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Robertson DJ, Dominitz JA, Beed A, Boardman KD, Del Curto BJ, Guarino PD, Imperiale TF, LaCasse A, Larson MF, Gupta S, Lieberman D, Planeta B, Shaukat A, Sultan S, Menees SB, Saini SD, Schoenfeld P, Goebel S, von Rosenvinge EC, Baffy G, Halasz I, Pedrosa MC, Kahng LS, Cassim R, Greer KB, Kinnard MF, Bhatt DB, Dunbar KB, Harford WV, Mengshol JA, Olson JE, Patel SG, Antaki F, Fisher DA, Sullivan BA, Lenza C, Prajapati DN, Wong H, Beyth R, Lieb JG, Manlolo J, Ona FV, Cole RA, Khalaf N, Kahi CJ, Kohli DR, Rai T, Sharma P, Anastasiou J, Hagedorn C, Fernando RS, Jackson CS, Jamal MM, Lee RH, Merchant F, May FP, Pisegna JR, Omer E, Parajuli D, Said A, Nguyen TD, Tombazzi CR, Feldman PA, Jacob L, Koppelman RN, Lehenbauer KP, Desai DS, Madhoun MF, Tierney WM, Ho MQ, Hockman HJ, Lopez C, Carter Paulson E, Tobi M, Pinillos HL, Young M, Ho NC, Mascarenhas R, Promrat K, Mutha PR, Pandak WM, Shah T, Schubert M, Pancotto FS, Gawron AJ, Underwood AE, Ho SB, Magno-Pagatzaurtundua P, Toro DH, Beymer CH, Kaz AM, Elwing J, Gill JA, Goldsmith SF, Yao MD, Protiva P, Pohl H, Kyriakides T. Baseline Features and Reasons for Nonparticipation in the Colonoscopy Versus Fecal Immunochemical Test in Reducing Mortality From Colorectal Cancer (CONFIRM) Study, a Colorectal Cancer Screening Trial. JAMA Netw Open 2023; 6:e2321730. [PMID: 37432690 PMCID: PMC10336619 DOI: 10.1001/jamanetworkopen.2023.21730] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/12/2023] [Indexed: 07/12/2023] Open
Abstract
Importance The Colonoscopy Versus Fecal Immunochemical Test in Reducing Mortality From Colorectal Cancer (CONFIRM) randomized clinical trial sought to recruit 50 000 adults into a study comparing colorectal cancer (CRC) mortality outcomes after randomization to either an annual fecal immunochemical test (FIT) or colonoscopy. Objective To (1) describe study participant characteristics and (2) examine who declined participation because of a preference for colonoscopy or stool testing (ie, fecal occult blood test [FOBT]/FIT) and assess that preference's association with geographic and temporal factors. Design, Setting, and Participants This cross-sectional study within CONFIRM, which completed enrollment through 46 Department of Veterans Affairs medical centers between May 22, 2012, and December 1, 2017, with follow-up planned through 2028, comprised veterans aged 50 to 75 years with an average CRC risk and due for screening. Data were analyzed between March 7 and December 5, 2022. Exposure Case report forms were used to capture enrolled participant data and reasons for declining participation among otherwise eligible individuals. Main Outcomes and Measures Descriptive statistics were used to characterize the cohort overall and by intervention. Among individuals declining participation, logistic regression was used to compare preference for FOBT/FIT or colonoscopy by recruitment region and year. Results A total of 50 126 participants were recruited (mean [SD] age, 59.1 [6.9] years; 46 618 [93.0%] male and 3508 [7.0%] female). The cohort was racially and ethnically diverse, with 748 (1.5%) identifying as Asian, 12 021 (24.0%) as Black, 415 (0.8%) as Native American or Alaska Native, 34 629 (69.1%) as White, and 1877 (3.7%) as other race, including multiracial; and 5734 (11.4%) as having Hispanic ethnicity. Of the 11 109 eligible individuals who declined participation (18.0%), 4824 (43.4%) declined due to a stated preference for a specific screening test, with FOBT/FIT being the most preferred method (2820 [58.5%]) vs colonoscopy (1958 [40.6%]; P < .001) or other screening tests (46 [1.0%] P < .001). Preference for FOBT/FIT was strongest in the West (963 of 1472 [65.4%]) and modest elsewhere, ranging from 199 of 371 (53.6%) in the Northeast to 884 of 1543 (57.3%) in the Midwest (P = .001). Adjusting for region, the preference for FOBT/FIT increased by 19% per recruitment year (odds ratio, 1.19; 95% CI, 1.14-1.25). Conclusions and Relevance In this cross-sectional analysis of veterans choosing nonenrollment in the CONFIRM study, those who declined participation more often preferred FOBT or FIT over colonoscopy. This preference increased over time and was strongest in the western US and may provide insight into trends in CRC screening preferences.
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Affiliation(s)
- Douglas J Robertson
- VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Jason A Dominitz
- VA Puget Sound Health Care System, Seattle, Washington
- University of Washington School of Medicine, Seattle
| | - Alexander Beed
- Cooperative Studies Program Coordinating Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Kathy D Boardman
- Department of Veterans Affairs Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, New Mexico
| | - Barbara J Del Curto
- Department of Veterans Affairs Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, New Mexico
| | - Peter D Guarino
- Statistical Center of HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Thomas F Imperiale
- Center for Innovation, Health Services Research and Development, Richard L. Roudebush VA Medical Center and Department of Medicine, Indiana University School of Medicine, Indianapolis
| | | | | | - Samir Gupta
- Section of Gastroenterology, VA San Diego, and Department of Medicine, University of California, San Diego
| | - David Lieberman
- Division of Gastroenterology and Hepatology, Portland VA Medical Center, and Oregon Health and Science University, Portland
| | - Beata Planeta
- Cooperative Studies Program Coordinating Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Aasma Shaukat
- New York Harbor VA Healthcare System and New York University Grossman School of Medicine, New York
| | - Shanaz Sultan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis VA Healthcare System, Minneapolis
| | - Stacy B Menees
- Division of Gastroenterology, Department of Internal Medicine, Ann Arbor VA Medical Center, Ann Arbor, Michigan
- Division of Gastroenterology, Michigan Medicine, Ann Arbor
| | - Sameer D Saini
- US Department of Veteran Affairs Health Services Research and Development Center for Clinical Management Research, Ann Arbor, Michigan
- Division of Gastroenterology, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | | | - Stephan Goebel
- Atlanta VA Medical Center, Decatur, Georgia
- Emory University, Atlanta, Georgia
| | - Erik C von Rosenvinge
- VA Maryland Health Care System, Baltimore
- University of Maryland School of Medicine, Baltimore
| | - Gyorgy Baffy
- Department of Medicine, VA Boston Healthcare System, Harvard Medical School, Boston, Massachusetts
| | - Ildiko Halasz
- Department of Medicine, VA Boston Healthcare System, Harvard Medical School, Boston, Massachusetts
- Primary Care, West Roxbury, Massachusetts
| | - Marcos C Pedrosa
- Department of Medicine, VA Boston Healthcare System, Harvard Medical School, Boston, Massachusetts
- Boston University, Boston, Massachusetts
| | - Lyn Sue Kahng
- Gastroenterology Section, Jesse Brown VA Medical Center, and University of Illinois at Chicago
| | - Riaz Cassim
- Louis A. Johnson VA Medical Center, Clarksburg, West Virginia
- Department of Surgery, West Virginia University, Morgantown
| | - Katarina B Greer
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Louis Stokes VA Medical Center, Cleveland, Ohio
| | - Margaret F Kinnard
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
- VA Northeast Ohio Healthcare System, Cleveland
| | - Divya B Bhatt
- VA North Texas Health Care Center, University of Texas Southwestern Medical School, Dallas
| | - Kerry B Dunbar
- VA North Texas Healthcare System, University of Texas Southwestern, Dallas
| | - William V Harford
- VA North Texas Health Care Center, University of Texas Southwestern Medical School, Dallas
| | - John A Mengshol
- Division of Gastroenterology and Hepatology University of Colorado School of Medicine, Denver
| | - Jed E Olson
- Rocky Mountain Regional VA Medical Center, University of Colorado Anschutz Medical Center, Aurora
| | - Swati G Patel
- Division of Gastroenterology and Hepatology, Rocky Mountain Regional VA Medical Center, University of Colorado Anschutz Medical Center, Aurora
| | - Fadi Antaki
- John D. Dingell VA Medical Center and Wayne State University School of Medicine, Detroit, Michigan
| | | | - Brian A Sullivan
- Division of Gastroenterology, Durham VA Medical Center, Durham, North Carolina
- Division of Gastroenterology, Duke University Medical Center, Durham, North Carolina
| | | | - Devang N Prajapati
- VA Central California Health Care System, University of California, San Francisco, Fresn
| | - Helen Wong
- VA Central California Health Care System, University of California, San Francisco, Fresn
| | - Rebecca Beyth
