Section of General Internal Medicine

Medicine Lodge, United States

Section of General Internal Medicine

Medicine Lodge, United States
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Gross C.P.,Public Policy and Effectiveness Research Center | Gross C.P.,Yale University | Long J.B.,Public Policy and Effectiveness Research Center | Long J.B.,Yale University | And 9 more authors.
JAMA Internal Medicine | Year: 2013

Background: Little is known about the cost to Medicare of breast cancer screening or whether regionallevel screening expenditures are associated with cancer stage at diagnosis or treatment costs, particularly because newer breast cancer screening technologies, like digital mammography and computer-aided detection (CAD), have diffused into the care of older women. Methods: Using the linked Surveillance, Epidemiology, and End Results-Medicare database, we identified 137 274 women ages 66 to 100 years who had not had breast cancer and assessed the cost to fee-for-service Medicare of breast cancer screening and workup during 2006 to 2007. For women who developed cancer, we calculated initial treatment cost. We then assessed screeningrelated cost at the Hospital Referral Region (HRR) level and evaluated the association between regional expenditures and workup test utilization, cancer incidence, and treatment costs. Results: In the United States, the annual costs to feefor- service Medicare for breast cancer screening-related procedures (comprising screening plus workup) and treatment expenditures were S1.08 billion and S1.36 billion, respectively. For women 75 years or older, annual screening- related expenditures exceeded S410 million. Agestandardized screening-related cost per beneficiary varied more than 2-fold across regions (from S42 to 107 per beneficiary); digital screening mammography and CAD accounted for 65% of the difference in screening-related cost between HRRs in the highest and lowest quartiles of cost. Women residing in HRRs with high screening costs were more likely to be diagnosed as having earlystage cancer (incidence rate ratio, 1.78 [95% CI, 1.40- 2.26]). There was no significant difference in the cost of initial cancer treatment per beneficiary between the highest and lowest screening cost HRRs (S151 vs S115; P=.20). Conclusions: The cost to Medicare of breast cancer screening exceeds S1 billion annually in the fee-forservice program. Regional variation is substantial and driven by the use of newer and more expensive technologies; it is unclear whether higher screening expenditures are achieving better breast cancer outcomes. © 2013 American Medical Association.


Peek M.E.,Section of General Internal Medicine | Peek M.E.,University of Chicago | Wagner J.,University of Connecticut | Tang H.,University of Chicago | And 4 more authors.
Medical Care | Year: 2011

Background: Self-reported racial discrimination in healthcare has been associated with negative health outcomes, but little is known about its association with diabetes outcomes. Methods: We used data from the Behavioral Risk Factor Surveillance System to investigate associations between self-reported healthcare discrimination and the following diabetes outcomes: (1) quality of care, (2) self-management and (3) complications. Results: In unadjusted logistic regression models, significant associations were found between self-reported healthcare discrimination and most measures of quality of care [diabetes-related primary care visits odds ratio (OR), 0.38; 95% confidence interval (CI), 0.21-0.66), HbA1c testing (OR, 0.42; 95%CI, 0.21-0.82), and earlier eye examination interval (OR, 0.48; 95% CI, 0.24-0.93)] and health outcomes [foot disorders (OR, 2.32, 95%CI: 1.15, 4.68) and retinopathy (OR, 2.26; 95%CI, 1.24-4.12)], but not the number of provider foot examinations (P=0.48) or diabetes self-management (self glucose monitoring, P=0.42; self foot examinations, P=0.74; diabetes class participation, P=0.37). The effects of self-reported discrimination were attenuated or eliminated after controlling for sociodemographics, health status, and access to care. Conclusions: Self-reported racial/ethnic discrimination in healthcare was associated with worse diabetes care and more diabetes complications, but not self-care behaviors, suggesting that factors beyond patients' own behaviors may be the main source of differential outcomes. The relationships between self-reported discrimination and diabetes outcomes were eliminated once adjusting for sociodemographics, health status, and access to care. Our findings suggest that other factors (ie, race, insurance, health status) may play equally or more important roles in determining diabetes health disparities, and that a comprehensive strategy is needed to effectively address health disparities. Copyright © 2011 by Lippincott Williams & Wilkins.


