1
|
Vijayan S, Kulkarni MS, Jain CP, Shetty S, Aroor MN, Rao SK. Bifocal Stabilisation of Acute Acromioclavicular Joint Dislocation using Suture Anchor and Temporary K-Wires: A Retrospective Analysis. Malays Orthop J 2022; 16:104-112. [PMID: 36589364 PMCID: PMC9791893 DOI: 10.5704/moj.2211.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 06/04/2022] [Indexed: 12/13/2022] Open
Abstract
Introduction The acromioclavicular joint (ACJ) is a major link connecting the upper limb to the torso. The acromioclavicular and coracoclavicular (CC) ligaments help in stabilising the joint. We feel it is prudent to address both these ligament injuries, to achieve optimum result. This study was undertaken to analyse the results of a simple frugal surgical technique we used to deal with this injury considering stabilisation for both these ligaments. Materials and methods In this retrospective study, skeletally mature patients with Type III, IV or V ACJ dislocations who underwent open reduction and stabilisation of the joint with temporary K-wires, repair of the capsule and augmentation of CC ligaments with suture anchors were included. Clinico-radiological and functional outcome was evaluated. Functional assessment of the upper limb was analysed using the Disabilities of Arm, Shoulder, and Hand Score (DASH), Constant shoulder score (CSS) and Oxford shoulder score (OSS). Results Clinical and radiological evaluation of the 32 patients who had completed two years from the index surgery, was done. Out of the 37 patients included initially, five were lost in follow-up. Majority of the subjects included were males and type V was the most common injury. Mean pre-operative CC distance on the affected side was 13.92±4.94mm. In the immediate post-operative radiograph, it was 7.63±2.08mm and in the final follow- up was 9.36±2.75mm. Measurements were taken by two independent investigators and inter, and intra-observer reliability were analysed by Interclass correlation coefficient. Excellent functional outcome was noted despite the 1.81±1.50mm average loss of correction. At final follow-up, mean DASH score was 4.67±4.18, Oxford shoulder score was 44.06±2.44 and Constant shoulder score was 86.37±5.81. The severity of the injury had no significant effect on the functional outcome post our method of stabilisation and rehabilitation. Conclusion Bifocal fixation restores the multidirectional stability of the disrupted ACJ. Adequate radiological reduction, good functional outcome and simplicity of execution make this technique an undemanding one for use in regular practice.
Collapse
Affiliation(s)
- S Vijayan
- Department of Orthopaedics, Kasturba Medical College Manipal - MAHE, Manipal, India
| | - MS Kulkarni
- Department of Orthopaedics, Kasturba Medical College Manipal - MAHE, Manipal, India
| | - CP Jain
- Department of Orthopaedics, Kasturba Medical College Manipal - MAHE, Manipal, India
| | - S Shetty
- Department of Orthopaedics, Kasturba Medical College Manipal - MAHE, Manipal, India,Corresponding Author: Sourab Shetty, Department of Orthopaedics, Kasturba Medical College Manipal - MAHE, Madhav Nagar, Manipal, Karnataka 576104, India
| | - MN Aroor
- Department of Orthopaedics, Kasturba Medical College Manipal - MAHE, Manipal, India
| | - SK Rao
- Department of Orthopaedics, Kasturba Medical College Manipal - MAHE, Manipal, India
| |
Collapse
|
2
|
Lee J, Israel E, Weinstein H, Kinane TB, Pasternack M, Linov P, Kaafarani HMA, Greenspan P, Rao SK. Using Physician-Level Emergency Department Utilization Reports to Address Avoidable Visits by Patients Managed by Pediatric Specialists. Hosp Pediatr 2019; 7:686-691. [PMID: 29055023 DOI: 10.1542/hpeds.2017-0054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Emergency department (ED) utilization is a major driver of cost. Specialist physicians have an important role in addressing ED utilization, especially at tertiary medical centers that treat highly specialized patients. We analyzed if reporting of ED utilization to pediatric specialist physicians can decrease ED visits. METHODS Physicians within pediatric neurology, hematology and oncology, infectious diseases, and pulmonary divisions received their ED use reports. By using control charts, we examined if this intervention decreased the rate of ED utilization. RESULTS Overall, for the 4 divisions, specialty-related ED utilization decreased significantly during all hours, weekdays, and office hours. This was in the setting of ED utilization increasing for all diagnoses ED visits. Pediatric ED volume did not change during the study period. CONCLUSIONS Physician-level reporting of ED utilization was associated with a reduction in ED use by patients managed by our pediatric specialists.
Collapse
Affiliation(s)
- Jarone Lee
- Departments of Emergency Medicine, .,Massachusetts General Physician Organization, Boston, Massachusetts.,Surgery
| | - Esther Israel
- Massachusetts General Physician Organization, Boston, Massachusetts.,Pediatrics, and
| | - Howard Weinstein
- Massachusetts General Physician Organization, Boston, Massachusetts.,Pediatrics, and
| | - T Bernard Kinane
- Massachusetts General Physician Organization, Boston, Massachusetts.,Pediatrics, and
| | - Mark Pasternack
- Massachusetts General Physician Organization, Boston, Massachusetts.,Pediatrics, and
| | - Pamela Linov
- Massachusetts General Physician Organization, Boston, Massachusetts
| | | | | | - Sandhya K Rao
- Pediatrics, and.,Medicine, Massachusetts General Hospital, Boston, Massachusetts; and
| |
Collapse
|
3
|
Aaronson EL, Kim J, Hard GA, Yun BJ, Kaafarani HMA, Rao SK, Weilburg JB, Lee J. Emergency department visits by patients with an internal medicine specialist: understanding the role of specialists in reducing ED crowding. Intern Emerg Med 2019; 14:777-782. [PMID: 30796698 DOI: 10.1007/s11739-019-02051-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 02/11/2019] [Indexed: 10/27/2022]
Abstract
As emergency department (ED) crowding continues to worsen, many visits are at academic referral hospitals. As a result, engaging specialty services will be essential to decompressing the ED. To do this, it will be important to understand which specialties to focus interventions on for the greatest impact. To characterize the ED utilization of non-surgical adult patients with an ambulatory specialist who were seen and discharged from the ED. Retrospective cohort study of all consecutive patients currently under the care from a specialist presenting to an urban, university affiliated hospital between 01 January 2015 and 31 December 2016. The identification of ED visits attributable to specialists was based on the primary diagnosis of ED visits and the frequency of visit with specialists within a given timeframe. Only patients who were discharged directly from the ED were included in the analysis. There were 29,853 ED visits by patients currently under the care of a specialist during the study period. 17.76% of these visits were related to the medical specialty of the specialist. Of these visits, 41.73% occurred during office hours, and 24.81% occurred during weekends. The specialties with the largest proportion of ED visits related to their specialty was cardiology, gastroenterology, and pulmonary, respectively. Nearly 18% of all patients that have a specialist and are treated and discharged from the ED present with a diagnosis related to their specialist's practice. This may indicate that there is a role for specialty service to play in decreasing some ED utilization that may be appropriate for the out-patient clinical setting. By focusing attention on specific specialties and interventions targeted during office hours, there may be an opportunity to decrease ED utilization.
Collapse
Affiliation(s)
- Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, MA, USA
| | - Jungyeon Kim
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Gregory A Hard
- Clinical Trials Network and Institute, Massachusetts General Hospital, Boston, MA, USA
| | - Brian J Yun
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Haytham M A Kaafarani
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Sandhya K Rao
- Department of Primary Care, Massachusetts General Hospital, Boston, MA, USA
| | - Jeffery B Weilburg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Jarone Lee
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
| |
Collapse
|
4
|
Shah SJ, Schwamm LH, Cohen AB, Simoni MR, Estrada J, Matiello M, Venkataramani A, Rao SK. Virtual Visits Partially Replaced In-Person Visits In An ACO-Based Medical Specialty Practice. Health Aff (Millwood) 2019; 37:2045-2051. [PMID: 30633681 DOI: 10.1377/hlthaff.2018.05105] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Specialty care contributes significantly to total medical expenditures, for which accountable care organizations (ACOs) are responsible. ACOs have sought to replace costly in-person visits with lower-cost alternatives such as virtual visits (videoconferencing with physicians). In fee-for-service environments, virtual visits appear to add to in-person visits instead of replacing them. While this may be less of a problem within ACOs, whether virtual visits reduce in-person visits in an ACO is not known. Using data from over 35,000 patients in the period 2014-17 within a Massachusetts-based ACO, we found that the use of virtual visits reduced in-person visits by 33 percent but increased total visits (virtual plus in-person visits) by 80 percent over 1.5 years. While the use of virtual visits reduced in-person visits soon after registering with the program, the effect did not endure beyond a year. Whether and how virtual visits can substitute for in-person care in the long term are open questions.
