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Background: Colorectal cancer (CRC) prevention is a Veterans Affairs (VA) priority. Colonoscopy quality, especially adenoma detection rate (ADR), is critical for effective screening. Our research indicates considerable variation in ADR among VA providers. Even a slight increase in ADR can reduce fatal CRC rates, and audit and feedback strategies have improved ADR in other settings. A recent report identified deficiencies in VA colonoscopy quality, highlighting the need for standardized documentation and reporting. To address this, we developed the VA Endoscopy Quality Improvement Program (VA-EQuIP), which aims to improve colonoscopy quality through benchmarking and collaborative learning, aligning with VA's modernization priorities and HSR&D and QUERI goals of accelerating evidence-based implementation., Methods: We will conduct a stepped wedge cluster randomized trial to evaluate whether VA-EQuIP improves provider ADR compared to usual care, the implementation of VA-EQuIP, site-level factors associated with colonoscopy quality improvement, and components of provider behavior change. Using mixed methods our study will measure outcomes like reach, implementation, adoption, maintenance of VA-EQuIP, and provider behavior change. The analysis will include primary and secondary outcomes, such as overall and screening ADR, cecal intubation rate, and bowel preparation quality, using mixed effects generalized linear models and interrupted time-series analyses. Adoption and implementation will be evaluated through usage statistics, surveys, and qualitative interviews to identify factors influencing success., Discussion: This study will assess the impact of VA-EQuIP on colonoscopy quality metrics and factors associated with effective implementation. VA-EQuIP infrastructure allows for national-scale implementation and evaluation of quality reporting with minimal manual labor, guiding future quality improvement efforts to ensure optimal patient care., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The author is an Editorial Board Member/Editor-in-Chief/Associate Editor/Guest Editor for [CONCLI] and was not involved in the editorial review or the decision to publish this article., (Copyright © 2024. Published by Elsevier Inc.) more...

Prostate-specific membrane antigen (PSMA) PET was approved by the U.S. Food and Drug Administration in 2020 for the staging of newly diagnosed prostate cancer, yet rates of adoption and real-world positivity rates are unknown. We characterized patients undergoing PSMA PET staging and describe positive findings in a large national cohort. Methods: We identified all newly diagnosed prostate cancer patients in the national Veterans Health Administration from June 2020 to August 2023. Demographics, staging imaging reports, and cancer-related information were obtained from electronic medical record data. To assess positive findings, we chart-reviewed 1,994 patients ( n = 657 low to intermediate risk) with staging PSMA PET reports available. Results: Among 31,838 patients with newly diagnosed prostate cancer, 4,538 (14%) underwent PSMA staging. Use of PSMA staging increased rapidly from near 0 in early 2021 to approximately 70% of patients with high- or very-high-risk disease by August 2023. Among patients who were N0/M0 by conventional imaging, PSMA PET positivity rates (N1 or M1) were 5.9% for favorable intermediate risk, 8.2% for unfavorable intermediate risk, 14% for high risk, and 34% for very high risk. Conclusion: PSMA PET staging for newly diagnosed prostate cancer increased rapidly in the Veterans Health Administration. Positivity rates were less than 10% in this large intermediate-risk cohort. These data confirm the utility of PSMA PET staging in high-risk disease and suggest that additional study is needed to refine patient selection in intermediate-risk disease., (© 2025 by the Society of Nuclear Medicine and Molecular Imaging.) more...

