Association of Progestogens and Venous Thromboembolism Among Women of Reproductive Age.

OBJECTIVE: To evaluate associations between use of seven progestogens and incident acute venous thromboembolism (VTE) among women of reproductive age. METHODS: This nested matched case-control study identified women aged 15-49 years from January 1, 2010, through October 8, 2018, in the IBM MarketScan databases, a nationwide sample of private insurance claims in the United States. After exclusions, 21,405 women with incident acute VTE (case group), identified by diagnosis codes, were matched 1:5 by year of birth and index date through risk set sampling to 107,025 women without prior VTE (control group). From lowest to highest systemic dose based on a modified hierarchy, progestogens studied were levonorgestrel-releasing intrauterine device (LNG-IUD), oral norethindrone, etonogestrel implant, oral progesterone, oral medroxyprogesterone acetate, oral norethindrone acetate, and depot medroxyprogesterone acetate (DMPA). Conditional logistic regression models adjusted for 16 VTE risk factors were used to estimate odds ratios and 99% CIs for incident acute VTE associated with current progestogen use compared with nonuse. The primary analysis treated each progestogen as a binary exposure. Dose, which varied for oral formulations, and chronicity were explored separately. Significance was set at P <.01 to allow for multiple comparisons. RESULTS: Current use of higher-dose progestogens was significantly associated with increased odds of VTE compared with nonuse (oral norethindrone acetate: adjusted odds ratio [aOR] 3.00, 99% CI 1.96-4.59; DMPA: aOR 2.37, 99% CI 1.95-2.88; and oral medroxyprogesterone acetate: aOR 1.98, 99% CI 1.41-2.80). Current use of other progestogens was not significantly different from nonuse (LNG-IUD, etonogestrel implant, and oral progesterone) or had reduced odds of VTE (oral norethindrone). Sensitivity analyses that assessed misclassification bias supported the primary findings. CONCLUSION: Among reproductive-aged women using one of seven progestogens, only use of norethindrone acetate and medroxyprogesterone acetate-considered higher-dose progestogens-was significantly associated with increased odds of incident acute VTE. The roles of progestogen type, dose, and indication for use warrant further study.

Impact of diabetes group visits on patient clinical and self-reported outcomes in community health centers.

BACKGROUND: Diabetes group visits (GVs) are a promising way to deliver high quality care but have been understudied in community health centers (CHCs), across multiple sites, or with a focus on patient-centered outcomes. METHODS: We trained staff and healthcare providers from six CHCs across five Midwestern states to implement a 6-month GV program at their sites. We assessed the impact of diabetes GVs on patient clinical and self-reported outcomes and processes of care compared to patients receiving usual care at these sites during the same period using a prospective controlled study design. RESULTS: CHCs enrolled 51 adult patients with diabetes with glycosylated hemoglobin (A1C) ≥ 8% for the GV intervention and conducted chart review of 72 patients receiving usual care. We analyzed A1C at baseline, 6, and 12 months, low-density lipoproteins (LDL), blood pressure, and patient-reported outcomes. GV patients had a larger decrease in A1C from baseline to 6 months (-1.04%, 95% CI: -1.64, -0.44) and 12 months (-1.76, 95% CI: -2.44, -1.07) compared to usual care; there was no change in blood pressure or LDL. GV patients had higher odds of receiving a flu vaccination, foot exam, eye exam, and lipid panel in the past year compared to usual care but not a dental exam, urine microalbumin test, or blood pressure check. For GV patients, diabetes distress decreased, diabetes-related quality of life improved, and self-reported frequency of healthy eating and checking blood sugar increased from baseline to 6 months, but there was no change in exercise or medication adherence. CONCLUSIONS: A diabetes GV intervention improved blood glucose levels, self-care behaviors, diabetes distress, and processes of care among adults with elevated A1Cs compared to patients receiving usual care. Future studies are needed to assess the sustainability of clinical improvements and costs of the GV model in CHCs.

Moral Elevation, Physician Role Models, and Selected Markers of Professional Identity Formation and Well-Being: A Secondary Analysis from Two National Surveys.

