Use of Rheumatologic Testing in Patients Who Eventually Receive a Diagnosis of Rheumatoid Arthritis.

OBJECTIVES: Anti-cyclic citrullinated peptide antibody (ACPA) has excellent specificity and prognostic value in patients with early rheumatoid arthritis (RA). The American College of Rheumatology included ACPA in their 2010 classification criteria for RA, but we hypothesize that primary care physicians (PCPs) underuse ACPA, even when clinical suspicion for RA is high. We aimed to describe their use of diagnostic testing in patients who were referred to a rheumatologist and eventually diagnosed as having RA. METHODS: In this retrospective cohort study, a systematic abstraction tool was used to review the medical records of patients seen between January 1, 2010 and June 15, 2014 in two rheumatology clinics: one private practice and one community health center associated with an academic medical center. For purposes of hypothesis generation, we compared the characteristics of patients with and without testing using unpaired t tests or Fisher exact tests. RESULTS: We identified 173 patients with RA referred from 141 different PCPs: 82.7% were women with a mean ± standard deviation age of 55.5 ± 18.6 years. ACPA and rheumatoid factor were ordered in 28.9% (95% confidence interval 22.6-36.2) and 41.0% (95% confidence interval 33.9-48.6) of patients, respectively. Imaging was underused. Almost half (45.7%, or 37/81) of the patients with documented symptom duration had a delay of at least 1 year before referral; however, ACPA utilization was not associated with the delay to treatment initiation. CONCLUSIONS: Most PCPs failed to order diagnostic tests for RA before referring a patient with polyarthritis who eventually received a diagnosis of RA. We also observed delays in diagnosis, with half of the patients waiting >1 year from symptom onset to diagnosis. These findings suggest educational efforts for PCPs should focus on emphasizing earlier diagnostic workups, especially ACPA, in patients suspected to have RA.

Feasibility, safety, and patient satisfaction of same-day discharge following peripheral arterial interventions: A randomized controlled study.

OBJECTIVE: To assess feasibility, safety, and patient satisfaction of same-day discharge (SD) following peripheral arterial interventions. BACKGROUND: Although diagnostic angiography is routinely performed as a same-day procedure, same-day percutaneous trans-luminal angioplasty is less common. Because there is very low incidence of peri-procedural complications after 4 hr, discharge after this window is possible provided the patient is able to ambulate and has necessary social support. To-date, safety and patient satisfaction related to SD has not been studied systematically in this population. METHOD: After providing informed consent, patients undergoing out-patient peripheral arterial interventions in a single institution between 2011 and 2015 were randomized to usual care (overnight stay, OS) or SD following successful interventions. Patient satisfaction, complications, and readmission status was ascertained by blinded telephone interviewers at 48-72 hr and 10 days post-procedure. RESULTS: A total of 24 patients consented. Of these, 5 (21.7%) failed screening, leaving 19 patients for randomization to control (n = 10) and experimental group (n = 9) conditions. The SD group experienced zero complications, however their Likert scale rating scores were significantly lower than OS for perceived level of safety (P = 0.02) and likelihood of having the procedure again (P = 0.004). CONCLUSION: This small, single-center randomized study found that among carefully selected peripheral arterial interventions, SD may be feasible and safe. However, patient satisfaction and perceived safety were significantly lower among SD compared to the OS condition. Larger prospective studies are warranted to confirm these findings.

A Multicenter Evaluation of Adherence to 4 Major Elements of the Baveno Guidelines and Outcomes for Patients With Acute Variceal Hemorrhage.

GOALS: To determine the rate of and outcomes associated with guideline adherence in the care of acute variceal hemorrhage (AVH). BACKGROUND: Four major elements of high-quality care for AVH defined by the Baveno consensus (VI) include timely endoscopy (≤12 h), antibiotics, and somatostatin analogs before endoscopy and band ligation as primary therapy for esophageal varices. STUDY: We retrospectively evaluated 239 consecutive admissions of 211 patients with AVH admitted to 2 centers in Massachusetts from 2010 to 2015. The primary outcome was 6-week mortality; secondary outcomes included treatment failure (shock, hemoglobin drop by 3 g/dL, hematemesis, death ≤5 d), length of stay, and 30-day readmission. RESULTS: Guideline adherence was variable: endoscopy ≤12 hours (79.9%), antibiotics (84.9%), band ligation (78.7%), and somatostatin analogs (90.8%). However, only 150 (62.8%) received care that was adherent to all indicated criteria. The 6-week mortality rate was 22.6%. Treatment failure occurred in 50 (21.0%) admissions. Among the 198 patients who survived to discharge, 41 (20.7%) were readmitted within 30 days. Octreotide before endoscopy was associated with a reduction in 30-day readmission (18.4% vs. 42.1%; P=0.03), whereas banding of esophageal varices was associated with a reduced risk of treatment failure (15.0% vs. 50.0%; P≤0.001). However, adherence to quality metrics did not significantly reduce the risk of death within 6 weeks. CONCLUSIONS: Adherence to quality metrics may not reduce the risk of mortality but could improve secondary outcomes of AVH. Variation in practice should be addressed through quality improvement interventions.

