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Mandibular distraction has variable outcomes in Treacher-Collins syndrome. Dual syndromic diagnosis is a rare occurrence that complicates management. Here, the authors present a patient with Treacher-Collins syndrome and severe retrognathia requiring tracheostomy who failed repeat mandibular distraction and decannulation. A genetic workup later revealed Angelman syndrome with severe developmental delay. We discuss explanations for difficulties encountered during mandibular distraction as well as surgical options for patients with Treacher-Collins who fail multiple attempts at decannulation. Overall, patients with dual diagnoses can exhibit an underlying problem in bone formation and mineralization, which challenges any attempt at craniofacial manipulation., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Summary Statement: Health care policies have the potential to improve patient outcomes, access to care, and reduce health disparities. However, new policy is often tested in the field, where unintended consequences are paid for by patients. In this perspective, we argue that health care simulations, which can elucidate the potential for policy to hinder clinicians' ability to provide high-quality care, are a complement to large-scale policy evaluations in the field., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Society for Simulation in Healthcare.)

Objective: Microtia is a congenital ear deformity with variability in surgical techniques and tools across surgeons pursuing an autologous reconstruction. Different techniques have emerged over time, and surgeons opt for various tools to aid in creating the complex three-dimensional cartilaginous ear framework. The purpose of this study was to understand the current state of microtia reconstruction in the United States., Methods: Microtia surgeons affiliated with the nonprofit, Ear Community, were invited to complete a 20-item survey. Data were collected on demographic information regarding surgeons, considerations when approaching microtia repair in patients, and techniques and comfort levels. Additional data were collected on materials, tools, flaps, and skin grafts used for reconstruction., Results: Twenty-two surgeons responded to the survey reporting 3 different techniques learned and utilized in practice including the Brent, Nagata, and Firmin techniques. About two-thirds of surgeons were "extremely comfortable" with their techniques and one-third were "extremely uncomfortable" or "somewhat uncomfortable." Most respondents reported using a tunneled temporoparietal fascial flap or a posterior fascial flap along with a full-thickness skin graft for the second stage (ear elevation). Most surgeons utilized a combination of scalpels and gouges when carving the ear framework along with sutures or wire., Conclusions: This study highlights the current state of autogenous microtia reconstruction underscoring the variability in approaches and preferences. These data may guide future directions that aim to improve patient outcomes. Surgeons may gain insight into different practices and choose to adopt different aspects to enhance their surgical approach., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Autologous ear reconstruction remains a gold standard surgical technique for the treatment of external ear deformities. This highly technical procedure requires experience, an understanding of aesthetic principles, and a surgical approach that can consistently produce optimal results. As an experienced microtia surgeon having trained under Dr Satoru Nagata, the senior author has emphasized the importance of appropriate surgical tools during this procedure. Here, we present results of a novel surgical handle and gouge meant to optimize complex cartilage carving. The senior author regularly holds microtia workshops to help train individuals around the United States. During 2 of such workshops held in 2022, participants were given access to both the standard, commercially available surgical gouge as well as a prototype of a novel surgical gouge developed by the authors. Participants were then given a Likert-scale survey to assess their subjective feedback for both tools. Twenty-seven total participants completed the postworkshop survey. Cumulatively, the results demonstrated that participants rated the custom gouge significantly higher than its counterpart (4.2 versus 3.2, P<0.001). They also had a significantly higher likelihood of using the custom gouge again (4.1 versus 3.2, P=0.023). The custom gouge designed by the senior author demonstrated higher subjective ratings when compared with what is currently available on the market. This serves as a primary validation study that demonstrates feasibility for further assessment in a true operative setting., Competing Interests: B.P.A., N.K.R., N.D.S., and A.Y. are the co-inventors of the device discussed in the paper. The other author reports no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Noninvoluting congenital hemangiomas (NICHs) persist in a high-flow state into childhood and often require surgical excision. The inherent vascular nature of these tumors make effective surgical treatment challenging. Here we report on a patient that underwent intraoperative glue embolization and complete excision of a large gluteal NICH. Concurrent glue embolization followed by complete excision allows for decreased intraoperative blood loss and easier discrimination between the tumor and surrounding structures. Treating difficult vascular tumors with a multidisciplinary approach and subsequent intraoperative glue embolization with surgical excision allows for an effective, single-stage approach to NICHs., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Background: The American Board of Plastic Surgery collects data on 20 common plastic surgery operations as part of the Continuous Certification process. The goal of this study was to describe clinical trends in Dupuytren contracture repair since 2008 as they relate to evidence-based medicine articles published in this timeframe., Methods: Cumulative tracer data for Dupuytren contracture were reviewed for the period from February of 2008 to March of 2020 and compared with evidence-based medicine articles published in Plastic and Reconstructive Surgery . Topics were categorized as (1) pearls, addressed in both the tracer data and evidence-based medicine articles, (2) topics only addressed in tracer data, and (3) topics only addressed in evidence-based medicine articles., Results: As of March of 2020, 230 cases of Dupuytren contracture had been entered. The median age at time of surgery was 65 years (range, 38 to 91 years). Practice patterns from 2008 through 2014 were compared with those between 2015 and 2020. The most common surgical technique was limited fasciectomy (62 percent of cases). Differences in practice between these time periods included decrease in the use of radical fasciectomy (34 percent versus 16 percent, p = 0.002), increase in percutaneous cordotomy (0 percent versus 13 percent), and increase in the use of collagenase injections (0 percent versus 9 percent, p = 0.001). Use of Bier blocks increased (1 percent versus 7 percent), and tourniquet use decreased (97 percent versus 80 percent). Significant changes were also noted in postoperative management., Conclusion: By examining American Board of Plastic Surgery tracer data, the authors have described national trends in presentation and surgical techniques for Dupuytren contracture repair over a 14-year period., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Background: The American Board of Plastic Surgery has been collecting practice data on carpal tunnel syndrome treatment since 2004 as part of its Continuous Certification Program. These data allow plastic surgeons to compare their surgical experience to national trends and analyze those trends in relation to current evidence-based medicine., Methods: Data on carpal tunnel syndrome treatment from 2004 to 2014 were compared to those from 2015 to 2020. National practice trends observed in these data were evaluated relative to current literature regarding evidence-based practices., Results: A total of 11,090 carpal tunnel syndrome cases were included from 2004 to 2020. Electrodiagnostic and imaging studies were performed on most patients despite adding little sensitivity and specificity when physical examination tests are performed and not being considered cost-effective. An open "mini" approach has remained the most common surgical technique in carpal tunnel release for the last 15 years, with growing usage (53 percent versus 59 percent, p < 0.001). Splinting has decreased significantly over the last 15 years, from usage in 39 percent of patients to 28 percent (p < 0.001). Formal postoperative hand therapy has declined from 27 percent of patients to 22 percent (p < 0.001). Despite their low efficacy, 63 percent of patients received one or more perioperative doses of antibiotics., Conclusions: Analysis of the Continuous Certification Program tracer data from the American Board of Plastic Surgery provides an excellent overview of current practice and its development over the 15 years since its inception. This analysis provides insight into how effectively plastic surgeons have remained aligned with developments in best practices in treating carpal tunnel syndrome., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Background: There are limited data on uninsured patients presenting with acute myocardial infarction-cardiogenic shock (AMI-CS). This study sought to compare the management and outcomes of AMI-CS between uninsured and privately insured individuals., Methods: Using the National Inpatient Sample (2000-2016), a retrospective cohort of adult (≥18 years) uninsured admissions (primary payer-self-pay or no charge) were compared with privately insured individuals. Interhospital transfers were excluded. Outcomes of interest included in-hospital mortality, temporal trends in admissions, use of cardiac procedures, do-not-resuscitate status, palliative care referrals, and resource utilization., Results: Of 402 182 AMI-CS admissions, 21 966 (5.4%) and 93 814 (23.3%) were uninsured and privately insured. Compared with private insured individuals, uninsured admissions were younger, male, from a lower socioeconomic status, had lower comorbidity, higher rates of acute organ failure, ST-segment elevation AMI-CS (77.3% versus 76.4%), and concomitant cardiac arrest (33.8% versus 31.9%; all P <0.001). Compared with 2000, in 2016, there were more uninsured (adjusted odds ratio, 1.15 [95% CI, 1.13-1.17]; P <0.001) and less privately insured admissions (adjusted odds ratio, 0.85 [95% CI, 0.83-0.87]; P <0.001). Uninsured individuals received less frequent coronary angiography (79.5% versus 81.0%), percutaneous coronary intervention (60.8% versus 62.2%), mechanical circulatory support (54% versus 55.5%), and had higher palliative care (3.8% versus 3.2%) and do-not-resuscitate status use (4.4% versus 3.2%; all P <0.001). Uninsured admissions had higher in-hospital mortality (adjusted odds ratio, 1.62 [95% CI, 1.55-1.68]; P <0.001) and resource utilization., Conclusions: Uninsured individuals have higher in-hospital mortality and lower use of guideline-directed therapies in AMI-CS compared with privately insured individuals.

