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Randall DJ, Peacock K, Nickel KB, Olsen MA, Kazmers NH. Moving Minor Hand Surgeries Out of the Operating Room and Into the Office-Based Procedure Room: A Population-Based Trend Analysis. J Hand Surg Am 2022; 47:1137-1145. [PMID: 36471499 PMCID: PMC9731346 DOI: 10.1016/j.jhsa.2022.08.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 07/22/2022] [Accepted: 08/17/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Our primary purpose was to quantify the proportion of minor hand surgeries performed in the procedure room (PR) setting in a population-based cohort. Given the increase in the literature that has emerged since the mid-2000s highlighting the benefits of the PR setting, we hypothesized that a trend analysis would reveal increased utilization over time. METHODS We used the 2006-2017 MarketScan Commercial Database to identify adults who underwent isolated minor hand surgeries performed in PR and operation room surgical settings in the United States. The Cochran-Armitage trends test was used to determine whether the proportion of all procedures (PR + operation room) changed over time. RESULTS A total of 257,581 surgeries were included in the analysis, of which 24,966 (11.5%) were performed in the PR. There was an increase in the overall number of surgeries under study as well as increased utilization of the PR setting for open carpal tunnel release, trigger digit release, DeQuervain release, hand or finger mass excision, and hand or finger cyst excision. The magnitude of the increases in PR utilization was small: between 2006 and 2017, the PR utilization increased by 1.4% for open carpal tunnel release, 5.4% for trigger digit release, 2.9% for DeQuervain release, 10.1% for hand or finger mass excision, and 6.5% for hand or finger cyst excision. CONCLUSIONS Despite the published benefits of the PR setting, we observed that the majority of these 5 common minor hand surgeries are performed in the operation room setting. Between 2006 and 2017, the office-based PR utilization increased slightly. The identification of barriers to PR utilization is needed to improve the value of care. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.
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Affiliation(s)
- Dustin J Randall
- Oakland University William Beaumont School of Medicine, Rochester, MI; Department of Orthopaedics, University of Utah, Salt Lake City, UT
| | - Kate Peacock
- Center for Administrative Data Research, Institute of Clinical and Translational Sciences, Washington University in St. Louis, St. Louis, MO
| | - Katelin B Nickel
- Center for Administrative Data Research, Institute of Clinical and Translational Sciences, Washington University in St. Louis, St. Louis, MO
| | - Margaret A Olsen
- Center for Administrative Data Research, Institute of Clinical and Translational Sciences, Washington University in St. Louis, St. Louis, MO
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Che M, Wang Y, Zhao Y, Zhang S, Yu J, Gong W, Zhang D, Liu M. Finite Element Analysis of a New Type of Spinal Protection Device for the Prevention and Treatment of Osteoporotic Vertebral Compression Fractures. Orthop Surg 2022; 14:577-586. [PMID: 35147295 PMCID: PMC8926982 DOI: 10.1111/os.13220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 12/06/2021] [Accepted: 12/20/2021] [Indexed: 12/13/2022] Open
Abstract
Objective To study the effectiveness of a new spinal protection device for preventing and treating osteoporotic vertebral compression fractures (OVCFs) by finite element analysis (FEA). Methods One healthy volunteer and one patient with 1‐segment lumbar vertebral compression fractures were included in this experimental study. The DICOM files of two different lumbar spiral computed tomography (CT) scans were converted into STL files, and 3D finite element models of the lumbar spine were generated for normal and L1 vertebral fracture spines. A new type of spinal protection device was applied to reduce the stress on the anterior vertebral edge and direct the center of gravity posteriorly. The stress distribution characteristics of different finite element models of the lumbar spine were analyzed, revealing the characteristics of the stress distributed along the spine under the action of the new spinal protection device. Results Under normal conditions, the stress was mainly distributed in the middle and posterior columns of the spine. When the anterior border of the L1 vertebral body was fractured and collapsed, the stress distribution shifted toward the anterior column due to the center of gravity being directed forward. According to finite element analysis of the spine with the new protection device, the stress in the middle and posterior columns tended to increase, and that in the anterior column decreased. After the new type of spinal fixation device was applied, the stress at the L1 and L2 vertebral endplates decreased to a certain extent, especially that at the L1 vertebral body. The maximum stress on the L1 vertebral body decreased by 20% after the auxiliary device was applied. Conclusions According to the FEA results, the new spinal protection device can effectively prevent and treat osteoporotic vertebral compression fractures (OVCFs), and can alter the stress distribution in the spine and reduce the stress in the anterior column of the vertebral body, especially in vertebral compression fractures.