Rationale and Objectives: In 2019, Centers for Medicare and Medicaid Services enforced regulation from the Affordable Care Act, requiring all U.S. hospitals to publish standard hospital charges annually. This study assesses top U.S academic hospitals' chargemasters for selected advanced diagnostic imaging services and the usability of publicly available information to allow consumers to determine out-of-pocket costs., Materials and Methods: Publicly available chargemasters and associated websites for the top 20 ranked hospitals in U.S. News and World Report were assessed for several features including: file format, inclusion of CPT codes, disclaimers on charges versus costs and professional fees, and tools allowing determination of actual out-of-pocket costs for selected advanced diagnostic imaging examinations., Results: All hospitals had publicly available chargemasters, 90% of which were in Microsoft Excel format. Ten percent of chargemasters included CPT codes. All chargemaster websites had disclaimers regarding differences between charges versus patient costs; 20% had disclaimers regarding professional fees. 20% of hospitals provided out-of-pocket costs for uninsured patients or tools allowing out-of-pocket cost determination. Median (range) MR exam charges were: brain with and without contrast: $5375 ($834-$13,857), noncontrast knee: $3402 (4530-$6924); noncontrast lumbar spine: $ 3449 ($473-$7367). Median (range) CT exam charges were: noncontrast head: $1923 ($165-$4974), noncontrast chest: $1947 ($282-$2991); contrast abdomen/pelvis: $4307 ($486-$11,726)., Conclusion: While all top-ranked hospitals had publicly available chargemasters, they rarely provided transparent information to allow patients to determine out-of-pocket costs for advanced diagnostic imaging services., (Copyright © 2019 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.) more...

Objectives: Hospital care accounts for up to one-third of the cost of inflammatory bowel disease (IBD) management. A select group of patients with IBD is responsible for a large proportion of this utilization, demonstrating the burden of frequent hospitalizations. We aim to better understand the burden of 30-day readmissions among patients with IBD using a national hospital database., Study Design: Retrospective cohort study of state-specific inpatient databases., Methods: The State Inpatient Databases for New York and Florida were used to identify patients with IBD hospitalized between 2009 and 2013. The prevalence of 30-day IBD-specific readmission was determined. The association between 30-day readmission and visit outcomes, specifically length of stay and a composite of comorbid conditions (venous thromboembolism, pneumonia, sepsis, Clostridium difficile infection, enteral and parenteral nutrition, and blood transfusion), was analyzed using multivariable logistic regression., Results: Patients with IBD accounted for 35,514 and 39,506 inpatient stays in New York and Florida, respectively. Of these stays, 13.7% to 16.2% resulted in a 30-day readmission. On multivariable analysis, 30-day readmissions were associated with a longer length of stay than index hospitalizations by 1.00 day (adjusted regression coefficient, 1.00; 95% CI, 0.73-1.26) and a higher likelihood of having a comorbid condition (adjusted odds ratio, 1.83; 95% CI, 1.68-1.99) in New York. Similar associations were confirmed in Florida., Conclusions: Nearly 1 in 7 hospitalizations of patients with IBD lead to a 30-day readmission. These IBD-specific readmissions are associated with increased utilization and comorbidity. Patients at risk for readmission need to be targeted to improve outcomes and IBD care quality. more...

Objectives: Inflammatory bowel disease (IBD) is a complex chronic disease that often requires a multispeciality approach; thus, IBD patients are prone to care fragmentation. We aim to determine the prevalence of fragmentation among hospitalized IBD patients and identify associated predictors and visit-level outcomes., Methods: The State Inpatient Databases for New York and Florida were used to identify 90-day readmissions among IBD inpatients from 2009 to 2013. The prevalence of fragmentation, defined as a readmission to a non-index hospital, was reported. Characteristics associated with fragmented care were identified using multivariable logistic regression. Multivariable models were utilized to determine the association between fragmentation and outcomes (in-hospital mortality, readmission length of stay, and inpatient colonoscopy)., Results: Among IBD inpatients, 25,241 and 29,033 90-day readmission visits were identified, in New York and Florida, respectively. The prevalence of fragmentation was 26.4% in New York and 32.5% in Florida. Younger age, a non-emergent admission type, public payer or uninsured status, mood disorder, and substance abuse were associated with fragmented care, while female gender and a primary diagnosis of an IBD-related complication had an inverse association. Fragmented inpatient care is associated with a higher likelihood of in-hospital death, higher rates of inpatient colonoscopy, and a longer readmission length of stay., Conclusions: Over one in four IBD inpatient readmissions are fragmented. Disparities and differences in fragmentation exist and contribute to poor patient outcomes. Additional efforts targeting fragmentation should be made to better coordinate IBD management, reduce healthcare gaps, and promote high-value care. more...

