The growth of specialty hospitalist medicine is an opportunity to improve patient outcomes, but the evolution of care delivery must be closely watched, according to one of the authors of an editorial in the Journal of the American Medical Association.

"It's a mistake to dig your heels in and insist on preserving traditional practice models when they may no longer fit," says John Nelson, MD, MHM, FACP, medical director of the hospitalist practice at Overlake Hospital Medical Center, Bellevue, Wash. "It's just as big a mistake to blindly hop on the hospitalist bandwagon without thinking deliberately about its costs and benefits and how to make it the best it can be."

Dr. Nelson, an SHM co-founder and practice management columnist for The Hospitalist, penned the editorial, "Specialty Hospitalists: Analyzing an Emerging Phenomenon,” with SHM CEO Larry Wellikson, MD, SFHM, and HM pioneer Robert Wachter, MD, MHM. The two-page article suggests that the growth of the hospitalist model to include such specialties as neurology, dermatology, obstetrics, surgery, and psychiatry is a natural extension of how the hospitalist model blossomed in the early 1990s.

"Doctors are headed elsewhere, away from the hospital," Dr. Nelson says. "The solution is, in many cases, if we can't get a lot of these doctors to do hospital work some of the time, can we get a few doctors to do hospital work all of the time?"

The article, which echoes a 2011 blog post by Dr. Wachter, proposes four guiding questions on whether the use of the hospitalist model is appropriate for a given specialty. Those answers are being answered by the marketplace which, in turn, is propelling the trend of specialty HM doctors.

"So many things that happen in medicine are engineered and tracked by some entity," Dr. Nelson says. "Not in this case—and that is huge."

The growth of specialty hospitalist medicine is an opportunity to improve patient outcomes, but the evolution of care delivery must be closely watched, according to one of the authors of an editorial in the Journal of the American Medical Association.

"It's a mistake to dig your heels in and insist on preserving traditional practice models when they may no longer fit," says John Nelson, MD, MHM, FACP, medical director of the hospitalist practice at Overlake Hospital Medical Center, Bellevue, Wash. "It's just as big a mistake to blindly hop on the hospitalist bandwagon without thinking deliberately about its costs and benefits and how to make it the best it can be."

Dr. Nelson, an SHM co-founder and practice management columnist for The Hospitalist, penned the editorial, "Specialty Hospitalists: Analyzing an Emerging Phenomenon,” with SHM CEO Larry Wellikson, MD, SFHM, and HM pioneer Robert Wachter, MD, MHM. The two-page article suggests that the growth of the hospitalist model to include such specialties as neurology, dermatology, obstetrics, surgery, and psychiatry is a natural extension of how the hospitalist model blossomed in the early 1990s.

"Doctors are headed elsewhere, away from the hospital," Dr. Nelson says. "The solution is, in many cases, if we can't get a lot of these doctors to do hospital work some of the time, can we get a few doctors to do hospital work all of the time?"

The article, which echoes a 2011 blog post by Dr. Wachter, proposes four guiding questions on whether the use of the hospitalist model is appropriate for a given specialty. Those answers are being answered by the marketplace which, in turn, is propelling the trend of specialty HM doctors.

"So many things that happen in medicine are engineered and tracked by some entity," Dr. Nelson says. "Not in this case—and that is huge."

The growth of specialty hospitalist medicine is an opportunity to improve patient outcomes, but the evolution of care delivery must be closely watched, according to one of the authors of an editorial in the Journal of the American Medical Association.

"It's a mistake to dig your heels in and insist on preserving traditional practice models when they may no longer fit," says John Nelson, MD, MHM, FACP, medical director of the hospitalist practice at Overlake Hospital Medical Center, Bellevue, Wash. "It's just as big a mistake to blindly hop on the hospitalist bandwagon without thinking deliberately about its costs and benefits and how to make it the best it can be."

Dr. Nelson, an SHM co-founder and practice management columnist for The Hospitalist, penned the editorial, "Specialty Hospitalists: Analyzing an Emerging Phenomenon,” with SHM CEO Larry Wellikson, MD, SFHM, and HM pioneer Robert Wachter, MD, MHM. The two-page article suggests that the growth of the hospitalist model to include such specialties as neurology, dermatology, obstetrics, surgery, and psychiatry is a natural extension of how the hospitalist model blossomed in the early 1990s.

"Doctors are headed elsewhere, away from the hospital," Dr. Nelson says. "The solution is, in many cases, if we can't get a lot of these doctors to do hospital work some of the time, can we get a few doctors to do hospital work all of the time?"

The article, which echoes a 2011 blog post by Dr. Wachter, proposes four guiding questions on whether the use of the hospitalist model is appropriate for a given specialty. Those answers are being answered by the marketplace which, in turn, is propelling the trend of specialty HM doctors.

"So many things that happen in medicine are engineered and tracked by some entity," Dr. Nelson says. "Not in this case—and that is huge."

SHM has joined the American Board of Internal Medicine (ABIM) Foundation's Choosing Wisely campaign, through which medical societies identify tests and procedures that are common in their specialties but often unnecessary.

The campaign, launched in April, currently includes nine societies that have each crafted lists of "five things physicians and patients should question." SHM's Healthcare Quality and Patient Safety Committee is now working on its own evidence-based list, with a focus on the inpatient setting. The list should be released this fall, says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Healthcare Improvement and Innovation.

"We will also be looking for innovative methods to reinforce these messages and integrate them into daily practice," Dr. Maynard says. Unless physicians squeeze out healthcare's waste and inefficiency in ways that actually improve care, he says, "healthcare spending could be cut in potentially destructive ways."

University of California at San Francisco's Robert Wachter, MD, MHM, a co-founder of SHM who also is chair-elect of ABIM's board of directors, calls the campaign a significant advance for the quality movement, "which has not previously embraced cost and waste reduction as strongly as it needs to."

Dr. Wachter advises hospitalists take advantage of the currently available lists of questionable treatments in such areas as cardiology, radiology, and nephrology. "This is extraordinarily hopeful. The medical profession is finally stepping up to the plate," he says.

SHM has joined the American Board of Internal Medicine (ABIM) Foundation's Choosing Wisely campaign, through which medical societies identify tests and procedures that are common in their specialties but often unnecessary.

The campaign, launched in April, currently includes nine societies that have each crafted lists of "five things physicians and patients should question." SHM's Healthcare Quality and Patient Safety Committee is now working on its own evidence-based list, with a focus on the inpatient setting. The list should be released this fall, says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Healthcare Improvement and Innovation.

"We will also be looking for innovative methods to reinforce these messages and integrate them into daily practice," Dr. Maynard says. Unless physicians squeeze out healthcare's waste and inefficiency in ways that actually improve care, he says, "healthcare spending could be cut in potentially destructive ways."

University of California at San Francisco's Robert Wachter, MD, MHM, a co-founder of SHM who also is chair-elect of ABIM's board of directors, calls the campaign a significant advance for the quality movement, "which has not previously embraced cost and waste reduction as strongly as it needs to."

Dr. Wachter advises hospitalists take advantage of the currently available lists of questionable treatments in such areas as cardiology, radiology, and nephrology. "This is extraordinarily hopeful. The medical profession is finally stepping up to the plate," he says.

SHM has joined the American Board of Internal Medicine (ABIM) Foundation's Choosing Wisely campaign, through which medical societies identify tests and procedures that are common in their specialties but often unnecessary.

