Size thresholds for repair of abdominal aortic aneurysms warrant reconsideration.

BACKGROUND: The historical size threshold for abdominal aortic aneurysm (AAA) repair is widely accepted to be 5.5 cm for men and 5.0 cm for women. However, contemporary AAA rupture risks may be lower than historical benchmarks, which has implications for when AAAs should be repaired. Our objective was to use contemporary AAA rupture rates to inform optimal size thresholds for AAA repair. METHODS: We used a Markov chain analysis to estimate life expectancy for patients with AAA. The primary outcome was AAA-related mortality. We estimated survival using Social Security Administration life tables and published contemporary AAA rupture estimates. For those undergoing repair, we modified survival estimates using data from the Vascular Quality Initiative and Medicare on complications, late rupture, and open conversion. We used this model to estimate the AAA repair size threshold that minimizes AAA-related mortality for 60-year-old average-health men and women. We performed a sensitivity analysis of poor-health patients and 70- and 80-year-old base cases. RESULTS: The annual risk of all-cause mortality under surveillance for a 60-year-old woman presenting with a 5.0 cm AAA using repair thresholds of 5.5 cm, 6.0 cm, 6.5 cm, and 7.0 cm was 1.7%, 2.3%, 2.7%, and 2.8%, respectively. The corresponding risk for a man was 2.3%, 2.9%, 3.3%, and 3.4% for the same repair thresholds, respectively. For a 60-year-old average-health woman, an AAA repair size of 6.1 cm was the optimal threshold to minimize AAA-related mortality. Life expectancy varied by <2 months for repair at sizes from 5.7 cm to 7.1 cm. For a 60-year-old average-health man, an AAA repair size of 6.9 cm was the optimal threshold to minimize AAA-related mortality. Life expectancy varied by <2 months for repair at sizes from 6.0 cm to 7.4 cm. Women in poor health, at various age strata, had optimal AAA repair size thresholds that were >6.5 cm, whereas men in poor health, at all ages, had optimal repair size thresholds that were >8.0 cm. CONCLUSIONS: The optimal threshold for AAA repair is more nuanced than a discrete size. Specifically, there appears to be a range of AAA sizes for which repair is reasonable to minmized AAA-related mortality. Notably, they all are greater than current guideline recommendations. These findings would suggest that contemporary AAA size thresholds for repair should be reconsidered.

Self-pay insurance status is associated with failure of medical therapy in patients with acute uncomplicated type B aortic dissection.

BACKGROUND: Traditionally, acute uncomplicated type B aortic dissections are managed medically, and acute complicated dissections are managed surgically. Self-pay patients with medically managed acute uncomplicated type B aortic dissections may fare worse than their insured counterparts. METHODS: In this single-center, retrospective cohort study, demographics, follow-up, and outcomes of patients with acute type B aortic dissections from 2011 to 2020 were analyzed. RESULTS: In total, 159 patients presented with acute type B aortic dissections; 102 were complicated and managed with thoracic endovascular aortic repair, and 57 were uncomplicated and managed medically. A total of 32% (n = 51) were self-pay. Self-pay patients were from areas with worse area deprivation indices (71% vs 63%, P = .024). They more often reported alcohol abuse (28% vs 7%, P < .001), cocaine/methamphetamine use (16% vs 5%, P = .028), and nonadherence to home antihypertensives (35% vs 11%, P < .001). Self-pay patients less often had a primary care physician (65% vs 7%, P < .001) or took antihypertensives before admission (31% vs 58%, P = .003). Self-pay patients frequently required financial assistance at discharge (63%), most often using charity funds (46%). Few patients (7%) qualified for our hospital's financial assistance program, and most (78%) remained uninsured at the first follow-up. Self-pay acute uncomplicated type B aortic dissections patients had the lowest rate of follow-up (31% vs 66%, P < .001) and were more likely to represent emergently (75% vs 0%, P = .033) compared to insured acute uncomplicated type B aortic dissections patients. Self-pay patients were more likely to follow up after thoracic endovascular aortic repair for acute complicated type B aortic dissections (82% vs 31%, P < .001). CONCLUSION: Self-pay patients have multiple, interconnected, complex socioeconomic factors that likely influence preadmission risk for dissection and post-discharge adherence to optimal medical management. Further research is needed to clarify treatment strategies in this high-risk group.