Background and Aims: Opioid use disorder [OUD] has become a public health crisis among patients with chronic disease. Inflammatory bowel disease [IBD] patients are at high risk for OUD because they suffer from chronic relapsing-remitting pain. We aimed to describe the prevalence and trends in OUD-related diagnoses among hospitalised IBD patients., Methods: A retrospective study was performed using weighted Nationwide Inpatient Sample data from 2005 to 2014. Adult IBD hospital visits and OUD-related diagnoses were identified using a previously published schema. Annual diagnoses were calculated. Characteristics associated with OUD were assessed using multivariable logistic regression. Associations between OUD and length of stay were assessed overall and separately for surgical and non-surgical stays., Results: In all, 2.2% of 2585174 weighted discharges with any diagnosis of IBD also had an OUD-related diagnosis, with an 8.8% average annual increase. In multivariable analysis, Crohn's disease, public payer or no insurance, and psychiatric comorbidities were associated with a higher likelihood of OUD, whereas a primary diagnosis of an IBD-related complication was associated with a lower likelihood. An OUD-related diagnosis was associated with 0.84 days (95% confidence interval [CI] 0.71, 0.97] increased length of stay overall, 2.79 days [95% CI 1.44, 4.14] for surgical stays, and 0.71 days [95% CI 0.59, 0.82] for non-surgical stays., Conclusions: OUD-related diagnoses are increasing among IBD patients and are associated with increased length of stay. With a rising prevalence, it is important to screen and diagnose OUD in IBD and refer patients for evidence-based treatment to address unmet patient needs and reduce health care utilisation., (Copyright © 2018 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.) more...

Background and Aims: Primary care providers (PCPs) play a critical role in colon cancer screening by initiating referrals to gastroenterologists for colonoscopy, but little is known about their role in pre-colonoscopy bowel preparation selection and pre-colonoscopy follow-up care. This study aimed to better understand coordination of care between PCPs and gastroenterologists as well as the current availability of "open-access" screening colonoscopy., Methods: A multiple-choice survey was developed to assess PCPs' experiences with open-access colonoscopy, their involvement in the pre-colonoscopy process, and follow-up after colonoscopy. The survey was distributed electronically to a nationally representative sample of PCPs, via the American College of Physicians (ACP) Research Center's Internal Medicine Insider Research Panel., Results: Of 442 PCPs invited to participate, 210 responded (response rate, 210/442, 48%), and 29 were ineligible (spent <25% of their time on clinical care or placed no referrals to colonoscopy), yielding 181 completed surveys. A total of 39% reported that open access was "rarely" or "never" available in their practice setting. The majority reported that pre-colonoscopy care was coordinated by gastroenterologists rather than PCPs. For example, 93% reported that gastroenterologists were responsible for bowel preparation selection in their practice setting. Post-colonoscopy, 54% of PCPs reported that they were responsible for ordering subsequent colonoscopies., Conclusions: PCPs frequently coordinate follow-up care postprocedure but play a relatively minor role in the pre-colonoscopy bowel preparation process. Open access availability for screening colonoscopy remains limited in this national sample of PCPs. more...

Background and Aims: Corticosteroids are effective for the short-term treatment of inflammatory bowel disease (IBD). Long-term use, however, is associated with significant adverse effects. To define the: (1) frequency and duration of corticosteroid use, (2) frequency of escalation to corticosteroid-sparing therapy, (3) rate of complications related to corticosteroid use, (4) rate of appropriate bone density measurements (dual energy X-ray absorptiometry [DEXA] scans), and (5) factors associated with escalation and DEXA scans., Methods: Retrospective review of Veterans Health Administration (VHA) data from 2002-2010., Results: Of the 30,456 Veterans with IBD, 32% required at least one course of corticosteroids during the study time period, and 17% of the steroid users had a prolonged course. Among these patients, only 26.2% underwent escalation of therapy. Patients visiting a gastroenterology (GI) physician were significantly more likely to receive corticosteroid-sparing medications. Factors associated with corticosteroid-sparing medications included younger age (OR = 0.96 per year,95%CI:0.95, 0.97), male gender (OR = 2.00,95%CI:1.16,3.46), GI visit during the corticosteroid evaluation period (OR = 8.01,95%CI:5.85,10.95) and the use of continuous corticosteroids vs. intermittent corticosteroids (OR = 2.28,95%CI:1.33,3.90). Rates of complications per 1000 person-years after IBD diagnosis were higher among corticosteroid users (venous thromboembolism [VTE] 9.0%; fragility fracture 2.6%; Infections 54.3) than non-corticosteroid users (VTE 4.9%; fragility fracture 1.9%; Infections 26.9). DEXA scan utilization rates among corticosteroid users were only 7.8%., Conclusions: Prolonged corticosteroid therapy for the treatment of IBD is common and is associated with significant harm to patients. Patients with prolonged use of corticosteroids for IBD should be referred to gastroenterology early and universal efforts to improve the delivery of high quality care should be undertaken. more...

