Outcomes at Bariatric Surgery Centers of Excellence and Non-Designated Centers: A Retrospective Cohort Study in a TRICARE Population.

In 2013, the Centers for Medicare and Medicaid Services reversed their coverage policy that limited bariatric operations to Centers of Excellence (COE). Data from Centers for Medicare and Medicaid Services may not be generalizable to younger, healthier populations; additional data are needed to inform coverage policies for other plans. This retrospective cohort study used the 2010 to 2011 administrative claims data from the TRICARE military healthcare program to evaluate readmission rates, readmission length of stay, and postoperative healthcare costs among patients who had bariatric surgery at a COE versus non-designated centers. Outcomes were reported at 30, 60, and 90 days, and compared using logistic and linear regression models while controlling for age, gender, and military status. A total of 3027 patients underwent bariatric operations (mean age 44.16, 84.11% female). At 30 days, there were no significant differences between patients in COEs (n = 2413) and non-designated centers (n = 614), in readmission rates (4.77%, 4.40%, P = 0.70), mean length of stay (5.5 days, 6.7 days, P = 0.41), or mean postoperative healthcare costs ($754, $962, P = 0.398). There were no significant differences in any outcomes at 60 or 90 days. Combined with concerns related to COE patient access barriers, these findings strengthen the evidence that reject the requirement for bariatric surgeries to be performed at COEs.

Use of palliative radiotherapy among patients with metastatic non-small-cell lung cancer.

PURPOSE: Radiotherapy (RT) is known to effectively palliate many symptoms of patients with metastatic non-small-cell lung cancer (NSCLC). Anecdotally, RT is believed to be commonly used in this setting, but limited population-based data are available. The objective of this study was to examine the utilization patterns of palliative RT among elderly patients with Stage IV NSCLC and, in particular, to identify factors associated with its use. METHODS AND MATERIALS: A retrospective population-based cohort study was performed using linked Surveillance, Epidemiology and End Results (SEER)-Medicare data to identify 11,084 Medicare beneficiaries aged > or =65 years who presented with Stage IV NSCLC in the 11 SEER regions between 1991 and 1996. The primary outcome was receipt of RT. Logistic regression analysis was used to identify factors associated with receipt of RT. RESULTS: A total of 58% of these patients received RT, with its use decreasing over time (p = 0.01). Increasing age was negatively associated with receipt of treatment (p <0.001), as was increasing comorbidities (p <0.001). Factors positively associated with the receipt of RT included income (p = 0.001), hospitalization (p <0.001), and treatment with chemotherapy (p <0.001). Although the use varied across the SEER regions (p = 0.001), gender, race/ethnicity, and distance to the nearest RT facility were not associated with treatment. CONCLUSIONS: Elderly patients with metastatic NSCLC frequently receive palliative RT, but its use varies, especially with age and receipt of chemotherapy. Additional research is needed to determine whether this variability reflects good quality care.

Characteristics of the pediatric hospitalist workforce: its roles and work environment.

OBJECTIVE: Over the past 10 years, the use of hospitalists has grown in both the adult and pediatric setting as a response to pressure to deliver cost-effective, high-quality care. However, there is a paucity of information regarding the variation in the clinical roles, educational responsibilities, work patterns, and employment characteristics of pediatric hospitalists. This lack of information hampers efforts to define the nature of the field and determine whether any formalized, additional training or experience should be required for physicians in this clinical practice domain. DESIGN: We conducted a telephone survey of a national sample of pediatric hospitalist program directors (n = 116). Questionnaire items focused on exploring the clinical roles, work patterns, employment characteristics, and training of pediatric hospitalists within each institution. Results were stratified by teaching hospitals, urban/rural location, hospital size, and membership in the National Association of Children's Hospitals and Related Institutions. RESULTS: The response rate was 97%. The majority of hospitals surveyed (70%) reported that hospitalists do not generate enough income from professional billing to pay their salaries. Fewer than half (39%) of respondents reported that their hospital measures pediatric clinical outcomes associated with hospitalist care. A total of 42% of hospitalist program directors reported that most of their hospitalists had an average duration of employment of <3 years. In programs with residents, hospitalists serve as teaching attendings for pediatric patients in almost all cases (89%). CONCLUSIONS: Hospital medicine is a rapidly growing enterprise. A better understanding of both its participants, as well as those affected by its practice, will enable planning for a future that meets as many needs as possible while ensuring the best possible care for children.

