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Prehabilitation for Shoulder Dysfunction in Breast Cancer

Fri, 05/06/2016 - 4:26pm

Objective: To evaluate prehabilitation exercises to improve shoulder pain and abduction range of motion (ROM) after breast cancer surgery; to evaluate methods of exercise teaching; to assess postsurgical seroma formation.

Design: Pilot study

Setting: Academic medical center

Participants: 60 breast cancer patients were randomly assigned to either personal exercise instruction, group 1, n=36, or video only instruction, group 2, n=24.

Interventions: Shoulder exercises were assigned to both groups 1 month prior to surgery at an outpatient visit. Group 1 received personal instruction on exercises, plus written exercise instruction, and a link to access an online video. Group 2 received only written exercise instruction and a link to access the online video.

Main Outcome Measures: Exercise compliance, pain (via visual analog scale), shoulder abduction ROM (via goniometer), and presence or absence of seroma.

Results or Clinical Course: 76% of study patients chose to exercise. There was no difference in exercise compliance between personal instruction versus video teaching. (75%, 24/32 in-person vs. 77%, 10/13 video only, OR=1.03). 66% of patients (20/30) lost greater than 10 degrees shoulder abduction ROM at 1 month post surgery. 29% of patients (9/31) had worse shoulder pain at one month post surgery than at baseline (24%, 6/25 exercisers, and 50%, 3/6 non-exercisers). 15% of patients (4/27) had worse shoulder pain at 3 months post surgery than at baseline (8%, 2/25 exercisers, and 100%, 2/2 non-exercisers). Prehabilitation exercise program inferred no additional risk of seroma formation (21%, 7/33 exercisers vs. 22%, 2/9 non-exercisers OR=.94).

Conclusion: In-person teaching does not appear superior to video teaching for prehabilitation exercises in breast cancer. A high quality randomized controlled trial is necessary to assess efficacy of prehabilitation for improving post surgical outcomes. Prehabilitation exercises do not appear to increase risk of seroma formation in breast cancer surgery.

Prehabilitation Before Lumpectomy Can Prevent Loss of Range of Motion

Fri, 05/06/2016 - 3:59pm

Case Diagnosis: On intake exam, patient reported twenty year history of shoulder pain and history of bilateral subacromial bursitis . On the day of the exam, she rated her left shoulder pain (ipsilateral to breast cancer) at 2/10. Physical exam showed tenderness over left subacromial bursa, pain with resisted shoulder abduction and external rotation and ROM limited 120 degrees or less bilaterally.

Case Description: Here, we report the case of a 73 year old woman with a 20 year history of bilateral subacromial bursitis and left shoulder pain who began an independent daily shoulder exercise regimen as instructed by a physiatrist 2.5 weeks prior to left sided lumpectomy for breast cancer, and continued the exercises following the operation. One month post-surgery, physical exam revealed no loss in range of motion (ROM) in flexion and abduction of the left and right shoulders. Patient reported intermittent pain, manageable with NSAIDs, which started only after tamoxifen use.

Discussion: Decline in physical functioning such as loss of ROM, decreased strength, and pain following surgery for breast cancer is a well-documented phenomenon associated with difficulties in performing activities of daily living (ADL). Studies have shown that rehabilitation interventions during treatment period following breast cancer surgery result in improvements in shoulder and arm function; however, no study to date investigated the effectiveness of interventions initiated before surgery (prehabilitation) for breast cancer.

Conclusions: A daily exercise regimen prior to and following lumpectomy for breast cancer may prevent the development of shoulder dysfunction that is often reported in the cancer treatment period.

Health literacy-listening skill and patient questions following cancer prevention and screening discussions

Wed, 05/04/2016 - 2:33pm

OBJECTIVE: Patient question-asking is essential to shared decision making. We sought to describe patients' questions when faced with cancer prevention and screening decisions, and to explore differences in question-asking as a function of health literacy with respect to spoken information (health literacy-listening).

METHODS: Four-hundred and thirty-three (433) adults listened to simulated physician-patient interactions discussing (i) prophylactic tamoxifen for breast cancer prevention, (ii) PSA testing for prostate cancer and (iii) colorectal cancer screening, and identified questions they would have. Health literacy-listening was assessed using the Cancer Message Literacy Test-Listening (CMLT-Listening). Two authors developed a coding scheme, which was applied to all questions. Analyses examined whether participants scoring above or below the median on the CMLT-Listening asked a similar variety of questions.

