Vaginal practices among women at risk for HIV acquisition in Soweto, South Africa.

BACKGROUND: Vaginal practices (VP) may adversely affect normal vaginal flora and mucosal integrity, and increase acquisition risk of HIV and other genital tract infections. OBJECTIVE: The aim of this study was to describe self-reported VP, changes in the reported number of VP over time and factors associated with VP in a cohort of young Sowetan women enrolled in the HVTN 915 observational study. METHOD: We longitudinally assessed self-reported VP in 50 young women at risk of HIV acquisition aged 18-25 years in a prospective study over 3 months in Soweto, South Africa. Interviewer-administered HIV behavioural risk questionnaires were completed. No intervention to reduce VP was specified per protocol, but clinicians provided education at their discretion. The generalised estimating equation with inverse probability weights assessed VP over time. RESULTS: The mean age at screening was 22 years; women reported multiple sexual partnerships with a mean of one main and 2 casual partners in the last 30 days. Consistent condom use was 2% (n = 1), 25% (n = 12) and 43% (n = 3) with main, casual and new partners, respectively. Commonly reported VP included washing the vagina with water (44%) and using fingers (48%). VP decreased significantly over time (p < 0.001). Women who used condoms inconsistently or whose last sex was with a casual partner were 3 times more likely to report VP (p = 0.001). CONCLUSION: Despite the high incidence of HIV in our setting, VP are still common and are associated with other behavioural risks for HIV. Further study is needed to assess whether clinician education may reduce VP and therefore should be included in HIV risk reduction counselling.

Mobile Phone Questionnaires for Sexual Risk Data Collection Among Young Women in Soweto, South Africa.

Recall and social desirability bias undermine self-report of paper-and-pencil questionnaires. Mobile phone questionnaires may overcome these challenges. We assessed and compared sexual risk behavior reporting via in-clinic paper-and-pencil and mobile phone questionnaires. HVTN 915 was a prospective cohort study of 50 adult women in Soweto, who completed daily mobile phone, and eight interviewer-administered in-clinic questionnaires over 12 weeks to assess sexual risk. Daily mobile phone response rates were 82% (n = 3486/4500); 45% (n = 1565/3486) reported vaginal sex (median sex acts 2 (IQR: 1-3)) within 24 h and 40% (n = 618/1565) consistent condom. Vaginal sex reporting was significantly higher via mobile phone across all visits (p < 0.0001). There was no significant difference in condom use reporting by mobile phone and in-clinic paper-based questionnaires across all visits (p = 0.5134). The results show high adherence and reporting of sex on the mobile phone questionnaire. We demonstrate feasibility in collecting mobile phone sexual risk data.

Long term survival with stereotactic ablative radiotherapy (SABR) versus thoracoscopic sublobar lung resection in elderly people: national population based study with propensity matched comparative analysis.