- Department of Medicine, University of Florida, Gainesville
| | - John G Lieb
- Division of Gastroenterology, University of Florida, Gainesville
- Malcolm Randall VA Medical Center, Gainesville, Florida
| | | | | | - Rhonda A Cole
- Department of Gastroenterology, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Natalia Khalaf
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Charles J Kahi
- Richard L. Roudebush VA Medical Center, Indiana University School of Medicine, Indianapolis
| | - Divyanshoo Rai Kohli
- Kansas City VA Medical Center, Kansas City, Missouri
- Providence Sacred Heart Medical Center, Spokane, Washington
| | - Tarun Rai
- Borland Groover Clinic, Jacksonville, Florida
| | - Prateek Sharma
- Division of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City
- Division of Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, Missouri
| | - Jiannis Anastasiou
- Central Arkansas Veterans Healthcare System, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock
| | - Curt Hagedorn
- Gastroenterology Division, New Mexico Veterans Healthcare System, and Department of Medicine, University of New Mexico School of Medicine, Albuquerque
| | - Ronald S Fernando
- VA Loma Linda Healthcare System, Loma Linda, California
- Department of Medicine, University of California, Riverside
| | - Christian S Jackson
- VA Loma Linda Healthcare System, Loma Linda, California
- Department of Medicine, University of California, Riverside
| | - M Mazen Jamal
- Department of Medicine, University of California, Riverside
- Oceana Gastroenterology Associates, Corona, California
| | - Robert H Lee
- VA Long Beach Health Care System, Long Beach, California
- University of California, Irvine
| | | | - Folasade P May
- Greater Los Angeles VA Healthcare System, Los Angeles, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joseph R Pisegna
- Division of Gastroenterology, Hepatology and Parenteral Nutrition, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Departments of Medicine and Human Genetics, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Endashaw Omer
- University of Louisville, Louisville, Kentucky
- Robley Rex VA Medical Center, Louisville, Kentucky
| | - Dipendra Parajuli
- Robley Rex VA Medical Center, Louisville, Kentucky
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky
| | - Adnan Said
- William S. Middleton VA Medical Center, Madison, Wisconsin
- Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison
| | - Toan D Nguyen
- Memphis VA Medical Center, Memphis, Tennessee
- University of Tennessee Health Science Center, Memphis
| | | | | | - Leslie Jacob
- Bruce W. Carter VA Medical Center, Miami, Florida
| | | | | | - Deepak S Desai
- Northport VA Medical Center, State University of New York Stony Brook, Northport
| | - Mohammad F Madhoun
- Oklahoma City VA Medical Center, Oklahoma City
- Section of Digestive Diseases and Nutrition, Department of Medicine, University of Oklahoma, Oklahoma City
| | | | - Minh Q Ho
- Department of Infectious Disease, Orlando VA Healthcare System, University of Central Florida, Orlando
| | | | | | - Emily Carter Paulson
- VA Medical Center, Philadelphia, Pennsylvania
- University of Philadelphia, Philadelphia, Pennsylvania
| | - Martin Tobi
- Department of Research and Development, John D. Dingell VA Medical Center, Detroit, Michigan
| | - Hugo L Pinillos
- Phoenix VA Healthcare System, Phoenix, Arizona
- University of Arizona College of Medicine, Phoenix
| | | | - Nancy C Ho
- Division of Gastroenterology and Hepatology, Portland VA Medical Center, and Oregon Health and Science University, Portland
| | - Ranjan Mascarenhas
- Central Texas Veterans Health Care System, Austin Outpatient Clinic, Austin, Texas
- Department of Medicine, Dell Medical School, The University of Texas at Austin
| | - Kirrichai Promrat
- Providence VA Medical Center, Providence, Rhode Island
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Pritesh R Mutha
- McGuire VA Medical Center, Richmond, Virginia; Now with The University of Texas Health Science Center, Houston
| | - William M Pandak
- Richmond VA Medical Center, Richmond, Virginia
- Virginia Commonwealth University, Richmond, Virginia
| | - Tilak Shah
- Digestive Disease and Surgery Institute, Cleveland Clinic Florida, Weston
| | - Mitchell Schubert
- Virginia Commonwealth University, Richmond, Virginia
- Central Virginia VA Healthcare System, Richmond
| | - Frank S Pancotto
- Salisbury VA Medical Center, Salisbury, North Carolina
- Wake Forrest University School of Medicine, Winston-Salem, North Carolina
| | - Andrew J Gawron
- Salt Lake City VA Medical Center, Salt Lake City, Utah
- University of Utah, Salt Lake City
| | | | - Samuel B Ho
- VA Medical Center San Diego, San Diego, California
| | | | - Doris H Toro
- Section of Gastroenterology, VA Caribbean Healthcare System, San Juan, Puerto Rico
| | - Charles H Beymer
- VA Puget Sound Healthcare System, Seattle, Washington
- University of Washington School of Medicine, Seattle
| | - Andrew M Kaz
- University of Washington School of Medicine, Seattle
- Gastroenterology Section, VA Puget Sound Healthcare System, Seattle, Washington
| | - Jill Elwing
- St Louis VA Medical Center, St Louis, Missouri
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri
| | - Jeffrey A Gill
- James A. Haley VA Hospital, Tampa, Florida
- University of South Florida College of Medicine, Tampa
| | | | - Michael D Yao
- Gastroenterology and Hepatology Section, VA Medical Center, Washington, District of Columbia
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Petr Protiva
- VA Connecticut Healthcare System, West Haven, Connecticut
- Department of Medicine (Digestive Diseases), Yale University School of Medicine, New Haven, Connecticut
| | - Heiko Pohl
- VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Tassos Kyriakides
- Cooperative Studies Program Coordinating Center, VA Connecticut Healthcare System, West Haven, Connecticut
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Wallace A, Stanley J, Parker-Oliver D, Uphold C, Smith C, Jr MM, Beyth R. Systematic Review of Caregivers and Palliative Intent Radiation Therapy: Barriers, Facilitators, Decision Making Needs. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.1356] [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] [Indexed: 10/20/2022]
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Shaddock R, Anderson KV, Beyth R. Renal Repercussions of Medications. Prim Care 2020; 47:691-702. [DOI: 10.1016/j.pop.2020.08.006] [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] [Indexed: 11/29/2022]
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Wallace A, Stanley J, Parker-Oliver D, Apicelli A, White P, Fiveash J, Uphold C, Moghanaki D, Smith C, Beyth R. Systematic Review of Caregivers and Palliative Intent Radiation Therapy: Barriers, Facilitators, Decision Making Needs. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.1361] [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] [Indexed: 11/28/2022]
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Ortel TL, Neumann I, Ageno W, Beyth R, Clark NP, Cuker A, Hutten BA, Jaff MR, Manja V, Schulman S, Thurston C, Vedantham S, Verhamme P, Witt DM, D Florez I, Izcovich A, Nieuwlaat R, Ross S, J Schünemann H, Wiercioch W, Zhang Y, Zhang Y. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood Adv 2020; 4:4693-4738. [PMID: 33007077 PMCID: PMC7556153 DOI: 10.1182/bloodadvances.2020001830] [Citation(s) in RCA: 541] [Impact Index Per Article: 135.3] [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: 03/06/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), occurs in ∼1 to 2 individuals per 1000 each year, corresponding to ∼300 000 to 600 000 events in the United States annually. OBJECTIVE These evidence-based guidelines from the American Society of Hematology (ASH) intend to support patients, clinicians, and others in decisions about treatment of VTE. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and adult patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 28 recommendations for the initial management of VTE, primary treatment, secondary prevention, and treatment of recurrent VTE events. CONCLUSIONS Strong recommendations include the use of thrombolytic therapy for patients with PE and hemodynamic compromise, use of an international normalized ratio (INR) range of 2.0 to 3.0 over a lower INR range for patients with VTE who use a vitamin K antagonist (VKA) for secondary prevention, and use of indefinite anticoagulation for patients with recurrent unprovoked VTE. Conditional recommendations include the preference for home treatment over hospital-based treatment for uncomplicated DVT and PE at low risk for complications and a preference for direct oral anticoagulants over VKA for primary treatment of VTE.