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Affiliation(s)
- Mingxue Che
- Department of Spinal Surgery, The First Hospital of Jilin University, Changchun, China.,Jilin Engineering Research Center for Spine and Spinal Cord Injury, Changchun, China
| | - Yongjie Wang
- Department of Spinal Surgery, The First Hospital of Jilin University, Changchun, China.,Jilin Engineering Research Center for Spine and Spinal Cord Injury, Changchun, China
| | - Yao Zhao
- Department of Joint Surgery, The First Hospital of Jilin University, Changchun, China
| | - Shaokun Zhang
- Department of Spinal Surgery, The First Hospital of Jilin University, Changchun, China.,Jilin Engineering Research Center for Spine and Spinal Cord Injury, Changchun, China
| | - Jun Yu
- Department of medical imaging, Jilin Provincial Armed Police Corps Hospital, Changchun, China
| | - Weiquan Gong
- Department of Spinal Surgery, The First Hospital of Jilin University, Changchun, China.,Jilin Engineering Research Center for Spine and Spinal Cord Injury, Changchun, China
| | - Debao Zhang
- Department of Joint Surgery, The First Hospital of Jilin University, Changchun, China
| | - Mingxi Liu
- Department of Orthopaedic Traumatology, The First Hospital of Jilin University, Changchun, China
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Affiliation(s)
| | - Sachin H Jain
- SCAN Group and Health Plan, Long Beach, California
- Stanford University, Palo Alto, California
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van Munster JJCM, Zamanipoor Najafabadi AH, de Boer NP, Peul WC, van den Hout WB, van Benthem PPG. Impact of surgical intervention trials on healthcare: A systematic review of assessment methods, healthcare outcomes, and determinants. PLoS One 2020; 15:e0233318. [PMID: 32442235 PMCID: PMC7244162 DOI: 10.1371/journal.pone.0233318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 05/01/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Frameworks used in research impact evaluation studies vary widely and it remains unclear which methods are most appropriate for evaluating research impact in the field of surgical research. Therefore, we aimed to identify and review the methods used to assess the impact of surgical intervention trials on healthcare and to identify determinants for surgical impact. METHODS We searched journal databases up to March 10, 2020 for papers assessing the impact of surgical effectiveness trials on healthcare. Two researchers independently screened the papers for eligibility and performed a Risk of Bias assessment. Characteristics of both impact papers and trial papers were summarized. Univariate analyses were performed to identify determinants for finding research impact, which was defined as a change in healthcare practice. RESULTS Sixty-one impact assessments were performed in 37 included impact papers. Some surgical trial papers were evaluated in more than one impact paper, which provides a total of 38 evaluated trial papers. Most impact papers were published after 2010 (n = 29). Medical records (n = 10), administrative databases (n = 22), and physician's opinion through surveys (n = 5) were used for data collection. Those data were analyzed purely descriptively (n = 3), comparing data before and after publication (n = 29), or through time series analyses (n = 5). Significant healthcare impact was observed 49 times and more often in more recent publications. Having impact was positively associated with using medical records or administrative databases (ref.: surveys), a longer timeframe for impact evaluation and more months between the publication of the trial paper and the impact paper, data collection in North America (ref.: Europe), no economic evaluation of the intervention, finding no significant difference in surgical outcomes, and suggesting de-implementation in the original trial paper. CONCLUSIONS AND IMPLICATIONS Research impact evaluation receives growing interest, but still a small number of impact papers per year was identified. The analysis showed that characteristics of both surgical trial papers and impact papers were associated with finding research impact. We advise to collect data from either medical records or administrative databases, with an evaluation time frame of at least 4 years since trial publication.
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Affiliation(s)
- Juliëtte J. C. M. van Munster
- Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Center (LUMC), Leiden University, Leiden, the Netherlands
- Leiden University Neurosurgical Center Holland (UNCH), LUMC and The Hague Medical Center (HMC), Leiden, the Netherlands
| | - Amir H. Zamanipoor Najafabadi
- Leiden University Neurosurgical Center Holland (UNCH), LUMC and The Hague Medical Center (HMC), Leiden, the Netherlands
| | - Nick P. de Boer
- Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Center (LUMC), Leiden University, Leiden, the Netherlands
| | - Wilco C. Peul
- Leiden University Neurosurgical Center Holland (UNCH), LUMC and The Hague Medical Center (HMC), Leiden, the Netherlands
| | - Wilbert B. van den Hout
- Department of Biomedical Data Science–Medical Decision Making, Leiden University Medical Center, Leiden University, Leiden, the Netherlands
| | - Peter Paul G. van Benthem
- Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Center (LUMC), Leiden University, Leiden, the Netherlands
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Buchbinder R, Busija L. Why we should stop performing vertebroplasties for osteoporotic spinal fractures. Intern Med J 2020; 49:1367-1371. [PMID: 31713338 DOI: 10.1111/imj.14628] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 06/17/2019] [Accepted: 06/23/2019] [Indexed: 11/29/2022]
Abstract
While vertebroplasty enjoys continued use in some settings, there is now high-moderate quality evidence based on systematic review that includes five placebo-controlled trials that it provides no benefits over placebo and these results do not differ according to pain duration (≤6 vs >6 weeks). A clinically important increased risk of incident symptomatic vertebral fractures or other serious adverse events cannot be excluded due to small event numbers. Serious harms including cord compression, ventricular perforation, pulmonary embolism, infection and death have been reported. This unfavourable risk-benefit ratio should be convincing doctors and patients to stop the use of vertebroplasty. At the very least, clinicians should fully inform their patients about the evidence including the likelihood of improving without vertebroplasty and the potential harms, so that patients can make evidence-informed decisions about their treatment. They should also warn patients about the pitfalls of relying on information sourced from the internet or from 'awareness raising' campaigns.