Perioperative Use of Focused Transthoracic Cardiac Ultrasound: A Survey of Current Practice and Opinion.

BACKGROUND: The advent of portable ultrasound machines in recent years has led to greater availability of focused cardiac ultrasound (FoCUS) in the perioperative and critical care setting. To our knowledge, its use in the perioperative setting among anesthesiologists remains undefined. We sought to assess the use of FoCUS by members of the Society of Cardiovascular Anesthesiologists (SCA) in clinical practice, to identify variations in its application, to outline limits to its use, and to understand the level of training of physicians using this technology. METHODS: A 26-question anonymous and voluntary online survey assessing the participants' training level with FoCUS, frequency of use, and opinions regarding incorporating it into residency training and developing a pathway to basic certification. The survey was distributed to the members of the SCA via email. RESULTS: The survey was completed by 379 of 3660 members of the SCA (10%). Of the respondents, the majority (67%) had completed a cardiovascular anesthesiology fellowship with 58% identifying their practice as academic, while 37% stated they were in private practice, and 6% were military/Veterans Administration. Most (84%) of the respondents practiced in North America. Eighty-one percent reported familiarity with FoCUS, while 47% stated they use it in their clinical practice. Those practicing in North America were significantly less likely to utilize FoCUS in their practice as compared to other respondents. With regard to training and certification, 88% believe FoCUS education should be integrated into residency training programs and 74% believe there should be a pathway to basic certification for FoCUS. CONCLUSIONS: While most cardiovascular anesthesiologists are familiar with FoCUS, a minority have integrated it into their practice. Roadblocks such as lack of training, the fear of missing diagnoses, lack of resources, and the lack of a formal certification process must be addressed to allow for more widespread use of perioperative cardiac ultrasound.

Radiologists' Recommendations for Additional Imaging on Inpatient CT Studies: Do Referring Physicians Follow Them?

OBJECTIVES: Studies have found that recommendations for additional imaging (RAI) accompany up to 31% of index computed tomography (CT) scans. In this study we assessed the frequency with which recommendations are accepted by the referring physician and the impact of AI on case management. METHODS: We performed a cross-sectional study of all index CT scans of the chest, abdomen, and pelvis performed on adult inpatients during a 1-month period at a tertiary medical center. Each radiology report was examined for mention of RAI. We used a standardized abstraction tool to review medical records for the indication for the RAI (related to original diagnosis vs incidental finding), the clinician's rationale for pursuing or discarding the RAI, and the impact of the AI on the inpatient treatment plan. RESULTS: Among the 430 scans reviewed, most (57.7%) were of the abdomen/pelvis. RAI was recommended in 67 cases (odds ratio [OR] 15.6%; 95% confidence interval [CI] 12.4-19.3) and AI was completed in 24 of 67 cases (35.8%). Factors associated with a recommendation for AI were the presence of an incidental finding (OR 3.5, 95% CI 1.7-6.8) and verbal communication of the result to the ordering provider (OR 2.09, 95% CI 1.23-3.5). When performed, AI altered the treatment plan 75% (18/24) of the time. Among the 43 cases in which AI was not performed, 34.1% were deferred to outpatient, 13.6% underwent alternative clinical intervention, and 13.6% were judged unnecessary by the primary team. No rationale was documented in the chart for the remaining 38.6%. CONCLUSIONS: Despite concerns about autoreferral by radiologists for AI studies, we found a lower rate than in many prior studies, which may reflect a change in clinical practice. One-third of these recommendations were implemented and verbal communication was strongly associated with the likelihood of second image ordering. In the majority of the cases, the AI affected patient management. Based on these findings, radiologists should consider calling the ordering provider to increase the likelihood that the primary team will follow their recommendations.

Focused Transthoracic Cardiac Ultrasound: A Survey of Training Practices.