Collapse
Affiliation(s)
- Sachin J Shah
- Sachin J. Shah ( ) is an assistant professor of medicine at the University of California San Francisco
| | - Lee H Schwamm
- Lee H. Schwamm is executive vice chair of neurology and director of the Center for TeleHealth at Massachusetts General Hospital, and a professor of neurology at Harvard Medical School, both in Boston
| | - Adam B Cohen
- Adam B. Cohen is health technologies program manager at the Johns Hopkins University Applied Physics Laboratory, in Laurel, and an assistant professor of neurology in the Johns Hopkins Hospital and Health System, in Baltimore, both in Maryland
| | - Marcy R Simoni
- Marcy R. Simoni is director of the Virtual Visit Program at the Center for TeleHealth, Massachusetts General Hospital
| | - Juan Estrada
- Juan Estrada is senior director of the Virtual Consult Program at the Center for TeleHealth, Massachusetts General Hospital
| | - Marcelo Matiello
- Marcelo Matiello is director of Neurology Inpatient Services and Routine and Urgent Teleneurology Program at Massachusetts General Hospital and an assistant professor of neurology at Harvard Medical School, in Boston
| | - Atheendar Venkataramani
- Atheendar Venkataramani is an assistant professor of medical ethics and of health policy at the University of Pennsylvania Perelman School of Medicine, in Philadelphia
| | - Sandhya K Rao
- Sandhya K. Rao is senior medical director for population health management at Partners Healthcare and an assistant professor of medicine at Harvard Medical School, both in Boston
| |
Collapse
|
5
|
Mendu ML, Ahmed S, Maron JK, Rao SK, Chaguturu SK, May MF, Mutter WP, Burdge KA, Steele DJR, Mount DB, Waikar SS, Weilburg JB, Sequist TD. Development of an electronic health record-based chronic kidney disease registry to promote population health management. BMC Nephrol 2019; 20:72. [PMID: 30823871 PMCID: PMC6397481 DOI: 10.1186/s12882-019-1260-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/18/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Electronic health record (EHR) based chronic kidney disease (CKD) registries are central to population health strategies to improve CKD care. In 2015, Partners Healthcare System (PHS), encompassing multiple academic and community hospitals and outpatient care facilities in Massachusetts, developed an EHR-based CKD registry to identify opportunities for quality improvement, defined as improvement on both process measures and outcomes measures associated with clinical care. METHODS Patients are included in the registry based on the following criteria: 1) two estimated glomerular filtration rate (eGFR) results < 60 ml/min/1.73m2 separated by 90 days, including the most recent eGFR being < 60 ml/min/1.73m2; or 2) the most recent two urine protein values > 300 mg protein/g creatinine on either urine total protein/creatinine ratio or urine albumin/creatinine ratio; or 3) an EHR problem list diagnosis of end stage renal disease (ESRD). The registry categorizes patients by CKD stage and includes rates of annual testing for eGFR and proteinuria, blood pressure control, use of angiotensin converting enzyme inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs), nephrotoxic medication use, hepatitis B virus (HBV) immunization, vascular access placement, transplant status, CKD progression risk; number of outpatient nephrology visits, and hospitalizations. RESULTS The CKD registry includes 60,503 patients and has revealed several opportunities for care improvement including 1) annual proteinuria testing performed for 17% (stage 3) and 31% (stage 4) of patients; 2) ACE-I/ARB used in 41% (stage 3) and 46% (stage 4) of patients; 3) nephrotoxic medications used among 23% of stage 4 patients; and 4) 89% of stage 4 patients lack HBV immunity. For advanced CKD patients there are opportunities to improve vascular access placement, transplant referrals and outpatient nephrology contact. CONCLUSIONS A CKD registry can identify modifiable care gaps across the spectrum of CKD care and enable population health strategy implementation. No linkage to Social Security Death Master File or US Renal Data System (USRDS) databases limits our ability to track mortality and progression to ESRD.
Collapse
Affiliation(s)
- Mallika L. Mendu
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, One Brigham Circle, Boston, MA 02115 USA
| | - Salman Ahmed
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, One Brigham Circle, Boston, MA 02115 USA
| | | | - Sandhya K. Rao
- Partners Healthcare, Center for Population Health Management, Boston, MA USA
| | | | - Megan F. May
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, One Brigham Circle, Boston, MA 02115 USA
| | - Walter P. Mutter
- Division of Nephrology, Newton Wellesley Hospital, Boston, MA USA
| | - Kelly A. Burdge
- Division of Renal Medicine, North Shore Medical Center, Boston, MA USA
| | - David J. R. Steele
- Division of Renal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - David B. Mount
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, One Brigham Circle, Boston, MA 02115 USA
| | - Sushrut S. Waikar
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, One Brigham Circle, Boston, MA 02115 USA
| | | | - Thomas D. Sequist
- Partners Healthcare, Quality Safety and Value, Boston, MA USA
- Division of General Medicine, Brigham and Women’s Hospital, Boston, MA USA
- Department of Health Care Policy, Harvard Medical School, Boston, MA USA
| |
Collapse
|
6
|
Lee J, Rao SK, Weilburg J, Raja AS. Reducing Emergency Department Utilization by Engaging Specialists. Ann Emerg Med 2018; 72:732-733. [PMID: 30454801 DOI: 10.1016/j.annemergmed.2018.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Jarone Lee
- Departments of Emergency Medicine and Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | | | | | - Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| |
Collapse
|
7
|
Kim J, Yun BJ, Aaronson EL, Kaafarani HMA, Linov P, Rao SK, Weilburg JB, Lee J. The next step to reducing emergency department (ED) crowding: Engaging specialist physicians. PLoS One 2018; 13:e0201393. [PMID: 30125284 PMCID: PMC6101357 DOI: 10.1371/journal.pone.0201393] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 07/13/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Much work on reducing ED utilization has focused on primary care practices, but few studies have examined ED visits from patients followed by specialists, especially when the ED visit is related to the specialist's clinical practice. OBJECTIVE To determine the proportion and characteristics of patients that utilized the ED for specialty-related diagnosis. METHODS Retrospective, population-based, cohort study was conducted using information from electronic health records and billing database between January 2016 and December 2016. Patients who had seen a specialist during the last five years from the index ED visit date were included. The identification of ED visits attributable to specialists was based on the primary diagnosis of ED visits and the frequency of visit with specialists within a given timeframe. RESULTS Approximately 28% of ED visits analyzed were attributable to specialists. ED visits attributed specialists were represented by older patients and occurred more during working hours and early days of week. The most common diagnoses related to ED visits attributed to specialists were Circulatory, Musculoskeletal, Skin, Breast and Mental. Multiple departments, subdivisions and specialists were involved with each ED visit. The number of specialists following the patients who visited the ED ranged from one to six and the number of departments/subdivisions ranged from one to four. Patients that used the ED often were more likely to belong to departments (OR = 1.53) and specialists (OR = 1.18) associated with high ED utilization patterns. CONCLUSION Patients coming to the ED with specialty-related complaints are unique and require full engagement of the specialist and the specialty group. This study offers a new view of connections patients have with their specialists and engaging specialists both at department level and individual specialist level may be an important factor to reduce ED overcrowding.
Collapse
Affiliation(s)
- Jungyeon Kim
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Brian J. Yun
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Emily L. Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Haytham M. A. Kaafarani
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Pamela Linov
- Massachusetts General Physician Organization, Boston, Massachusetts, United States of America
| | - Sandhya K. Rao
- Department of Primary Care, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Jeffery B. Weilburg
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Jarone Lee
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| |
Collapse
|
8
|
Venkatesh RD, Campbell EJ, Thiim M, Rao SK, Ferris TG, Wasfy JH, Richter JM. e-Consults in gastroenterology: An opportunity for innovative care. J Telemed Telecare 2018; 25:499-505. [DOI: 10.1177/1357633x18781189] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background and aim Deploy and evaluate a gastroenterology (GI) electronic consultation (e-consult) program. E-consults are a promising approach to enhance provider communication, facilitate timely specialty advice and may replace some outpatient visits. Study As part of our health system’s efforts to provide more cost-effective care under risk-based contracts, we implemented an e-consult program where referring providers submit patient-specific clinical questions electronically via an electronic referral system. A GI consultant then reviews the patient’s record and provides a written recommendation back to the referring physician. For our program evaluation, we conducted chart reviews of each e-consult to understand how the program was being used and surveyed the participating providers and consultants. Results From September 2015 to March 2016, we received 144 e-consults, with most questions concerning GI symptoms or abnormal hepatology labs. Only 36% of e-consults recommended an in-person GI consult or procedure. In our survey of participating providers, referring providers strongly agreed that the GI e-consults promoted good patient care (88%) and were satisfied with the program (84%). The majority of GI consultants felt strongly that e-consults were useful for referring providers and their patients, but that current reimbursement and time allotted were not adequate. Conclusions We report on the implementation of a GI e-consult program within an ACO, showing that many clinical questions could be answered using this mechanism. E-consults in gastroenterology have the potential to reduce unnecessary visits and/or procedures for patients who can be managed by their primary provider, potentially increasing access for other patients.
Collapse
Affiliation(s)
- Rajitha D Venkatesh
- Duke Pediatric GI & Nutrition, Duke University Medical Center, Durham, NC, USA
| | - Emily J Campbell
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Thiim
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sandhya K Rao
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Timothy G Ferris
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jason H Wasfy
- Harvard Medical School, Boston, MA, USA
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| |
Collapse
|
9
|
Glover M, Duszak R, Silva E, Rao SK, Babb JS, Rosenkrantz AB. Participation and payments in the PQRS Maintenance of Certification Program: Implications for future merit based payment programs. Healthcare (Basel) 2018; 6:28-32. [DOI: 10.1016/j.hjdsi.2017.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 07/19/2017] [Accepted: 08/18/2017] [Indexed: 10/18/2022] Open
|
10
|
Rao SK, Wallace LMK, Theou O, Rockwood K. Is it better to be happy or not depressed? Depression mediates the effect of psychological well-being on adverse health outcomes in older adults. Int J Geriatr Psychiatry 2017; 32:1000-1008. [PMID: 27524809 DOI: 10.1002/gps.4559] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/30/2016] [Accepted: 07/01/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To examine the relationship between psychological well-being and depression in older adults and the relative contribution these psychological factors have on risk of functional disability, frailty, and mortality. METHODS This is a secondary analysis of 1668 community-dwelling older adults without dementia who participated in the second wave of the Canadian Study of Health and Aging. Baseline assessments of psychological well-being (Ryff scale) and depression (Geriatric Depression Scale; GDS) were collected. At 5-year follow-up, mortality data were collected; frailty and disability in activities of daily living were evaluated using the frailty index (FI) and the Lawton-Brody scale, respectively. RESULTS Area under the receiver-operating characteristic curve indicated that GDS and Ryff scores were able to independently discriminate whether individuals were considered frail (C = 0.66; C = 0.59, respectively), had limitations in basic (C = 0.64; C = 0.57, respectively) or instrumental (C = 0.70; C = 0.57, respectively) activities of daily living, or had died (C = 0.63; C = 0.57) at follow-up (all P < 0.01). Regression models in which the Ryff and GDS were included in the same model demonstrated that the GDS significantly predicted frailty, disability, and mortality, whereas the Ryff effect was not significant. Mediation analysis determined that the effect of psychological well-being on adverse outcomes was fully mediated by depression. CONCLUSIONS Our results suggest that although both depression and psychological well-being appear to modulate risk for adverse physical health outcomes, depression mediates this relationship. Detecting and treating depressive symptoms should be of high priority in older patients to mitigate risk of future physical health adversities including mortality. Copyright © 2016 John Wiley & Sons, Ltd.
