Joint injection practice variations in pediatric rheumatology - a global survey and call for action.

BACKGROUND: Intraarticular injections (IAI) were first reported in adult rheumatology in the 1950s and subsequently gained acceptance as a safe and efficacious treatment in Juvenile idiopathic arthritis (JIA). IAIs are now widely performed and recommended as the initial or only treatment of oligoarticular JIA and ancillary treatment of actively inflamed joints in other varieties of JIA. However, the performance of the procedure is currently not guided by standardized recommendations, and several practice variations are observed. METHODS: This worldwide survey of pediatric rheumatologists (with 48.5% response from Pediatric Rheumatology International Trials Organization [PRINTO and Pediatric Rheumatology Collaborative Study Group [PRCSG] members) captures the differences in pre-procedural, procedural and post-procedural protocols and practices observed across the globe and asks the necessity of developing consensus in this area of Pediatric Rheumatology. RESULTS: This worldwide survey of Pediatric Rheumatologists had a response rate of just under 50% and the views of about 42% who routinely performed the procedure. It captured the differences in IAI protocols and practices observed across the globe. Significant variations in practice were noted in use of Local anesthesia, choice, and dose of therapeutic agent for the intraarticular injection and use of ultrasound to guide injections. While some practice variations may be explained by institutional protocols in different parts of the world, the clinical implications of these are largely unknown and beg the need for further studies. CONCLUSIONS: Given these practice variations, the authors recommend further studies to explore the cost and clinical implications and subsequently work towards developing consensus plans to ensure uniformity in this widely used procedure in Pediatric Rheumatology.

A Proposed Revision of the International Classification of Diseases, 11th Revision, Chapter 26.

In 2019, the World Health Assembly approved the International Classification of Diseases, 11th Revision (ICD-11), which included a traditional medicine chapter. This means that traditional medicine (TM) is incorporated into the mainstream medicine of the world. For TM to contribute to human health, the role of ICD-11, chapter 26 (ICD-11-26), is important. Since the ICD-11-26 is "a union set of harmonized traditional medicine conditions of the Chinese, Japanese, and Korean classifications," it is advisable to supplement the essential patterns while maintaining the already adopted patterns. The ICD-11-26 was originated from the World Health Organization International Standard Terminologies on Traditional Medicine in the Western Pacific Region (WHO-IST), and the WHO-IST is the world's most authoritative TM standard terminology system with an emphasis on traditional and conventional expression. In addition, it includes patterns that are widely used in TM clinical practice and have representative prescriptions at the same time. Therefore, future revisions of ICD-11-26 should make WHO-IST the main reference. Based on this spirit, this proposed revision is a modification of ICD-11-26's structure, order, and expression (English translation) with more essential patterns.

Characteristics and practice patterns of advanced practice registered nurses caring for older adults: A survey of Gerontological Advanced Practice Nurses Association members.

BACKGROUND: Advanced practice registered nurses (APRNs) play a pivotal role in meeting the increasing needs of elder care given the aging population. A good understanding of the characteristics of gerontological APRNs is important for future workforce planning. PURPOSE: To understand the demographic, employment, and practice characteristics of APRNs who provide elder care. METHODS: A 34-item survey was distributed to 2,500 current members of the Gerontological Advanced Practice Nurses Association. Three hundred and sixty-four members provided demographic information and employment and practice patterns. To examine the sample representativeness, the survey sample was compared with a sample drawn from the National Sample Survey of Nurse Practitioners 2012. Descriptive statistics were used for analysis. RESULTS: Most respondents were older than 55 years, held a master's degree, were certified as a Gerontology APRN, worked in a long-term/elder care setting as an APRN, earned a salary ranging from $105,001 to $125,000, and practiced in urban or suburban areas. Most respondents worked full time, provided care for people who were 55 to 75 years old, and prescribed under a collaborative agreement. IMPLICATIONS FOR PRACTICE: The study results suggested that gerontological APRNs have the experience and competence to meet the increasing needs of elder care, practice in a variety of settings, including in rural areas, and spend much time with patients. Future efforts are needed to support APRN practice, such as improving their autonomy and independence.

