Prevalence and performance of private equity-affiliated fertility practices in the United States.

OBJECTIVE: To quantify the proportion of annual assisted reproductive technology (ART) cycles performed at private equity-affiliated fertility practices and to test for differences in services and success rates between private equity-affiliated and nonaffiliated practices. DESIGN: Cross-sectional analysis of national data set. SETTING: Not applicable. PATIENT(S): None. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): The primary outcome measures were the volume of ART cycles performed, the percentage of retrievals resulting in live births, and the percentage of transfers resulting in live births. The secondary outcomes included the median income of the practice location, the use of preimplantation genetic testing, the clinical service availability, and the patient reasons for seeking treatment. RESULT(S): Of the practices listed on the Centers for Disease Control's 2018 Fertility Clinic Success Rates Report, 14.7% had a private equity affiliation. Of the 305,883 ART cycles performed in 2018, 29.3% (89,535) occurred at private equity-affiliated practices. Patients at private equity-affiliated practices were 6.75% (95% confidence interval [CI], -10.15%, -3.36%) less likely to initiate a cycle due to male factor infertility, and 10.60% (95% CI, 3.49, 17.76) more likely to use preimplantation genetic testing before embryo transfer. No statistically significant differences were found in success rates among women aged <35 years. The average median household income (standard error) in zip codes with private equity-affiliated practices compared with nonaffiliated practices was $83,610 ($35,990) and $72,161 ($32,314), respectively. CONCLUSION(S): A major portion of fertility practices in the United States are private equity-affiliated, and these practices perform an even greater portion of ART cycles in the United States each year. Fertility appears to be the medical specialty with the greatest market share owned by private equity. Our findings corroborate preliminary research, which forecasts the increasing involvement and consolidation by private equity in fertility. Future research should continue monitoring for differences in outcomes, financing, case mix, service use, and accessibility.

Vasectomy Reversal Online Marketing Practices: What Are We Putting Out There?

OBJECTIVE: To determine characteristics of providers marketing vasectomy reversal (VR) online, degree of information available online, the ease with which patients can compare providers, and the differences in VR practice patterns between academic and private practices. MATERIALS AND METHODS: We identified VR practices operating within the top 50 most populous metropolitan areas in the US. Practice websites were reviewed to obtain information such as provider educational background, level of magnification, ability to perform vasoepididymostomy, surgical volume, and cost. Based on information available, providers were assigned a novel REVERSAL score created by the authors. Descriptive statistics were used to compare results. RESULTS: Of the 107 providers identified (29 academic, 78 private), the majority were male urologists with a Doctor of Medicine degree. Academic providers were more likely to have fellowship training than private practice providers, 96.6 vs 43.6%, respectively (P = 0.00001). Compared to non-urologists, urologists were less likely to purchase online ads or disclose cost. Non-urologists charged significantly less than urologists, $3,584 ± 1,554 and $6,591 ± 1,518, respectively (P = 0.00001). Only one provider provided complete information as defined by REVERSAL score of 12, with the majority (61.7%) of providers achieving score ≤6. CONCLUSION: There is significant lack of transparency in publicly available information from VR practices. Practices should implement measures to improve dissemination of information to the public, so that patients can more easily compare providers and make informed decisions regarding VR.

Evaluating Quality Improvement and Patient Safety Amongst Practicing Urologists: Analysis of the 2018 American Urological Association Census.