OBJECTIVES: Moral elevation is the underlying emotion that arises when witnessing admirable acts, and it is theorized to be the psychological mechanism driving the impact that positive clinical role models have on medical students' professional identity formation (eg, growth in professional virtues, higher sense of meaning, and well-being). This proof-of-concept study explores the development of the Moral Elevation Scale in Medicine by testing the association of moral elevation with various markers of professional identity formation. METHODS: A secondary data analysis of two nationally representative samples of 960 medical students and 2000 physicians was performed. Respondents completed validated measures of moral elevation as well as markers of professional identity formation, including patient-centered virtues (empathic compassion, interpersonal generosity, mindfulness) and measures of well-being (life meaning, life satisfaction, spirituality, burnout). RESULTS: The study obtained adjusted response rates of 56.2% (1047/1863, physician survey) and 48.7% (448/919, student survey). The national estimates for mean moral elevation in medical students and physicians are 4.34/5.00 and 4.22/5.00, respectively. In medical students and physicians, high moral elevation was associated with higher empathic compassion (student odds ratio [OR] 1.30, 95% confidence interval [CI] 1.02-1.67; physician OR 1.22, 95% CI 1.23-1.65) and, similarly, generosity. In addition, higher moral elevation in the physician cohort was associated with greater life meaning (OR 2.03, 95% CI 1.25-3.32) and similarly spirituality. CONCLUSIONS: In medical students and practicing physicians, self-reported experiences of high moral elevation with physician role models were associated with higher self-reported measures of patient-centered virtues, spirituality, and life meaning. Our Moral Elevation Scale in Medicine demonstrates preliminary promise as a measure to assess environmental precursors needed for virtue development in professional identity formation, but further reliability and validity testing of this measure is needed.

Impact of Early Video Capsule Endoscopy on Hospitalization and Post-hospitalization Outcomes: A Propensity Score-Matching Analysis.

INTRODUCTION: Video capsule endoscopy (VCE) has become the accepted evaluation of choice for patients with suspected small bowel bleeding. Our aim was to evaluate the impact of early as compared to delayed inpatient VCE on post-index hospitalization readmission rates. METHODS: We performed a retrospective study using medical claims from the IBM® Marketscan® Commercial Database from January 1, 2004, through September 30, 2018, including adult patients that underwent an inpatient VCE. Early VCE was defined as occurring on days 0, 1, or 2 of the index hospitalizations, whereas delayed VCE was performed on days 3-7. Propensity matching was performed to create an analytic cohort, and outcomes were assessed using logistic regression. RESULTS: Following propensity score matching, 607 patients undergoing early VCE were matched 1:1 with 607 patients undergoing delayed VCE. The median patient age was 65 (IQR: 56-78) years, and 560 (37.9%) of the included patients were female. The mean time to VCE was 1.6 (± 0.6) days for the early VCE group and 4.0 (± 1.2) days from admission for delayed VCE. In unadjusted comparisons, we found no significant difference between early VCE and delayed VCE with respect to 90-day all-cause readmission (18.6% vs. 17.0%, P = 0.5) or 90-day rebleeding risk (10.5% vs. 8.7%, P = 0.331). Patients undergoing an early VCE had a shorter hospital LOS and less total hospitalization charges. CONCLUSION: Early as compared to delayed inpatient VCE was associated with a reduction in index hospitalization resource utilization. No differences were found with respect to reductions in readmissions or rebleeding events.

Restarting Warfarin vs Direct Oral Anticoagulants After Major Gastrointestinal Bleeding and Associated Outcomes in Atrial Fibrillation: A Cohort Study.