The campaign, launched in April, currently includes nine societies that have each crafted lists of "five things physicians and patients should question." SHM's Healthcare Quality and Patient Safety Committee is now working on its own evidence-based list, with a focus on the inpatient setting. The list should be released this fall, says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Healthcare Improvement and Innovation.

"We will also be looking for innovative methods to reinforce these messages and integrate them into daily practice," Dr. Maynard says. Unless physicians squeeze out healthcare's waste and inefficiency in ways that actually improve care, he says, "healthcare spending could be cut in potentially destructive ways."

University of California at San Francisco's Robert Wachter, MD, MHM, a co-founder of SHM who also is chair-elect of ABIM's board of directors, calls the campaign a significant advance for the quality movement, "which has not previously embraced cost and waste reduction as strongly as it needs to."

Dr. Wachter advises hospitalists take advantage of the currently available lists of questionable treatments in such areas as cardiology, radiology, and nephrology. "This is extraordinarily hopeful. The medical profession is finally stepping up to the plate," he says.

BOSTON – Children treated in the emergency department for abuse or neglect are at increased risk for further maltreatment, even after medical or social service intervention, a study has shown.

Among nearly 44,000 pediatric emergency department (ED) visits with at least one ICD-9 code for maltreatment, 3% of the children returned one or more times and were again identified as victims of maltreatment, reported Michael C. Monuteaux, Sc.D., of Harvard Medical School, Boston.

Children who were admitted to a patient floor or to an intensive care unit on their initial visit were twice as likely as those who were treated and released to be readmitted on subsequent ED visits. Children under 5 years of age were the most vulnerable, the authors found.

"Even when maltreatment is identified in the ED, children are at risk for further victimization resulting in future ED care," Dr. Monuteaux said at the annual meeting of the Pediatric Academic Societies.

Coinvestigator Dr. Daniel M. Lindberg, an emergency physician at Brigham and Women’s Hospital in Boston, said in an interview that the Child Protective Services workers have "a tremendously difficult" job made even more difficult by increasing caseloads and proposed reductions in funding.

"If that happens, [there will be] fewer investigators or case workers who can do the kind of checking in to make sure that safety plans are being followed or dangerous people are kept away from kids at risk. My hope is that any intervention to support Child Protective Services workers, and decrease caseloads, will help decrease rates of recurrent abuse," he said.

Dr. Monuteaux and Dr. Lindberg took a retrospective look at data from an administrative database on children under 18 treated in the emergency departments of 41 U.S. hospitals in 2005-2010.

They identified 43,824 ED visits by 42,354 children with one or more ICD-9 principal or secondary diagnoses of physical or sexual abuse, or other/unspecified maltreatment, and used medical record numbers to track patients over time.

In all, 1,286 maltreated children (3.0%) returned for another ED visit and received a second diagnosis of maltreatment. The median age of the children was 3 years (range, 1-8 years), 63% were girls, and 60% were white. The majority of the children (90%) had two ED visits, 8% had three visits, and 2% were seen in the ED four or more times.

One-fourth of the returning patients were seen again in the emergency department within 21 days, half within 150 days, and two-thirds within 1 year.

Abuse and neglect was the primary diagnosis in 38%, sexual abuse in 18%, physical abuse in 17%, and other maltreatment or injury in 27%.

Overall, 20% were admitted to the hospital at the initial visit, 3% were admitted to an ICU, and 6% underwent surgery for their injuries.

Of 253 children admitted at the initial visit, 42% were also admitted on their second visit. In comparison, of the 1,033 children not admitted at their first ED visit, 7% were admitted on the second visit. The odds ratio (OR) for being admitted a second time after a first admission was 2.1 (95% confidence interval [CI], 1.6-2.8).

Similarly, of 78 children with an initial ICU stay, 17% went back to the ICU at the second ED visit, compared with 2% of those who were not put in intensive care at their first ED visit (OR, 2.2; 95% CI, 1.4-3.6).

In a multivariate analysis controlled for demographic and clinical factors, the only significant predictor of repeat ED visits was age younger than 5 years (OR, 1.47; 95% CI, 1.22-1.78).

Dr. Monuteaux noted that the study might underestimate the actual number of repeat abuse cases because of its reliance on ICD-9 codes and because some of the children may have had ED visits for abuse or neglect before the start of the study. It is also possible that the code for physical abuse reflects long-term complications from prior abuse and not a new episode. Additionally, the data were drawn from academic pediatric hospitals and may not reflect the experience of community and general hospitals.

"Despite the dedicated work of ED and child protection workers, children diagnosed with maltreatment in the ED are at risk for additional victimization and subsequent emergency care for maltreatment, which leads us to suggest that improvements in the child protection apparatus should be considered," Dr. Monuteaux concluded.

The study was internally funded. The authors reported having no relevant financial relationships.

BOSTON – Children treated in the emergency department for abuse or neglect are at increased risk for further maltreatment, even after medical or social service intervention, a study has shown.

Among nearly 44,000 pediatric emergency department (ED) visits with at least one ICD-9 code for maltreatment, 3% of the children returned one or more times and were again identified as victims of maltreatment, reported Michael C. Monuteaux, Sc.D., of Harvard Medical School, Boston.

Children who were admitted to a patient floor or to an intensive care unit on their initial visit were twice as likely as those who were treated and released to be readmitted on subsequent ED visits. Children under 5 years of age were the most vulnerable, the authors found.

"Even when maltreatment is identified in the ED, children are at risk for further victimization resulting in future ED care," Dr. Monuteaux said at the annual meeting of the Pediatric Academic Societies.

Coinvestigator Dr. Daniel M. Lindberg, an emergency physician at Brigham and Women’s Hospital in Boston, said in an interview that the Child Protective Services workers have "a tremendously difficult" job made even more difficult by increasing caseloads and proposed reductions in funding.

"If that happens, [there will be] fewer investigators or case workers who can do the kind of checking in to make sure that safety plans are being followed or dangerous people are kept away from kids at risk. My hope is that any intervention to support Child Protective Services workers, and decrease caseloads, will help decrease rates of recurrent abuse," he said.

Dr. Monuteaux and Dr. Lindberg took a retrospective look at data from an administrative database on children under 18 treated in the emergency departments of 41 U.S. hospitals in 2005-2010.

They identified 43,824 ED visits by 42,354 children with one or more ICD-9 principal or secondary diagnoses of physical or sexual abuse, or other/unspecified maltreatment, and used medical record numbers to track patients over time.

In all, 1,286 maltreated children (3.0%) returned for another ED visit and received a second diagnosis of maltreatment. The median age of the children was 3 years (range, 1-8 years), 63% were girls, and 60% were white. The majority of the children (90%) had two ED visits, 8% had three visits, and 2% were seen in the ED four or more times.

One-fourth of the returning patients were seen again in the emergency department within 21 days, half within 150 days, and two-thirds within 1 year.

Abuse and neglect was the primary diagnosis in 38%, sexual abuse in 18%, physical abuse in 17%, and other maltreatment or injury in 27%.

Overall, 20% were admitted to the hospital at the initial visit, 3% were admitted to an ICU, and 6% underwent surgery for their injuries.

Of 253 children admitted at the initial visit, 42% were also admitted on their second visit. In comparison, of the 1,033 children not admitted at their first ED visit, 7% were admitted on the second visit. The odds ratio (OR) for being admitted a second time after a first admission was 2.1 (95% confidence interval [CI], 1.6-2.8).