Differences in surgical resection rate and risk of malignancy in thyroid cytopathology practice between Western and Asian countries: A systematic review and meta-analysis.

There is increasing evidence showing that clinicians employ different management strategies in their use of The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC). In this meta-analysis, we investigated the differences in diagnosis frequency, resection rate (RR), and risk of malignancy (ROM) between Western (ie, American and European) and Asian cytopathology practices. We searched PubMed and Web of Science from January 2010 to January 2019. Proportion and 95% CIs were calculated using a random-effect model. We used independent sample t tests to compare frequencies, RR, and ROM between Western and Asian practices. We analyzed a total of 38 studies with 145,066 fine-needle aspirations. Compared with Asian practice, Western series had a significantly lower ROM in most of TBSRTC categories, whereas the RR was not statistically different. Focusing on indeterminate nodules, the RR in Western series was significantly higher (51.3% vs 37.6%; P = .048), whereas the ROM was significantly lower (25.4% vs 41.9%; P = .002) compared with those in Asian series. The addition of Asian cohorts increased ROM for most of diagnostic categories compared with the original TBSRTC. In conclusion, this study demonstrates a difference in Western and Asian thyroid cytology practice, especially regarding the indeterminate categories. Lower RR and higher ROM suggest that Asian clinicians adopt a more conservative approach, whereas immediate diagnostic surgery is favored in Western practice for indeterminate nodules. The addition of Asian series into a meta-analysis of TBSRTC altered ROM for several categories, which should be considered in future revisions of TBSRTC.

Development and validation of an instrument designed to measure factors influencing physician prescribing decisions

BACKGROUND: Previous attempts to develop an instrument to measure factors that influence prescribing decisions among physicians were relatively insufficient and lacked validation scale. OBJECTIVE: We present a new tool that attempts to address this shortcoming. Hence, this study aims to develop and validate a self-administrated instrument to explain factors that influence the prescribing decisions of physicians. METHODS: The questionnaire was developed based on literature and then subjected to an exhaustive assessment by a board of professionals and a pilot examination before being administered to 705 physicians. Three pre-tests were carried out to evaluate the quality of the survey items. In pre-test 1, after items are generated and the validity of their content is assessed by academics and physicians. In pre-test 2, the scale is carried out with a small sample of 20 respondents of physicians. In pre-test 3, fifty drop-off questionnaires were piloted amongst physicians to test the reliability. RESULTS: On the basis of partial least squares structural equation modelling (PLS-SEM) analyses using SmartPLS 3, the content and convergent validity of the instrument were confirmed with 44 items grouped into four categories, namely, marketing efforts, patient characteristics, pharmacist variables, and contextual factors with 13 reflective constructs. CONCLUSIONS: The study outcomes prove that the scale is more valid and reliable for measuring factors that influence the decision of the physician to prescribe the drug. The development and presentation of a scale of thirteen factors related to physicians prescribing decisions help to ensure valid findings and facilitates comparisons of studies and research settings

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Management of dry eye disease to optimize cataract surgery outcomes: Two tables for a daily clinical practice.

The increase in life expectancy has resulted in a greater number of patients presenting for cataract surgery as well as an increasing prevalence of dry eye disease (DED) symptoms or signs noted in these patients. Low grade and/or non-symptomatic DED is common and can be exacerbated after surgery. DED can induce errors in IOL power calculation. DED can impair the visual prognosis and patient comfort after cataract surgery, leading to dissatisfaction of both the patient and the surgeon. Hence, preoperative evaluation for DED for all cataract candidates is crucial to mitigate these risks. To optimize clinical efficiency during the screening examination, we propose a strategy of three levels of DED screening, according to a patient's risk of DED given his or her history. We also propose a summary of the main clinical points before, during and after cataract surgery in eyes with DED.

Emergency Physician Opioid Prescribing and Risk of Long-term Use in the Veterans Health Administration: an Observational Analysis.