Collapse
Affiliation(s)
- S K Rao
- Department of Psychiatry, University of Ottawa, Ottawa, Canada.,The Royal Ottawa Mental Health Centre, Ottawa, Canada
| | - L M K Wallace
- Division of Geriatric Medicine, Dalhousie University, Halifax, Canada
| | - O Theou
- Division of Geriatric Medicine, Dalhousie University, Halifax, Canada
| | - K Rockwood
- Division of Geriatric Medicine, Dalhousie University, Halifax, Canada.,Centre for Health Care of the Elderly, Nova Scotia Health Authority, Halifax, Canada
| |
Collapse
|
11
|
Glover M, Prabhakar AM, Rao SK, Weilburg JB, Hirsch JA. Accuracy of Self-Reported Specialty and Practice Location Among Radiologists. J Am Coll Radiol 2017; 14:1169-1172. [DOI: 10.1016/j.jacr.2017.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 04/11/2017] [Indexed: 11/27/2022]
|
12
|
Mendu ML, Waikar SS, Rao SK. Kidney Disease Population Health Management in the Era of Accountable Care: A Conceptual Framework for Optimizing Care Across the CKD Spectrum. Am J Kidney Dis 2017; 70:122-131. [DOI: 10.1053/j.ajkd.2016.11.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 11/20/2016] [Indexed: 11/11/2022]
|
13
|
Kalwani NM, Rao SK, Chittle MD, Isselbacher EM, Ferris TG, Wasfy JH. Abstract 117: A Value-Based Assessment of a Mature Cardiology E-Consult Program. Circ Cardiovasc Qual Outcomes 2017. [DOI: 10.1161/circoutcomes.10.suppl_3.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Cardiology electronic consults (e-consults) are asynchronous communications between cardiologists and primary care providers that can replace some traditional in-person consults. We have previously evaluated the initial and intermediate-term impact of e-consults in cardiology. To improve clinical value, e-consults should substitute for traditional consults while avoiding excessive diagnostic testing. Little is known, however, about the rates of in-person follow up or diagnostic testing in a mature e-consult program.
Methods:
We conducted detailed medical record reviews of all patients with cardiology e-consults at the Massachusetts General Hospital from January 9, 2014 to September 11, 2015. Charts were reviewed to determine (1) the proportion of e-consults that were followed by in-person cardiology visits within 6 months and (2) the proportion of e-consults that recommended further cardiac testing.
Results:
From January 9, 2014 to September 11, 2015, 454 cardiology e-consults were performed. Of those, 304 had six months of follow-up available for review. In 254/304 (83.6%) cases, patients had no in-person visit with a cardiologist within six months of the e-consult (see Figure 1). In 37/304 (12.2%) cases, patients had an in-person visit that was recommended by the e-consult. Additional testing was recommended in 155/454 (34.1%) e-consults, including echocardiograms recommended in 98/454 (21.6%) e-consults, Holter/event recorders recommended in 58/454 (12.8%) e-consults, and stress tests recommended in 50/454 (11.0%) e-consults. Medication changes were recommended in 87/454 (19.2%) e-consults.
Conclusions:
In this cohort of patients receiving cardiology e-consults, only one sixth subsequently presented for traditional in-person cardiology visits within six months. E-consults therefore appear to replace traditional consults, rather than simply postponing them. Furthermore, e-consults do not appear to be associated with high rates of downstream testing. These results reflect nearly two years of experience with a mature e-consult program, and imply that e-consults may be an effective tool to improve value in cardiology care.
Collapse
|
14
|
Wiesner GL, Rao SK, Ashworth DR, Thomas KA, Lammers PE. Abstract P3-08-10: Highly accurate hereditary risk assessment tool for low-income breast cancer patients. Cancer Res 2017. [DOI: 10.1158/1538-7445.sabcs16-p3-08-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction: Genetic testing is known to improve outcomes in high-risk women by finding cancers in the earliest most treatable stage or through prophylactic measures. However, these life-saving services may not be available to low-income women due to lack of insurance or access to genetic providers. To address this need, a collaboration between the Hereditary Cancer Clinic at Vanderbilt-Ingram Cancer Center (VICC) and the Robert E. Hardy Cancer Clinic at Nashville General Hospital at Meharry Medical College (MMC) was established in 2015 to systematically screen all MMC breast cancer patients for hereditary traits and refer them for genetic counseling (1). We hypothesized that high risk women could be accurately identified using this clinic based screening tool.
Methods: MMC clinic staff screened breast cancer patients using a 10-item Family Cancer Risk Assessment tool (RISK) that has been designed for use in a busy clinic environment (2). We tested the accuracy of the RISK by comparing the results to a 3-generation pedigree and the current NCCN guidelines for referral of patients to genetic services (3). The project was approved by the IRBs at each institution and study data were collected and managed using RedCap electronic data capture tools hosted at Vanderbilt University (4). Summary statistics and Chi-square for significance were performed.
Results: 73 breast cancer patients completed the RISK during their clinic visits and 41 (56%) had a high-risk score of 6 or more. All 41 patients have been referred for genetic counseling, with 18 (44%) women having completed a pedigree interview over the phone. 11 of these 18 patients (61%) were African-American; 5 (27.7%) were Caucasian; and one each (5% each) were of Asian and Hispanic ancestry. 9/18 were diagnosed < 50 years (Mean entire group =50 yrs; range 36 -57). 5/18 (27.7%) had triple negative markers on pathology and 2/18 were ER+/PR+/Her2+, and the remainder had ER+/PR+/HER2- cancers. Among the 18 patients with full pedigrees, 17 (95%) patients met current NCCN guidelines based on pedigree analysis. The one outlier had a revised RISK score based on updated information obtained during the pedigree interview. Genetic testing was offered to 10 patients seen in VICC clinic and 1 declined testing. The other 8 patients either failed (n=4) or are awaiting an appointment (n=4). No deleterious mutations were seen in those tested. 4 VUSs (BRCA2, NBN, SMARCA4, and RAD51D) were found in 3 of the 9 tested patients. No significant differences were found in race, age or type of tumor.
Conclusion: Point of care risk assessment using the Family Cancer Risk Assessment screening tool is highly accurate for identifying patients at high genetic risk for hereditary breast cancer. While the tool was completed using pen and paper, it could easily be computerized for ease of administration and calculation of risk scores. This approach benefits the busy oncologist in identifying and referring appropriate patients for genetic testing.
1. Funds awarded by GreaterGood.org. 2. Joseph G. et al. 2012 Public Health Genomics. 3. National Comprehensive Cancer Network: Genetic/High-risk Breast_Ovarian (Version 2.2016). 4. Harris et al. 2009. J Biomed Inform.
Citation Format: Wiesner GL, Rao SK, Ashworth DR, Thomas KA, Lammers PE. Highly accurate hereditary risk assessment tool for low-income breast cancer patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-08-10.
Collapse
Affiliation(s)
- GL Wiesner
- Vamderbilt-Ingram Cancer Center, Nashville, TN; Vanderbilt University Medical Center, Nashville, TN; Meharry Medical College, Nashville, TN
| | - SK Rao
- Vamderbilt-Ingram Cancer Center, Nashville, TN; Vanderbilt University Medical Center, Nashville, TN; Meharry Medical College, Nashville, TN
| | - DR Ashworth
- Vamderbilt-Ingram Cancer Center, Nashville, TN; Vanderbilt University Medical Center, Nashville, TN; Meharry Medical College, Nashville, TN
| | - KA Thomas
- Vamderbilt-Ingram Cancer Center, Nashville, TN; Vanderbilt University Medical Center, Nashville, TN; Meharry Medical College, Nashville, TN
| | - PE Lammers
- Vamderbilt-Ingram Cancer Center, Nashville, TN; Vanderbilt University Medical Center, Nashville, TN; Meharry Medical College, Nashville, TN
| |
Collapse
|
15
|
Rao SK, Kimball AB, Lehrhoff SR, Hidrue MK, Colton DG, Ferris TG, Torchiana DF. The Impact of Administrative Burden on Academic Physicians: Results of a Hospital-Wide Physician Survey. Acad Med 2017; 92:237-243. [PMID: 28121687 DOI: 10.1097/acm.0000000000001461] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
PURPOSE To determine the characteristics of clinically active academic physicians most affected by administrative burden; the correlation between administrative burden, burnout, and career satisfaction among academic physicians; and the relative value and burden of specific administrative tasks. METHOD The authors analyzed data from the 2014 Massachusetts General Physicians Organization Survey. Respondents reported the percentage of time they spent on patient-related administrative duties and rated the value and burden associated with specific administrative tasks. A five-point Likert scale and multivariate regression identified predictors of administrative burden and assessed the impact of administrative burden on perceived quality of care, career satisfaction, and burnout. RESULTS Of the eligible workforce, 1,774 physicians (96%) responded to the survey. On average, 24% of working hours were spent on administrative duties. Primary care physicians and women reported spending more time on administrative duties compared with other physicians. Two-thirds of respondents reported that administrative duties negatively affect their ability to deliver high-quality care. Physicians who reported higher percentages of time spent on administrative duties had lower levels of career satisfaction, higher levels of burnout, and were more likely to be considering seeing fewer patients in the future. Prior authorizations, clinical documentation, and medication reconciliation were rated the most burdensome tasks. CONCLUSIONS Administrative duties required substantial physician time and affected physicians' perceptions of being able to deliver high-quality care, career satisfaction, burnout, and likelihood to continue clinical practice. There is variation in administrative burden across specialties, and multiple areas of work contribute to overall administrative workload.
