Caught Between a ROCR and a Hard Place: Improving Proposed Radiation Oncology Alternative Payment Models.

PURPOSE: The Radiation Oncology Case Rate (ROCR) aims to shift radiation reimbursement from fee-for-service (FFS) to bundled payments, which would decouple fractionation from reimbursement in the United States. This study compares historical reimbursement rates from three large centers and a national Medicare sample with proposed base rates from ROCR. It also tests the impact of methodological inclusion of treatment and disease characteristics to determine if any variables are associated with greater rate differences that may lead to inequitable reimbursement. METHODS: Using XXXX electronic medical record data from 2017-2020 and Part B claims from the Medicare 5% research identifiable files (RIF), episodic 90-day historical reimbursement rates for 15 cancer types were calculated per the ROCR payment methodology. XXXX reimbursement rates were stratified by disease and treatment characteristics and multiple linear regression was performed to assess the association of these variables on historical episode reimbursement rates. RESULTS: From XXXX, 3,498 patient episodes were included and 480,526 from the RIF. From both datasets, 25% of brain metastases and 13% of bone metastases episodes included ≥2 treatment courses with an average of 51 days between courses. Accounting for all 15 cancer types, ROCR base rates resulted in an average -2.4% and -2.9% reduction in rates for XXXX and the RIF respectively compared to historical reimbursement. On multivariate analysis of XXXX data, treatment intent (curative vs. palliative) was associated with higher historical reimbursement (+$477 to +$7,417; p ≤ 0.05) for 12 out of 12 applicable cancer types. Stage (3-4 vs. 1-2) was associated with higher historical reimbursement (+$1,169 to +$3,917; p ≤ 0.05) for 8 out of 12 applicable cancer types. CONCLUSION: Our data suggest ROCR base rates introduce an average ≤3% reimbursement rate decrease compared to historical FFS reimbursement per cancer type, which could produce the Medicare savings required for congressional approval of ROCR. Estimating comparisons with future FFS reimbursement would require consideration of additional factors such as the increased utilization of hypofractionation, proposed FFS rate cuts, and inflationary updates. A distinct rate and shortened episode duration (≤ 30 days) should be considered for palliative episodes. Applying a base rate modifier per cancer stage may mitigate disproportionate reductions in reimbursement for facilities with a higher volume of curative advanced stage patients such as freestanding centers in rural settings.

The traditional Chinese version of the Geriatric Anxiety Inventory: Psychometric properties and cutoff point for detecting anxiety.

The study aimed to translate the Geriatric Anxiety Inventory into traditional Chinese (GAI-TC), examine its psychometric properties, and identify the optimal cutoff point. This research recruited 337 older adults from two community activity centers. Structured questionnaires were used, including demographic information and characteristics, the GAI-TC, and the State-Trait Anxiety Inventory (STAI). Cronbach's α of the GAI-TC was 0.93. The intraclass correlation coefficient was 0.90. The content validity index was 1.0. An exploratory factor analysis revealed that three factors in the GAI-TC, including cognition anxiety, impact of anxiety, and somatic anxiety, explained 59.46 % of the variance. The criterion-related validity showed a significant positive correlation between the GAI-TC and STAI, with an optimal cutoff of 9/10 for detecting anxiety in older persons living in the community. The GAI-TC had good reliability and validity and can provide professionals with a tool for the early identification of anxiety among older adults.

Furosemide and Ductus Arteriosus Closure in Very-Low-Birth-Weight Preterm Infants: A Comprehensive Retrospective Study.