BACKGROUND: Treatment by high-opioid prescribing physicians in the emergency department (ED) is associated with higher rates of long-term opioid use among Medicare beneficiaries. However, it is unclear if this result is true in other high-risk populations such as Veterans. OBJECTIVE: To estimate the effect of exposure to high-opioid prescribing physicians on long-term opioid use for opioid-naïve Veterans. DESIGN: Observational study using Veterans Health Administration (VA) encounter and prescription data. SETTING AND PARTICIPANTS: Veterans with an index ED visit at any VA facility in 2012 and without opioid prescriptions in the prior 6 months in the VA system ("opioid naïve"). MEASUREMENTS: We assigned patients to emergency physicians and categorized physicians into within-hospital quartiles based on their opioid prescribing rates. Our primary outcome was long-term opioid use, defined as 6 months of days supplied in the 12 months subsequent to the ED visit. We compared rates of long-term opioid use among patients treated by high versus low quartile prescribers, adjusting for patient demographic, clinical characteristics, and ED diagnoses. RESULTS: We identified 57,738 and 86,393 opioid-naïve Veterans managed by 362 and 440 low and high quartile prescribers, respectively. Patient characteristics were similar across groups. ED opioid prescribing rates varied more than threefold between the low and high quartile prescribers within hospitals (6.4% vs. 20.8%, p < 0.001). The frequency of long-term opioid use was higher among Veterans treated by high versus low quartile prescribers, though above the threshold for statistical significance (1.39% vs. 1.26%; adjusted OR 1.11, 95% CI 0.997-1.24, p = 0.056). In subgroup analyses, there were significant associations for patients with back pain (adjusted OR 1.25, 95% CI 1.01-1.55, p = 0.04) and for those with a history of depression (adjusted OR 1.28, 95% CI 1.08-1.51, p = 0.004). CONCLUSIONS: ED physician opioid prescribing varied by over 300% within facility, with a statistically non-significant increased rate of long-term use among opioid-naïve Veterans exposed to the highest intensity prescribers.

Overcoming Barriers to Prescribing Buprenorphine for the Treatment of Opioid Use Disorder: Recommendations from Rural Physicians.

PURPOSE: The United States is in the midst of a severe opioid use disorder epidemic. Buprenorphine is an effective office-based treatment that can be prescribed by physicians, nurse practitioners, and physician assistants with a Drug Enforcement Administration (DEA) waiver. However, many providers report barriers that keep them from either getting a DEA waiver or fully using it. The study team interviewed rural physicians successfully prescribing buprenorphine to identify strategies for overcoming commonly cited barriers for providing this service. METHODS: Interview candidates were randomly selected from a list of rurally located physicians with a DEA waiver to prescribe buprenorphine who reported treating high numbers of patients on a 2016 survey. Forty-three rural physicians, who were prescribing buprenorphine to a high number of patients, were interviewed about how they overcame prescribing barriers previously identified in that survey. FINDINGS: Interviewed physicians reported numerous ways to overcome common barriers to providing buprenorphine treatment in rural areas. Key recommendations included ways to (1) get started and maintain medication-assisted treatment, (2) minimize DEA intrusion and medication diversion, and (3) address the lack of mental health providers and stigma surrounding opioid use disorder (OUD). Overall, physicians found providing this service to be very rewarding. CONCLUSIONS: Despite known barriers, rural physicians around the country have been successful in adding buprenorphine treatment to their practices. Nonprescribing providers can learn from the strategies used by successful prescribers to add this service.

Assessment of variability in Turkish spine surgeons' trauma practices.