National Institutes of Health funding among vascular surgeons is rare.

BACKGROUND: The National Institutes of Health (NIH) is an essential source of funding for vascular surgeons conducting research. NIH funding is frequently used to benchmark institutional and individual research productivity, help determine eligibility for academic promotion, and as a measure of scientific quality. We sought to appraise the current scope of NIH funding to vascular surgeons by appraising the characteristics of NIH-funded investigators and projects. In addition, we also sought to determine whether funded grants addressed recent Society for Vascular Surgery (SVS) research priorities. METHODS: In April 2022, we queried the NIH Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER) database for active projects. We only included projects that had a vascular surgeon as a principal investigator. Grant characteristics were extracted from the NIH Research Portfolio Online Reporting Tools Expenditures and Results database. Principal investigator demographics and academic background information were identified by searching institution profiles. RESULTS: There were 55 active NIH awards given to 41 vascular surgeons. Only 1% (41/4037) of all vascular surgeons in the United States receive NIH funding. Funded vascular surgeons are an average of 16.3 years out of training; 37% (n = 15) are women. The majority of awards (58%; n = 32) were R01 grants. Among the active NIH-funded projects, 75% (n = 41) are basic or translational research projects, and 25% (n = 14) are clinical or health services research projects. Abdominal aortic aneurysm and peripheral arterial disease are the most commonly funded disease areas and together accounted for 54% (n = 30) of projects. Three SVS research priorities are not addressed by any of the current NIH-funded projects. CONCLUSIONS: NIH funding of vascular surgeons is rare and predominantly consists of basic or translational science projects focused on abdominal aortic aneurysm and peripheral arterial disease research. Women are well-represented among funded vascular surgeons. Although the majority of SVS research priorities receive NIH funding, three SVS research priorities are yet to be addressed by NIH-funded projects. Future efforts should focus on increasing the number of vascular surgeons receiving NIH grants and ensuring all SVS research priorities receive NIH funding.

Prostatic Artery Embolization for Treatment of Lower Urinary Tract Symptoms: A Markov Model-Based Cost-Effectiveness Analysis.

PURPOSE: The aim of this study was to investigate whether prostatic artery embolization (PAE) can be considered a long-term cost-effective treatment option in patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia in comparison to transurethral resection of the prostate (TURP). METHODS: The in-hospital costs of PAE and TURP in the United States were obtained from a recent cost analysis. Clinical outcomes including nature and rate of adverse events for TURP and PAE along with rates of retreatment because of complications or clinical failure were obtained from peer-reviewed literature. A decision tree-based Markov model was created, analyzing long-term cost-effectiveness for TURP and PAE from a US health care sector perspective. Cost-effectiveness over a time frame of 5 years was estimated while assuming a willingness to pay of $50,000 per quality-adjusted life-year (QALY). The primary outcome was incremental cost-effectiveness ratio. RESULTS: PAE resulted in overall cost of $6,464.92 and an expected outcome of 4.566 QALYs. In comparison, TURP cost $9,221.09 and resulted in expected outcome of 4.577 QALYs per treatment. The incremental cost-effectiveness ratio for TURP was $247,732.65 per QALY. On the basis of the willingness-to-pay threshold, PAE is cost effective compared with TURP. CONCLUSIONS: On the basis of our model, PAE in comparison with TURP can be regarded as a cost-effective treatment option for patients with lower urinary tract symptoms within the US health care system.

Follow-Up 18F-FDG PET/CT versus Contrast-Enhanced CT after Ablation of Liver Metastases of Colorectal Carcinoma-A Cost-Effectiveness Analysis.