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Affiliation(s)
- Thomas L Ortel
- Division of Hematology, Department of Medicine, Duke University, Durham NC
| | | | - Walter Ageno
- Department of Medicine and Surgery, University of Insurbria, Varese, Italy
| | - Rebecca Beyth
- Division of General Internal Medicine, Department of Medicine, University of Florida, Gainesville, FL
- Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Nathan P Clark
- Clinical Pharmacy Anticoagulation Service, Kaiser Permanente, Aurora, CO
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Barbara A Hutten
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Veena Manja
- University of California Davis, Sacramento, CA
- Veterans Affairs Northern California Health Care System, Mather, CA
| | - Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - Suresh Vedantham
- Division of Diagnostic Radiology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Peter Verhamme
- KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Daniel M Witt
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT
| | - Ivan D Florez
- Department of Pediatrics, University of Antioquia, Medellin, Colombia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Ariel Izcovich
- Internal Medicine Department, German Hospital, Buenos Aires, Argentina; and
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Stephanie Ross
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Yuqing Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Kadle N, Westerveld DR, Banerjee D, Jacobs C, Gesiotto F, Moon N, Forde JJ, Conti M, Hatamleh D, Taylor R, Brar T, Riverso M, Jawaid S, Perbtani YB, Zhang Y, Draganov PV, Beyth R, Yang D. Discrepancy between self-reported and actual colonoscopy polypectomy practices for the removal of small polyps. Gastrointest Endosc 2020; 91:655-662.e2. [PMID: 31669181 DOI: 10.1016/j.gie.2019.10.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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] [Received: 08/07/2019] [Accepted: 10/13/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Cold snare polypectomy (CSP) is associated with higher rates of complete resection compared with cold biopsy forceps (CBF) for the removal of small polyps (4-9 mm). This study aimed to evaluate self-reported polypectomy preferences and actual practice patterns among endoscopists at an academic center and to identify factors associated with the use of CSP for small polyps. METHODS In phase A, endoscopists completed a survey evaluating preferences for polypectomy techniques. In phase B, we performed a retrospective analysis of all consecutive colonoscopies with polypectomy (January 2016 to September 2018). Uni- and multivariate analysis were performed to identify factors associated with CSP for small polyps. RESULTS Nineteen of 26 (73%) endoscopists completed the survey (phase A); 3 (15.8%) were interventional endoscopists. Most respondents indicated that they use CSP (89.5%) for small polyps and identified no reasons for choosing CBF over CSP (73.7%). In phase B, we identified 1118 colonoscopies with 2625 polypectomies for polyps ≤9 mm. Most diminutive polyps (≤3 mm) were removed with CBF (819 of 912; 90%). CBF (46.2%) was also preferentially used for removal of small polyps (n = 1713), followed by hot snare polypectomy (27.2%), and CSP (26.6%). On multivariate analysis, interventional endoscopists were associated with a higher likelihood of using CSP for small polyps (odds ratio, 1.38; 95% confidence interval, 1.07-1.79; P = .01). CONCLUSIONS Significant discrepancy exists between self-reported preferences and actual polypectomy practices. CBF is still preferentially used over CSP for the removal of polyps sized 4-9 mm; further strategies are needed to monitor and implement adequate polypectomy techniques.
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Affiliation(s)
- Nikhil Kadle
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Donevan R Westerveld
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Debdeep Banerjee
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Chelsea Jacobs
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Francesca Gesiotto
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Nabeel Moon
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Justin J Forde
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Mathew Conti
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Diana Hatamleh
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Robert Taylor
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Tony Brar
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Michael Riverso
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Salmaan Jawaid
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Yaseen B Perbtani
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Yang Zhang
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Rebecca Beyth
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
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Khatib R, Ross S, Kennedy SA, Florez ID, Ortel TL, Nieuwlaat R, Neumann I, Witt DM, Schulman S, Manja V, Beyth R, Clark NP, Wiercioch W, Schünemann HJ, Zhang Y. Home vs hospital treatment of low-risk venous thromboembolism: a systematic review and meta-analysis. Blood Adv 2020; 4:500-513. [PMID: 32040553 PMCID: PMC7013254 DOI: 10.1182/bloodadvances.2019001223] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 11/12/2019] [Accepted: 12/20/2019] [Indexed: 12/22/2022] Open
Abstract
Increasing evidence supports the safety and effectiveness of managing low-risk deep vein thrombosis (DVT) or pulmonary embolism (PE) in outpatient settings. We performed a systematic review to assess safety and effectiveness of managing patients with DVT or PE at home compared with the hospital. Medline, Embase, and Cochrane databases were searched up to July 2019 for relevant randomized clinical trials (RCTs), and prospective cohort studies. Two investigators independently screened titles and abstracts of identified citations and extracted data from relevant full-text papers. Risk ratios (RRs) were calculated, and certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Seven RCTs (1922 patients) were included in meta-analyses on managing patients with DVT. Pooled estimates indicated decreased risk of PE (RR = 0.64; 95% confidence interval [CI], 0.44-0.93) and recurrent DVT (RR = 0.61; 95% CI, 0.42-0.90) for home management, both with moderate certainty of the evidence. Reductions in mortality and major bleeding were not significant, both with low certainty of the evidence. Two RCTs (445 patients) were included in meta-analyses on home management of low-risk patients with PE. Pooled estimates indicated no significant difference in all-cause mortality, recurrent PE, and major bleeding, all with low certainty of the evidence. Results of pooled estimates from 3 prospective cohort studies (234 patients) on home management of PE showed similar results. Our findings indicate that low-risk DVT patients had similar or lower risk of patient-important outcomes with home treatment compared with hospital treatment. In patients with low-risk PE, there was important uncertainty about a difference between home and hospital treatment.