OBJECTIVES: The aim of this study was to analyse the variability among Turkish spinal surgeons in the management of thoracolumbar fractures by carrying out a web survey. METHODS: An invitation text and web-link of the survey were sent to the members of the Turkish Spine Society mail group. A fictitious spine trauma vignette, a 23 year-old male with a L1 burst fracture, was presented and 25 questions were asked to participants. Variability of answers in a given question was assessed with the Index of Qualitative Variation (IQV). Questions with high IQV values (>%80) were selected to evaluate the relation between participant factors (speciality, age, degree and experience level of the surgeon, type of the work centre and volume of the trauma patients). RESULTS: Sixty-four (88%) among the 73 participating surgeons completed the survey. 45 (70%) of them were orthopaedic surgeons and 19 (30%) were neurosurgeons. 11 questions had very high variability (IQV ≥ 0.80), 5 had high variability (0.58-0.75) and 2 had low variability (IQV≤0.20). The question with the highest variability was related to the use of brace after surgery (IQV = 0.93). Following one was about the selection of fixation levels (IQV = 0.91). Neurosurgeons were more likely to use brace postoperatively and professors were less likely to perform decompression. CONCLUSION: This survey shows that thoracolumbar spine trauma practice significantly varies among Turkish spine surgeons. Surgeons' characteristics affected some specific answers. Lack of enough knowledge about spine trauma care, fracture classifications and surgical techniques and/or ethical factors may be other reasons for this variability.

Finding discriminative and interpretable patterns in sequences of surgical activities.

OBJECTIVE: Surgery is one of the riskiest and most important medical acts that is performed today. Understanding the ways in which surgeries are similar or different from each other is of major interest to understand and analyze surgical behaviors. This article addresses the issue of identifying discriminative patterns of surgical practice from recordings of surgeries. These recordings are sequences of low-level surgical activities representing the actions performed by surgeons during surgeries. MATERIALS AND METHOD: To discover patterns that are specific to a group of surgeries, we use the vector space model (VSM) which is originally an algebraic model for representing text documents. We split long sequences of surgical activities into subsequences of consecutive activities. We then compute the relative frequencies of these subsequences using the tf*idf framework and we use the Cosine similarity to classify the sequences. This process makes it possible to discover which patterns discriminate one set of surgeries recordings from another set. RESULTS: Experiments were performed on 40 neurosurgeries of anterior cervical discectomy (ACD). The results demonstrate that our method accurately identifies patterns that can discriminate between (1) locations where the surgery took place, (2) levels of expertise of surgeons (i.e., expert vs. intermediate) and even (3) individual surgeons who performed the intervention. We also show how the tf*idf weight vector can be used to both visualize the most interesting patterns and to highlight the parts of a given surgery that are the most interesting. CONCLUSIONS: Identifying patterns that discriminate groups of surgeon is a very important step in improving the understanding of surgical processes. The proposed method finds discriminative and interpretable patterns in sequences of surgical activities. Our approach provides intuitive results, as it identifies automatically the set of patterns explaining the differences between the groups.

[Use of the ICF in medical rehabilitation in Germany: claims and reality]. / Nutzung der ICF in der medizinischen Rehabilitation in Deutschland: Anspruch und Wirklichkeit.

BACKGROUND: The International Classification of Functioning, Disability and Health (ICF) is being used in the medical rehabilitation practice in different ways. The World Health Organization (WHO) and many other stakeholders have formulated claims and expectations for its use. OBJECTIVES: A comparative presentation of the claims of various stakeholders for the use of the ICF with examples in current practice. MATERIALS AND METHODS: Database searches (PubMed, REHADAT, and Google Scholar) were conducted for studies concerning claims and the current use of the ICF in practice. RESULTS: There are different requirements regarding the use of the ICF. While lawmakers and social insurance agencies remain very cautious and vague, other stakeholders (research institutions, organizations, stakeholders, service providers) formulate higher expectations and call for greater use of the ICF. In practice, the ICF is used in the form of a bio-psycho-social model, a common language and many different adaptations. CONCLUSIONS: The different requirements for the use of ICF demonstrate the motivations and interests of the stakeholders. Signals must now be sent both by politics and by social insurance agencies that go far beyond non-binding declarations. Furthermore it is necessary to systematize and evaluate the many use adaptations that are primarily being used by service providers. Research is needed on the concrete use of ICF-based instruments and its intended and unintended effects.

Determining the acceptable level of physician compliance with a treat-to-target strategy in early rheumatoid arthritis.