OBJECTIVES:  To compare cancer specific survival after thoracoscopic sublobar lung resection and stereotactic ablative radiotherapy (SABR) for tumors ≤2 cm in size and thoracoscopic resection (sublobar resection or lobectomy) and SABR for tumors ≤5 cm in size. DESIGN:  National population based retrospective cohort study with propensity matched comparative analysis. SETTING:  Surveillance, Epidemiology, and End Results (SEER) registry linked with Medicare database in the United States. PARTICIPANTS:  Patients aged ≥66 with lung cancer undergoing SABR or thoracoscopic lobectomy or sublobar resection from 1 Oct 2007 to 31 June 2012 and followed up to 31 December 2013. MAIN OUTCOME MEASURES:  Cancer specific survival after SABR or thoracoscopic surgery for lung cancer. RESULTS:  690 (275 (39.9%) SABR and 415 (60.1%) thoracoscopic sublobar lung resection) and 2967 (714 (24.1%) SABR and 2253 (75.9%) thoracoscopic resection) patients were included in primary and secondary analyses. The average age of the entire cohort was 76. Follow-up of the entire cohort ranged from 0 to 6.25 years, with an average of three years. In the primary analysis of patients with tumors sized ≤2 cm, 37 (13.5%) undergoing SABR and 44 (10.6%) undergoing thoracoscopic sublobar resection died from lung cancer, respectively. The cancer specific survival diverged after one year, but in the matched analysis (201 matched patients in each group) there was no significant difference between the groups (SABR v sublobar lung resection mortality: hazard ratio 1.32, 95% confidence interval 0.77 to 2.26; P=0.32). Estimated cancer specific survival at three years after SABR and thoracoscopic sublobar lung resection was 82.6% and 86.4%, respectively. The secondary analysis (643 matched patients in each group) showed that thoracoscopic resection was associated with improved cancer specific survival over SABR in patients with tumors sized ≤5 cm (SABR v resection mortality: hazard ratio 2.10, 1.52 to 2.89; P<0.001). Estimated cancer specific survival at three years was 80.0% and 90.3%, respectively. CONCLUSIONS:  This propensity matched analysis suggests that patients undergoing thoracoscopic surgical resection, particularly for larger tumors, might have improved cancer specific survival compared with patients undergoing SABR. Despite strategies used in study design and propensity matching analysis, there are inherent limitations to this observational analysis related to confounding, similar to most studies in healthcare of non-surgical technologies compared with surgery. As the adoption of SABR for the treatment of early stage operable lung cancer would be a paradigm shift in lung cancer care, it warrants further thorough evaluation before widespread adoption in practice.

Comparison of Open, Laparoscopic, and Robotic Colectomies Using a Large National Database: Outcomes and Trends Related to Surgery Center Volume.

BACKGROUND: Previous studies have shown that high-volume centers and laparoscopic techniques improve outcomes of colectomy. These evidence-based measures have been slow to be accepted, and current trends are unknown. In addition, the current rates and outcomes of robotic surgery are unknown. OBJECTIVE: The purpose of this study was to examine current national trends in the use of minimally invasive surgery and to evaluate hospital volume trends over time. DESIGN: This was a retrospective study. SETTINGS: This study was conducted in a tertiary referral hospital. PATIENTS: Using the National Inpatient Sample, we evaluated trends in patients undergoing elective open, laparoscopic, and robotic colectomies from 2009 to 2012. Patient and institutional characteristics were evaluated and outcomes compared between groups using multivariate hierarchical-logistic regression and nonparametric tests. The National Inpatient Sample includes patient and hospital demographics, admission and treating diagnoses, inpatient procedures, in-hospital mortality, length of hospital stay, hospital charges, and discharge status. MAIN OUTCOME MEASURES: In-hospital mortality and postoperative complications of surgery were measured. RESULTS: A total of 509,029 patients underwent elective colectomy from 2009 to 2012. Of those 266,263 (52.3%) were open, 235,080 (46.2%) laparoscopic, and 7686 (1.5%) robotic colectomies. The majority of minimal access surgery is still being performed at high-volume compared with low-volume centers (37.5% vs 28.0% and 44.0% vs 23.0%; p < 0.001). A total of 36% of colectomies were for cancer. The number of robotic colectomies has quadrupled from 702 in 2009 to 3390 (1.1%) in 2012. After adjustment, the rate of iatrogenic complications was higher for robotic surgery (OR = 1.73 (95% CI, 1.20-2.47)), and the median cost of robotic surgery was higher, at $15,649 (interquartile range, $11,840-$20,183) vs $12,071 (interquartile range, $9338-$16,203; p < 0.001 for laparoscopic). LIMITATIONS: This study may be limited by selection bias by surgeons regarding the choice of patient management. In addition, there are limitations in the measures of disease severity and, because the database relies on billing codes, there may be inaccuracies such as underreporting. CONCLUSIONS: Our results show that the majority of colectomies in the United States are still performed open, although rates of laparoscopy continue to increase. There is a trend toward increased volume of laparoscopic procedures at specialty centers. The role of robotics is still being defined, in light of higher cost, lack of clinical benefit, and increased iatrogenic complications, albeit comparable overall complications, as compared with laparoscopic colectomy.

Centralization of pancreatoduodenectomy a decade later: Impact of the volume-outcome relationship.

