Same-Day Sinus and Brain CT Imaging in the Medicare Population: Are Practice Patterns Changing in Association with Medicare Policy Initiatives?

BACKGROUND AND PURPOSE:Monitoring the frequency of same-day sinus and brain CT (Outpatient Measure 14, “OP-14”) is part of a recent large Centers for Medicare and Medicaid Services hospital outpatient quality initiative to improve imaging efficiency. This study investigates patient-level claims data in the Medicare population focusing on where same-day sinus and brain CT imaging is performed and how the frequency of same-day studies changed with time before and during OP-14 measure program implementation.MATERIALS AND METHODS:Research Identifiable Files were used to identify all sinus and brain CT examinations from 2004 through 2012 for a 5% random patient sample of Medicare fee-for-service beneficiaries. Overall and site of service use rates were calculated for same- and non-same-day examinations. Changes were mapped to policy initiative timetables.RESULTS:The number of same-day sinus and brain CT studies from 2004 to 2012 increased 67% from 1.85 (95% CI, 1.78–1.91) per 1000 Medicare beneficiaries in 2004 to 3.08 (95% CI, 3.00–3.15) in 2012. The biggest driver of increased same-day studies was the emergency department setting, from 0.56 (95% CI, 0.53–0.60) per 1000 to 1.78 (95% CI, 1.72–1.84; +215.7%). Overall use of brain CT from 146.0 (95% CI, 145.1–146.9) per 1000 to 176.3 (95% CI, 175.4–177.2; +21%) and sinus CT from 12.6 (95% CI, 12.4–12.8) per 1000 to 15.4 (95% CI, 15.2–15.6; +22%) increased until 2009 and remained stable through 2012.CONCLUSIONS:Previously increasing same-day sinus and brain CT in Medicare beneficiaries plateaued in 2009, coinciding with the implementation of targeted measures by the Centers for Medicare and Medicaid Services. Same-day imaging continues to increase in the emergency department setting.

Rising health care costs in the United States have resulted in a number of policy initiatives and professional society campaigns¹ to use limited resources more judiciously. The rapid increase in spending on medical imaging during the early part of the past decade,^2,3 along with an increased societal awareness of radiation dose,⁴ has focused those initiatives and campaigns on imaging services. The injudicious use of sinus CT imaging, for example, received considerable attention as part of the multispecialty “Choosing Wisely” initiative.¹ In response to Congressional legislation in 2006,⁵ the Centers for Medicare and Medicaid Services (CMS) also focused on potentially inappropriate sinus CT imaging as part of its outpatient imaging efficiency program. With the rationale that except in specific and narrow circumstances, same-day sinus and brain CT imaging is rarely indicated, CMS established metric Outpatient Measure 14 (OP-14) to track the use by facilities of such same-day imaging.⁶ The goals of the initiative were to improve transparency through public reporting and potentially serve as the basis for value-based payments. Although the overall program was announced in 2006, testing did not begin until 2010 and was not officially implemented until 2012. Nonetheless, even before that official implementation, it received widespread media coverage.⁷Using just 2 years of CMS Web site data, Rosenkrantz and Doshi⁸ recently reported a relatively low incidence of same-day sinus and brain CT imaging but did not examine how that frequency changed during program rollout or expand their analysis beyond the specific target of the CMS initiative (ie, hospital outpatient setting). Thus, despite the attention this program has received in the media, little is known about how physician-testing behavior has changed in association with its implementation.The aim of our investigation was to study patient-level claims data in the Medicare population, focusing on where same-day sinus and brain CT imaging is performed and how the frequency of same-day studies changed with time before and during the OP-14 measure program implementation.     

微载体培养MEK和Vero细胞试制甲肝灭活疫苗

目的探索微载体培养细胞大量制备甲肝病毒抗原及其灭活疫苗的可行性。方法使用 Cytodex- 1培养恒河猴胚肾细胞和 Vero细胞制备 HAV ,经过初步纯化、甲醛灭活、吸附佐剂 ,制成甲肝灭活疫苗 ,免疫昆明种小白鼠 ,测定免疫原性。结果 HAV X株和 W株抗原滴度分别为 1∶ 2 5 6、1∶ 12 8,感染滴度 (log TCID5 0 / m l)分别为 8.5 0、8.17,与静止培养获得的滴度相当。小鼠抗 HAV抗体第 45 d达到峰值 ,滴度分别为 1∶ (96 .0± 78.4)、1∶ (12 8.0± 70 .1)。结论实验性甲肝灭活疫苗具有良好的免疫原性 ,应用微载体培养细胞制备甲肝灭活疫苗是可行的。     

急性脑梗死中医治疗现状的思考

简要论述急性脑梗死中医治疗的现状,提出现代中医治疗急性脑梗死应关注的问题,并指出急性脑梗死的发病主要由肝肾不足、脾气亏虚而引发。临床治疗中应重视气虚、肾虚与血瘀的关系,并对活血、凉肝、清热解毒、化痰祛瘀等治法的运用进行探讨。     