Abstract: Factors impacting the accuracy of ultrasound (US) diagnosis of cleft lip (CL) and its subsequent effect on parents are not well understood. Our objectives were to evaluate how the type of CL (complete versus incomplete) and associated cleft palate affect the accuracy of CL's prenatal diagnosis and to evaluate differences between parents' perception of prenatal US in cases of true-positive versus false-negative results. The authors performed a retrospective review of all patients who underwent repair for nonsyndromic CL following prenatal US. Patients were stratified by type of CL and associated cleft palate. Parents were called to determine if their child's CL was diagnosed via US and their perception of the results. Forty-seven children with complete and 40 with incomplete CL responded to phone calls. The presence of a complete CL (P = 0.001) and an associated cleft palate (P = 0.014) were independently associated with an increased likelihood of prenatal diagnosis. Parents who received a true-positive prenatal diagnosis of CL were more satisfied than those who received a false-negative diagnosis (P = 0.0063). True-positives perceived knowing of their child's diagnosis in advance to be more helpful than false-negatives believed it would have been. These results afford an improved context to interpret US studies and help physicians provide more informed prenatal counseling., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Background: Patients with atrial fibrillation and severely decreased kidney function were excluded from the pivotal non-vitamin K antagonist oral anticoagulants (NOAC) trials, thereby raising questions about comparative safety and effectiveness in patients with reduced kidney function. The study aimed to compare oral anticoagulants across the range of kidney function in patients with atrial fibrillation., Methods and Results: Using a US administrative claims database with linked laboratory data, 34 569 new users of oral anticoagulants with atrial fibrillation and estimated glomerular filtration rate ≥15 mL/(min·1.73 m 2 ) were identified between October 1, 2010 to November 29, 2017. The proportion of patients using NOACs declined with decreasing kidney function-73.5%, 69.6%, 65.4%, 59.5%, and 45.0% of the patients were prescribed a NOAC in estimated glomerular filtration rate ≥90, 60 to 90, 45 to 60, 30 to 45, 15 to 30 mL/min per 1.73 m 2 groups, respectively. Stabilized inverse probability of treatment weighting was used to balance 4 treatment groups (apixaban, dabigatran, rivaroxaban, and warfarin) on 66 baseline characteristics. In comparison to warfarin, apixaban was associated with a lower risk of stroke (hazard ratio [HR], 0.57 [0.43-0.75]; P <0.001), major bleeding (HR, 0.51 [0.44-0.61]; P <0.001), and mortality (HR, 0.68 [0.56-0.83]; P <0.001); dabigatran was associated with a similar risk of stroke but a lower risk of major bleeding (HR, 0.57 [0.43-0.75]; P <0.001) and mortality (HR, 0.68 [0.48-0.98]; P =0.04); rivaroxaban was associated with a lower risk of stroke (HR, 0.69 [0.51-0.94]; P =0.02), major bleeding (HR, 0.84 [0.72-0.99]; P =0.04), and mortality (HR, 0.73 [0.58-0.91]; P =0.006). There was no significant interaction between treatment and estimated glomerular filtration rate categories for any outcome. When comparing one NOAC to another NOAC, there was no significant difference in mortality, but some differences existed for stroke or major bleeding. No relationship between treatments and falsification end points was found, suggesting no evidence for substantial residual confounding., Conclusions: Relative to warfarin, NOACs are used less frequently as kidney function declines. However, NOACs appears to have similar or better comparative effectiveness and safety across the range of kidney function.