Introduction: Given the sharp rise in opioid prescribing and heightened recognition of opioid addiction and overdose, opioid safety has become a priority. Clinical guidelines on long-term opioid therapy (LTOT) for chronic pain consistently recommend routine monitoring and screening for problematic behaviours. Yet, there is no consensus definition regarding what constitutes a problematic behaviour, and recommendations for appropriate management to inform front-line providers, researchers and policymakers are lacking. This creates a barrier to effective guideline implementation. Thus, our objective is to present the protocol for a Delphi study designed to: (1) elicit expert opinion to identify the most important problematic behaviours seen in clinical practice and (2) develop consensus on how these behaviours should be managed in the context of routine clinical care., Methods/analysis: We will include clinical experts, defined as individuals who provide direct patient care to adults with chronic pain who are on LTOT in an ambulatory setting, and for whom opioid prescribing for chronic non-malignant pain is an area of expertise. The Delphi study will be conducted online in 4 consecutive rounds. Participants will be asked to list problematic behaviours and identify which behaviours are most common and challenging. They will then describe how they would manage the most frequently occurring common and challenging behaviours, rating the importance of each management strategy. Qualitative analysis will be used to categorise behaviours and management strategies, and consensus will be based on a definition established a priori., Ethics/dissemination: This study has been approved by the Institutional Review Board (IRB) of the University of Alabama at Birmingham (UAB). This study will generate Delphi-based expert consensus on the management of problematic behaviours that arise in individuals on LTOT, which we will publish and disseminate to appropriate professional societies. Ultimately, our findings will provide guidance to front-line providers, researchers and policymakers., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/) more...

Purpose: The radiology job market remains daunting. Trainees choosing fellowships benefit from understanding employers' likely future needs. Radiology practices may similarly refine recruiting practices. This study quantitatively analyzes the current radiology job landscape., Methods: Job postings on the ACR Career Center online portal between June 2014 and June 2015 were reviewed. As entries are frequently added and removed, posts were manually collected weekly. Postings were recorded in a database and included date, practice, location, specialty/subspecialty, job type, years of experience, salary, and job description. The database was analyzed to characterize employer needs, salary, partnership track availability, and job availability by geography., Results: A total of 1,778 jobs were posted during the study period. Of these, 1,529 (86.0%) were diagnostic; 240 (13.5%) were interventional; and 9 (0.5%) were administrative. Most jobs were in private practice (75.7%), compared with academic (16.3%) and other (7.9%). Although many did not require a specific specialty (46%), the most-frequent needs were breast (17%), neuroradiology (11%), musculoskeletal (8%), and body (7%). Of non-breast-imaging jobs, roughly 30% indicated an interest in breast-imaging skills. A minority (13%) requested prior experience of greater than 1 year, with some seeking 7-10 years of experience. Although most (87%) were full-time positions, part-time, temporary, and contractor roles were described in the remaining 13%. Salary data were rarely reported (7%), with a range of $98,967-$1,000,000. The most jobs were based in California (11%); New York (7%); Pennsylvania (7%); and Illinois (6%). However, when indexed per million population, the highest job rates were in Nevada (14.1); Washington DC (13.7); Hawaii (13.4); Montana (9.8); and Pennsylvania (9.1). Roughly 31% of postings described partnership tracks, with the highest rates in New England (58%), the Pacific Northwest (56%), the Midwest (40%), and Southern (40%) regions; the lowest were in the Mountain (26%), Mid-Atlantic (25%), and Southwest (21%) regions., Conclusions: Most radiology jobs remain in private practice general radiology. Breast, neuroradiology, and musculoskeletal radiology were most frequently desired among areas of subspecialty training. Advertised partnership tracks were less common and varied widely geographically., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.) more...