BACKGROUND: The hospital volume-outcome relationship for complex procedures has led to the suggestion that care should be centralized. This study was performed to investigate whether centralization is occurring for pancreatoduodenectomy (PD) and to examine its effect on short-term postoperative outcomes. METHODS: We queried the New York State Statewide Planning and Research Cooperative System database (n = 6,185, 2002-2011) and the California and Florida State Inpatient Databases (n = 6,766 and 4,810, respectively, 2002-2011) for PD. Hospitals were divided into low (≤10), medium (11-25), high (25-60), and very high (≥61) groups depending on annual volume. Hierarchical logistic modeling accounted for patient clustering within hospitals. RESULTS: A migration of cases from low-volume to medium, high, and very high-volume (MHVH) hospitals occurred in these 3 states (P < .01). There was an increase in the number of MHVH hospitals and a decrease in the number of low-volume hospitals performing PD across all states over time, with a large number of hospitals ceasing to perform PD cases entirely. Comorbidities such as congestive heart failure and diabetes were more prevalent in low-volume hospitals. After we adjusted for all predictors, MHVH hospitals had less rates of mortality and morbidity and shorter durations of stay than low-volume hospitals (P < .05); 30-day readmission rates were similar across all volume groups. CONCLUSION: Centralization of PD is occurring in these 3 states and probably across the nation. After PD, MHVH hospitals had statistically better outcomes (mortality, morbidity, and duration of stay) than low-volume hospitals. Readmission rates were not affected by volume.

Association of Breast Conservation Surgery for Cancer With 90-Day Reoperation Rates in New York State.

IMPORTANCE: For early-stage breast cancer, breast conservation surgery (BCS) is a conservative option for women and involves removing the tumor with a margin of surrounding breast tissue. If margins are not tumor free, patients undergo additional surgery to avoid local recurrence. OBJECTIVES: To investigate the use of BCS in New York State and to determine rates of reoperation, procedure choice, and the effect of surgeon experience on the odds of a reoperation 90 days after BCS. DESIGN, SETTING, AND PARTICIPANTS: A population-based sample of 89 448 women undergoing primary BCS for cancer were selected and examined from January 1, 2003, to December 31, 2013, in New York State mandatory reporting databases. All hospitals and ambulatory surgery centers in New York State were included. Data were analyzed from December 15, 2014, to November 1, 2015. MAIN OUTCOMES AND MEASURES: Rate of reoperations within 90 days of the initial BCS procedure. RESULTS: During the study period, 89 448 women 20 years or older (mean [SD] age, 61.7 [13.7] years) underwent primary BCS. In 2013, 1416 women in New York aged 20 to 49 years underwent BCS compared with 3068 women aged 50 to 64 years and 3644 women 65 years or older. These numbers represent a significant decrease from 1960 women younger than 50 years in 2003 who underwent BCS (P < .001 for trend) but little change from the 2899 women aged 50 to 64 years and 3270 women 65 years or older who underwent BCS in 2003. Mean overall rate of 90-day reoperation was 30.9% (27 010 of 87 499 patients) and decreased over time from 39.5% (6630 of 16 805 patients) in 2003 to 2004 to 23.1% (5148 of 22 286 patients) in 2011 to 2013. Rates of reoperation were highest in women aged 20 to 49 years (37.7% [6990 of 18 524]) and lowest in women 65 years or older (26.3% [9656 of 36 691]) (P < .001 for trend). Over time, more patients underwent BCS as a subsequent procedure, from 4237 of 6630 patients (63.9%) in 2003 to 2004 to 4258 of 5148 (82.7%) in 2011 to 2013 (P < .001 for trend). Among the 19 466 women who underwent BCS as a second procedure, 2429 (12.5%) required a third intervention (2.7% of all women included). Significant surgeon-level variation was found in the data; 90-day rates of reoperations by surgeon ranged from 0% to 100%. Low-volume surgeons (<14 cases per year) had an unadjusted rate of 35.2% compared with 29.6% in middle-volume (14-33 cases per year) and 27.5% in high-volume (≥34 cases per year) surgeons. The difference persisted in adjusted analyses (odds ratio for low-volume surgeons, 1.49 [95% CI, 1.19-1.87]; for middle-volume surgeons, 1.20 [95% CI, 0.93-1.56]) compared with high-volume surgeons (used as the reference category). CONCLUSIONS AND RELEVANCE: Use of BCS has decreased overall, most steeply in younger women. Nearly 1 in 4 women underwent a reoperation within 90 days of BCS across New York State from 2011 to 2013, compared with 2 in 5 from 2003 to 2004. Rates vary significantly by surgeon, and initial BCS performed by high-volume surgeons was associated with a 33% lower risk for a reoperation.