Background: The National Comprehensive Cancer Network and American Society of Clinical Oncology recommend consideration of the use of echocardiography 6 to 12 months after completion of anthracycline-based chemotherapy in at-risk populations. Assessment of BNP (B-type natriuretic peptide) has also been suggested by the American College of Cardiology/American Heart Association/Heart Failure Society of America for the identification of Stage A (at risk) heart failure patients. The real-world frequency of the use of these tests in patients after receipt of anthracycline therapy, however, has not been studied previously., Methods and Results: In this retrospective study, using administrative claims data from the OptumLabs Data Warehouse, we identified 31 447 breast cancer and lymphoma patients (age ≥18 years) who were treated with an anthracycline in the United States between January 1, 2008 and January 31, 2018. Continuous medical and pharmacy coverage was required for at least 6 months before the initial anthracycline dose and 12 months after the final dose. Only 36.1% of patients had any type of cardiac surveillance (echocardiography, BNP, or cardiac imaging) in the year following completion of anthracycline therapy (29.7% echocardiography). Surveillance rate increased from 37.5% in 2008 to 42.7% in 2018 (25.6% in 2008 to 40.5% echocardiography in 2018). Lymphoma patients had a lower likelihood of any surveillance compared with patients with breast cancer (odds ratio, 0.79 [95% CI, 0.74-0.85]; P <0.001). Patients with preexisting diagnoses of coronary artery disease and arrhythmia had the highest likelihood of cardiac surveillance (odds ratio, 1.54 [95% CI, 1.39-1.69] and odds ratio, 1.42 [95% CI, 1.3-1.53]; P <0.001 for both), although no single comorbidity was associated with a >50% rate of surveillance., Conclusions: The majority of survivors of breast cancer and lymphoma who have received anthracycline-based chemotherapy do not undergo cardiac surveillance after treatment, including those with a history of cardiovascular comorbidities, such as heart failure.

Objective: Experts cautioned that patients affected by the November 2010 withdrawal of the opioid analgesic propoxyphene might receive riskier prescriptions. To explore this, we compared drug receipts and outcomes among propoxyphene users before and aftermarket withdrawal., Study Design: Using OptumLabs data, we studied 3 populations: commercial, Medicare Advantage (MA) aged (age 65+ y) and MA disabled (age below 65 y) enrollees. The exposed enrollees received propoxyphene in the 3 months before market withdrawal (n=13,622); historical controls (unexposed) received propoxyphene 1 year earlier (n=9971). Regression models estimated daily milligrams morphine equivalent (MME), daily prescription acetaminophen dose, potentially toxic acetaminophen doses, nonopioid prescription analgesics receipt, emergency room visits, and diagnosed falls, motor vehicle accidents, and hip fractures., Principal Findings: Aged MA enrollees illustrate the experience of all 3 populations examined. Following the market withdrawal, propoxyphene users in the exposed cohort experienced an abrupt decline of 69% in average daily MME, compared with a 14% decline in the unexposed. Opioids were discontinued by 34% of the exposed cohort and 18% of the unexposed. Tramadol and hydrocodone were the most common opioids substituted for propoxyphene. The proportion of each group receiving ≥4 g of prescription acetaminophen per day decreased from 12% to 2% in the exposed group but increased from 6% to 8% among the unexposed. Adverse events were rare and not significantly different in exposed versus unexposed groups., Conclusions: After propoxyphene market withdrawal, many individuals experienced abrupt discontinuation of opioids. Policymakers might consider supporting appropriate treatment transitions and monitoring responses following drug withdrawals.