OBJECTIVE: To describe factors associated with Quality improvement and patient safety (QIPS) participation using 2018 American Urological Association Census data. QIPS have become increasingly important in medicine. However, studies about QIPS in urology suggest low levels of participation, with little known about factors predicting non-participation. METHODS: Results from 2339 census respondents were weighted to estimate 12,660 practicing urologists in the United States. Our primary outcome was participation in QIPS. Predictor variables included demographics, practice setting, rurality, fellowship training, QIPS domains in practice, years in practice, and non-clinical/clinical workload. RESULTS: QIPS participants and non-participants significantly differed in distributions of age (P = .0299), gender (P = .0013), practice setting (P <.0001), employment (employee vs partner vs owner vs combination; P <.0001), and fellowship training (P <.0001). QIPS participants reported fewer years in practice (21.3 vs 25.9, P = .018) and higher clinical (45.2 vs 39.2, P = .022) and non-clinical (8.76 vs 5.28, P = .002) work hours per week. Non-participation was associated with male gender (OR = 2.68, 95% CI 1.03-6.95) and Asian race (OR = 2.59, 95% CI 1.27-5.29) for quality programs and private practice settings (ORs = 8.72-27.8) for patient safety initiatives. CONCLUSION: QIPS was associated with academic settings. Interventions to increase rates of quality and safety participation should target individual and system-level factors, respectively. Future work should discern barriers to QIPS engagement and its clinical benefits.

Plastic and reconstructive surgeons' views of a single payer health care system: Implications for patients and practice.

BACKGROUND: Rising health care costs and the high number of uninsured Americans has led to the increasing popularity of a single payer alternative. While opinions of physicians at large have been studied, we present the first data examining the views of United States (U.S.) board-certified plastic surgeons on a single payer health care system and its implications for patients and practice. METHODS: A total of 3,431 US plastic and reconstructive surgeons were sent a 25-item Qualtrics survey and responses collected from September 1 to November 1, 2019. Independent variables included surgeon sociodemographic characteristics. The association between these and a preference for a single payer was evaluated using the logistic regression. RESULTS: There was a 11% response rate (n = 383). The majority of respondents were in private practice (64.5%). Forty-four percent believed that it is the government's responsibility to ensure care is provided for all; 34% were willing to give up income in exchange for reduced paperwork and administrative burden. Sixty-three percent would not work the same number of hours under single payer. Private practice plastic surgeons were significantly less likely to favor single payer (95% CI: 0.19 and 0.76). Among academic plastic surgeons, 24% would consider leaving if single payer were enacted and 60% would decrease the reconstructive portion of their practice. CONCLUSIONS: Most U.S. plastic and reconstructive surgeons do not support a single payer health care system. Its enactment could have sweeping implications for plastic surgeons nationwide, among the most significant being a shift from academic to private practice with a potential reduction in patient access to complex reconstructive procedures.

Italian experiences in the management of andrological patients at the time of Coronavirus pandemic.

The SARS-CoV-2 (Severe acute respiratory syndrome coronavirus 2) was first reported in December 2019, then its rapid spread around the world caused a global pandemic in March 2020 recording a high death rate. The epicenter of the victims moved from Asia to Europe and then to the United States. In this Pandemic, the different governance mechanisms adopted by local health regional authorities made the difference in terms of contagiousness and mortality together with a community strong solidarity. This document analyzes the andrological urgencies management in public hospitals and in private practice observed in Italy and in particular in the most affected Italian Regions: Emilia-Romagna and Marche.

Corticosteroid utilization among otolaryngologists for the treatment of acute upper respiratory tract infections.

PURPOSE: To determine the effects of knowledge and practice variations on prescribing patterns of systemic corticosteroids (SC) for acute upper respiratory tract infections (URTI). MATERIALS AND METHODS: A cross-sectional evaluation of practicing otolaryngologists in the United States through the use of a 16-question Knowledge, Attitude, and Practice survey. The survey was self-administered through email delivery to practicing members of the American Academy of Otolaryngology-Head and Neck Surgery. RESULTS: Of 349 respondents, the majority were attending physicians in private practice and used SC 25% to 50% of the time. There was a higher rate of SC use by clinicians in the Southeast United States (adjusted odds ratio [aOR], 2.10; 95% confidence intervals [95% CI], 1.18-3.72) and by those in private practice (aOR, 2.67; 95% CI, 1.63-4.37). Levels of SC knowledge did not vary across respondents; however, knowledge was associated with increased use of SC. Only 62.8% of respondents answered all 4 Knowledge questions correctly and this was associated with a 3.5-fold decrease in SC use (aOR, 0.29; 95% CI, 0.19-0.44). Attitudes toward SC use reflected prescribing practices and were also linked to levels of knowledge, as respondents with less knowledge were more likely to have a favorable outlook toward use of SC. CONCLUSION: Use of SC for treatment of acute URTI is associated with clinician demographics and knowledge. Otolaryngologists are more likely to use SC for acute URTI in the Southeast United States and in private practice. Knowledge and provider education are key factors in prescribing patterns.