Vest M.T.,Section of Pulmonary and Critical Care Medicine | Herrin J.,Section of Cardiology | Herrin J.,Public Policy and Effectiveness Research Center | Herrin J.,Health Research and Educational Trust | And 11 more authors.
Chest | Year: 2013

Background: Many older patients with early stage non-small cell lung cancer (NSCLC) do not receive curative therapy. New surgical techniques and radiation therapy modalities, such as videoassisted thoracoscopic surgery (VATS), potentially allow more patients to receive treatment. The adoption of these techniques and their impact on access to cancer care among Medicare benefi - ciaries with stage I NSCLC are unknown. Methods: We used the Surveillance, Epidemiology and End Results-Medicare database to identify patients with stage I NSCLC diagnosed between 1998 and 2007. We assessed temporal trends and created hierarchical generalized linear models of the relationship between patient, clinical, and regional factors and type of treatment. Results: The sample comprised 13,458 patients with a mean age of 75.7 years. The proportion of patients not receiving any local treatment increased from 14.6% in 1998 to 18.3% in 2007. The overall use of surgical resection declined from 75.2% to 67.3% ( P , .001), although the proportion of patients undergoing VATS increased from 11.3% to 32.0%. Similarly, although the use of new radiation modalities increased from 0% to 5.2%, the overall use of radiation remained stable. The oldest patients were less likely to receive surgical vs no treatment (OR, 0.12; 95% CI, 0.09-0.16) and more likely to receive radiation vs surgery (OR, 13.61; 95% CI, 9.75-19.0). Conclusion: From 1998 to 2007, the overall proportion of older patients with stage I NSCLC receiving curative local therapy decreased, despite the dissemination of newer, less-invasive forms of surgery and radiation. CHEST 2013; 143(2):429-435 © 2013 American College of Chest Physicians.


Vest M.T.,Section of Pulmonary and Critical Care Medicine | Tanoue L.,Section of Pulmonary and Critical Care Medicine | Soulos P.R.,Section of General Internal Medicine | Kim A.W.,Section of Thoracic Surgery | And 3 more authors.
Journal of Thoracic Oncology | Year: 2012

Introduction: Guidelines recommend that patients with clinical stage IIIA non-small cell lung cancer (NSCLC) undergo histologic confirmation of pathologic lymph nodes. Studies have suggested that invasive mediastinal staging is underutilized, although practice patterns have not been rigorously evaluated. Methods: We used the Surveillance, Epidemiology, and End Results-Medicare database to identify patients with stage IIIA NSCLC diagnosed from 1998 through 2005. Invasive staging and use of positron emission tomography (PET) scanning were assessed using Medicare claims. Multivariable logistic regression was used to identify patient characteristics associated with use of invasive staging. Results: Of 7583 stage IIIA NSCLC patients, 1678 (22%) underwent invasive staging. Patients who received curative intent cancer treatment were more likely to undergo invasive staging than patients who did not receive cancer-specific therapy (30% versus 9.8%, adjusted odds ratio, 3.31; 95% confidence interval, 2.78-3.95). The oldest patients (age, 85-94 years) were less likely to receive invasive staging than the youngest (age, 67-69 years; 27.6% versus 11.9%; odds ratio, 0.46; 95% confidence interval, 0.34-0.61). Sex, marital status, income, and race were not associated with the use of the invasive staging. The use of invasive staging was stable throughout the study period, despite an increase in the use of PET scanning from less than 10% of patients before 2000 to almost 70% in 2005. Conclusion: Nearly 80% of Medicare beneficiaries with stage IIIA NSCLC do not receive guideline adherent mediastinal staging; this failure cannot be entirely explained by patient factors or a reliance on PET imaging. Incentives to encourage use of invasive staging may improve care. Copyright © 2011 by the International Association for the Study of Lung Cancer.


Morgan C.K.,University of Texas Health Science Center at Houston | Varas G.M.,Section of General Internal Medicine | Pedroza C.,University of Texas Health Science Center at Houston | Almoosa K.F.,University of Texas Health Science Center at Houston
Critical Care Medicine | Year: 2014

OBJECTIVE:: Withdrawal or withholding of life-sustaining therapies precedes most deaths in the modern ICU. As goals of care for critically ill patients change from curative to palliative, this transition often occurs abruptly, but a slower more staggered approach may also be used. One such approach is "no escalation of care", often the first step in this transition at the end-of-life. We aimed to determine the prevalence of no escalation of care designation for ICU decedents and identify which interventions are involved. DESIGN:: We performed a retrospective medical record review of all patients who died over a two year period. Records with documentation of no escalation of care in physician orders or progress notes, or other instructions suggesting sequential or selective limitation of interventions were included. SETTING:: Sixteen bed medical ICU at a single large academic hospital. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: Of a total of 310 ICU decedents, 95 (30%) had a no escalation of care designation before death. Hemodialysis, vasopressors, and blood transfusions were the interventions more likely to be withheld. For ongoing therapies, hemodialysis, blood transfusions, and antibiotics were more likely to be withdrawn. Mechanical ventilation, hydration, and nutrition were less likely to be withheld or withdrawn. A minority had a palliative care consult (15%) or ethics consult (4%) while in the ICU. Time from no escalation of care designation to death averaged 0.8 days (range, 0-5 d). CONCLUSION:: No escalation of care designation occurs in a significant proportion of ICU decedents shortly before death. Some interventions are more likely to be limited than others using a no escalation of care approach. © 2013 by the Society of Critical Care Medicine and Lippincott.