Background: Patients with end-stage kidney disease (ESKD) on dialysis were excluded from clinical trials of direct oral anticoagulants for atrial fibrillation (AF). Recent data have raised concerns regarding the safety of dabigatran and rivaroxaban, but apixaban has not been evaluated despite current labeling supporting its use in this population. The goal of this study was to determine patterns of apixaban use and its associated outcomes in dialysis-dependent patients with ESKD and AF., Methods: We performed a retrospective cohort study of Medicare beneficiaries included in the United States Renal Data System (October 2010 to December 2015). Eligible patients were those with ESKD and AF undergoing dialysis who initiated treatment with an oral anticoagulant. Because of the small number of dabigatran and rivaroxaban users, outcomes were only assessed in patients treated with apixaban or warfarin. Apixaban and warfarin patients were matched (1:3) based on prognostic score. Differences between groups in survival free of stroke or systemic embolism, major bleeding, gastrointestinal bleeding, intracranial bleeding, and death were assessed using Kaplan-Meier analyses. Hazard ratios (HRs) and 95% CIs were derived from Cox regression analyses., Results: The study population consisted of 25 523 patients (45.7% women; 68.2±11.9 years of age), including 2351 patients on apixaban and 23 172 patients on warfarin. An annual increase in apixaban prescriptions was observed after its marketing approval at the end of 2012, such that 26.6% of new anticoagulant prescriptions in 2015 were for apixaban. In matched cohorts, there was no difference in the risks of stroke/systemic embolism between apixaban and warfarin (HR, 0.88; 95% CI, 0.69-1.12; P=0.29), but apixaban was associated with a significantly lower risk of major bleeding (HR, 0.72; 95% CI, 0.59-0.87; P<0.001). In sensitivity analyses, standard-dose apixaban (5 mg twice a day; n=1034) was associated with significantly lower risks of stroke/systemic embolism and death as compared with either reduced-dose apixaban (2.5 mg twice a day; n=1317; HR, 0.61; 95% CI, 0.37-0.98; P=0.04 for stroke/systemic embolism; HR, 0.64; 95% CI, 0.45-0.92; P=0.01 for death) or warfarin (HR, 0.64; 95% CI, 0.42-0.97; P=0.04 for stroke/systemic embolism; HR, 0.63; 95% CI, 0.46-0.85; P=0.003 for death)., Conclusions: Among patients with ESKD and AF on dialysis, apixaban use may be associated with a lower risk of major bleeding compared with warfarin, with a standard 5 mg twice a day dose also associated with reductions in thromboembolic and mortality risk.

Background: The US Food and Drug Administration approved the use of sacubitril/valsartan in patients with heart failure with reduced ejection fraction in July 2015. We aimed to assess the adoption and prescription drug costs of sacubitril/valsartan in its first 18 months after Food and Drug Administration approval., Methods and Results: Using a large US insurance database, we identified privately insured and Medicare Advantage beneficiaries who filled a first prescription for sacubitril/valsartan between July 1, 2015, and December 31, 2016. We compared them to patients treated with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. Outcomes included adoption, prescription drug costs, and 180-day adherence, defined as a proportion of days covered ≥80%. A total of 2244 patients initiated sacubitril/valsartan. Although the number of users increased over time, the proportion of heart failure with reduced ejection fraction patients taking sacubitril/valsartan remained low (<3%). Patients prescribed sacubitril/valsartan were younger, more often male, with less comorbidity than those taking an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. Although a majority of prescription costs were covered by the health plan (mean, $328.37; median, $362.44 per 30-day prescription), out-of-pocket costs were still high (mean, $71.16; median, $40.27). By comparison, median out-of-pocket costs were $2 to $3 for lisinopril, losartan, carvedilol, and spironolactone. Overall, 59.1% of patients were adherent to sacubitril/valsartan. Refill patterns suggested that nearly half of nonadherent patients discontinued sacubitril/valsartan within 180 days of starting., Conclusions: Adoption of sacubitril/valsartan after Food and Drug Administration approval has been slow and may be associated with the high cost., (© 2018 American Heart Association, Inc.)

Background: Individualized diabetes management would benefit from prospectively identifying well-controlled patients at risk of losing glycemic control., Objectives: To identify patterns of hemoglobin A1c (HbA1c) change among patients with stable controlled diabetes., Research Design: Cohort study using OptumLabs Data Warehouse, 2001-2013. We develop and apply a machine learning framework that uses a Bayesian estimation of the mixture of generalized linear mixed effect models to discover glycemic trajectories, and a random forest feature contribution method to identify patient characteristics predictive of their future glycemic trajectories., Subjects: The study cohort consisted of 27,005 US adults with type 2 diabetes, age 18 years and older, and stable index HbA1c <7.0%., Measures: HbA1c values during 24 months of observation., Results: We compared models with k=1, 2, 3, 4, 5 trajectories and baseline variables including patient age, sex, race/ethnicity, comorbidities, medications, and HbA1c. The k=3 model had the best fit, reflecting 3 distinct trajectories of glycemic change: (T1) rapidly deteriorating HbA1c among 302 (1.1%) youngest (mean, 55.2 y) patients with lowest mean baseline HbA1c, 6.05%; (T2) gradually deteriorating HbA1c among 902 (3.3%) patients (mean, 56.5 y) with highest mean baseline HbA1c, 6.53%; and (T3) stable glycemic control among 25,800 (95.5%) oldest (mean, 58.5 y) patients with mean baseline HbA1c 6.21%. After 24 months, HbA1c rose to 8.75% in T1 and 8.40% in T2, but remained stable at 6.56% in T3., Conclusions: Patients with controlled type 2 diabetes follow 3 distinct trajectories of glycemic control. This novel application of advanced analytic methods can facilitate individualized and population diabetes care by proactively identifying high risk patients.