Faculty of Radiation Oncology 2018 workforce census: the status of the radiation oncology workforce in New Zealand.

AIM: This paper outlines the results of the Royal Australian and New Zealand College of Radiologists (RANZCR) Faculty of Radiation Oncology (FRO) 2018 workforce census. Here we report the responses of New Zealand radiation oncologists and trainees in order to understand characteristics of the New Zealand radiation oncology workforce. METHOD: The workforce census was conducted online during July-September 2018. Distribution was by Survey Monkey to all radiation oncologists (fellows, life members, educational affiliates, retired) and trainees on the RANZCR membership database, including members from Australia, New Zealand and Singapore. All responses were aggregated for analysis. This paper addresses only responses from New Zealand members. The census was designed to explore issues relevant to the New Zealand workforce, and questions from previous workforce censuses were repeated in order to monitor trends. RESULTS: The response rate for New Zealand radiation oncologists was 73.3% (44/60). The majority (67%) were male. The average age was 50.8 years. Three-fifths (59.5%) reported New Zealand ethnicity. One-third obtained their specialist qualifications outside of Australia and New Zealand. Most worked in the public sector only (63.4%), with only two in exclusive private practice. Most radiation oncologists attained a consultant post immediately on completion of training, but there were 26 who pursued an overseas fellowship. Most worked one full-time equivalent or greater (FTE), with 17.5% working less than 1.0 FTE. Radiation oncologists reported working a median of 50.0 hours per week, with half working over 10 hours above their contracted hours. Most time was spent on clinical duties with minimal time spent on research. Radiation oncologists reported seeing an average of 235 new patients per year (median: 230). Leadership positions were held by 21/43 respondents. Within 15 years, 55% of the current workforce reported an intention to retire, including 30% of those currently practising highly specialised brachytherapy. Females in the workforce were less likely to work fulltime and spent less time in research and management activities. All trainees reported full-time work, although 50% expressed a desire for part-time training. Half of the trainees reported working 6-10 hours on call, and 60% reported two or less hours of protected teaching per week. Despite this, 90% of trainees were satisfied with their career choice. CONCLUSIONS: Radiation oncology is a small specialty in New Zealand, with a significant reliance on overseas-trained specialists. The specialty continues to work significant overtime hours while time spent on research and non-clinical duties remains low. The growth in staffing between the 2014 and 2018 census has been low. Trainee numbers do not appear sufficient to meet the demand for replacing staff, due to retirements and the reduction of hours. Radiation intervention rates are low in New Zealand, but growth would be reliant on an expansion of the workforce beyond simply replacing staff losses. The radiation oncology workforce in New Zealand remains vulnerable, and careful consideration must be given to expansion and retention to ensure a viable workforce for the future.

Current State and Future of Private Practice Nephrology in the United States.

Chronic kidney disease remains highly prevalent and exerts a heavy economic burden. The practice of nephrology has come a long way in managing this disease, though there remains room for improvement. The private domain, where more than half of the adult nephrology workforce operates, faces serious challenges. Interest has decreased in the field, leading to diminished recruitment. There has been a reduction in both reimbursement rates and revenues. We discuss the current state of private practice nephrology and strategies to reinvigorate our discipline. There needs to be a focus on preparing fellows during training not only for academic careers, but also for effective functioning in the environment of private practice and development of pathways for growth. We believe that private practice nephrology must expand its frontiers to be fulfilling professionally, challenging academically, and successful financially. The United States government has recently announced the Advancing American Kidney Health Executive Order which seeks to prioritize optimal treatments for patients with kidney disease. We are optimistic that there is a renaissance afoot in nephrology and that our field is in the process of rediscovering itself, with its best days yet to come.