Similarly, of 78 children with an initial ICU stay, 17% went back to the ICU at the second ED visit, compared with 2% of those who were not put in intensive care at their first ED visit (OR, 2.2; 95% CI, 1.4-3.6).

In a multivariate analysis controlled for demographic and clinical factors, the only significant predictor of repeat ED visits was age younger than 5 years (OR, 1.47; 95% CI, 1.22-1.78).

Dr. Monuteaux noted that the study might underestimate the actual number of repeat abuse cases because of its reliance on ICD-9 codes and because some of the children may have had ED visits for abuse or neglect before the start of the study. It is also possible that the code for physical abuse reflects long-term complications from prior abuse and not a new episode. Additionally, the data were drawn from academic pediatric hospitals and may not reflect the experience of community and general hospitals.

"Despite the dedicated work of ED and child protection workers, children diagnosed with maltreatment in the ED are at risk for additional victimization and subsequent emergency care for maltreatment, which leads us to suggest that improvements in the child protection apparatus should be considered," Dr. Monuteaux concluded.

The study was internally funded. The authors reported having no relevant financial relationships.

BOSTON – Children treated in the emergency department for abuse or neglect are at increased risk for further maltreatment, even after medical or social service intervention, a study has shown.

Among nearly 44,000 pediatric emergency department (ED) visits with at least one ICD-9 code for maltreatment, 3% of the children returned one or more times and were again identified as victims of maltreatment, reported Michael C. Monuteaux, Sc.D., of Harvard Medical School, Boston.

Children who were admitted to a patient floor or to an intensive care unit on their initial visit were twice as likely as those who were treated and released to be readmitted on subsequent ED visits. Children under 5 years of age were the most vulnerable, the authors found.

"Even when maltreatment is identified in the ED, children are at risk for further victimization resulting in future ED care," Dr. Monuteaux said at the annual meeting of the Pediatric Academic Societies.

Coinvestigator Dr. Daniel M. Lindberg, an emergency physician at Brigham and Women’s Hospital in Boston, said in an interview that the Child Protective Services workers have "a tremendously difficult" job made even more difficult by increasing caseloads and proposed reductions in funding.

"If that happens, [there will be] fewer investigators or case workers who can do the kind of checking in to make sure that safety plans are being followed or dangerous people are kept away from kids at risk. My hope is that any intervention to support Child Protective Services workers, and decrease caseloads, will help decrease rates of recurrent abuse," he said.

Dr. Monuteaux and Dr. Lindberg took a retrospective look at data from an administrative database on children under 18 treated in the emergency departments of 41 U.S. hospitals in 2005-2010.

They identified 43,824 ED visits by 42,354 children with one or more ICD-9 principal or secondary diagnoses of physical or sexual abuse, or other/unspecified maltreatment, and used medical record numbers to track patients over time.

In all, 1,286 maltreated children (3.0%) returned for another ED visit and received a second diagnosis of maltreatment. The median age of the children was 3 years (range, 1-8 years), 63% were girls, and 60% were white. The majority of the children (90%) had two ED visits, 8% had three visits, and 2% were seen in the ED four or more times.

One-fourth of the returning patients were seen again in the emergency department within 21 days, half within 150 days, and two-thirds within 1 year.

Abuse and neglect was the primary diagnosis in 38%, sexual abuse in 18%, physical abuse in 17%, and other maltreatment or injury in 27%.

Overall, 20% were admitted to the hospital at the initial visit, 3% were admitted to an ICU, and 6% underwent surgery for their injuries.

Of 253 children admitted at the initial visit, 42% were also admitted on their second visit. In comparison, of the 1,033 children not admitted at their first ED visit, 7% were admitted on the second visit. The odds ratio (OR) for being admitted a second time after a first admission was 2.1 (95% confidence interval [CI], 1.6-2.8).

Similarly, of 78 children with an initial ICU stay, 17% went back to the ICU at the second ED visit, compared with 2% of those who were not put in intensive care at their first ED visit (OR, 2.2; 95% CI, 1.4-3.6).

In a multivariate analysis controlled for demographic and clinical factors, the only significant predictor of repeat ED visits was age younger than 5 years (OR, 1.47; 95% CI, 1.22-1.78).

Dr. Monuteaux noted that the study might underestimate the actual number of repeat abuse cases because of its reliance on ICD-9 codes and because some of the children may have had ED visits for abuse or neglect before the start of the study. It is also possible that the code for physical abuse reflects long-term complications from prior abuse and not a new episode. Additionally, the data were drawn from academic pediatric hospitals and may not reflect the experience of community and general hospitals.

"Despite the dedicated work of ED and child protection workers, children diagnosed with maltreatment in the ED are at risk for additional victimization and subsequent emergency care for maltreatment, which leads us to suggest that improvements in the child protection apparatus should be considered," Dr. Monuteaux concluded.

The study was internally funded. The authors reported having no relevant financial relationships.

Management of recurrent non-small cell lung cancer (NSCLC) is a clinical challenge. Around one third of patients who are diagnosed with NSCLC will experience a localregional or advanced stage recurrence. The median time to recurrence from initial diagnosis is 11.5 months. The median age of initial diagnosis of NSCLC is 71 years of age, patients with recurrent disease tend therefore to be even older. Treatment is a challenge, as this elderly patient population tends to have multiple comorbidities, polypharmacy and socioeconomic factors, that have not been accounted for in clinical trials in patients that define our current treatment recommendations. This case-based review outlines some of these challenges and outlines the need for further research.

*For a PDF of the full article, click in the link to the left of this introduction.

Management of recurrent non-small cell lung cancer (NSCLC) is a clinical challenge. Around one third of patients who are diagnosed with NSCLC will experience a localregional or advanced stage recurrence. The median time to recurrence from initial diagnosis is 11.5 months. The median age of initial diagnosis of NSCLC is 71 years of age, patients with recurrent disease tend therefore to be even older. Treatment is a challenge, as this elderly patient population tends to have multiple comorbidities, polypharmacy and socioeconomic factors, that have not been accounted for in clinical trials in patients that define our current treatment recommendations. This case-based review outlines some of these challenges and outlines the need for further research.

*For a PDF of the full article, click in the link to the left of this introduction.

Management of recurrent non-small cell lung cancer (NSCLC) is a clinical challenge. Around one third of patients who are diagnosed with NSCLC will experience a localregional or advanced stage recurrence. The median time to recurrence from initial diagnosis is 11.5 months. The median age of initial diagnosis of NSCLC is 71 years of age, patients with recurrent disease tend therefore to be even older. Treatment is a challenge, as this elderly patient population tends to have multiple comorbidities, polypharmacy and socioeconomic factors, that have not been accounted for in clinical trials in patients that define our current treatment recommendations. This case-based review outlines some of these challenges and outlines the need for further research.

*For a PDF of the full article, click in the link to the left of this introduction.

BOSTON – Children who present to a primary care practice following a head or facial injury must be carefully evaluated for signs and symptoms of concussion, and those with concussion should be advised to give their brains a break, recommended a pediatric injury specialist at the annual meeting of the Pediatric Academic Societies.

Cognitive rest involves limiting "cognitive activity to a level that does not elicit symptoms." For children, this means forgoing computers, video games, texting/social media, reading for school and/or homework, and avoiding noisy or busy environments.