Collapse
Affiliation(s)
- Sandhya K Rao
- S.K. Rao is associate medical director for quality improvement, Massachusetts General Physicians Organization, a practicing general internist, and instructor in medicine, Harvard Medical School, Boston, Massachusetts.A.B. Kimball is president and chief executive officer, Harvard Medical Faculty Physicians, a practicing dermatologist, and professor of dermatology, Harvard Medical School, Boston, Massachusetts.S.R. Lehrhoff is director of physician programs, Strategic Communications and Physician Programs Department, Massachusetts General Physicians Organization, Boston, Massachusetts.M.K. Hidrue is senior economist, Performance Analytics and Improvement Department, Massachusetts General Physicians Organization, Boston, Massachusetts.D.G. Colton is chief of staff for the Partners Healthcare president and chief executive officer, Boston, Massachusetts.T.G. Ferris is senior vice president for population health, Massachusetts General Physicians Organization and Partners Healthcare, a practicing internist, and associate professor of medicine, Harvard Medical School, Boston, Massachusetts.D.F. Torchiana is president and chief executive officer, Partners Healthcare, and associate professor of surgery, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | |
Collapse
|
16
|
Wasfy JH, Rao SK, Essien UR, Richardson CA, Jeune T, Goldstein SA, Laikhter E, Chittle MD, Weil M, Wein M, Ferris TG. Initial experience with endocrinology e-consults. Endocrine 2017; 55:640-642. [PMID: 27507674 DOI: 10.1007/s12020-016-1053-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 07/04/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Sandhya K Rao
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Utibe R Essien
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Tamika Jeune
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Susan A Goldstein
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Elizabeth Laikhter
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Melissa D Chittle
- Division of Interventional Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michelle Weil
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marc Wein
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Timothy G Ferris
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
17
|
Affiliation(s)
- S Vidyadhara
- Trauma and Joint Replacement Services, Department of Orthopaedics, Kasturba Medical College, Manipal, Karnataka, India
| | - SK Rao
- Trauma and Joint Replacement Services, Department of Orthopaedics, Kasturba Medical College, Manipal, Karnataka, India
| |
Collapse
|
18
|
Tanguturi VK, Temin E, Yeh RW, Thompson RW, Rao SK, Mallick A, Cavallo E, Ferris TG, Wasfy JH. Clinical Interventions to Reduce Preventable Hospital Readmission After Percutaneous Coronary Intervention. Circ Cardiovasc Qual Outcomes 2016; 9:600-4. [DOI: 10.1161/circoutcomes.116.003086] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hospital readmissions are common and costly and, in some cases, may be related to problems with care processes. We sought to reduce readmissions after percutaneous coronary intervention (PCI) in a large tertiary care facility through programs to target vulnerabilities predischarge, after discharge, and during re-presentation to the emergency department. During initial hospitalization, we assessed patients’ readmission risk with a validated risk score and used a discharge checklist to ensure access to appropriate medications and close follow-up for high-risk patients. We also developed patient education videos about chest discomfort and heart failure. After discharge, we established a new follow-up clinic with cardiology fellows. A computerized system was developed to automatically notify cardiologists when patients presented to the emergency department within 30 days of PCI to enhance patient access to cardiology care in the emergency department. Early cardiologist assessment and assistance with triage was encouraged, and the emergency department used a risk stratification algorithm derived from a local database of patients to triage patients presenting with chest discomfort after PCI. We tracked the number of patients readmitted after PCI to our hospital. With our interventions, from 2011 to 2015, the index hospital readmission rate has declined from 9.6% to 5.3%. This program could provide tangible structural changes that can be implemented in other healthcare centers, both reducing the cost of care and improving the quality of care for patients with PCI.
Collapse
Affiliation(s)
- Varsha K. Tanguturi
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (V.K.T.); Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (E.T.); Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.W.Y.); Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.T., A.M.); and Massachusetts
| | - Elizabeth Temin
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (V.K.T.); Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (E.T.); Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.W.Y.); Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.T., A.M.); and Massachusetts
| | - Robert W. Yeh
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (V.K.T.); Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (E.T.); Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.W.Y.); Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.T., A.M.); and Massachusetts
| | - Ryan W. Thompson
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (V.K.T.); Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (E.T.); Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.W.Y.); Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.T., A.M.); and Massachusetts
| | - Sandhya K. Rao
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (V.K.T.); Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (E.T.); Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.W.Y.); Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.T., A.M.); and Massachusetts
| | - Aditi Mallick
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (V.K.T.); Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (E.T.); Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.W.Y.); Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.T., A.M.); and Massachusetts
| | - Elena Cavallo
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (V.K.T.); Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (E.T.); Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.W.Y.); Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.T., A.M.); and Massachusetts
| | - Timothy G. Ferris
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (V.K.T.); Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (E.T.); Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.W.Y.); Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.T., A.M.); and Massachusetts
| | - Jason H. Wasfy
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (V.K.T.); Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (E.T.); Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.W.Y.); Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.T., A.M.); and Massachusetts
| |
Collapse
|
19
|
Lee J, Greenspan PT, Israel E, Katz A, Fasano A, Kaafarani HMA, Linov PL, Raja AS, Rao SK. Emergency Department Utilization Report to Decrease Visits by Pediatric Gastroenterology Patients. Pediatrics 2016; 138:peds.2015-3586. [PMID: 27287727 DOI: 10.1542/peds.2015-3586] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Emergency department (ED) utilization is a major driver of health care costs. Specialist physicians have an important role in addressing ED utilization, especially at highly specialized, academic medical centers. We sought to investigate whether reporting of ED utilization to specialist physicians can decrease ED visits. METHODS This study analyzed an intervention to reduce ED utilization among ED patients who were followed by pediatric gastroenterologists. In May 2013, each pediatric gastroenterologist began receiving reports with rates of ED use by their patients. The reports generated discussion that resulted in a cultural and process change in which patients with urgent gastrointestinal (GI)-related complaints were preferentially seen in the office. Using control charts, we examined GI-related and all-diagnoses ED use over a 2-year period. RESULTS The rate of GI-related ED visits decreased by 60% after the intervention, from 4.89 to 1.95 per 1000 office visits (P < .001). Similarly, rates of GI-related ED visits during office hours decreased by 59% from 2.19 to 0.89 per 1000 (P < .001). Rates of all-diagnoses ED visits did not change. CONCLUSIONS Physician-level reporting of ED utilization to pediatric gastroenterologists was associated with physician engagement and a cultural and process change to preferentially treat patients with urgent issues in the office.
Collapse
Affiliation(s)
- Jarone Lee
- Departments of Emergency Medicine, Surgery, and Massachusetts General Physicians Organization, Boston, Massachusetts; and
| | - Peter T Greenspan
- Massachusetts General Physicians Organization, Boston, Massachusetts; and MassGeneral Hospital for Children, Boston, Massachusetts
| | - Esther Israel
- MassGeneral Hospital for Children, Boston, Massachusetts
| | - Aubrey Katz
- MassGeneral Hospital for Children, Boston, Massachusetts
| | - Alessio Fasano
- MassGeneral Hospital for Children, Boston, Massachusetts
| | | | - Pamela L Linov
- Massachusetts General Physicians Organization, Boston, Massachusetts; and
| | | | - Sandhya K Rao
- Massachusetts General Physicians Organization, Boston, Massachusetts; and Medicine, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
20
|
Khullar D, Rao SK, Chaguturu SK, Rajkumar R. The evolving role of subspecialties in population health management and new healthcare delivery models. Am J Manag Care 2016; 22:e192-e195. [PMID: 27355905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
New healthcare delivery models, including accountable care organizations (ACOs) and patient-centered medical homes, emphasize a more robust role for primary care. However, it is less clear how the roles and responsibilities of subspecialists should change as we enter a new paradigm of alternative payment models. Health systems seeking to better manage population health and control costs will need a clearer understanding of how best to incorporate subspecialty practitioners: What is a subspecialist's role? How does it vary by subspecialty? How should they be compensated? We argue that subspecialist compensation in ACOs and other new care delivery models should recognize the range of ways in which specialists can provide value to patients across a population-which varies depending on the provider's role in a patient's care. Only by more thoughtfully engaging, equipping, and compensating subspecialty practitioners can we achieve reform's central goal of better population health at a lower cost.
Collapse
Affiliation(s)
- Dhruv Khullar
- Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114. E-mail:
| | | | | | | |
Collapse
|
21
|
Rao SK, Carballo V, Cummings BM, Millham F, Jacobson JO. Developing an Interdisciplinary, Team-Based Quality Improvement Leadership Training Program for Clinicians: The Partners Clinical Process Improvement Leadership Program. Am J Med Qual 2016; 32:271-277. [PMID: 27259877 DOI: 10.1177/1062860616648773] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although there has been tremendous progress in quality improvement (QI) education for students and trainees in recent years, much less has been published regarding the training of active clinicians in QI. The Partners Clinical Process Improvement Leadership Program (CPIP) is a 6-day experiential program. Interdisciplinary teams complete a QI project framed by didactic sessions, interactive exercises, case-based problem sessions, and a final presentation. A total of 239 teams composed of 516 individuals have graduated CPIP. On completion, participant satisfaction scores average 4.52 (scale 1-5) and self-reported understanding of QI concepts improved. At 6 months after graduation, 66% of survey respondents reported sustained QI activity. Three opportunities to improve the program have been identified: (1) increasing faculty participation through online and tiered course offerings, (2) integrating the faculty-focused program with the trainee curriculum, and (3) developing a postgraduate curriculum to address the challenges of sustained improvement.
Collapse
Affiliation(s)
- Sandhya K Rao
- 1 Massachusetts General Hospital, Boston, MA.,2 Harvard Medical School, Boston, MA.,3 Partners HealthCare, Boston, MA
| | | | - Brian M Cummings
- 1 Massachusetts General Hospital, Boston, MA.,2 Harvard Medical School, Boston, MA.,3 Partners HealthCare, Boston, MA
| | - Frederick Millham
- 2 Harvard Medical School, Boston, MA.,4 South Shore Hospital, Quincy, MA
| | - Joseph O Jacobson
- 2 Harvard Medical School, Boston, MA.,5 Dana Farber Cancer Center, Boston, MA
| |
Collapse
|
22
|
Rao JP, Agrawal P, Mohammad R, Rao SK, Reddy GR, Dechamma HJ, S Suryanarayana VV. Expression of VP1 protein of serotype A and O of foot-and-mouth disease virus in transgenic sunnhemp plants and its immunogenicity for guinea pigs. Acta Virol 2016; 56:91-9. [PMID: 22720698 DOI: 10.4149/av_2012_02_91] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
UNLABELLED Recently, transgenic plants expressing immunogenic proteins of foot-and-mouth disease virus (FMDV) have been used as oral or parenteral vaccines against foot-and-mouth disease (FMD). They exhibit advantages like cost effectiveness, absence of processing, thermostability, and easy oral application. FMDV VP1 protein of single serotype has been mostly used as immunogen. Here we report the development of a bivalent vaccine with tandem-linked VP1 proteins of two serotypes, A and O, present in transgenic forage crop Crotalaria juncea. The expression of the bivalent protein in the transgenic plants was confirmed by Western blot analysis. Guinea pig reacted to orally or parenterally applied vaccine by humoral as well as cell-mediated immune responses including serum antibodies and stimulated lymphocytes, respectively. The vaccine protected the animals against a challenge with the virus of serotype A as well as O. This is the first report on the development of a bivalent FMD vaccine using a forage crop. KEYWORDS foot-and-mouth disease; sunnhemp; Agrobacterium tumefaciens; FMDV-VP1 gene; serotype O and A; in planta transformation; transgenic plants; bivalent vaccine.