PURPOSE: After a percutaneous ablation of colorectal liver metastases (CRLM), follow-up investigations to evaluate potential tumor recurrence are necessary. The aim of this study was to analyze whether a combined 18F-Fluordesoxyglucose positron emission tomography-computed tomography (18F-FDG PET/CT) scan is cost-effective compared to a contrast-enhanced computed tomography (CE-CT) scan for detecting local tumor progression. MATERIALS AND METHODS: A decision model based on Markov simulations that estimated lifetime costs and quality-adjusted life years (QALYs) was developed. Model input parameters were obtained from the recent literature. Deterministic sensitivity analysis of diagnostic parameters based on a Monte-Carlo simulation with 30,000 iterations was performed. The willingness-to-pay (WTP) was set to $100,000/QALY. RESULTS: In the base-case scenario, CE-CT resulted in total costs of $28,625.08 and an efficacy of 0.755 QALYs, whereas 18F-FDG PET/CT resulted in total costs of $29,239.97 with an efficacy of 0.767. Therefore, the corresponding incremental cost-effectiveness ratio (ICER) of 18F-FDG PET/CT was $50,338.96 per QALY indicating cost-effectiveness based on the WTP threshold set above. The results were stable in deterministic and probabilistic sensitivity analyses. CONCLUSION: Based on our model, 18F-FDG PET/CT can be considered as a cost-effective imaging alternative for follow-up investigations after percutaneous ablation of colorectal liver metastases.

The influence of leadership facilitation on relational coordination among primary care team members of accountable care organizations.

BACKGROUND: Teamwork is a central aspect of integrated care delivery and increasingly critical to primary care practices of accountable care organizations. Although the importance of leadership facilitation in implementing organizational change is well documented, less is known about the extent to which strong leadership facilitation can positively influence relational coordination among primary care team members. PURPOSE: The aim of this study was to examine the association of leadership facilitation of change and relational coordination among primary care teams of accountable care organization-affiliated practices and explore the role of team participation and solidarity culture as mediators of the relationship between leadership facilitation and relational coordination among team members. METHODOLOGY/APPROACH: Survey responses of primary care clinicians and staff (n = 764) were analyzed. Multilevel linear regression estimated the relationships among leadership facilitation, team participation, group solidarity, and relational coordination controlling for age, time, occupation, gender, team tenure, and team size. Models included practice site random effects to account for the clustering of respondents within practices. RESULTS: Leadership facilitation (ß = 0.19, p < .001) and team participation (ß = 0.18, p < .001) were positively associated with relational coordination, but solidarity culture was not associated. The association of leadership facilitation and relational coordination was only partially mediated (9%) by team participation. CONCLUSIONS: Leadership facilitation of change is positively associated with relational coordination of primary care team members. The relationship is only partially explained by better team participation, indicating that leadership facilitation has a strong direct effect on relational coordination. Greater solidarity was not associated with better relational coordination and may not contribute to better team task coordination. PRACTICE IMPLICATIONS: Leadership facilitation of change may have a positive and direct impact on high relational coordination among primary care team members.

A deep learning model for pediatric patient risk stratification.

OBJECTIVES: Current models for patient risk prediction rely on practitioner expertise and domain knowledge. This study presents a deep learning model-a type of machine learning that does not require human inputs-to analyze complex clinical and financial data for population risk stratification. STUDY DESIGN: A comparative predictive analysis of deep learning versus other popular risk prediction modeling strategies using medical claims data from a cohort of 112,641 pediatric accountable care organization members. METHODS: "Skip-Gram," an unsupervised deep learning approach that uses neural networks for prediction modeling, used data from 2014 and 2015 to predict the risk of hospitalization in 2016. The area under the curve (AUC) of the deep learning model was compared with that of both the Clinical Classifications Software and the commercial DxCG Intelligence predictive risk models, each with and without demographic and utilization features. We then calculated costs for patients in the top 1% and 5% of hospitalization risk identified by each model. RESULTS: The deep learning model performed the best across 6 predictive models, with an AUC of 75.1%. The top 1% of members selected by the deep learning model had a combined healthcare cost $5 million higher than that of the group identified by the DxCG Intelligence model. CONCLUSIONS: The deep learning model outperforms the traditional risk models in prospective hospitalization prediction. Thus, deep learning may improve the ability of managed care organizations to perform predictive modeling of financial risk, in addition to improving the accuracy of risk stratification for population health management activities.

