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Manchester Center, VT, United States

Pohl H.,Medical Center | Pohl H.,VA Outcomes Group | Pohl H.,Dartmouth Hitchcock Medical Center | Wrobel K.,Charite University Hospitals | And 5 more authors.
American Journal of Gastroenterology | Year: 2013

OBJECTIVES:It is assumed that esophageal adenocarcinoma is the end result of a stepwise disease process that transitions through gastroesophageal reflux disease (GERD) and Barrett's esophagus. The aim of this study was to examine at what stage known risk factors exert their influence toward the progression to cancer.METHODS:We enrolled 113 consecutive outpatients without GERD, 188 with GERD, 162 with Barrett's esophagus, and 100 with esophageal adenocarcinoma or high-grade dysplasia (HGD). All patients underwent a standard upper endoscopy and completed a standardized questionnaire about their social history, symptoms, dietary habits, and prescribed medications. We used adjusted logistic regression analysis to assess risk factors between each two consecutive disease stages from the absence of reflux disease to esophageal adenocarcinoma.RESULTS: Overall, male gender, smoking, increased body mass index (BMI), low fruit and vegetable intake, duration of reflux symptoms, and presence of a hiatal hernia were risk factors for cancer/HGD. However, different combinations of risk factors were associated with different disease stages. Hiatal hernia was the only risk factor to be strongly associated with the development of GERD. For GERD patients, male gender, age, an increased BMI, duration of reflux symptoms, and presence of a hiatal hernia were all associated with the development of Barrett's esophagus. Finally, the development of cancer/HGD among patients with Barrett's esophagus was associated with male gender, smoking, decreased fruit and vegetable intake, and a long segment of Barrett's esophagus, but not with age, BMI, or a hiatal hernia.CONCLUSIONS:While some risk factors act predominantly on the initial development of reflux disease, others appear to be primarily responsible for the development of more advanced disease stages. © 2013 by the American College of Gastroenterology.

Andrus B.W.,Dartmouth Hitchcock Medical Center | Andrus B.W.,Dartmouth Institute for Health Care Policy and Clinical Practice | Welch H.G.,Dartmouth Institute for Health Care Policy and Clinical Practice | Welch H.G.,VA Outcomes Group
Circulation: Cardiovascular Quality and Outcomes | Year: 2012

Background-Services provided by cardiologists represent a major portion of Medicare expenditures for specialist physicians. The absolute growth and distribution of these services over the past decade have not been well described. Methods and Results-We analyzed fee-for-service Medicare Part B claims for each year from 1999-2008 and selected claims from physicians whose specialty code was cardiology. We then grouped approximately 1000 CPT-9 codes into 45 specific service groups that were then further aggregated into 3 broad service categories: Evaluation and management, noninvasive procedures, and invasive procedures. Our main outcome measures were services and allowed charges per 1000 beneficiaries. Sample size ranged from 30.9 million beneficiaries in 1999 to 31.7 million in 2008. During this 10-year period, the number of claims from cardiologists increased 44% (from 2082-2997 per 1000 beneficiaries) while the allowed charges increased 28% after adjusting for inflation (in 2008 dollars, from $181 397-231 728 per 1000 beneficiaries). Evaluation and management services and invasive procedures contributed relatively little to this growth. Instead, most of the growth involved noninvasive procedures-with a 70% increase in claims. Although the most dramatic increases in noninvasive procedures involved emerging imaging technologies (cardiac CT, MRI, and PET scanning), the bulk of the growth occurred in two established technologies: Resting echocardiograms and stress tests with nuclear imaging. Conclusions-Most of the growth in services provided by cardiologists over the past decade is the result of increased noninvasive imaging. © 2011 American Heart Association, Inc.