National study of utilization of male incontinence procedures.

AIMS: We explored re-interventions and short and long term adverse events associated with procedures for male incontinence among Medicare beneficiaries. METHODS: All inpatient and outpatient claims for a simple random sample of Medicare beneficiaries for 2000-2011 were queried to identify patients of interest. All male patients with an International Classification of Diseases, 9th Edition (ICD-9) diagnosis code for stress incontinence or mixed incontinence were included. Artificial urinary sphincter recipients, patients who underwent a sling operation and those receiving an injection of a bulking agent were identified with Current Procedure Terminology (CPT-4) and ICD-9 Procedure Codes. RESULTS: The entire cohort of 1,246 patients were operated on between 2001 and 2011. 34.9% of them received an artificial urinary sphincter (AUS), 28.7% with a bulking agent, and 36.4% with a sling. There were no statistically significant differences in demographics or comorbidities between the treatment groups, except that more sling patients were obese (P = 0.006) and fewer bulk patients had diabetes (P = 0.007). There are, however, significant changes in procedures selected over time (P < 0.001). In the first year and over the entire follow-up after surgery, patients treated with bulking agents had the most subsequent interventions (40.1% and 52.9%), followed by sling (10.4% and 15.5%), and AUS (2.3% and 20%) (P < 0.001). Post-operative and 90 day complications were low. CONCLUSIONS: All three treatments seem to be safe among Medicare beneficiaries with multiple comorbidities. The urological, infectious, and neurological complication occurrences were low.

Clipping and Coiling of Unruptured Intracranial Aneurysms Among Medicare Beneficiaries, 2000 to 2010.

BACKGROUND AND PURPOSE: Endovascular coiling therapy is increasingly popular for obliteration of unruptured intracranial aneurysms, but older patients face higher procedural risks and shorter periods during which an untreated aneurysm may rupture causing subarachnoid hemorrhage (SAH). We assessed trends in clipping and coiling of unruptured intracranial aneurysms, outcomes after clipping and coiling of unruptured intracranial aneurysms, and in SAH among Medicare beneficiaries. METHODS: Using 2000 to 2010 Medicare Provider Analysis and Review data, we identified 2 cohorts of patients admitted electively for clipping or coiling of an unruptured aneurysm: (1) utilization cohort (2000-2010): patients ≥65 years enrolled ≥1 month in a given year and (2) outcomes cohort (2001-2010): patients ≥66 years of age enrolled in Medicare for ≥1 year. We calculated rates of clipping, coiling, and SAH per 100 000 Medicare beneficiaries. We tested for trends in the risk of in-hospital mortality and complications, discharge destination, 30-day mortality, 30-day readmissions, and length of hospitalization. RESULTS: Characteristics of patients undergoing clipping (n=4357) or coiling (n=7942) did not change appreciably. Overall, 30-day mortality, in-hospital complications, and 30-day readmissions decreased, generally reaching their lowest levels in 2008 to 2010 (1.6%, 25.0%, and 14.5% for clipping and 1.5%, 13.8%, and 11.0% for coiling, respectively). Procedural treatment rates per 100 000 beneficiaries increased from 1.4 in 2000 to 6.0 in 2010, driven mainly by increased use of coiling but SAH rates did not decrease. CONCLUSIONS: Although outcomes tended to improve over time, increased preventative treatment of unruptured intracranial aneurysms among Medicare beneficiaries did not result in a population-level decrease in SAH rates.

The Effect of Center Volume on In-Hospital Mortality After Aortic and Mitral Valve Surgical Procedures: A Population-Based Study.