Who claims to be a pediatrician?

OBJECTIVE: The purpose of this study was to determine the proportion of physicians who self or otherwise declare themselves to be pediatricians but who have never achieved board certification. STUDY DESIGN: We compared a roster from the state licensure file of eight geographically diverse states containing those designated as pediatricians with a listing from the American Board of Pediatrics (ABP) of those who had ever achieved board certification. We then sent a mail survey to a sample of 500 physicians who appeared as pediatricians on the state licensure files but for whom there was no record of certification with the ABP. RESULTS: The proportion of unmatched pediatricians ranges from 6.9% in Massachusetts to 16.8% in Maryland, and averages 11% across all of the states in our study. The survey response rate was 64%. The majority (61%) of respondents described having undertaken residency training in categorical pediatrics or medicine-pediatrics. The remainder reported surgical residencies (31%) or were combined into an "other" category (8%). Eighty-five percent reported having completed 3 or more years of postgraduate training. Almost all (94%) completed training in the United States or Canada. CONCLUSIONS: There is increasing attention to board certification and patient safety among the media and public. A clearer delineation of the proportion of physicians in a given state reporting to be pediatricians who have not completed board certification can help inform parents of the odds they will encounter noncertified physicians in the hospitals and among the health plans in which they seek care for their children.

Determinants of colorectal cancer screening use, attempts, and non-use.

BACKGROUND: Relatively little is known about the experiences and preferences of users and those who attempt colorectal cancer (CRC) screening. This study describes factors influencing CRC screening decisions among users, attempters, attempter users (individuals who both attempted and completed at least one screening procedure), and non-users; identifies factors interfering with test completion; and describes correlates of screening preferences. METHODS: A primarily stratified random sample of patients from the University of Michigan Health System clinics, Ann Arbor, Michigan, with oversampling of FOBT attempters, completed a mailed questionnaire in fall, 2003. Descriptive and multivariate approaches evaluated factors influencing screening use and preferences. RESULTS: "Accuracy of results" was reported most often as important when deciding about CRC screening regardless of screening status. The importance of psychological decisional factors differed significantly by screening status (P<0.05). Among factors interfering with test completion, 38.5% attempting FOBT reported they "forgot" whereas 29.8% attempting colonoscopy were "afraid of pain." Approximately 56.3% indicated a preference for a CRC test: respondents who considered "discomfort" important preferred FOBT (OR: 0.39, 95% CI: 0.17, 0.87); those with a prior colonoscopy preferred an invasive test (OR: 6.50, 95% CI: 2.90, 14.50). CONCLUSIONS: To improve adherence to CRC screening recommendations, physicians should tailor discussions to patients' prior experiences and test-specific concerns and elicit preferences for screening.

An informed decision? Breast cancer patients and their knowledge about treatment.

OBJECTIVE: Although involving women in breast cancer treatment decisions is advocated, there is little understanding of whether women have the information they need to make informed decisions. The objective of the current study was to evaluate women's knowledge of survival and recurrence rates for mastectomy and breast conserving surgery (BCS) and the factors associated with this knowledge. METHODS: We used a population-based sample of women diagnosed with breast cancer in metropolitan Los Angeles and Detroit between December 2001 and January 2003. All women with ductal carcinoma in situ and a random sample of women with invasive disease were selected (N=2382), of which 1844 participated (77.4%). All participants were mailed surveys. The main outcome measures were knowledge of survival and recurrence rates by surgical treatment type. RESULTS: Only 16% of women knew that recurrence rates were different for mastectomy and BCS, and 48% knew that the survival rates were equivalent across treatment. Knowledge about survival and recurrence was improved by exposure to the Internet and health pamphlets (p<0.01). Women who had a female (versus male) surgeon, and/or a surgeon who explained both treatments (rather than just one treatment) demonstrated higher survival knowledge (p<0.01). The majority of women had inadequate knowledge with which to make informed decisions about breast cancer surgical treatment. CONCLUSION: Previous explanations for poor knowledge, such as irrelevance of knowledge to decision making and lack of access to information, were not shown to be plausible explanations for the low levels of knowledge observed in this sample. PRACTICE IMPLICATIONS: These results suggest a need for fundamental changes in patient education to ensure that women are able to make informed decisions about their breast cancer treatment. These changes may include an increase in the use of decision aids and in decreasing the speed at which treatment decisions are made.