"The primary focus of pediatric concussion management should be return to cognitive activities and then return to the playing field," Dr. Kristy B. Arbogast said.

A review of records from a large pediatric primary care network showed that 25% of patients with concussion symptoms did not have concussion mentioned in the medical assessment or diagnosis, and nearly half of children in a random sample presented for reevaluation of concussion or persistent concussion symptoms, said Dr. Arbogast, an emergency physician and director of the Pediatric Injury Prevention Program at Children’s Hospital of Philadelphia.

"So-called ‘mild’ traumatic brain injuries are often far from mild. They lead to poor neurological outcomes that can adversely affect a child’s quality of life," she said.

Children with concussion make an estimated 144,000 emergency department visits annually in the United States. As children’s participation in year-round sports has increased, their risk of mild traumatic brain injury (TBI) has also increased, Dr. Arbogast noted.

Concussions among professional athletes receive considerable attention in the popular press, where the stories center on physical recovery and returning to the game. But for school kids, who are at significant risk for learning disabilities, memory problems, and emotional or behavioral changes after a TBI, the focus should be on physical and cognitive rest, she said.

Dr. Arbogast and her colleagues reviewed the concussion management and return-to-school practices of pediatric primary care providers by reviewing records from their hospital’s primary care network.

They looked for data on children aged 5-18 years with any presentation of mild TBI based on ICD-9 codes for skull fracture, concussion, intracranial injury, head injury (unspecified), or facial fracture. The children received initial or continuing care during the study period of July 2010 through June 2011.

The researchers included children who presented with one or more injury characteristics such as amnesia, loss of consciousness, cognitive symptoms (decline in school performance, report of being "in a fog"), emotional symptoms, and physical symptoms or exam findings including eye-tracking problems, headache, nausea/vomiting, poor balance, sleep disturbances, slow reaction times, or visual disturbance. Children with moderate or severe head trauma were excluded from the study.

The investigators randomly selected a sample of 193 patients who met all of the criteria. In all, 51% had a sports-related injury, 8% had previously had a concussion, and 6% had sustained a loss of consciousness.

There was no mention of concussion in the medical assessment or diagnosis of 25% of the sample. Of 94 children who presented for reevaluation of concussion, 33% reported a decline in school performance, 13% said they felt like they were "in a fog," 12% reported vision problems, 12% reported fatigue, and 11% had concentration problems (some reported more than one symptom).

When the authors looked at the written instructions primary care providers gave to the patients, they found that while 54% received return-to-play instructions, only 34% received return-to-school instructions, suggesting that in many cases the practitioners may have failed to recognize the importance of cognitive rest, Dr. Arbogast said. The remaining 12% of patients did not have written instructions documented.

She recommended that clinicians caring for children with suspected concussion ask about all symptoms individually in a systematic fashion, and prescribe a return-to-school protocol with a stepwise approach. The protocol includes a return to the previous step if an action elicits the return of symptoms, sending a standardized letter to notify the child’s school of the plan, and training the child’s parent or guardian to oversee the child’s progression from one step to the next.

The study was funded by the Children’s Hospital of Philadelphia and the University of Pennsylvania, also in Philadelphia. Dr. Arbogast and coinvestigators reported having no conflicts of interest to disclose.

BOSTON – Children who present to a primary care practice following a head or facial injury must be carefully evaluated for signs and symptoms of concussion, and those with concussion should be advised to give their brains a break, recommended a pediatric injury specialist at the annual meeting of the Pediatric Academic Societies.

Cognitive rest involves limiting "cognitive activity to a level that does not elicit symptoms." For children, this means forgoing computers, video games, texting/social media, reading for school and/or homework, and avoiding noisy or busy environments.

"The primary focus of pediatric concussion management should be return to cognitive activities and then return to the playing field," Dr. Kristy B. Arbogast said.

A review of records from a large pediatric primary care network showed that 25% of patients with concussion symptoms did not have concussion mentioned in the medical assessment or diagnosis, and nearly half of children in a random sample presented for reevaluation of concussion or persistent concussion symptoms, said Dr. Arbogast, an emergency physician and director of the Pediatric Injury Prevention Program at Children’s Hospital of Philadelphia.

"So-called ‘mild’ traumatic brain injuries are often far from mild. They lead to poor neurological outcomes that can adversely affect a child’s quality of life," she said.

Children with concussion make an estimated 144,000 emergency department visits annually in the United States. As children’s participation in year-round sports has increased, their risk of mild traumatic brain injury (TBI) has also increased, Dr. Arbogast noted.

Concussions among professional athletes receive considerable attention in the popular press, where the stories center on physical recovery and returning to the game. But for school kids, who are at significant risk for learning disabilities, memory problems, and emotional or behavioral changes after a TBI, the focus should be on physical and cognitive rest, she said.

Dr. Arbogast and her colleagues reviewed the concussion management and return-to-school practices of pediatric primary care providers by reviewing records from their hospital’s primary care network.

They looked for data on children aged 5-18 years with any presentation of mild TBI based on ICD-9 codes for skull fracture, concussion, intracranial injury, head injury (unspecified), or facial fracture. The children received initial or continuing care during the study period of July 2010 through June 2011.

The researchers included children who presented with one or more injury characteristics such as amnesia, loss of consciousness, cognitive symptoms (decline in school performance, report of being "in a fog"), emotional symptoms, and physical symptoms or exam findings including eye-tracking problems, headache, nausea/vomiting, poor balance, sleep disturbances, slow reaction times, or visual disturbance. Children with moderate or severe head trauma were excluded from the study.

The investigators randomly selected a sample of 193 patients who met all of the criteria. In all, 51% had a sports-related injury, 8% had previously had a concussion, and 6% had sustained a loss of consciousness.

There was no mention of concussion in the medical assessment or diagnosis of 25% of the sample. Of 94 children who presented for reevaluation of concussion, 33% reported a decline in school performance, 13% said they felt like they were "in a fog," 12% reported vision problems, 12% reported fatigue, and 11% had concentration problems (some reported more than one symptom).

When the authors looked at the written instructions primary care providers gave to the patients, they found that while 54% received return-to-play instructions, only 34% received return-to-school instructions, suggesting that in many cases the practitioners may have failed to recognize the importance of cognitive rest, Dr. Arbogast said. The remaining 12% of patients did not have written instructions documented.

She recommended that clinicians caring for children with suspected concussion ask about all symptoms individually in a systematic fashion, and prescribe a return-to-school protocol with a stepwise approach. The protocol includes a return to the previous step if an action elicits the return of symptoms, sending a standardized letter to notify the child’s school of the plan, and training the child’s parent or guardian to oversee the child’s progression from one step to the next.

The study was funded by the Children’s Hospital of Philadelphia and the University of Pennsylvania, also in Philadelphia. Dr. Arbogast and coinvestigators reported having no conflicts of interest to disclose.

BOSTON – Children who present to a primary care practice following a head or facial injury must be carefully evaluated for signs and symptoms of concussion, and those with concussion should be advised to give their brains a break, recommended a pediatric injury specialist at the annual meeting of the Pediatric Academic Societies.

Cognitive rest involves limiting "cognitive activity to a level that does not elicit symptoms." For children, this means forgoing computers, video games, texting/social media, reading for school and/or homework, and avoiding noisy or busy environments.

