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Keeling SO, Bissonauth A, Bernatsky S, Vandermeer B, Fortin PR, Gladman DD, Peschken C, Urowitz MB. Practice Variations in the Diagnosis, Monitoring, and Treatment of Systemic Lupus Erythematosus in Canada. J Rheumatol 2018; 45:1440-1447. [PMID: 30068762 DOI: 10.3899/jrheum.171307] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the diagnosis, monitoring, and treatment of systemic lupus erythematosus (SLE) in Canada. METHODS A 63-question electronic survey was developed with the Canadian Rheumatology Association and others. Descriptive analyses of responses were performed. RESULTS Survey respondents (n = 175) reported varying practices in the diagnosis, monitoring, and treatment of SLE. Performance of laboratory investigations for diagnosis and monitoring varied, with 78% of responders performing them at least every 6 months. Validated measures of SLE disease activity and damage were not commonly used. Most common first-line agents besides steroids for induction therapy for class III or IV lupus nephritis included intravenous cyclophosphamide and mycophenolate mofetil. Antimalarial use was common, with 96% of respondents using these in active skin disease. Over 60% of respondents indicated that 80-100% of their patients were taking antimalarials, while another 25% indicated they used these drugs in up to 80% of their patients. There were 71% of responders who reported completing frequent (6-12 mos) ophthalmology screening in patients taking antimalarials. Biologics were infrequently used. Responders were more likely to stop azathioprine and chloroquine than hydroxychloroquine in pregnant patients with SLE. Other aspects of routine care including vaccination and cardiovascular risk management varied considerably. The majority (80%) agreed that a dedicated multidisciplinary care team would improve SLE care. CONCLUSION Considerable practice variation in SLE management was noted. This may help inform future recommendations for the diagnosis, monitoring, and treatment of SLE in Canada.
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Affiliation(s)
- Stephanie O Keeling
- From the Division of Rheumatology, University of Alberta, Edmonton, Alberta; Division of Rheumatology, McGill University, Montreal, Quebec; Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta; Division of Rheumatology, CHU de Québec, Université Laval, Quebec City, Quebec; Division of Rheumatology, University of Toronto, Toronto, Ontario; Division of Rheumatology, University of Manitoba, Winnipeg, Manitoba, Canada. .,S.O. Keeling, MD, MSc, FRCP(C), Division of Rheumatology, University of Alberta; A. Bissonauth, MRes, Research Coordinator, Division of Rheumatology, University of Alberta; S. Bernatsky, MD, PhD, FRCPC, Professor of Medicine, Division of Rheumatology, McGill University; B. Vandermeer, MSc, Biostatistician, Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta; P.R. Fortin, MD, FRCPC, Professor of Medicine, Division of Rheumatology, CHU de Québec, Université Laval; D.D. Gladman, MD, FRCPC, Professor of Medicine, Division of Rheumatology, University of Toronto; C. Peschken, MD, FRCPC, Associate Professor of Medicine, Division of Rheumatology, University of Manitoba; M.B. Urowitz, MD, FRCPC, Division of Rheumatology, University of Toronto.
| | - Asvina Bissonauth
- From the Division of Rheumatology, University of Alberta, Edmonton, Alberta; Division of Rheumatology, McGill University, Montreal, Quebec; Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta; Division of Rheumatology, CHU de Québec, Université Laval, Quebec City, Quebec; Division of Rheumatology, University of Toronto, Toronto, Ontario; Division of Rheumatology, University of Manitoba, Winnipeg, Manitoba, Canada.,S.O. Keeling, MD, MSc, FRCP(C), Division of Rheumatology, University of Alberta; A. Bissonauth, MRes, Research Coordinator, Division of Rheumatology, University of Alberta; S. Bernatsky, MD, PhD, FRCPC, Professor of Medicine, Division of Rheumatology, McGill University; B. Vandermeer, MSc, Biostatistician, Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta; P.R. Fortin, MD, FRCPC, Professor of Medicine, Division of Rheumatology, CHU de Québec, Université Laval; D.D. Gladman, MD, FRCPC, Professor of Medicine, Division of Rheumatology, University of Toronto; C. Peschken, MD, FRCPC, Associate Professor of Medicine, Division of Rheumatology, University of Manitoba; M.B. Urowitz, MD, FRCPC, Division of Rheumatology, University of Toronto
| | - Sasha Bernatsky
- From the Division of Rheumatology, University of Alberta, Edmonton, Alberta; Division of Rheumatology, McGill University, Montreal, Quebec; Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta; Division of Rheumatology, CHU de Québec, Université Laval, Quebec City, Quebec; Division of Rheumatology, University of Toronto, Toronto, Ontario; Division of Rheumatology, University of Manitoba, Winnipeg, Manitoba, Canada.,S.O. Keeling, MD, MSc, FRCP(C), Division of Rheumatology, University of Alberta; A. Bissonauth, MRes, Research Coordinator, Division of Rheumatology, University of Alberta; S. Bernatsky, MD, PhD, FRCPC, Professor of Medicine, Division of Rheumatology, McGill University; B. Vandermeer, MSc, Biostatistician, Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta; P.R. Fortin, MD, FRCPC, Professor of Medicine, Division of Rheumatology, CHU de Québec, Université Laval; D.D. Gladman, MD, FRCPC, Professor of Medicine, Division of Rheumatology, University of Toronto; C. Peschken, MD, FRCPC, Associate Professor of Medicine, Division of Rheumatology, University of Manitoba; M.B. Urowitz, MD, FRCPC, Division of Rheumatology, University of Toronto