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Affiliation(s)
- Rasha Khatib
- Advocate Research Institute, Advocate Health Care, Downers Grove, IL
| | - Stephanie Ross
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Sean Alexander Kennedy
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Ivan D Florez
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Pediatrics, University of Antioquia, Medellin, Colombia
| | - Thomas L Ortel
- Division of Hematology, Medicine and Pathology, Duke University Medical Center, Durham, NC
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Ignacio Neumann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Daniel M Witt
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT
| | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Obstetrics and Gynecology, The First I. M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Veena Manja
- Department of Surgery, University of California Davis, Sacramento, CA
| | - Rebecca Beyth
- Division of General Internal Medicine, Department of Medicine, University of Florida, Gainesville, FL
- Malcom Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Nathan P Clark
- Clinical Pharmacy Anticoagulation Service, Kaiser Permanente Colorado, Aurora, CO; and
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Yuqing Zhang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Guang' anmen Hospital, China Academy of Chinese Medical Science, Xicheng District, Beijing, China
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8
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Canales MT, Bozorgmehri S, Ishani A, Weiner ID, Berry R, Beyth R. Prevalence and correlates of sleep apnea among US Veterans with chronic kidney disease. J Sleep Res 2020; 29:e12981. [PMID: 31912641 DOI: 10.1111/jsr.12981] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 10/30/2019] [Accepted: 12/12/2019] [Indexed: 12/12/2022]
Abstract
The prevalence and correlates of sleep apnea (SA) among Veterans with chronic kidney disease (CKD), a population at high risk of both SA and CKD, are unknown. We performed a cross-sectional analysis of 248 Veterans (18-89 years) selected only for presence of moderate to severe CKD. All participants underwent full, unattended polysomnography, measurement of renal function and a sleepiness questionnaire. Logistic regression with backward selection was used to identify predictors of prevalent SA (apnea-hypopnea index [AHI, ≥15 events/hr] and prevalent nocturnal hypoxia [NH, % of total sleep time spent at <90% oxygen saturation]). The mean age of our cohort was 73.2 ± 9.6 years, 95% were male, 78% were Caucasian and the mean body mass index (BMI) was 30.3 ± 4.8 kg/m2 . The prevalence of SA was 39%. There was no difference in daytime sleepiness among those with and without SA. In the final model, older age, higher BMI and diabetes mellitus (DM) were associated with higher odds of SA, after controlling for age, BMI, race and sex. Higher BMI, DM, unemployed/retired status, current smoking and higher serum bicarbonate level were associated with prevalent NH. To sum, SA was common among Veterans with moderate to severe CKD. Although some traditional risk factors for SA were associated with SA in this population, sleepiness did not correlate with SA. Further study is needed to validate our findings and understand how best to address the high burden of SA among Veterans with CKD.
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Affiliation(s)
- Muna T Canales
- Division of Nephrology, Department of Medicine, Malcom Randall VA Medical Center, University of Florida, Gainesville, FL, USA
| | - Shahab Bozorgmehri
- Division of Nephrology, Department of Medicine, Malcom Randall VA Medical Center, University of Florida, Gainesville, FL, USA
| | - Areef Ishani
- Minneapolis VA Medical Center, University of Minnesota, Minneapolis, MN, USA
| | - I David Weiner
- Division of Nephrology, Department of Medicine, Malcom Randall VA Medical Center, University of Florida, Gainesville, FL, USA
| | - Richard Berry
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Malcom Randall VA Medical Center, University of Florida, Gainesville, FL, USA
| | - Rebecca Beyth
- Division of General Medicine, Department of Medicine, Malcom Randall VA Medical Center, University of Florida, Gainesville, FL, USA
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Vaughn IA, Beyth R, Ayers ML, Thornton JE, Tandon R, Gingrich T, Mudra SA. Multispecialty Opioid Risk Reduction Program Targeting Chronic Pain and Addiction Management in Veterans. Fed Pract 2019; 36:406-411. [PMID: 31571808 PMCID: PMC6752814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
A primary care pain clinic and telehealth program manages veterans at high-risk for noncancer chronic pain and addiction, offering education and support to multidisciplinary health care providers to reduce dependence on high-level opioids.
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Affiliation(s)
- Ivana A Vaughn
- is a Research Scientist at the New York Academy of Medicine in New York City. is the Associate Director for Clinical Innovation at the North Florida/South Georgia Geriatric Research Education and Clinical Center. is a Clinic Chief, Anesthesia Pain Medicine; and is Chief, Primary Care Pain Management; both at the Malcom Randall VA Medical Center in Gainesville, Florida. is a VISN 19 Lead Physician Primary Care and a staff physician at the Veterans Affairs Eastern Colorado Health Care System in Denver. is an Associate Professor of Psychiatry, Ted Gingrich is a Courtesy Clinical Assistant Professor of Anesthesiology, and Rebecca Beyth is a Professor of Medicine, all at the University of Florida College of Medicine in Gainesville. Mary Lynn Ayers is an Assistant Professor at the University of Colorado - Anschutz Medical Campus. is a Professor and Chair, Department of Psychiatry, Western Michigan University School of Medicine
| | - Rebecca Beyth
- is a Research Scientist at the New York Academy of Medicine in New York City. is the Associate Director for Clinical Innovation at the North Florida/South Georgia Geriatric Research Education and Clinical Center. is a Clinic Chief, Anesthesia Pain Medicine; and is Chief, Primary Care Pain Management; both at the Malcom Randall VA Medical Center in Gainesville, Florida. is a VISN 19 Lead Physician Primary Care and a staff physician at the Veterans Affairs Eastern Colorado Health Care System in Denver. is an Associate Professor of Psychiatry, Ted Gingrich is a Courtesy Clinical Assistant Professor of Anesthesiology, and Rebecca Beyth is a Professor of Medicine, all at the University of Florida College of Medicine in Gainesville. Mary Lynn Ayers is an Assistant Professor at the University of Colorado - Anschutz Medical Campus. is a Professor and Chair, Department of Psychiatry, Western Michigan University School of Medicine
| | - Mary Lynn Ayers
- is a Research Scientist at the New York Academy of Medicine in New York City. is the Associate Director for Clinical Innovation at the North Florida/South Georgia Geriatric Research Education and Clinical Center. is a Clinic Chief, Anesthesia Pain Medicine; and is Chief, Primary Care Pain Management; both at the Malcom Randall VA Medical Center in Gainesville, Florida. is a VISN 19 Lead Physician Primary Care and a staff physician at the Veterans Affairs Eastern Colorado Health Care System in Denver. is an Associate Professor of Psychiatry, Ted Gingrich is a Courtesy Clinical Assistant Professor of Anesthesiology, and Rebecca Beyth is a Professor of Medicine, all at the University of Florida College of Medicine in Gainesville. Mary Lynn Ayers is an Assistant Professor at the University of Colorado - Anschutz Medical Campus. is a Professor and Chair, Department of Psychiatry, Western Michigan University School of Medicine
| | - Joseph E Thornton