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Affiliation(s)
- Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lucy Busija
- Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Victoria, Australia.,Biostatistics Consulting Platform, Research Methodology Division, School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
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Hinde K, Maingard J, Hirsch JA, Phan K, Asadi H, Chandra RV. Mortality Outcomes of Vertebral Augmentation (Vertebroplasty and/or Balloon Kyphoplasty) for Osteoporotic Vertebral Compression Fractures: A Systematic Review and Meta-Analysis. Radiology 2020; 295:96-103. [PMID: 32068503 DOI: 10.1148/radiol.2020191294] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Osteoporotic vertebral compression fractures (OVCFs) are prevalent, with associated morbidity and mortality. Vertebral augmentation (VA), defined as either vertebroplasty and/or balloon kyphoplasty (BKP), is a minimally invasive surgical treatment to reduce pain and further collapse and/or renew vertebral body height by introducing bone cement into fractured vertebrae. Nonsurgical management (NSM) for OVCF carries inherent risks. Purpose To summarize the literature and perform a meta-analysis on the mortality outcomes of patients with OVCF treated with VA compared with those in patients treated with NSM. Materials and Methods A single researcher performed a systematic literature review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, or PRISMA, guidelines. Online scientific databases were searched in April 2018 for English-language publications. Included studies investigated mortality in patients with OVCF with VA as the primary intervention and NSM as the comparator. A meta-analysis was performed for studies that reported hazard ratios (HRs) and 95% confidence intervals (CIs). HR was used as a summary statistic and was random-effect-models tested. The χ2 test was used to study heterogeneity between trials, and the I2 statistic was calculated to estimate variation across studies. Results Of the 16 included studies, eight reported mortality benefits in VA, seven reported no mortality difference, and one reported mixed results. Seven studies were included in a meta-analysis examining findings in more than 2 million patients with OVCF (VA = 382 070, NSM = 1 707 874). The pooled HR comparing VA to NSM was 0.78 (95% CI: 0.66, 0.92; P = .003), with mortality benefits across 2- and 5-year periods (HR = 0.70, 95% CI: 0.69, 0.71, P < .001; and HR = 0.79, 95% CI: 0.62, 0.9999, P = .05; respectively). Balloon kyphoplasty provided mortality benefits over vertebroplasty, with HRs of 0.77 (95% CI: 0.77, 0.78; P < .001) and 0.87 (95% CI: 0.87, 0.88; P < .001), respectively. Conclusion In a meta-analysis of more than 2 million patients, those with osteoporotic vertebral compression fractures who underwent vertebral augmentation were 22% less likely to die at up to 10 years after treatment than those who received nonsurgical treatment. © RSNA, 2020 See also the editorial by Jennings in this issue.
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Affiliation(s)
- Kenji Hinde
- From the Department of Radiology, Western Health, Western Hospital, Footscray, Melbourne, Victoria 3011, Australia (K.H.); Interventional Radiology Service-Department of Radiology, Austin Hospital, Melbourne, Australia (J.M., H.A.); Interventional Neuroradiology Service-Department of Radiology, Austin Hospital, Melbourne, Australia (J.M., H.A.); School of Medicine-Faculty of Health, Deakin University, Warrun Ponds, Australia (J.M., H.A.); Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (J.A.H.); Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia (H.A.); NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Sydney, Australia (K.P.); Interventional Neuroradiology Unit, Monash Imaging, Melbourne, Australia (J.M., H.A., R.V.C.); and School of Medicine, Monash University, Melbourne, Australia (R.V.C.)
