Recruiting a diverse sample of pregnant women for clinical research is a challenging but crucial task for improving obstetric services and maternal and child health outcomes.
To compare the feasibility and cost of recruiting pregnant women for survey research using social media-based and clinic-based approaches.
Advertisements were used to recruit pregnant women from the social media website Facebook. In-person methods were used to recruit pregnant women from the outpatient clinic of a large, tertiary care center. In both approaches, potential respondents were invited to participate in a 15-minute Web-based survey. Each recruitment method was monitored for 1 month. Using bivariate statistics, we compared the number, demographic characteristics, and health characteristics of women recruited and the cost per completed survey for each recruitment method.
The social media-based approach recruited 1178 women and the clinic-based approach recruited 219 women. A higher proportion of subjects recruited through social media identified as African American (29.4%, 207/705 vs 11.2%, 20/179), reported household incomes
Web-based recruitment through a social networking platform is a feasible, inexpensive, and rapid means of recruiting a large, diverse sample of pregnant women for survey research.
pregnant women; surveys and questionnaires; methods; social media
The impact of insurance expansion on the currently insured population is largely unknown. We examine rates of elective surgery in previously insured individuals before and after Massachusetts healthcare reform.
Using the State Inpatient Databases for Massachusetts and two control states (New York and New Jersey) that did not expand coverage, we identified patients aged 69 and older who underwent surgery from January 1, 2003, through December 31, 2010. We studied five elective operations (knee and hip replacement, transurethral resection of prostate, inguinal hernia repair, back surgery). We examined statewide utilization rates before and after implementation of healthcare reform, using a difference-in-differences technique to adjust for secular trends. We also performed subgroup analyses according to race and income strata.
We observed no increase in the overall rate of selected discretionary inpatient surgeries in Massachusetts versus control states for the entire population (−1.4%, p=0.41), as well as among the white (−1.6%, p=0.43) and low-income (−2.2%, p=0.26) subgroups. We did, however, find evidence for a woodwork effect in the subgroup of non-white elderly patients, among whom the rate of these procedures increased by 20.5% (p=0.001). Among non-whites, the overall result reflected increased utilization of all five individual procedures, with statistically significant changes for knee replacement (18%, p<0.01), back surgery (18%, p=0.05), transurethral resection of the prostate (28%, p=0.05), and hernia repair (71%, p=0.03).
Our findings suggest that national insurance expansion may increase the use of elective surgery among subgroups of previously insured patients.
Successful perception depends on combining sensory input with prior knowledge. However, the underlying mechanism by which these two sources of information are combined is unknown. In speech perception, as in other domains, two functionally distinct coding schemes have been proposed for how expectations influence representation of sensory evidence. Traditional models suggest that expected features of the speech input are enhanced or sharpened via interactive activation (Sharpened Signals). Conversely, Predictive Coding suggests that expected features are suppressed so that unexpected features of the speech input (Prediction Errors) are processed further. The present work is aimed at distinguishing between these two accounts of how prior knowledge influences speech perception. By combining behavioural, univariate, and multivariate fMRI measures of how sensory detail and prior expectations influence speech perception with computational modelling, we provide evidence in favour of Prediction Error computations. Increased sensory detail and informative expectations have additive behavioural and univariate neural effects because they both improve the accuracy of word report and reduce the BOLD signal in lateral temporal lobe regions. However, sensory detail and informative expectations have interacting effects on speech representations shown by multivariate fMRI in the posterior superior temporal sulcus. When prior knowledge was absent, increased sensory detail enhanced the amount of speech information measured in superior temporal multivoxel patterns, but with informative expectations, increased sensory detail reduced the amount of measured information. Computational simulations of Sharpened Signals and Prediction Errors during speech perception could both explain these behavioural and univariate fMRI observations. However, the multivariate fMRI observations were uniquely simulated by a Prediction Error and not a Sharpened Signal model. The interaction between prior expectation and sensory detail provides evidence for a Predictive Coding account of speech perception. Our work establishes methods that can be used to distinguish representations of Prediction Error and Sharpened Signals in other perceptual domains.