BACKGROUND & AIMS: Limited data exist on the management of anticoagulation after hospitalization for gastrointestinal bleeding (GIB) and the risks of recurrent GIB and thromboembolism in patients who are prescribed warfarin vs direct oral anticoagulants (DOACs). The purpose of this study was to assess the risk of recurrent GIB and thromboembolism with resumption of anticoagulation after GIB. METHODS: This was a retrospective analysis of adults with atrial fibrillation prescribed warfarin or DOACs and subsequently hospitalized for GIB. We used claims data from IBM MarketScan Databases from January 2008 through December 2017. Multivariable time-varying regression was used to determine the risks of recurrent GIB and thromboembolism within 6 months of the index hospitalization. RESULTS: There were 2991 patients hospitalized for GIB on anticoagulants (warfarin, n = 1872; rivaroxaban, n = 676; dabigatran, n = 293; and apixaban, n = 250). Of warfarin users, 46% (n = 869) resumed warfarin after discharge compared with 43% (n = 483) of DOAC users who resumed DOACs. In the regression analysis modeling time-varying coefficients for anticoagulant use, warfarin resumption was associated with an increased risk of recurrent GIB (hazard ratio [HR], 2.12; 95% CI, 1.43-3.14; P = .0002) compared with no anticoagulant resumption, whereas there was no association with DOAC resumption and recurrent bleeding (HR, 1.43; 95% CI, 0.81-2.52; P = .22). Rivaroxaban was the only individual DOAC that was associated with recurrent GIB (HR, 2.73; 95% CI, 1.43-5.20; P = .002). Both warfarin (HR, 0.61; 95% CI, 0.39-0.96; P = .033) and DOAC (HR, 0.52; 95% CI, 0.28-0.98; P = .044) resumption as a class was associated with a decreased risk of thromboembolism. CONCLUSIONS: Either warfarin or DOAC resumption after hospitalization for GIB was associated with a decreased risk of thromboembolism, whereas warfarin and rivaroxaban resumption were associated with an increased risk of recurrent GIB.

Persistent Opioid Usage After Urologic Intervention and the Impact of Tramadol.

OBJECTIVE: To determine if patients who receive tramadol are as likely to develop persistent usage compared to other opioids after urologic surgery and procedures. METHODS: We identified adults 18 to 64 years old who underwent a urologic procedure in the years 2014 to 2017 using the Truven MarketScan database and subsequently filled an opioid prescription within two weeks of discharge. Patients were excluded if they had any previous opioid prescriptions in the year before surgery. A multivariate logistic regression model was constructed to estimate influence of type of opioid on discharge and various comorbidities on persistent use to determine if persistent use was related to the choice of discharge opioid. We also compared these rates to a 1:3 comorbidities matched, non-surgical cohort of patients from the general population. RESULTS: Overall, 115,687 patients were included. After 1 year, 14.8% of the urologic surgery cohort had persistent opioid usage compared to 10.8% in the opioid naïve matched non-surgical cohort (OR = 1.37; 95% CI 1.35-1.39). Discharge with tramadol was associated with a higher odd of persistent usage compared to class II opioids controlling for type of urologic surgery, age, gender, and pain related comorbidities (OR = 1.23 95% CI 1.13-1.35). The odds of persistent usage varied slightly by type of urologic procedure, but all were higher than matched non-surgical cohort. CONCLUSION: Patients developed persistent opiate usage after urologic surgery compared to a comorbidity matched non-surgical cohort. In this model, tramadol specifically was associated with higher odds of novel persistent opioid usage compared to other opioids. Urologists should not consider tramadol to be a safer choice with regard to developing persistent usage and consider prospective validation of these results.

Medical Assistant Protocol Improves Disparities in Depression Screening Rates.

INTRODUCTION: Depression is a prevalent condition for which screening rates remain low and disparities in screening exist. This study examines the impacts of a medical assistant screening protocol on the rates of depression screening, overall and by sociodemographic groups, in a primary care setting. METHODS: Between September 2016 and August 2018, a quasi-experimental study of adult primary care visits was conducted at an urban academic clinic to ascertain the change in the rates of completion of the Patient Health Questionnaire-2 after the implementation of a medical assistant protocol (intervention) versus that of physician-only screening (control arm). Analyses were conducted between April 2019 and April 2020 and used interrupted time-series models with generalized estimating equations. RESULTS: A total of 45,157 visits by 21,377 unique patients were included. Overall, screening increased from 18% (physician-only screening) to 57% (medical assistant protocol) (p<0.0001). Screening increased for all measured demographics. With physician screening, depression screening was less likely to occur at visits by women (than at visits by men; OR=0.91, 95% CI=0.85, 0.98) and at visits by Black/African American patients (than at visits by White; OR=0.91, 95% CI=0.84, 0.99). However, with the medical assistant protocol, depression screening was more likely to occur at visits by women (than at visits by men; OR=1.07, 95% CI=1.0002, 1.14) and at visits by Black/African American patients (than at visits by White; OR=1.11, 95% CI=1.02, 1.20). In addition, age-related disparities were mitigated for visits by patients aged 40-64 and ≥65 years (e.g., age ≥65 years: physician, OR=0.66, 95% CI=0.59, 0.73; medical assistant protocol, OR=0.78, 95% CI=0.71, 0.85), compared with visits by patients aged 18-39 years. CONCLUSIONS: Implementation of a medical assistant protocol in a primary care setting may significantly increase depression screening rates while mitigating or removing sociodemographic disparities.