RESULTS: Questions were coded into six major function categories: risks/benefits, procedure details, personalizing information, additional information, decision making and credibility. Participants who scored higher on the CMLT-Listening asked a greater variety of risks/benefits questions; those who scored lower asked a greater variety of questions seeking to personalize information. This difference persisted after adjusting for education.

CONCLUSION: Patients' health literacy-listening is associated with distinctive patterns of question utilization following cancer screening and prevention counselling. Providers should not only be responsive to the question functions the patient favours, but also seek to ensure that the patient is exposed to the full range of information needed for shared decision making.

Lean body mass and risk of incident atrial fibrillation in post-menopausal women

Wed, 05/04/2016 - 2:33pm

AIMS: High body mass index (BMI) is a risk factor for atrial fibrillation (AF). The aim of this study was to determine whether lean body mass (LBM) predicts AF.

METHODS AND RESULTS: The Women's Health Initiative is a study of post-menopausal women aged 50-79 enrolled at 40 US centres from 1994 to 1998. A subset of 11 393 participants at three centres underwent dual-energy X-ray absorptiometry. Baseline demographics and clinical histories were recorded. Incident AF was identified using hospitalization records and diagnostic codes from Medicare claims. A multivariable Cox hazard regression model adjusted for demographic and clinical risk factors was used to evaluate associations between components of body composition and AF risk. After exclusion for prevalent AF or incomplete data, 8832 participants with an average age of 63.3 years remained for analysis. Over the 11.6 years of average follow-up time, 1035 women developed incident AF. After covariate adjustment, all measures of LBM were independently associated with higher rates of AF: total LBM [hazard ratio (HR) 1.24 per 5 kg increase, 95% confidence intervals (CI) 1.14-1.34], central LBM (HR 1.51 per 5 kg increase, 95% CI 1.31-1.74), and peripheral LBM (HR 1.39 per 5 kg increase, 95% CI 1.19-1.63). The association between total LBM and AF remained significant after adjustment for total fat mass (HR 1.22 per 5 kg increase, 95% CI 1.13-1.31).

CONCLUSION: Greater LBM is a strong independent risk factor for AF. After adjusting for obesity-related risk factors, the risk of AF conferred by higher BMI is primarily driven by the association between LBM and AF.

HLA Class I Supertype Associations With Clinical Outcome of Secondary Dengue Virus Infections in Ethnic Thais

Wed, 05/04/2016 - 2:32pm

BACKGROUND: Human leukocyte antigen (HLA) supertypes are groups of functionally related alleles that present structurally similar antigens to the immune system.

OBJECTIVES: To analyze HLA class I supertype associations with clinical outcome in hospitalized Thai children with acute dengue illness.

METHODS: Seven hundred sixty-two patients and population-matched controls recruited predominantly in Bangkok were HLA-A and -B typed. HLA supertype frequencies were compared and tested for significant dengue disease associations using logistic regression analyses. Multivariable models were built by conducting forward stepwise selection procedures.

RESULTS: In the final logistic regression model, the HLA-B44 supertype was protective against dengue hemorrhagic fever (DHF) in secondary infections (odds ratio [OR] = 0.46, 95% confidence interval [CI], .30-.72), while the HLA-A02 supertype (OR = 1.92, 95% CI, 1.30-2.83) and the HLA-A01/03 supertype (OR = 3.01, 95% CI, 1.01-8.92) were associated with susceptibility to secondary dengue fever. The B07 supertype was associated with susceptibility to secondary DHF in the univariate analysis (OR = 1.60, 95% CI, 1.05-2.46), whereas that was not retained in the final model.

CONCLUSIONS: As the HLA-B44 supertype is predicted to target conserved epitopes in dengue, our results suggest that B44 supertype-restricted immune responses to highly conserved regions of the dengue proteome may protect against secondary DHF.