The New Zealand podiatry profession - a workforce in crisis?

BACKGROUND: This is the first study to explore workforce data from the Podiatrists Board of New Zealand. The study analysed data from an online survey which New Zealand podiatrists complete as part of their application for an Annual Practising Certificate. METHODS: Survey responses between 2015 and 2019 were analysed. Data was related to work setting, employment status, work hours, location, professional affiliations, and number of graduates entering practice. Survey data was downloaded by a second party who provide data security for the Podiatrists Board of New Zealand workforce data. All data supplied for analysis were deidentified and could not be re-linked to an individual practitioner. RESULTS: In 2019 there were 430 podiatrists who held an Annual Practising Certificate. Eighty percent of podiatrists who work in New Zealand are in private practice, with 8% employed in the public health sector. Podiatrist's work is a mix of general podiatry, diabetes care and sports medicine. The majority are self-employed (40%) or business owners (19%). Approximately 40% work between 31 to 40 h per week and 46 to 50 weeks per year. The majority are female (67%) with most practising in the North Island (69%) and located in the Auckland region (33%). On average 76% of new graduates were issued an Annual Practising Certificate between 2015 and 2019. CONCLUSION: The New Zealand podiatry profession is small and growing at a slow rate, consequently there is evidence of a workforce shortage. To maintain a per-capita ratio of podiatrists approximate to Australia and the United Kingdom an additional 578 podiatrists are required in the New Zealand workforce. There are not enough new graduate practitioners entering the workforce and once practising, the majority enter private practice in the face of limited public health employment opportunities.

Private practice metropolitan telepsychiatry in larger Australian states during the COVID-19 pandemic: an analysis of the first 2 months of new MBS telehealth item psychiatrist services.

OBJECTIVE: Private practice psychiatry in Australia was largely office-based until the Commonwealth Government introduced new psychiatrist Medicare Benefits Schedule (MBS) telehealth items in response to the first wave of the COVID-19 pandemic. We investigate the uptake of (1) video and telephone telehealth consultations in April-May 2020, and (2) the overall changing rates of consultation, i.e. total telehealth and in-person consultations across the larger states of Australia. METHOD: MBS item service data were extracted for COVID-19 psychiatrist video- and telephone-telehealth item numbers and compared with a baseline of the 2018-2019-financial-year monthly average of in-person consultations for New South Wales, Queensland, Victoria, and Western Australia. RESULTS: Total psychiatry consultations (telehealth and in-person) rose during the first wave of the pandemic by 10%-20% compared to the previous year. The majority of private practice was conducted by telehealth in April but was lower in May as new COVID-19 case rates fell. Most telehealth provision was by telephone for short consultations of ⩽15-30 min. Video consultations increased from April into May. CONCLUSIONS: For large states, there has been a rapid adoption of the MBS telehealth psychiatrist items, followed by a trend back to face-to-face as COVID-19 new case rates reduced. There was an overall increased consultation rate (in-person plus telehealth) for April-May 2020.

Socio-economic and psychological impact of the COVID-19 outbreak on private practice and public hospital radiologists.

