assess potential cost benefits of single-use flexible cystoscopes. METHODS: Cost data regarding the purchasing, maintaining, and reprocessing of reusable flexible cystoscopes were collected using a micro-costing approach at a high-volume outpatient urology clinic. We estimated the costs to facilities with a range of annual procedure volumes (1000-3000) performed with a fleet of cystoscopes ranging from 10 to 25. We also compared the total cost per double-J ureteral stent removal procedure performed using single-use flexible cystoscopes versus reusable devices. RESULTS: The cost associated with reusable flexible cystoscopes ranged from $105 to $224 per procedure depending on the annual procedure volume and cystoscopes available. As a practice became more efficient by increasing the ratio of procedures performed to cystoscopes in the fleet, the proportion of the total cost due to cystoscope reprocessing increased from 22 to 46%. For ureteral stent removal procedures, the total cost per procedure using reusable cystoscopes (range $165-$1469) was higher than that using single-use devices ($244-$420), unless the annual procedure volume was sufficiently high relative to the number of reusable cystoscopes in the fleet (≥ 350 for a practice with ten reusable cystoscopes, ≥ 700 for one with 20 devices). CONCLUSION: The cost of reprocessing reusable cystoscopes represents a large fraction of the total cost per procedure, especially for high-volume facilities. It may be economical to adopt single-use cystoscopes specifically for stent removal procedures, especially for lower-volume facilities.

Underutilization of Needle Biopsy Before Breast Surgery: A Measure of Low-Value Care.

BACKGROUND: Breast core needle biopsy (CNB) can obviate the need for breast surgery in patients with an unknown breast lesion; however, variation in compliance with this guideline may represent a disparity in health care and a surrogate measure of unnecessary surgery. We evaluated variation in breast CNB rates prior to initial breast cancer surgery. METHODS: We performed a retrospective analysis using Medicare claims from 2015 to 2017 to evaluate the proportion of patients who received a CNB within 6 months prior to initial breast cancer surgery. Outlier practice pattern was defined as a preoperative CNB rate ≤ 70%. Logistic regression was used to evaluate surgeon characteristics associated with outlier practice pattern. RESULTS: We identified 108,935 female patients who underwent initial breast cancer surgery performed by 3229 surgeons from July 2015 to June 2017. The mean CNB rate was 86.7%. A total of 7.7% of surgeons had a CNB performed prior to initial breast surgery ≤ 70% of the time, and 2.0% had a CNB performed ≤ 50% of the time. Outlier breast surgeons were associated with practicing in a micropolitan area (odds ratio [OR] 1.88, 95% confidence interval [CI] 1.29-2.73), in the South (OR 1.84, 95% CI 1.20-2.84) or West region (OR 1.78, 95% CI 1.11-2.86), > 20 years in practice (OR 1.52, 95% CI 1.09-2.11), and low breast cancer surgery volume (< 30 cases in the study period; OR 4.03, 95% CI 2.75-5.90). CONCLUSIONS: Marked variation exists in whether a breast core biopsy is performed prior to initial breast surgery, which may represent unnecessary surgery on individual patients. Providing surgeon-specific feedback on guideline compliance may reduce unwarranted variation.

Endoscope infection transmission state-of-the-art: beyond duodenoscopes to a culture of infection prevention.

PURPOSE OF REVIEW: The elevator mechanism of the duodenoscope was the focus of endoscopically transmitted infections prior to the COVID-19 pandemic. Since that time, the 'suspicious suspects' in the endoscopy unit have grown in number in the eyes of both patients and endoscopists. RECENT FINDINGS: This review summarizes the existing guidelines related to infection control in the endoscopy unit and emerging technologies to address gaps, identifies recommendations proposed during the COVID-19 pandemic, and reminds the reader that infection prevention has not changed since the emergence of COVID-19, only the importance of infection prevention has increased in visibility. SUMMARY: Infection prevention has been and will always be necessary in the gastrointestinal endoscopy unit. Although outbreaks of antibiotic-resistant organisms and infectious diseases like COVID-19 raise the profile of infection control, there have been no major changes to infection control practice recommendations because of the global pandemic. The history of lapses in infection control, persistent contamination of reprocessed endoscopes, and failure of many endoscopy units to identify certain endoscopic procedures as aerosol-generating procedures prior to the pandemic emphasize the need for better knowledge and implementation of infection control practices within endoscopy units.