OBJECTIVE: The role of focused assessment by transthoracic echocardiography or focused cardiac ultrasound (FoCUS) in the perioperative setting is uncertain and evolving. To the authors' knowledge, there are no studies that evaluate the current teaching practices regarding FoCUS in US anesthesiology residencies. The authors surveyed residents and residency program directors to examine the frequency, type, and variability of instruction regarding training of FoCUS. DESIGN: A survey study. SETTING: Anesthesiology residency programs in the United States. PARTICIPANTS: All 133 Accreditation Council for Graduate Medical Education anesthesiology program directors and their residents were invited to participate in an anonymous electronic survey. MEASUREMENTS AND MAIN RESULTS: In all, 292 respondents replied to the survey, and 245 were included in the analysis. Overall response rate was 30% for program directors. The majority of the respondents were trainees (83.7%). FoCUS training was reported to be present by 36% of respondents. Respondents from institutions in which>10% of attending physicians used FoCUS were nearly 3 times as likely as those in which fewer attending physicians used FoCUS to report presence of FoCUS training program. The most common training mode is lectures with simulation (34%), followed by bedside training (31%). The most frequently reported responsible training parties were anesthesiologists (75%), followed by cardiologists (14%). Although FoCUS training is relatively rare, most respondents (187 of 205 residents and 26 of 40 program directors) said that FoCUS should be the standard in training for anesthesia residents. CONCLUSIONS: Despite the increasing availability and use of ultrasound in clinical practice, FoCUS-related use and training remain uncommon in anesthesiology. Trainees in anesthesiology are not receiving adequate instruction in FoCUS despite their desire to acquire this skill.

Reappearance and treatment of penicillin-susceptible Staphylococcus aureus in a tertiary medical centre.

OBJECTIVES: The purpose of this study was to describe trends in the prevalence and treatment patterns of penicillin-susceptible Staphylococcus aureus (SA) infections. METHODS: This was a cross-sectional study of MSSA isolates from blood cultures at a tertiary-care centre between 1 January 2003 and 31 December 2012. All blood cultures positive for MSSA drawn during the study period were used to calculate the prevalence of penicillin-susceptible SA. Repeat cultures were excluded if they were isolated within 6 weeks of the index culture. The analysis was then restricted to inpatient blood cultures to assess treatment patterns. Antibiotics administered 48-96 h after the culture were analysed. RESULTS: A total of 446 blood cultures positive for MSSA were included in the analysis. There was a distinct trend showing an increase in the percentage of penicillin-susceptible SA over 10 years from 13.2% (95% CI 4.1%-22.3%) in 2003 to 32.4% (95% CI 17.3%-47.5%) in 2012 (P trend <0.001). During the study period, penicillin use for penicillin-susceptible SA bacteraemia increased from 0.0% in 2003-04 to 50.0% in 2011-12 (P trend = 0.007). CONCLUSIONS: Over a decade, there was an ∼3-fold increase in penicillin susceptibility among MSSA blood cultures at a large tertiary-care facility. Although treatment with penicillin increased over the study period, only 50% of penicillin-susceptible SA was treated with penicillin in the final study period. This study suggests that while susceptibility to penicillin appears to be returning in SA, the use of penicillin for penicillin-susceptible SA bacteraemia is low.

Mobile vitreous opacities on ocular ultrasonography are not always pathologic: a cross-sectional survey in an asymptomatic population.

BACKGROUND: Ultrasonography is often used in the evaluation of patients with ocular concerns; however, several pathologic conditions and even some age-related changes can have similar sonographic appearances. One approach that clinicians use is to assume that unilateral findings visible at normal gain are acute, whereas bilateral findings requiring high gain are chronic, especially in the elderly population. To date, no studies have systematically evaluated this assumption. OBJECTIVES: The objectives are to determine the prevalence of monocular and binocular mobile vitreous opacities (MVOs) in the vitreous chamber in an asymptomatic population at normal and high gain levels and to determine its prevalence with higher age stratifications. METHODS: We conducted a cross-sectional survey using 2-dimensional ultrasonography with a high-frequency transducer of 105 asymptomatic subjects aged 20-89 years and evaluated each subject's eyes for the presence of MVOs at both normal and high gain levels in progressive age stratifications. RESULTS: Ultrasonographic scans were obtained on 105 subjects. At normal gain levels, MVO was present in only 1 subject (0.95%; 95% confidence interval, 0.0%-5.0%). At high gain levels, MVO was present in 28.6% (30/105) of subjects. Of the subjects with MVO at high gain, 60% (18/30) had unilateral MVO. Mobile vitreous opacity was found more frequently with advancing age, being present in 23 subjects older than 59 years, compared with 7 subjects 59 years and younger (51.1% vs 11.7%, P < .001). CONCLUSIONS: Mobile vitreous opacity in the vitreous chamber visualized at high gain levels is relatively common and may not be pathologic, even if unilateral and occurring at a relatively young age.