Collapse
|
23
|
Wasfy JH, Rao SK, Kalwani N, Chittle MD, Richardson CA, Gallen KM, Isselbacher EM, Kimball AB, Ferris TG. Longer-term impact of cardiology e-consults. Am Heart J 2016; 173:86-93. [PMID: 26920600 DOI: 10.1016/j.ahj.2015.11.019] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 11/25/2015] [Indexed: 10/22/2022]
Abstract
AIMS Cardiac e-consults may be an effective way to deliver value-oriented outpatient cardiology care in an accountable care organization. Initial results of cardiac e-consults have demonstrated high satisfaction among both patients and referring providers, no known adverse events, and low rates of diagnostic testing. Nevertheless, differences between e-consults and traditional consults, effects of e-consults on traditional consult volume, and whether patients seek traditional consults after e-consults are unknown. METHODS AND RESULTS We established a cardiac e-consult program on January 13, 2014. We then conducted detailed medical record reviews of all patients with e-consults to detect any adverse clinical events and detect subsequent traditional visits to cardiologists. We also performed 2 comparisons. First, we compared age, gender, and referral reason for e-consults vs traditional consults. Second, we compared changes in volume of referrals to cardiology vs other medical specialties that did not have e-consults. From January 13 to December 31, 2014, 1,642 traditional referrals and 165 e-consults were requested. The proportion of e-consults of all evaluations requested over that period was 9.1%. Gender balance was similar among traditional consults and e-consults (44.8% male for e-consults vs 45.0% for traditional consults, P = .981). E-consult patients were younger than traditional consult patients (55.3 vs 60.4 years, P < .001). After the introduction of cardiac e-consults, the increase in traditional cardiac visit requests was less than the increase in traditional visit requests for control specialties (4.5% vs 10.1%, P < .001). For e-consults with at least 6 months of follow-up, 75.6% patients did not have any type of traditional cardiology visit during the follow-up period. CONCLUSION E-consults are an effective and safe mechanism to enhance value in outpatient cardiology care, with low rates of bounceback to traditional consults. E-consults can account for nearly one-tenth of total outpatient consultation volume at 1 year within an accountable care organization and are associated with a reduction in traditional referrals to cardiologists.
Collapse
|
24
|
Rao SK, Kimball AB, Torchiana DF. Teachable Action for Leaders Committed to Improving Physician Work Life: Continuing Education. Mayo Clin Proc 2015; 90:1455-6. [PMID: 26434970 DOI: 10.1016/j.mayocp.2015.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 07/21/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Sandhya K Rao
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Alexa B Kimball
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | |
Collapse
|
25
|
Chittle MD, Rao SK, Jaff MR, Patel VI, Gallen KM, Avadhani R, Ferris TG, Wasfy JH. Asynchronous vascular consultation via electronic methods: A feasibility pilot. Vasc Med 2015; 20:551-6. [PMID: 26385414 DOI: 10.1177/1358863x15601734] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Management of chronic disease often requires multidisciplinary clinical efforts and specialist care. With the emergence of Accountable Care Organizations (ACOs), health care systems are incentivized to evaluate methods of information exchange between generalists and specialists in order to provide value while preserving quality. Our objective was to evaluate patient and referring provider satisfaction and outcomes of asynchronous electronic consultations in vascular care in a large tertiary academic medical center. Referring providers were offered a vascular 'e-consult' option through an electronic referral management system. We conducted chart review to understand the downstream effects and surveyed patients and referring providers to assess satisfaction. From 24 March 2014 to 1 March 2015, 54 e-consults were completed. Additional testing and recommendations were made in 49/54 (90.7%) e-consults, including lower-extremity venous duplex ultrasonography with reflux testing, duplex ultrasonography of the carotid artery, computed tomography, magnetic resonance imaging, non-invasive physiology arterial studies, laboratory tests, medications, compression stockings, and sequential lymphedema compression therapy. Referring providers were compliant with recommendations in 40/49 (81.6%) of e-consults. A total of 17/54 (31.5%) patients were surveyed with a median patient satisfaction score of 13.7/15 (91.3%) (SD ± 6.4). The program was associated with high referring provider satisfaction, with 87.0% finding the e-consult very helpful and 80.0% stating it averted the need for a traditional visit. Our experience suggests that e-consults are an effective way to provide vascular care in some patients and are associated with high patient and provider satisfaction. E-consults may therefore be an efficient method of care delivery for vascular patients within an ACO.
Collapse
Affiliation(s)
- Melissa D Chittle
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Sandhya K Rao
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael R Jaff
- Paul and Phyllis Fireman Vascular Center, Massachusetts General Hospital, Boston, MA, USA
| | - Virendra I Patel
- Division of Vascular and Endovascular surgery, Paul and Phyllis Fireman Vascular Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kathleen M Gallen
- Paul and Phyllis Fireman Vascular Center, Massachusetts General Hospital, Boston, MA, USA Division of Vascular and Endovascular surgery, Paul and Phyllis Fireman Vascular Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Radhika Avadhani
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Timothy G Ferris
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jason H Wasfy
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
26
|
Aizer AA, Paly JJ, Zietman AL, Nguyen PL, Beard CJ, Rao SK, Kaplan ID, Niemierko A, Hirsch MS, Wu CL, Olumi AF, Michaelson MD, D'Amico AV, Efstathiou JA. Models of care and NCCN guideline adherence in very-low-risk prostate cancer. J Natl Compr Canc Netw 2014; 11:1364-72. [PMID: 24225970 DOI: 10.6004/jnccn.2013.0160] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
NCCN Guidelines recommend active surveillance as the primary management option for patients with very-low-risk prostate cancer and an expected survival of less than 20 years, reflecting the favorable prognosis of these men and the lack of perceived benefit of immediate, definitive treatment. The authors hypothesized that care at a multidisciplinary clinic, where multiple physicians have an opportunity to simultaneously review and discuss each case, is associated with increased rates of active surveillance in men with very-low-risk prostate cancer, including those with limited life expectancy. Of 630 patients with low-risk prostate cancer managed at 1 of 3 tertiary care centers in Boston, Massachusetts in 2009, 274 (43.5%) had very-low-risk classification. Patients were either seen by 1 or more individual practitioners in sequential settings or at a multidisciplinary clinic, in which concurrent consultation with 2 or more of the following specialties was obtained: urology, radiation oncology, and medical oncology. Patients seen at a multidisciplinary prostate cancer clinic were more likely to select active surveillance than those seen by individual practitioners (64% vs 30%; P<.001), an association that remained significant on multivariable logistic regression (odds ratio [OR], 4.16; P<.001). When the analysis was limited to patients with an expected survival of less than 20 years, this association remained highly significant (72% vs 34%, P<.001; OR, 5.19; P<.001, respectively). Multidisciplinary care is strongly associated with selection of active surveillance, adherence to NCCN Guidelines and minimization of overtreatment in patients with very-low-risk prostate cancer.
Collapse
Affiliation(s)
- Ayal A Aizer
- From the aHarvard Radiation Oncology Program, and bDepartment of Radiation Oncology, Massachusetts General Hospital; cDepartment of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute; dDepartment of Medicine, Division of General Internal Medicine, Massachusetts General Hospital; eDepartment of Radiation Oncology, Beth Israel Deaconess Medical Center; fDepartment of Radiation Oncology, Division of Biostatistics and Biomathematics, Massachusetts General Hospital; gDepartment of Pathology, Brigham and Women's Hospital; and hDepartment of Pathology, iDepartment of Urology, and jDepartment of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Wasfy JH, Rao SK, Isselbacher EM, Ferris TG. Abstract 346: Initial Results from a Cardiac Curbside Program. Circ Cardiovasc Qual Outcomes 2014. [DOI: 10.1161/circoutcomes.7.suppl_1.346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Improving value in outpatient cardiology care is an important goal. Some clinical questions for cardiologists involve interpretation of imaging data, and do not require in-person evaluation by a cardiologist. Creating a formal mechanism to process these questions outside the traditional framework of an in-office consult might reduce cost, improve access, and enhance patient satisfaction.
Methods:
We offered referring doctors at the Massachusetts General Hospital the opportunity to request cardiac “curbside” consults, with a formal mechanism for the cardiologist to annotate the electronic medical record with recommendations. This pilot started on January 13. We tracked volume of referrals by week before and after the new option became available. We compared traditional gastroenterology consults (excluding screening colonoscopy requests) over the same time period as a control. The volume of consults for cardiology and gastroenterology before and after the intervention was compared with a Fisher exact test.
Results:
During the first two weeks of the pilot, 14 cardiac curbsides were requested. Of those, 1 was rejected by the cardiologist, and 1 eventually led to a traditional office visit. In a 15 week lead in period before the new mechanism, 2384 gastroenterology consults were requested and 1329 cardiology consults were requested. In the 2 weeks after the intervention, 359 gastroenterology consults were requested and 203 traditional cardiology consults were requested. In the 15 week lead in period, the ratio of traditional cardiology consults to gastroenterology consults was 0.557. After the intervention, the ratio of traditional cardiology consults to gastroenterology consults was 0.565 (p = 0.888).
Conclusions:
In the initial phase of a cardiac curbside pilot, demand for curbsides accounted for about one-tenth of total referral volume. The volume of traditional cardiology consults has not yet declined at this early stage. Such interventions have the potential to improve efficiency and value.
Collapse
|
28
|
Abstract
BACKGROUND Periodontal medicine defines a rapidly emerging branch of Periodontology focusing on establishing a strong relationship between periodontal health and systemic health. It is speculated that the major common dysregulation which links Periodontitis with Rheumatoid arthritis (RA) is being played by the mediators of immune inflammatory response. OBJECTIVES To determine whether there is any relationship between periodontal disease and Rheumatoid arthritis. METHODS A total of 100 patients were included for the present study which was divided into two groups: one group (cases) included 50 patients attending the Department of Orthopedics, Kasturba Medical College, Manipal who were diagnosed of Rheumatoid arthritis. Another subject population included 50 patients as controls attending the Department of Oral Medicine, Manipal College of Dental Sciences, Manipal with age and gender matched with those of rheumatoid arthritis group. Specific measures for periodontitis included plaque index, gingival index, number of missing teeth, and radiographic alveolar bone loss scores. Measures of rheumatoid arthritis included health assessment questionaires, levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Various periodontal parameters were compared between the cases and controls. RESULTS The average alveolar bone loss was statistically more severe in Rheumatoid arthritis (RA) group than in the controls although there were similar plaque index in both the groups. The gingival index was statistically higher in the RA group. The Erythrocyte Sedimentation Rate (ESR) and C- Reactive Protein (CRP) levels of RA patients were also significantly associated with the severity of periodontal disease. CONCLUSION There was a significant association between Rheumatoid arthritis and Periodontitis which may be due to a common underlying deregulation of the inflammatory response in these individuals.