Clinical codes combined with procedure codes increase diagnostic accuracy of Crohn's disease in a US Military health record.

Background and aims: Previous examinations of International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes to predict accuracy of diagnosis in inflammatory bowel disease have had limited chart review to confirm diagnosis. We aimed to evaluate using the ICD-9-CM for identifying Crohn's disease (CD) in a large electronic health record (EHR) database. Methods: This is a retrospective case-control study with a 3:1 allocation of EHRs of active duty service members diagnosed with CD from 1996 to 2012. Subjects were selected by having two ICD-9-CM codes for CD during the study period. Gastroenterologists reviewed each chart and confirmed the diagnosis of CD by analysing medication history and clinical, endoscopic, histological, and radiographic exams. Results: 300 cases of CD were selected; 14 cases were discarded due to lack of data, limiting our analysis to 284 subjects. Two diagnostic codes for CD had sensitivity, specificity, and positive predictive value (PPV) of 1.0, 0.53, and 0.69, respectively, for confirmed CD. If two encounters listing CD were with a gastroenterologist, the sensitivity, specificity, and PPV was 0.76, 0.81, and 0.80, respectively. If a colonoscopy was performed within 90 days of any three encounters with a CD code, the sensitivity, specificity, and PPV was 0.51, 0.94, and 0.89, respectively. Conclusions: The poor PPV of ICD-9-CM codes in making the diagnosis of CD should be taken into consideration when interpreting results and when conducting research using such codes. Limiting these codes to those patients who have been given this diagnosis by a gastroenterologist, or to those who have had a colonoscopy near the time of diagnosis, increases the PPV.

Antitumour necrosis factor-α agents and development of new-onset cirrhosis or non-alcoholic fatty liver disease: a retrospective cohort.

Objective: Elevated tumour necrosis factor (TNF)-α has been implicated in the progression of liver fibrosis and pathogenesis of non-alcoholic fatty liver disease (NAFLD). We aim to investigate the impact of anti-TNF-α agents on the development of cirrhosis and NAFLD. Design: This retrospective cohort study used a US claims database between 1 January 2010 and 31 December 2016. We identified adult patients with ankylosing spondylitis, inflammatory bowel disease, psoriatic arthritis or rheumatoid arthritis. Anti-TNF-α agents of interest included adalimumab, certolizumab, etanercept, golimumab and infliximab. The primary composite outcome was the development of new-onset cirrhosis, NAFLD or non-alcoholic steatohepatitis (NASH). The secondary outcomes were the development of (1) cirrhosis and (2) NAFLD or NASH. Propensity score for anti-TNF-α agent use was generated by logistic regression. Cox proportional hazard models adjusting for the propensity score were used with regard to time-varying anti-TNF-α agent exposure. Results: This study included 226 555 incident patients with immune-related diseases. During the median 1.5 years follow-up, there was an increased hazard with anti-TNF-α agent use in regard to liver outcomes (composite outcome HR: 1.47, 95% CI 1.27 to 1.70; cirrhosis HR 1.47, 95% CI 0.96 to 2.23; NAFLD or NASH HR 1.53, 95% CI 1.32 to 1.77). The composite outcome hazard was increased for each immune-related disease (HR 1.25-1.90). Conclusion: In the short term, we did not observe a beneficial effect of anti-TNF-α agent use for development of cirrhosis, NAFLD or NASH in patients with immune-related diseases.

Levels of Vitamin D Are Low After Crohn's Disease Is Established But Not Before.