Procedural sedation for MRI in children with ADHD.

BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood, affecting 5-8% of children. It has been observed that these children have poor sedation experiences; however, to date there is minimal research on procedural sedation in this population. AIM: To examine whether children with ADHD required larger doses of propofol for magnetic resonance imaging (MRI) sedation. METHODS: The hospital's administrative billing database was used to identify all billing codes for MRI brain scans (with and without contrast) in children aged between 5 and 12 years over the preceding 5.5 years. The hospital's electronic medical record database provided baseline demographics. The sedation record was reviewed for propofol dose, psychostimulant use, and prescribed dose. All children received a standard weight-based dose of midazolam prior to receiving the necessary amount of propofol. Primary outcome was the dose of propofol administered (mg·kg(-1) ) to achieve adequate sedation. RESULTS: A total of 258 procedures met the inclusion criteria. The sample was 52% male, 74% White, 7.8% Black, 7.8% Hispanic, 4.3% Asian, and 6.2% other. ADHD was documented for 49 procedures with a prevalence of 18.5%. Patients with ADHD were older, more likely to be male, Hispanic, or to report race as 'Refused/Unknown'. Indications for MRI for patients with ADHD varied significantly, with 'Behavioral' and 'Neurocutaneous' being significantly overrepresented in the ADHD group. The average sedative dose for all patients was 2.8 mg·kg(-1) (95% CI 2.62-2.94). Sedative dose was similar among children with and without ADHD diagnosis. CONCLUSIONS: Our study illustrates that children with ADHD do not have higher sedative requirements to achieve a successful brain MRI.

Heart rate response to a caudal block in children anesthetized with sevoflurane after ultrasound confirmation of placement.

INTRODUCTION: Previous studies identified decreasing heart rate (HR) as a predictor of successful caudal placement in children using halothane and isoflurane. No changes were found in HR in the one study using sevoflurane. We documented HR changes in children following a caudal block during sevoflurane anesthesia utilizing ultrasound to confirm successful caudal placement. METHODS: Seventy-one children (1-82 months) were anesthetized with sevoflurane. A caudal block was placed with confirmation by ultrasound. Four aliquots of bupivacaine 0.2% with epinephrine 5 µg · cc(-1) were administered for a total volume of 1 cc · kg(-1) with HR recorded for 4 min. The outcomes measured were HR changes from the initial baseline and during each 1-min interval. The age-related differences in HR were also analyzed. RESULTS: Heart rate change from the initial baseline after placing the caudal needle and allowing for equilibration ranged from -10.2% to +8.9% and the HR change from the baseline at the start of each aliquot injection ranged from -9.5% to +8.9%. Most participants (n = 60, 84.5%) experienced at least one HR reduction over the observation period. For patients < 36 months, the HR change ranged from -11 to +12 b · min(-1) (mean -0.3); for patients aged ≥ 36 months, the HR change ranged from -10 to +6 b · min(-1) (mean -1.1). CONCLUSIONS: Heart rate changes following a caudal block in children ≤ 82 months of age anesthetized with sevoflurane is not a reliable indicator of a successful block. Despite 100% caudal success, many children had no decrease in HR, and in those that did, the decline was of a magnitude indeterminate from beat-to-beat variability.

Healthcare Professionals' Perceptions and Knowledge of the USPSTF Guidelines on Breast Self-Examination.

OBJECTIVES: In 2009, the US Preventive Services Task Force (USPSTF) published revised guidelines for breast cancer screening, which recommended against teaching breast self-examination (BSE). The objective of this study was to assess providers' perceptions and knowledge regarding these updated guidelines. METHODS: A cross-sectional survey study was administered to 205 attending and resident physicians, nurse practitioners, physician's assistants, and registered nurses working in five medical and gynecological practices affiliated with a large academic teaching hospital in western Massachusetts. The survey solicited demographic data and inquired about practitioners' perceptions and knowledge of the revised guidelines. RESULTS: Fewer than half (41.1%) of respondents correctly identified the new USPSTF guidelines for BSE. Among those who stated they were aware of guidelines, only 37.1% adhered to them. Overall, 70% report that they teach patients to perform BSE. Teaching BSE was associated with female sex (odds ratio [OR] 2.64, 95% confidence interval [CI] 1.11-6.29), a belief that BSE reduces morbidity and mortality (OR 2.91, 95% CI 1.08-7.81), and internal medicine residency (OR 0.18, 95% CI 0.06-0.59). CONCLUSIONS: Knowledge of the 2009 USPSTF guidelines is suboptimal and greater efforts should be made to educate healthcare professionals about them.