Brush D.R.,Section of Pulmonary and Critical Care | Brush D.R.,University of Chicago | Brown C.E.,Section of General Internal Medicine | Alexander G.C.,Section of General Internal Medicine | And 2 more authors.
Critical Care Medicine | Year: 2012

Objective: To describe how critical care physicians manage conflicts with surrogates about withdrawing or withholding patients' life support. Design: Qualitative analysis of key informant interviews with critical care physicians during 2010. We transcribed interviews verbatim and used grounded theory to code and revise a taxonomy of themes and to identify illustrative quotes. Setting: Three academic medical centers, one academic-affiliated medical center, and four private practice groups or private hospitals in a large Midwestern city Subjects: Fourteen critical care physicians. Interventions: None. Measurements and Main Results: Physicians reported tailoring their approach to address specific reasons for disagreement with surrogates. Five common approaches were identified: 1) building trust; 2) educating and informing; 3) providing surrogates more time; 4) adjusting surrogate and physician roles; and 5) highlighting specific values. When mistrust was an issue, physicians endeavored to build a more trusting relationship with the surrogate before readdressing decision making. Physicians also reported correcting misunderstandings by providing targeted education, and some reported highlighting specific patient, surrogate, or physician values that they hoped would guide surrogates to agree with them. When surrogates struggled with decisionmaking roles, physicians attempted to reinforce the concept of substituted judgment. Physicians noted that some surrogates needed time to "come to terms" with the patent's illness before agreeing with physicians. Many physicians had witnessed colleagues negotiate in ways they found objectionable such as providing misleading information, injecting their own values into the negotiation or behaving unprofessionally toward surrogates. Although some physicians viewed their efforts to encourage surrogates' agreement as persuasive, others strongly denied persuading surrogates and described their actions as "guiding" or "negotiating." Conclusions: Physicians reported using a tailored approach to resolve decisional conflicts about life support and attempted to change surrogates' decisions in accordance with what the physician thought was in the patients' best interests. Although physicians acknowledged their efforts to change surrogates' decisions, many physicians did not perceive these efforts as persuasive. © 2012 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.


Rose A.J.,Center for Health Quality | Hylek E.M.,Section of General Internal Medicine | Ozonof A.,Center for Health Quality | Ozonof A.,Boston University | And 5 more authors.
Circulation: Cardiovascular Quality and Outcomes | Year: 2011

Background-Oral anticoagulation is safer and more effective when patients receive high-quality care. However, there have been no prior efforts to measure quality of oral anticoagulation care or to risk adjust it to ensure credible comparisons. Our objective was to profile site performance in the Veterans Health Administration (VA) using risk-adjusted percent time in therapeutic range (TTR). Methods and Results-We included 124 551 patients who received outpatient oral anticoagulation from 100 VA sites of care for indications other than valvular heart disease from October 1, 2006, to September 30, 2008. We calculated TTR for each patient and mean TTR for each site of care. Expected TTR was calculated for each patient and each site based on the variables in the risk adjustment model, which included demographics, comorbid conditions, medications, and hospitalizations. Mean TTR for the entire sample was 58%. Site-observed TTR varied from 38% to 69% or from poor to excellent. Site-expected TTR varied from 54% to 62%. Site risk-adjusted performance ranged from 18% below expected to 12% above expected. Risk adjustment did not alter performance rankings for many sites, but for other sites, it made an important difference. For example, the site ranked 27th of 100 before risk adjustment was one of the best (risk-adjusted rank, 7). Risk-adjusted site rankings were consistent from year to year (correlation between years, 0.89). Conclusions-Risk-adjusted TTR can be used to profile the quality of outpatient oral anticoagulation in a large, integrated health system. This measure can serve as the basis for quality measurement and quality improvement efforts. © 2011 American Heart Association, Inc.