BACKGROUND & AIMS: Low serum levels of vitamin D have been associated with Crohn's disease (CD). However, it is unclear whether low vitamin D levels cause CD or CD reduces serum vitamin D. METHODS: United States military personnel with CD (n = 240) and randomly selected individuals without CD (controls, n = 240) were matched by age, sex, race, military branch, and geography. We measured 25-hydroxyvitamin D in sera 8-3 years (pre-2) and 3 years to 3 months before diagnosis (pre-1) and 3 months before through 21 months after diagnosis (pre-0). We genotyped VDR and GC vitamin D related polymorphisms. We used conditional logistic regression, including adjustments for smoking, season, enlistment status, and deployment, to estimate relative odds of CD according to vitamin D levels and interactions between genetic factors and levels of vitamin D. RESULTS: Levels of vitamin D before diagnosis were not associated with CD in pre-2 (P trend = .65) or pre-1 samples (P trend = .84). However, we found an inverse correlation between CD and highest tertile of vitamin D level in post-diagnosis samples (P trend = .01; odds ratio, 0.51; 95% CI, 0.30-0.86). Interactions were not detected between vitamin D levels and VDR or GC polymorphisms. We observed an association between VDR Taq1 polymorphism and CD (independent of vitamin D) (P = .02). CONCLUSIONS: In serum samples from military personnel with CD and matched controls, we found no evidence for an association between CD and vitamin D levels up to 8 years before diagnosis. However, we observed an inverse-association between post-diagnosis vitamin D levels and CD. These findings suggest that low vitamin D does not contribute to development of CD-instead, CD leads to low vitamin D.

Optimizing opioid prescribing and pain treatment for surgery: Review and conceptual framework.

PURPOSE: Millions of Americans who undergo surgical procedures receive opioid prescriptions as they return home. While some derive great benefit from these medicines, others experience adverse events, convert to chronic opioid use, or have unused medicines that serve as a reservoir for potential nonmedical use. Our aim was to investigate concepts and methods relevant to optimal opioid prescribing and pain treatment in the perioperative period. METHODS: We reviewed existing literature for trials on factors that influence opioid prescribing and optimization of pain treatment for surgical procedures and generated a conceptual framework to guide future quality, safety, and research efforts. RESULTS: Opioid prescribing and pain treatment after discharge from surgery broadly consist of 3 key interacting perspectives, including those of the patient, the perioperative team, and, serving in an essential role for all patients, the pharmacist. Systems-based factors, ranging from the organizational environment's ability to provide multimodal analgesia and participation in enhanced recovery after surgery programs to other healthcare system and macro-level trends, shape these interactions and influence opioid-related safety outcomes. CONCLUSIONS: The severity and persistence of the opioid crisis underscore the urgent need for interventions to improve postoperative prescription opioid use in the United States. Such interventions are likely to be most effective, with the fewest unintended consequences, if based on sound evidence and built on multidisciplinary efforts that include pharmacists, nurses, surgeons, anesthesiologists, and the patient. Future studies have the potential to identify the optimal amount to prescribe, improve patient-focused safety and quality outcomes, and help curb the oversupply of opioids that contributes to the most pressing public health crisis of our time.

Familial aggregation of inflammatory bowel disease in India: prevalence, risks and impact on disease behavior.

BACKGROUND/AIMS: Information about familial aggregation of inflammatory bowel disease (IBD) in Asia is limited. We aimed to analyze the prevalence and risk of familial IBD in an Indian cohort and compare familial and sporadic cases. METHODS: Familial IBD cases were identified from a large prospectively maintained IBD registry. The prevalence of IBD in first- and seconddegree relatives of index cases was evaluated. The disease behavior was compared to that of sporadic cases. RESULTS: Total 3,553 patients (ulcerative colitis [UC], 2,053; Crohn's disease [CD], 1,500) were included. Familial IBD was noted in 4.13% of CD and 4.34% of UC patients. Family history was commoner in pediatric group (< 18 years) (P= 0.0002; odds ratio [OR], 2.8; 95% confidence interval [CI], 1.6-4.8). Majority had paternal transmission (UC, 67.42%; CD, 70.97%). Concordance of disease type was higher in UC (79.7%) compared to CD (37.1%). Familial IBD was associated with higher cumulative relapse rate (CD, P< 0.001; UC, P< 0.001), higher cumulative rate of surgery (CD, P< 0.001; UC, P< 0.001) and higher rate of biologic use (CD, P= 0.010; UC, P= 0.015). Pan-colitis was higher in familial UC (P= 0.003; OR, 1.935; 95% CI, 1.248-3.000). Fistulizing disease was commoner in familial CD (P= 0.041; OR, 2.044; 95% CI, 1.030-4.056). CONCLUSIONS: The prevalence of familial IBD in India appears comparable to rest of Asia but lower than the West. It is associated with a younger age of onset, higher incidence of pan-colitis in UC and fistulizing complications in CD. Familial IBD has higher cumulative relapse, surgery and biologic use rates. Hence, family history of IBD could have important prognostic implications.