Financial implications of coding inaccuracies in patients undergoing elective endovascular abdominal aortic aneurysm repair.

OBJECTIVE: Previous cost analyses have found small to negative margins between hospitalization cost and reimbursement for endovascular aneurysm repair (EVAR). Hospitals obtain reimbursement on the basis of Medicare Severity Diagnosis Related Group (MS-DRG) coding to distinguish patient encounters with or without major comorbidity or complication (MCC). This study's objective was to evaluate coding accuracy and its effect on hospital cost for patients undergoing EVAR. METHODS: A retrospective, single university hospital review of all elective, infrarenal EVARs performed from 2010 to 2015 was completed. Index procedure hospitalizations were reviewed for MS-DRG classification, comorbidities, complications, length of stay (LOS), and hospitalization cost. Patients' comorbidities and postoperative complications were tabulated to verify accuracy of MS-DRG classification. Misclassified patients were audited and reclassified as "standard" or "complex" on the basis of a corrected MS-DRG: standard for 238 (major cardiovascular procedure without MCC) and complex for 237 (major cardiovascular procedure with MCC). RESULTS: There were 104 EVARs identified, including 91 standard (original MS-DRG 238, n = 85; MS-DRG 254, n = 6) and 13 complex hospitalizations (original MS-DRG 237, n = 9; MS-DRG 238, n = 3; MS-DRG 253, n = 1). On review, 3% (n = 3) of the originally assigned MS-DRG 238 patients were undercoded while actually meeting MCC criteria for a 237 designation. Hospitalizations coded with MS-DRG 253 and 254 were considered billing errors because MS-DRG 237 and 238 are more appropriate and specific classifications as major cardiovascular procedures. Overall, there was a 9.6% miscoding rate (n = 10), representing a total lost billing opportunity of $587,799. Mean LOS for standard and complex hospitalizations was 3.0 ± 1.5 days vs 7.8 ± 6.0 days (P < .001), with respective intensive care unit LOS of 0.4 ± 0.7 day vs 2.6 ± 3.1 days (P < .001). Postoperative complications occurred in 23% of patients; however, not all met the Centers for Medicare and Medicaid Services criteria as MCC. Miscoded complexity was found to be due to postoperative events in all patients rather than to missed comorbidities. Mean hospitalization cost for standard and complex patients was $28,833 ± $5597 vs $41,543 ± $12,943 (P < .001). Based on institutional reimbursement data, this translates to a mean loss of $5407 per correctly coded patient. Miscoded patients represent an additional overall reimbursement loss of $140,102. CONCLUSIONS: Our study reveals a large lost billing opportunity with miscoding of elective EVARs from 2010 to 2015, with errors in categorization of the procedure as well as miscoding of complexity. The revenue impact is potentially significant in this population, and additional reviews of coding practices should be considered.

Cost-effectiveness of Endovascular Therapy for Acute Ischemic Stroke: A Systematic Review of the Impact of Patient Age.

Purpose To determine the impact of patient age on the cost-effectiveness of endovascular therapy (EVT) in addition to standard care (SC) in large-vessel-occlusion stroke for patients aged 50 to 100 years in the United States. Materials and Methods A decision-analytic Markov model was used to estimate direct and indirect lifetime costs and quality-adjusted life years (QALYs). Age-dependent input parameters were obtained from the literature. Deterministic and probabilistic sensitivity analysis for age at index stroke were used. The willingness-to-pay (WTP) was set to thresholds of $50 000, $100 000, and $150 000 per QALY. The study applied a U.S. setting for health care and societal perspectives. Incremental costs and effectiveness were derived from deterministic and probabilistic sensitivity analysis. Acceptability rates at different WTP thresholds were determined. Results EVT+SC was the dominant strategy in patients aged 50 to 79 years. The highest incremental effectiveness (2.61 QALYs) and cost-savings (health care perspective, $99 555; societal perspective, $146 385) were obtained in 50-year-old patients. In octogenarians (80-89 years), EVT+SC led to incremental QALYs at incremental costs with acceptability rates of more than 85%, more than 99%, and more than 99% at a WTP of $50 000, $100 000, and $150 000 per QALY, respectively. In nonagenarians (90-99 years), acceptability rates at a WTP of $50 000 per QALY dropped but stayed higher than 85% and higher than 95% at thresholds of $100 000 and $150 000 per QALY. Conclusion Using contemporary willingness-to-pay thresholds in the United States, endovascular therapy in addition to standard care reduces lifetime costs for patients up to 79 years of age and is cost-effective for patients aged 80 to 100 years.