Endoplasmic Reticulum Stress Activates the Inflammasome via NLRP3- and Caspase-2-Driven Mitochondrial Damage

Wed, 05/04/2016 - 2:32pm

Endoplasmic reticulum (ER) stress is observed in many human diseases, often associated with inflammation. ER stress can trigger inflammation through nucleotide-binding domain and leucine-rich repeat containing (NLRP3) inflammasome, which might stimulate inflammasome formation by association with damaged mitochondria. How ER stress triggers mitochondrial dysfunction and inflammasome activation is ill defined. Here we have used an infection model to show that the IRE1alpha ER stress sensor regulates regulated mitochondrial dysfunction through an NLRP3-mediated feed-forward loop, independently of ASC. IRE1alpha activation increased mitochondrial reactive oxygen species, promoting NLRP3 association with mitochondria. NLRP3 was required for ER stress-induced cleavage of caspase-2 and the pro-apoptotic factor, Bid, leading to subsequent release of mitochondrial contents. Caspase-2 and Bid were necessary for activation of the canonical inflammasome by infection-associated or general ER stress. These data identify an NLRP3-caspase-2-dependent mechanism that relays ER stress to the mitochondria to promote inflammation, integrating cellular stress and innate immunity.

Low-Fat Dietary Pattern Intervention and Health-Related Quality of Life: The Women's Health Initiative Randomized Controlled Dietary Modification Trial

Wed, 05/04/2016 - 2:31pm

BACKGROUND: Intensive dietary intervention programs may lead to benefits in vitality and other components of health quality. The Women's Health Initiative Dietary Modification (DM) intervention includes a large randomized controlled trial of an intensive intervention.

OBJECTIVE: To evaluate whether the intervention is associated with improved health-related quality of life (HRQoL) subscales, overall self-reported health, depression symptoms, cognitive functioning, and sleep quality.

DESIGN: This randomized controlled trial was analyzed as intent to treat.

PARTICIPANTS: Between 1993 and 1998, 48,835 women aged 50 to 79 years were recruited by 40 clinical centers across the United States. Eligibility included having fat intake at baseline > /=32% of total calories, and excluded women with any prior colorectal or breast cancer, recent other cancers, type 1 diabetes, or medical conditions with predicted survival < 3 years.

INTERVENTION: Goals were to reduce calories from fat to 20%, increase vegetables and fruit to 5+ servings, and increase grain servings to 6+ servings a day. During the first year, 18 group sessions were held, with quarterly sessions thereafter.

MAIN OUTCOME MEASURES: The RAND 36-Item Health Survey was used to assess HRQoL at baseline, Year 1, and close-out (about 8 years postrandomization), and estimate differential HRQoL subscale change scores.

STATISTICAL ANALYSES PERFORMED: Mean change in HRQoL scores (Year 1 minus baseline) were compared by randomization group using linear models.

RESULTS: At 1 year, there was a differential change between intervention and comparison group of 1.7 units (95% CI 1.5, 2.0) in general health associated with the intervention. DM intervention improved physical functioning by 2.0 units (95% CI 1.7, 2.3), vitality by 1.9 units (95% CI 1.6, 2.2), and global quality of life by 0.09 units (95% CI 0.07, 0.12). With the exception of global quality of life, these effects were significantly modified by body mass index at baseline.

CONCLUSIONS: DM intervention was associated with small, but significant improvements in three HRQoL subscales: general health, physical functioning, and vitality at 1 year follow-up, with the largest improvements seen in the women with the greatest baseline body mass index.

Endovascular management of radiation-induced subclavian and axillary artery aneurysms

Wed, 05/04/2016 - 2:31pm

Subclavian and axillary artery aneurysms are rare occurrences and are associated with serious sequelae if they are untreated. Little is known about these aneurysms, and best practice guidelines are lacking. We describe an 87-year-old man with a history of chest irradiation who presented with radiation-induced subclavian and axillary aneurysms and acute upper extremity ischemia. An endovascular stent graft procedure was undertaken because of his prohibitive high risk for open surgical treatment. Follow-up duplex ultrasound revealed patent stent grafts with complete exclusion of aneurysm sacs. Endovascular therapy is a viable option for upper extremity aneurysms in patients at high risk for open surgical repair.