Neuroimaging and computational modelling explain how the human brain uses prior expectations to improve our perception of degraded speech.
Perception inevitably depends on combining sensory input with prior expectations. This is particularly critical for identifying degraded input. However, the underlying neural mechanism by which expectations influence sensory processing is unclear. Predictive Coding theories suggest that the brain passes forward the unexpected part of the sensory input while expected properties are suppressed (i.e., Prediction Error). However, evidence to rule out the opposite mechanism in which the expected part of the sensory input is enhanced or sharpened (i.e., Sharpening) has been lacking. In this study, we investigate the neural mechanisms by which sensory clarity and prior knowledge influence the perception of degraded speech. A univariate measure of brain activity obtained from functional magnetic resonance imaging (fMRI) is in line with both neural mechanisms (Prediction Error and Sharpening). However, combining multivariate fMRI measures with computational simulations allows us to determine the underlying mechanism. Our key finding was an interaction between sensory input and prior expectations: for unexpected speech, increasing speech clarity increases the amount of information represented in sensory brain areas. In contrast, for speech that matches prior expectations, increasing speech clarity reduces the amount of this information. Our observations are uniquely simulated by a model of speech perception that includes Prediction Errors.
The objective of this study was to examine the effectiveness of a novel nonpharmacological intervention – breathing-controlled electrical stimulation (BreEStim) – for neuropathic pain management in spinal cord injury (SCI) patients.
Subjects and methods
There were two experiments: 1) to compare the effectiveness between BreEStim and conventional electrical stimulation (EStim) in Experiment (Exp) 1 and 2) to examine the dose–response effect of BreEStim in Exp 2. In Exp 1, 13 SCI subjects (6 males and 7 females, history of SCI: 58.2 months, from 7 to 150 months, impairments ranging from C4 AIS B to L1 AIS B) received both BreEStim and EStim in a randomized order with at least 3 days apart. A total of 120 electrical stimuli to the median nerve transcutaneously were triggered by voluntary inhalation during BreEStim or were randomly delivered during EStim. In Exp 2, a subset of 7 subjects received BreEStim120 and 240 stimuli randomly on two different days with 7 days apart (BreEStim120 vs BreEStim240). The primary outcome variable was the visual analog scale (VAS) score.
In Exp 1, both BreEStim and EStim showed significant analgesic effects. Reduction in VAS score was significantly greater after BreEStim (2.6±0.3) than after EStim (0.8±0.3) (P<0.001). The duration of analgesic effect was significantly longer after BreEStim (14.2±6 hours) than after EStim (1.9±1 hours) (P=0.04). In Exp 2, BreEStim120 and BreEStim240 had similar degree and duration of analgesic effects.
The findings from this preliminary study suggest that BreEStim is an effective alternative nonpharmacological treatment for chronic neuropathic pain in patients suffering from SCI.
neuromodulation; neuropathic pain; spinal cord injury; electrical stimulation; BreEStim
Recent policy initiatives such as the Affordable Care Act and Mental Health
Parity and Addiction Equity Act have expanded coverage of mental health services.
However, it is unclear to what extent the public supports mandated insurance coverage of
mental health care relative to other specific medical services.
A cross-sectional, national poll of the US adult population. Respondents
(n=2124) were asked whether health plans should be required to provide coverage
for mental health care and other types of services. Logistic regression was used to
assess the association of respondent characteristics with support for coverage.
78% (95% CI=75–81%) of respondents
supported mandated coverage of mental health care. This was higher than the level of
support for birth control medications, equivalent to dental/tooth care, but lower than
all other medical services.
True parity for mental health care may be limited if public support lags behind
that for other medical services.
We sought to determine the age at which U.S. parents first turned their child’s car seat to face forward and information sources used to make that decision at the time of the release of the 2011 guidelines for child passenger safety and 30 months later.
Two separate cross-sectional Web-based surveys of nationally representative panels of U.S. parents, May 2011 and November 2013. Survey participation rate was 54% in both years. Parents of children ≤4 years old responded to questions about transitioning from rear-facing to forward-facing car seats (n=495 in 2011; n=521 in 2013).