OBJECTIVE: To determine the minimum cut-points for rate of physician compliance with a treat-to-target (T2T) strategy needed to achieve optimal rates of remission or low disease activity (LDA). METHOD: In this analysis of longitudinal observational data from patients with early RA, physician compliance with a T2T treatment protocol was determined for each clinic visit over 3 years. Remission and LDA were measured by Disease Activity Score in 28 joints (DAS28), simplified disease activity index (SDAI) and clinical disease activity index (CDAI). The minimum physician compliance rates for predicting these outcomes were calculated using receiver operating characteristic (ROC) curves. RESULT: Overall, 149 patients completed 3078 clinic visits over 3 years of follow-up. Treatment decisions complied with the T2T protocol in 2343 of these visits (76.1%). The minimum cut-points for physician compliance rates that predicted remission and LDA according to DAS28 were 81.1% and 70.7%, respectively, and to predict remission and LDA according to SDAI, the respective cut-points were 92.7% and 77.4%. Based on these cut-points, three categories of physician compliance with T2T were proposed: high (to maximize the likelihood of achieving remission, > 80% according to DAS28 or > 90% according to SDAI/CDAI); medium (the minimal physician compliance to achieve LDA, 70-79% according to DAS28 or 75-89% for SDAI/CDAI); and low (< 70% for DAS28 and < 75% for SDAI/CDAI), where remission and LDA are unlikely). When patients were stratified by baseline disease activity, the physician compliance rate cut-points were similar for most outcomes at year 3. CONCLUSION: Using real-life clinical data, we determined the thresholds for physician compliance with a T2T strategy that stratified patients according to their disease outcomes and proposed a system for classifying physician compliance as high, medium and low.

The Relationship Between Tear Ferning Patterns and Non-invasive Tear Break-up Time in Normal Asian Population / Relación entre los patrones del Test de Ferning lagrimal y el TBUT no invasivo en la población normal de Asia

Purpose: To investigate the relationship between tear ferning patterns (TFP) and non-invasive tear break-up time (NIBUT) in normal Asian subjects. Methods: One hundred and forty-five adults with no ocular surface disorders were recruited. TFP and NIBUT were determined. Tears were collected using a capillary tube and allowed to air dry at room temperature for 10min. TFP was later observed using a light microscope and classified according to Rolando's classification. Measurement for NIBUT was obtained using a Tearscope with the slit lamp magnification. Results: It was found that there is no significant difference between gender in TFP (Z=−1.77, P>.05) and NIBUT (Z=−1.475, P>.05). There is also no significant difference between Malay, Chinese, Indian, and other races in TFP, (H(3)=4.85, P>.05) and NIBUT (H(3)=2.18, P>.05). However, there is a significant difference between age groups of 20-29, 30-39, 40-49,and 50-60 years old in both TFP (H(3)=28.25, P<.01) and NIBUT (H(3)=36.50, P<.001). Spearman's correlation showed there was a significant relationship between TFP and NIBUT (r=−0.55, P<.001), age and NIBUT (r=−0.50, P<.001), age and TFP (r=0.41, P<.001), McMonnies score and NIBUT (r=−0.40, P<.001), McMonnies score and TFP (r=0.31, P<.001), as well as age and McMonnies score (r=0.52, P<.001). Conclusion: TFP and NIBUT was age dependent but not gender and race dependent. Older subjects had higher grade of TFP and McMonnies questionnaire score but lower NIBUT value. TFP and NIBUT can be used to assess the tear film quality (AU)