Impact of a medical scribe on clinical efficiency and quality in an academic general internal medicine practice.

BACKGROUND: Scribes have been proposed as an intervention to decrease physician electronic health record (EHR) workload and improve clinical quality. We aimed to assess the impact of a scribe on clinical efficiency and quality in an academic internal medicine practice. METHODS: Six faculty physicians worked with one scribe at an urban academic general internal medicine clinic April through June 2017. Patient visits during the 3 months prior to intervention (baseline, n = 789), unscribed visits during the intervention (concurrent control, n = 605), and scribed visits (n = 579) were included in the study. Clinical efficiency outcomes included time to close encounter, patient time in clinic, and number of visits per clinic session. Quality outcomes included EHR note quality, rates of medication and immunization review, population of patient instructions, reconciliation of outside information, and completion of preventative health recommendations. RESULTS: Median time to close encounter (IQR) was lower for scribed visits [0.4 (4.8) days] compared to baseline and unscribed visits [1.2 (5.9) and 2.9 (5.4) days, both p < 0.001]. Scribed notes were more likely to have a clear history of present illness (HPI) [OR = 7.30 (2.35-22.7), p = 0.001] and sufficient HPI information [OR = 2.21 (1.13-4.35), p = 0.02] compared to unscribed notes. Physicians were more likely to review the medication list during scribed vs. baseline visits [OR = 1.70 (1.22-2.35), p = 0.002]. No differences were found in the number of visits per clinic session, patient time in clinic, completion of preventative health recommendations, or other outcomes. CONCLUSIONS: Working with a scribe in an academic internal medicine practice was associated with more timely documentation.

Febrile Neutropenia Syndromes in Children: Risk Factors and Outcomes of Primary, Prolonged, and Recurrent Fever.

BACKGROUND: The approach to recurrent febrile neutropenia (FN) in children with cancer has not been sufficiently addressed and was cited as a research gap in the International Pediatric Fever and Neutropenia (IPFNP) Guideline 2017. METHODS: Retrospective medical record review for all pediatric cancer patients with a diagnosis of FN was performed. Variables were collected at 2 different time sets (at day 1 and day 4 of presentation). Three FN syndromes have been defined based on the duration and time course of the fever: (1) primary: fever resolved before 96 hours and did not follow with recurrent fever; (2) prolonged fever: episodes failing to defervesce after at least 96 hours of antibacterial therapy; (3) recurrent fever: a new episode of fever >72 hours after resolution of the initial fever when a patient remained neutropenic and on antibiotics or if a fever developed within 1 week after antibiotic discontinuation. These entities were compared with define risk factors and adverse outcomes associated with recurrent fever. RESULTS: A total of 633 FN episodes (FNEs) were identified in 268 patients. Each FNE was classified as primary (n=453, 71.5%), prolonged (n=119, 18.7%), or recurrent (n=61, 9.7%). In multivariable analysis, acute myelogenous leukemia (odds ratio [OR]=4.6, 95% confidence interval [CI]: 2.95-7.24), allogeneic stem cell transplant (SCT) (OR=4.9, 95% CI: 2.61-7.35), absolute lymphocyte count <300/mm3 (OR=3.8, 95% CI: 1.30-5.02), prior neutropenia of ≥10 days, (OR=3.95, 95% CI: 1.70-5.93) and hypotension (OR=3.65, 95% CI: 1.30-5.86) on day 1 of presentation were all associated with an increased risk of recurrent fever when compared with primary fever. In subset analysis for only the high-risk FN group, hypotension (OR=3.2, 95% CI: 1.80-4.96), prior neutropenia ≥10 days (OR=2.55, 95% CI: 1.40-6.22), and absolute lymphocyte count <300/mm3 at presentation (OR=2.6, P=0.03, 95% CI: 2.65-7.12) were associated with an increased risk of recurrent fever when compared with high-risk FN not developing recurrent fever. Allogeneic SCT (OR=5.9, 95% CI: 2.65-7.12) and prior neutropenia ≥10 days (OR=2.11, 95% CI: 1.25-9.32) were significantly associated with recurrent fever when compared with prolonged fever. Invasive fungal disease was a more common etiology with recurrent fever compared with primary and prolonged fever (P=0.001 and 0.01, respectively). Recurrent fever episodes were more likely to be admitted to the pediatric intensive care unit (OR=3, 95% CI: 1.27-6.23) and had a higher 30-day mortality (OR=8, 95% CI: 1.87-71.85) when compared with primary fever. CONCLUSIONS: Knowledge of risk factors for recurrent fever may enable the early detection infection-related complications of this high-risk group, and possible improved approaches to treatment resulting in decreased morbidity and mortality.