Ductus arteriosus closure may be delayed in preterm infants, and prostaglandin, a vasodilator, can affect ductal patency. Furosemide can increase renal prostaglandin synthesis, so its net effect on patent ductus arteriosus (PDA) is uncertain. Our goal is to explore the relationship between furosemide and spontaneous ductal closure in very-low-birth-weight preterm infants. Our treatment for PDA involves fluid restriction initially and furosemide administration for hemodynamically significant PDA until closure is confirmed by the echocardiogram. We enrolled 105 infants from 1 January 2019 to 30 June 2022 and evaluated the impact of furosemide on ductal closure, including exposure duration and cumulative dose. There is no correlation between furosemide exposure and spontaneous ductal closure (p = 0.384). Furosemide exposure does not delay the postmenstrual age at which spontaneous ductal closure occurs (p = 0.558). The time for spontaneous ductal closure is positively associated with furosemide prescription days (coefficient value = 0.547, p = 0.026) and negatively with gestational age (coefficient value = -0.384, p = 0.062). The prescription of furosemide does not impact the probability or time duration of ductus arteriosus spontaneous closure. The cumulative dose of furosemide has minimal impact on ductal closure. The correlation between furosemide exposure duration and ductal patency duration is likely due to our treatment protocol, with gestational age being a significant factor.

Radiologists' 2021 Quality Reporting and Performance in Medicare's Merit-Based Incentive Payment System: Analysis by Practice Type.

This study of national CMS data shows differences in quality reporting and performance of Merit-Based Incentive Payment System (MIPS)-participating radiologists by practice specialty mix. For certain practice types, radiologist-reported quality measures were commonly not radiology measures. The results support a need to expand radiology measures and to better align measure reporting with clinician specialty.

Pregnancy-related breast cancer: 14-year experience in a tertiary institution in Hong Kong.

BACKGROUND: The incidence of pregnancy-associated breast cancer (PABC) is increasing. Its tumor characteristics and overall survival compared with those in nonpregnant patients remain controversial. While there have been suggestions that PABC patients have a 40 % increase in the risk of death compared to non-pregnant patients, other studies suggested similar disease outcomes. This study aims to review our local experience with PABC. METHODS: Twenty-eight patients diagnosed with PABC and twenty-eight patients diagnosed at premenopausal age randomly selected by a computer-generated system during the same period were recruited. Background characteristics, tumor features, and survival were compared. RESULTS: Among the twenty-eight pregnant patients, seventeen were diagnosed during pregnancy, and eleven were diagnosed in the postpartum period. Compared to the non-pregnant breast cancer patients, they presented with less progesterone receptor-positive tumor (35.7 % vs. 64.2 %, p = 0.03). Although there was no statistically significant difference in tumor size (p = 0.44) and nodal status (p = 0.16), the tumor tended to be larger in size (2.94 +/- 1.82 vs 2.40 +/- 1.69 cm) and with more nodal involvement (35.7 % vs 25.0 %). There was also a trend of delayed presentation to medical attention, with a mean duration of 13.1 weeks in the PABC group and 8.6 weeks in the control group. However, the overall survival did not differ (p = 0.63). CONCLUSION: PABC is increasing in incidence. They tend to have more aggressive features, but overall survival remains similar. A multidisciplinary approach is beneficial for providing the most appropriate care.

Effects of different conditions on the artificial incubation effect and physiological indexes of redclaw crayfish eggs.

We explored the effects of different conditions on the artificial incubation of redclaw crayfish eggs in an effort to improve this process. Samples at the egg and juvenile stages were selected. The samples at different stages were separated from the pleopods, then they were placed in incubator boxes and sterilized with different disinfectant solutions. The density was 300,400 and 500 eggs/incubator box, the vibration frequency was 11,16 and 26 vibrations/min, and the water circulation cycle was 2.1, 4.8 and 7.1 cycles/h. The results showed the eggs disinfected with 3000 ppm formaldehyde for 15 min had stronger antioxidant capacity. The hatching and survival rates of five pairs of appendage stage group were significantly lower than those of other groups. In the egg stage, acid phosphatase (ACP) level of compound eye pigmentation stage group was significantly higher than those of other groups. In the juvenile stage, malondialdehyde (MDA) content of five pairs of appendage stage group was significantly higher than those of other groups. The survival rate of 500 eggs/box group was significantly higher than that of other groups. In the egg stage, alkaline phosphatase (AKP) level of 400 eggs/box group was significantly higher than that of other groups. The survival rate of 11 vibrations/min group was significantly higher than that of other groups. In the egg stage, ACP and AKP levels of 11 vibrations/min group were significantly higher than those of 26 vibrations/min group. In the juvenile stage, superoxide dismutase (SOD), ACP and AKP levels of 11 vibrations/min group was significantly higher than those of 26 vibrations/min group. In the juvenile stage, AKP level of 4.8 cycles/h group was significantly lower than that of other groups. In conclusion, egg development at the stage after seven pairs of appendages, with a density of 400 eggs/box, vibration frequencies set at 11 vibrations/min achieved high hatching rates (93.58 %) and survival rates (75.67 %). Moreover, bronopol or hydrogen peroxide might have a better choice to replace formaldehyde if further exploration was conducted to reduce stimulation of the in vitro-grown egg. These conditions could be used on a large scale to optimize the production of redclaw crayfish.

