Incorporating Expected Outcomes Into Clinical Decision-Making for Total Knee Arthroplasty.

OBJECTIVE: Expected outcomes (e.g., expected survivorship after a cancer treatment) have improved decision-making around treatment options in many clinical fields. Our objective was to evaluate the effect of expected values of 3 widely available total knee arthroplasty (TKA) outcomes (risk of serious complications, time to revision, and improvement in pain and function at 2 years after surgery) on clinical recommendation of TKA. METHODS: The RAND/University of California Los Angeles appropriateness criteria method was used to evaluate the role of the 3 expected outcomes in clinical recommendation of TKA. The expected outcomes were added to 5 established preoperative factors from the modified Escobar appropriateness criteria. The 8 indication factors were used to develop 279 clinical scenarios, and a panel of 9 clinicians rated the appropriateness of TKA for each scenario as inappropriate, inconclusive, and appropriate. Classification tree analysis was applied to these ratings to identify the most influential of the 8 factors in discriminating TKA appropriateness classifications. RESULTS: Ratings for the 279 appropriateness scenarios deemed 34.4% of the scenarios as appropriate, 40.1% as inconclusive, and 25.5% as inappropriate. Classification tree analyses showed that expected improvement in pain and function and expected time to revision were the most influential factors that discriminated among the TKA appropriateness classification categories. CONCLUSION: Our results showed that clinicians would use expected postoperative outcome factors in determining appropriateness for TKA. These results call for further work in this area to incorporate estimates of expected pain/function and revision outcomes into clinical practice to improve decision-making for TKA.

Resveratrol causes cell cycle arrest, decreased collagen synthesis, and apoptosis in rat intestinal smooth muscle cells.

One of the most difficult and treatment-resistant complications of Crohn's disease is the development of fibrotic intestinal strictures due to mesenchymal cell hyperplasia and collagen deposition. Resveratrol, a phytoalexin found in berries, peanuts, grapes, and red wine, has been shown to inhibit fibrosis in vasculature, heart, lung, kidney, liver, and esophagus in animal models. Resveratrol has also been shown to inhibit oxidation, inflammation, and cell proliferation and to decrease collagen synthesis in several cell types or animal models. The aim of this study was to determine whether resveratrol has antifibrotic effects on intestinal smooth muscle cells. Responses to resveratrol by cultured smooth muscle cells isolated from colons of untreated Lewis rats were examined; this rat strain is used in a model of Crohn's disease with prominent intestinal fibrosis. A relative decrease in cell numbers following treatment with 50 and 100 µM resveratrol was evident at 24 h (P ≤ 0.005). This effect was largely due to cell cycle arrest, with an increase in the percent of cells in S phase from 8 to 25-35% (P < 0.05). Cell viability was unchanged until 2-3 days of treatment when there was a 1.2- to 5.0-fold increase in the percent of apoptotic cells, depending on the assay (P < 0.05). Expression of collagen type I protein was decreased following treatment with resveratrol for 24 h (to 44 and 25% of control levels with 50 and 100 µM resveratrol, respectively; P < 0.05). Expression of procollagen types I and III mRNA was also decreased with resveratrol treatment. Resveratrol (50 µM) diminished the proliferative response to TGF-ß1 (P = 0.02) as well as IGF-I-stimulated collagen production (P = 0.02). Thus resveratrol decreases intestinal smooth muscle cell numbers through its effects on cell cycle arrest and apoptosis and also decreases collagen synthesis by the cells. These effects could be useful in preventing the smooth muscle cell hyperplasia and collagen deposition that characterize stricture formation in Crohn's disease.

Variations in US hospital performance on imaging-use measures.