Association of Metformin Use With Age-Related Macular Degeneration: A Case-Control Study.

Importance: Age-related macular degeneration (AMD), the leading cause of irreversible blindness in older adults, appears to have no effective preventive measures. The common antidiabetic drug metformin has been shown to have protective outcomes in multiple age-associated diseases and may have the potential to protect against the development of AMD. Objective: To determine whether metformin use is associated with reduced odds of developing AMD. Design, Setting, and Participants: This case-control study of patients from a nationwide health insurance claims database included a population-based sample of patients. Those aged 55 years and older with newly diagnosed AMD from January 2008 to December 2017 were defined as cases and matched with control participants. Data analyses were completed from June 2019 to February 2020. Exposures: Dosage of metformin and exposure to other prescribed medications, as identified from outpatient drug claims. Main Outcomes and Measures: Risk of developing AMD. Results: A total of 312 404 affected individuals were included (181 817 women [58.2%]). After matching, 312 376 control participants were included (172 459 women [55.2%]; age range, 55 to 107 years). The case group had a slightly higher percentage of participants with diabetes (81 262 participants [26.0%]) compared with the control group (79 497 participants [25.5%]). Metformin use was associated with reduced odds of developing AMD (odds ratio [OR], 0.94 [95% CI, 0.92-0.96]). This association was dose dependent, with low to moderate doses of metformin showing the greatest potential benefit (dosages over 2 years: 1-270 g, OR, 0.91 [95% CI, 0.88-0.94]; 271-600 g, OR, 0.90 [95% CI, 0.87-0.93]; 601-1080 g, OR, 0.95 [95% CI, 0.92-0.98]). Doses of more than 1080 g of metformin over 2 years did not have reduced odds of developing AMD. Both the reduction in odds ratio and the dose-dependent response were preserved in a cohort consisting only of patients with diabetes. Metformin use was associated with a decreased OR of AMD in patients with diabetes without coexisting diabetic retinopathy (OR, 0.93 [95% CI, 0.91-0.95]) but was a risk factor in patients with diabetic retinopathy (OR, 1.07 [95% CI, 1.01-1.15]). Conclusion and Relevance: In this study, metformin use was associated with reduced odds of developing AMD. This association was dose dependent, with the greatest benefit at low to moderate doses. When looking only at patients with diabetes, we saw a preservation of the dose-dependent decrease in the odds of patients developing AMD. Metformin does not appear to be protective in patients with diabetes and coexisting diabetic retinopathy. This study suggests that metformin may be useful as a preventive therapy for AMD and provides the basis for potential prospective clinical trials.

Frequency and Outcomes of Preoperative Stress Testing in Total Hip and Knee Arthroplasty from 2004 to 2017.