In 2011, 33% of parents of 1-to 4-year-old children who had been turned to face forward (n=409) turned at or before 12 months and 16% turned at 2 years or older. In 2013, 24% of parents of 1- to 4-year-old children who had been turned to face forward (n=413) turned at or before 12 months and 23% turned at 2 years or older. Car seat packaging and clinicians were the most common information sources. Demographic characteristics associated with turning to face forward at or before 12 months of age in 2011 (parent age, education, household income, rural residence) were not significantly associated with transitioning at or before 12 months in 2013.
Delaying the transition to a forward-facing car seat still represents an opportunity to improve passenger safety in the U.S. As common sources of information, clinicians may be influential in a parent’s decision to turn their child’s car seat to face forward.
Car seats; child passenger safety; parent survey
To describe the association between weight status and sexual practices among 18-19 year-old women.
We analyzed a population-based longitudinal study of 18-19 year-old women residing in a Michigan county at cohort inception. Weekly journal surveys measured sexual practices, including contraceptive behaviors. Outcomes included proportion of weeks with a partner, proportion of weeks with sexual intercourse, number of partners, average length of relationships, proportion of weeks with contraception use, and proportion of weeks where contraception was used consistently. We examined 26,545 journal surveys from 900 women over the first study year. Ordinary least squares regression models for each outcome examined differences by weight status, controlling for sociodemographic characteristics.
The mean proportion of weeks in which adolescents reported sexual intercourse was 52%; there was no difference by weight status. Among weeks in which adolescents reported sexual activity, obese adolescents had a lower proportion of weeks where any contraception was used compared with normal-weight adolescents (84% vs 91%, p=0.011). Among weeks in which adolescents reported sexual activity and contraceptive use, obese adolescents had a lower proportion of weeks with consistent contraceptive use (68% vs 78%, p=0.016) and oral contraceptive pill use (27% vs 45%, p=0.001) compared with normal-weight adolescents. All other relationships by weight status were not statistically significant.
In this longitudinal study, obese adolescent women were less likely to use contraception, and less likely to use it consistently when compared with normal-weight peers. Findings suggest obesity may be an important factor associated with adolescent women’s sexual behavior.
Pregnancy; contraception; obese; overweight; sexual behavior
In this paper, we argue that individuals – as members of society – play an important role in the expectations of whether or not companies are responsible for addressing environmental issues, and whether or not governments should regulate them. From this perspective of corporate social responsibility as a social contract we report the results of a survey of 1066 individuals. The aim of the survey was to assess participants’ belief in anthropogenic climate change, free-market ideology, and beliefs around who is responsible for dealing with climate change. Results showed that both climate change views and free market ideology have a strong effect on beliefs that companies are responsible for dealing with climate change and on support for regulatory policy to that end. Furthermore, we found that free market ideology is a barrier in the support of corporate regulatory policy. The implications of these findings for research, policy, and practice are discussed.
corporate social responsibility; environmental responsibility; climate change; pro-environmental behavior; behavior change; micro CSR
The reproductive homeobox X-linked, Rhox, genes encode transcription factors that are selectively expressed in reproductive tissues. While there are 33 Rhox genes in mice, only Rhox and Rhox8 are expressed in Sertoli cells, suggesting that they may regulate the expression of somatic-cell gene products crucial for germ cell development. We previously characterized Rhox5-null mice, which are subfertile, exhibiting excessive germ cell apoptosis and compromised sperm motility. To assess the role of Rhox8 in Sertoli cells, we used a tissue-specific RNAi approach to knockdown RHOX8 in vivo, in which the Rhox5 promoter was used to drive Rhox8-siRNA transgene expression in the postnatal Sertoli cells. Western and immunohistochemical analysis confirmed Sertoli-specific knockdown of RHOX8. However, other Sertoli markers, Gata1 and Rhox5, maintained normal expression patterns, suggesting that the knockdown was specific. Interestingly, male RHOX8-knockdown animals showed significantly reduced spermatogenic output, increased germ cell apoptosis, and compromised sperm motility, leading to impaired fertility. Importantly, our results revealed that while some RHOX5-dependent factors were also misregulated in Sertoli cells of RHOX8-knockdown animals, the majority were not, and novel putative RHOX8-regulated genes were identified. This suggests that while reduction in levels of RHOX5 and RHOX8 in Sertoli cells elicits similar phenotypes, these genes are not entirely redundant. Taken together, our study underscores the importance of Rhox genes in male fertility and suggests that Sertoli cell-specific expression of Rhox5 and Rhox8 is critical for complete male fertility.