Teaching Medical Students to Help Patients Quit Smoking: Outcomes of a 10-School Randomized Controlled Trial

Wed, 05/04/2016 - 2:30pm

BACKGROUND: Early in medical education, physicians must develop competencies needed for tobacco dependence treatment.

OBJECTIVE: To assess the effect of a multi-modal tobacco dependence treatment curriculum on medical students' counseling skills.

DESIGN: A group-randomized controlled trial (2010-2014) included ten U.S. medical schools that were randomized to receive either multi-modal tobacco treatment education (MME) or traditional tobacco treatment education (TE).

SETTING/PARTICIPANTS: Students from the classes of 2012 and 2014 at ten medical schools participated. Students from the class of 2012 (N = 1345) completed objective structured clinical examinations (OSCEs), and 50 % (N = 660) were randomly selected for pre-intervention evaluation. A total of 72.9 % of eligible students (N = 1096) from the class of 2014 completed an OSCE and 69.7 % (N = 1047) completed pre and post surveys.

INTERVENTIONS: The MME included a Web-based course, a role-play classroom demonstration, and a clerkship booster session. Clerkship preceptors in MME schools participated in an academic detailing module and were encouraged to be role models for third-year students.

MEASUREMENTS: The primary outcome was student tobacco treatment skills using the 5As measured by an objective structured clinical examination (OSCE) scored on a 33-item behavior checklist. Secondary outcomes were student self-reported skills for performing 5As and pharmacotherapy counseling.

RESULTS: Although the difference was not statistically significant, MME students completed more tobacco counseling behaviors on the OSCE checklist (mean 8.7 [SE 0.6] vs. mean 8.0 [SE 0.6], p = 0.52) than TE students. Several of the individual Assist and Arrange items were significantly more likely to have been completed by MME students, including suggesting behavioral strategies (11.8 % vs. 4.5 %, p < 0.001) and providing information regarding quitline (21.0 % vs. 3.8 %, p < 0.001). MME students reported higher self-efficacy for Assist, Arrange, and Pharmacotherapy counseling items (ps < /=0.05).

LIMITATIONS: Inclusion of only ten schools limits generalizability.

CONCLUSIONS: Subsequent interventions should incorporate lessons learned from this first randomized controlled trial of a multi-modal longitudinal tobacco treatment curriculum in multiple U.S. medical schools.

NIH Trial Registry Number: NCT01905618.

Local Health Department Engagement in Community Physical Activity Policy

Wed, 05/04/2016 - 2:30pm

INTRODUCTION: This study assessed correlates of self-reported local health department (LHD) participation in community policy/advocacy activities that support physical activity.

METHODS: In 2014, cross-sectional data from the nationally representative 2013 National Profile of Local Health Departments study administered by the National Association of County and City Health Officials were analyzed. Outcomes were participation in policy/advocacy activities related to urban design/land use, active transportation, and access to recreational facilities. Independent variables included structural characteristics, performance improvement efforts, and collaboration. Multivariate logistic regression models were computed.

RESULTS: Representatives of 490 LHDs participated (79% response rate). Respondents reported similar participation in urban design/land use (25%); active transportation (16%); and recreational facility access (23%) policy/advocacy. LHDs with populations of > /=500,000 were more likely to report urban design/land use (p=0.004) as well as active transportation policy/advocacy participation (p=0.007) compared with those with populations of < /=50,000. LHDs with a community health improvement plan were more likely to participate in urban design/land use policy/advocacy (p=0.001). LHDs who regularly use the Community Guide were more likely to report policy/advocacy activity on active transportation (p=0.007) and expanding access to recreation facilities (p=0.009). LHDs engaged in a land use partnership were more likely to report urban design/land use (p < 0.001) and active transportation (p=0.001) policy/advocacy participation.

CONCLUSIONS: Participation in community physical activity policy/advocacy among LHDs was low in this study and varied by LHD characteristics. Intervention opportunities include assisting smaller LHDs and promoting performance improvement efforts and evidence-based practice resources. Inc.