Healthcare Providers' Knowledge of Diets and Dietary Advice.

OBJECTIVES: Little is known about healthcare providers' knowledge of dietary evidence or about what dietary advice providers offer to patients. The objective of our study was to determine which diets providers recommended to patients and providers' beliefs about the evidence behind those recommendations. METHODS: This was a 22-question cross-sectional survey conducted between February 2013 and September 2013, in 45 ambulatory practices within two health systems. Attending physicians, housestaff, and advanced practitioners in internal medicine, medicine-pediatrics, family medicine, cardiology, and endocrinology practices were audited. Providers' attitudes, perceptions, and beliefs about diet modification were collected. Knowledge scores were constructed based on the number of correct responses to specific questions. RESULTS: Of 343 provider responses, largely from primary care specialties (n = 3027, 90%), the top dietary recommendations were low-salt diet (71%) for hypertension, low-carbohydrate diet (64%) for uncontrolled diabetes mellitus, low saturated fat diet (73%) for dyslipidemia, low-calorie diet (72%) for obesity, and low saturated fat diet (63%) for coronary heart disease. Providers believed that 51% of diet recommendations were supported by randomized trial evidence when they were not. Respondents' overall knowledge of randomized trial evidence for dietary interventions was low (mean [standard deviation] knowledge score 44.3% [22.4%], range 0.0%-100.0%). The survey study from two health systems, using a nonvalidated survey tool limits external and internal validity. CONCLUSIONS: Providers report recommending different diets depending on specific risk factors and generally believe that their recommendations are evidence based. Substantial gaps between their knowledge and the randomized trial evidence regarding diet for disease prevention remain.

Measurement of the quality of care of patients admitted with decompensated cirrhosis.

BACKGROUND & AIMS: Process-based quality measures are increasingly used to evaluate hospital performance. However, practices vary, and patients with cirrhosis are a challenge to manage, given their risks of mortality, morbidity, and resources utilization. In 2010, process-based quality measures were developed to improve the care of these patients. We examined adherence with these quality measures for a cohort of patients admitted with decompensated cirrhosis in 2009. METHODS: We performed a retrospective analysis of all patients admitted to a tertiary-care hospital with decompensated cirrhosis in 2009 (n = 149,379) hospitalizations. Quality indicator (QI) scores were calculated for each admission as a fraction, i.e., the number of quality markers met divided by the number of possible quality indices, given the patient's presentation (range, 0-1). QI scores were correlated with patient characteristics and clinical outcomes (30-day readmission; inpatient death). RESULTS: Quality indicators were met 45% of the time (95% confidence interval, 40-51%). In multivariable analysis, QI scores were significantly lower among non-English-speaking patients and those who had congestive heart failure. QI scores were higher among patients with gastrointestinal bleeding or encephalopathy-related admission to the hospital. QI scores were not associated with inpatient mortality or 30-day readmission. CONCLUSION: There is substantial opportunity to improve the care of patients hospitalized for decompensated cirrhosis. Additional research is needed to identify effective strategies for closing gaps in care. Adherence to quality measures did not affect clinical outcomes, but if easily measured in other settings could be used to compare hospitals and practices.

Do physicians underrecognize obesity?