| | - Julian Maingard
- From the Department of Radiology, Western Health, Western Hospital, Footscray, Melbourne, Victoria 3011, Australia (K.H.); Interventional Radiology Service-Department of Radiology, Austin Hospital, Melbourne, Australia (J.M., H.A.); Interventional Neuroradiology Service-Department of Radiology, Austin Hospital, Melbourne, Australia (J.M., H.A.); School of Medicine-Faculty of Health, Deakin University, Warrun Ponds, Australia (J.M., H.A.); Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (J.A.H.); Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia (H.A.); NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Sydney, Australia (K.P.); Interventional Neuroradiology Unit, Monash Imaging, Melbourne, Australia (J.M., H.A., R.V.C.); and School of Medicine, Monash University, Melbourne, Australia (R.V.C.)
| | - Joshua A Hirsch
- From the Department of Radiology, Western Health, Western Hospital, Footscray, Melbourne, Victoria 3011, Australia (K.H.); Interventional Radiology Service-Department of Radiology, Austin Hospital, Melbourne, Australia (J.M., H.A.); Interventional Neuroradiology Service-Department of Radiology, Austin Hospital, Melbourne, Australia (J.M., H.A.); School of Medicine-Faculty of Health, Deakin University, Warrun Ponds, Australia (J.M., H.A.); Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (J.A.H.); Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia (H.A.); NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Sydney, Australia (K.P.); Interventional Neuroradiology Unit, Monash Imaging, Melbourne, Australia (J.M., H.A., R.V.C.); and School of Medicine, Monash University, Melbourne, Australia (R.V.C.)
| | - Kevin Phan
- From the Department of Radiology, Western Health, Western Hospital, Footscray, Melbourne, Victoria 3011, Australia (K.H.); Interventional Radiology Service-Department of Radiology, Austin Hospital, Melbourne, Australia (J.M., H.A.); Interventional Neuroradiology Service-Department of Radiology, Austin Hospital, Melbourne, Australia (J.M., H.A.); School of Medicine-Faculty of Health, Deakin University, Warrun Ponds, Australia (J.M., H.A.); Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (J.A.H.); Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia (H.A.); NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Sydney, Australia (K.P.); Interventional Neuroradiology Unit, Monash Imaging, Melbourne, Australia (J.M., H.A., R.V.C.); and School of Medicine, Monash University, Melbourne, Australia (R.V.C.)
| | - Hamed Asadi
- From the Department of Radiology, Western Health, Western Hospital, Footscray, Melbourne, Victoria 3011, Australia (K.H.); Interventional Radiology Service-Department of Radiology, Austin Hospital, Melbourne, Australia (J.M., H.A.); Interventional Neuroradiology Service-Department of Radiology, Austin Hospital, Melbourne, Australia (J.M., H.A.); School of Medicine-Faculty of Health, Deakin University, Warrun Ponds, Australia (J.M., H.A.); Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (J.A.H.); Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia (H.A.); NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Sydney, Australia (K.P.); Interventional Neuroradiology Unit, Monash Imaging, Melbourne, Australia (J.M., H.A., R.V.C.); and School of Medicine, Monash University, Melbourne, Australia (R.V.C.)
| | - Ronil V Chandra
- From the Department of Radiology, Western Health, Western Hospital, Footscray, Melbourne, Victoria 3011, Australia (K.H.); Interventional Radiology Service-Department of Radiology, Austin Hospital, Melbourne, Australia (J.M., H.A.); Interventional Neuroradiology Service-Department of Radiology, Austin Hospital, Melbourne, Australia (J.M., H.A.); School of Medicine-Faculty of Health, Deakin University, Warrun Ponds, Australia (J.M., H.A.); Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (J.A.H.); Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia (H.A.); NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Sydney, Australia (K.P.); Interventional Neuroradiology Unit, Monash Imaging, Melbourne, Australia (J.M., H.A., R.V.C.); and School of Medicine, Monash University, Melbourne, Australia (R.V.C.)
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Abstract
OBJECTIVE To determine whether women treated by older physicians are more likely to undergo episiotomy. DATA SOURCES/STUDY SETTING Hospital discharge data from Pennsylvania for the period 1994 to 2010. STUDY DESIGN We examined the impact of the year in which physicians started delivering babies (a proxy for age) in Pennsylvania on episiotomy rates using a linear probability model with hospital fixed effects. DATA COLLECTION/EXTRACTION METHODS Using diagnosis and procedure codes, we identified women delivering vaginally (N = 1 658 327) and determined the proportion who had an episiotomy. PRINCIPAL FINDINGS The average physician-level episiotomy rate declined from 54 percent in 1994 to 13 percent in 2010. Rates declined among older and younger physicians, but, at any point in time, women treated by older physicians were more likely to have an episiotomy. A 10-year difference in physician age is associated with a 6 percentage point increase in episiotomy rates. CONCLUSIONS Results indicate that older physicians, who entered practice when episiotomy was common, were slow to adjust their practices in response to evidence showing that routine episiotomy is unnecessary.