- is a Research Scientist at the New York Academy of Medicine in New York City. is the Associate Director for Clinical Innovation at the North Florida/South Georgia Geriatric Research Education and Clinical Center. is a Clinic Chief, Anesthesia Pain Medicine; and is Chief, Primary Care Pain Management; both at the Malcom Randall VA Medical Center in Gainesville, Florida. is a VISN 19 Lead Physician Primary Care and a staff physician at the Veterans Affairs Eastern Colorado Health Care System in Denver. is an Associate Professor of Psychiatry, Ted Gingrich is a Courtesy Clinical Assistant Professor of Anesthesiology, and Rebecca Beyth is a Professor of Medicine, all at the University of Florida College of Medicine in Gainesville. Mary Lynn Ayers is an Assistant Professor at the University of Colorado - Anschutz Medical Campus. is a Professor and Chair, Department of Psychiatry, Western Michigan University School of Medicine
| | - Rajiv Tandon
- is a Research Scientist at the New York Academy of Medicine in New York City. is the Associate Director for Clinical Innovation at the North Florida/South Georgia Geriatric Research Education and Clinical Center. is a Clinic Chief, Anesthesia Pain Medicine; and is Chief, Primary Care Pain Management; both at the Malcom Randall VA Medical Center in Gainesville, Florida. is a VISN 19 Lead Physician Primary Care and a staff physician at the Veterans Affairs Eastern Colorado Health Care System in Denver. is an Associate Professor of Psychiatry, Ted Gingrich is a Courtesy Clinical Assistant Professor of Anesthesiology, and Rebecca Beyth is a Professor of Medicine, all at the University of Florida College of Medicine in Gainesville. Mary Lynn Ayers is an Assistant Professor at the University of Colorado - Anschutz Medical Campus. is a Professor and Chair, Department of Psychiatry, Western Michigan University School of Medicine
| | - Ted Gingrich
- is a Research Scientist at the New York Academy of Medicine in New York City. is the Associate Director for Clinical Innovation at the North Florida/South Georgia Geriatric Research Education and Clinical Center. is a Clinic Chief, Anesthesia Pain Medicine; and is Chief, Primary Care Pain Management; both at the Malcom Randall VA Medical Center in Gainesville, Florida. is a VISN 19 Lead Physician Primary Care and a staff physician at the Veterans Affairs Eastern Colorado Health Care System in Denver. is an Associate Professor of Psychiatry, Ted Gingrich is a Courtesy Clinical Assistant Professor of Anesthesiology, and Rebecca Beyth is a Professor of Medicine, all at the University of Florida College of Medicine in Gainesville. Mary Lynn Ayers is an Assistant Professor at the University of Colorado - Anschutz Medical Campus. is a Professor and Chair, Department of Psychiatry, Western Michigan University School of Medicine
| | - Stephen A Mudra
- is a Research Scientist at the New York Academy of Medicine in New York City. is the Associate Director for Clinical Innovation at the North Florida/South Georgia Geriatric Research Education and Clinical Center. is a Clinic Chief, Anesthesia Pain Medicine; and is Chief, Primary Care Pain Management; both at the Malcom Randall VA Medical Center in Gainesville, Florida. is a VISN 19 Lead Physician Primary Care and a staff physician at the Veterans Affairs Eastern Colorado Health Care System in Denver. is an Associate Professor of Psychiatry, Ted Gingrich is a Courtesy Clinical Assistant Professor of Anesthesiology, and Rebecca Beyth is a Professor of Medicine, all at the University of Florida College of Medicine in Gainesville. Mary Lynn Ayers is an Assistant Professor at the University of Colorado - Anschutz Medical Campus. is a Professor and Chair, Department of Psychiatry, Western Michigan University School of Medicine
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Winchester DE, Beyth R. Quality Improvement in Cardiovascular Imaging. Cardiovascular Innovations and Applications 2019. [DOI: 10.15212/cvia.2019.0002] [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] [Indexed: 11/18/2022] Open
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Johnson LA, Bozogmehri S, Ishani A, Weiner D, Berry R, Beyth R, Canales M. 0876 Sleep Apnea and Change in Quality of Life Among Veterans with Kidney Disease: A Prospective Cohort Study. Sleep 2018. [DOI: 10.1093/sleep/zsy061.875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- L A Johnson
- Malcom Randall VA Medical Center, Gainesville, FL
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida College of Medicine, Gainesville, FL
| | - S Bozogmehri
- Malcom Randall VA Medical Center, Gainesville, FL
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida College of Medicine, Gainesville, FL
| | - A Ishani
- Minneapolis VA Medical Center, Minneapolis, MN
- University of Minnesota, Minneapolis, MN
| | - D Weiner
- Malcom Randall VA Medical Center, Gainesville, FL
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida College of Medicine, Gainesville, FL
| | - R Berry
- Malcom Randall VA Medical Center, Gainesville, FL
| | - R Beyth
- Malcom Randall VA Medical Center, Gainesville, FL
| | - M Canales
- Malcom Randall VA Medical Center, Gainesville, FL
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida College of Medicine, Gainesville, FL
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Holzworth M, Canales M, Berry R, Beyth R, Gumz ML. Tick‐Tock, Tick‐Tock: Clock Gene Expression is Altered in Sleep Apnea. FASEB J 2018. [DOI: 10.1096/fasebj.2018.32.1_supplement.585.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Muna Canales
- North Florida/South Georgia Veterans Health SystemGainesvilleFL
- Department of MedicineUniversity of FloridaGainesvilleFL
| | - Richard Berry
- Department of MedicineUniversity of FloridaGainesvilleFL
| | - Rebecca Beyth
- Department of MedicineUniversity of FloridaGainesvilleFL
| | - Michelle L. Gumz
- North Florida/South Georgia Veterans Health SystemGainesvilleFL
- Department of MedicineUniversity of FloridaGainesvilleFL
- Department of BiochemistryUniversity of FloridaGainesvilleFL
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Bozorgmehri S, Gilbert S, Cook RL, Beyth R, Ozrazgat-Baslanti T, Bihorac A, Canales M. PD13-09 ACUTE KIDNEY INJURY AFTER UROLOGIC SURGERIES. J Urol 2018. [DOI: 10.1016/j.juro.2018.02.783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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14
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Bozorgmehri S, Gilbert S, Lu X, Cook RL, Beyth R, Canales M. MP10-04 EFFECT OF RADICAL CYSTECTOMY AND URINARY DIVERSION FOR BLADDER CANCER TREATMENT ON RENAL FUNCTION OVER TIME. J Urol 2017. [DOI: 10.1016/j.juro.2017.02.332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Winchester DE, Kline K, Plumb J, Huo T, Beyth R. Abstract 227: Patient and Provider Generated Appropriateness Ratings for Myocardial Perfusion Imaging: Agreement With Published Criteria. Circ Cardiovasc Qual Outcomes 2016. [DOI: 10.1161/circoutcomes.9.suppl_2.227] [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:
Appropriate use criteria (AUC) for myocardial perfusion imaging (MPI) help doctors decide which patients may benefit from MPI. The AUC development process does not include patients. Ordering providers are included, but their opinions on AUC have not been more broadly studied. We conducted an anonymous survey of patients and providers on the appropriateness of MPI in various settings. We hypothesize that both groups will overestimate the appropriateness of MPI compared to AUC.
Methods:
We administered our survey to patients in primary care clinics, cardiology clinics, and nuclear medicine laboratories at our academic medical center and affiliated Veterans Affairs medical center. Participating providers were physicians, nurse practioners, and physician assistants within primary care, cardiology, and hospital medicine. The primary outcome was a comparison of patient and provider appropriateness ratings as compared to published AUC. Respondents used the same methodology as used to develop the AUC; five clinical scenarios were rated on a 1 (inappropriate) to 9 (appropriate) scale. Scenarios were based on common MPI indications and included appropriate, inappropriate, and uncertain examples (symptomatic with prior revascularization, symptomatic with low risk of heart disease, asymptomatic with low risk of heart disease, symptomatic with intermediate risk of heart disease, and asymptomatic with prior revascularization). We used subgroup analyses and logistic regression models for both groups to investigate associations between ratings and respondent characteristics.