gene regulation; rodents (rats; mice; guinea pigs; voles); sertoli cells; spermatogenesis; testis
An unacceptably high number of children who do not pass universal newborn hearing screening (UNHS) are lost to follow-up.
Our objective was to gain insight into parent recall of UNHS. We compared responses of parents whose children were born before versus after UNHS.
Nationally representative cross-sectional survey
1,539 parent households surveyed in May 2012
Main Outcome(s) and Measures
Outcome measures included recall of hearing screen at birth, hearing screen results, and recommendations for follow-up. All outcome measures were based on parent recall and report. We used descriptive statistics and multiple logistic regression analysis.
Only 62.9% of parents recall a newborn hearing screen, and among those children with risk indicators for hearing loss, only 68.6% recall a hearing screen. Higher parent education (p=0.034), younger age of the child (OR 1.16, 95% CI 1.11 – 1.23, p<0.001), and the presence of any risk indicator for hearing loss (OR 1.5, 95% CI 1.13 – 2.13, p=0.007) were associated with parent recall of hearing screen. Reported pass rates were higher than expected. Parents’ recall of follow-up recommendations was not always consistent with guidelines.
Conclusions and Relevance
While this study is inherently limited by recall bias, our findings demonstrate a lack of parent awareness of UNHS. We believe changes in the system of reporting UNHS results are necessary to improve parents’ recall of screen results and improve follow up for children who do not pass the screen.
Bioluminescence is primarily a marine phenomenon with 80% of metazoan bioluminescent genera occurring in the world’s oceans. Here we show that bioluminescence has evolved repeatedly and is phylogenetically widespread across ray-finned fishes. We recover 27 independent evolutionary events of bioluminescence, all among marine fish lineages. This finding indicates that bioluminescence has evolved many more times than previously hypothesized across fishes and the tree of life. Our exploration of the macroevolutionary patterns of bioluminescent lineages indicates that the present day diversity of some inshore and deep-sea bioluminescent fish lineages that use bioluminescence for communication, feeding, and reproduction exhibit exceptional species richness given clade age. We show that exceptional species richness occurs particularly in deep-sea fishes with intrinsic bioluminescent systems and both shallow water and deep-sea lineages with luminescent systems used for communication.
Neurointervention is a rapidly evolving and complex field practiced by clinicians with backgrounds ranging from neurosurgery to radiology, neurology, cardiology, and vascular surgery. New devices, techniques, and clinical applications create exciting opportunities for impacting patient care, but also carry the potential for new iatrogenic injuries. Every step of every neurointerventional procedure carries risk, and a thorough appreciation of potential complications is fundamental to maximizing safety. This article presents the most frequent and dangerous iatrogenic injuries, their presentation, identification, prevention, and management.