中西医结合治疗输卵管阻塞的临床分析

将 32例输卵管阻塞致不孕的患者分成中药组和对照组,两组患者行输卵管疏通术后在应用抗生素治疗的同时,中药组再口服“通管方”和“灌肠 2号方”灌肠,以 1个月为一疗程,进行两组保持通畅率以及妊娠率的比较。结果保持通畅率中药组优于对照组(P<0. 05),妊娠率两组无显著性差异(P>0. 05)。     

Diagnostic algorithm for relapsing demyelinating syndromes of the CNS in children

Background

Paediatric relapsing demyelinating syndromes of the CNS define a group of diseases that have different phenotypes. Although for some of them, such as multiple sclerosis and neuromyelitis optica spectrum disorder (NMOSD), diagnostic criteria have been developed, diagnostic uncertainties are not uncommon. We aimed to identify the key features that unify phenotypes, and focused on patients with myelin oligodendrocyte glycoprotein (MOG) antibodies, to investigate whether they show distinctive clinical and radiological features, independently of their original diagnosis. We then generated a diagnostic algorithm for clinical use.

Student experiences of medicines management training and education

Nurses on registration are expected to have sufficient knowledge and skills in medicine management to practice safely and competently. This article reports on research involving midwifery and nursing students, who were asked to complete a questionnaire related to their experiences of medicines-related training and education, and how it prepared them for practice. The results showed an overall satisfaction with the pre-registration delivery, but differences emerged in the perceived efficacy of different educational strategies. Clinically-based and simulated aspects of the programme delivery were highly rated, with theoretical delivery scoring poorly in contrast. A stepped approach is suggested, with medicine course delivery needing to be strongly highlighted as a lead up to safe and competent nursing interventions when administering medication and all other related interventions. A grant from the innovation fund at the University of Huddersfield funded an evaluation of students' experiences of medicines management education and training using a self-administered questionnaire.     

Nonresectional palliative abdominal surgery for patients with advanced colorectal cancer

Objective Nonresectional palliative abdominal surgery (e.g. defunctioning stoma/bypass) may be appropriate for patients unsuitable for curative resection, to deal with complications of advanced colorectal malignancy such as obstruction. Our aim was to review the outcome of surgery in these patients within our institution. Method All patients undergoing palliative surgery without resection for colorectal carcinoma between July 1998 and January 2007 were identified from our prospectively compiled colorectal cancer database. Data were extracted related to patients’ demographics, presentation, tumour site, operative intervention, complications, oncological therapies, length of hospital stay and postoperative survival. Results One hundred and ninety‐three patients were identified with a median age of 79 years (31–94 years). Fifty per cent were operated on an emergent basis for obstruction or perforation, and 50% on an elective basis. One hundred and sixty‐nine patients had defunctioning stomas formed of which 156 were loop stomas. Twenty‐four patients underwent bypass procedures. Thirty‐day mortality rate was 13.5% and postoperative morbidity rate 47%. Median survival was 247 days, with 1‐year survival of 38%. Patients undergoing operation on an emergent basis had poorer long‐term survival (127 vs 320 days, P = 0.002). Conclusion Nonresectional palliative abdominal surgery is associated with relatively high morbidity and mortality, particularly when performed in the emergency setting. However, in this patient group with a very poor outlook, it may be offered with reasonable survival expectations.     

Performing stable angina pectoris: an ethnographic study

Symptoms play a crucial part in the formulation of medical diagnoses, yet the construction and interpretation of symptom narratives is not well understood. The diagnosis of angina is largely based on symptoms, but a substantial minority of patients diagnosed with "non-cardiac" chest pain go on to have a heart attack. In this ethnographic study our aims were to understand: (1) how the patients' accounts are performed or enacted in consultations with doctors; (2) the ways in which ambiguity in the symptom narrative is managed by doctors; and (3) how doctors reach or do not reach a diagnostic decision. We observed 59 consultations of patients in a UK teaching hospital with new onset chest pain who had been referred for a specialist opinion in ambulatory care. We found that patients rarely gave a history that, without further interrogation, satisfied the doctors, who actively restructured the complex narrative until it fitted a diagnostic canon, detaching it from the patient's interpretation and explanation. A minority of doctors asked about chest pain symptoms outside the canon. Re-structuring into the canonical classification was sometimes resisted by patients who contested key concepts, like exertion. Symptom narratives were sometimes unstable, with central features changing on interrogation and re-telling. When translation was required for South Asian patients, doctors considered the history less relevant to the diagnosis. Diagnosis and effective treatment could be enhanced by research on the diagnostic and prognostic value of the terms patients use to describe their symptoms.