Initial medical and surgical management of inflammatory bowel disease in the biologic era: A comparison between the United States and China.

BACKGROUND AND AIMS: We compared the initial medical and surgical management of Crohn's disease (CD) and ulcerative colitis (UC) between the United States and China, with aims to better characterize the global variation in the treatment patterns of inflammatory bowel disease (IBD). METHODS: Participants from the United States and China completed a questionnaire on demographic and clinical characteristics, medications (biologics, immunomodulators, aminosalicylates, steroids), and IBD-related surgical history. Patients diagnosed in 2006 and later were eligible. Analysis was restricted to treatment patterns within 1 year of diagnosis. Multivariable logistic regressions examined differences by country. RESULTS: We recruited 202 CD (US: 49%, China: 51%) and 133 UC (US: 63%, China: 37%) participants. Median age at survey was 31 years (range: 18-76) and at diagnosis was 28 years (range: 12-70). Biologics were commonly used in the United States for CD (66%) and UC (28%) and less commonly in China for CD (19%) and UC (0%). On regression, US CD participants were more likely to receive biologics (odds ratio [OR] 23.82 [95% confidence interval [CI] 8.98-63.14]), aminosalicylates (OR 4.93 [2.00-12.15]), and steroids (OR 4.36 [1.87-10.16]). US UC participants were more likely to receive immunomodulators (OR 3.45 [1.09-10.90]) and steroids (OR 3.31 [1.55-7.06]). There existed minimal differences regarding undergoing surgery for CD (US: 16%, China: 16%) and UC (US: 5%, China: 2%). A proportion (US: 12%, China: 19%) underwent IBD-related surgery prior to diagnosis (median: 5 years; range: 1-39). CONCLUSION: US, relative to Chinese, participants were more likely to report early biologic use. There were no differences between countries in undergoing early surgery. Evaluating global practice variation is integral to optimizing early pharmacological therapy and timing of surgery for patients with IBD.

Evaluation of a Peer-to-Peer Data Transparency Intervention for Mohs Micrographic Surgery Overuse.