Collapse
Affiliation(s)
- J Rajkarnikar
- Department of Periodontics and Implantology, College of Dental Sciences and Hospital- Nepal Medical College (CODSH- NMC), Attarkhel, Nepal
| | | | | |
Collapse
|
29
|
Aizer AA, Paly JJ, Michaelson MD, Rao SK, Nguyen PL, Kaplan ID, Niemierko A, Olumi AF, Efstathiou JA. Medical oncology consultation and minimization of overtreatment in men with low-risk prostate cancer. J Oncol Pract 2014; 10:107-12. [PMID: 24399853 DOI: 10.1200/jop.2013.000902] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Specialist bias, in which specialists recommend the therapy that they are capable of delivering, is thought to influence the treatment of patients with localized prostate cancer and to contribute to overtreatment of men with limited life expectancy. Consequently, rates of active surveillance, the preferred management modality per the National Comprehensive Cancer Network (NCCN) for patients with low- and very low-risk disease and a life expectancy of less than 10 and less than 20 years, respectively, are low. We sought to determine whether consultation with a medical oncologist is associated with increased rates of active surveillance in men with low-risk prostate cancer. METHODS We identified 188 patients with low-risk prostate cancer undergoing active surveillance at one of three referral centers in Boston, MA in 2009. Multivariable logistic regression was used to determine whether consultation with a medical oncologist was associated with selection of active surveillance. The data were reanalyzed for patients with low- and very low-risk disease and a life expectancy of less than 10 and less than 20 years, respectively. RESULTS Consultation with a medical oncologist was associated with increased rates of active surveillance (37% v 21%, P = .01), an association that remained significant on multivariable logistic regression (odds ratio [OR] = 2.70; 95% CI, 1.27 to 5.75; P = .01). When applied to patients with limited life expectancy, this finding remained significant (OR = 4.74; 95% CI, 1.17 to 19.25; P = .03). CONCLUSION Consultation with a medical oncologist is associated with increased rates of active surveillance, adherence to NCCN guidelines, and minimization of overtreatment in men with early prostate cancer and limited life expectancy.
Collapse
Affiliation(s)
- Ayal A Aizer
- Harvard Radiation Oncology Program; Massachusetts General Hospital; Brigham and Women's Hospital-Dana-Farber Cancer Institute; and Beth Israel Deaconess Medical Center, Boston, MA
| | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Torchiana DF, Colton DG, Rao SK, Lenz SK, Meyer GS, Ferris TG. Massachusetts General Physicians Organization’s Quality Incentive Program Produces Encouraging Results. Health Aff (Millwood) 2013; 32:1748-56. [DOI: 10.1377/hlthaff.2013.0377] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- David F. Torchiana
- David F. Torchiana is chairman and CEO of the Massachusetts General Physicians Organization (MGPO) and a physician at Massachusetts General Hospital, in Boston
| | | | - Sandhya K. Rao
- Sandhya K. Rao is associate medical director of the MGPO and a physician at Massachusetts General Hospital
| | - Sarah K. Lenz
- Sarah K. Lenz is director of physician incentive programs at the MGPO
| | - Gregg S. Meyer
- Gregg S. Meyer is chief clinical officer and executive vice president for population health at Dartmouth-Hitchcock Medical Center, in Hanover, New Hampshire
| | - Timothy G. Ferris
- Timothy G. Ferris is medical director of the MGPO and a physician at Massachusetts General Hospital
| |
Collapse
|
31
|
Abstract
US health-care costs are growing at an alarming rate. "Value-based" payment models that hold providers accountable for outcomes and costs of care are becoming more prevalent. In these arrangements, provider groups will be accountable for the costs of lab tests, many of which have traditionally been revenue-generating. "Stewardship" programs aimed at newer, high-cost specialized tests, decision support on more routine tests, variation reporting, and incentives are familiar tactics that will need to be deployed in this new context.
Collapse
Affiliation(s)
- Sandhya K Rao
- General Medicine Division, Massachusetts General Hospital, United States.
| |
Collapse
|
32
|
Aizer AA, Paly JJ, Zietman AL, Nguyen PL, Beard C, Rao SK, Kaplan ID, Niemierko A, Hirsch MS, Wu CL, Olumi AF, Michaelson MD, D'Amico AV, Efstathiou JA. Multidisciplinary care and management of very low-risk prostate cancer. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.6_suppl.55] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
55 Background: The National Comprehensive Cancer Network (NCCN) recommends active surveillance (AS) as the primary management option for patients with very low-risk prostate cancer (VLRPC) and an expected survival of <20 years. Factors associated with selection of AS are therefore of clinical importance. We hypothesized that care at a multidisciplinary clinic (MC), where multiple physicians simultaneously review each case, will be associated with increased rates of AS in men with VLRPC, including those with limited life expectancy. Methods: Of 630 patients with low-risk prostate cancer managed at one of three tertiary care centers in Boston, MA in 2009, 274 (43.5%) had VLRPC. Patients were either seen by one or more individual providers in sequential visits (N=178) or at an MC (N=96), in which concurrent consultation with two or more of the following specialties was obtained: urology, medical oncology, and radiation oncology. Results: Patients seen at an MC were more likely to select AS than those seen by individual providers (64% vs 30%, p<.001), an association which remained significant on multivariable logistic regression (OR=4.16, p<.001), see Table. When the analysis was limited to patients with an expected survival of <20 years based on the 2007 Social Security Life Table, this association remained highly significant (OR=5.19, p<.001). Conclusions: Multidisciplinary care is strongly associated with selection of AS, adherence to NCCN guidelines, and minimization of over-treatment in patients with VLRPC. [Table: see text]
Collapse
Affiliation(s)
| | | | | | - Paul Linh Nguyen
- Dana-Farber Cancer Institute/Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Clair Beard
- Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | | | | | - Aria F. Olumi
- Department of Urology, Massachusetts General Hospital, Boston, MA
| | | | | | | |
Collapse
|
33
|
Monappa V, Naik AM, Mathew M, Rao L, Rao SK, Ramachandra L, PadmaPriya J. Phosphaturic mesenchymal tumour of the mandible--the useful criteria for a diagnosis on fine needle aspiration cytology. Cytopathology 2012. [PMID: 23198882 DOI: 10.1111/cyt.12030] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- V Monappa
- Department of Pathology, Kasturba Medical College, Manipal University, Manipal, Karnataka, IndiaOrthopaedic Surgery, Kasturba Medical College, Manipal University, Manipal, Karnataka, IndiaGeneral Surgery, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | | | | | | | | | | | | |
Collapse
|
34
|
Dhanushkodi A, Akano EO, Roguski EE, Xue Y, Rao SK, Matta SG, Rex TS, McDonald MP. A single intramuscular injection of rAAV-mediated mutant erythropoietin protects against MPTP-induced parkinsonism. Genes Brain Behav 2012. [PMID: 23190369 DOI: 10.1111/gbb.12001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Erythropoietin (Epo) is neuroprotective in a number of preparations, but can lead to unacceptably high and even lethal hematocrit levels. Recent reports show that modified Epo variants confer neuroprotection in models of glaucoma and retinal degeneration without raising hematocrit. In this study, neuroprotective effects of two Epo variants (EpoR76E and EpoS71E) were assessed in a model of Parkinson's disease. The constructs were packaged in recombinant adeno-associated viral (rAAV) vectors and injected intramuscularly. After 3 weeks, mice received five daily injections of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) and were killed 5 weeks later. The MPTP-lesioned mice pretreated with rAAV.eGFP (negative control) exhibited a 7- to 9-Hz tremor and slower latencies to move on a grid test (akinesia). Both of these symptomatic features were absent in mice pretreated with either modified Epo construct. The rAAV.eGFP-treated mice lesioned with MPTP exhibited a 41% reduction in tyrosine hydroxylase (TH)-positive neurons in the substantia nigra. The rAAV.EpoS71E construct did not protect nigral neurons, but neuronal loss in mice pretreated with rAAV.EpoR76E was only half that of rAAV.eGFP controls. Although dopamine levels were normal in all groups, 3,4-dihydroxyphenylacetic acid (DOPAC) was significantly reduced only in MPTP-lesioned mice pretreated with rAAV.eGFP, indicating reduced dopamine turnover. Analysis of TH-positive fibers in the striatum showed normalized density in MPTP-lesioned mice pretreated with rAAV.EpoS71E, suggesting that enhanced sprouting induced by EpoS71E may have been responsible for normal behavior and dopaminergic tone in these mice. These results show that systemically administered rAAV-generated non-erythropoietic Epo may protect against MPTP-induced parkinsonism by a combination of neuroprotection and enhanced axonal sprouting.