Bone as a Target Organ in Rheumatic Disease: Impact on Osteoclasts and Osteoblasts

Wed, 05/04/2016 - 2:30pm

Dysregulated bone remodeling occurs when there is an imbalance between bone resorption and bone formation. In rheumatic diseases, including rheumatoid arthritis (RA) and seronegative spondyloarthritis, systemic and local factors disrupt the process of physiologic bone remodeling. Depending upon the local microenvironment, cell types, and local mechanical forces, inflammation results in very different effects on bone, promoting bone loss in the joints and in periarticular and systemic bone in RA and driving bone formation at enthesial and periosteal sites in diseases such as ankylosing spondylitis (AS), included within the classification of axial spondyloarthritis. There has been a great deal of interest in the role of osteoclasts in these processes and much has been learned over the past decade about osteoclast differentiation and function. It is now appreciated that osteoblast-mediated bone formation is also inhibited in the RA joint, limiting the repair of erosions. In contrast, osteoblasts function to produce new bone in AS. The Wnt and BMP signaling pathways have emerged as critical in the regulation of osteoblast function and the outcome for bone in rheumatic diseases, and these pathways have been implicated in both bone loss in RA and bone formation in AS. These pathways provide potential novel approaches for therapeutic intervention in diseases in which inflammation impacts bone.

Development of Preliminary Remission Criteria for Gout Using Delphi and 1000Minds(R) Consensus Exercises

Wed, 05/04/2016 - 2:29pm

OBJECTIVES: The aim of this study was to establish consensus for potential remission criteria for use in clinical trials of gout.

METHODS: Experts (n=88) in gout from multiple countries were invited to participate in a web-based questionnaire study. Three rounds of Delphi consensus exercises were conducted using SurveyMonkey(R) followed by a discrete choice experiment using 1000Minds(R). The exercises focused on identifying domains, definitions for each domain and the timeframe over which remission should be defined.

RESULTS: There were 49 respondents (56% response) to the initial survey with subsequent response rates ranging from 57% to 90%. Consensus was reached for the inclusion of serum urate (98% agreement), flares (96%), tophi (92%), pain (83%) and patient global assessment (93%) of disease activity as measurement domains in remission criteria. Consensus was also reached for domain definitions including serum urate ( < 0.36mM), pain ( < 2 on a 10-point scale) and patient global assessment ( < 2 on a 10-point scale), all of which should be measured at least twice over a set time interval. Consensus was not achieved in the Delphi exercise for the timeframe for remission with equal responses for six months (51%) and one year (49%). In the discrete choice experiment, there was a preference towards 12 months as a timeframe for remission.

CONCLUSION: These consensus exercises have identified domains and provisional definitions for gout remission criteria. Based on the results of these exercises, preliminary remission criteria are proposed with domains of serum urate, acute flares, tophus, pain and patient global assessment. These preliminary criteria now require testing in clinical datasets.

Civilian deaths from weapons used in the Syrian conflict

Wed, 05/04/2016 - 2:29pm

Article introduction:

What started as a peaceful uprising in Syria in March 2011 escalated quickly to an armed conflict. By 2012 conflict had become the leading cause of death of Syrians. Health systems have been reshaped, now being separated into areas controlled by the government, the opposition, or self proclaimed Islamic State factions—we group the last two as non-state armed groups (NSAG; fig 1). These areas differ vastly in terms of service delivery capacity, number of trained staff, and accessto essential medicines.

Indirect conflict related deaths have arisen from poor sanitation and severe disruption to Syria’s healthcare system. In December 2014, 20% of Syria’s public hospitals were completely non-functional, and another 35% provided only partial services. Direct conflict related deaths are those that are caused by weapons and other violent methods used in warfare.

In this article we assess the direct conflict related deaths (hereafter termed violent deaths) of women and children among civilians killed in the Syrian conflict, because they are identified as vulnerable populations in public health and under specific laws of war such as the Geneva Conventions.