The learning healthcare system uses health information technology and the health data infrastructure to apply scientific evidence at the point of clinical care while simultaneously collecting insights from that care to promote innovation in optimal healthcare delivery and to fuel new scientific discovery. To achieve these goals, the learning healthcare system requires systematic redesign of the current healthcare system, focusing on 4 major domains: science and informatics, patient-clinician partnerships, incentives, and development of a continuous learning culture. This scientific statement provides an overview of how these learning healthcare system domains can be realized in cardiovascular disease care. Current cardiovascular disease care innovations in informatics, data uses, patient engagement, continuous learning culture, and incentives are profiled. In addition, recommendations for next steps for the development of a learning healthcare system in cardiovascular care are presented., (© 2017 American Heart Association, Inc.)

Publicly reported hospital ratings aim to encourage transparency, spur quality improvement, and empower patient choice. Travel burdens may limit patient choice, particularly for older adults (aged 65 years and more) who receive most medical care. For 3 major hospital ratings systems, we estimated travel burden as the additional 1-way travel distance to receive care at a better-rated hospital.Distances were estimated from publicly available data from the US Census, US News Top Hospitals, Society of Thoracic Surgeons composite rating for coronary artery bypass grafting (STS-CABG), and Centers for Medicare and Medicaid Services Hospital Consumer Assessment of Healthcare Providers and Services (HCAHPS).Hospitals were rated for HCAHPS (n = 4656), STS-CABG (n = 470), and US News Top Hospitals (n = 15). Older adults were commonly located within 25 miles of their closest HCAHPS hospital (89.6%), but less commonly for STS-CABG (62.9%). To receive care at a better-rated hospital, travel distances commonly exceeded 25 miles: HCAHPS (39.2%), STS-CABG (62.7%), and US News Top Hospital (85.2%). Additional 1-way travel distances exceeded 25 miles commonly: HCAHPS (23.7%), STS-CABG (36.7%), US News Top Hospitals (81.8%).Significant travel burden is common for older adults seeking "better" care and is an important limitation of current hospital ratings for empowering patient choice.

Background: Percutaneous coronary intervention (PCI) for stable coronary artery disease does not reduce the risk of death and myocardial infarction compared with optimal medical therapy (OMT), but many patients think otherwise. PCI Choice, a decision aid (DA), was designed for use during the clinical visit and includes information on quality of life and mortality outcomes for PCI with OMT versus OMT alone for stable coronary artery disease., Methods and Results: We conducted a randomized trial to assess the impact of the PCI Choice DA compared with usual care when there is a choice between PCI and optimal medical therapy. Primary outcomes were patient knowledge and decisional conflict, and the secondary outcome was an objective measure of shared decision making. A total of 124 patients were eligible for final analysis. Knowledge was higher among patients receiving the DA compared with usual care (60% DA; 40% usual care; P =0.034), and patients felt more informed ( P =0.043). Other measures of decisional quality were not improved, and engagement of the patient by the clinician in shared decision making did not change with use of the DA. There was evidence that clinicians used the DA as an educational tool., Conclusions: The PCI Choice DA improved patient knowledge but did not significantly impact decisional quality. Further work is needed to effectively address clinician knowledge gaps in shared decision-making skills, even in the context of carefully designed DAs., Clinical Trial Registration: URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01771536., (© 2016 American Heart Association, Inc.)

Objective: To assess the impact of wellness center attendance on weight loss and costs., Methods: A retrospective analysis was conducted using employee data, administrative claims, and electronic health records. A total of 3199 employees enrolled for 4 years (2007 to 2010) were included. Attendance was categorized as follows: 1 to 60, 61 to 180, 181 to 360, and more than 360 visits. Weight loss was defined as moving to a lower body mass index category. Total costs included paid amounts for both medical and pharmacy services., Results: Subjects with 181 to 360 and more than 360 visits were 46% (P = 0.05) and 72% (P = 0.01) more likely to have body mass index improvement compared with those with 1 to 60 visits. Compared with the mean annual cost of $13,267 for 1 to 60 visits, the mean for subjects with 61 to 180, 181 to 360, and more than 360 visits had significantly lower costs at $9538, $9332 and $8293, respectively (all P < 0.01). Higher attendance was associated with weight loss and significantly lower annual costs.