Intercorrelation of Molecular Biomarkers and Clinical Phenotype Measures in Fragile X Syndrome.

This study contributes to a greater understanding of the utility of molecular biomarkers to identify clinical phenotypes of fragile X syndrome (FXS). Correlations of baseline clinical trial data (molecular measures-FMR1 mRNA, CYFIP1 mRNA, MMP9 and FMRP protein expression levels, nonverbal IQ, body mass index and weight, language level, NIH Toolbox, adaptive behavior rating, autism, and other mental health correlates) of 59 participants with FXS ages of 6-32 years are reported. FMR1 mRNA expression levels correlated positively with adaptive functioning levels, expressive language, and specific NIH Toolbox measures. The findings of a positive correlation of MMP-9 levels with obesity, CYFIP1 mRNA with mood and autistic symptoms, and FMR1 mRNA expression level with better cognitive, language, and adaptive functions indicate potential biomarkers for specific FXS phenotypes. These may be potential markers for future clinical trials for targeted treatments of FXS.

Heart health for South Asians: improved cardiovascular risk factors with a culturally tailored health education program.

BACKGROUND/AIM: The Kaiser Permanente (KP) Northern California Heart Health for South Asians (HHSA) Program is a two-hour educational class that provides culturally relevant lifestyle and dietary recommendations to South Asian (SA) patients, in an effort to reduce their known disproportionate burden of cardiovascular (CV) disease. We evaluated the impact of the HHSA Program on CV risk factors and major adverse CV events (MACE). METHODS: A retrospective cohort study identified 1517 participants of SA descent, ≥ 18 years old from 2006 to 2019. We evaluated the change in risk factors with program attendance (median follow up of 6.9 years) for systolic blood pressure (SBP), diastolic blood pressure (DBP), triglycerides (TG), LDL, HDL, BMI, and HbA1c. We also performed a propensity matched analysis to evaluate differences in MACE including stroke, myocardial infarction (MI), coronary revascularization, and all-cause mortality. RESULTS: There were significant improvements in DBP, TG, LDL-c, HDL-c, BMI, and HbA1c at one year follow up and sustained improvements in DBP (-1.01mmHg, p = 0.01), TG (-13.74 mg/dL, p = 0.0001), LDL-c (-8.43 mg/dL, p = < 0.0001), and HDL-c (3.16 mg/dL, p = < 0.0001) levels at the end of follow up. In the propensity matched analysis, there was a significant reduction in revascularization (OR 0.33, 95% CI 0.14-0.78, p = 0.011) and mortality (OR 0.41, 95% CI 0.22-0.79, p = 0.008), and a trend towards reduction in stroke. CONCLUSIONS: Our study demonstrates the efficacy of a culturally tailored SA health education program in improving CV risk factors and reducing MACE. The program highlights the importance and value of providing culturally tailored health education in primary CV disease prevention.

Awareness of and subjective needs for post-discharge healthcare services among older adult patients.