Objectives: The Accreditation Council for Graduate Medical Education (ACGME) emphasizes the importance of medical trainees meeting specific performance benchmarks and demonstrating readiness for unsupervised practice. The aim of this study was to examine the readiness of Gastroenterology (GI) fellowship programs for competency-based evaluation in endoscopic procedural training., Methods: ACGME-accredited GI program directors (PDs) and GI trainees nationwide completed an online survey of domains relevant to endoscopy training and competency assessment. Participants were queried about current methods and perceived quality of endoscopy training and assessment of competence. Participants were also queried about factors deemed important in endoscopy competence assessment. Five-point Likert items were analyzed as continuous variables by an independent t-test and χ(2)-test was used for comparison of proportions., Results: Survey response rate was 64% (94/148) for PDs and 47% (546/1,167) for trainees. Twenty-three percent of surveyed PDs reported that they do not have a formal endoscopy curriculum. PDs placed less importance (1—very important to 5—very unimportant) on endoscopy volume (1.57 vs. 1.18, P<0.001), adenoma detection rate (2.00 vs. 1.53, P<0.001), and withdrawal times (1.96 vs. 1.68, P=0.009) in determining endoscopy competence compared with trainees. A majority of PDs report that competence is assessed by procedure volume (85%) and teaching attending evaluations (96%). Only a minority of programs use skills assessment tools (30%) or specific quality metrics (28%). Specific competencies are mostly assessed by individual teaching attending feedback as opposed to official documentation or feedback from a PD. PDs rate the overall quality of their endoscopy training and assessment of competence as better than overall ratings by trainees., Conclusions: Although the majority of PDs and trainees nationwide believe that measuring specific metrics is important in determining endoscopy competence, most programs still rely on procedure volume and subjective attending evaluations to determine overall competence. As medical training transitions from an apprenticeship model to competency-based education, there is a need for improved endoscopy curricula which are better suited to demonstrate readiness for unsupervised practice. more...

Background: Proof-of-concept studies with omalizumab in patients with chronic idiopathic urticaria (CIU) have shown significant decreases in mean urticaria activity scores (UASs)., Objective: We sought to evaluate the efficacy and safety of omalizumab in patients with CIU who remain symptomatic despite concomitant H(1)-antihistamine therapy., Methods: This phase II, prospective, double-blind, placebo-controlled, dose-ranging study investigated omalizumab in patients aged 12 to 75 years in the United States and 18 to 75 years in Germany with a UAS over 7 days (UAS7) of 12 or greater despite antihistamine therapy. Patients were randomized 1:1:1:1 to receive a single subcutaneous dose of 75, 300, or 600 mg of omalizumab or placebo added to a stable dose of H(1)-antihistamine. The primary efficacy outcome was change from baseline to week 4 in UAS7. Patients were followed for an additional 12 weeks to monitor safety., Results: Ninety patients from the United States or Germany were enrolled. Both the 300-mg omalizumab group (-19.9 vs -6.9, P < .001) and the 600-mg omalizumab group (-14.6 vs -6.9, P = .047) showed greater improvement versus the placebo group in UAS7. No meaningful difference was observed for the 75-mg omalizumab group. Similar results were seen for key secondary end points of weekly hive and itch scores. Onset of effect occurred after 1 to 2 weeks. Omalizumab was well tolerated, and the incidence of adverse events was similar across treatment groups., Conclusion: This study demonstrated that a fixed dose of 300 or 600 mg of omalizumab provides rapid and effective treatment of CIU in patients who are symptomatic despite treatment with H(1)-antihistamines., (Copyright © 2011 American Academy of Allergy, Asthma & Immunology. Published by Mosby, Inc. All rights reserved.) more...