Background: With the growing concerns about overtreatment in prostate cancer, the extent to which radiation oncologists and urologists perceive active surveillance (AS) as effective and recommend it to patients are unknown., Objective: To assess opinions of radiation oncologists and urologists about their perceptions of AS and treatment recommendations for low-risk prostate cancer., Research Design: National survey of specialists., Participants: Radiation oncologists and urologists practicing in the United States., Measures: A total of 1366 respondents were asked whether AS was effective and whether it was underused nationally, whether their patients were interested in AS, and treatment recommendations for low-risk prostate cancer. Pearson's χ test and multivariate logistic regression were used to test for differences in physician perceptions on AS and treatment recommendations., Results: Overall, 717 (52.5%) of physicians completed the survey with minimal differences between specialties (P=0.92). Although most physicians reported that AS is effective (71.9%) and underused in the United States (80.0%), 71.0% stated that their patients were not interested in AS. For low-risk prostate cancer, more physicians recommended radical prostatectomy (44.9%) or brachytherapy (35.4%); fewer endorsed AS (22.1%). On multivariable analysis, urologists were more likely to recommend surgery [odds ratio (OR): 4.19; P<0.001] and AS (OR: 2.55; P<0.001), but less likely to recommend brachytherapy (OR: 0.13; P<0.001) and external beam radiation therapy (OR: 0.11; P<0.001) compared with radiation oncologists., Conclusions and Relevance: Most prostate cancer specialists in the United States believe AS effective and underused for low-risk prostate cancer, yet continue to recommend the primary treatments their specialties deliver.

Population health data are used to profile local conditions, call attention to areas of need, and evaluate health-related programs. Demand for data to inform health care decision making has spurred development of data sources and online systems, but these are often poorly integrated or limited in scope. Our objective was to identify existing data about diabetes mellitus-related conditions in Minnesota, build an online data resource, and identify what data are currently missing that, if available, would better inform assessment of health conditions in the state. A Web site was developed and populated with existing data and data not available elsewhere. It features functionality identified as most important by users, such as maps and county profiles. The site could serve as a flexible tool for stakeholder engagement, but issues were identified during development, including concerns about interpreting map data and open questions about sustainability, that need to be addressed.

Objectives: Computed tomography (CT) use has increased dramatically over the past 2 decades, leading to increased radiation exposure at the population level. We assessed trends in CT use in a primary care (PC) population from 2000 to 2010., Methods: Trends in CT use from 2000 to 2010 were assessed in an integrated, multi-specialty group practice. Administrative data were used to identify patients associated with a specific primary care provider and all CT imaging procedures. Utilization rates per 1000 patients and CT rates by type and medical specialty were calculated., Results: Of 179,032 PC patients, 55,683 (31%) underwent CT. Mean age (SD) was 31.0 (23.6) years; 53% were female patients. In 2000, 178.5 CT scans per 1000 PC patients were performed, increasing to 195.9 in 2010 (10% absolute increase, P = 0.01). Although utilization rates across the 10-year period remained stable, emergency department (ED) CT examinations rose from 41.1 per 1000 in 2000 to 74.4 per 1000 in 2010 (81% absolute increase, P < 0.01). CT abdomen accounted for more than 50% of all CTs performed, followed by CT other (19%; included scans of the spine, extremities, neck and sinuses), CT chest (16%), and CT head (14%). Top diagnostic CT categories among those undergoing CT were abdominal pain, lower respiratory disease, and headache., Conclusions: Although utilization rates across the 10-year period remained stable, CT use in the ED substantially increased. CT abdomen and CT chest were the two most common studies performed and are potential targets for interventions to improve the appropriateness of CT use.

Background: Poor fidelity to practice guidelines in the care of people with multiple chronic conditions (MCC) may result from patients and clinicians struggling to apply recommendations that do not consider the interplay of MCC, socio-personal context, and patient preferences., Objective: The objective of the study was to assess the quality of guideline development and the extent to which guidelines take into account 3 important factors: the impact of MCC, patients' socio-personal contexts, and patients' personal values and preferences., Research Design: We conducted a systematic search of clinical practice guidelines for patients with type 2 diabetes mellitus published between 2006 and 2012. Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Scopus, EBSCO CINAHL, and the National Guideline Clearinghouse were searched. Two reviewers working independently selected studies, extracted data, and evaluated the quality of the guidelines., Results: We found 28 eligible guidelines, which, on average, had major methodological limitations (AGREE II mean score 3.8 of 7, SD=1.6). Patients or methodologists were not included in the guideline development process in 20 (71%) and 24 (86%) guidelines, respectively. There was a complete absence of incorporating the impact of MCC, socio-personal context, and patient preferences in 8 (29%), 11 (39%), and 16 (57%) of the 28 guidelines, respectively. When mentioned, MCC were considered biologically, but not as contributors of complexity or patient work or as motivation to focus on patient-centered outcomes., Conclusions: Extant clinical practice guidelines for one chronic disease sometimes consider the context of the patient with that disease, but only do so narrowly. Guideline panels must remove their contextual blinders if they want to practically guide the care of patients with MCC.

Background: Despite little available evidence to determine whether recently introduced selective α-1 blockers and 5-α reductase inhibitors (5-ARIs) are superior to the existing agents in treating benign prostatic hyperplasia (BPH), they are being increasingly prescribed., Objective: To describe the prescribing patterns of new and existing agents among patients with incident BPH after the introduction of several new agents and determine whether these varied by physician specialty., Research Design: We analyzed a retrospective cohort from an administrative claims database from January 2004 through December 2010., Subjects: Patients diagnosed with incident BPH aged 40 years and above and those who received medical management., Measures: Receipt of medical therapy for incident BPH (ie, selective α-1 blockers [prazosin (released 1976), terazosin (1987), doxazosin (1990), tamsulosin (1997), alfuzosin (2003), silodosin (2009)] and 5-ARIs [finasteride (1992) and dutasteride (2002)])., Results: A total of 42,769 men with incident BPH received any selective α-1 blocker or 5-ARI. Tamsulosin and dutasteride were the most widely prescribed agents of their respective drug classes. Predicted probabilities showed that urologists were more likely to prescribe alfuzosin (24.0% vs. 7.8%; P<0.001) and silodosin (2.3% vs. 0.4%; P<0.001) when compared with primary care providers (PCPs) at 6 months after diagnosis. Urologists were more likely to prescribe 5-ARIs but less likely to prescribe older α-1 blockers (terazosin, prazosin, and doxazosin) than PCPs at 6 months postdiagnosis., Conclusions: Among insured patients diagnosed with BPH, our study suggests that the overall use of new agents is rising. In particular, urologists were more likely to prescribe newer selective α-1 blockers compared with PCPs.