BACKGROUND: We aimed to determine the relationship between hospital volume and use of dual aortic and mitral valve surgical procedures. METHODS: Patients who underwent both aortic and mitral valve repair or replacement during the same hospital stay were identified from the Nationwide Inpatient Sample (NIS). We compared patients' characteristics and in-hospital outcomes by the average annual center volume for multiple-heart valve surgical procedures, grouped into tertiles of patients with low (1 to 8), medium (9 to 18), and high (19+) volume categories using χ(2) tests and adjusted hierarchical logistic regression models. RESULTS: From 1998 to 2011 an estimated total of 87,675 patients underwent combined aortic and mitral valve surgical procedures across the United States. Although most patients' characteristics were similar across volume groups, high-volume centers were more likely to treat older patients with coronary artery disease and to perform concomitant tricuspid valve operations. Low-volume centers replaced the aortic and mitral valves concomitantly more frequently with mechanical valves compared with high-volume centers (66.1% vs 45.5%), and this difference persisted across age groups. Compared with low-volume centers, the risk-adjusted odds ratios for in-hospital mortality at medium- and high-volume centers were 0.85 (95% confidence interval [CI]: 0.74 to 0.99) and 0.66 (95% CI: 0.55 to 0.80), respectively. No significant interaction was found between overall facility major cardiac surgery volume and multiple-valve procedure volume with respect to mortality (p = 0.143). CONCLUSIONS: Hospital volume remains an important factor influencing risk-adjusted mortality after combined aortic and mitral valve surgical procedures. Hospitals that perform more than eight combined aortic and mitral heart valve operations demonstrate a superior statistical hospital survival compared with those that perform less than eight multiple-heart valve operations a year. Further policy interventions aimed to lower hospital mortality in low-volume centers may offer possibilities for quality improvement in the field of valve surgery.

National trends in utilization and in-hospital outcomes of mechanical versus bioprosthetic aortic valve replacements.

OBJECTIVE: Substantial controversy surrounds the choice between a mechanical versus bioprosthetic prosthesis for aortic valve replacement (AVR), based on age. This study aims to investigate national trends and in-hospital outcomes of the 2 prosthesis choices. METHODS: All patients aged >18 years in the National Inpatient Sample who received an AVR between 1998 and 2011 were considered. Valve-type use was examined by patient, procedural, and hospital characteristics, after which we matched patients based on their propensity score for receiving a bioprosthetic valve and compared their in-hospital outcomes. RESULTS: Bioprosthetic valves comprised 53.3% of 767,375 implanted valves, an increase in use from 37.7% in the period 1998 to 2001 to 63.6% in the period 2007 to 2011. The median age was 74 years for patients receiving bioprosthetic valves, and 67 years for those receiving mechanical valves. Use of bioprosthetic valves increased across all age groups, most markedly in patients age 55 to 64 years. Compared with patients receiving mechanical valves, these patients had a higher incidence of renal disease (8.0% vs 4.2%), coronary artery disease (58.5% vs 50.5%), concomitant coronary artery bypass grafting (46.7% vs 41.9%), and having surgery in a high-volume (>250 cases per year) center (31.3% vs 18.5%). Patients receiving bioprosthetic valves had a higher occurrence of in-hospital complications (55.9% vs 48.6%), but lower in-hospital mortality (4.4% vs 4.9%) than patients receiving mechanical valves. This difference was confirmed in propensity-matched analyses (complications: 52.7% vs 51.5%; mortality: 4.3% vs 5.2%). CONCLUSIONS: Use of bioprosthetic valves in AVR increased dramatically from 1998 to 2011, particularly in patients age 55 to 64 years. Prosthesis selection varied significantly by facility, with low-volume facilities favoring mechanical valves. Aortic valve replacement with a bioprosthetic valve, compared with a mechanical valve, was associated with lower in-hospital mortality.

A population-based analysis of robotic-assisted mitral valve repair.