IMPORTANCE: Mohs micrographic surgery (MMS) is a skin cancer treatment that uses staged excisions based on margin status. Wide surgeon-level variation exists in the mean number of staged resections used to treat a tumor, resulting in a cost disparity and question of appropriateness. OBJECTIVE: To evaluate the effectiveness of a behavioral intervention aimed at reducing extreme overuse in MMS, as defined by the specialty society, by confidentially sharing stages-per-case performance data with individual surgeons benchmarked to their peers nationally. DESIGN, SETTING, AND PARTICIPANTS: This nonrandomized controlled intervention study included 2329 US surgeons who performed MMS procedures from January 1, 2016, to March 31, 2018. Physicians were identified using a 100% capture of Medicare Part B claims. The intervention group included physicians affiliated with the American College of Mohs Surgery, and the control group included physicians not affiliated with the American College of Mohs Surgery. INTERVENTIONS: Individualized performance reports were delivered to all outlier surgeons, defined by the specialty society as those with mean stages per case 2 SDs above the mean, and inlier surgeons in the intervention group. MAIN OUTCOMES AND MEASURES: The primary outcome was surgeon-level change in mean stages per case between the prenotification (January 2016 to January 2017) and postnotification (March 2017 to March 2018) periods. A multivariable linear regression model was used to evaluate the association of notification with this surgeon-level outcome. The surgeon-level metric of mean stages per case was not risk adjusted. The mean Medicare cost savings associated with changes in practice patterns were calculated. RESULTS: Of the 2329 included surgeons, 1643 (70.5%) were male and 2120 (91.0%) practiced in metropolitan areas. In the intervention group (n = 1045), 53 surgeons (5.1%) were outliers; in the control group (n = 1284), 87 surgeons (6.8%) were outliers. Among the outliers in the intervention group, 44 (83%) demonstrated a reduction in mean stages per case compared with 60 outliers in the control group (69%; difference, 14%; 95% CI of difference, -1 to 27; P = .07). There was a mean stages-per-case reduction of 12.6% among outliers in the intervention group compared with 9.0% among outliers in the control group, and outliers in the intervention group had an adjusted postintervention differential decrease of 0.14 stages per case (95% CI, -0.19 to -0.09; P = .002). The total administrative cost of the intervention program was $150 000, and the estimated reduction in Medicare spending was $11.1 million. CONCLUSIONS AND RELEVANCE: Sharing personalized practice pattern data with physicians benchmarked to their peers can reduce overuse of MMS among outlier physicians.

Same-Day vs Different-Day Elective Upper and Lower Endoscopic Procedures by Setting.

Importance: Performing elective upper and lower endoscopic procedures on the same day is a patient-centered and less costly approach than a 2-stage approach performed on different days, when clinically appropriate. Whether this practice pattern varies based on practice setting has not been studied. Objectives: To estimate the rate of different-day upper and lower endoscopic procedures in 3 types of outpatient settings and investigate the factors associated with the performance of these procedures on different days. Design, Setting, and Participants: A retrospective analysis was conducted of Medicare claims between January 1, 2011, and June 30, 2018, for Medicare beneficiaries who underwent a pair of upper and lower endoscopic procedures performed within 90 days of each other at hospital outpatient departments (HOPDs), freestanding ambulatory surgery centers (ASCs), and physician offices. Main Outcomes and Measures: Undergoing an upper and a lower endoscopic procedure on different days, adjusted for patient characteristics (age, sex, race/ethnicity, residence location and region, comorbidity, and procedure indication) and physician characteristics (sex, years in practice, procedure volume, and primary specialty). Adjusted odds ratios (aORs) and 95% CIs were calculated. Results: A total of 4 028 587 procedure pairs were identified, of which 52.5% were performed in HOPDs, 43.3% in ASCs, and 4.2% in physician offices. The rate of different-day procedures was 13.6% in HOPDs, 22.2% in ASCs, and 47.7% in physician offices. For the 7564 physicians who practiced at both HOPDs and ASCs, their different-day procedure rate changed from 14.1% at HOPDs to 19.4% at ASCs. For the 993 physicians who practiced at both HOPDs and physician offices, their different-day procedure rate changed from 15.8% at HOPDs to 37.4% at physician offices. Patients were more likely to undergo different-day procedures at physician offices and ASCs compared with HOPDs, even after adjusting for patient and physician characteristics (physician office vs HOPD: aOR, 2.02; 95% CI, 1.85-2.20; ASC vs HOPD: aOR, 1.27; 95% CI, 1.23-1.32). Older age (85-94 years vs 65-74 years: aOR, 1.10; 95% CI, 1.08-1.11; 95 years or older vs 65-74 years: aOR, 1.14; 95% CI, 1.03-1.26), black and Hispanic race/ethnicity (black: aOR, 1.15; 95% CI, 1.12-1.17; Hispanic: aOR, 1.12; 95% CI, 1.10-1.14), and residing in the Northeast region (adjusted OR, 1.32; 95% CI, 1.28-1.36) were risk factors for undergoing different-day procedures. Micropolitan location (aOR, 0.94; 95% CI, 0.92-0.96) and rural location (aOR, 0.91; 95% CI, 0.89-0.93), more comorbidities (≥5: aOR, 0.75; 95% CI, 0.74-0.76), physician's fewer years in practice (aOR, 0.84; 95% CI, 0.81-0.87), physician's higher procedure volume (aOR, 0.65; 95% CI, 0.62-0.68), and physician's specialty of general surgery (aOR, 0.86; 95% CI, 0.80-0.91) were protective factors. Conclusions and Relevance: Physician offices and ASCs had much higher different-day procedure rates compared with HOPDs. This disparity may represent an opportunity for quality improvement and financial savings for common endoscopic procedures.