Morris L.G.T.,Sloan Kettering Cancer Center | Sikora A.G.,Mount Sinai School of Medicine | Tosteson T.D.,Leibniz University of Hanover | Davies L.,VA Outcomes Group | Davies L.,Leibniz University of Hanover
Thyroid | Year: 2013

Background: The rapidly rising incidence of papillary thyroid cancer may be due to overdiagnosis of a reservoir of subclinical disease. To conclude that overdiagnosis is occurring, evidence for an association between access to health care and the incidence of cancer is necessary. Methods: We used Surveillance, Epidemiology, and End Results (SEER) data to examine U.S. papillary thyroid cancer incidence trends in Medicare-age and non-Medicare-age cohorts over three decades. We performed an ecologic analysis across 497 U.S. counties, examining the association of nine county-level socioeconomic markers of health care access and the incidence of papillary thyroid cancer. Results: Papillary thyroid cancer incidence is rising most rapidly in Americans over age 65 years (annual percentage change, 8.8%), who have broad health insurance coverage through Medicare. Among those under 65, in whom health insurance coverage is not universal, the rate of increase has been slower (annual percentage change, 6.4%). Over three decades, the mortality rate from thyroid cancer has not changed. Across U.S. counties, incidence ranged widely, from 0 to 29.7 per 100,000. County papillary thyroid cancer incidence was significantly correlated with all nine sociodemographic markers of health care access: it was positively correlated with rates of college education, white-collar employment, and family income; and negatively correlated with the percentage of residents who were uninsured, in poverty, unemployed, of nonwhite ethnicity, non-English speaking, and lacking high school education. Conclusion: Markers for higher levels of health care access, both sociodemographic and age-based, are associated with higher papillary thyroid cancer incidence rates. More papillary thyroid cancers are diagnosed among populations with wider access to healthcare. Despite the threefold increase in incidence over three decades, the mortality rate remains unchanged. Together with the large subclinical reservoir of occult papillary thyroid cancers, these data provide supportive evidence for the widespread overdiagnosis of this entity. © Mary Ann Liebert, Inc.

Hoang J.K.,Duke University | Nguyen X.V.,Ohio State University | Davies L.,VA Outcomes Group | Davies L.,The Dartmouth Institute for Health Policy and Clinical Practice
Academic Radiology | Year: 2015

Thyroid cancer fulfills the criteria for overdiagnosis by having a reservoir of indolent cancers and practice patterns leading to the diagnosis of incidental cancers from the reservoir. The occurrence of overdiagnosis is also supported by population-based data showing an alarming rise in thyroid cancer incidence without change in mortality. Because one of the activities leading to overdiagnosis is the workup of incidental thyroid nodules detected on imaging, it is critical that radiologists understand the issue of overdiagnosis and their role in the problem and solution. This article addresses 1) essential thyroid cancer facts, 2) the evidence supporting overdiagnosis, 3) the role of radiology in overdiagnosis, 4) harms of overdiagnosis, and 5) steps radiologists can take to minimize the problem. © 2015 AUR.

Davies L.,VA Outcomes Group | Davies L.,Dartmouth Institute for Health Policy and Clinical Practice
Otolaryngology - Head and Neck Surgery (United States) | Year: 2012

Objective. To describe time trends in total laryngectomy health services utilization across the United States, such as rates of surgery, cost, length of stay, and insurance payer, and to compare this to important milestones in recommendations for laryngeal cancer treatment. Study Design. Population-based cohort study Setting. Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) 1997-2008: stratified sample of all US hospital discharges. Subjects and Methods. All patients with the principal procedure of complete laryngectomy. The unit of analysis was the discharge. Results. Between 1997 and 2008, the number of laryngectomies done in the United States decreased by 48%. New cases of laryngeal cancer decreased 33% during the same time. The proportion of patients older than 65 years decreased from 48% to 43%. Mortality for the procedure was 1.4% in 1997 and 1.1% in 2008. Mean length of stay over the study period increased from 13 days to 14 days. Mean hospital charges rose from $58,000 in 1997 to $109,000 in 2008, consistent with the overall rise in US health care costs. Medicare was the dominant insurer throughout. Home health was ordered in 50% of 2008 discharges but only 32% in 1997. Conclusions. The rate of total laryngectomy has dropped more than the incidence of laryngeal cancer has dropped, consistent with the trend toward nonsurgical treatment. Lower surgical volumes and/or salvage laryngectomy surgeries are hypothesized to play a role in longer length of stay, stable mortality rates despite younger patient age, and increased need for home services after discharge. © 2012 American Academy of Otolaryngology - Head and Neck Surgery Foundation.

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