"The primary focus of pediatric concussion management should be return to cognitive activities and then return to the playing field," Dr. Kristy B. Arbogast said.

A review of records from a large pediatric primary care network showed that 25% of patients with concussion symptoms did not have concussion mentioned in the medical assessment or diagnosis, and nearly half of children in a random sample presented for reevaluation of concussion or persistent concussion symptoms, said Dr. Arbogast, an emergency physician and director of the Pediatric Injury Prevention Program at Children’s Hospital of Philadelphia.

"So-called ‘mild’ traumatic brain injuries are often far from mild. They lead to poor neurological outcomes that can adversely affect a child’s quality of life," she said.

Children with concussion make an estimated 144,000 emergency department visits annually in the United States. As children’s participation in year-round sports has increased, their risk of mild traumatic brain injury (TBI) has also increased, Dr. Arbogast noted.

Concussions among professional athletes receive considerable attention in the popular press, where the stories center on physical recovery and returning to the game. But for school kids, who are at significant risk for learning disabilities, memory problems, and emotional or behavioral changes after a TBI, the focus should be on physical and cognitive rest, she said.

Dr. Arbogast and her colleagues reviewed the concussion management and return-to-school practices of pediatric primary care providers by reviewing records from their hospital’s primary care network.

They looked for data on children aged 5-18 years with any presentation of mild TBI based on ICD-9 codes for skull fracture, concussion, intracranial injury, head injury (unspecified), or facial fracture. The children received initial or continuing care during the study period of July 2010 through June 2011.

The researchers included children who presented with one or more injury characteristics such as amnesia, loss of consciousness, cognitive symptoms (decline in school performance, report of being "in a fog"), emotional symptoms, and physical symptoms or exam findings including eye-tracking problems, headache, nausea/vomiting, poor balance, sleep disturbances, slow reaction times, or visual disturbance. Children with moderate or severe head trauma were excluded from the study.

The investigators randomly selected a sample of 193 patients who met all of the criteria. In all, 51% had a sports-related injury, 8% had previously had a concussion, and 6% had sustained a loss of consciousness.

There was no mention of concussion in the medical assessment or diagnosis of 25% of the sample. Of 94 children who presented for reevaluation of concussion, 33% reported a decline in school performance, 13% said they felt like they were "in a fog," 12% reported vision problems, 12% reported fatigue, and 11% had concentration problems (some reported more than one symptom).

When the authors looked at the written instructions primary care providers gave to the patients, they found that while 54% received return-to-play instructions, only 34% received return-to-school instructions, suggesting that in many cases the practitioners may have failed to recognize the importance of cognitive rest, Dr. Arbogast said. The remaining 12% of patients did not have written instructions documented.

She recommended that clinicians caring for children with suspected concussion ask about all symptoms individually in a systematic fashion, and prescribe a return-to-school protocol with a stepwise approach. The protocol includes a return to the previous step if an action elicits the return of symptoms, sending a standardized letter to notify the child’s school of the plan, and training the child’s parent or guardian to oversee the child’s progression from one step to the next.

The study was funded by the Children’s Hospital of Philadelphia and the University of Pennsylvania, also in Philadelphia. Dr. Arbogast and coinvestigators reported having no conflicts of interest to disclose.

ABSTRACT

Background: Little is known about how young adults (YAs) cope with cancer or about the relationship between coping and psychological distress in YAs with advanced cancer.

Objectives: The goals of this study were to identify coping strategies
used by YAs with advanced cancer and examine the relationship between
these coping strategies and psychological distress.

Methods: Using structured clinical interviews with 53 YAs (aged 20–40 years) with advanced cancer, researchers assessed coping methods, depression, anxiety, and grief. A principal components factor analysis identified underlying coping factors. Regression analyses examined the relationship between these coping factors and depression, anxiety, and grief.

Results: Six coping factors emerged and were labeled as proactive, distancing, negative expression, support-seeking, respite-seeking, and acceptance coping. Acceptance and support-seeking coping styles were used most frequently. Coping by negative expression was positively associated with severity of grief after researchers controlled for depression, anxiety, and confounding variables. Support-seeking coping was positively associated with anxiety after researchers controlled for depression and grief.

Limitations: This study was limited by a cross-sectional design, small sample size, and focus on YAs with advanced cancer.

Conclusions: YAs with advanced cancer utilize a range of coping responses that are uniquely related to psychological distress.

To read this article, click on the FILES link at left.

ABSTRACT

Background: Little is known about how young adults (YAs) cope with cancer or about the relationship between coping and psychological distress in YAs with advanced cancer.

Objectives: The goals of this study were to identify coping strategies
used by YAs with advanced cancer and examine the relationship between
these coping strategies and psychological distress.

Methods: Using structured clinical interviews with 53 YAs (aged 20–40 years) with advanced cancer, researchers assessed coping methods, depression, anxiety, and grief. A principal components factor analysis identified underlying coping factors. Regression analyses examined the relationship between these coping factors and depression, anxiety, and grief.

Results: Six coping factors emerged and were labeled as proactive, distancing, negative expression, support-seeking, respite-seeking, and acceptance coping. Acceptance and support-seeking coping styles were used most frequently. Coping by negative expression was positively associated with severity of grief after researchers controlled for depression, anxiety, and confounding variables. Support-seeking coping was positively associated with anxiety after researchers controlled for depression and grief.

Limitations: This study was limited by a cross-sectional design, small sample size, and focus on YAs with advanced cancer.

Conclusions: YAs with advanced cancer utilize a range of coping responses that are uniquely related to psychological distress.

To read this article, click on the FILES link at left.

ABSTRACT

Background: Little is known about how young adults (YAs) cope with cancer or about the relationship between coping and psychological distress in YAs with advanced cancer.

Objectives: The goals of this study were to identify coping strategies
used by YAs with advanced cancer and examine the relationship between
these coping strategies and psychological distress.

Methods: Using structured clinical interviews with 53 YAs (aged 20–40 years) with advanced cancer, researchers assessed coping methods, depression, anxiety, and grief. A principal components factor analysis identified underlying coping factors. Regression analyses examined the relationship between these coping factors and depression, anxiety, and grief.

Results: Six coping factors emerged and were labeled as proactive, distancing, negative expression, support-seeking, respite-seeking, and acceptance coping. Acceptance and support-seeking coping styles were used most frequently. Coping by negative expression was positively associated with severity of grief after researchers controlled for depression, anxiety, and confounding variables. Support-seeking coping was positively associated with anxiety after researchers controlled for depression and grief.

Limitations: This study was limited by a cross-sectional design, small sample size, and focus on YAs with advanced cancer.

Conclusions: YAs with advanced cancer utilize a range of coping responses that are uniquely related to psychological distress.

To read this article, click on the FILES link at left.

ABSTRACT

Background: Breast cancer survivors receive routine medical follow-up but are screened less frequently to detect symptom severity and interference with function in daily life.

Objectives: Among breast cancer survivors, we describe the usual and worst severity of 5 common symptoms and the extent to which these symptoms interfere with general activity and enjoyment of life, we determine the associations among symptoms and the interference items, and we explore associations of interference with function and the most prevalent symptoms.