Objetivo: Investigar la relación entre los patrones del test de Ferning (TFP) y el test de rotura lagrimal no invasivo (NIBUT) en sujetos asiáticos normales. Métodos: Se incluyó a ciento cuarenta y cinco adultos, sin trastornos en la superficie ocular. Se calcularon el TFP y el NIBUT. Se recolectaron lágrimas utilizando un tubo capilar, dejándose secar a temperatura ambiente durante diez minutos. Se observó posteriormente el TFP utilizando un microscopio óptico, clasificándose el patrón mediante los criterios de Rolando. La medición del NIBUT se obtuvo utilizando el Tearscope, con imagen ampliada en el biomicroscopio. Resultados: Se comprobó que no existen diferencias por sexo en relación a TFP (Z=-1,77, p>0.05) y NIBUT (Z=-1,475, p>0,05). Tampoco existen diferencias significativas entre las razas Malaya, China, India y demás en relación a TFP, (H(3)=4,85, p>0,05) y NIBUT (H(3)=2,18, p>0,05). Sin embargo, existe una diferencia considerable entre los grupos de edad de 20-29, 30-39, 40-49 y 50-60 años tanto en relación a TFP (H(3)=28,25, p<0,01) como a NIBUT (H(3)=36,50, p <0,001). La correlación de Spearman reflejó una relación significativa entre TFP y NIBUT (r=-0,55, p<0,001), la edad y NIBUT (r=-0,50, p< 0,001), la edad y TFP (r=0,41, p<0,001), la puntuación de McMonnies y NIBUT (r=-0,40, p<0,001), la puntuación de McMonnies y TFP (r=0,31, p<0,001), y la edad y la puntuación de McMonnies (r=0,52, p<0,001). Conclusión: TFP y NIBUT dependen de la edad, pero no del sexo ni la raza. Los sujetos de mayor edad reflejaron un grado superior de TFP y de puntuación del cuestionario de McMonnies, pero un valor inferior de NIBUT. TFP y NIBUT pueden utilizarse para evaluar la calidad de la película lagrimal (AU)

Rheumatologists and Ophthalmologists Differ in Treatment Decisions for Ocular Behçet Disease.

BACKGROUND: Ocular involvement in patients with Behçet disease represents a significant clinical morbidity in this disease, and the prevention of visual impairment is an important treatment goal. There are no randomized controlled trials for the treatment of ocular Behçet disease; however, clinicians must still make treatment decisions. OBJECTIVES: The goals of this study were to describe the treatment preferences of rheumatologists and ophthalmologists for the treatment of ocular Behçet disease and to identify factors that influence these decisions. METHODS: Eight hundred fifty-two rheumatologists and 934 ophthalmologists were surveyed via e-mail regarding their choice of therapy for a hypothetical patient with ocular Behçet disease. Respondents were asked to select first- and second-choice therapies and then reselect first and second choices assuming there would be no issues with cost or insurance prior authorization. RESULTS: One hundred thirty two physicians (7.4%) who were willing to recommend treatment completed the survey: 68 rheumatologists and 64 ophthalmologists. The most common first-choice therapy for both specialties was a biologic agent. Significantly more rheumatologists than ophthalmologists chose methotrexate (P < 0.025) and azathioprine (P < 0.005) as their first-choice therapy. After assuming there were no concerns with cost or prior authorization, rheumatologists were still more likely to choose azathioprine compared with ophthalmologists (P < 0.02), and ophthalmologists were more likely to choose local steroid implants (P < 0.02). Both rheumatologists and ophthalmologists increased their choice of an anti-tumor necrosis factor agent when cost and prior authorization issues were removed (P < 0.0001 and 0.008, respectively). CONCLUSIONS: Physician decision making is influenced by medical specialty and concerns regarding cost and prior authorization.

A multidisciplinary approach to vascular surgery procedure coding improves coding accuracy, work relative value unit assignment, and reimbursement.

