Perspective on patient payment.

Concerns over patient collections, a common cause of distress for practice administrators, can be attributed to an increase in high-deductible health plans, according to MGMA's Practice ctives on Patient Payments research.

Analysis of the long-term effects of drug-eluting stents on coronary arterial wall morphology as assessed by virtual histology intravascular ultrasound.

BACKGROUND: Animal models show impairment of arterial healing after drug-eluting stents (DES) compared with bare-metal stents (BMS). Virtual histology intravascular ultrasound (VH-IVUS) offers an opportunity to assess lesion morphology in vivo. METHODS: We used VH-IVUS in 80 patients to assess long-term (median = 10 months) native artery vascular responses after 76 implantations of DES compared with 32 BMS. The presence of "necrotic core abutting the lumen" was evaluated at baseline and follow-up. RESULTS: At baseline, necrotic core abutting the lumen through the stent struts was observed in 76% of DES and 75% of BMS. Although the percentage of necrotic core within the plaque behind the stents did not change during follow-up in DES (23% [18%, 28%] to 22% [17%, 27%], P = .57) or BMS (22% [19%, 27%] to 20% [12%, 26%], P = .29), necrotic core abutting the lumen through the stent struts decreased more in BMS (75% to 19%, P < .001) than DES (76% to 61%, P = .036) because of the lack of an overlying, protective neointima in DES-treated lesions. Furthermore, within the adjacent reference segments, the incidence of necrotic core abutting the lumen decreased in BMS-treated lesions (proximal 23% to 0%, P = .023; distal 21% to 0%, P = .023), but not in DES (proximal 22% to 17%, P = .48; distal 23% to 21%, P = .82). CONCLUSIONS: Serial VH-IVUS analysis of DES-treated lesions showed a greater frequency of unstable lesion morphometry at follow-up compared with BMS. The apparent mechanism was a suppression of the protective neointimal hyperplasia layer coupled with a lack of vulnerable plaque resolution at reference segments in DES compared with BMS.

Medical practice today: what you have to say. Your top challenges: results from MGMA's second annual member opinion survey.

Results from our annual questionnaire asking about the challenges you face in your job and career put the sagging economy at the forefront. But you emphasized that you also must contend with myriad other issues--and offer commentary on topics ranging from physician recruitment to ethics to quality in health care.

Intravascular ultrasound measures of coronary atherosclerosis are associated with the Framingham risk score: an analysis from a global IVUS registry.

AIMS: In addition to an adjunctive imaging platform during coronary angiography, intravascular ultrasound (IVUS) with Virtual Histology (VH) is increasingly being used to quantify coronary atherosclerosis. The relationship between VH-IVUS measures of coronary atherosclerosis and traditional cardiovascular risk factors has not been completely described. The objective of this study was to determine if an association exists between VH-IVUS measures of coronary atherosclerosis and the Framingham risk score in a prospective, multinational registry. METHODS AND RESULTS: Patients enrolled from 2004-2006 at 37 multinational centres in the prospective VHIVUS Global Registry were analysed. All subjects underwent diagnostic coronary angiography followed by IVUS. A Framingham risk score (FRS) was calculated for each subject, then stratified into three exclusive estimates (<10%, 10-19%, or >or= 20%) for future coronary heart disease (CHD) event risk over 10 years. Among 531 patients, plaque volume of the most diseased 10 mm segment increased with increasing FRS (P=0.006, adjusted for multiple comparisons). Patients with higher FRS estimates of CHD risk had a higher proportion of plaque classified as thin cap fibroatheroma compared with patients in the middle and lower risk score categories (21.4% vs 15.2% and 11.3%, respectively, P=0.008, adjusted for multiple comparisons). CONCLUSIONS: Using data from a large, multinational VH-IVUS registry we describe an association between the Framingham risk score and VH-IVUS measures of atherosclerosis within the most diseased 10 mm segment, namely plaque volume and the proportion of thin cap fibroatheroma.

Medical practice today. What members have to say. Rising operating costs + declining reimbursement + EHR implementation = your top challenges.

We invited you to share your thoughts on the practice and career challenges that confront you today. You responded emphatically to our questionnaire, and two issues--maintaining physician compensation as reimbursement declines, and operating costs that are escalating faster than revenues--essentially tied for first place. The threat of further cuts in Medicare reimbursement makes these dilemmas even more acute. Another issue--implementing an electronic health record (EHR)--ranked third as a hot topic. See the poll data and read the comments and complaints, insights and observations in this special feature all about you and your profession.

Adoption and perceptions of electronic health record systems by ophthalmologists: an American Academy of Ophthalmology survey.

OBJECTIVE: To assess the current state of electronic health record (EHR) use by ophthalmologists, including adoption rate and user satisfaction. DESIGN: Population-based, cross-sectional study. PARTICIPANTS: A total of 592 members of the American Academy of Ophthalmology (AAO) participated. METHODS: A total of 3796 AAO members were randomly selected on the basis of geography and solicited to participate in a study of EHR adoption. Among those solicited, 392 members completed a web-based version of the survey and 200 members completed a telephone-based version. The survey included sections assessing the current level of EHR adoption, the value of various EHR features, the practice demographics, and, for participants with an EHR, the details of their system. Responses were collected and analyzed using univariate statistical tests. MAIN OUTCOME MEASURES: Current adoption rate of EHRs, user satisfaction with EHRs, and importance of various EHR features to both users and nonusers. RESULTS: Overall, 12% of the practices surveyed had already implemented an EHR, 7% were in the process of doing so, and another 10% had plans to do so within 12 months. Both EHR users and nonusers rated the same EHR features as having the most value to their practices, and the 2 groups rated options for simplifying the EHR selection process similarly. Among those with an EHR in their practice, 69% were satisfied or extremely satisfied with their system, 64% reported increased or stable overall productivity, 51% reported decreased or stable overall costs, and 76% would recommend an EHR to a fellow ophthalmologist. CONCLUSIONS: The adoption rate of EHRs by ophthalmology practices is low but comparable to that seen in other specialties. The satisfaction of those ophthalmologists already using an EHR is high. Because EHRs are part of the rapidly changing health information technology marketplace, the AAO Medical Information Technology Committee is planning to update these results on a regular basis.