Methods: The cross-sectional, descriptive 1-page Breast Cancer Survivor Symptom Survey was mailed to breast cancer survivors identified in a clinical database (ONCOBASE). In total, 184/457 (40.3%) surveys were returned and 162 (35.4%) were used. Participants recorded usual and worst severity of 5 symptoms (fatigue, disturbed sleep, pain, distress, and numbness/tingling) and symptom interference with general activity and enjoyment of life during the past 7 days.

Results: Participants reported usual symptom severity as mild and highest for sleep disturbance, followed by fatigue, distress, numbness/tingling, and pain. Participants recorded worst sleep disturbance and fatigue as moderately severe. Higher pain and fatigue were associated with all other symptoms, whereas disturbed sleep and distress were related to all except numbness/tingling. All symptoms interfered with general activity and enjoyment of life. Pain and numbness/tingling were associated with lower function and disturbed sleep, and made a unique contribution to fatigue.

Limitations: Limitations of the study include relatively low response and use of a modification of an established scale.

Conclusion: Symptoms often coexisted and contributed to interference with daily function. Pain was most consistently associated with interference with function and severity of other symptoms.

To read this study, please click on the Link to the left of this abstract.

ABSTRACT

Background: Breast cancer survivors receive routine medical follow-up but are screened less frequently to detect symptom severity and interference with function in daily life.

Objectives: Among breast cancer survivors, we describe the usual and worst severity of 5 common symptoms and the extent to which these symptoms interfere with general activity and enjoyment of life, we determine the associations among symptoms and the interference items, and we explore associations of interference with function and the most prevalent symptoms.

Methods: The cross-sectional, descriptive 1-page Breast Cancer Survivor Symptom Survey was mailed to breast cancer survivors identified in a clinical database (ONCOBASE). In total, 184/457 (40.3%) surveys were returned and 162 (35.4%) were used. Participants recorded usual and worst severity of 5 symptoms (fatigue, disturbed sleep, pain, distress, and numbness/tingling) and symptom interference with general activity and enjoyment of life during the past 7 days.

Results: Participants reported usual symptom severity as mild and highest for sleep disturbance, followed by fatigue, distress, numbness/tingling, and pain. Participants recorded worst sleep disturbance and fatigue as moderately severe. Higher pain and fatigue were associated with all other symptoms, whereas disturbed sleep and distress were related to all except numbness/tingling. All symptoms interfered with general activity and enjoyment of life. Pain and numbness/tingling were associated with lower function and disturbed sleep, and made a unique contribution to fatigue.

Limitations: Limitations of the study include relatively low response and use of a modification of an established scale.

Conclusion: Symptoms often coexisted and contributed to interference with daily function. Pain was most consistently associated with interference with function and severity of other symptoms.

To read this study, please click on the Link to the left of this abstract.

ABSTRACT

Background: Breast cancer survivors receive routine medical follow-up but are screened less frequently to detect symptom severity and interference with function in daily life.

Objectives: Among breast cancer survivors, we describe the usual and worst severity of 5 common symptoms and the extent to which these symptoms interfere with general activity and enjoyment of life, we determine the associations among symptoms and the interference items, and we explore associations of interference with function and the most prevalent symptoms.

Methods: The cross-sectional, descriptive 1-page Breast Cancer Survivor Symptom Survey was mailed to breast cancer survivors identified in a clinical database (ONCOBASE). In total, 184/457 (40.3%) surveys were returned and 162 (35.4%) were used. Participants recorded usual and worst severity of 5 symptoms (fatigue, disturbed sleep, pain, distress, and numbness/tingling) and symptom interference with general activity and enjoyment of life during the past 7 days.

Results: Participants reported usual symptom severity as mild and highest for sleep disturbance, followed by fatigue, distress, numbness/tingling, and pain. Participants recorded worst sleep disturbance and fatigue as moderately severe. Higher pain and fatigue were associated with all other symptoms, whereas disturbed sleep and distress were related to all except numbness/tingling. All symptoms interfered with general activity and enjoyment of life. Pain and numbness/tingling were associated with lower function and disturbed sleep, and made a unique contribution to fatigue.

Limitations: Limitations of the study include relatively low response and use of a modification of an established scale.

Conclusion: Symptoms often coexisted and contributed to interference with daily function. Pain was most consistently associated with interference with function and severity of other symptoms.

To read this study, please click on the Link to the left of this abstract.

LAS VEGAS -- Drug-eluting stents placed below the knee worked well to revascularize critically ischemic limbs in a study of 20 patients. Within a mean 10 months’ follow-up, wounds in 17 of the 20 patients in the study (85%) were healed after stenting, and 16 patients (80%) reported pain relief. Only two needed subsequent amputations.

"Stents are just emerging for below the knee. We certainly have one of the early, large-volume [series], with reasonable follow-up," said Dr. Michael Wilderman, a vascular surgeon at Hackensack (N.J.) University Medical Center.

Before they were stented, the patients had, on average, Rutherford stage 4.9 disease, indicating pain at rest and ischemic toe or foot ulcers. The majority had already lost some tissue, and seven (35%) had cellulitis.

Diabetes, hypertension, heart disease, and other comorbidities – plus an average age of 79 years – were found to make open repair too risky, according to Dr. Wilderman, who spoke at the annual meeting of the Society for Clinical Vascular Surgery.

The 25 lesions, in 22 limbs, were located in the below-knee popliteal artery, tibioperoneal trunk, anterior tibial artery, peroneal artery, and posterior tibial artery. Five lesions threatened distal reversed saphenous vein grafts.

The researchers placed everolimus-eluting stents (average diameter, 3 mm) using standard percutaneous techniques. The lesions they addressed were short, and thus could be adequately covered with a 3-cm stent.

Complications were minimal: One patient had a groin hematoma, and another had a puncture-site pseudoaneurysm.

"Initially, we were not planning to stent the first couple we did. We were just going to balloon and see what happens, because that’s what everyone else does," Dr. Wilderman said.

However, because the vessels did not look good angiographically, his team put a stent in and the patients did well. "We found that if we had a short, focal [lesion] that we could stent, we would just stent it," he explained.

Because drug-eluting stents work well for coronary arteries, and tibial arteries share similar histology and luminal diameters, it made sense to try them for below-the-knee ischemia, he said.

Asked for comment, Dr. George Meier, chief of vascular surgery at the University of Cincinnati, noted that coronary drug-eluting stents have been used off label below the knee before. "It’s something we occasionally do in recurrent lesions when we have nothing else to do. The difficulty is following it out long enough to see if it makes an impact," he said.

Dr. Wilderman and Dr. Meier reported that they had no relevant financial disclosures.

LAS VEGAS -- Drug-eluting stents placed below the knee worked well to revascularize critically ischemic limbs in a study of 20 patients. Within a mean 10 months’ follow-up, wounds in 17 of the 20 patients in the study (85%) were healed after stenting, and 16 patients (80%) reported pain relief. Only two needed subsequent amputations.

"Stents are just emerging for below the knee. We certainly have one of the early, large-volume [series], with reasonable follow-up," said Dr. Michael Wilderman, a vascular surgeon at Hackensack (N.J.) University Medical Center.

Before they were stented, the patients had, on average, Rutherford stage 4.9 disease, indicating pain at rest and ischemic toe or foot ulcers. The majority had already lost some tissue, and seven (35%) had cellulitis.

Diabetes, hypertension, heart disease, and other comorbidities – plus an average age of 79 years – were found to make open repair too risky, according to Dr. Wilderman, who spoke at the annual meeting of the Society for Clinical Vascular Surgery.