BACKGROUND: Increasing patient awareness of post-discharge care resources is an effective strategy to reduce rehospitalization rates and medical costs. Therefore, the purpose of this study was to explore hospitalized older adult patients' awareness of and subjective demands for post-discharge healthcare services. METHODS: A cross-sectional study design was conducted from November 2018 to May 2020. STROBE statement was completed. Participants were inpatients over 65 years of age in the general ward of a medical center in northern Taiwan. A questionnaire was used to collect data by face-to-face interviews. Two hundred and twelve participants were recruited. Home nursing care, home rehabilitation, home respiratory therapy, home services, assistive devices rental, and transportation were the main post-discharge healthcare services in this study. RESULTS: Overall, 83.5% of older adult patients were aware of and 55.7% of the older adult patients demanded at least one post-discharge healthcare services. Logistic regression results found that, patients experiencing moderate to severe disability and cognitive impairment, and those hospitalized in the past year had significantly higher demands for services. CONCLUSIONS: Developing post-discharge healthcare services for older adult patients provides continuous patient-centered services for assisting patients and their families in adapting to the transition period of the post-acute stage. Satisfying these demands is beneficial for older adult patients and their families, as well as for reducing readmissions and medical costs.

Effect of esophageal cancer screening on mortality among patients with oral cancer and second primary esophageal cancer in Taiwan.

OBJECTIVE: Oral and esophageal cancer are the fourth and fifth leading causes of cancer deaths among men in Taiwan. Despite a good prognosis for oral cavity cancer patients, survival is worse for those who develop second primary esophageal cancer. There remains no consensus regarding early prevention of potential second primary esophageal cancer in patients with oral cavity cancer. Our study aimed to compare 5-year mortality between endoscopically screened and non-screened patients with oral cavity cancer and second primary esophageal cancer. MATERIALS AND METHODS: This study identified patients with incident oral cavity cancer and second primary esophageal cancer during 2004 and 2013 using the Taiwan Cancer Registry and National Health Insurance Research Database. We compared 5-year mortality from the second primary esophageal cancer diagnosis date between screened and non-screened groups of patients with oral cavity cancer and second primary esophageal cancer. RESULTS: A total of 217 screened and 305 non-screened oral cavity cancer patients with second primary esophageal cancer were studied. Endoscopic screening significantly improved early detection of second primary esophageal cancer (adjusted odds ratio: 0.34, 95 % confidence interval [CI]: 0.23-0.49) and reduced all-cause mortality (adjusted hazard ratio: 0.80; 95 % CI: 0.66-0.98). CONCLUSIONS: Oral cavity cancer patients with second primary esophageal cancer may have worse overall survival than those without. Early detection of second primary esophageal cancer is a crucial mediator between endoscopic screening and mortality. Endoscopic screening after the diagnosis of incident oral cavity cancer significantly increased early detection and reduced all-cause mortality.

Improvement of the Identification of Seniors at Risk scale for predicting adverse health outcomes of elderly patients in the emergency department.

OBJECTIVES: To explore the validity of the Chinese version of the Identification of Seniors at Risk (ISAR) screening tool in emergency rooms (ERs) to identify elderly patients prone to adverse outcomes after being discharged from the ER. METHODS: A prospective single-center observational study design was adopted and included 497 elderly (aged ≥65 years) ER patients of a medical center in northern Taiwan. Before discharge from the ER, baseline sociodemographic and clinic data were collected by researchers and the ISAR was administered. Adverse health outcomes (ER revisits, readmissions, and mortality) at 30 days were evaluated by medical records and follow-up telephone interviews. RESULTS: ISAR screening showed that 334 (67.2%) elderly patients in the ER were at high risk after discharge. Higher-risk patients were older, had had a fall within the previous 6 months, and had complex comorbidities. The ISAR had good sensitivity (0.77∼1.00) for screening adverse health outcomes in these elderly patients. The discrimination of the ISAR for adverse health outcomes was 0.60∼0.77, and it increased to 0.64∼0.80 when the age-adjusted Charlson comorbidity index (ACCI) was simultaneously considered. CONCLUSIONS: The ISAR exhibited good sensitivity for screening adverse outcomes for elderly patients at risk. The ACCI is recommended to simultaneously be considered to improve the prognostic performance of the ISAR.

Predictors, Mediators and Moderators of Police Work-Related Stress: A Scoping Review.

