Impact of Variability in Portal Venous Phase Acquisition Timing in Tumor Density Measurement and Treatment Response Assessment: Metastatic Colorectal Cancer as a Paradigm.

PURPOSE: New response patterns to anticancer drugs have led tumor size-based response criteria to shift to also include density measurements. Choi criteria, for instance, categorize antiangiogenic therapy response as a decrease in tumor density > 15% at the portal venous phase (PVP). We studied the effect that PVP timing has on measurement of the density of liver metastases (LM) from colorectal cancer (CRC). METHODS: Pretreatment PVP computed tomography images from 291 patients with LM-CRC from the CRYSTAL trial (Cetuximab Combined With Irinotecan in First-Line Therapy for Metastatic Colorectal Cancer; ClinicalTrials.gov identifier: NCT00154102) were included. Four radiologists independently scored the scans' timing according to a three-point scoring system: early, optimal, late PVP. Using this, we developed, by machine learning, a proprietary computer-aided quality-control algorithm to grade PVP timing. The reference standard was a computer-refined consensus. For each patient, we contoured target liver lesions and calculated their mean density. RESULTS: Contrast-product administration data were not recorded in the digital imaging and communications in medicine headers for injection volume (94%), type (93%), and route (76%). The PVP timing was early, optimal, and late in 52, 194, and 45 patients, respectively. The mean (95% CI) accuracy of the radiologists for detection of optimal PVP timing was 81.7% (78.3 to 85.2) and was outperformed by the 88.6% (84.8 to 92.4) computer accuracy. The mean ± standard deviation of LM-CRC density was 68 ± 15 Hounsfield units (HU) overall and 59.5 ± 14.9 HU, 71.4 ± 14.1 HU, 62.4 ± 12.5 HU at early, optimal, and late PVP timing, respectively. LM-CRC density was thus decreased at nonoptimal PVP timing by 14.8%: 16.7% at early PVP ( P < .001) and 12.6% at late PVP ( P < .001). CONCLUSION: Nonoptimal PVP timing should be identified because it significantly decreased tumor density by 14.8%. Our computer-aided quality-control system outperformed the accuracy, reproducibility, and speed of radiologists' visual scoring. PVP-timing scoring could improve the extraction of tumor quantitative imaging biomarkers and the monitoring of anticancer therapy efficacy at the patient and clinical trial levels.

Community-wide intervention to improve the attention-deficit/hyperactivity disorder assessment and treatment practices of community physicians.

OBJECTIVES: The goals were to implement and to test a quality-improvement intervention aimed at improving community-based primary care providers' adherence to the American Academy of Pediatrics, evidence-based diagnostic and treatment guidelines for attention-deficit/hyperactivity disorder. METHODS: Nineteen practices (with 84 primary care providers) from a large urban community were trained by using quality-improvement methods with some academic detailing. Pretraining and posttraining adherence to evidence-based practices was assessed through review of patient charts. RESULTS: Preintervention rates of guideline usage were uniformly low. After the intervention, primary care providers showed substantial improvement in their use of the guidelines for the assessment and treatment of elementary school-aged patients with newly diagnosed attention-deficit/hyperactivity disorder. Use of parent and teacher assessment rating scales increased from levels of 52% to 55% to levels of nearly 100%. Systematic monitoring of responses to medication improved from a baseline level of 9% to 40%. CONCLUSIONS: Quality-improvement interventions such as the one used in this study seem quite effective in improving primary care providers' practices at offices that express interest in improving the quality of care for attention-deficit/hyperactivity disorder. The design of the intervention, problems associated with improving and sustaining treatment monitoring, and issues related to generalizability of the intervention model are discussed.

Implementing an evidence-based acute gastroenteritis guideline at a children's hospital.

BACKGROUND: Guidelines for preventing and treating acute gastroenteritis (AGE) have generally not been incorporated into medical practice. An evidence-based clinical practice guideline was adapted from national guidelines to meet the practice styles characterizing care in southwestern Ohio and implemented at the Children's Hospital Medical Center (Cincinnati). Its efficacy was assessed in terms of emergency department (ED) encounters and admissions, mean and total hospital costs, and mean length of hospitalization. METHODS: Comparisons were made between patients seen during peak gastroenteritis months (December-May) before (fiscal year [FYs] 1994-1997) and after (FYs 1998 and 1999) guideline implementation. Data were extracted from hospital charts, clinical databases, and billing records. RESULTS: Following implementation, mean yearly ED encounters for AGE decreased 22% and mean yearly admissions decreased 33%. The percentage of admitted children with minor illness decreased (p = 0.002). Mean length of stay decreased 21% for children with minor illness (p = 0.0001) and 5% for others. Hydration status was noted in only 15% of ED charts examined but increased to 63% in FY 1998 and 86% in FY 1999 (p < 0.001). The proportion of admitted patients who advanced to a regular diet by discharge increased from 4.9% (FY 1997) to 23% (FY 1998) and 76% (FY 1999; p < 0.0001). Total inpatient days/year decreased by 43%. Mean hospital costs did not change significantly. DISCUSSION: Following implementation, fewer patients with AGE were seen in the ED and fewer were admitted to the hospital for care. Hospital stays were shorter, and children were more likely to resume their diets before discharge.