Results:
The survey was completed by 449 respondents, 338 patients and 111 providers between June and August 2014. Patient sampling was distributed between cardiology clinic (32.2%), primary care clinic (36.0%), and nuclear medicine (31.9%) laboratory. Providers were cardiology (35.1%), primary care (37.7%), hospital medicine (22.8%), and other (4.4%); 86.8% physicians. Of the five scenarios, the patient and provider ratings differed from AUC for three. In two cases, the patient generated rating was higher than the provider or published rating (5 versus 3.5 and 3, p<0.0001; 5 versus 2 and 1, p<0.0001). In the third case, the provider generated rating was lower than both the patient and published rating (2 versus 6 and 6, p<0.0001). Subgroup comparisons and logistic regression did not reveal any significant correlations between ratings and respondent characteristics.
Conclusion:
In some clinical scenarios, patients and healthcare providers have differences of opinion about the appropriateness of nuclear MPI as compared to published AUC. Patients tended to overvalue MPI while healthcare providers undervalued one of the published AUC ratings. Evidence of differences in opinion raise the question as to what role patients should play in future iterations of AUC.
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16
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Rajasekhar A, Elmariah H, Lottenberg L, Beyth R, Lottenberg R, Ang D. Inferior Vena Cava Filters in Trauma Patients: A National Practice Patterns Survey of U.S. Trauma Centers. Am Surg 2014. [DOI: 10.1177/000313481408001226] [Citation(s) in RCA: 5] [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: 11/17/2022]
Abstract
Inferior vena cava filters (IVCFs) for thromboprophylaxis in trauma patients are being increasingly used despite a lack of strong clinical data in support of their efficacy and conflicting clinical practice guidelines. This national survey elucidates practice patterns of IVCF use across U.S. trauma centers. A web-based survey was administered to members of the Eastern Association for the Surgery of Trauma between September 2011 and October 2011. The survey queried: 1) background and professional practice; 2) trauma patient population; 3) IVCF placement; 4) IVCF retrieval and follow-up; and 5) pharmacologic prophylaxis. Two hundred eighty-one of 1059 eligible providers completed the survey (27%). Respondents were from a wide spectrum of training backgrounds and clinical practice settings. IVCFs were used by 98.9 per cent of respondents. IVCFs in patients without known venous thromboembolism were considered by 93.2 per cent of respondents. Indications and timing of IVCF retrieval vary. Follow-up care of patients with IVCFs was not uniform. An IVCF registry was maintained by 38 per cent of trauma programs. Adjunctive pharmacologic prophylaxis was used by 96.8 per cent of respondents. This study elucidates the gaps and variations in contemporary practices of IVCF use in trauma patients. Identification of best practices in IVCF use and retrieval awaits well-designed comparative effectiveness studies.
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Affiliation(s)
- Anita Rajasekhar
- Department of Medicine, University of Florida, College of Medicine, Gainesville, Florida
| | - Hany Elmariah
- Department of Medicine, Duke University, College of Medicine, Durham, NC
| | - Lawrence Lottenberg
- Department of Surgery, University of Florida, College of Medicine, Gainesville, Florida
| | - Rebecca Beyth
- Department of Medicine, University of Florida, College of Medicine and Malcom Randall VA Medical Center, Gainesville, Florida; and
| | - Richard Lottenberg
- Department of Medicine, University of Florida, College of Medicine, Gainesville, Florida
| | - Darwin Ang
- Ocala Regional Medical Center, Ocala, Florida
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17
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Rajasekhar A, Elmariah H, Lottenberg L, Beyth R, Lottenberg R, Ang D. Inferior vena cava filters in trauma patients: a national practice patterns survey of U.S. Trauma centers. Am Surg 2014; 80:1237-1244. [PMID: 25513923] [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: 06/04/2023]
Abstract
Inferior vena cava filters (IVCFs) for thromboprophylaxis in trauma patients are being increasingly used despite a lack of strong clinical data in support of their efficacy and conflicting clinical practice guidelines. This national survey elucidates practice patterns of IVCF use across U.S. trauma centers. A web-based survey was administered to members of the Eastern Association for the Surgery of Trauma between September 2011 and October 2011. The survey queried: 1) background and professional practice; 2) trauma patient population; 3) IVCF placement; 4) IVCF retrieval and follow-up; and 5) pharmacologic prophylaxis. Two hundred eighty-one of 1059 eligible providers completed the survey (27%). Respondents were from a wide spectrum of training backgrounds and clinical practice settings. IVCFs were used by 98.9 per cent of respondents. IVCFs in patients without known venous thromboembolism were considered by 93.2 per cent of respondents. Indications and timing of IVCF retrieval vary. Follow-up care of patients with IVCFs was not uniform. An IVCF registry was maintained by 38 per cent of trauma programs. Adjunctive pharmacologic prophylaxis was used by 96.8 per cent of respondents. This study elucidates the gaps and variations in contemporary practices of IVCF use in trauma patients. Identification of best practices in IVCF use and retrieval awaits well-designed comparative effectiveness studies.
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Affiliation(s)
- Anita Rajasekhar
- Department of Medicine, University of Florida, College of Medicine, Gainesville, Florida, USA
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Zipkin DA, Umscheid CA, Keating NL, Allen E, Aung K, Beyth R, Kaatz S, Mann DM, Sussman JB, Korenstein D, Schardt C, Nagi A, Sloane R, Feldstein DA. Evidence-based risk communication: a systematic review. Ann Intern Med 2014; 161:270-80. [PMID: 25133362 DOI: 10.7326/m14-0295] [Citation(s) in RCA: 230] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Effective communication of risks and benefits to patients is critical for shared decision making. PURPOSE To review the comparative effectiveness of methods of communicating probabilistic information to patients that maximize their cognitive and behavioral outcomes. DATA SOURCES PubMed (1966 to March 2014) and CINAHL, EMBASE, and the Cochrane Central Register of Controlled Trials (1966 to December 2011) using several keywords and structured terms. STUDY SELECTION Prospective or cross-sectional studies that recruited patients or healthy volunteers and compared any method of communicating probabilistic information with another method. DATA EXTRACTION Two independent reviewers extracted study characteristics and assessed risk of bias. DATA SYNTHESIS Eighty-four articles, representing 91 unique studies, evaluated various methods of numerical and visual risk display across several risk scenarios and with diverse outcome measures. Studies showed that visual aids (icon arrays and bar graphs) improved patients' understanding and satisfaction. Presentations including absolute risk reductions were better than those including relative risk reductions for maximizing accuracy and seemed less likely than presentations with relative risk reductions to influence decisions to accept therapy. The presentation of numbers needed to treat reduced understanding. Comparative effects of presentations of frequencies (such as 1 in 5) versus event rates (percentages, such as 20%) were inconclusive. LIMITATION Most studies were small and highly variable in terms of setting, context, and methods of administering interventions. CONCLUSION Visual aids and absolute risk formats can improve patients' understanding of probabilistic information, whereas numbers needed to treat can lessen their understanding. Due to study heterogeneity, the superiority of any single method for conveying probabilistic information is not established, but there are several good options to help clinicians communicate with patients. PRIMARY FUNDING SOURCE None.