The 25 lesions, in 22 limbs, were located in the below-knee popliteal artery, tibioperoneal trunk, anterior tibial artery, peroneal artery, and posterior tibial artery. Five lesions threatened distal reversed saphenous vein grafts.

The researchers placed everolimus-eluting stents (average diameter, 3 mm) using standard percutaneous techniques. The lesions they addressed were short, and thus could be adequately covered with a 3-cm stent.

Complications were minimal: One patient had a groin hematoma, and another had a puncture-site pseudoaneurysm.

"Initially, we were not planning to stent the first couple we did. We were just going to balloon and see what happens, because that’s what everyone else does," Dr. Wilderman said.

However, because the vessels did not look good angiographically, his team put a stent in and the patients did well. "We found that if we had a short, focal [lesion] that we could stent, we would just stent it," he explained.

Because drug-eluting stents work well for coronary arteries, and tibial arteries share similar histology and luminal diameters, it made sense to try them for below-the-knee ischemia, he said.

Asked for comment, Dr. George Meier, chief of vascular surgery at the University of Cincinnati, noted that coronary drug-eluting stents have been used off label below the knee before. "It’s something we occasionally do in recurrent lesions when we have nothing else to do. The difficulty is following it out long enough to see if it makes an impact," he said.

Dr. Wilderman and Dr. Meier reported that they had no relevant financial disclosures.

LAS VEGAS -- Drug-eluting stents placed below the knee worked well to revascularize critically ischemic limbs in a study of 20 patients. Within a mean 10 months’ follow-up, wounds in 17 of the 20 patients in the study (85%) were healed after stenting, and 16 patients (80%) reported pain relief. Only two needed subsequent amputations.

"Stents are just emerging for below the knee. We certainly have one of the early, large-volume [series], with reasonable follow-up," said Dr. Michael Wilderman, a vascular surgeon at Hackensack (N.J.) University Medical Center.

Before they were stented, the patients had, on average, Rutherford stage 4.9 disease, indicating pain at rest and ischemic toe or foot ulcers. The majority had already lost some tissue, and seven (35%) had cellulitis.

Diabetes, hypertension, heart disease, and other comorbidities – plus an average age of 79 years – were found to make open repair too risky, according to Dr. Wilderman, who spoke at the annual meeting of the Society for Clinical Vascular Surgery.

The 25 lesions, in 22 limbs, were located in the below-knee popliteal artery, tibioperoneal trunk, anterior tibial artery, peroneal artery, and posterior tibial artery. Five lesions threatened distal reversed saphenous vein grafts.

The researchers placed everolimus-eluting stents (average diameter, 3 mm) using standard percutaneous techniques. The lesions they addressed were short, and thus could be adequately covered with a 3-cm stent.

Complications were minimal: One patient had a groin hematoma, and another had a puncture-site pseudoaneurysm.

"Initially, we were not planning to stent the first couple we did. We were just going to balloon and see what happens, because that’s what everyone else does," Dr. Wilderman said.

However, because the vessels did not look good angiographically, his team put a stent in and the patients did well. "We found that if we had a short, focal [lesion] that we could stent, we would just stent it," he explained.

Because drug-eluting stents work well for coronary arteries, and tibial arteries share similar histology and luminal diameters, it made sense to try them for below-the-knee ischemia, he said.

Asked for comment, Dr. George Meier, chief of vascular surgery at the University of Cincinnati, noted that coronary drug-eluting stents have been used off label below the knee before. "It’s something we occasionally do in recurrent lesions when we have nothing else to do. The difficulty is following it out long enough to see if it makes an impact," he said.

Dr. Wilderman and Dr. Meier reported that they had no relevant financial disclosures.

Endovascular lower-extremity revascularization by vascular specialists resulted in more transfusions and ICU use, as well as a longer hospital stay, more repeat revascularization procedures and amputations, and higher costs, compared with the same procedures performed by interventional radiologists, according to the results of a large database analysis of the Medicare 5% Standard Analytical Files.

Dr. Abdul M. Zafar of the Vascular Disease Research Center, Brown University Alpert Medical School, Providence, and his colleagues extracted claims for endovascularlower extremity revascularization (ELER) index procedures using Current Procedural Terminology (CPT) codes in the years 2005 through 2007.

They recorded the unique IDs of the 15,455 patients who underwent these procedures and for whom an inpatient or outpatient claim corresponding to the index procedure claim was available. This comprised all claims for percutaneous angioplasty, atherectomy, and stent implantation of lower extremity arteries.

The self-designated specialty code of the physician performing the procedure was used to determine specialist type: vascular surgeons (VS), interventional radiologists (IR); interventional cardiologists (IC); and "other."

After excluding patients who might have undergone hybrid procedures and those who underwent thrombolysis procedures in the same year as the index procedure, the final sample of 14,608 patients was analyzed for the following outcomes: length of hospital stay; use of intensive care unit (ICU) services; transfusions; in-hospital mortality; and repeat intervention (defined as any ELER, open lower-extremity revascularization, or amputation of the lower extremity).

The researchers built risk-adjusted logistic regression models by using maximum-likelihood estimates to compare various patient outcomes across different specialties, and they used a linear regression model employing ordinary least squares to analyze length of stay. Cost analysis was performed using a linear regression model based on the least-squares approach. All models were adjusted for age, sex, race, admission type (emergency or ambulatory), and other comorbidities using the Elixhauser comorbidities software available from the Agency for Healthcare Research and Quality. Other regression models that included the International Classification of Disease-9 code for disease severity were developed, but were less predictive and had lower R² values, according to the authors. All logistic regression models passed the goodness-of-fit test at the 99% confidence level. In addition, linear regression models were also found to be satisfactory at the same level, according to the authors.

Within the study, there were 3,565 index procedures done by IRs; 5,489 by ICs; 5,358 by VSs; and 196 performed by "other" specialties (J. Vasc. Interven. Radiol 2012;23:3-9).

Dr. Zafar and his colleagues reported that VS outcomes were significantly worse than when the procedures were performed by an IR or IC. IRs had a 32% lower likelihood of ICU use (P less than .001) and a 37% lower likelihood of repeat lower-extremity revascularization or amputation (P less than .001) compared with VS. "Although statistical significance was not reached, both transfusion use and in-hospital mortality were 19% less likely after IRs performed procedures compared with VSs (P = .113 and P =.351, respectively)."

"Vascular surgeons were the only specialists with post-index procedure length of stay exceeding 3 days, significantly longer than observed for other specialties. The adjusted average 1-year costs per index procedure were 9% greater for vascular surgeons than for interventional radiologists ($19,012 vs. $17,640)," they said.

"The reasons for worse outcomes among VSs are not known, but may be related to insufficient training in catheter-based interventions as a result of the extensive time learning and practicing open surgical procedure compared with IRs and ICs, whose focus is catheter interventions," they said. "Medicare data indicate that patients who need lower-extremity endovascular revascularization services experience shorter hospital stays, require less transfusions and ICU services, have lower in-hospital mortality rates, and have much less chance of a subsequent revascularization or amputation within one year if treated by an IR rather than a VS," they concluded.

The study was supported by a grant from the Society of Interventional Radiology and internal funds from the Vascular Disease Research Center. One authors received research funding from Cordis/Johnson&Johnson, and Abbott Vascular and consulting for Microvention/Terumo.