Collapse
Affiliation(s)
- A Dhanushkodi
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | | | | | | | | | | | | | | |
Collapse
|
35
|
Aizer AA, Paly JJ, Zietman AL, Nguyen PL, Beard CJ, Rao SK, Kaplan ID, Niemierko A, Hirsch MS, Wu CL, Olumi AF, Michaelson MD, D'Amico AV, Efstathiou JA. Multidisciplinary care and pursuit of active surveillance in low-risk prostate cancer. J Clin Oncol 2012; 30:3071-6. [PMID: 22851571 DOI: 10.1200/jco.2012.42.8466] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Multidisciplinary clinics offer a unique approach to the management of patients with cancer. Yet, limited data exist to show that such clinics affect management. The purpose of this study was to determine whether consultation at a multidisciplinary clinic is associated with selection of active surveillance in patients with low-risk prostate cancer. PATIENTS AND METHODS The study comprised 701 men with low-risk prostate cancer managed at three tertiary care centers in Boston, MA in 2009. Patients either obtained consultation at a multidisciplinary prostate cancer clinic, at which they were seen by a combination of urologic, radiation, and medical oncologists in a concurrent setting, or they were seen by individual practitioners in sequential settings. The primary outcome was selection of active surveillance. RESULTS Crude rates of selection of active surveillance in patients seen at a multidisciplinary clinic were double that of patients seen by individual practitioners (43% v 22%), whereas the proportion of men treated with prostatectomy or radiation decreased by approximately 30% (P < .001). On multivariate logistic regression, older age (odds ratio [OR], 1.09; 95% CI, 1.05 to 1.12; P < .001), unmarried status (OR, 1.66; 95% CI, 1.01 to 2.72; P = .04), increased Charlson comorbidity index (OR, 1.37; 95% CI, 1.06 to 1.77; P = .02), fewer positive cores (OR, 0.92; 95% CI, 0.90 to 0.94; P < .001), and consultation at a multidisciplinary clinic (OR, 2.15; 95% CI, 1.13 to 4.10; P = .02) were significantly associated with pursuit of active surveillance. CONCLUSION Multidisciplinary care is associated with increased selection of active surveillance in men with low-risk prostate cancer. This finding may have an important clinical, social, and economic impact.
Collapse
Affiliation(s)
- Ayal A Aizer
- Harvard Radiation Oncology Program, Massachusetts General Hospital, Department of Radiation Oncology, 100 Blossom St, Cox 3, Boston, MA 02114, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Aizer A, Paly JJ, Zietman AL, D'Amico AV, Nguyen PL, Beard C, Rao SK, Kaplan ID, Hirsch MS, Wu CL, Efstathiou JA. Multidisciplinary care and pursuit of active surveillance in low-risk prostate cancer. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.5_suppl.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
131 Background: Factors associated with pursuit of active surveillance in men with low-risk prostate cancer are not well-delineated. Methods: 701 patients with low-risk prostate cancer (clinical stage < T2b, Gleason score < 7, and PSA < 10 ng/mL), treated in 2009 at three tertiary care centers affiliated with the same medical school and within the same health care system were identified. All patients were evaluated by one or more urological, radiation, and/or medical oncologists specializing in genitourinary malignancies, either sequentially at independent appointments with differing dates/locations, or concurrently at a multidisciplinary genitourinary oncology clinic in which all three specialists evaluated the patient jointly during a single visit. Pre-treatment and treatment-related variables were recorded. Logistic regression was performed to identify demographic and clinical factors associated with the employment of active surveillance. Results: Forty three percent of patients referred to a multidisciplinary clinic underwent active surveillance, as opposed to 22% of patients seen by individual practitioners (p<.001). On multivariate logistic regression, older age (OR 1.09 (per year), p <.001), increased comorbidities (OR 1.41 (per unit increase in Charlson score), p=.01), unmarried social status (OR 1.76, p=.04), a smaller percentage of positive cores (OR 0.92 (per percent core increase), p<.001), and referral to a multidisciplinary clinic (OR 2.22, p<.01) were all significantly associated with pursuit of active surveillance. The number of physicians or specialities seen in consultation was not significantly associated with pursuit of active surveillance. Conclusions: Older age, increased comorbidities, unmarried social status, and a smaller percentage of positive cores are associated with pursuit of active surveillance. Notably, referral to a multidisciplinary genitourinary oncology clinic significantly increases rates of active surveillance in men with low-risk prostate cancer, implying that the multidisciplinary clinic itself, and not merely the number or type of physicians seen, is important to the shared decision making process for a patient to elect active surveillance.
Collapse
Affiliation(s)
- Ayal Aizer
- Brigham and Women's Hospital/Massachusetts General Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - Jonathan J. Paly
- Brigham and Women's Hospital/Massachusetts General Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - Anthony L. Zietman
- Brigham and Women's Hospital/Massachusetts General Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - Anthony Victor D'Amico
- Brigham and Women's Hospital/Massachusetts General Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - Paul Linh Nguyen
- Brigham and Women's Hospital/Massachusetts General Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - Clair Beard
- Brigham and Women's Hospital/Massachusetts General Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - Sandhya K Rao
- Brigham and Women's Hospital/Massachusetts General Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - Irving D. Kaplan
- Brigham and Women's Hospital/Massachusetts General Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - Michelle S. Hirsch
- Brigham and Women's Hospital/Massachusetts General Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - Chin-Lee Wu
- Brigham and Women's Hospital/Massachusetts General Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - Jason Alexander Efstathiou
- Brigham and Women's Hospital/Massachusetts General Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA; Brigham and Women's Hospital, Boston, MA
| |
Collapse
|
37
|
Avadhani A, Rao PS, Rao SK. Effect of tibial tunnel position on arthroscopically assisted anterior cruciate ligament reconstruction using bone-patellar tendon-bone grafts: a prospective study. Singapore Med J 2010; 51:413-417. [PMID: 20593146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
INTRODUCTION The aim of this research was to study the effect of the tibial tunnel position in anterior cruciate ligament (ACL) reconstruction using bone-patellar tendon-bone (BPTB) grafts in ensuring optimal knee functioning. METHODS A prospective study was conducted on 41 patients who underwent arthroscopically assisted ACL reconstruction using a BPTB graft and who were followed up for a minimum period of two years. The radiographic position of the tibial tunnel was compared with the clinical outcome using the International Knee Documentation Committee (IKDC) and modified Lysholm knee scores at two years after surgery. RESULTS Six out of eight patients with a fair outcome based on the modified Lysholm score and five out of eight patients with an abnormal outcome based on the IKDC score had their tibial tunnel within the 10 percent to 25 percent anteroposterior width of the tibial plateau. The tibial tunnel of patients with a fair Lysholm outcome (mean 22.2 percent) was significantly anterior compared to that of those with an excellent (mean 38.1 percent) and good (mean 34.1 percent) outcome (p is less than 0.01). The analysis using the IKDC score showed a similar trend. CONCLUSION Placing the tibial tunnel in the anterior 25 percent of the tibial plateau is associated with a poor knee outcome. More predictable results can be achieved through 35 percent to 46 percent anteroposterior placement of the tibial tunnel.
Collapse
Affiliation(s)
- A Avadhani
- Department of Orthopaedics, Kasturba Medical College, Madhav Nagar, Manipal 576104, Karnataka, India.
| | | | | |
Collapse
|
38
|
Rao SK, Bhat GS, Aradhya S, Devi A, Bhat M. Study of the efficacy of toothpaste containing casein phosphopeptide in the prevention of dental caries: a randomized controlled trial in 12- to 15-year-old high caries risk children in Bangalore, India. Caries Res 2009; 43:430-5. [PMID: 19864905 DOI: 10.1159/000252976] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2007] [Accepted: 09/04/2009] [Indexed: 11/19/2022] Open
Abstract
Casein phosphopeptide (CPP) has the potential to be added to mouth rinses, gels, toothpastes, chewing gums and confectioneries. Until now CPP has been studied in vitro, in situ and in animals, but clinical trials are lacking. This study was conducted to evaluate the efficacy of CPP-containing toothpaste in preventing dental caries in schoolchildren. The study was conducted among 150 schoolchildren randomly divided into three groups, each using one of three types of toothpastes: (a) containing 2% w/w CPP; (b) containing 1,190 mg/kg fluoride as 0.76% sodium monofluorophosphate (SMFP); (c) placebo toothpaste without CPP or fluoride. Students brushed with the given toothpastes for 24 months. Oral hygiene and caries experience were assessed at baseline, 12 and 24 months. The increments in caries lesions were calculated and analyzed to assess the caries-preventive effect. A significant reduction in caries increment was observed among students using CPP toothpaste or SMFP toothpaste, compared with the group using the placebo toothpaste. The reduction in caries increment was not significantly different between the CPP and SMFP groups. Oral Hygiene Index score increased from the 12-month to the 24-month examination. It is concluded that CPP can be effectively incorporated into calcium carbonate-based toothpaste and that toothpaste containing CPP is effective in preventing caries. Toothpaste containing 2% CPP seemed to have an efficacy similar to paste containing 1,190 mg/kg SMFP in the prevention of caries.
Collapse
Affiliation(s)
- S K Rao
- Manipal College of Dental Sciences, Manipal, India.
| | | | | | | | | |
Collapse
|
39
|
Chong KKL, Fan DSP, Lai CHY, Rao SK, Lam PTH, Lam DSC. Unilateral ptosis correction with mersilene mesh frontalis sling in infants: thirteen-year follow-up report. Eye (Lond) 2009; 24:44-9. [PMID: 19300466 DOI: 10.1038/eye.2009.48] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To assess surgical, visual, refractive, and aesthetic outcomes 13 years after mersilene mesh frontalis sling (MMFS) operation for severe unilateral congenital ptosis performed in 10 infants before 1 year of age. METHODS Longitudinal follow-up of an interventional case series by structured ocular examinations, external photographs, and questionnaire-based interviews. RESULTS Mean age at surgery was 6.9+/-2.7 months. After a mean follow-up of 13.0+/-0.6 years, one patient (10%) had recurrent ptosis with the upper lid 2 mm below the superior limbus at 3 months postoperatively. Best-corrected visual acuities were within two Snellen lines between the two eyes in all patients. Astigmatic errors were 1.20+/-1.00 D and 1.10+/-1.70 D between operated and unoperated eyes. Four patients had 2 mm lid lag on down-gaze and one of them had 2 mm lagophthalmos. Mean satisfaction scores (scale of 1 to 100) for lid position, cosmesis, function, and to the procedure were 83.3+/-11.8, 77.0+/-22.9, 89.4+/-5.5, and 86.8+/-6.3, respectively. No case of overcorrection, sling extrusion, stitch granuloma, or exposure keratopathy was noted. CONCLUSIONS In view of the low recurrence rate (10%) and absence of serious complication or need for revision after 13 years, the use of MMFS seems effective and feasible in infants less than 1 year old. Achieving compatible long-term stability, satisfactory aesthetic, and visual outcomes, MMFS may offer an alternative to delaying operations for autogenous fascia lata harvesting in infants requiring early ptosis correction.