BACKGROUND: Robotic-assisted mitral valve repair is becoming more frequently performed in cardiac surgery. However, little is known about its utilization and safety at a national level. METHODS: Patients undergoing mitral valve repair in the United States from 2008 to 2012 were identified in the National Inpatient Sample. Inhospital mortality, complications, length of stay, and cost for patients undergoing robotic-assisted mitral valve repair were compared with patients undergoing nonrobotic procedures. RESULTS: We identified 50,408 isolated mitral valve repair surgeries, of which 3,145 were done with robotic assistance. In a propensity score matched analysis of 631 pairs of patients, we found no difference between patients undergoing robotic-assisted and nonrobotic-assisted mitral valve repair with respect to inhospital mortality, complications, or composite outcomes in unadjusted or multivariable analyses. Robotic-assisted mitral valve repair surgery was associated with a shorter median length of stay (4 versus 6 days, p < 0.001), and there was no difference in median total costs between the two procedures. CONCLUSIONS: In our analysis of a large national database with its inherent limitations, robotic-assisted mitral valve repair was found to be safe, with an acceptable morbidity and mortality profile.

Safety of robotic prostatectomy over time: a national study of in-hospital injury.

OBJECTIVE: To assess national trends of iatrogenic complications and associated burden of care among patients undergoing open and minimally invasive prostatectomy using a population-based cohort. METHODS: Using the nationally representative cohort, we identified patients who were diagnosed with prostate cancer, and underwent prostatectomy during 2001 and 2011. We determined the risk of iatrogenic complication and length of stay (LOS) over time among open and minimally invasive surgery (MIS) patients. Hierarchical multivariable logistic regression was performed to assess the changes over time and elucidate independent predictors of iatrogenic complications. RESULTS: We identified 556,932 and 219,434 prostate cancer patients undergoing open and minimally invasive prostatectomy. We found that iatrogenic complications for MIS were less frequent in later years (years 09-11 vs. year 01-02 odds ratio (OR), 0.21; 95% confidence intervals (CI), 0.09-0.40). MIS was associated with higher risk of iatrogenic complications in early period (years 01-02 OR, 3.81; 95% CI, 1.72-8.41), but lower risk in late period (years 09-11 OR 0.72 95% CI 0.61-0.86). Patients who experienced iatrogenic complications tended to have longer LOS (Median: Open vs. MIS, 4 days vs. 3 day) than those who didn't (Median: Open vs. MIS, 2 days vs. 1 day), regardless of procedure type. CONCLUSION: We found that minimally invasive prostatectomy is associated with lower risk of iatrogenic complications when compared with open surgery (OS). However, as "learning curve" is overcome over time, MIS becomes safer than OS. Iatrogenic complications are not benign and seem to be associated with higher burden of inpatient care.

A distributed health data network analysis of survival outcomes: the International Consortium of Orthopaedic Registries perspective.

The International Consortium for Orthopaedic Registries is a multinational initiative established by the United States Food and Drug Administration to develop a health data network aimed at providing a robust infrastructure to facilitate evidence-based decision-making on performance of medical devices. Through the International Consortium for Orthopaedic Registries, individual data holders have complete control of their data and can choose to participate in studies of their choice. In this article, we present an overview of the data extraction process and the analytic strategy employed to answer several device performance-related questions in total hip arthroplasty and total knee arthroplasty. In the process, we discuss some nuances pertinent to International Consortium for Orthopaedic Registries data that pose certain statistical challenges, and we briefly suggest strategies to be adopted to address them.

Multinational comprehensive evaluation of the fixation method used in hip replacement: interaction with age in context.