Policies and practices related to the role of board certification and recertification of pediatricians in hospital privileging.

CONTEXT: Privileging involves the granting of permission to perform specific professional activities under the jurisdiction of a governing body's (hospital) authority. In 1951, the Joint Commission on the Accreditation of Hospitals (later renamed the Joint Commission on Accreditation of Healthcare Organizations) was formed to codify the process of hospital assessment. In the early part of the 20th century, a parallel process was being undertaken by the medical specialties to evaluate and recognize competence among physicians through the creation of specialty boards. OBJECTIVES: To describe the use of board certification in hospital privileging policies for general pediatricians and pediatric subspecialists and to identify any variation among types of hospitals. DESIGN, SETTING, AND PARTICIPANTS: A telephone survey between January 1 and June 30, 2005, of privileging personnel among a random, weighted sample of 200 nonspecialty hospitals stratified by teaching status, children's vs general hospitals, freestanding children's hospital vs part of hospital system, and urban vs rural location. MAIN OUTCOME MEASURES: Proportion of hospitals that require board certification at initial privileging or at some point to maintain privileges and recertification to maintain privileges. RESULTS: Of 200 hospitals, 7 hospitals were ineligible because they did not have at least 1 pediatrician on staff. One hundred fifty-nine hospitals completed the telephone interview, resulting in an overall response rate of 82%. A total of 124 (78%) of 159 hospitals did not require general pediatricians to be board certified at initial privileging; however, 111 (70%) did require pediatricians to become board certified at some point during their tenure. Of these 124 hospitals, 52 (42%) did not report a time frame in which certification must be achieved. Forty-nine (43%) of 113 hospitals required pediatric subspecialists to achieve subspecialty certification within a specific time frame. CONCLUSIONS: These results raise issues regarding the manner in which board certification is used or not used by hospitals in their efforts to ensure the practice of high-quality care within their institutions. The premise for recertification is the need to assure the public of continued competence of physicians over the course of their professional careers. Increased attention by the public and regulatory agencies regarding patient safety and quality of care will likely have an impact on hospital privileging processes.

Use of board certification and recertification of pediatricians in health plan credentialing policies.

CONTEXT: Health plans conduct credentialing processes to select and retain qualified physicians who will provide high-quality care to their subscribers. One of the tools available to health plans to help ensure physician competence is assessment of board certification status. OBJECTIVE: To determine the credentialing policies of health plans regarding the use of board certification and recertification for general pediatricians and pediatric subspecialists. DESIGN, SETTING, AND PARTICIPANTS: Telephone survey conducted February through July 2005 of credentialing personnel from a US national sample of 244 health plans stratified by enrollment size, Medicaid proportion, and for-profit or not-for-profit status. MAIN OUTCOME MEASURES: Proportion of health plans that require general or subspecialty board certification at initial contract or at any time during association with the plan and recertification to maintain credentialing or to bill as a specialist or subspecialist; percentage of physicians credentialed in each health plan and credentialing goals for each plan regarding the proportion of physicians to be board certified. RESULTS: Response rate was 193 of 244 (79%). Overall, 174 (90%) of the plans do not require general pediatricians to be board certified at the time of initial credentialing, and only 41% ever require a general pediatrician to become board certified. Similarly, only 80 (40%) ever require subspecialists to become board certified in their subspecialty. Although 80 of 192 (41%) report requiring recertification of general pediatricians, almost half do not have a time frame in which recertification must occur. Seventy-seven percent of plans allow physicians to bill as subspecialists with expired certificates. CONCLUSIONS: These findings, although specific to pediatrics, likely apply to other primary care disciplines and raise questions regarding the ability of plans to ensure initial or continued competence of their credentialed physicians. Growing public concern regarding patient safety, as well as demonstrated patient preferences for certified physicians, will likely result in greater emphasis on quality assessments in physician credentialing.

Correlates of breast reconstruction: results from a population-based study.