Importance: Cardiac stress testing is often performed prior to noncardiac surgery, although trends in use of preoperative stress testing and the effect of testing on cardiovascular outcomes are currently unknown. Objective: To describe temporal trends and outcomes of preoperative cardiac stress testing from 2004 to 2017. Design, Setting, and Participants: Cross-sectional study of patients undergoing elective total hip or total knee arthroplasty from 2004 to 2017. Trend analysis was conducted using Joinpoint and generalized estimating equation regression. The study searched IBM MarketScan Research Databases inpatient and outpatient health care claims for private insurers including supplemental Medicare coverage and included patients with a claim indicating an elective total hip or total knee arthroplasty from January 1, 2004, to December 31, 2017. Exposures: Elective total hip or knee arthroplasty. Main Outcomes and Measures: Trend in yearly frequency of preoperative cardiac stress testing. Results: The study cohort consisted of 801 396 elective total hip (27.9%; n = 246 168 of 801 396) and total knee (72.1%; 555 228 of 801 396) arthroplasty procedures, with a median age of 62 years (interquartile range, 57-70 years) and 58.1% women (n = 465 545 of 801 396). The overall rate of stress testing during the study period was 10.4% (n = 83 307 of 801 396). The rate of stress tests increased 0.65% (95% CI, 0.09-1.21; P = .03) annually from quarter (Q) 1 of 2004 until Q2 of 2006. A joinpoint was identified at Q3 of 2006 (95% CI, 2005 Q4 to 2007 Q4) when preoperative stress test use decreased by -0.71% (95% CI, -0.79% to 0.63%; P < .001) annually. A second joinpoint was identified at the Q4 of 2013 (95% CI, 2011 Q3 to 2015 Q3), when the decline in stress testing rates slowed to -0.40% (95% CI, -0.57% to -0.24%; P < .001) annually. The overall rate of myocardial infarction and cardiac arrest was 0.24% (n = 1677 of 686 067). Rates of myocardial infraction and cardiac arrest were not different in patients with at least 1 Revised Cardiac Risk Index condition who received a preoperative stress test and those who did not (0.60%; n = 221 of 36 554 vs 0.57%; n = 694 of 122 466; P = .51). Conclusions and Relevance: The frequency of preoperative stress testing declined annually from 2006 through 2017. Among patients with at least 1 Revised Cardiac Risk Index condition, no difference was observed in cardiovascular outcomes between patients who did and did not undergo preoperative testing.

The Productivity Requirements of Implementing a Medical Scribe Program.

BACKGROUND: Economic analyses of medical scribes have been limited to individual, specialty-specific clinics. OBJECTIVE: To determine the number of additional patient visits various specialties would need to recover the costs of implementing scribes in their practice at 1 year. DESIGN: Modeling study based on 2015 data from the Centers for Medicare & Medicaid Services (CMS) and National Ambulatory Medical Care Survey. Scribe costs were based on literature review and a third-party contractor model. Revenue was calculated from direct visit billing, CPT (Current Procedural Terminology) billing, and data from the National Ambulatory Medical Care Survey. DATA SOURCES: 2015 data from CMS and the National Ambulatory Medical Care Survey. TARGET POPULATION: Health care providers. TIME HORIZON: 1 year. PERSPECTIVE: Office-based clinic. OUTCOME MEASURES: The number of additional patient visits a physician must have to recover the costs of a scribe program at 1 year. RESULTS OF BASE-CASE ANALYSIS: An average of 1.34 additional new patient visits per day (295 per year) were required to recover scribe costs (range, 0.89 [cardiology] to 1.80 [orthopedic surgery] new patient visits per day). For returning patients, an average of 2.15 additional visits per day (472 per year) were required (range, 1.65 [cardiology] to 2.78 [orthopedic surgery] returning visits per day). The addition of 2 new patient (or 3 returning) visits per day was profitable for all specialties. RESULTS OF SENSITIVITY ANALYSIS: Results were not sensitive to most inputs, with the exception of hourly scribe cost and inclusion of CPT revenue. LIMITATION: Use of Medicare data and failure to account for indirect costs, downstream revenue, or changes in documentation quality. CONCLUSION: For all specialties, modest increases in productivity due to scribes may allow physicians to see more patients and offset scribe costs, making scribe programs revenue-neutral. PRIMARY FUNDING SOURCE: University of Chicago Medicine's Center for Healthcare Delivery Science and Innovation and the Bucksbaum Institute.

Two-Year Outcomes Comparing Anti-VEGF Injections to Laser for ROP Using a Commercial Claims Database.