Professional associations advocate for their members' interests; provide forums for education, training, and certification; and support domain-specific research and development efforts. The purpose of this study was to determine the amount of resources devoted to the leadership committees of professional radiology associations in the United States. Internet research was conducted to identify general, subspecialty, and special interest radiology associations, followed by a survey that focused on the number of committees and the average number of members per committee for each association. Established or published benchmarks were used to calculate committee-related annual expenditures from the survey data. Two hundred forty full-time equivalents, or nearly $100 million, are devoted to leadership activities within radiology associations each year. This is equivalent to approximately 1% of the professional income in radiology. These resources have enabled individual radiologists and societies to cooperate on important initiatives. More research should be conducted on other specialties or industries to provide comparable data on the optimal investment in the leadership effort., (Copyright (c) 2010 American College of Radiology. Published by Elsevier Inc. All rights reserved.) more...

Unlabelled: Despite dramatic improvements in antiviral therapy for hepatitis C, there is reason to believe that the uptake of antiviral therapy remains limited. The aims of this study were to determine the number of patients being treated with antiviral therapy in the U.S., to estimate the public health impact of these treatment patterns, and to identify barriers to treatment for patients with hepatitis C. Data on the number of new patient pegylated interferon prescriptions each year, from 2002-2007, was obtained from Wolters Kluwer Inc., which maintains an electronic audit of pharmacies nationwide. A Markov model was created of the population with chronic hepatitis C in the U.S. from 2002 to 2030, and was used to estimate the number of liver-related deaths caused by hepatitis C that will be prevented by current treatment patterns. The National Health and Nutrition Evaluation Survey (NHANES) Hepatitis C Follow-Up Questionnaire was used to investigate reasons for lack of treatment and to identify strategies for improving access. Approximately 663,000 patients received antiviral therapy between 2002 and 2007, and treatment rates appear to be declining. If this trend continues, only 14.5% of liver-related deaths caused by hepatitis C from 2002-2030 will be prevented by antiviral therapy. Results from the NHANES questionnaire suggest that the primary barrier to treatment is lack of diagnosis, with 69/133 (adjusted proportion 49%) of respondents previously unaware that they had hepatitis C., Conclusion: Efforts to improve rates of diagnosis and treatment will be required if the future public health burden of hepatitis C is to be ameliorated. more...

Purpose: To determine the individual technical costs of general diagnostic radiographic, ultrasonographic (US), computed tomographic (CT), magnetic resonance (MR) imaging, and scintigraphic examinations and interventional radiology., Materials and Methods: The Radiology Cost and Productivity Benchmarking Study method of the University HealthSystem Consortium, a cooperative group of academic medical centers, was modified and extended to the six imaging modalities in a tertiary care academic setting. Hospital billing and cost records were analyzed for fiscal year 1996. Costs were divided into labor and nonlabor categories and were allocated to individual imaging modalities on the basis of resources consumed. Physician cost and hospital overhead were not included. Unit costs were analyzed per technical relative value unit (RVU) and per examination., Results: The costs per technical RVU for diagnostic radiography, US, CT, MR imaging, scintigraphy, and interventional radiology were $65. 06, $28.74, $20.95, $17.69, $42.19, and $89.03, respectively. The technical costs per examination for diagnostic radiography, US, CT, MR imaging, scintigraphy, and interventional radiology were $41.92, $50.28, $112.32, $266.96, $196.88, and $692.60, respectively., Conclusion: The method of unit cost analysis for individual imaging modalities was successfully tested in a tertiary care setting. The method should be adopted to allow cost comparison across many institutions, which will permit the promotion of best practices. more...

American adolescent psychiatric patients had significantly higher levels of suicidal behavior (49% vs. 19%) and a higher percentage of depression diagnoses (78% vs. 24%) than Israeli psychiatric inpatients. After controlling for the diagnosis of depression, American male patients obtained significantly higher scores on the Obsessive-Compulsive, Aggression, and Hyperactive subscales of the Child Behavior Checklist (CBCL) than the Israeli males. American females scored higher on the Depression subscale than Israeli females. Differences may be attributed to less tolerance or differing perceptions of deviant behavior in America, clinical practice, and/or the CBCL's greater applicability to American inpatient samples. more...