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Haring B, Leng X, Robinson J, Johnson KC, Jackson RD, Beyth R, Wactawski-Wende J, von Ballmoos MW, Goveas JS, Kuller LH, Wassertheil-Smoller S. Cardiovascular disease and cognitive decline in postmenopausal women: results from the Women's Health Initiative Memory Study. J Am Heart Assoc 2013; 2:e000369. [PMID: 24351701 PMCID: PMC3886762 DOI: 10.1161/jaha.113.000369] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Data on cardiovascular diseases (CVD) and cognitive decline are conflicting. Our objective was to investigate if CVD is associated with an increased risk for cognitive decline and to examine whether hypertension, diabetes, or adiposity modify the effect of CVD on cognitive functioning. Methods and Results Prospective follow‐up of 6455 cognitively intact, postmenopausal women aged 65 to 79 years old enrolled in the Women's Health Initiative Memory Study (WHIMS). CVD was determined by self‐report. For cognitive decline, we assessed the incidence of mild cognitive impairment (MCI) or probable dementia (PD) via modified mini‐mental state examination (3 MS) score, neurocognitive, and neuropsychiatric examinations. The median follow‐up was 8.4 years. Women with CVD tended to be at increased risk for cognitive decline compared with those free of CVD (hazard ratio [HR], 1.29; 95% CI: 1.00, 1.67). Women with myocardial infarction or other vascular disease were at highest risk (HR, 2.10; 95% CI: 1.40, 3.15 or HR, 1.97; 95% CI: 1.34, 2.87). Angina pectoris was moderately associated with cognitive decline (HR 1.45; 95% CI: 1.05, 2.01) whereas no significant relationships were found for atrial fibrillation or heart failure. Hypertension and diabetes increased the risk for cognitive decline in women without CVD. Diabetes tended to elevate the risk for MCI/PD in women with CVD. No significant trend was seen for adiposity. Conclusions CVD is associated with cognitive decline in elderly postmenopausal women. Hypertension and diabetes, but not adiposity, are associated with a higher risk for cognitive decline. More research is warranted on the potential of CVD prevention for preserving cognitive functioning.
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Affiliation(s)
- Bernhard Haring
- Department of Internal Medicine I, Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Bavaria, Germany
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20
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Winchester DE, Meral R, Nguyen D, Ryals S, Dusaj R, Shaw L, Beyth R. Abstract 356: Comparison Of Inappropriate Myocardial Perfusion Imaging By Specialty Training And Encounter Location. Circ Cardiovasc Qual Outcomes 2013. [DOI: 10.1161/circoutcomes.6.suppl_1.a356] [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
Objective:
To investigate the association between inappropriate use of myocardial perfusion imaging (MPI), specialty training of the ordering provider, and location of the clinical encounter.
Methods:
We conducted a retrospective analysis of MPI performed in a single Veterans Affairs (VA) medical center from August 2010 through November 2011. We classified the indication for each MPI test using the 2009 Appropriate Use Criteria (AUC). We investigated for associations between MPI ordered for inappropriate indications, the subspecialty training of the ordering provider (cardiology vs. other), and the location of the clinical encounter (emergency department [ED], inpatient, or outpatient).
Results:
We analyzed 598 subjects, 95% of whom were male. Diabetes (41.2%), hypertension (82.3%), and hyperlipidemia (76.0%) were common, as were prior myocardial infarction (40.5%) and prior revascularization (34.6%). Overall, 78.4% of MPI were appropriate, 9.5% uncertain, and 10.5% were inappropriate. An indication could not be determined for 3.2% of patients. Distribution of appropriateness by provider type and location of encounter are demonstrated in the Figure. The most common inappropriate indication did differ between groups. For Cardiology providers the most common inappropriate MPI was for asymptomatic patients within 2 years of percutaneous coronary intervention (AUC indication #59) while for noncardiology providers, the most common was asymptomatic patients with intermediate coronary heart disease (CHD) risk and a normal electrocardiogram (AUC indication #13). For inpatient MPI, definite acute coronary syndrome (AUC indication #10) was the most common inappropriate test, while for outpatient MPI, asymptomatic patients with low CHD risk was the most common (AUC indication #12), and for ED MPI syncope with low CHD risk was the most common (AUC indication #20).
Conclusions:
The proportion of MPI ordering for inappropriate indications was similar when comparing the specialty training of the ordering provider and the location of the ordering encounter. The most common inappropriate indications ordered by each group, however, were different. Our findings suggest that initiatives to reduce inappropriate use should be aimed at all providers, but targeted to specific inappropriate indications.
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Abstract
Critically ill patients are at increased risk for development of thrombosis. In addition, thrombosis is often unrecognized in this population. Furthermore, these patients are particularly susceptible to bleeding complications from anticoagulants. Herein the authors review the pharmacology, data from clinical trials, management of bleeding complications, and perioperative use of these agents in the intensive care unit population. Well-designed clinical trials are needed to improve our understanding of the safety and efficacy of these newer agents in critically ill patients.
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Affiliation(s)
- Anita Rajasekhar
- Department of Medicine, University of Florida, College of Medicine, Gainesville, FL 32610-0278, USA
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Heneghan C, Ward A, Perera R, Bankhead C, Fuller A, Stevens R, Bradford K, Tyndel S, Alonso-Coello P, Ansell J, Beyth R, Bernardo A, Christensen TD, Cromheecke ME, Edson RG, Fitzmaurice D, Gadisseur APA, Garcia-Alamino JM, Gardiner C, Hasenkam JM, Jacobson A, Kaatz S, Kamali F, Khan TI, Knight E, Körtke H, Levi M, Matchar D, Menéndez-Jándula B, Rakovac I, Schaefer C, Siebenhofer A, Souto JC, Sunderji R, Gin K, Shalansky K, Völler H, Wagner O, Zittermann A. Self-monitoring of oral anticoagulation: systematic review and meta-analysis of individual patient data. Lancet 2012; 379:322-34. [PMID: 22137798 DOI: 10.1016/s0140-6736(11)61294-4] [Citation(s) in RCA: 225] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Uptake of self-testing and self-management of oral anticoagulation [corrected] has remained inconsistent, despite good evidence of their effectiveness. To clarify the value of self-monitoring of oral anticoagulation, we did a meta-analysis of individual patient data addressing several important gaps in the evidence, including an estimate of the effect on time to death, first major haemorrhage, and thromboembolism. METHODS We searched Ovid versions of Embase (1980-2009) and Medline (1966-2009), limiting searches to randomised trials with a maximally sensitive strategy. We approached all authors of included trials and requested individual patient data: primary outcomes were time to death, first major haemorrhage, and first thromboembolic event. We did prespecified subgroup analyses according to age, type of control-group care (anticoagulation-clinic care vs primary care), self-testing alone versus self-management, and sex. We analysed patients with mechanical heart valves or atrial fibrillation separately. We used a random-effect model method to calculate pooled hazard ratios and did tests for interaction and heterogeneity, and calculated a time-specific number needed to treat. FINDINGS Of 1357 abstracts, we included 11 trials with data for 6417 participants and 12,800 person-years of follow-up. We reported a significant reduction in thromboembolic events in the self-monitoring group (hazard ratio 0·51; 95% CI 0·31-0·85) but not for major haemorrhagic events (0·88, 0·74-1·06) or death (0·82, 0·62-1·09). Participants younger than 55 years showed a striking reduction in thrombotic events (hazard ratio 0·33, 95% CI 0·17-0·66), as did participants with mechanical heart valve (0·52, 0·35-0·77). Analysis of major outcomes in the very elderly (age ≥85 years, n=99) showed no significant adverse effects of the intervention for all outcomes. INTERPRETATION Our analysis showed that self-monitoring and self-management of oral coagulation is a safe option for suitable patients of all ages. Patients should also be offered the option to self-manage their disease with suitable health-care support as back-up. FUNDING UK National Institute for Health Research (NIHR) Technology Assessment Programme, UK NIHR National School for Primary Care Research.