Knowledge, Attitudes and Provider Advice by Pre-Pregnancy Weight Status: A Qualitative Study of Pregnant Latinas With Excessive Gestational Weight Gain

Wed, 05/04/2016 - 2:28pm

Latina women are at high risk of excessive gestational weight gain (GWG) during pregnancy; yet little is known about whether factors related to GWG differ by pre-pregnancy body mass index (BMI) within this population. We conducted in-depth interviews with 62 pregnant Latina women with pre-pregnancy BMIs in the healthy, overweight, and obese ranges, gestational age > /=22 weeks, and GWG for gestational age above Institute of Medicine (IOM) guidelines. Compared to healthy weight and obese women, overweight women least often reported viewing weight as important, making efforts to control their GWG, being aware of the role of diet on GWG, and receiving GWG advice from health-care providers. Among those who received GWG advice, overweight women more often recalled a target GWG above IOM guidelines. Obese women more often reported low acceptance of their GWG, concern about GWG, having received GWG advice from providers, difficulty following providers' dietary advice, and emotional eating as a challenge for controlling GWG. Participants welcomed practical advice to manage GWG. Future interventions to prevent excessive GWG among Latina women should consider differences among women of varying pre-pregnancy BMIs and include multi-level strategies to address psychosocial as well as provider factors.

Development of a Short Version of the Thyroid-Related Patient-Reported Outcome ThyPRO

Wed, 05/04/2016 - 2:28pm

BACKGROUND: Thyroid diseases affect quality of life (QoL). The Thyroid-Related Patient-Reported Outcome (ThyPRO) is an international comprehensive well-validated patient-reported outcome, measuring thyroid-related QoL. The current version is rather long--85 items. The purpose of the present study was to develop an abbreviated version of the ThyPRO, with conserved good measurement properties.

METHODS: A cross-sectional (N = 907) and a longitudinal sample (N = 435) of thyroid patients were analyzed. A graded item response theory (IRT) model was fitted to the cross-sectional data. Short-form scales with three items were aimed for, by selecting items with best fit according to the IRT model, avoiding cross-culturally noninvariant items. Seven scales measuring mental and social well-being and function as well as one overall QoL impact item were analyzed in a bifactor model, to develop a supplementary composite score. Short-form scales were linked to original scales with IRT-based summed-score-linking. Agreement between the short and long form was estimated by agreement plots, intraclass correlations, and mean score levels. Responsiveness was compared by relative validity indices, clinical validity by ability to detect clinically relevant differences, and test-retest reliability by intra-class correlation.

RESULTS: One four-item scale was not abbreviated and one two-item scale was omitted from the short-form. For the 11 scales undergoing abbreviation, 10 with three and one with four items were developed. A bifactor model with good overall fit was fitted to the composite score, including the single QoL item. Responsiveness and clinical validity of the short-form scales were preserved, as were test-retest reliability (0.75-0.89). Short- versus long-form intraclass correlations were high (0.89-0.98), and the mean scale levels were similar.

CONCLUSIONS: A 39-item version of the ThyPRO, with good measurement properties, was developed and is recommended for clinical use.

Why Women Join the Military: Enlistment Decisions and Postdeployment Experiences of Service Members and Veterans

Wed, 05/04/2016 - 2:28pm

Over the past three decades women's enlistment has continued to increase. In an effort to help social workers better meet the needs of female veterans, this study sought to learn women's enlistment motivations and postdeployment experiences. This qualitative study was nested within the Women Veterans Cohort Study. Using a semistructured interview guide, authors interviewed 18 enlisted female service members and veterans. The themes that emerged, based on grounded theory, included not only opportunity and calling, but also outcomes. Unexpectedly, enlistment resulted in a professional military career, with over half of the participants making the military their life's work. Further study on the motivation, retention, and the reintegration needs of women postmilitary is necessary, particularly with military recruitment targets of 20 percent women by the year 2020 and the increased awareness of the military as a potentially hostile work environment for women.

Prevalence and Correlates of Indoor Tanning in Nonsalon Locations Among a National Sample of Young Women

Wed, 05/04/2016 - 2:27pm

Indoor tanning is a public health threat, and the Surgeon General has called for its reduction in adolescents and young adults. Research on indoor tanning has not distinguished between tanning-only salons vs other businesses and private residences that provide tanning (ie, nonsalon tanning). For example, gyms often offer free tanning, which may lead to riskier tanning habits. Better understanding of nonsalon tanning could have policy, prevention, and clinical implications. Our study addresses this literature gap by examining the prevalence and correlates of nonsalon tanning in a nationally representative sample of young women, who have the highest rates of indoor tanning use.