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Affiliation(s)
- David H Howard
- Department of Health Policy and Management, Emory University, Atlanta, Georgia
| | - Jason Hockenberry
- Department of Health Policy and Management, Emory University, Atlanta, Georgia
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Trends in vertebral augmentation for spinal fractures in myeloma patients: a 2002–2012 population-based study using a large national cancer registry. J Neurointerv Surg 2017; 10:183-190. [DOI: 10.1136/neurintsurg-2017-013011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/09/2017] [Accepted: 03/10/2017] [Indexed: 11/03/2022]
Abstract
PurposeTo evaluate temporal trends and factors associated with vertebral augmentation use in myeloma patients with spinal fractures from 2002 to 2012.MethodsThis retrospective cohort study used the Surveillance, Epidemiology and End Results (SEER)-Medicare claims database for 2002 through 2012. We included patients age ≥66 years with myeloma and spinal fractures. First, we evaluated receipt of vertebral augmentation. Second, multivariate logistic regression was used to assess the impact of sociodemographic factors, treatment facility type, and underlying comorbidities on the odds of undergoing vertebral augmentation.ResultsOf 4725 myeloma patients with spinal fractures, 653 underwent vertebral augmentation. Procedures increased initially from <1.7% in 2002 to 21.0% (109/520) in 2007, 18.6% (81/435) in 2008, 21.4% (109/509) in 2009, and 17.5% (76/435) in 2011. Patients with a spinal fracture before myeloma diagnosis were twice as likely to undergo vertebral augmentation as patients with fracture after myeloma diagnosis (OR 2.06, 95% CI 1.55 to 2.75). Black patients were half as likely to undergo vertebral augmentation as white patients (OR 0.48, 95% CI 0.34 to 0.68). Patients with 3–5 comorbidities (OR 0.78, 95% CI 0.64 to 0.96) and ≥6 comorbidities (OR 0.69, 95% CI 0.54 to 0.87) were less likely than patients with 0–2 comorbidities to undergo vertebral augmentation.ConclusionsVertebral augmentation for myeloma patients with spinal fractures peaked between 2007 and 2009 and then declined. Providers may have adopted vertebral augmentation in myeloma patients since its introduction, and potentially modified practice patterns following the publication of trials of vertebral augmentation in patients with osteoporotic spinal fractures.
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Savulescu J, Wartolowska K, Carr A. Randomised placebo-controlled trials of surgery: ethical analysis and guidelines. JOURNAL OF MEDICAL ETHICS 2016; 42:776-783. [PMID: 27777269 PMCID: PMC5256399 DOI: 10.1136/medethics-2015-103333] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 09/06/2016] [Accepted: 09/27/2016] [Indexed: 05/03/2023]
Abstract
Use of a placebo control in surgical trials is a divisive issue. We argue that, in principle, placebo controls for surgery are necessary in the same way as for medicine. However, there are important differences between these types of trial, which both increase justification and limit application of surgical studies. We propose that surgical randomised placebo-controlled trials are ethical if certain conditions are fulfilled: (1) the presence of equipoise, defined as a lack of unbiased evidence for efficacy of an intervention; (2) clinically important research question; (3) the risk to patients is minimised and reasonable; (4) there is uncertainty about treatment allocation rather than deception; (5) there is preliminary evidence for efficacy, which justifies a placebo-controlled design; and (6) ideally, the placebo procedure should have some direct benefit to the patient, for example, as a diagnostic tool. Placebo-controlled trials in surgery will most often be justified when surgery is performed to improve function or relieve symptoms and when objective outcomes are not available, while the risk of mortality or significant morbidity is low. In line with medical placebo-controlled trials, the surgical trial (1) should be sufficiently powered and (2) standardised so that its results are valid, (3) consent should be valid, (4) the standard treatment or rescue medication should be provided if possible, and (5) after the trial, the patients should be told which treatment they received and there should be provision for post-trial care if the study may result in long-term negative effects. We comment and contrast our guidelines with those of the American Medical Association.