Background: Escalating rates of prescription opioid use and abuse have occurred in the context of efforts to improve the treatment of nonmalignant pain., Objective: The aim of the study was to characterize the diagnosis and management of nonmalignant pain in ambulatory, office-based settings in the United States between 2000 and 2010., Design, Setting, and Participants: Serial cross-sectional and multivariate regression analyses of the National Ambulatory Medical Care Survey (NAMCS), a nationally representative audit of office-based physician visits, were conducted., Measures: (1) Annual visit volume among adults with primary pain symptom or diagnosis; (2) receipt of any pain treatment; and (3) receipt of prescription opioid or nonopioid pharmacologic therapy in visits for new musculoskeletal pain., Results: Primary symptoms or diagnoses of pain consistently represented one-fifth of visits, varying little from 2000 to 2010. Among all pain visits, opioid prescribing nearly doubled from 11.3% to 19.6%, whereas nonopioid analgesic prescribing remained unchanged (26%-29% of visits). One-half of new musculoskeletal pain visits resulted in pharmacologic treatment, although the prescribing of nonopioid pharmacotherapies decreased from 38% of visits (2000) to 29% of visits (2010). After adjusting for potentially confounding covariates, few patient, physician, or practice characteristics were associated with a prescription opioid rather than a nonopioid analgesic for new musculoskeletal pain, and increases in opioid prescribing generally occurred nonselectively over time., Conclusions: Increased opioid prescribing has not been accompanied by similar increases in nonopioid analgesics or the proportion of ambulatory pain patients receiving pharmacologic treatment. Clinical alternatives to prescription opioids may be underutilized as a means of treating ambulatory nonmalignant pain.

Background: The increasing prevalence of heart failure (HF) and high associated costs have spurred investigation of factors leading to adverse outcomes in patients with HF. Studies to date report inconsistent evidence on the link between depression and outcomes with only limited data on emergency department and outpatient visits., Methods and Results: Olmsted, Dodge, and Fillmore county, Minnesota residents with HF were prospectively recruited between October 2007 and December 2010 and completed a 1-time 9-item Patient Health Questionnaire for depression categorized as: none to minimal (Patient Health Questionnaire score, 0-4), mild (5-9), or moderate to severe (≥10). Andersen-Gill models were used to determine whether depression predicted hospitalizations and emergency department visits, whereas negative binomial regression models explored the association of depression with outpatient visits. Cox proportional hazards regression characterized the relationship between depression and all-cause mortality. Among 402 patients with HF (mean age, 73±13 years; 58% men), 15% had moderate to severe depression, 26% mild, and 59% none to minimal depression. During a mean follow-up of 1.6 years, 781 hospitalizations, 1000 emergency department visits, 15 515 outpatient visits, and 74 deaths occurred. After adjustment, moderate to severe depression was associated with nearly a 2-fold increased risk of hospitalization (hazard ratio, 1.79; 95% confidence interval, 1.30-2.47) and emergency department visits (hazard ratio, 1.83; 95% confidence interval, 1.34-2.50), a modest increase in outpatient visits (rate ratio, 1.20; 95% confidence interval, 1.00-1.45), and a 4-fold increase in all-cause mortality (hazard ratio, 4.06; 95% confidence interval, 2.35-7.01)., Conclusions: In this prospective cohort study, depression independently predicted an increase in the use of healthcare resources and mortality. Greater recognition and management of depression in HF may optimize clinical outcomes and resource utilization.

Background: The impact of collaborative care (CC) on depression and work productivity in routine, nonresearch primary care settings remains unclear due to limited evidence., Methods: This prospective study examined depression and work outcomes (eg, absenteeism, presenteeism) for 165 individuals in CC for depression versus 211 patients in practice as usual in a multisite primary care practice., Results: CC predicted greater adjusted 6-month improvements in treatment response, remission, and absenteeism versus practice as usual. Response/remission increased productivity overall., Conclusions: CC increased clinical and work improvements in a nonresearch care setting. Insurers and employers should consider CC's work benefits in developing payment structures.

Objective: To provide the simultaneous 7-year estimates of incremental costs of smoking and obesity among employees and dependents in a large health care system., Methods: We used a retrospective cohort aged 18 years or older with continuous enrollment during the study period. Longitudinal multivariate cost analyses were performed using generalized estimating equations with demographic adjustments., Results: The annual incremental mean costs of smoking by age group ranged from $1274 to $1401. The incremental costs of morbid obesity II by age group ranged from $5467 to $5530. These incremental costs drop substantially when comorbidities are included., Conclusions: Obesity and smoking have large long-term impacts on health care costs of working-age adults. Controlling comorbidities impacted incremental costs of obesity but may lead to underestimation of the true incremental costs because obesity is a risk factor for developing chronic conditions.