Al-Damluji M.S.,Section of General Internal Medicine | Dzara K.,Section of General Internal Medicine | Hodshon B.,Section of Cardiovascular Medicine | Punnanithinont N.,Erie County Medical Center | And 6 more authors.
Circulation: Cardiovascular Quality and Outcomes | Year: 2015

Background: Single-site studies have demonstrated inadequate quality of discharge summaries in timeliness, transmission, and content, potentially contributing to adverse outcomes. However, degree of hospital-level variation in discharge summary quality for patients hospitalized with heart failure (HF) is uncertain. Methods and Results: We analyzed discharge summaries of patients enrolled in the Telemonitoring to Improve Heart Failure Outcomes (Tele-HF) study. We assessed hospital-level performance on timeliness (fraction of summaries completed on the day of discharge), documented transmission to the follow-up physician, and content (presence of components suggested by the Transitions of Care Consensus Conference). We obtained 1501 discharge summaries from 1640 (91.5%) patients discharged alive from 46 hospitals. Among hospitals contributing ≥10 summaries, the median hospital dictated 69.2% of discharge summaries on the day of discharge (range, 0.0%-98.0%; P<0.001); documented transmission of 33.3% of summaries to the follow-up physician (range, 0.0%-75.7%; P<0.001); and included 3.6 of 7 Transitions of Care Consensus Conference elements (range, 2.9-4.5; P<0.001). Hospital course was typically included (97.2%), but summaries were less likely to include discharge condition (30.7%), discharge volume status (16.0%), or discharge weight (15.7%). No discharge summary included all 7 Transitions of Care Consensus Conference-endorsed content elements, was dictated on the day of discharge, and was sent to a follow-up physician. Conclusions: Even at the highest performing hospital, discharge summary quality is insufficient in terms of timeliness, transmission, and content. Improvements in all aspects of discharge summary quality are necessary to enable the discharge summary to serve as an effective transitional care tool. © 2015 American Heart Association, Inc.


Peek M.E.,Section of General Internal Medicine | Peek M.E.,University of Chicago | Nunez-Smith M.,Yale University | Drum M.,University of Chicago | Lewis T.T.,Yale University
Ethnicity and Disease | Year: 2011

Objective: Despite evidence that discrimination within the health care system may play an important role in perpetuating health disparities, instruments designed to measure discrimination within the health care setting have not been adequately tested or validated. Consequently, we sought to test the psychometric properties of a modified version of the Everyday Discrimination scale, adapted for medical settings. Design: Cross-sectional study. Setting: Academic medical center in Chicago. Participants: Seventy-four African American patients. Outcome measures: We measured factor analysis, internal consistency, test-retest reliability, convergent validity and discriminant validity. Results: Seventy-four participants completed the baseline interviews and 66 participants (89%) completed the follow-up interviews. Eighty percent were women. The Discrimination in Medical Settings (DMS) Scale had a single factor solution (eigenvalue of 4.36), a Cronbach's alpha of 0.89 and test-retest reliability of .58 (P<.0001). The DMS was significantly correlated with an overall measure of societal discrimination (EOD) (r=.51, P<.001) as well as two of its three subscales (unfair: r=2.04, P=.76; discrimination: r=.45, P,0.001; worry: r=2.36, P=.002). The DMS was associated with the overall African American Trust in Health Care Scale (r=.27, P=.02) as well as two key subscales (racism: r=.31, P<.001; disrespect: r=.44, P<.001). The DMS scale was inversely associated with the Social Desirability Scale (r=.18, P=.13). The DMS scale was not correlated with the Center for Epidemiologic Studies Depression Scale (r=.03, P=.80). Conclusions: The Discrimination in Medical Settings Scale has excellent internal consistency, test-retest reliability, convergent validity and discriminant validity among our sample of African American patients. Further testing is warranted among other racial/ethnic groups.


PubMed | Sections of Academic Pediatrics and., Sections of Academic Pediatrics and, University of Chicago, Harvard University and Section of General Internal Medicine
Type: Journal Article | Journal: Pediatrics | Year: 2016

Claims-based measures of low-value pediatric services could facilitate the implementation of interventions to reduce the provision of potentially harmful services to children. However, few such measures have been developed.We developed claims-based measures of 20 services that typically do not improve child health according to evidence-based guidelines (eg, cough and cold medicines). Using these measures and claims from 4.4 million commercially insured US children in the 2014 Truven MarketScan Commercial Claims and Encounters database, we calculated the proportion of children who received at least 1 low-value pediatric service during the year, as well as total and out-of-pocket spending on these services. We report estimates based on narrow measures designed to only capture instances of service use that were low-value. To assess the sensitivity of results to measure specification, we also reported estimates based on broad measures designed to capture most instances of service use that were low-value.According to the narrow measures, 9.6% of children in our sample received at least 1 of the 20 low-value services during the year, resulting in $27.0 million in spending, of which $9.2 million was paid out-of-pocket (33.9%). According to the broad measures, 14.0% of children in our sample received at least 1 of the 20 low-value services during the year.According to a novel set of claims-based measures, at least 1 in 10 children in our sample received low-value pediatric services during 2014. Estimates of low-value pediatric service use may vary substantially with measure specification.

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