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Affiliation(s)
- Carl Heneghan
- Oxford University, Department of Primary Care Health Sciences, Oxford, UK.
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Kowalczyk L, Shah P, George T, Lu L, Sarosi G, Beyth R, Sultan S. Impact of a simple intervention that improves colon cancer lymph node yield and assessement. J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.e15058] [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
e15058 Background: The National Quality Forum has endorsed the 12 lymph node (LN) benchmark as a quality metric. Currently, less than 40% of institutions meet this requirement. The purpose of this study was to determine whether implementation of a simple pathology template with dedicated fields for LN reporting led to an increase in the number of colon cancer resections where >12 LNs were reported. Methods: A simple pathology template, derived from the College of American Pathology, using standardized terminology and dedicated fields for LN reporting was implemented in August 2007. Using a pre and post- test design, all consecutive pathology cases were retrospectively reviewed. Inclusion criteria consisted of all stage 0-IV colon cancer patients who underwent surgical resection at a single Veterans Affairs Medical Center. The primary outcome was the percentage of cases in which >12 LNs were assessed between the pre and post-template group. Age, gender, anatomic location, and stage were also collected. Statistical comparisons were made using chi-square and Fisher's exact t-test. Results: 111 pre-template and 71 post-template cases were analyzed. The majority of patients were Caucasian (74%) males (97%). There were no significant differences between the two groups (see Table 1 ), however there was a trend towards more right-sided colon cancers in the pre-template group. 51% of all pre-template pathology reports evaluated >12 LNs compared to 68% of post-template reports (33% improvement in LN yield; p=0.03). Conclusions: Examination of >12 LNs has important therapeutic and prognostic implications in colon cancer patients. Use of a standardized pathology template with dedicated fields for LN reporting is a simple intervention that can increase yield of LN reporting. This can have a significant impact for institutions striving to reach the 12 LN quality metric. [Table: see text] No significant financial relationships to disclose.
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Affiliation(s)
| | - P. Shah
- University of Florida, Gainesville, FL
| | - T. George
- University of Florida, Gainesville, FL
| | - L. Lu
- University of Florida, Gainesville, FL
| | - G. Sarosi
- University of Florida, Gainesville, FL
| | - R. Beyth
- University of Florida, Gainesville, FL
| | - S. Sultan
- University of Florida, Gainesville, FL
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Deswal A, Petersen NJ, Urbauer DL, Wright SM, Beyth R. Racial variations in quality of care and outcomes in an ambulatory heart failure cohort. Am Heart J 2006; 152:348-54. [PMID: 16875921 DOI: 10.1016/j.ahj.2005.12.004] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2005] [Accepted: 12/06/2005] [Indexed: 12/20/2022]
Abstract
BACKGROUND Few recent studies have demonstrated similar quality of care for hospitalized black and white patients with heart failure (HF). However, systematic evaluation of racial differences in both the quality of care and outcomes is needed in the outpatient setting, where most patients with HF are treated and where care may be more fragmented. METHODS We examined racial differences in quality-of-care measures and outcomes of 1-year mortality and hospitalization in a national cohort of 18,611 ambulatory patients with HF treated at Veterans Affairs medical centers between October 2000 and September 2002. RESULTS Black patients were more likely to have left ventricular ejection fraction assessment than whites (risk-adjusted OR 1.29, 95% CI 1.11-1.49). In patients with left ventricular ejection fraction <40%, blacks were as likely as whites to be on treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (risk-adjusted OR 1.06, 95% CI 0.85-1.33) and beta-blockers (risk-adjusted OR 0.92, 95% CI 0.79-1.07). However, black patients more frequently had uncontrolled hypertension and were more likely to be hospitalized for any cause (OR 1.20, 95% CI 1.08-1.33) or for HF (OR 1.43, 95% CI 1.23-1.66), although 1-year mortality did not differ by race (OR 1.03, 95% CI 0.89-1.20). CONCLUSIONS In a financially "equal access" health care system, the quality of outpatient HF care assessed by select quality measures and 1-year mortality was similar in black compared to white patients. However, blacks were more likely to be hospitalized, especially with HF. Identifying and targeting potentially modifiable factors such as uncontrolled hypertension in black patients may narrow the racial gap in hospitalizations.
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Affiliation(s)
- Anita Deswal
- Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, TX 77030, USA
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Beyth R. Conventional-intensity was more effective than low-intensity warfarin therapy for preventing recurrent venous thromboembolism. ACP J Club 2004; 140:37. [PMID: 15122857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
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Levitan N, Dowlati A, Remick SC, Tahsildar HI, Sivinski LD, Beyth R, Rimm AA. Rates of initial and recurrent thromboembolic disease among patients with malignancy versus those without malignancy. Risk analysis using Medicare claims data. Medicine (Baltimore) 1999; 78:285-91. [PMID: 10499070 DOI: 10.1097/00005792-199909000-00001] [Citation(s) in RCA: 621] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Although the association between malignancy and thromboembolic disease is well established, the relative risk of developing initial and recurrent deep vein thrombosis (DVT) or pulmonary embolism (PE) among patients with malignancy versus those without malignancy has not been clearly defined. The Medicare Provider Analysis and Review Record (MEDPAR) database was used for this analysis. Patients hospitalized during 1988-1990 with DVT/PE alone, DVT/PE and malignancy, malignancy alone, or 1 of several nonmalignant diseases (other than DVT/PE) were studied. The association of malignancy and nonmalignant disease with an initial episode of DVT/PE, recurrent DVT/PE, and mortality were analyzed. The percentage of patients with DVT/PE at the initial hospitalization was higher for those with malignancy compared with those with nonmalignant disease (0.6% versus 0.57%, p = 0.001). The probability of readmission within 183 days of initial hospitalization with recurrent thromboembolic disease was 0.22 for patients with prior DVT/PE and malignancy compared with 0.065 for patients with prior DVT/PE and no malignancy (p = 0.001). Among those patients with DVT/PE and malignant disease, the probability of death within 183 days of initial hospitalization was 0.94 versus 0.29 among those with DVT/PE and no malignancy (p = 0.001). The relative risk of DVT/PE among patients with specific types of malignancy is described. This study demonstrates that patients with concurrent DVT/PE and malignancy have a more than threefold higher risk of recurrent thromboembolic disease and death (from and cause) than patients with DVT/PE without malignancy. An alternative management strategy may be indicated for such patients.
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Affiliation(s)
- N Levitan
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Abstract
An area survey of tanning salon proprietors was conducted in a medium-sized midwestern city. Proprietors reported they were in compliance with federal safety regulations, but not all had age, frequency, or duration restrictions. Similarly, proprietors were not uniformly informing patrons of potential tanning hazards, including the possibility of skin cancer, and were not knowledgeable about the risk and benefits of tanning. Some establishments reported selling psoralens to patrons to enhance tanning. More explicit guidelines regarding the use of tanning equipment and more accurate consumer information are needed.
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Affiliation(s)
- R Beyth
- Department of Medicine, College of Human Medicine, Michigan State University, East Lansing 48824-1315
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