[Assessment of Body-Related Avoidance Behaviour: Validation of the German Version of the Body Image Avoidance Questionnaire (BIAQ) in Adolescents with Anorexia and Bulimia Nervosa and Healthy Controls]. / Körperbezogenes Vermeidungsverhalten: Validierung des deutschsprachigen Body Image Avoidance Questionnaire (BIAQ) an Jugendlichen mit Anorexia und Bulimia Nervosa sowie einer gesunden Kontrollgruppe.

Body image avoidance is conceptualised as a behavioural manifestation of body image disturbance, and describes efforts to avoid confrontation with one's own body. While studies have provided hints that body image avoidance in adulthood contributes to the development and maintenance of eating disorders, so far, there are no corresponding findings for adolescence. The Body Image Avoidance Questionnaire (BIAQ) is the most widely used international questionnaire for measuring body-related avoidance behaviour. As its German version has only been validated in an adult sample, the aim of the present study is to statistically test the questionnaire in adolescents with eating disorders. In total, N=127 female adolescents, including n=57 with Anorexia Nervosa, n=24 with Bulimia Nervosa, and n=46 healthy controls, answered the BIAQ as well as various other instruments for assessing body image disturbance and eating disorder symptoms. The factor structure assumed for the original English version, comprising the higher-order factor "body-related avoidance behaviour" and the 4 subfactors "clothing", "social activities", "eating restraint" and "grooming and weighing", was confirmed by a confirmatory factor analysis. With the exception of the scale "grooming and weighing", all scales showed mostly acceptable internal consistencies, test-retest reliability, differential validity and construct validity. Due to their satisfying psychometric properties, the use of the BIAQ scales "clothing", "social activities" and "eating restraint" can be recommended in research and practice for adolescence.

Improving Care Transitions Management: Examining the Role of Accountable Care Organization Participation and Expanded Electronic Health Record Functionality.

OBJECTIVE: Examine the extent to which physician organization participation in an accountable care organization (ACO) and electronic health record (EHR) functionality are associated with greater adoption of care transition management (CTM) processes. DATA SOURCES/STUDY SETTING: A total of 1,398 physician organizations from the third National Study of Physician Organization survey (NSPO3), a nationally representative sample of medical practices in the United States (January 2012-May 2013). STUDY DESIGN: We used data from the third National Study of Physician Organization survey (NSPO3) to assess medical practice characteristics, including CTM processes, ACO participation, EHR functionality, practice type, organization size, ownership, public reporting, and pay-for-performance participation. DATA COLLECTION/EXTRACTION METHODS: Multivariate linear regression models estimated the extent to which ACO participation and EHR functionality were associated with greater CTM capabilities, controlling for practice size, ownership, public reporting, and pay-for-performance participation. PRINCIPAL FINDINGS: Approximately half (52.4 percent) of medical practices had a formal program for managing care transitions in place. In adjusted analyses, ACO participation (p < .001) and EHR functionality (p < .001) were independently associated with greater use of CTM processes among medical practices. CONCLUSIONS: The growth of ACOs and similar provider risk-bearing arrangements across the country may improve the management of care transitions by physician organizations.

[Training background, everyday practice, and training needs of group therapists working in inpatient psychotherapy - Results of a survey]. / Ausbildungshintergrund, Alltagspraxis und Weiterbildungsbedarf von Gruppenpsychotherapeuten in der stationären Psychotherapie - Ergebnisse einer Umfrage.