BACKGROUND: Fixation in total hip replacements remains a controversial topic, despite the high level of its success. Data obtained from major orthopaedic registries indicate that there are large differences among preferred fixation and survival results. METHODS: Using a distributed registry data network, primary total hip arthroplasties performed for osteoarthritis from 2001 to 2010 were identified from six national and regional total joint arthroplasty registries. A multivariate meta-analysis was performed using linear mixed models with the primary outcome revision for any reason. Survival probabilities and their standard errors were extracted from each registry for each unique combination of the covariates. Fixation strategies were compared with regard to age group, sex, bearing, and femoral-head diameter. All comparisons were based on the random-effects model and the fixed-effects model. RESULTS: In patients who were seventy-five years of age and older, uncemented fixation had a significantly higher risk of revision (p < 0.001) than hybrid fixation, with a hazard ratio of 1.575 (95% confidence interval, 1.389 to 1.786). We found a similar, if lesser, effect in the intermediate age group of sixty-five to seventy-four years (hazard ratio, 1.16 [95% confidence interval, 1.023 to 1.315]; p = 0.021) and in the younger age group of forty-five to sixty-four years (hazard ratio, 1.205 [95% confidence interval, 1.008 to 1.442]; p = 0.041). There were no significant differences between hybrid and cemented bearings across age groups. CONCLUSIONS: We conclude that cementless fixation should be avoided in older patients (those seventy-five years of age or older), although this evidence is less strong in patients of intermediate and younger ages.

International comparative evaluation of knee replacement with fixed or mobile-bearing posterior-stabilized prostheses.

BACKGROUND: Posterior-stabilized total knee prostheses were introduced to address instability secondary to loss of posterior cruciate ligament function, and they have either fixed or mobile bearings. Mobile bearings were developed to improve the function and longevity of total knee prostheses. In this study, the International Consortium of Orthopaedic Registries used a distributed health data network to study a large cohort of posterior-stabilized prostheses to determine if the outcome of a posterior-stabilized total knee prosthesis differs depending on whether it has a fixed or mobile-bearing design. METHODS: Aggregated registry data were collected with a distributed health data network that was developed by the International Consortium of Orthopaedic Registries to reduce barriers to participation (e.g., security, proprietary, legal, and privacy issues) that have the potential to occur with the alternate centralized data warehouse approach. A distributed health data network is a decentralized model that allows secure storage and analysis of data from different registries. Each registry provided data on mobile and fixed-bearing posterior-stabilized prostheses implanted between 2001 and 2010. Only prostheses associated with primary total knee arthroplasties performed for the treatment of osteoarthritis were included. Prostheses with all types of fixation were included except for those with the rarely used reverse hybrid (cementless tibial and cemented femoral components) fixation. The use of patellar resurfacing was reported. The outcome of interest was time to first revision (for any reason). Multivariate meta-analysis was performed with linear mixed models with survival probability as the unit of analysis. RESULTS: This study includes 137,616 posterior-stabilized knee prostheses; 62% were in female patients, and 17.6% had a mobile bearing. The results of the fixed-effects model indicate that in the first year the mobile-bearing posterior-stabilized prostheses had a significantly higher hazard ratio (1.86) than did the fixed-bearing posterior-stabilized prostheses (95% confidence interval, 1.28 to 2.7; p = 0.001). For all other time intervals, the mobile-bearing posterior-stabilized prostheses had higher hazard ratios; however, these differences were not significant. CONCLUSIONS: Mobile-bearing posterior-stabilized prostheses had an increased rate of revision compared with fixed-bearing posterior-stabilized prostheses. This difference was evident in the first year.

Long term survival with thoracoscopic versus open lobectomy: propensity matched comparative analysis using SEER-Medicare database.

OBJECTIVE: To compare long term survival after minimally invasive lobectomy and thoracotomy lobectomy. DESIGN: Propensity matched analysis. SETTING: Surveillance, Epidemiology and End Results (SEER)-Medicare database. PARTICIPANTS: All patients with lung cancer from 2007 to 2009 undergoing lobectomy. MAIN OUTCOME MEASURE: Influence of less invasive thoracoscopic surgery on overall survival, disease-free survival, and cancer specific survival. RESULTS: From 2007 to 2009, 6008 patients undergoing lobectomy were identified (n=4715 (78%) thoracotomy). The median age of the entire cohort was 74 (interquartile range 70-78) years. The median length of follow-up for entire group was 40 months. In a matched analysis of 1195 patients in each treatment category, no statistical differences in three year overall survival, disease-free survival, or cancer specific survival were found between the groups (overall survival: 70.6% v 68.1%, P=0.55; disease-free survival: 86.2% v 85.4%, P=0.46; cancer specific survival: 92% v 89.5%, P=0.05). CONCLUSION: This propensity matched analysis showed that patients undergoing thoracoscopic lobectomy had similar overall, cancer specific, and disease-free survival compared with patients undergoing thoracotomy lobectomy. Thoracoscopic techniques do not seem to compromise these measures of outcome after lobectomy.