OBJECTIVES: A physician's advice is among the strongest predictors of efforts toward weight management made by obese patients, yet only a minority receives such advice. One contributor could be the physician's failure to recognize true obesity. The objectives of this study were to assess physicians' ability to recognize obesity and to identify factors associated with recognition and documentation of obesity. METHODS: Internal medicine residents and attending physicians at three academic urban primary care clinics and their adult patients participated in a study using recognition and documentation of patient obesity as the main measures. RESULTS: A total of 52 physicians completed weight assessments for 400 patients. The mean patient age was 51 years, 56% were women, 77% were Hispanic, and 67% had one or more obesity-related comorbidity. There were 192 (48%) patients, of whom 66% were correctly identified by physicians as being obese, 86% of those with a body mass index (BMI) ≥ 35, but only 49% of those with a BMI of 30 to 34.9 (P < 0.0001). Fewer obese Hispanic patients were identified than were non-Hispanic patients (62% vs 76%; P = 0.03). No physician characteristics were significantly associated with recognition of obesity. Physicians documented obesity as a problem for 51% of patients. Attending physicians documented obesity more frequently than did residents (64% vs 43%, odds ratio 2.5, 95% confidence interval 1.3-4.6) and normal-weight physicians documented obesity more frequently than overweight physicians (58% vs 41%, odds ratio 2.0, 95% confidence interval 1.0-4.0). Documentation was more common for patients with a BMI ≥ 35 and for non-Hispanics. Documentation was not more common for patients with obesity-related comorbidities. CONCLUSIONS: Physicians have difficulty recognizing obesity unless patients' BMI is ≥ 35. Training physicians to recognize true obesity may increase rates of documentation, a first step toward treatment.

Comparison of Healthcare Costs for Women with Treated Versus Untreated Vasomotor Symptoms Due to Menopause.

INTRODUCTION: The study objective was to estimate all-cause healthcare resource utilization (HCRU) and medical and pharmacy costs for women with treated versus untreated vasomotor symptoms (VMS) due to menopause. METHODS: A retrospective study was conducted using US claims data from Optum Research Database (study period: January 1, 2012-February 29, 2020). Women aged 40-63 years with a VMS diagnosis claim and ≥ 12 and ≥ 18 months of continuous enrollment during baseline and follow-up periods, respectively, were included. Women treated for VMS were propensity score matched 1:1 to untreated controls with VMS. Standardized differences (SDIFF) ≥ 10% were considered meaningful. A generalized linear model (gamma distribution, log link, robust standard errors) estimated the total cost of care ratio. Subgroup analyses of on- and off-label treatment costs were conducted. RESULTS: Of 117,582 women diagnosed with VMS, 20.5% initiated VMS treatment and 79.5% had no treatment. Treated women (n = 24,057) were matched to untreated VMS controls. There were no differences in HCRU at follow-up (SDIFF < 10%). Pharmacy ($487 vs $320, SDIFF 28.4%) and total ($1803 vs $1536, SDIFF 12.6%) costs were higher in the treated cohort. Total costs were 7% higher in the treated cohort (total cost ratio 1.07, 95% CI 1.05-1.10, P < 0.001). The on-label treatment pharmacy costs ($546 versus $315, SDIFF 38.6%) were higher in the treated cohort. Off-label treatment had higher medical costs ($1393 versus $1201, SDIFF 10.4%). CONCLUSIONS: Most women with VMS due to menopause were not treated within 6 months following diagnosis. While both on- and off-label treatment increased the total cost of care compared with untreated controls, those increases were modest in magnitude and should not impede treatment for women who report symptom improvement as a result of treatment.

Total cost of care of Medicare Advantage beneficiaries participating in an appointment-based model in a national pharmacy chain.

BACKGROUND: The appointment-based model (ABM) is a pharmacy service to improve medication-related health outcomes. ABM involves medication synchronization and medication review, plus other services such as medication reconciliation, medication therapy management, vaccine administration, and multimedication packaging. ABM can improve medication adherence, but the economic impact is unknown. OBJECTIVE: To assess the effect of a national pharmacy chain's ABM program for Medicare Advantage beneficiaries on total cost of care (TCOC). METHODS: This study analyzed administrative claims data from April 7, 2017, through February 29, 2020, for Medicare Advantage beneficiaries with Part D using a propensity score-matched cohort design. The national pharmacy chain provided a list of ABM participants. Eligibility criteria for the ABM and control (non-ABM) groups included age 65 years or older on the index date (initial participation, ABM; random fill date, control) and continuous enrollment from at least 6 months pre-index (baseline) date through at least 6 months post-index (follow-up) date. Medical inflation-adjusted (2020) TCOC was calculated as the sum of all health care spending from Medicare Advantage beneficiaries with Part D plan and patient paid amounts, standardized to per patient per month (PPPM), during the follow-up period. Secondary outcomes included medication adherence calculated across prevalent maintenance therapeutic classes using proportion of days covered (PDC). RESULTS: Each group contained 5,225 patients with balanced characteristics after matching: 64% female, 73% White, mean age 75 years, mean Quan-Charlson comorbidity index score 0.9, and hypertension and dyslipidemia, each >65%. Median baseline all-cause PPPM health care costs in the ABM and control groups, respectively, were $517 and $548 ($221 and $234 medical, $135 and $164 pharmacy). Baseline PDC of at least 80% was 83% in the ABM group and, similarly, 84% in the control group. The mean (SD) follow-up was 604 (155) days for the ABM group and 598 (151) days for the control group. During the follow-up period, the median PPPM TCOC for the ABM group was $656 and was $723 for the control group (P = 0.011). Median pharmacy costs were also significantly less in the ABM group ($161 vs $193, P < 0.001), whereas median medical costs were $328 in the ABM group and $358 among controls (P = 0.254). More patients in the ABM group were adherent during follow-up, with 84% achieving PDC of at least 80% vs 82% among controls (P = 0.009). CONCLUSIONS: The ABM program was associated with significantly lower follow-up median total costs (medical and pharmacy), driven primarily by pharmacy costs. More patients were adherent in the ABM program. Payers and pharmacies can use this evidence to assess ABM programs for their members.