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Affiliation(s)
- Julian Savulescu
- Faculty of Philosophy, Oxford Uehiro Centre for Practical Ethics, Oxford, UK
| | - Karolina Wartolowska
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Andy Carr
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
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Zhong BY, He SC, Zhu HD, Wu CG, Fang W, Chen L, Guo JH, Deng G, Zhu GY, Teng GJ. Risk Prediction of New Adjacent Vertebral Fractures After PVP for Patients with Vertebral Compression Fractures: Development of a Prediction Model. Cardiovasc Intervent Radiol 2016; 40:277-284. [PMID: 27812782 DOI: 10.1007/s00270-016-1492-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 10/26/2016] [Indexed: 12/14/2022]
Abstract
PURPOSE We aim to determine the predictors of new adjacent vertebral fractures (AVCFs) after percutaneous vertebroplasty (PVP) in patients with osteoporotic vertebral compression fractures (OVCFs) and to construct a risk prediction score to estimate a 2-year new AVCF risk-by-risk factor condition. MATERIALS AND METHODS Patients with OVCFs who underwent their first PVP between December 2006 and December 2013 at Hospital A (training cohort) and Hospital B (validation cohort) were included in this study. In training cohort, we assessed the independent risk predictors and developed the probability of new adjacent OVCFs (PNAV) score system using the Cox proportional hazard regression analysis. The accuracy of this system was then validated in both training and validation cohorts by concordance (c) statistic. RESULTS 421 patients (training cohort: n = 256; validation cohort: n = 165) were included in this study. In training cohort, new AVCFs after the first PVP treatment occurred in 33 (12.9%) patients. The independent risk factors were intradiscal cement leakage and preexisting old vertebral compression fracture(s). The estimated 2-year absolute risk of new AVCFs ranged from less than 4% in patients with neither independent risk factors to more than 45% in individuals with both factors. CONCLUSIONS The PNAV score is an objective and easy approach to predict the risk of new AVCFs.
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Affiliation(s)
- Bin-Yan Zhong
- Department of Radiology, Medical School, Zhongda Hospital, Southeast University, 87 DingjiaqiaoRoad, Nanjing, 210009, China
| | - Shi-Cheng He
- Department of Radiology, Medical School, Zhongda Hospital, Southeast University, 87 DingjiaqiaoRoad, Nanjing, 210009, China
| | - Hai-Dong Zhu
- Department of Radiology, Medical School, Zhongda Hospital, Southeast University, 87 DingjiaqiaoRoad, Nanjing, 210009, China
| | - Chun-Gen Wu
- Department of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600 Yi Shan Road, Shanghai, 200233, China
| | - Wen Fang
- Department of Radiology, Medical School, Zhongda Hospital, Southeast University, 87 DingjiaqiaoRoad, Nanjing, 210009, China
| | - Li Chen
- Department of Radiology, Medical School, Zhongda Hospital, Southeast University, 87 DingjiaqiaoRoad, Nanjing, 210009, China
| | - Jin-He Guo
- Department of Radiology, Medical School, Zhongda Hospital, Southeast University, 87 DingjiaqiaoRoad, Nanjing, 210009, China
| | - Gang Deng
- Department of Radiology, Medical School, Zhongda Hospital, Southeast University, 87 DingjiaqiaoRoad, Nanjing, 210009, China
| | - Guang-Yu Zhu
- Department of Radiology, Medical School, Zhongda Hospital, Southeast University, 87 DingjiaqiaoRoad, Nanjing, 210009, China
| | - Gao-Jun Teng
- Department of Radiology, Medical School, Zhongda Hospital, Southeast University, 87 DingjiaqiaoRoad, Nanjing, 210009, China.
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Howard DH, Soulos PR, Chagpar AB, Mougalian S, Killelea B, Gross CP. Contrary To Conventional Wisdom, Physicians Abandoned A Breast Cancer Treatment After A Trial Concluded It Was Ineffective. Health Aff (Millwood) 2016; 35:1309-15. [DOI: 10.1377/hlthaff.2015.1490] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- David H. Howard
- David H. Howard ( ) is an associate professor in the Department of Health Policy and Management and Winship Cancer Institute at Emory University, in Atlanta, Georgia
| | - Pamela R. Soulos
- Pamela R. Soulos is a program manager and data analyst at the Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center at the Yale University School of Medicine and the Yale Cancer Center, in New Haven, Connecticut
| | - Anees B. Chagpar
- Anees B. Chagpar is an associate professor of surgery in the Department of Surgery at the Yale University School of Medicine
| | - Sarah Mougalian
- Sarah Mougalian is an associate professor of surgery at the COPPER Center at the Yale University School of Medicine and the Yale Cancer Center
| | - Brigid Killelea
- Brigid Killelea is an associate professor of surgery at the COPPER Center at the Yale University School of Medicine and the Yale Cancer Center
| | - Cary P. Gross
- Cary P. Gross is a professor of medicine in the Section of General Internal Medicine at the Yale University School of Medicine
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Wong RH, Smieliauskas F, Pan IW, Lam SK. Interrupted time-series analysis: studying trends in neurosurgery. Neurosurg Focus 2015; 39:E6. [DOI: 10.3171/2015.9.focus15374] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Neurosurgery studies traditionally have evaluated the effects of interventions on health care outcomes by studying overall changes in measured outcomes over time. Yet, this type of linear analysis is limited due to lack of consideration of the trend’s effects both pre- and postintervention and the potential for confounding influences. The aim of this study was to illustrate interrupted time-series analysis (ITSA) as applied to an example in the neurosurgical literature and highlight ITSA’s potential for future applications.
