Value-Based Care for Chest Physicians.

Value-based care aims to improve the health outcomes of patients, eliminate waste and unwarranted clinical variation, and reduce the total cost of care. Professional medical societies have put forward guidelines to raise awareness on unproven practice patterns (Choosing Wisely Campaign), and payers have sought to replace the traditional fee-for-service payment models with value-based contracts that share financial gains or losses based on achieving high-quality outcomes and lowering the cost of care. Regardless of whether their practices are engaged in value-based arrangements, chest physicians should seek understanding of these principles, participate in designing and implementing practical and impactful high-value initiatives in their practices, and have a national voice on the path forward.

Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis.

This guideline is a revision of the clinical practice guideline, "Diagnosis and Management of Bronchiolitis," published by the American Academy of Pediatrics in 2006. The guideline applies to children from 1 through 23 months of age. Other exclusions are noted. Each key action statement indicates level of evidence, benefit-harm relationship, and level of recommendation. Key action statements are as follows:

Monitoring of nonsteroidal immunosuppressive drugs in patients with lung disease and lung transplant recipients: American College of Chest Physicians evidence-based clinical practice guidelines.

OBJECTIVES: Immunosuppressive pharmacologic agents prescribed to patients with diffuse interstitial and inflammatory lung disease and lung transplant recipients are associated with potential risks for adverse reactions. Strategies for minimizing such risks include administering these drugs according to established, safe protocols; monitoring to detect manifestations of toxicity; and patient education. Hence, an evidence-based guideline for physicians can improve safety and optimize the likelihood of a successful outcome. To maximize the likelihood that these agents will be used safely, the American College of Chest Physicians established a committee to examine the clinical evidence for the administration and monitoring of immunosuppressive drugs (with the exception of corticosteroids) to identify associated toxicities associated with each drug and appropriate protocols for monitoring these agents. METHODS: Committee members developed and refined a series of questions about toxicities of immunosuppressives and current approaches to administration and monitoring. A systematic review was carried out by the American College of Chest Physicians. Committee members were supplied with this information and created this evidence-based guideline. CONCLUSIONS: It is hoped that these guidelines will improve patient safety when immunosuppressive drugs are given to lung transplant recipients and to patients with diffuse interstitial lung disease.

How do adolescents access health information? And do they ask their physicians?

OBJECTIVE: To improve understanding about how high school students use electronic tools to obtain health information and how this information affects their behavior. DESIGN/METHODS: Using a cross-sectional design, we administered an anonymous survey to high school students in grades 9 through 12 at a single private Catholic high school, inquiring about their use of electronic tools to obtain health information, topics of interest, sources used to obtain information, and modifications in their behavior based on that information. Descriptive statistics and multivariate analysis of variance were used to compare trends across grade levels. RESULTS: Of 705 students enrolled, 24.7% were either absent or chose not to participate in the survey. Of the remaining 531 students, 497 completed the surveys, for a response rate of 70.5% (497 of 705) and a participation rate of 93.6% (497 of 531). All students were comfortable using the Internet, and >90% used it at home and in school. Access to broadband applications averaged 95% at home and 80% at school. A significant proportion (0.66; p < 0.0001) of students reported that they trusted the information found online, and 22% (not significant) modified their behavior on the basis of the information they found. Forty-two percent searched for general health information, and 43% investigated specific medical conditions or disease states. Topics related to skin were researched significantly more than nutrition, birth control, and sexually transmitted diseases. Although a significant number of students (p < 0.05) reported conducting e-mail conversations related to health topics with their teachers, <5% had e-mail communications with physicians. CONCLUSIONS: These data indicate that most high school students used the Internet and broadband applications at school and at home as resources for health care information. A significant number of students trusted the online information, and at nearly one-quarter subsequently modified their behavior. Students conducted e-mail conversations with teachers about health-related topics, but few students used this tool to communicate with their physicians. This information raises questions about design and implementation of strategies to provide adolescents access to appropriate health care information, including that provided by physicians.

The vexing problem of guidelines and conflict of interest: a potential solution.

Issues of financial and intellectual conflict of interest in clinical practice guidelines have raised increasing concern. Professional organizations have responded by more rigorous regulation of conflict of interest. Nevertheless, tension remains between the competing goals of optimizing guideline quality by using the experience and insight of experts and ensuring that financial and intellectual conflicts of interest do not influence recommendations. The executive committee of the American College of Chest Physicians' Antithrombotic Guidelines has developed a strategy comprising 3 innovative aspects to address this tension: First, place equal emphasis on intellectual and financial conflicts and provide explicit criteria for both; second, a methodologist without important conflicts of interest should have primary responsibility for each chapter; and third, experts with important financial or intellectual conflicts of interest can collect and interpret evidence, but only panel members without important conflicts can be involved in developing the recommendation for a specific question. These strategies may help to achieve the benefits of expert input without conflicts of interest influencing recommendations.