Comparative effectiveness of robotic-assisted vs thoracoscopic lobectomy.

BACKGROUND: Robotic-assisted lobectomy is being offered increasingly to patients. However, little is known about its safety, complication profile, or effectiveness. METHODS: Patients undergoing lobectomy in in the United States from 2008 to 2011 were identified in the Nationwide Inpatient Sample. In-hospital mortality, complications, length of stay, and cost for patients undergoing robotic-assisted lobectomy were compared with those for patients undergoing thoracoscopic lobectomy. RESULTS: We identified 2,498 robotic-assisted and 37,595 thoracoscopic lobectomies performed from 2008 to 2011. The unadjusted rate for any complication was higher for those undergoing robotic-assisted lobectomy than for those undergoing thoracoscopic lobectomy (50.1% vs 45.2%, P < .05). Specific complications that were higher included cardiovascular complications (23.3% vs 20.0%, P < .05) and iatrogenic bleeding complications (5.0% vs 2.0%, P < .05). The higher risk of iatrogenic bleeding complications persisted in multivariable analyses (adjusted OR, 2.64; 95% CI, 1.58-4.43). Robotic-assisted lobectomy costs significantly more than thoracoscopic lobectomy ($22,582 vs $17,874, P < .05). CONCLUSIONS: In this early experience with robotic surgery, robotic-assisted lobectomy was associated with a higher rate of intraoperative injury and bleeding than was thoracoscopic lobectomy, at a significantly higher cost.

A curriculum in measurement-based care: screening and monitoring of depression in a psychiatric resident clinic.

OBJECTIVE: The goal of this curriculum was to train residents in measurement-based care (MBC). METHOD: Third-year psychiatry residents were educated in MBC through didactic seminars and a quality-improvement (QI) initiative with the goal of implementing the Patient Health Questionnaire Depression Scale (PHQ-9) to screen and monitor patients for symptoms of depression. RESULTS: Residents suggested strategies for integrating the PHQ-9 into the clinic. Over the first 6 months, residents showed an increase in rate of depression screening from 4% to 92% of patients. Also, they increased monthly monitoring of outpatients with a diagnosis of depression from 1% to 76%. Residents who used the PHQ-9 to monitor patients with depression were significantly more likely to use additional standardized assessments. CONCLUSIONS: Combining an educational intervention with QI strategies can significantly affect residents' use of standardized assessments in an outpatient setting. Using standardized measures allows residents to assess their own clinical effectiveness, an emerging priority in training.

The feasibility of standardized patient assessments as a best practice in an academic training program.

The use of standardized patient assessments (SPAs) in psychiatry is an emerging best practice. This column describes a survey of resident and faculty supervisors at a large academic department examining current practices, attitudes, and perceived barriers to incorporating SPAs into clinical practice. Although the study found that SPAs were not routinely used in clinical practice or supervision, residents and faculty were fairly optimistic about their potential value. The results suggest that educational initiatives should be integrated into clinical practice, start early within training, include both trainees and faculty supervisors, and set use of SPAs as an expected standard of care.

Training psychiatry residents in quality improvement: an integrated, year-long curriculum.

OBJECTIVE The authors describe a curriculum for psychiatry residents in Quality Improvement (QI) methodology. METHODS All PGY3 residents (N=12) participated in a QI curriculum that included a year-long group project. Knowledge and attitudes were assessed before and after the curriculum, using a modified Quality Improvement Knowledge Assessment Tool (QIKAT) and a QI Self-Assessment survey. RESULTS QIKAT scores were significantly higher for residents after participating in the curriculum when compared with pretest scores. Self-efficacy ratings in QI improved after the course for each item. Residents demonstrated gains in QI skills through participation in the group projects in which they increased rates of depression-screening and monitoring in an outpatient clinic. CONCLUSIONS Combining didactic and experiential learning can be an effective means for training psychiatry residents in QI.