Owing to the complication in organisation, the dangerous job nature and the rise of demonstrations and protests across the world in the past decade, police work-related stress has become a topic of global concern. This review aimed to provide an understanding of predictors, mediators and moderators of police work-related stress from a multi-level perspective. Using a scoping review approach underpinned by the six-stage methodological framework, studies were found from six electronic databases (MEDLINE, Web of Science, Sociological Abstracts, Scopus, PsycINFO and PsychiatryOnline) and grey literature sources. Thirty studies were yielded across 35,446 participants from 12 locations. This review contributes to a systematic understanding of the factors affecting police work-related stress by identifying six predictors, four mediators and three moderators. It then discusses limitations and future research.

Harm Avoidance is Correlated with the Reward System in Adult Patients with Attention Deficit Hyperactivity Disorder: A Functional Magnetic Resonance Imaging Study.

Objective: Hypoactivity in the reward system among patients with attention deficit hyperactivity disorder (ADHD) is a well-known phenomenon. Whether the activity in the reward pathway is related to harm avoidance, such as in sensitivity to punishment, is unclear. Evidence regarding the potential difference between ADHD patients and controls in terms of this association is scarce. Methods: Event-related functional magnetic resonance imaging was conducted on subjects performing the Iowa gambling test. Fourteen adults with ADHD and 14 controls were enrolled in the study. Results: Harm avoidance was found to be positively correlated with the activities of the bilateral orbitofrontal cortex and right insula in individuals with ADHD. A group difference was also confirmed. Conclusion: Understanding the roles of harm avoidance and brain activation during risk tasks is important.

An LW-Opsin Mutation Changes the Gene Expression of the Phototransduction Pathway: A Cryptochrome1 Mutation Enhances the Phototaxis of Male Plutella xylostella (Lepidoptera: Plutellidae).

Plutella xylostella is a typical phototactic pest. LW-opsin contributes to the phototaxis of P. xylostella, but the expression changes of other genes in the phototransduction pathway caused by the mutation of LW-opsin remain unknown. In the study, the head transcriptomes of male G88 and LW-opsin mutants were compared. A GO-function annotation showed that DEGs mainly belonged to the categories of molecular functions, biological processes, and cell composition. Additionally, a KEGG-pathway analysis suggested that DEGs were significantly enriched in some classical pathways, such as the phototransduction-fly and vitamin digestion and absorption pathways. The mRNA expressions of genes in the phototransduction-fly pathway, such as Gq, ninaC, and rdgC were significantly up-regulated, and trp, trpl, inaD, cry1, ninaA and arr1 were significantly down-regulated. The expression trends of nine DEGs in the phototransduction pathway confirmed by a RT-qPCR were consistent with transcriptomic data. In addition, the influence of a cry1 mutation on the phototaxis of P. xylostella was examined, and the results showed that the male cry1 mutant exhibited higher phototactic rates to UV and blue lights than the male G88. Our results indicated that the LW-opsin mutation changed the expression of genes in the phototransduction pathway, and the mutation of cry1 enhanced the phototaxis of a P. xylostella male, providing a basis for further investigation on the phototransduction pathway in P. xylostella.

Complex Inferior Vena Cava Filter Retrievals: Success Rate and Predictors of Adverse Events at a Large Specialized Referral Center.