| | - Ben Vandermeer
- From the Division of Rheumatology, University of Alberta, Edmonton, Alberta; Division of Rheumatology, McGill University, Montreal, Quebec; Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta; Division of Rheumatology, CHU de Québec, Université Laval, Quebec City, Quebec; Division of Rheumatology, University of Toronto, Toronto, Ontario; Division of Rheumatology, University of Manitoba, Winnipeg, Manitoba, Canada.,S.O. Keeling, MD, MSc, FRCP(C), Division of Rheumatology, University of Alberta; A. Bissonauth, MRes, Research Coordinator, Division of Rheumatology, University of Alberta; S. Bernatsky, MD, PhD, FRCPC, Professor of Medicine, Division of Rheumatology, McGill University; B. Vandermeer, MSc, Biostatistician, Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta; P.R. Fortin, MD, FRCPC, Professor of Medicine, Division of Rheumatology, CHU de Québec, Université Laval; D.D. Gladman, MD, FRCPC, Professor of Medicine, Division of Rheumatology, University of Toronto; C. Peschken, MD, FRCPC, Associate Professor of Medicine, Division of Rheumatology, University of Manitoba; M.B. Urowitz, MD, FRCPC, Division of Rheumatology, University of Toronto
| | - Paul R Fortin
- From the Division of Rheumatology, University of Alberta, Edmonton, Alberta; Division of Rheumatology, McGill University, Montreal, Quebec; Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta; Division of Rheumatology, CHU de Québec, Université Laval, Quebec City, Quebec; Division of Rheumatology, University of Toronto, Toronto, Ontario; Division of Rheumatology, University of Manitoba, Winnipeg, Manitoba, Canada.,S.O. Keeling, MD, MSc, FRCP(C), Division of Rheumatology, University of Alberta; A. Bissonauth, MRes, Research Coordinator, Division of Rheumatology, University of Alberta; S. Bernatsky, MD, PhD, FRCPC, Professor of Medicine, Division of Rheumatology, McGill University; B. Vandermeer, MSc, Biostatistician, Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta; P.R. Fortin, MD, FRCPC, Professor of Medicine, Division of Rheumatology, CHU de Québec, Université Laval; D.D. Gladman, MD, FRCPC, Professor of Medicine, Division of Rheumatology, University of Toronto; C. Peschken, MD, FRCPC, Associate Professor of Medicine, Division of Rheumatology, University of Manitoba; M.B. Urowitz, MD, FRCPC, Division of Rheumatology, University of Toronto
| | - Dafna D Gladman
- From the Division of Rheumatology, University of Alberta, Edmonton, Alberta; Division of Rheumatology, McGill University, Montreal, Quebec; Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta; Division of Rheumatology, CHU de Québec, Université Laval, Quebec City, Quebec; Division of Rheumatology, University of Toronto, Toronto, Ontario; Division of Rheumatology, University of Manitoba, Winnipeg, Manitoba, Canada.,S.O. Keeling, MD, MSc, FRCP(C), Division of Rheumatology, University of Alberta; A. Bissonauth, MRes, Research Coordinator, Division of Rheumatology, University of Alberta; S. Bernatsky, MD, PhD, FRCPC, Professor of Medicine, Division of Rheumatology, McGill University; B. Vandermeer, MSc, Biostatistician, Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta; P.R. Fortin, MD, FRCPC, Professor of Medicine, Division of Rheumatology, CHU de Québec, Université Laval; D.D. Gladman, MD, FRCPC, Professor of Medicine, Division of Rheumatology, University of Toronto; C. Peschken, MD, FRCPC, Associate Professor of Medicine, Division of Rheumatology, University of Manitoba; M.B. Urowitz, MD, FRCPC, Division of Rheumatology, University of Toronto
| | - Christine Peschken
- From the Division of Rheumatology, University of Alberta, Edmonton, Alberta; Division of Rheumatology, McGill University, Montreal, Quebec; Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta; Division of Rheumatology, CHU de Québec, Université Laval, Quebec City, Quebec; Division of Rheumatology, University of Toronto, Toronto, Ontario; Division of Rheumatology, University of Manitoba, Winnipeg, Manitoba, Canada.,S.O. Keeling, MD, MSc, FRCP(C), Division of Rheumatology, University of Alberta; A. Bissonauth, MRes, Research Coordinator, Division of Rheumatology, University of Alberta; S. Bernatsky, MD, PhD, FRCPC, Professor of Medicine, Division of Rheumatology, McGill University; B. Vandermeer, MSc, Biostatistician, Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta; P.R. Fortin, MD, FRCPC, Professor of Medicine, Division of Rheumatology, CHU de Québec, Université Laval; D.D. Gladman, MD, FRCPC, Professor of Medicine, Division of Rheumatology, University of Toronto; C. Peschken, MD, FRCPC, Associate Professor of Medicine, Division of Rheumatology, University of Manitoba; M.B. Urowitz, MD, FRCPC, Division of Rheumatology, University of Toronto