PURPOSE: The COVID-19 pandemic has led to an urgent reorganisation of the healthcare system to prevent hospitals from overflowing and the virus from spreading. Our objective was to evaluate the socioeconomic and psychological impact of the COVID-19 outbreak on radiologists. MATERIAL AND METHODS: French radiologists were invited to answer an online survey during the pandemic through mailing lists. The questionnaire was accessible for nine days. It covered socio-demographic information, exposure to COVID-19 at work and impact on work organisation, and included the Insomnia Severity Index and Hospital Anxiety and Depression Scale. Outcomes were moderate to severe insomnia, definite symptoms of depression or anxiety. Risk and protective factors were identified through multivariate binary logistic regression. RESULTS: 1515 radiologists answered the survey. Overall, 674 (44.5 %) worked in a highCOVID-19 density area, 671 (44.3 %) were women, and 809 (53.4 %) worked in private practice. Among responders, 186 (12.3 %) expressed insomnia, 222 (14.6 %) anxiety, and 189 (12.5 %) depression symptoms. Lack of protective equipment, increased teleradiology activity and negative impact on education were risk factors for insomnia (respectively OR [95 %CI]:1.7[1.1-2.7], 1.5[1.1-2.2], and 2.5[1.8-3.6]). Female gender, respiratory history, working in COVID-19 high density area, increase of COVID-19 related activity, and impacted education were risk factors for anxiety (OR[95 %CI]:1.7[1.2-2.3], 2[1.1-3.4], 1.5[1.1-2], 1.2[1-1.4], and 2.1[1.5-3]). Conversely, working in a public hospital was a protective factor against insomnia, anxiety, and depression (OR[95 %CI]:0.4[0.2-0.7], 0.6[0.4-0.9], and 0.5[0.3-0.8]). CONCLUSIONS: During COVID-19 pandemic, many radiologists expressed depression, anxiety and insomnia symptoms. Working in a public hospital was a protective factor against every psychological symptom. Socio-economic impact was also major especially in private practice.

Differences in treatment choices for localised prostate cancer diagnosed in private and public health services.

OBJECTIVE: To compare treatments for localised prostate cancer for men diagnosed in private and public health services in Victoria. DESIGN: Retrospective analysis of Victorian Cancer Registry data linked to population-based administrative health datasets. SETTING, PARTICIPANTS: 29 325 Victorian men diagnosed with prostate cancer during 2011-2017. MAIN OUTCOME MEASURES: Proportions of men in private and public health services receiving radical prostatectomy (with or without curative radiation therapy) or curative external beam radiation therapy alone within 12 months of diagnosis. RESULTS: After adjusting for age, tumour classification and comorbidity, men diagnosed in private health services received radical treatment more frequently than men diagnosed in public health services (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.31-1.49). The proportion of private patients who underwent radical prostatectomy was larger than that for public patients (44% v 28%; OR, 2.28; 95% CI, 2.13-2.44) and the proportion of private patients who received curative external beam radiation therapy alone (excluding brachytherapy) was smaller (9% v 19%; OR, 0.45; 95% CI, 0.42-0.49). These differences were apparent for all International Society of Urological Pathology (ISUP) tumour grades. The magnitude of the difference for prostatectomy was greater for men aged 70 years or more; for radiation therapy alone, it was larger for those diagnosed before age 70. The differences between private and public services narrowed during 2011-2017 for men with ISUP grade 1 disease, but not ISUP grade 2-5 tumours. CONCLUSION: Prostate cancer treatment choices differ substantially between men diagnosed in private and public health services in Victoria. These differences are not explained by disease severity or comorbidity.

Impact of the SARS-CoV-2 epidemic on private ENT consulting practice during the first month of lockdown in Réunion Island in 2020.

OBJECTIVE: To analyze the impact of the first month of lockdown related to the 2020 SARS-Cov-2 epidemic on the consulting activity of private ENT physicians in Réunion Island. MATERIAL AND METHODS: A multicenter prospective study analyzed the consulting activity of 12 ENT physicians in full-time private practice. The main endpoints were the number, characteristics and conditions of consultations. Secondary endpoints comprised presenting symptoms, diagnosis, prescriptions, adverse effects, and progression of monthly consulting turnover. RESULTS: Six hundred and ninety three consultations were performed during the study period (Appendix 1), with 50% emergency consultations. In 57.9% were face-to-face, 28.4% by phone and 13.7% video. In face-to-face consultation, the physician wore gloves in 53.8% of cases and a mask in 92.2%: surgical mask in 71.6% of cases and FFP2 in 28.4%. The three most frequent symptoms (48.5% of cases) were otalgia, hearing impairment, and vertigo. The three most frequent diagnoses (60.6% of cases) were otitis, intra-auricular foreign body (including wax), and pharyngeal infection. The three most frequently prescribed complementary exams (74.3% of cases) were imaging, hearing work-up, and specialist opinion. The three most frequently prescribed treatments (52.7% of cases) were intra-auricular drops, oral antibiotics, and nasal spray. The incidence of adverse effects was 0.001%. None of the physicians or patients seemed to have been infected by Covid-19 during the study period. There was a 47.3-91% (median, 75.6%) drop in monthly consultation turnover. CONCLUSION: The present study underscored the availability and adaptability of ENT physicians in the Réunion Island in an epidemic context, although economic impact was detrimental.