interventional radiology; neuroradiography; cerebral angiography; complications; iatrogenic disorders
Microvascular hyperpermeability that occurs at the level of the blood-brain barrier (BBB) often leads to vasogenic brain edema and elevated intracranial pressure following traumatic brain injury (TBI). At a cellular level, tight junction proteins (TJPs) between neighboring endothelial cells maintain the integrity of the BBB via TJ associated proteins particularly, zonula occludens-1 (ZO-1) that binds to the transmembrane TJPs and actin cytoskeleton intracellularly. The pro-inflammatory cytokine, interleukin-1β (IL-1β) as well as the proteolytic enzymes, matrix metalloproteinase-9 (MMP-9) are key mediators of trauma-associated brain edema. Recent studies indicate that melatonin a pineal hormone directly binds to MMP-9 and also might act as its endogenous inhibitor. We hypothesized that melatonin treatment will provide protection against TBI-induced BBB hyperpermeability via MMP-9 inhibition. Rat brain microvascular endothelial cells grown as monolayers were used as an in vitro model of the BBB and a mouse model of TBI using a controlled cortical impactor was used for all in vivo studies. IL-1β (10 ng/mL; 2 hours)-induced endothelial monolayer hyperpermeability was significantly attenuated by melatonin (10 μg/mL; 1 hour), GM6001 (broad spectrum MMP inhibitor; 10 μM; 1 hour), MMP-9 inhibitor-1 (MMP-9 specific inhibitor; 5 nM; 1 hour) or MMP-9 siRNA transfection (48 hours) in vitro. Melatonin and MMP-9 inhibitor-1 pretreatment attenuated IL-1β-induced MMP-9 activity, loss of ZO-1 junctional integrity and f-actin stress fiber formation. IL-1β treatment neither affected ZO-1 protein or mRNA expression or cell viability. Acute melatonin treatment attenuated BBB hyperpermeability in a mouse controlled cortical impact model of TBI in vivo. In conclusion, one of the protective effects of melatonin against BBB hyperpermeability occurs due to enhanced BBB integrity via MMP-9 inhibition. In addition, acute melatonin treatment provides protection against BBB hyperpermeability in a mouse model of TBI indicating its potential as a therapeutic agent for brain edema when established in humans.
Biofluorescence has recently been found to be widespread in marine fishes, including sharks. Catsharks, such as the Swell Shark (Cephaloscyllium ventriosum) from the eastern Pacific and the Chain Catshark (Scyliorhinus retifer) from the western Atlantic, are known to exhibit bright green fluorescence. We examined the spectral sensitivity and visual characteristics of these reclusive sharks, while also considering the fluorescent properties of their skin. Spectral absorbance of the photoreceptor cells in these sharks revealed the presence of a single visual pigment in each species. Cephaloscyllium ventriosum exhibited a maximum absorbance of 484 ± 3 nm and an absorbance range at half maximum (λ1/2max) of 440–540 nm, whereas for S. retifer maximum absorbance was 488 ± 3 nm with the same absorbance range. Using the photoreceptor properties derived here, a “shark eye” camera was designed and developed that yielded contrast information on areas where fluorescence is anatomically distributed on the shark, as seen from other sharks’ eyes of these two species. Phylogenetic investigations indicate that biofluorescence has evolved at least three times in cartilaginous fishes. The repeated evolution of biofluorescence in elasmobranchs, coupled with a visual adaptation to detect it; and evidence that biofluorescence creates greater luminosity contrast with the surrounding background, highlights the potential importance of biofluorescence in elasmobranch behavior and biology.
Rationale: Recent pediatric studies suggest a survival benefit exists for higher-volume extracorporeal membrane oxygenation (ECMO) centers.
Objectives: To determine if higher annual ECMO patient volume is associated with lower case-mix–adjusted hospital mortality rate.
Methods: We retrospectively analyzed an international registry of ECMO support from 1989 to 2013. Patients were separated into three age groups: neonatal (0–28 d), pediatric (29 d to <18 yr), and adult (≥18 yr). The measure of hospital ECMO volume was age group–specific and adjusted for patient-level case-mix and hospital-level variance using multivariable hierarchical logistic regression modeling. The primary outcome was death before hospital discharge. A subgroup analysis was conducted for 2008–2013.