An Exploratory Study of Physician Decision-Making When Treating Uncontrolled COPD.

Purpose: Current guidelines recommend triple therapy maintenance inhalers for patients with recurrent exacerbations of chronic obstructive pulmonary disease (COPD); however, these maintenance therapies are underutilized. This study aimed to understand how physicians make COPD treatment decisions, and how combination maintenance therapies are utilized in a real-world setting. Patients and Methods: This exploratory, hypothesis-generating, non-interventional study used a cross-sectional online survey that was administered to a sample of practicing physicians in the United States. The survey included five fictitious vignettes detailing common symptoms experienced by patients with COPD. Survey questions included factors physicians consider in their decisions, and perceived barriers to prescribing treatments. Repeated measures multivariable analyses were conducted to evaluate how likely physicians were to switch to triple therapy versus no change to patient's current maintenance therapy or change to another maintenance therapy. Results: In total, 200 physicians completed the survey. Cost of treatment and patient access to treatment were reported as the most common barriers physicians consider in their prescribing decisions. Physicians were more likely to switch a patient's maintenance inhaler to triple therapy versus no change to maintenance inhaler if they considered the patient's history of new symptoms, insurance status, and clinical guidelines in their decision. Physicians with more experience treating patients with COPD, and those who treat more patients with COPD per week, were more likely to switch to triple therapy versus no change to maintenance inhaler. Conclusion: This study demonstrates the complexity of factors that can influence physicians' decisions when prescribing treatments for patients with COPD, including considerations of treatment cost, patient access and adherence, patient comorbidities, efficacy of current treatment, clinical guidelines, and provider's level of experience treating COPD. Further research may help elucidate the relative importance of the factors influencing physicians' decisions and inform what types of decision-support tools would be most beneficial.

Chronic obstructive pulmonary disease (COPD) symptoms can be effectively managed with maintenance therapies, which are treatments that are taken routinely to help improve symptoms. A combination of three different therapies (triple therapy maintenance) has been shown to be more effective than a combination of two different therapies (dual therapy maintenance) in patients with moderate-to-severe COPD. However, maintenance therapies, including triple therapy, are underutilized. This study aimed to explore how physicians make their treatment decisions for patients with COPD, and how combination maintenance therapies are utilized. To do so, we administered a survey to a sample of practicing physicians in the United States. The survey included five clinically based, fictitious profiles, or vignettes, of patients with COPD, with common symptoms and patient characteristics being described. Physicians were then asked to answer questions about what treatment they would prescribe for each patient, and any factors they considered when deciding on a treatment for a patient. We found that cost of treatment and patient access to treatment were the most common barriers that physicians considered when choosing a treatment. Physicians were also more likely to switch a patient's maintenance inhaler to a triple therapy maintenance inhaler if they considered the patient's history of new symptoms, patient's insurance status, and clinical guidelines when making their decisions. Our study shows that there are many complex factors that influence physicians' decisions when deciding on a treatment for patients with COPD.

Unwarranted variability in antibiotic prophylaxis for cesarean section delivery: a national survey of anesthesiologists.