| | - Murray B Urowitz
- From the Division of Rheumatology, University of Alberta, Edmonton, Alberta; Division of Rheumatology, McGill University, Montreal, Quebec; Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta; Division of Rheumatology, CHU de Québec, Université Laval, Quebec City, Quebec; Division of Rheumatology, University of Toronto, Toronto, Ontario; Division of Rheumatology, University of Manitoba, Winnipeg, Manitoba, Canada.,S.O. Keeling, MD, MSc, FRCP(C), Division of Rheumatology, University of Alberta; A. Bissonauth, MRes, Research Coordinator, Division of Rheumatology, University of Alberta; S. Bernatsky, MD, PhD, FRCPC, Professor of Medicine, Division of Rheumatology, McGill University; B. Vandermeer, MSc, Biostatistician, Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta; P.R. Fortin, MD, FRCPC, Professor of Medicine, Division of Rheumatology, CHU de Québec, Université Laval; D.D. Gladman, MD, FRCPC, Professor of Medicine, Division of Rheumatology, University of Toronto; C. Peschken, MD, FRCPC, Associate Professor of Medicine, Division of Rheumatology, University of Manitoba; M.B. Urowitz, MD, FRCPC, Division of Rheumatology, University of Toronto
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Alvin MD, Lubelski D, Alam R, Williams SK, Obuchowski NA, Steinmetz MP, Wang JC, Melillo AJ, Pahwa A, Benzel EC, Modic MT, Quencer R, Mroz TE. Spine Surgeon Treatment Variability: The Impact on Costs. Global Spine J 2018; 8:498-506. [PMID: 30258756 PMCID: PMC6149049 DOI: 10.1177/2192568217739610] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Cross-sectional analysis. OBJECTIVES Given the lack of strong evidence/guidelines on appropriate treatment for lumbar spine disease, substantial variability exists among surgical treatments utilized, which is associated with differences in costs to treat a given pathology. Our goal was to investigate the variability in costs among spine surgeons nationally for the same pathology in similar patients. METHODS Four hundred forty-five spine surgeons completed a survey of clinical and radiographic case scenarios on patients with recurrent lumbar disc herniation, low back pain, and spondylolisthesis. Those surveyed were asked to provide various details including their geographical location, specialty, and fellowship training. Treatment options included no surgery, anterior lumbar interbody fusion, posterolateral fusion, and transforaminal/posterior lumbar interbody fusion. Costs were estimated via Medicare national payment amounts. RESULTS For recurrent lumbar disc herniation, no difference in costs existed for patients undergoing their first revision microdiscectomy. However, for patients undergoing another microdiscectomy, surgeons who operated <100 times/year had significantly lower costs than those who operated >200 times/year (P < .001) and those with 5-15 years of experience had significantly higher costs than those with >15 years (P < .001). For the treatment of low back pain, academic surgeons kept costs about 55% lower than private practice surgeons (P < .001). In the treatment of spondylolisthesis, there was significant treatment variability without significant differences in costs. CONCLUSIONS Significant variability in surgical treatment paradigms exists for different pathologies. Understanding why variability in treatment selection exists in similar clinical contexts across practices is important to ensure the most cost-effective delivery of care among spine surgeons.
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Affiliation(s)
- Matthew D. Alvin
- Department of Radiology, The Johns Hopkins Hospital, Baltimore, MD,
USA
| | - Daniel Lubelski
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, MD,
USA
| | - Ridwan Alam
- The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Seth K. Williams
- University of Wisconsin Department of Orthopedics and Rehabilitation,
Madison, WI, USA
| | | | - Michael P. Steinmetz
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA,Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH,
USA
| | | | - Alfred J. Melillo
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH,
USA
| | - Amit Pahwa
- Department of Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Edward C. Benzel
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA,Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH,
USA
| | - Michael T. Modic
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA,Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH,
USA
| | - Robert Quencer
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Thomas E. Mroz
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA,Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH,
USA,Thomas E. Mroz, Neurological Institute, Cleveland
Clinic Center for Spine Health, Departments of Orthopaedic and Neurological Surgery, The
Cleveland Clinic, 9500 Euclid Avenue, S-80, Cleveland, OH 44195, USA.
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