Measurements and Main Results: From 1989 to 2013, a total of 290 centers provided ECMO support to 56,222 patients (30,909 neonates, 14,725 children, and 10,588 adults). Annual ECMO mortality rates varied widely across ECMO centers: the interquartile range was 18–50% for neonates, 25–66% for pediatrics, and 33–92% for adults. For 1989–2013, higher age group–specific ECMO volume was associated with lower odds of ECMO mortality for neonates and adults but not for pediatric cases. In 2008–2013, the volume–outcome association remained statistically significant only among adults. Patients receiving ECMO at hospitals with more than 30 adult annual ECMO cases had significantly lower odds of mortality (adjusted odds ratio, 0.61; 95% confidence interval, 0.46–0.80) compared with adults receiving ECMO at hospitals with less than six annual cases.
Conclusions: In this international, case-mix–adjusted analysis, higher annual hospital ECMO volume was associated with lower mortality in 1989–2013 for neonates and adults; the association among adults persisted in 2008–2013.
extracorporeal membrane oxygenation; high-volume hospitals; low-volume hospitals; pediatric; adult
Our aim was to characterize the temporal changes in burden that Clostridium difficile infection (CDI) added to the hospital care of children and young adults with inflammatory bowel disease (IBD) in the United States.
Retrospective analysis of annual, nationally-representative samples of children and young adults with IBD.
There was a five-fold increase in IBD hospitalizations with CDI from 1997 to 2011 (P for trend <0.01). Over the same period, IBD hospitalizations without CDI increased two-fold (P for trend <0.01). Mean length of stay (LOS) for IBD hospitalizations with CDI was consistently longer than hospitalizations without CDI and did not significantly change over time (P for trend = 0.47). CDI-related total hospital days in the US rose from 1,702 to 10,194 days per million individuals per year from 1997 to 2011 (P for trend < 0.01). Children and young adults hospitalized with CDI had a significantly lower odds of colectomy (0.31) compared to those without CDI. Total charges for CDI-related hospitalizations among children and young adults in the U.S. rose from $8.7 million in 1997 to $68.2 million in 2011.
A widening gap in burden has opened between IBD hospitalizations with and without CDI over the last decade and a half. CDI-related hospitalizations are associated with disproportionately longer lengths of stay, more hospital days, and more charges than hospitalizations without CDI over time. Further work within health systems, hospitals, and practices, can help us better understand this enlarging gap to improve clinical care for this vulnerable population.
national trends; Clostridium difficile; inflammatory bowel disease; Nationwide Inpatient Sample; variance-weighted regression
Objectives and Hypothesis
Our objectives were to characterize the quality of acute sinusitis care and to identify non-clinical factors associated with antibiotic use for acute sinusitis. We hypothesized that we would identify provider level factors associated with antibiotic use.
Retrospective cohort at a single academic institution.
We developed and clinically annotated an administrative dataset of adult patients diagnosed with acute sinusitis between January 1, 2005 and December 31, 2006. We used identify factors associated with receipt of antibiotics.
We find that 66.0% of patients with mild symptoms of short duration are given antibiotics and that non-clinical factors, including the individual provider, the provider's specialty, and the presence of a medical trainee, significantly influence antibiotic use. Relative to internal medicine providers, family medicine providers use fewer antibiotics and emergency medicine providers use more antibiotics for acute sinusitis.
Antibiotics continue to be over used for patients with mild acute sinusitis of short duration. Non-clinical characteristics, including the individual provider, the provider's specialty, and the presence of a medical trainee significantly influence use of antibiotics for acute sinusitis.
sinusitis; adult; retrospective cohort; survey; provider
Social networking sites such as Facebook provide a new way to seek and receive social support, a factor widely recognized as important for one's health. However, few studies have used actual conversations from social networking sites to study social support for health related matters. We studied 3,899 Facebook users, among a sample of 33,326 monitored adults, who initiated a conversation that referred to surgery on their Facebook Wall during a six-month period to explore predictors of social support as measured by number of response posts from “friends.” Among our sample, we identified 8,343 Facebook conversation threads with the term “surgery” in the initial post with, on average, 5.7 response posts (SD 6.2). We used a variant of latent semantic analysis to explore the relationship between specific words in the posts that allowed us to develop three thematic categories of words related to family, immediacy of the surgery, and prayer. We used generalized linear mixed models to examine the association between characteristics of the Facebook user as well as the thematic categories on the likelihood of receiving response posts following the announcement of a surgery. Words from the three thematic categories were used in 32.5% (family), 39.5 (immediacy), and 50.7% (prayer) of root posts. Surprisingly, few user characteristics were associated with response in multivariate models [rate ratios, RR, 1.08 (95% CI 1.01,1.15) for married/living with partner; 1.10 (95% CI 1.03,1.19) for annual income ≥ $75,000]. In multivariate models adjusted for Facebook user characteristics and network size, use of family and prayer words were associated with significantly higher number of response posts, RR 1.40 (95% CI 1.37,1.43) and 2.07 (95% CI 2.02,2.12) respectively. We found some evidence of social support on Facebook for surgery and that the language used in the initial post of a conversation thread is predictive of overall response.