BACKGROUND: Current guidelines from the American College of Obstetricians and Gynecologists recommend antibiotic prophylaxis for cesarean delivery immediately before incision. The purpose of this study was to measure and describe correlates of adherence to these guidelines in a sample of United States anesthesiologists. METHODS: We invited a random sample of the membership of the American Society of Anesthesiologists (n = 10,000) to complete an online survey. RESULTS: Of 1052 respondents (10.5%) with complete information for analysis, 63.5% (95% confidence interval 60.6%, 66.3%, n = 668) reported preincision prophylaxis as the standard of care for scheduled cesarean delivery. Twenty-eight percent (n = 299) agreed that the anesthesiologist should take primary responsibility for prophylaxis timing. In a multivariable model, significant variability in preincision prophylaxis was noted for hospital type (community versus teaching, 62% vs 70%, P = 0.004), region (West versus Southeast, 70% vs 59%, P = 0.01; West versus Southwest, 70% vs 58%, P = 0.02), and respondents' belief in appropriate preincision timing (those endorsing routine preincision administration [80%], routine after cord clamp administration [17%], at the discretion of the obstetrician [47%], and the belief that more information was needed [43%]) (P < 0.001 all comparisons). Respondents' belief about appropriate preincision timing was the strongest discriminator in the model (change in area under the receiver operating characteristic curve = 0.13 vs ≤0.02 for all others). CONCLUSION: Adherence with current prophylactic antibiotic administration guidelines for cesarean delivery is not uniform. Education initiatives, regulatory maneuvers, and process improvement should be targeted at sites where anesthesiologists do not comply with current guidelines.

Effect of patients' awareness of CVD risk factors on health-related behaviors.

OBJECTIVES: In 2010, the American Heart Association unveiled a strategic plan to reduce cardiovascular deaths by targeting seven components of ideal cardiovascular health. Although education is a sensible first step, it is not known whether awareness correlates with healthy behavior. The objective of the study was to examine the association between awareness of risk factors and ideal cardiovascular health behavior. METHODS: We surveyed patients 40 years and older at five ambulatory clinics. The survey measured demographics, health management behaviors, comorbidities, and awareness of five modifiable cardiac risk factors (smoking, obesity, high cholesterol, hypertension and diabetes mellitus) and one protective factor (exercise). Healthy behavior was defined as follows: diabetes, hemoglobin A1c <8.0%; hypertension, systolic blood pressure <140 mm Hg), high cholesterol, medication adherence; obesity, attempting to lose weight; smoking, abstinence; and exercise, ≥ 30 minutes/day, ≥ 3 times per week. RESULTS: For five modifiable risk factors, awareness was positively associated with healthy behavior in multivariable models: obesity, hypertension, exercise, cholesterol, and diabetes. Awareness was inversely associated with smoking abstention. CONCLUSIONS: Awareness that a specific factor increases the risk for cardiovascular disease was positively associated with healthy behavior regarding most risk factors; however, the association was modest, suggesting that awareness alone does not motivate behavior.

Ethnic differences in the self-recognition of obesity and obesity-related comorbidities: a cross-sectional analysis.

BACKGROUND: Obesity and its related co-morbidities place a huge burden on the health care system. Patients who know they are obese may better control their weight or seek medical attention. Self-recognition may be affected by race/ethnicity, but little is known about racial/ethnic differences in knowledge of obesity's health risks. OBJECTIVE: To examine awareness of obesity and attendant health risks among US whites, Hispanics and African-Americans. DESIGN: Cross-sectional self-administered survey. PARTICIPANTS: Adult patients at three general medical clinics and one cardiology clinic. MAIN MEASURES: Thirty-one questions regarding demographics, height and weight, and perceptions and attitudes regarding obesity and associated health risks. Multiple logistic regression was used to quantify the association between ethnicity and obesity awareness, controlling for socio-demographic confounders. KEY RESULTS: Of 1,090 patients who were offered the survey, 1,031 completed it (response rate 95%); a final sample size of 970 was obtained after exclusion for implausible BMI, mixed or Asian ethnicity. Mean age was 47 years; 64% were female, 39% were white, 39% Hispanic and 22% African-American; 48% were obese (BMI ≥30 kg/m(2)). Among obese subjects, whites were more likely to self-report obesity than minorities (adjusted proportions: 95% of whites vs. 84% of African-American and 86% of Hispanics, P = 0.006). Ethnic differences in obesity recognition disappeared when BMI was >35 kg/m(2). African-Americans were significantly less likely than whites or Hispanics to view obesity as a health problem (77% vs. 90% vs. 88%, p < 0.001); African-Americans and Hispanics were less likely than whites to recognize the link between obesity and hypertension, diabetes and heart disease. Of self-identified obese patients, 99% wanted to lose weight, but only 60% received weight loss advice from their health care provider. CONCLUSIONS: African-Americans and Hispanics are significantly less likely to self report obesity and associated health risks. Educational efforts may be necessary, especially for patients with BMIs between 30 and 35.