Endovascular lower-extremity revascularization by vascular specialists resulted in more transfusions and ICU use, as well as a longer hospital stay, more repeat revascularization procedures and amputations, and higher costs, compared with the same procedures performed by interventional radiologists, according to the results of a large database analysis of the Medicare 5% Standard Analytical Files.

Dr. Abdul M. Zafar of the Vascular Disease Research Center, Brown University Alpert Medical School, Providence, and his colleagues extracted claims for endovascularlower extremity revascularization (ELER) index procedures using Current Procedural Terminology (CPT) codes in the years 2005 through 2007.

They recorded the unique IDs of the 15,455 patients who underwent these procedures and for whom an inpatient or outpatient claim corresponding to the index procedure claim was available. This comprised all claims for percutaneous angioplasty, atherectomy, and stent implantation of lower extremity arteries.

The self-designated specialty code of the physician performing the procedure was used to determine specialist type: vascular surgeons (VS), interventional radiologists (IR); interventional cardiologists (IC); and "other."

After excluding patients who might have undergone hybrid procedures and those who underwent thrombolysis procedures in the same year as the index procedure, the final sample of 14,608 patients was analyzed for the following outcomes: length of hospital stay; use of intensive care unit (ICU) services; transfusions; in-hospital mortality; and repeat intervention (defined as any ELER, open lower-extremity revascularization, or amputation of the lower extremity).

The researchers built risk-adjusted logistic regression models by using maximum-likelihood estimates to compare various patient outcomes across different specialties, and they used a linear regression model employing ordinary least squares to analyze length of stay. Cost analysis was performed using a linear regression model based on the least-squares approach. All models were adjusted for age, sex, race, admission type (emergency or ambulatory), and other comorbidities using the Elixhauser comorbidities software available from the Agency for Healthcare Research and Quality. Other regression models that included the International Classification of Disease-9 code for disease severity were developed, but were less predictive and had lower R² values, according to the authors. All logistic regression models passed the goodness-of-fit test at the 99% confidence level. In addition, linear regression models were also found to be satisfactory at the same level, according to the authors.

Within the study, there were 3,565 index procedures done by IRs; 5,489 by ICs; 5,358 by VSs; and 196 performed by "other" specialties (J. Vasc. Interven. Radiol 2012;23:3-9).

Dr. Zafar and his colleagues reported that VS outcomes were significantly worse than when the procedures were performed by an IR or IC. IRs had a 32% lower likelihood of ICU use (P less than .001) and a 37% lower likelihood of repeat lower-extremity revascularization or amputation (P less than .001) compared with VS. "Although statistical significance was not reached, both transfusion use and in-hospital mortality were 19% less likely after IRs performed procedures compared with VSs (P = .113 and P =.351, respectively)."

"Vascular surgeons were the only specialists with post-index procedure length of stay exceeding 3 days, significantly longer than observed for other specialties. The adjusted average 1-year costs per index procedure were 9% greater for vascular surgeons than for interventional radiologists ($19,012 vs. $17,640)," they said.

"The reasons for worse outcomes among VSs are not known, but may be related to insufficient training in catheter-based interventions as a result of the extensive time learning and practicing open surgical procedure compared with IRs and ICs, whose focus is catheter interventions," they said. "Medicare data indicate that patients who need lower-extremity endovascular revascularization services experience shorter hospital stays, require less transfusions and ICU services, have lower in-hospital mortality rates, and have much less chance of a subsequent revascularization or amputation within one year if treated by an IR rather than a VS," they concluded.

The study was supported by a grant from the Society of Interventional Radiology and internal funds from the Vascular Disease Research Center. One authors received research funding from Cordis/Johnson&Johnson, and Abbott Vascular and consulting for Microvention/Terumo.

Endovascular lower-extremity revascularization by vascular specialists resulted in more transfusions and ICU use, as well as a longer hospital stay, more repeat revascularization procedures and amputations, and higher costs, compared with the same procedures performed by interventional radiologists, according to the results of a large database analysis of the Medicare 5% Standard Analytical Files.

Dr. Abdul M. Zafar of the Vascular Disease Research Center, Brown University Alpert Medical School, Providence, and his colleagues extracted claims for endovascularlower extremity revascularization (ELER) index procedures using Current Procedural Terminology (CPT) codes in the years 2005 through 2007.

They recorded the unique IDs of the 15,455 patients who underwent these procedures and for whom an inpatient or outpatient claim corresponding to the index procedure claim was available. This comprised all claims for percutaneous angioplasty, atherectomy, and stent implantation of lower extremity arteries.

The self-designated specialty code of the physician performing the procedure was used to determine specialist type: vascular surgeons (VS), interventional radiologists (IR); interventional cardiologists (IC); and "other."

After excluding patients who might have undergone hybrid procedures and those who underwent thrombolysis procedures in the same year as the index procedure, the final sample of 14,608 patients was analyzed for the following outcomes: length of hospital stay; use of intensive care unit (ICU) services; transfusions; in-hospital mortality; and repeat intervention (defined as any ELER, open lower-extremity revascularization, or amputation of the lower extremity).

The researchers built risk-adjusted logistic regression models by using maximum-likelihood estimates to compare various patient outcomes across different specialties, and they used a linear regression model employing ordinary least squares to analyze length of stay. Cost analysis was performed using a linear regression model based on the least-squares approach. All models were adjusted for age, sex, race, admission type (emergency or ambulatory), and other comorbidities using the Elixhauser comorbidities software available from the Agency for Healthcare Research and Quality. Other regression models that included the International Classification of Disease-9 code for disease severity were developed, but were less predictive and had lower R² values, according to the authors. All logistic regression models passed the goodness-of-fit test at the 99% confidence level. In addition, linear regression models were also found to be satisfactory at the same level, according to the authors.

Within the study, there were 3,565 index procedures done by IRs; 5,489 by ICs; 5,358 by VSs; and 196 performed by "other" specialties (J. Vasc. Interven. Radiol 2012;23:3-9).

Dr. Zafar and his colleagues reported that VS outcomes were significantly worse than when the procedures were performed by an IR or IC. IRs had a 32% lower likelihood of ICU use (P less than .001) and a 37% lower likelihood of repeat lower-extremity revascularization or amputation (P less than .001) compared with VS. "Although statistical significance was not reached, both transfusion use and in-hospital mortality were 19% less likely after IRs performed procedures compared with VSs (P = .113 and P =.351, respectively)."

"Vascular surgeons were the only specialists with post-index procedure length of stay exceeding 3 days, significantly longer than observed for other specialties. The adjusted average 1-year costs per index procedure were 9% greater for vascular surgeons than for interventional radiologists ($19,012 vs. $17,640)," they said.

"The reasons for worse outcomes among VSs are not known, but may be related to insufficient training in catheter-based interventions as a result of the extensive time learning and practicing open surgical procedure compared with IRs and ICs, whose focus is catheter interventions," they said. "Medicare data indicate that patients who need lower-extremity endovascular revascularization services experience shorter hospital stays, require less transfusions and ICU services, have lower in-hospital mortality rates, and have much less chance of a subsequent revascularization or amputation within one year if treated by an IR rather than a VS," they concluded.

The study was supported by a grant from the Society of Interventional Radiology and internal funds from the Vascular Disease Research Center. One authors received research funding from Cordis/Johnson&Johnson, and Abbott Vascular and consulting for Microvention/Terumo.