METHODS
The methods used in previous neurosurgical studies were analyzed and then compared with the methodology of ITSA.
RESULTS
The ITSA method was identified in the neurosurgical literature as an important technique for isolating the effect of an intervention (such as a policy change or a quality and safety initiative) on a health outcome independent of other factors driving trends in the outcome. The authors determined that ITSA allows for analysis of the intervention’s immediate impact on outcome level and on subsequent trends and enables a more careful measure of the causal effects of interventions on health care outcomes.
CONCLUSIONS
ITSA represents a significant improvement over traditional observational study designs in quantifying the impact of an intervention. ITSA is a useful statistical procedure to understand, consider, and implement as the field of neurosurgery evolves in sophistication in big-data analytics, economics, and health services research.
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Affiliation(s)
- Ricky H. Wong
- 1Department of Neurosurgery, University of South Florida, Tampa, Florida
| | | | - I-Wen Pan
- 3Department of Neurosurgery, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Sandi K. Lam
- 3Department of Neurosurgery, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
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Schwartz AL, Chernew ME, Landon BE, McWilliams JM. Changes in Low-Value Services in Year 1 of the Medicare Pioneer Accountable Care Organization Program. JAMA Intern Med 2015; 175:1815-25. [PMID: 26390323 PMCID: PMC4928485 DOI: 10.1001/jamainternmed.2015.4525] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Wasteful practices are widespread in the US health care system. It is unclear if payment models intended to improve health care efficiency, such as the Medicare accountable care organization (ACO) programs, discourage the provision of low-value services. OBJECTIVE To assess whether the first year of the Medicare Pioneer ACO program was associated with a reduction in use of low-value services. DESIGN, SETTING, AND PARTICIPANTS In a difference-in-differences analysis, we compared use of low-value services between Medicare fee-for-service beneficiaries attributed to health care provider groups that entered the Pioneer program (ACO group) and beneficiaries attributed to other health care providers (control group) before (2009-2011) vs after (2012) Pioneer ACO contracts began. Data analysis was conducted from December 1, 2014, to June 27, 2015. Comparisons were adjusted for beneficiaries' sociodemographic and clinical characteristics as well as for geography. We decomposed estimates according to service characteristics (clinical category, price, and sensitivity to patient preferences) and compared estimates between subgroups of ACOs with higher vs lower baseline use of low-value services. MAIN OUTCOMES AND MEASURES Use of, and spending on, 31 services in instances that provide minimal clinical benefit, measured as annual service counts per 100 beneficiaries and price-standardized annual service spending per 100 beneficiaries. RESULTS During the precontract period, trends in the use of low-value services were similar for the ACO and control groups. The first year of ACO contracts was associated with a differential reduction (95% CI) of 0.8 low-value services per 100 beneficiaries for the ACO group (-1.2 to -0.4; P < .001), corresponding to a 1.9% differential reduction in service quantity (-2.9% to -0.9%) and a 4.5% differential reduction in spending on low-value services (-7.5% to -1.4%; P = .004). Differential reductions were similar for services less sensitive vs more sensitive to patient preferences and for higher- vs lower-priced services. The ACOs with higher than their markets' mean baseline levels of low-value service use experienced greater service reductions (-1.2 services per 100 beneficiaries; -1.7 to -0.7; P < .001) than did ACOs with use below the mean (-0.2 services per 100 beneficiaries, -0.6 to -0.2; P = .41; P = .003 for test of difference between subgroups). CONCLUSIONS AND RELEVANCE During its first year, the Pioneer ACO program was associated with modest reductions in low-value services, with greater reductions for organizations providing more low-value care. Accountable care organization-like risk contracts may be able to discourage use of low-value services even without specifying services to target.