social support; social media; surgery
The purpose of this study is to 1) understand national variation in delay of emergency procedures in patients with open tibial fracture at the hospital level and 2) compare length of stay (LOS) and cost in patients cared for at the best and worst performing hospitals for delay.
We retrospectively analyzed the 2003 – 2009 Nationwide Inpatient Sample. Adult patients with primary diagnosis of open tibial fracture were selected for inclusion. We calculated hospital probability of delay of emergency procedures beyond the day of admission (day 0). Multilevel linear regression random effects models were created to evaluate the relationship between the treating hospital’s tendency for delay (in quartiles) and the log-transformed outcomes of LOS and cost, while adjusting for patient and hospital variables.
The final sample included 7,029 patients from 332 hospitals. Adjusted analyses demonstrate that patients treated at hospitals in the fourth (worst) quartile for delay were estimated to have 12% (95% CI 2–21%) higher cost compared to patients treated at hospitals in the first quartile. In addition, patients treated at hospitals in the fourth quartile had an estimated 11% (CI 4–17%) longer LOS compared to patients treated at hospitals in the first quartile.
Patients with open tibial fracture treated at hospitals with more timely initiation of surgical care had lower cost and shorter LOS than patients treated at hospitals with less timely initiation of care. Policies directed toward mitigating variation in care are not only beneficial for patient outcomes, but may also reduce unnecessary waste.
Level II (Prognostic)
amputation; debridement; emergent procedures; lower extremity reconstruction; lower extremity trauma; open tibial fracture; practice variation; treatment delay
For surgical treatment of thumb carpometacarpal (CMC) arthritis, current evidence suggests that simple trapeziectomy is as effective and may be safer than trapeziectomy and ligament reconstruction (LR) with or without tendon interposition (TI). We examined whether current practice patterns in the surgical treatment of thumb CMC arthritis reflect adoption of simple trapeziectomy as best practice. Furthermore, we investigated whether surgeon preferences and third-party payer patterns are associated with use of simple trapeziectomy.
We performed a retrospective cross-sectional study of 6776 surgical treatments for thumb CMC arthritis using the all-payer State Ambulatory Surgery Database (SASD) for Florida, during 2006–2009. We applied multinomial regression analysis to examine associations between covariates, describing surgeon and third-party payer factors and the type of procedure performed. We calculated an intra-class correlation coefficient (ICC) to determine how much of the difference in patient outcome (procedure type) is due to differences among surgeons.
Across surgeon characteristics included in the analysis, patients’ outcome probabilities were over 90% in favor of treatment with trapeziectomy and LR with or without TI. Additionally, the level of intra-class correlation amongst patients clustered within a surgeon showed that individual surgeons contribute substantially to determining what procedure type a patient undergoes.
In this multi-year one state study, it appears that current evidence demonstrating the equivalent effectiveness of simple trapeziectomy compared to more involved alternatives did not result in wide adoption of the technique. This finding is consistent with studies in many clinical disciplines that highlight the difficulty of influencing clinical practice with available evidence.
Level of Evidence
CMC; arthritis; CMC; arthrodesis; CMC; synovectomy evidence; partial/complete trapeziectomy with; LR/LRTI; prosthetic arthroplasty; simple complete trapeziectomy; soft-tissue arthroplasty