OBJECTIVES: A survey serves to clarify whether psychotherapists working in inpatient and day treatment psychotherapeutic hospitals feel sufficiently trained as group therapists and what their specific training needs are. METHODS: The survey queried 175 therapists from different hospitals and professions who perform group psychotherapy in their hospital. The questionnaire focussed on training experiences, everyday group practice, and training needs. RESULTS: As expected, only some of the therapists had completed training as group therapist. The therapists are faced with a wide variety of group formats and patients in their everyday work and reveal a broad spectrum of training needs. CONCLUSIONS: The survey, although not entirely representative, indicates general and specific needs of group therapists within psychotherapeutic hospitals and underlines the role of training and therapist experience in reducing uneasiness toward group psychotherapy.

Universal MRSA nasal surveillance: characterization of outcomes at a tertiary care center and implications for infection control.

BACKGROUND: Recognition of methicillin-resistant Staphylococcus aureus (MRSA) nasal carriage by active surveillance cultures has been widely debated. Our institution implemented universal nasal screening by polymerase chain reaction (PCR) for MRSA and isolation of screen positive patients in December 2007. Here we present data about the correlation between screen positivity and subsequent development of infection and the impact of isolation on surgical site infection rates. METHODS: This was a retrospective, observational study from January 1, 2008, through June 30, 2008, on all inpatient admissions with a nasal MRSA PCR screen. Genotype of 15 MRSA blood isolates was determined utilizing the Diversilab® (bioMérieux, Hazelwood, MO) system. A phenotypic rule was deduced and utilized for analyzing all MRSA clinical isolates. RESULTS: 5375 patients were screened at ≤48 hours following admission. 581 MRSA positive nasal carriers (10.80%) were identified. 496 (85.3%) were asymptomatic MRSA nasal carriers. There were a total of 158 MRSA clinical infections. 85 (14.6%) MRSA nasal carriers had clinical infection. Of the 4794 (89.1%) non-nasally colonized patients, 73 (1.5%) had MRSA clinical infection. MRSA surgical site infection rate remained unchanged during the intervention period. Phenotypic predictive rule inferred 59.8% community-acquired MRSA (CA-MRSA) infections and 40% hospital-acquired MRSA (HA-MRSA) infections. CONCLUSIONS: Our study showed a positive correlation between having a nasal screen positivity and subsequent development of infection. Isolation of MRSA screen positive patients alone as an intervention did not reduce the surgical site infection rates. Since most of our isolates are CA-MRSA, our institution is implementing several new interventions to further reduce the incidence of HA-MRSA conditions.

Impact of endograft design and product line on the device cost of endovascular aneurysm repair.

OBJECTIVE: Device cost is a substantial component of the overall cost of endovascular abdominal aneurysm repair (EVAR), and the four commercially available devices differ significantly in the cost of their basic configuration. This study examined the impact of three different endografts and their product lines on the overall cost of repair. METHODS: Implant records of 467 EVAR procedures performed during 2000 through 2006 were reviewed. The three devices used were the AneuRx in 178 (38.1%; Medtronic, Santa Rosa, Ca), the Excluder in 123 (26.3%; W. L. Gore & Associates, Flagstaff, Ariz), and the Zenith in 166 (35.5%; the Cook Zenith (Bloomington, Ind). The Powerlink device (Endologix, Irvine, Calif) was not studied. The specific device implanted was determined by its commercial availability at the time of repair, patient anatomy, and surgeon preference. Retail list prices were used for all calculations, and only devices used during the original repair were used for analysis. RESULTS: The device cost of the most basic configuration for repair (ie, 2 pieces for AneuRx and Excluder, 3 pieces for Zenith) differed by $3022 between the most expensive (Zenith) to the least expensive (AneuRx). However, the AneuRx system required the most number of extensions (1.90 +/- 1.25 per case; range, 0-7), whereas the Zenith required the fewest (0.21 +/- 0.51 per case; range, 0-3). When the costs of the extensions were added, the overall mean device costs per case were similar. CONCLUSION: The initial cost advantage of the AneuRx and Excluder endograft systems were offset by the more frequent need for proximal and distal extensions. The minimum device cost of a basic repair should not factor into the decision to select one specific device over another because additional devices may be required depending on the design and construction of the endograft system and the accuracy and reliability of their deployment mechanisms.