BACKGROUND: Immediate or early postmastectomy breast reconstruction is performed infrequently. To the authors' knowledge, little is known regarding surgeon or patient perspectives on reconstruction treatment decisions. The purpose of the current study was to identify patient attitudes and preferences associated with breast reconstruction, and whether these differed by race. METHODS: A sample of women age < or = 79 years who were diagnosed with ductal carcinoma in situ and invasive breast carcinoma between December 2001 and January 2003 was identified from the Surveillance, Epidemiology, and End Results (SEER) registries of Detroit and Los Angeles. Eligible subjects completed a questionnaire at a mean of 7 months after diagnosis. The Wald chi-square test and logistic regression were used for data analysis. RESULTS: Of the 1844 respondents, 646 underwent a mastectomy (35.0% of the total sample) and 245 of these patients received breast reconstruction (38.0%; of the mastectomy group). On multivariate analysis, younger patient age, higher educational levels, and earlier stage of disease were found to be significantly associated with breast reconstruction. Although 78.2% of women reported that breast reconstruction was discussed, only 11.2% correctly answered 3 basic knowledge questions regarding the procedure. The desire to avoid more surgery was the most common reason for not undergoing breast reconstruction. CONCLUSIONS: The results of the current study found that the majority of women were aware of breast reconstruction but choose not to undergo the procedure. Lack of knowledge and a greater perception of barriers to the procedure were more common among African-American patients and women with a lower education level, suggesting a need for improved educational strategies.

Surgeon perspectives about local therapy for breast carcinoma.

BACKGROUND: Geographic variations in the use of mastectomy and the use of radiation therapy (RT) after breast-conserving surgery (BCS) have motivated concerns that surgeons are not uniformly adhering to treatment standards. METHODS: The authors surveyed attending surgeons of a population-based sample of patients with breast carcinoma diagnosed in Detroit and Los Angeles from December 2001 to January 2003 (n = 365; response rate, 80.0%). Clinical scenarios were used to evaluate opinions about local therapy. RESULTS: On average, surgeons reported that they devoted 31.3% of their total practice to breast carcinoma. Approximately one-half of surgeons practiced in a community hospital setting, whereas 18.8% practiced in a cancer center. Compared to low volume surgeons, high volume surgeons were more likely to favor BCS with RT for invasive breast carcinoma (60.8%, 74.0%, and 87.2% for low, moderate, and high volume surgeons, respectively, P < 0.001). Surgeons who favored BCS were more likely to perceive greater quality of life (QOL) benefits for BCS than mastectomy (85.9%) compared with surgeons who favored mastectomy (28.6%) and those who did not favor 1 procedure over the other (60.0%, P < 0.001). In a ductal carcinoma in situ scenario, 35.0% of surgeons favored BCS without RT and 61.0% favored BCS with RT. Opinions regarding the role of RT after BCS varied by geographic site, surgeon volume, and patient age. CONCLUSIONS: Variation in surgeon opinion concerning local therapy reflected clinical uncertainty about the benefits of alternative treatments. High volume surgeons more frequently endorsed current clinical guidelines that favor BCS compared with mastectomy. This may partly be explained by the greater belief that BCS confers a better patient QOL than mastectomy.

Patient involvement in surgery treatment decisions for breast cancer.

PURPOSE: High rates of mastectomy and marked regional variations have motivated lingering concerns about overtreatment and failure to involve women in treatment decisions. We examined the relationship between patient involvement in decision making and type of surgical treatment for women with breast cancer. METHODS: All women with ductal carcinoma-in-situ and a 20% random sample of women with invasive breast cancer aged 79 years and younger who were diagnosed in 2002 and reported to the Detroit and Los Angeles Surveillance, Epidemiology, and End Results registries were identified and surveyed shortly after receipt of surgical treatment (response rate, 77.4%; n = 1,844). RESULTS: Mean age was 60.1 years; 70.2% of the women were white, 18.0% were African American, and 11.8% were from other ethnic groups. Overall, 30.2% of women received mastectomy as initial treatment. Most women reported that they made the surgical decision (41.0%) or that the decision was shared (37.1%); 21.9% of patients reported that their surgeon made the decision with or without their input. Among white women, only 5.3% of patients whose surgeon made the decision received mastectomy compared with 16.8% of women who shared the decision and 27.0% of women who made the decision (P < .001, adjusted for clinical factors, predisposing factors, and number of surgeons visited). However, this association was not observed for African American women (Wald test 10.0, P = .041). CONCLUSION: Most women reported that they made or shared the decision about surgical treatment. More patient involvement in decision making was associated with greater use of mastectomy. Racial differences in the association of involvement with receipt of treatment suggest that the decision-making process varies by racial groups.