BACKGROUND AND OBJECTIVE: To report ocular and neurodevelopmental outcomes among infants treated for retinopathy of prematurity (ROP) in a nationwide health insurance claims database. PATIENTS AND METHODS: Retrospective cohort study of 298 infants treated with laser or anti-vascular endothelial growth factor (VEGF) injection identified in the MarketScan database (2011-2017) with 2-year follow-up. RESULTS: A review of claims data found 298 patients with International Classification of Diseases and Common Procedural Technology codes for ROP treatment and 2 years of continuous insurance coverage. Of these, 63 infants received injections and 235 received laser. Overall, the anti-VEGF group had higher rates of underlying neurological comorbidities (35% vs. 23%; P = .05) and thrombocytopenia (17% vs. 8%; P = .02). Most ocular outcomes were similar, including retinal detachment (P = .87). There were higher rates of second procedures after injection (44% vs. 10%; P < .001). Rates of language, motor, and cognitive delays were similar. Rates of cerebral palsy were higher with injections but were not statistically significant after adjusting for comorbidities (odds ratio = 1.88; P = .10). CONCLUSIONS: The prevalence of retinal detachment after 2 years was similar comparing anti-VEGF to laser. Despite the higher rates of underlying neurologic comorbidity in the injection group, there were no differences in language, motor, or cognitive delays. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:486-493.].

Cervical disc replacement: examining "real-world" utilization of an emerging technology.

OBJECTIVE: Cervical disc replacement (CDR) has emerged as an alternative to anterior cervical discectomy and fusion (ACDF) for the management of cervical spondylotic pathology. While much is known about the efficacy of CDR within the constraints of a well-controlled, experimental setting, little is known about general utilization. The authors present an analysis of temporal and geographic trends in "real-world" utilization of CDR among those enrolled in private insurance plans in the US. METHODS: Eligible subjects were identified from the IBM MarketScan Databases between 2009 and 2017. Individuals 18 years and older, undergoing a single-level CDR or ACDF for cervical radiculopathy and/or myelopathy, were identified. US Census divisions were used to classify the region where surgery was performed. Two-level mixed-effects regression modeling was used to study regional differences in proportional utilization of CDR, while controlling for confounding by regional case-mix differences. RESULTS: A total of 47,387 subjects met the inclusion criteria; 3553 underwent CDR and 43,834 underwent ACDF. At a national level, the utilization of single-level CDR rose from 5.6 cases for every 100 ACDFs performed in 2009 to 28.8 cases per 100 ACDFs in 2017. The most substantial increases occurred from 2013 onward. The region of highest utilization was the Mountain region (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, and Wyoming), where 14.3 CDRs were performed for every 100 ACDFs (averaged over the 9-year period of study). This is in contrast to the East South Central region (Alabama, Kentucky, Mississippi, and Tennessee), where only 2.1 CDRs were performed for every 100 ACDFs. Patient factors that significantly increased the odds of undergoing a CDR were age younger than 40 years (OR 15.9 [95% CI 10.0-25.5]; p < 0.001), no clinical evidence of myelopathy/myeloradiculopathy (OR 1.5 [95% CI 1.4-1.7]; p < 0.001), and a Charlson Comorbidity Index score of 0 (OR 2.7 [95% CI 1.7-4.2]; p < 0.001). After controlling for these factors, significant differences in utilization rates remained between regions (chi-square test = 830.4; p < 0.001). CONCLUSIONS: This US national level study lends insight into the rate of uptake and geographic differences in utilization of the single-level CDR procedure. Further study will be needed to ascertain specific factors that predict adoption of this technology to explain observed geographic discrepancies.

Prostate Cancer Outcomes Following Solid-Organ Transplantation: A SEER-Medicare Analysis.