Background: Although direct medical costs for constipation-related medical visits are thought to be high, to date there have been no studies examining whether longitudinal resource use is persistently elevated in children with constipation. Our aim was to estimate the incremental direct medical costs and types of health care use associated with constipation from childhood to early adulthood., Methods: A nested case-control study was conducted to evaluate the incremental costs associated with constipation. The original sample consisted of 5718 children in a population-based birth cohort who were born during 1976 to 1982 in Rochester, MN. The cases included individuals who presented to medical facilities with constipation. The controls were matched and randomly selected among all noncases in the sample. Direct medical costs for cases and controls were collected from the time subjects were between 5 and 18 years of age or until the subject emigrated from the community., Results: We identified 250 cases with a diagnosis of constipation in the birth cohort. Although the mean inpatient costs for cases were $9994 (95% Confidence interval [CI] 2538-37,201) compared with $2391 (95% CI 923-7452) for controls (P = 0.22) during the time period, the mean outpatient costs for cases were $13,927 (95% CI 11,325-16,525) compared with $3448 (95% CI 3771-4621) for controls (P < 0.001) during the same time period. The mean annual number of emergency department visits for cases was 0.66 (95% CI 0.62-0.70) compared with 0.34 (95% CI 0.32-0.35) for controls (P < 0.0001)., Conclusions: Individuals with constipation have higher medical care use. Outpatient costs and emergency department use were significantly greater for individuals with constipation from childhood to early adulthood.

Objective: To compare the direct medical costs of clinically diagnosed patients with fibromyalgia with the medical costs of matched controls during a 4-yr period and to assess the impact of a fibromyalgia treatment program on healthcare utilization and associated medical costs., Design: A retrospective comparison of economic outcomes in 87 patients who participated in a fibromyalgia treatment program between 2001 and 2004 and who were local residents for the entire 4-yr period spanning their participation in the program, with age and sex-matched controls. Costs for the 2 yrs before and 2 yrs after program participation were also compared., Results: Four-year medical costs for controls were $7774 compared with $15,759 for those with fibromyalgia. There was no significant change in direct costs after participation in a brief fibromyalgia treatment program. Those with increased symptom severity averaged $2034 higher direct medical costs during the 4-yr period., Conclusions: Patients with clinically diagnosed fibromyalgia incur direct medical costs about twice that of their matched controls. This increased cost is related to the severity of their symptoms as measured by the Fibromyalgia Impact Questionnaire and was not impacted by participation in a brief cognitive behaviorally based fibromyalgia treatment program.

Background: Heart failure (HF) care constitutes an increasing economic burden on the health care system, and has become a key focus in the health care debate. However, there are limited data on the lifetime health care costs for individuals with HF after initial diagnosis., Methods and Results: Olmsted County residents with incident HF from 1987 to 2006 were identified. Direct medical costs incurred from the time of HF diagnosis until death or last follow-up were obtained using population-based administrative data through 2007. Costs were inflated to 2008 US dollars using the general Consumer Price Index. Inpatient, outpatient, and total costs were estimated using a 2-part model with adjustment for right censoring of data. Predictors of total costs were examined using a similar model. A total of 1054 incident HF patients were identified (mean age, 76.8 years; 46.1% men). After a mean follow-up of 4.6 years, 765 (72.6%) patients had died. The estimated total lifetime costs were $109 541 (95% confidence interval, $100 335 to 118 946) per person, with the majority accumulated during hospitalizations (mean, $83 980 per person). After adjustment for age, year of diagnosis, and comorbidity, diabetes mellitus and preserved ejection fraction (≥50%) were associated with 24.8% (P=0.003) and 23.6% (P=0.041) higher lifetime costs, respectively. Higher costs were observed at initial HF diagnosis and in the months immediately before death in those surviving >12 months after diagnosis., Conclusions: HF imposes a significant economic burden, primarily related to hospitalizations. Variations in cost over a lifetime can help identify strategies for efficient management of patients, particularly at the end of life.

Background: In recent years, there has been significant interest and investment in conducting comparative effectiveness research (CER) of medical treatments to improve the quality of care and reduce costs. The Agency for Healthcare Research and Quality (AHRQ) has been leading this effort and has invested a significant amount of resources to advance CER. However, little is known about translating the findings from CER into routine practice such that it provides value to the patients, clinicians, and the healthcare system., Methods: We present the role of shared decision making for patient-centered CER translation and its application to diabetes medications. CER of oral diabetes medications suggests that all medications are similar in their effects on glycemic control, but there is variability in side-effects, which may affect medication adherence and treatment intensification. Shared decision making, facilitated by tools such as decision aids, may enhance the quality of diabetes care by activating patients, enhancing the patient-clinician communication, and improving uptake and adherence to the medication that is determined to be consistent with patients' goals, values, and preferences. We describe the iterative, multidisciplinary process for developing and testing a diabetes medication decision aid, and examine the implications for CER translation., Results: In our pilot study we found the decision aid to be acceptable to patients and providers and effective for knowledge translation; however, it did not impact short-term outcomes., Discussion: Our pilot trial found that decision aids enhanced the discussion about diabetes medications without any adverse effects on the outcomes. Further issues related to the use of decision aids to translate CER need to be addressed in larger trials to understand the effectiveness and efficiency of translating evidence into routine practice in unique contexts of patients, providers, and healthcare systems.