Satisfaction with surgery outcomes and the decision process in a population-based sample of women with breast cancer.

OBJECTIVE: To better understand medical decision making in the context of "preference sensitive care," we investigated factors associated with breast cancer patients' satisfaction with the type of surgery received and with the decision process. DATA SOURCES/DATA COLLECTION: For a population-based sample of recently diagnosed breast cancer patients in the Detroit and Los Angeles metropolitan areas (N=1,633), demographic and clinical data were obtained from the Surveillance, Epidemiology, and End Results tumor registry, and self-reported psychosocial and satisfaction data were obtained through a mailed survey (78.4 percent response rate). STUDY DESIGN: Cross-sectional design in which multivariable logistic regression was used to identify sociodemographic and clinical factors associated with three satisfaction measures: low satisfaction with surgery type, low satisfaction with the decision process, and decision regret. PRINCIPAL FINDINGS: Overall, there were high levels of satisfaction with both surgery and the decision process, and low rates of decision regret. Ethnic minority women and those with low incomes were more likely to have low satisfaction or decision regret. In addition, the match between patient preferences regarding decision involvement and their actual level of involvement was a strong indicator of satisfaction and decision regret/ambivalence. While having less involvement than preferred was a significant indicator of low satisfaction and regret, having more involvement than preferred was also a risk factor. Women who received mastectomy without reconstruction were more likely to report low satisfaction with surgery (odds ratio [OR]=1.54, p<.05), low satisfaction with the process (OR=1.37, p<.05), and decision regret (OR=1.55, p<.05) compared with those receiving breast conserving surgery (BCS). An additional finding was that as patients' level of involvement in the decision process increased, the rate of mastectomy also increased (p<.001). CONCLUSIONS: A significant proportion of breast cancer patients experience a decision process that matches their preferences for participation, and report satisfaction with both the process and the outcome. However, women who report more involvement in the decision process are significantly less likely to receive a lumpectomy. Thus, increasing patient involvement in the decision process will not necessarily increase use of BCS or lead to greater satisfaction. The most salient aspect for satisfaction with the decision making process is the match between patients' preferences and experiences regarding participation.

Patterns and correlates of local therapy for women with ductal carcinoma-in-situ.

PURPOSE: Concerns have been raised about the quality of treatment for women with ductal carcinoma-in-situ (DCIS) because persistent high rates of mastectomy suggest overtreatment, whereas lower than expected rates of radiation therapy after breast-conserving surgery (BCS) suggest undertreatment. PATIENTS AND METHODS: All women with DCIS diagnosed in 2002 and who reported to the Detroit and Los Angeles Surveillance, Epidemiology, and End Results (SEER) registries were identified and surveyed shortly after receipt of surgery (response rate, 79.7%; n = 817). Analyses were restricted to patients with DCIS (n = 659) indicated by SEER stage data. RESULTS: Only 14.0% of patients at lowest risk of recurrence (based on tumor size and histologic grade) received a mastectomy compared with 22.8% and 52.6% of patients at intermediate and highest risk (P < .001). Only 13.1% of patients who were not influenced or slightly influenced by concerns about recurrence received mastectomy compared with 48.8% of women who were greatly influenced by this concern (P < .001). A between-geographic site difference in receipt of radiation after BCS was observed for the lowest risk group (38.9% in Los Angeles v 70.5% in Detroit) but not for the highest risk group (80.2% in Los Angeles v 85.9% in Detroit, P = .006 for site and risk group differences). Between-site differences in receipt of radiation after BCS were consistent with patient recall of surgeon discussions about treatment. CONCLUSION: Surgeons are tailoring their recommendations for local therapy options for DCIS based on important clinical factors. Patient attitudes also play an important role in treatment decisions. The substantial influence of both surgeon opinion and patient attitudes should temper concerns about the quality of treatment for women with DCIS.