Systemic nanoparticle paclitaxel (nab-paclitaxel) for in-stent restenosis I (SNAPIST-I): a first-in-human safety and dose-finding study.

BACKGROUND: Paclitaxel-eluting stents inhibit restenosis; however, this technology has drawbacks (e.g., stent thrombosis, requirement for long-term antiplatelet therapy, and cost--particularly for patients with multivessel disease). Systemic treatment with a novel 130-nm, albumin-bound particle form of paclitaxel (nab-paclitaxel) has been shown to reduce restenosis in animals. HYPOTHESIS: This study was designed to establish the safety and optimal dose of systemic nab-paclitaxel for reducing in-stent restenosis in humans. If well tolerated, systemic nab-paclitaxel may be used with any available bare-metal stent and at potentially lower cost than drug-eluting stents. METHODS: Patients received nab-paclitaxel 10, 30, 70, or 100 mg/m(2) intravenously after stenting of a single de novo lesion >or= 3 mm in diameter. Study endpoints included safety and major adverse cardiac events (MACE) at 2 and 6 months. RESULTS: Data were obtained for all 23 enrolled patients (mean age 66 +/- 10 years, 74% men, 26% with diabetes). No significant adverse events (AE) were attributable to nab-paclitaxel at 10 or 30 mg/m(2). Moderate neutropenia, moderate sensory neuropathy, and mild to moderate, reversible alopecia occurred only at doses of 70 and 100 mg/m(2); therefore, doses of 70 mg/m(2) or higher were considered unacceptable in this patient population. No MACE were reported at 2 months. At 6 months, 4 target lesion revascularizations (TLR) for restenoses were reported (2 each in the 10- and 100-mg/m(2)-dose groups). CONCLUSIONS: Systemic nab-paclitaxel was well tolerated at doses below 70 mg/m(2) in this group of patients; no unexpected AE were noted. Additional studies are under way to explore intravenous and intracoronary administration of nab-paclitaxel.

Clinical and angiographic outcome in the laser angioplasty for restenotic stents (LARS) multicenter registry

In-stent restenosis (ISR) when treated with balloon angioplasty (PTCA) alone, has a angiogrphic recurrence rate of 30%-85%. Ablating the hypertrophic neointimal tissue prior to PTCA is an attractive alternative, yet the late outcomes of such treatment have not been fully determined. This multicenter case control study assessed the angiographic and clinical outcomes of 157 consecutive procedures in 146 patients with ISR at nine institutions treated with either the PTCA alone (n=64)o excrimer laser assisted coronary angioplasty (ELCA, n=93) for ISR. Demographics were similar except more unstable angina at presentation in ELCA-treated patients (74.5% vs 63.5$; P=0.141). Lesions selected for ELCA were longer (16.8 +_ 11.2mm vs. 11.2+_ 8.6 mm;P < 0.001), more complex (ACC/AHA type C:35.1% vs. 13.6%;P<0.00001)...

Reestenose de stents coronarianos: resultados imediatos e tardios do tratamento com excimer laser / In-stent restenosis: acute and long-term outcomes after excimer laser coronary angioplasty

Objective - With the increased use of intracoronary stents, in-stent restenosis has become a clinically significant drawback in invasive cardiology. We retrospectively assessed the short-and long-term outcomes after excimer laser coronary angioplasty of in-stent restenosis. Methods - Twenty-five patients with 33 incidents of in-stent restenosis treated with excimer laser coronary angioplasty (ELCA) were analyzed. Sixty-six percent were males, mean age of 73+ 11 years, and 83 per cent were functional class III-IV (NYHA). ELCA was performed using 23 concentric and 10 eccentric catheters with a diameter of 1.6-2.2 mm, followed by balloon angioplasty (PTCA) and untrasound monitoring. The procedure was performed in the following vessels: left anterior descending artery, 10; left circunflex artery, 8; right coronary artery, 6; left main coronary artery; 2 and venous bypass graft, 7. Results - The ELCA was successful in 71 per cent of the cases, and PTCA was 100 per cent successful. The diameter of the treated vessels was 3.44+0.5 mm; the minimal luminal diameter (MLD) increased from 0.30mm pre-ELCA to 1,97mm post-ELCA, and to 2.94mm post-PTA (p<0.001). The percent stenosis was reduced from 91.4+9.5 per cent before ELCA to 42.3+14.9 per cent after ELCA and to 14.6+9.3 per cent after PTCA (P<0.001). Seventeen (68 per cent) patients were asymptomatic at 6 months and 15 (60 per cent) at 1 year. New restenosis rates were 8/33 (24.2 per cent) at 6 months and 9/33 (27.3 per cent) at 12 months. Conclusion - ELCA is safe effective for the treatment of in-stent restenosis. In the present sample, a slight increase in new restenotic lesions between 6 and 12 months was found.