BACKGROUND. Specialized inferior vena cava (IVC) filter referral centers can achieve improved retrieval outcomes, potentially facilitating complex retrievals after long filter dwell times. OBJECTIVE. The purpose of this study was to determine the success rate of complex IVC filter retrievals at a large specialized IVC filter referral center and to identify predictors of adverse events during complex retrievals. METHODS. This retrospective study included patients who underwent complex IVC filter retrieval from March 2014 to June 2018 at a large regional health system with specialized complex retrieval referral centers and interventional radiologists with expertise in such procedures. Complex retrievals methods included a range of loop snare, coaxial sheath, forceps, and snare techniques. Data were collected from the electronic medical record. The success rate of complex retrieval was determined. Factors associated with adverse events during retrieval procedures were explored. RESULTS. The study included 125 patients (51 women, 74 men; mean age, 60 years). The mean filter dwell time at retrieval was 47.5 months (median, 21.8 months). The complex retrieval success rate was 99.2% on the first attempt and 100.0% overall. A total of 11.2% (14/125) of patients experienced an adverse event during retrieval, including 10.4% (13/125) with minor and 0.8% (1/125) with major events. Prolonged dwell time was the only indication for complex retrieval that was significantly associated with adverse events (adverse event rate, 16.7% for patients with this indication vs 5.1% for patients without this indication; p = .04). In multiple regression analysis, the only significant independent predictor of adverse events was a filter dwell time of 5 years or longer (odds ratio, 6.98 [95% CI, 1.64-29.81]; p = .009). CONCLUSION. In a specialized referral system with expertise in complex retrieval methods, high retrieval success rates can be achieved in patients who have filters with long dwell times. Nonetheless, longer dwell times are associated with adverse events during retrieval procedures. CLINICAL IMPACT. The observations support performing early filter retrieval and referring patients who have filters with prolonged dwell times to specialized centers.

Tricholosterols A-D, four new ergosterol derivatives from the mushroom Tricholoma terreum.

Four ergosterol derivatives, named tricholosterols A-D (1-4), have been isolated from the fruiting bodies of Tricholoma terreum. Their chemical structures have been determined using a combination of spectroscopic analysis as well as computational methods. Compound 1 possesses a rare D-ring opening ergosterol skeleton, while compounds 2-4 are rare degraded ergosterols. Compounds 1 and 4 exhibited moderate inhibitory activity against NO production with IC50 values of 27.6 and 31.8 µM, respectively. This is the first report of steroids from T. terreum.

Prevalence of depressive symptoms and associated factors among foreign caregivers: A cross-sectional study.

AIM: To understand the prevalence of depressive symptoms among foreign caregivers and the associated factors. DESIGN: A cross-sectional study. METHODS: Data from 178 Indonesian foreign caregivers, selected based on convenience and snowball sampling in Taiwan, were collected between July 2019 and February 2020 using questionnaires. Stepwise multiple linear regression was used to identify the factors associated with depressive symptoms. RESULTS: Approximately 30.3% of the foreign caregivers displayed depressive symptoms. The symptoms were more prevalent among the participants who were younger; had more social support; shared a bed with others; and experienced higher work-related stress, more loneliness and physical discomfort. The findings suggest that nurses or nurse practitioners visiting patients at home should not only deliver care for them but also show concern for the psychological well-being of the foreign caregivers of these patients. Moreover, interventions should be developed to alleviate or prevent the emergence of depressive symptoms among foreign caregivers.

Definition and conceptualization of collaboration in drug rehabilitation: Systematic synthesis and comparison using a scoping review approach

Objective@#Although interagency collaboration in drug treatment and rehabilitation has been substantially studied, a lack of consensus on the nomenclature and definition of collaboration remains an unresolved issue in public health policy and practice. To facilitate further consensus, this review analyses previously used definition, conceptualization, and theorization on interagency collaboration in the field of drug rehabilitation.@*Methods@#We conducted evidence synthesis using a scoping review approach. This review is based on searches using the MEDLINE, CINAHL Complete, Embase, and PsychINFO databases and used the protocol proposed by Arksey and O’Malley.@*Results@#A total of 6,259 papers were retrieved from database and citation searches, 33 of which were eligible for inclusion in the analysis after screening and evaluation. Although the definitions varied, the common elements included (a) the presence of at least two entities, which were either services, programs or organizations; (b) these entities collaborated or shared resources; (c) partnership went through a development process; and (d) the intent of collaboration was to achieve a common purpose. There were five means of conceptualizing collaboration: (a) degrees, or level of intensity and formality; (b) elements, or the constitutive structure and activities; (c) stages, or the development of partnership over time; (d) levels, or the focus of the collaborative; and (e) type, or a distinction between collaboration on in policy and practice.@*Conclusion@#Scholarship in this field can benefit from studies that conceptualize collaboration not only crosssectionally through the description of degrees, elements, levels, and type, but also by considering the stages dimension of collaboration (i.e., evolution of collaboration initiative over time). Countries or jurisdictions may need to formalize a term and definition for collaboration as it applies to initiatives within their territories.