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Affiliation(s)
- Aaron L Schwartz
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Michael E Chernew
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Bruce E Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts2Division of General Internal Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - J Michael McWilliams
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts3Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Trends in vertebroplasty and kyphoplasty after thoracolumbar osteoporotic fracture: A large database study from 2005 to 2012. J Orthop 2015; 12:S217-22. [PMID: 27047226 DOI: 10.1016/j.jor.2015.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 10/04/2015] [Indexed: 01/25/2023] Open
Abstract
PURPOSE The aim of our study was to investigate the trends and incidence of vertebral augmentation procedures (VAPs) in treating osteoporotic vertebral compression fractures. RESULTS In total, 118,074 patients were analyzed. The overall incidence of VAPs was 15.2%. The incidence of VAPs was significantly higher in those 75-79 years old (20.4%), significantly higher in females than males (15.6% versus 14.9%), and most commonly performed in the South (17.7%). CONCLUSION There was a decline in the frequency of these procedures since 2008, but physicians are still performing these procedures, albeit at a much lower frequency than before 2009.
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Veizi E, Hayek S. Interventional therapies for chronic low back pain. Neuromodulation 2015; 17 Suppl 2:31-45. [PMID: 25395115 DOI: 10.1111/ner.12250] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 08/28/2014] [Accepted: 08/31/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Low back pain (LBP) is a highly prevalent condition and one of the leading causes of lost productivity and health-care costs. The objective of this review is to discuss the role of interventional pain procedures and evidence of their effectiveness in treatment of chronic LBP. METHODS This is a narrative review examining published studies on interventional procedures for LBP. The rationales, indications, technique, evidence, and complications for the interventional procedures are discussed. RESULTS Interventional pain procedures are used extensively in diagnosis and treatment of chronic pain. LBP is multifactorial, and while significant progress has been made in understanding its pathophysiology, this has not resulted in a proportional improvement of functional outcomes. For certain procedures, such as spinal cord stimulation, medical branch blocks and radiofrequency ablations, and epidural steroid injections for radiculopathy, safety, efficacy, and cost-effectiveness in treating LBP have been well studied. For others, such as interventions for discogenic pain, treatment successes have been modest at best. CONCLUSIONS Implementation of interventional pain procedures in the treatment framework of LBP has resulted in improvement of pain intensity in at least the short and medium terms, but equivocal results have been observed in functional improvement.
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Affiliation(s)
- Elias Veizi
- Department of Anesthesiology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA; Pain Medicine & Spine Care, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA
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Evans AJ, Kip KE, Brinjikji W, Layton KF, Jensen ML, Gaughen JR, Kallmes DF. Randomized controlled trial of vertebroplasty versus kyphoplasty in the treatment of vertebral compression fractures. J Neurointerv Surg 2015; 8:756-63. [PMID: 26109687 DOI: 10.1136/neurintsurg-2015-011811] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 06/04/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND We present the results of a randomized controlled trial evaluating the efficacy of vertebroplasty versus kyphoplasty in treating vertebral body compression fractures. METHODS Patients with vertebral body compression fractures were randomly assigned to treatment with kyphoplasty or vertebroplasty. Primary endpoints were pain (0-10 scale) and disability assessed using the Roland-Morris Disability Questionnaire (RMDQ). Outcomes were assessed at 3 days, 1 month, 6 months, and 1 year following the procedure. RESULTS 115 subjects were enrolled in the trial with 59 (51.3%) randomly assigned to kyphoplasty and 56 (48.7%) assigned to vertebroplasty. Mean (SD) pain scores at baseline, 3 days, 30 days, and 1 year for kyphoplasty versus vertebroplasty were 7.4 (1.9) vs 7.9 (2.0), 4.1 (2.8) vs 3.7 (3.0), 3.4 (2.5) vs 3.6 (2.9), and 3.0 (2.8) vs 2.3 (2.6), respectively (p>0.05 at all time points). Mean (SD) RMDQ scores at baseline, 3 days, 30 days, 180 days, and 1 year were 17.3 (6.6) vs 16.3 (7.4), 11.8 (7.9) vs 10.9 (8.2), 8.6 (7.2) vs 8.8 (8.5), 7.9 (7.4) vs 7.3 (7.7), 7.5 (7.2) vs 6.7 (8.0), respectively (p>0.05 at all time points). For baseline to 12-month assessment in average pain and RMDQ scores, the standardized effect size between kyphoplasty and vertebroplasty was small at -0.36 (95% CI -1.02 to 0.31) and -0.04 (95% CI -1.68 to 1.60), respectively. CONCLUSIONS Our study indicates that vertebroplasty and kyphoplasty appear to be equally effective in substantially reducing pain and disability in patients with vertebral body compression fractures. TRIAL REGISTRATION NUMBER NCT00279877.
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Affiliation(s)
- Avery J Evans
- University of Virginia, Charlottesville, Virginia, USA
| | - Kevin E Kip
- University of South Florida, Tampa, Florida, USA
| | | | | | - Mary L Jensen
- University of Virginia, Charlottesville, Virginia, USA
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