BACKGROUND: Vascular surgery procedural reimbursement depends on accurate procedural coding and documentation. Despite the critical importance of correct coding, there has been a paucity of research focused on the effect of direct physician involvement. We hypothesize that direct physician involvement in procedural coding will lead to improved coding accuracy, increased work relative value unit (wRVU) assignment, and increased physician reimbursement. METHODS: This prospective observational cohort study evaluated procedural coding accuracy of fistulograms at an academic medical institution (January-June 2014). All fistulograms were coded by institutional coders (traditional coding) and by a single vascular surgeon whose codes were verified by two institution coders (multidisciplinary coding). The coding methods were compared, and differences were translated into revenue and wRVUs using the Medicare Physician Fee Schedule. Comparison between traditional and multidisciplinary coding was performed for three discrete study periods: baseline (period 1), after a coding education session for physicians and coders (period 2), and after a coding education session with implementation of an operative dictation template (period 3). The accuracy of surgeon operative dictations during each study period was also assessed. An external validation at a second academic institution was performed during period 1 to assess and compare coding accuracy. RESULTS: During period 1, traditional coding resulted in a 4.4% (P = .004) loss in reimbursement and a 5.4% (P = .01) loss in wRVUs compared with multidisciplinary coding. During period 2, no significant difference was found between traditional and multidisciplinary coding in reimbursement (1.3% loss; P = .24) or wRVUs (1.8% loss; P = .20). During period 3, traditional coding yielded a higher overall reimbursement (1.3% gain; P = .26) than multidisciplinary coding. This increase, however, was due to errors by institution coders, with six inappropriately used codes resulting in a higher overall reimbursement that was subsequently corrected. Assessment of physician documentation showed improvement, with decreased documentation errors at each period (11% vs 3.1% vs 0.6%; P = .02). Overall, between period 1 and period 3, multidisciplinary coding resulted in a significant increase in additional reimbursement ($17.63 per procedure; P = .004) and wRVUs (0.50 per procedure; P = .01). External validation at a second academic institution was performed to assess coding accuracy during period 1. Similar to institution 1, traditional coding revealed an 11% loss in reimbursement ($13,178 vs $14,630; P = .007) and a 12% loss in wRVU (293 vs 329; P = .01) compared with multidisciplinary coding. CONCLUSIONS: Physician involvement in the coding of endovascular procedures leads to improved procedural coding accuracy, increased wRVU assignments, and increased physician reimbursement.

Doctors and Their Patients in the Seventeenth to Nineteenth Centuries.

How can these finings be interpreted in conclusion? Analysis has revealed firstly that, depending on the chosen period, the socio-geographical situation and the profile of the individual doctor's practice, the clientele varied widely in terms of gender, age and social rank. The consultation behaviour of men and women changed noticeably. Findings overall suggest that up until t8o the gender distribution varied in the individual practices. There was a trend for women to be overrepresented in urban practices during the earlier period. But in general, from the mid-nineteenth century they predominated - in towns as well as in the country in allopathic as well as homeopathic practices. The absence of children, which was bemoaned by many physicians, did not apply to the practices under investigation. On the contrary: the percentage is consistently high while older patients remained underrepresented right up until the end of the period under investigation, even though their proportion increased in the individual practices during the course of the nineteenth century In each of the nineteenth century practices investigated - and increasingly among the lower and middle classes - the physicians' services were used by several members of the same family. We have found no evidence to support the thesis that up until the nineteenth century academic physicians were mainly consulted by aristocratic or wealthy bourgeois patients. The theory probably applies only to early modern urban doctors. In the practices examined here, from the middle of the eighteenth century, patients from all social strata went to consult physicians. The participation of members of the lower classes or from an artisanal, (proto) industrial or agricultural background clearly increased over time 'despite ubiquitous economic and cultural barriers. That the annual numbers of consultations per physician increased - despite the growing number of physicians available - suggests that for economically disadvantaged social groups also, the consultation of learned physicians became more common: in towns from the first half of the nineteenth century and in the country from the middle of the century. In addition, the individual findings reveal that, prior to the introduction of statutory health insurance for salaried persons, patients of more secure social standing consulted a physician considerably more frequently in the course of the year than lower class patients. While the patient structure clearly changed around 1800, the relationship between physician and patient continued without major changes from the seventeenth to the nineteenth century. The therapeutic encounter up until the end of the investigated period can be summarized as a negotiation process. Patients were discerning in their choice of healer and did not refrain from using rival services. They sought help for unpleasant symptoms such as indigestion, pain or fever, and only rarely in cases of emergency Therapy was decided on after an exchange between a critical and autonomous client and the medical specialist who was generally willing to compromise. While the patient structure clearly changed around 1800, the relationship between physician and patient continued without major changes from the seventeenth to the nineteenth century. The therapeutic encounter up until the end of the investigated period can be summarized as a negotiation process. Patients were discerning in their choice of healer and did not refrain from using rival services. they sought help for unpleasant symptoms such as indigestion, pain or fever, and only rarely in cases of emergency. Therapy was decided on after an exchange between critical and autonomous client and the medical specialist who was generally willing to compromise.