An official American thoracic society statement: position statement on ATS activities for the promotion of respiratory and sleep/wake health and the care of the critically ill in the United States.

BACKGROUND: The 1997 American Thoracic Society (ATS) statement "A Framework for Health Care Policy in the United States" outlined core principles for the Society's activities in the public health arena. In the succeeding 10 years, profound changes have taken place in the United States health care environment. In addition, the 2005 publication of the Society's Vision highlighted some differences between the original Statement and our current priorities. Therefore, the Health Policy Committee embarked on a re-analysis and re-statement of the Society's attitudes and strategies with respect to health and public policy. This Statement reflects the findings of the Committee. PURPOSE: To outline the key aspects of an internal ATS strategy for the promotion of respiratory and sleep/wake health and the care of the critically ill in the United States. METHODS: Committee discussion and consensus-building occurred both before and after individual members performed literature searches and drafted sections of the document. Comments were solicited on the draft document from ATS committee and assembly chairs and the Executive Committee, resulting in substantive revisions of the final document. RESULTS: Specific strategies are suggested for the ATS in the arenas of research, training and education, patient care, and advocacy so as to enhance the delivery of health care in the fields of respiratory medicine, sleep medicine, and critical care. CONCLUSIONS: The American Thoracic Society's Mission, Core Principles, and Vision provide clear guidance for the formulation of specific strategies that will serve to promote improved respiratory health and care of the critically ill in the United States.

Flexible interlocked nailing of pediatric femoral fractures: experience with a new flexible interlocking intramedullary nail compared with other fixation procedures.

BACKGROUND: The optimal treatment of femoral shaft fractures in older children and adolescents remains controversial. We hypothesized that fixation with a flexible interlocking intramedullary nail (FIIN) reduces perioperative complications and improves outcomes, including leg-length discrepancy, time to healing, and time to weight bearing compared with other fixation procedures (OFPs) including standard elastic nail implants. METHODS: Using a retrospective cohort study design, we reviewed medical records and radiographs of children, 7 to 18 years of age, with femoral shaft fractures requiring open treatment between July 1, 1998, and June 30, 2003. Patients selected for the study had unilateral fracture sites proximal to the supracondylar region and distal to the lesser trochanter, presence of open femoral growth plates, and open surgical treatment. Analyses compared inpatient measures and patient outcomes between FIIN and OFP groups. RESULTS: Of the 160 patients eligible for inclusion, 23 were lost to follow-up. The remaining 137 patients had a mean follow-up of 396.3 days (SD, 320.4 days), with 58 receiving FIIN fixation and 79 OFP. Although the difference was not statistically significant, complications occurred in 19.0% of patients in the FIIN group and 30.4% in the OFP group. Trochanteric heterotopic ossification was the most common complication (13.8%) noted in the FIIN group and superficial infection (12.8%) in the OFP group. The FIIN group experienced less blood loss (P = 0.042) and shorter time to weight bearing (P = 0.001) without disturbance of proximal femoral geometry or avascular necrosis of the femoral head. In children weighing less than 45.5 kg (100 lb), complications were less common with FIIN (3.6%) compared with OFP (24.4%). A subgroup of patients less than 45.5 kg (100 lb) with standard elastic nail implants (n = 24) had 8.1 times the complications of patients with FIIN. CONCLUSIONS: Older children and adolescents with femoral shaft fractures treated with a FIIN showed improved outcomes compared with patients treated with OFP. LEVEL OF EVIDENCE: Level III, therapeutic study.

Association between practice patterns and body mass index percentile in infants and young children with cystic fibrosis.

BACKGROUND: Few guidelines focus on the preventive and maintenance care of infants with cystic fibrosis (CF). We explored how practice variability at accredited CF centers affected nutritional outcomes. METHODS: A retrospective cohort study using Cystic Fibrosis Foundation registry data (1993-2004) from three CF centers compared the initial management with respiratory, antimicrobial, and nutritional agents in infants. Further, we examined the association between dornase alpha use prior to two years of age and BMI percentile over time accounting for several possible factors including gender, race, CF center, presentation, age at diagnosis, sweat value, F508del status, first Pseudomonas aeruginosa infection age, second-year weight percentile, supplemental feedings use, and pancreatic enzymes use. RESULTS: Patient characteristics and prescribed therapies were similar at all sites for 165 patients who met inclusion criteria. However, one CF center prescribed dornase alpha significantly more frequently, 82% vs. 10% (p<0.001), and supplemental feeds significantly less frequently, 56% vs. 78% (p=0.04). Dornase alpha prescription prior to age two was associated with a 10-percentile increase in BMI through age six compared to infants not prescribed dornase alpha. CONCLUSIONS: Treating infants less than two years old with dornase alpha may improve nutritional outcome through age six.