National variation in preoperative imaging, carotid duplex ultrasound criteria, and threshold for surgery for asymptomatic carotid artery stenosis

Wed, 05/04/2016 - 2:27pm

OBJECTIVE: Carotid endarterectomy (CEA) for asymptomatic carotid artery stenosis is among the most common procedures performed in the United States. However, consensus is lacking regarding optimal preoperative imaging, carotid duplex ultrasound criteria, and ultimately, the threshold for surgery. We sought to characterize national variation in preoperative imaging, carotid duplex ultrasound criteria, and threshold for surgery for asymptomatic CEA.

METHODS: The Society for Vascular Surgery Vascular Quality Initiative (VQI) database was used to identify all CEA procedures performed for asymptomatic carotid artery stenosis between 2003 and 2014. VQI currently captures 100% of CEA procedures performed at > 300 centers by > 2000 physicians nationwide. Three analyses were performed to quantify the variation in (1) preoperative imaging, (2) carotid duplex ultrasound criteria, and (3) threshold for surgery.

RESULTS: Of 35,695 CEA procedures in 33,488 patients, the study cohort was limited to 19,610 CEA procedures (55%) performed for asymptomatic disease. The preoperative imaging modality used before CEA varied widely, with 57% of patients receiving a single preoperative imaging study (duplex ultrasound imaging, 46%; computed tomography angiography, 7.5%; magnetic resonance angiography, 2.0%; cerebral angiography, 1.3%) and 43% of patients receiving multiple preoperative imaging studies. Of the 16,452 asymptomatic patients (89%) who underwent preoperative duplex ultrasound imaging, there was significant variability between centers in the degree of stenosis (50%-69%, 70%-79%, 80%-99%) designated for a given peak systolic velocity, end diastolic velocity, and internal carotid artery-to-common carotid artery ratio. Although 68% of CEA procedures in asymptomatic patients were performed for an 80% to 99% stenosis, 26% were performed for a 70% to 79% stenosis, and 4.1% were performed for a 50% to 69% stenosis. At the surgeon level, the range in the percentage of CEA procedures performed for a < 80% asymptomatic carotid artery stenosis is from 0% to 100%. Similarly, at the center level, institutions range in the percentage of CEA procedures performed for a < 80% asymptomatic carotid artery stenosis from 0% to 100%.

CONCLUSIONS: Despite CEA being an extremely common procedure, there is widespread variation in the three primary determinants-preoperative imaging, carotid duplex ultrasound criteria, and threshold for surgery-of whether CEA is performed for asymptomatic carotid stenosis. Standardizing the approach to care for asymptomatic carotid artery stenosis will mitigate the significant downstream effects of this variation on health care costs.

Risk Factors for Relapse and Higher Costs Among Medicaid Members with Opioid Dependence or Abuse: Opioid Agonists, Comorbidities, and Treatment History

Wed, 05/04/2016 - 2:27pm

Clinical trials show that opioid agonist therapy (OAT) with methadone or buprenorphine is more effective than behavioral treatments, but state policymakers remain ambivalent about covering OAT for long periods. We used Medicaid claims for 52,278 Massachusetts Medicaid beneficiaries with a diagnosis of opioid abuse or dependence between 2004 and 2010 to study associations between use of methadone, buprenorphine or other behavioral health treatment without OAT, and time to relapse and total healthcare expenditures. Cox Proportional Hazards ratios for patients treated with either methadone or buprenorphine showed approximately 50% lower risk of relapse than behavioral treatment without OAT. Expenditures per month were from $153 to $233 lower for OAT episodes compared to other behavioral treatment. Co-occurring alcohol abuse/dependence quadrupled the risk of relapse, other non-opioid abuse/dependence doubled the relapse risk and severe mental illness added 80% greater risk compared to those without each of those disorders. Longer current treatment episodes were associated with lower risk of relapse. Relapse risk increased as prior treatment exposure increased but prior treatment was associated with slightly lower total healthcare expenditures. These findings suggest that the effectiveness of OAT that has been demonstrated in clinical trials persists at the population level in a less controlled setting and that OAT is associated with lower total healthcare expenditures compared to other forms of behavioral treatment for patients with opioid addiction. Co-occurring other substance use and mental illness exert strong influences on cost and risk of relapse, suggesting that individuals with these conditions need more comprehensive treatment.