BACKGROUND: The Hospital Outpatient Quality Reporting Program (HOQR) publicly reports measures of US hospitals' use of 4 imaging studies that may be problematic if overused: magnetic resonance imaging (MRI) for low back, follow-up imaging after screening mammography, and abdominal and thoracic computed tomography (CT) with and without contrast. OBJECTIVES: To characterize performance on these measures, determine whether performance was consistent across measures, and identify hospital characteristics associated with highest-decile imaging use. RESEARCH DESIGN: Cross-sectional analysis. MEASUREMENTS: Correlation across measures was assessed using Spearman rank order tests. We linked 2008 HOQR data to the 2009 American Hospital Association Survey and used multivariable logistic regression to examine associations between hospital characteristics and the likelihood of highest-decile imaging use. RESULTS: Imaging use varied widely. Imaging use was weakly correlated (ρ<0.10) across most measures. Compared with hospitals with moderate imaging volume (25th to 75th percentile), hospitals with low volume (<25th percentile) were more likely to report highest-decile imaging use on all measures [adjusted odds ratios (95% confidence interval) range from 1.38 (1.05-1.80) for CT Abdomen to 4.22 (3.04-5.84) for MRI Back]. Rural hospitals were more likely to report highest-decile use on most measures [MRI: 1.42 (1.21-1.68), CT Abdomen: 1.46 (1.28-1.66), and CT Thorax: 1.32 (1.16-1.51)]. For-profit hospitals were more likely to report highest-decile use on mammography [1.47 (1.10-1.98)] and CT Thorax measures [1.71 (1.28-2.27)]. CONCLUSIONS: Wide variations in imaging use and extraordinarily high use at some hospitals may indicate that imaging overuse occurs at US hospitals. The effectiveness of the HOQR measures to decrease imaging overuse remains to be seen.

Impact of an electronic alert and order set on smoking cessation medication prescription.

INTRODUCTION: Tobacco cessation medication use increases the likelihood of a successful quit attempt, but few smokers are prescribed medications. Electronic health records (EHRs) may increase cessation medication prescription. This study aimed to assess the impact of an electronic alert and linked order set on cessation medication prescription. METHODS: This pre- and postintervention cohort study was conducted in an urban academic general internal medicine practice with a comprehensive EHR. All active smokers with 2 or more visits to the practice in 2008 (preintervention cohort) or 2009 (postintervention cohort) were included. An electronic alert and linked order set were designed and implemented. The primary outcome was prescription of any cessation medication (nicotine replacement therapy, bupropion, or varenicline). Secondary outcomes included counseling referral and change in smoking status to quit during the study period (i.e., "quit rate"). RESULTS: There were 1,349 and 1,346 smokers in the pre- and postintervention cohorts, respectively. Cessation medication prescription did not significantly change after the intervention (14.4% vs. 13.4% of smokers in the preintervention cohort, p = .5). Counseling referrals increased from 2.0% to 7.2% in the postintervention cohort (p < .001). More smokers in the postintervention cohort changed their smoking status to quit during the study period (20.5% vs. 17.1%, p = .06). CONCLUSIONS: This provider-directed electronic alert and linked order set failed to increase cessation medication prescription. The consistent failure of provider-directed efforts to increase cessation medication use suggests that this is a patient-limited process. Future efforts to improve tobacco treatment should focus on overcoming patient-level barriers to cessation medication use.

Use of electronic health record data to evaluate overuse of cervical cancer screening.

BACKGROUND: National organizations historically focused on increasing use of effective services are now attempting to identify and discourage use of low-value services. Electronic health records (EHRs) could be used to measure use of low-value services, but few studies have examined this. The aim of the study was to: (1) determine if EHR data can be used to identify women eligible for an extended Pap testing interval; (2) determine the proportion of these women who received a Pap test sooner than recommended; and (3) assess the consequences of these low-value Pap tests. METHODS: Electronic query of EHR data identified women aged 30-65 years old who were at low-risk of cervical cancer and therefore eligible for an extended Pap testing interval of 3 years (as per professional society guidelines). Manual chart review assessed query accuracy. The use of low-value Pap tests (ie, those performed sooner than recommended) was measured, and adverse consequences of low-value Pap tests (ie, colposcopies performed as a result of low-value Pap tests) were identified. RESULTS: Manual chart review confirmed query accuracy. Two-thirds (1120/1705) of low-risk women received a Pap test sooner than recommended, and 21 colposcopies were performed as a result of this low-value Pap testing. CONCLUSION: Secondary analysis of EHR data can accurately measure the use of low-value services such as Pap testing performed sooner than recommended in women at low risk of cervical cancer. Similar application of our methodology could facilitate efforts to simultaneously improve quality and decrease costs, maximizing value in the US healthcare system.