Surveillance patterns of cervical cancer patients treated with conization alone.

OBJECTIVES: To determine surveillance patterns of stage I cervical cancer after cervical conization. METHODS: A 25-question electronic survey was sent to members of the Society of Gynecologic Oncology. Provider demographics, surveillance during year 1, years 1-3, and >3 years after cervical conization, use of pelvic examination, cytology, Human papillomavirus testing, colposcopy, and endocervical curettage were queried. Data were analyzed. RESULTS: 239/1175 (20.1%) responses were collected over a 5-week study period. All providers identified as gynecologic oncologists. During year 1, 66.7% of providers perform pelvic examination and 37.1% perform cytology every 3 months. During years 1-3, 61.6% perform pelvic examination and 46% perform cytology every 6 months. At >3 years, 54.4% perform pelvic examination every 6 months and 43% perform annual pelvic examination. 66.7% of respondents perform cytology annually, and 51.9% perform annual Human papilloma virus testing. 85% of providers do not offer routine colposcopy and 60% do not offer endocervical curettage at any point during 5-year follow-up. 76.3% of respondents screen patients for Human papilloma virus vaccination. CONCLUSIONS: To date, there are no specific surveillance guidelines for patients with stage I cervical cancer treated with cervical conization. The most common surveillance practice reported is pelvic examination with or without cytology every 3 months in year 1 and every 6 months thereafter. However, wide variation exists in visit frequency, cytology, and Human papillomavirus testing, and there is a clear trend away from using colposcopy and endocervical curettage. These disparate surveillance practices indicate a need for well-defined, uniform surveillance guidelines.

The Influence of Academic Hospitalists on Labor and Delivery Outcomes.

BACKGROUND: Our goal was to examine differences in maternal and neonatal outcomes following the transition from a private practice to an academic model at a community hospital. METHODS: This is a retrospective cohort study of a high-volume community hospital labor and delivery unit. A private practice hospitalist group was replaced with academic hospitalists. Maternal and neonatal outcomes for patients cared for by these groups were compared. The primary outcome was a composite of maternal morbidity that included blood transfusion, anal sphincter injuries, dilation and curettage, hysterectomy, chorioamnionitis, endometritis, wound infection, intensive care unit admission, and readmission. The secondary outcomes were cesarean delivery rate and a composite of neonatal morbidity that included Apgar score ≤3 at 5 min, shoulder dystocia, birth trauma, seizure, sepsis, necrotizing enterocolitis, intraventricular hemorrhage, or mechanical ventilation. RESULTS: 245 patients were delivered by private physicians and 447 by academic physicians over the study period. No difference in the composite maternal morbidity between private and academic hospitalist groups was identified (21 vs. 25%; aOR 1.37, 95% CI: 0.36-5.21). The academic hospitalist group had a higher cesarean delivery rate compared to the private group (25 vs. 18%; aOR 2.03, 95% CI: 1.17-3.53). There was no difference in a composite neonatal morbidity (9 vs. 8%; aOR 0.92, 95% CI: 0.052-1.63). CONCLUSION: Women cared for by academic hospitalists were more likely to have a cesarean delivery, but there was no difference in maternal or neonatal morbidity in patients delivered by private or academic hospitalists.