A national survey of spinal cord stimulation trial-to-permanent conversion rates

OBJECTIVES

Conversion rates from trial leads to permanent spinal cord stimulation (SCS) systems have recently come under scrutiny. Our goal was to examine the rate of conversion from trial lead to permanent system placement as well as identify factors associated with successful SCS conversion.

MATERIALS AND METHODS

We designed a large retrospective analysis using the Thomson Reuters MarketScan database. We included all patients who underwent a percutaneous trial of neurostimulatory electrodes from the years 2000 to 2009 who were aged 18 and older. Patients were then tracked to see if they went on to receive a permanent SCS system. Patients were also analyzed in univariate and multivariate models to identify factors associated with successful conversion.

RESULTS

A total of 21,672 unique instances of percutaneous trials were identified. Overall, 41.4% of those receiving trials went on to have a permanent SCS system installed within the subsequent three months. Factors associated with increased likelihood of successful conversion included having commercial insurance (43% vs. 37%, p < 0.0001), younger age (43% for those aged 35-44 vs. 39% for those aged 65 and older, p < 0.0001), and never having had a previous percutaneous trial attempt (44% for first-time trials vs. 27% for those on their second trial vs. 14% for those on their third or later trial, p < 0.0001). In multivariate analysis, we found significant variation in conversion rate by geographic area (patients in the North Central region vs. Northeast region: odds ratio 1.48, 95% confidence interval [1.31, 1.66]; p < 0.0001).

CONCLUSIONS

In this study of a national cohort of patients, we identified specific factors associated with higher conversion rates, along with significant geographical variation. In general, there is a need for better patient selection by physicians who practice neuromodulation.

Clearance of amyloid-beta by circulating lipoprotein receptors

Low-density lipoprotein receptor-related protein-1 (LRP) on brain capillaries clears amyloid beta-peptide (Abeta) from brain. Here, we show that soluble circulating LRP (sLRP) provides key endogenous peripheral 'sink' activity for Abeta in humans. Recombinant LRP cluster IV (LRP-IV) bound Abeta in plasma in mice and Alzheimer's disease-affected humans with compromised sLRP-mediated Abeta binding, and reduced Abeta-related pathology and dysfunction in a mouse model of Alzheimer disease, suggesting that LRP-IV can effectively replace native sLRP and clear Abeta.

Improved preventive care for asthma: a randomized trial of clinician prompting in pediatric offices

OBJECTIVE

To determine whether clinician prompting regarding a child's symptom severity and guideline recommendations at the time of an office visit improves the delivery of preventive asthma care.

DESIGN

Randomized controlled trial.

SETTING

Two inner-city pediatric practices in Rochester, NY.

PARTICIPANTS

Two hundred twenty-six children with persistent asthma (aged 2-12 years) presenting to the clinics for well-child care, asthma care, or non-asthma-related illness care. Intervention We assigned children randomly to a clinician-prompting group (single-page prompt including the child's symptoms and guideline recommendations given to the clinician at the time of the visit) or a standard-care group (no prompt given). Interviewers called parents after the visit to inquire about preventive measures taken, and medical charts were reviewed.

MAIN OUTCOME MEASURES

Any preventive action related to asthma taken at the visit.

RESULTS

Children in the clinician-prompting group were more likely to have had any preventive measures taken at the visit compared with children in the standard-care group (87% vs 69%). Specifically, visits for children in the clinician-prompting group were more likely to include delivery of an action plan (50% vs 24%), discussions regarding asthma (87% vs 76%), and recommendations for an asthma follow-up visit (54% vs 37%). In a regression model, children in the clinician-prompting group had 3-fold greater odds of receiving any preventive action compared with the standard-care group.

CONCLUSION

Clinician prompting regarding asthma severity and care guidelines at the time of an office visit significantly improved the delivery of preventive asthma care.