BACKGROUND: Immunosuppressive regimens associated with organ transplantation increase the risk of developing cancer. Transplant candidates and recipients with prostate cancer are often treated, even if low-risk features would ordinarily justify active surveillance. METHODS: Using SEER-Medicare, we identified 163 676 men aged 66 years and older diagnosed with nonmetastatic prostate cancer. History of solid organ transplant was identified using diagnosis or procedure codes. A propensity score-matched cohort was identified by matching transplanted men to nontransplanted controls by age, race, region, year, T-stage, grade, comorbidity, and cancer therapy. Fine-Gray competing risk models assessed associations between transplant status and prostate cancer-specific mortality (PCSM) and overall mortality (OM). RESULTS: We identified 620 men (0.4%) with transplant up to 10 years before (n = 320) or 5 years after (n = 300) prostate cancer diagnosis and matched them to 3100 men. At 10 years, OM was 55.7% and PCSM was 6.0% in the transplant cohort compared with 42.4% (P < .001) and 7.6% (P = .70) in the nontransplant cohort, respectively. Adjusted models showed no difference in PCSM for transplanted men (hazard ratio = 0.88, 95% confidence interval = 0.61 to 1.27, P = .70) or differences by prostate cancer therapy. Among 334 transplanted men with T1-2N0, well or moderately differentiated "low-risk" prostate cancer, PCSM was similar for treated and untreated men (hazard ratio = 0.92, 95% confidence interval = 0.47 to 1.81). CONCLUSIONS: Among men aged 66 years and older with prostate cancer, an organ transplant is associated with higher OM but no observable difference in PCSM. These findings suggest men with prostate cancer and previous or future organ transplantation should be managed per usual standards of care, including consideration of active surveillance for low-risk cancer characteristics.

National physician survey on glycemic goals and medical decision making for patients with type 2 diabetes.

To describe how patient characteristics influence physician decision-making about glycemic goals for Type 2 diabetes.2016 survey of 357 US physicians. The survey included two vignettes, representing a healthy patient and an unhealthy patient, adapted from a past survey of international experts and a factorial design vignette that varied age, heart disease history, and hypoglycemia history. Survey results were weighted to provide national estimates.Over half (57.6%) of physicians recommended a goal HbA1c <7.0% for most of their patients. For the healthy patient vignette, physicians recommended a goal similar to that of international experts (<6.66% (95% Confidence Interval (CI), 6.61-6.71%) vs <6.5% (Interquartile range (IQR), 6.5-6.8%)). For the unhealthy patient, physicians recommended a lower goal than international experts (<7.38% (CI, 7.30-7.46) vs <8.0% (IQR, 7.5-8.0%)). In the factorial vignette, physicians varied HbA1c goals by 0.35%, 0.06%, and 0.28% based on age, heart disease history, and hypoglycemia risk, respectively. The goal HbA1c range between the 55-year-old with no heart disease or hypoglycemic events and the 75-year-old with heart disease and hypoglycemic events was 0.65%.Despite guidelines that recommend HbA1c goals ranging from <6.5% to <8.5%, US physicians seem to be anchored on HbA1c goals around <7.0%.

The Impact of the Affordable Care Act Medicaid Expansion on Type 2 Diabetes Diagnosis and Treatment: A National Survey of Physicians.

In 2014, the Affordable Care Act (ACA) provided funding for states to expand Medicaid coverage to include citizens who earned up to 138% of the federal poverty line. We sought to ascertain whether physicians practicing in Medicaid expansion states reported an increase in Medicaid or newly insured patients with type 2 diabetes in their panels, compared to physicians practicing in non-expansion states. We conducted a 55-question cross-sectional survey of 356 physicians providing outpatient care for adults with type 2 diabetes. We used adjusted multivariate logistic regression analyses to compare responses from physicians who practiced in expansion versus non-expansion states regarding whether they observed an increase since 2014 in (1) the number of Medicaid or newly insured patients with diabetes and (2) the number of additional newly or previously diagnosed patients who were newly receiving care, in their panels, adjusting for physician, practice, and patient-level characteristics, weighted for the U.S. physician population. 41% of eligible recipients responded. 64.2% of physicians who practice in an expansion state report an increase in Medicaid or newly insured patients with diabetes compared with 46.1% who practice in non-expansion states (p = 0.05; Table 2). Compared with physicians who practice in non-expansion states, physicians who practice in Medicaid expansion states are more likely to report an increase in the number of Medicaid or newly insured patients with diabetes in their practice since 2014. The increased access associated with the Medicaid expansion may improve long-term outcomes for patients with type 2 diabetes.