Collapse
Affiliation(s)
- K K L Chong
- Department of Ophthalmology and Visual Sciences, Prince of Wales Hospital, Shatin, Hong Kong, PRC
| | | | | | | | | | | |
Collapse
|
40
|
Congdon N, Rao SK, Choi K, Wang W, Lin S, Chen S, Chen LJ, Liu K, Hu IC, Lam DSC. Sources of patient knowledge and financing of cataract surgery in rural China: the Sanrao Study of Cataract Outcomes and Up-Take of Services (SCOUTS), Report 6. Br J Ophthalmol 2008; 92:604-8. [DOI: 10.1136/bjo.2007.131680] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
41
|
Pandey V, Rao PS, Rao SK, Acharya KKV. Monocular blindness due to central retinal artery occlusion in bipolar hemireplacement arthroplasty of the hip. Singapore Med J 2008; 49:e96-e97. [PMID: 18418515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Though rare, perioperative loss of vision after non-ocular surgeries is a disastrous complication. This has been reported after spine surgery or cardiopulmonary bypass surgery. We present an otherwise healthy 54-year-old man who underwent bipolar hemireplacement for a fractured neck of femur, and developed perioperative monocular visual loss due to central retinal artery occlusion, a complication hitherto unreported in hip replacement surgeries. The possible aetiological factors and the measures to prevent this complication are discussed.
Collapse
Affiliation(s)
- V Pandey
- Department of Orthopaedics, Kasturba Medical College, Manipal, Karnataka 576104, India.
| | | | | | | |
Collapse
|
42
|
Abstract
PURPOSE To document the disease spectrum and evaluate the presence of perilimbal conjunctival pigmentation in Chinese patients with vernal keratoconjunctivitis (VKC). METHOD A case-control study was conducted between November 2004 and July 2005. Patients aged 18 or younger with VKC and age-matched children attending our eye clinic for refractive or orthoptic problems were recruited and compared. Detailed slit-lamp examination was performed noting in particular the presence of perilimbal conjunctival pigmentation, the severity of papillary reaction, and corneal complications of VKC. RESULTS A total of 19 patients and 23 controls were evaluated. The presence of bilateral large tarsal or limbal papillae and epithelial defect were significantly associated with symptoms severity (Fisher's exact test, P=0.015 and P=0.035 respectively). All VKC patients were found to have perilimbal conjunctival pigmentation in at least one eye. There was a significant correlation in the colour and density of pigments between the two eyes (Sperman's rho=0.93, P<0.001). None of the controls was found to have such perilimbal conjunctival pigmentation (Fisher's exact test, P<0.001). CONCLUSION The presence of perilimbal conjunctival pigmentation appears to be a consistent clinical finding in Chinese patients with VKC and may be a useful diagnostic sign for patients with subtle signs or symptoms.
Collapse
Affiliation(s)
- F O J Luk
- Department of Ophthalmology & Visual Science, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | | | | | | |
Collapse
|
43
|
Abstract
PURPOSE To analyse the 3 to 6 years' clinicoradiological outcome of 45 uncemented total hip arthroplasties performed in 37 patients using cementless Spotorno stem and St Nabor cup. METHODS The main indications for surgery were avascular necrosis of the femoral head and rheumatoid arthritis. Younger patients with good bone quality and a trumpet-shaped femur were eligible. A single surgeon performed all the operations using a posterolateral approach. Patients were reviewed at 6 weeks, 3 months, 6 months, and yearly thereafter. The clinical status was recorded using the Harris Hip Score. All radiographs were analysed by 2 independent blinded observers on 2 separate occasions. RESULTS The mean follow-up period was 49 months and the mean Harris Hip Score at the latest follow-up was 94. Osseointegration in the form of trabeculae running from the endosteum to the prosthesis surface along with tropism of the calcar was evident in 73% of the hips. None of the remaining hips showed any continuous radio-opaque lines suggestive of a lack of bone ongrowth. Patients with endosteal condensation had better Harris Hip Scores. Intra-operative stability of the implants could fairly predict outcome. CONCLUSION Initial clinicoradiological results of uncemented total hip arthroplasty are promising in younger patients with good bone quality and a trumpet-shaped femur.
Collapse
Affiliation(s)
- S Vidyadhara
- Trauma and Joint Replacement Services, Department of Orthopaedics, Kasturba Medical College, Manipal, 576 104, Karnataka, India.
| | | |
Collapse
|
44
|
Abstract
The medial collateral ligament (MCL) is the most commonly injured ligament of the knee joint. Proximal MCL tears occur more frequently than do distal ones. We report a 28-year-old man with a valgus injury of his left knee joint after a fall from a motorcycle. Magnetic resonance imaging of the affected knee joint revealed complete avulsion of the superficial MCL from both its femoral and tibial insertions. The meniscofemoral portion of the deep part of the MCL was also torn and the medial meniscus was subluxated. Such a pattern, an MCL tear with subluxation of the medial meniscus, is rare.
Collapse
Affiliation(s)
- A M Naik
- Kasturba Medical College Hospital, Manipal, Udupi District, Karnataka State, India.
| | | | | |
Collapse
|
45
|
Gamanagatti S, Thulkar S, Rao SK. Desmoplastic round cell tumour of the abdomen. Singapore Med J 2007; 48:e19-21. [PMID: 17245499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Desmoplastic round cell tumour is a very rare tumour of childhood and young adults, and is not usually suspected as an explanation of intraabdominal or pelvic tumour. We report two cases of desmoplastic round cell tumour of the abdomen in the paediatric age group, occurring in two boys, an 11-year-old and a 13-year-old. We aim to demonstrate the imaging findings and to emphasise the importance of including this tumour in the differential diagnosis of childhood intraabdominal and pelvic tumours.
Collapse
|
46
|
Vidyadhara S, Rao SK. Global reconstruction of type IIIA open comminuted femoral shaft fracture with segmental bone loss in an 11-year-old girl. Singapore Med J 2006; 47:817-9. [PMID: 16924367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
An 11-year-old girl with type IIIA open fracture of the femoral shaft and 4.5 cm bone loss, was treated by global reconstruction using a reamed, interlocking, intramedullary titanium nail, following meticulous primary debridement with pulsed lavage irrigation. The nail entry was carefully chosen at the lateral transtrochanteric point in order to avoid any vascular damage to the head of femur. The osteophilic nature of the titanium nail, in addition to the thick periosteum of the paediatric bone, helped satisfactory union despite a hostile environment. The child had 0-90 degrees flexion of the knee without any extensor lag at the last follow-up. To our knowledge, this is the first case described in the literature that proves the efficacy of nailing for such a fracture.
Collapse
Affiliation(s)
- S Vidyadhara
- Department of Orthopaedics, Kasturba Medical College, Manipal 576104, Karnataka, India.
| | | |
Collapse
|
47
|
Abstract
PURPOSE To study clinical and mechanical factors that predispose to failure of interlocking nails. METHODS Between October 1996 and December 2002, 286 femoral fractures, 211 tibial fractures, and 47 humeral fractures were repaired using variously designed interlocking nails. Fracture pattern, level and site, nail size and type, weight bearing after nailing, and union status were reviewed after a mean follow-up of 22 months. RESULTS Nail failure occurred in 27 fracture repairs (17 femoral, 9 tibial, and one humeral; 13 from our institution and 14 referred from elsewhere). In 55% of failed repairs, the fracture was distal. A high rate of tibial nail failure was noted. CONCLUSION Distal fractures and stress concentration at the distal screws predispose to interlocking nail failure and can be prevented by protected weight bearing combined with the use of longer and larger nails. Routine supplementary cancellous bone grafting is unnecessary during renailing surgery when adequate reaming and a larger nail are used.
Collapse
Affiliation(s)
- A K Bhat
- Department of Orthopaedics, Kasturba Medical College, Manipal, Karnataka, India.
| | | | | |
Collapse
|
48
|
Abstract
Walking barefoot is common in developing countries and the feet are therefore exposed to a variety of trivial injuries, some of which lead to cellulitis or abscess formation. If left untreated or improperly managed, osteomyelitis or septic arthritis, usually involving the heel or metatarsals, may follow. In countries with limited resources, the emphasis should be on clinical assessment for diagnosis, and good surgical technique for treatment. We report 4 patients with thorn prick osteomyelitis of the foot due to walking barefoot. All were treated with thorn removal, surgical debridement, and oral ofloxacin. Surgical removal of the thorn is the key to successful treatment and to avoiding recurrent infection.
Collapse
Affiliation(s)
- S Vidyadhara
- Department of Orthopaedics, Kasturba Medical College, Manipal, Karnataka, India.
| | | |
Collapse
|
49
|
Vidyadhara S, Rao SK. Techniques in the management of juxta-articular aggressive and recurrent giant cell tumors around the knee. Eur J Surg Oncol 2006; 33:243-51. [PMID: 16822642 DOI: 10.1016/j.ejso.2006.05.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2006] [Accepted: 05/31/2006] [Indexed: 11/30/2022]
Abstract
AIM Juxta-articular aggressive and recurrent giant cell tumors around the knee pose difficulties in management. This article reviews current problems and options in the management of these giant cell tumors. METHODS A systematic search was performed on juxta-articular aggressive and recurrent giant cell tumor. Additional information was retrieved from hand searching the literature and from relevant congress proceedings. We addressed the following issues: general consensus on early diagnosis and techniques in its management. In particular, we describe our results with resection arthrodesis performed combining the benefits of both interlocking intramedullary nail and Ilizarov fixator in the management of these tumors around the knee. RESULTS Mean operative age of the 22 patients undergoing resection arthrodesis was 35.63 years. Seven lesions were in the tibia and fifteen in the femur. Mean length of the bone defect was 12.34 cm. The mean external fixator index was 7.44 days/cm and the distraction index was 7.88 days/cm. Mean period of follow-up for the patients was 64.5 months. The function of the affected limb was rated excellent in 10 and good and fair in six patients each as per Enneking criteria. No local recurrence of tumor was seen. Seven complications occurred in five patients. CONCLUSION Two-ring construct, bifocal bone transport, and early definite plate osteosynthesis with additional bone grafting of the docking site at the end of distraction even before consolidation of the regenerate helps to reduce the problems of pin tract infections drastically. Thin-diameter long intramedullary nail in addition to preserving the endosteal blood supply also prevents mal-alignment of the regenerate. Thus resection arthrodesis using interlocking intramedullary nail and bone transport using Ilizarov fixator is cost effective and effective in achieving the desired goals of reconstruction with least complications in selected patients with specific indications.
Collapse
Affiliation(s)
- S Vidyadhara
- Department of Orthopaedics, Kasturba Medical College, Manipal, Udupi, Karnataka 576 104, India.
| | | |
Collapse
|
50
|
|