Association of State Share of Nonphysician Practitioners With Diagnostic Imaging Ordering Among Emergency Department Visits for Medicare Beneficiaries.

Importance: The use of nonphysician practitioners (NPPs) in the emergency department (ED) continues to expand, yet little is known about associations between NPPs and ED imaging use. Objective: To investigate whether the state share of ED visits for which an NPP was the clinician of record is associated with imaging studies ordered, given that state NPP share is associated with state-level NPP scopes of practice. Design, Setting, and Participants: This cross-sectional study compared diagnostic imaging ordering patterns associated with ED visits based on 2005-2020 Medicare claims for a nationally representative 5% sample of fee-for-service beneficiaries. For all 50 states and the District of Columbia, the state NPP share of ED visits by year was used to represent state-specific practice patterns for NPPs and physicians and how those patterns have evolved over time. The analysis controlled for patient demographic characteristics, Charlson Comorbidity Index scores, ED visit severity, year, and principal diagnosis. Exposures: The share of ED visits in each state in each year (state share) for which an NPP was the evaluation and management clinician. Main Outcomes and Measures: The main outcomes were the number and modality of imaging studies associated with ED visits. Analyses were by logistic regression and generalized linear model with γ-distribution and log-link function. Results: Among 16 922 274 ED visits, 60.0% involved women, and patients' mean (SD) age was 70.3 (16.1) years. The share of all ED visits with an NPP as the clinician increased from 6.1% in 2005 to 16.6% in 2020. Compared with no NPPs, the presence of NPPs in the ED was associated with 5.3% (95% CI, 5.1%-5.5%) more imaging studies per ED visit, including a 3.4% (95% CI, 3.2%-3.5%) greater likelihood of any imaging order per ED visit and 2.2% (95% CI, 2.0%-2.3%) more imaging studies ordered per visit involving imaging. Conclusions and Relevance: In this study, use of NPPs in the ED was associated with higher imaging use compared with the use of only physicians in the ED. Although expanded use of NPPs in the ED may improve patient access, the costs and radiation exposure associated with more imaging warrants additional study.

Comparative effectiveness and stage-shift effect of endoscopic exam among newly diagnosed oral cancer patients with different stages in Taiwan.

BACKGROUND: Patients with oral cancer are at higher risk of developing second primary esophageal cancer (SPEC) and the consensus for screening strategies remains unclear. This study aimed to examine comparative effectiveness and the stage-shift effect of endoscopic exam among patients with oral cancer. METHOD: A population-based longitudinal retrospective observational matched case and control cohort study with at least 5 years follow-up was conducted. We identified 45 457 newly diagnosed patients with oral cancer, 2004-2013, and the eligible patient with oral cancer was 39 401. Propensity score matching was used to match comparable groups, and the two groups (screening vs. nonscreening) was 5941, individually. The study primary endpoints were to compare detection of incident SPEC and the stage-shift effect of endoscopic screening between screened and nonscreened incident oral cancer patients. Cox proportional hazard and competing risk models were analyzed. Statistical analyses were conducted in 2020-2021. RESULT: Detection of incident SPEC in the screened group was significantly higher than in the nonscreened group (hazard ratio: 2.92, 95% confidence interval [CI]: 2.29-3.72). The stage-shift effect from endoscopic screening was found overall in patients with oral cancer (odds ratio [OR]: 0.39, 95%CI: 0.21-0.70), in particular in advanced-stage patients (OR: 0.25, 95%CI: 0.11-0.61), but not in early-stage patients (OR: 0.60, 95%CI: 0.26-1.40). CONCLUSION: This study confirmed that endoscopic screening achieved early detection of SPEC among patients with oral cancer. To improve the screening stage-shift effect, patients with oral cancer are encouraged to undergo routine endoscopic screening.