Burden of gastrointestinal and liver diseases in India, 1990-2016.

There is no comprehensive report on the burden of gastrointestinal (GI) and liver diseases in India. In this study, we estimated the age-standardized prevalence, mortality, and disability adjusted life years (DALY) rates of GI and liver diseases in India from 1990 to 2016 using data from the Global Burden of Disease (GBD) Study, which systematically reviews literature and reports for international disease burden trends. Despite a decrease in the overall burden from GI infectious disorders since 1990, they still accounted for the majority of DALYs in 2016. Among noncommunicable disorders (NCDs), there were increases in the prevalence and mortality rates for pancreatitis, liver cancer, paralytic ileus and intestinal obstruction, gallbladder and biliary tract cancer, vascular intestinal disorders, colorectal cancer, and inflammatory bowel disease. Prevalence and mortality rates decreased for peptic ulcer disease, hernias, appendicitis, and stomach and esophageal cancer. For gastritis and duodenitis, cirrhosis and other chronic liver diseases, and gallbladder and biliary tract diseases, there was an increase in prevalence but a decrease in mortality while the opposite was true for pancreatic cancer (decreased prevalence, increased mortality). Indian gastroenterologists and hepatologists must continue to attend to the large majority of patients with infectious diseases while also managing the increasing number of GI and liver diseases, noncommunicable nonmalignant and malignant.

Evaluation of Clinical Questions and Patient-Important Outcomes Associated With the Treatment of Age-Related Macular Degeneration.

Importance: Identifying and prioritizing unanswered clinical questions may help to best allocate limited resources for research associated with the treatment of age-related macular degeneration (AMD). Objective: To identify and prioritize clinical questions and outcomes for research associated with the treatment of AMD through engagement with professional and patient stakeholders. Design, Setting, and Participants: Multiple cross-sectional survey questions were used in a modified Delphi process for panel members of US and international organizations, the American Academy of Ophthalmology (AAO) Retina/Vitreous Panel (n=7), health care professionals from the American Society of Retinal Specialists (ASRS) (n=90), Atlantic Coast Retina Conference (ACRC) and Macula 2017 meeting (n=34); and patients from MD (Macular Degeneration) Support (n=46). Data were collected from January 20, 2015, to January 9, 2017. Main Outcomes and Measures: The prioritizing of clinical questions and patient-important outcomes for AMD. Results: Seventy clinical questions were derived from the AAO Preferred Practice Patterns for AMD and suggestions by the AAO Retina/Vitreous Panel. The AAO Retina/Vitreous Panel assessed all 70 clinical questions and rated 17 of 70 questions (24%) as highly important. Health care professionals assessed the 17 highly important clinical questions and rated 12 of 17 questions (71%) as high priority for research to answer; 9 of 12 high-priority clinical questions were associated with aspects of anti-vascular endothelial growth factor agents. Patients assessed the 17 highly important clinical questions and rated all as high priority. Additionally, patients identified 6 of 33 outcomes (18%) as most important to them (choroidal neovascularization, development of advanced AMD, retinal hemorrhage, gain of vision, slowing vision loss, and serious ocular events). Conclusions and Relevance: Input from 4 stakeholder groups suggests good agreement on which 12 priority clinical questions can be used to underpin research related to the treatment of AMD. The 6 most important outcomes identified by patients were balanced between intended effects of AMD treatment (eg, slowing vision loss) and adverse events. Consideration of these patient-important outcomes may help to guide clinical care and future areas of research.