RESUMEN
BACKGROUND: Effectiveness of carotid artery stenting (CAS) relative to carotid endarterectomy (CEA) among Medicare patients has not been established. We compared effectiveness of CAS versus CEA among Medicare beneficiaries. METHODS AND RESULTS: We linked Medicare data (2000-2009) to the Society for Vascular Surgery's Vascular Registry (2005-2008) and the National Cardiovascular Data Registry's (NCDR) Carotid Artery Revascularization and Endarterectomy Registry (2006-2008/2009). Medicare patients were followed up from procedure date until death, stroke/transient ischemic attack, periprocedural myocardial infarction, or a composite end point for these outcomes. We derived high-dimensional propensity scores using registry and Medicare data to control for patient factors and adjusted for provider factors in a Cox regression model comparing CAS with CEA. Among 5254 Society for Vascular Surgery's Vascular Registry (1999 CAS; 3255 CEA) and 4055 Carotid Artery Revascularization and Endarterectomy Registry (2824 CAS; 1231 CEA) Medicare patients, CAS patients had a higher comorbidity burden and were more likely to be at high surgical risk (Society for Vascular Surgery's Vascular Registry: 96.7% versus 44.5%; Carotid Artery Revascularization and Endarterectomy Registry: 71.3% versus 44.7%). Unadjusted outcome risks were higher for CAS. Mortality risks remained elevated for CAS after adjusting for patient-level factors (hazard ratio, 1.24; 95% confidence interval, 1.06-1.46). After further adjustment for provider factors, differences between CAS and CEA were attenuated or no longer present (hazard ratio for mortality, 1.13; 95% confidence interval, 0.94-1.37). Performance was comparable across subgroups defined by sex and degree of carotid stenosis, but there was a nonsignificant trend suggesting a higher risk of adverse outcomes in older (>80) and symptomatic patients undergoing CAS. CONCLUSIONS: Outcomes after CAS and CEA among Medicare beneficiaries were comparable after adjusting for both patient- and provider-level factors.
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Estenosis Carotídea/terapia , Endarterectomía Carotidea , Procedimientos Endovasculares/instrumentación , Beneficios del Seguro , Medicare , Stents , Anciano , Anciano de 80 o más Años , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/mortalidad , Investigación sobre la Eficacia Comparativa , Endarterectomía Carotidea/efectos adversos , Endarterectomía Carotidea/mortalidad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Ataque Isquémico Transitorio/etiología , Estimación de Kaplan-Meier , Masculino , Infarto del Miocardio/etiología , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/etiología , Factores de Tiempo , Resultado del Tratamiento , Estados UnidosRESUMEN
Introduction: Given its high prevalence, intimate partner violence (IPV) is an important public health issue. Oral health care providers (OHCPs) often encounter victims of intimate partner abuse in dental settings, but there is a lack of existing literature regarding OHCPs' attitudes toward and knowledge of IPV.Purpose: This study assessed OHCPs' knowledge and perception of preparedness in assessment and management for IPV.Methods: Using a validated survey tool called PREMIS, this study assessed a convenience sample of OHCPs' knowledge and attitudes about the identification, assessment, and management of IPV.Results: The survey results obtained from 117 OHCPs indicated 92% had had some form of IPV education, but 45% felt they did not have sufficient training to assist individuals who were victims of IPV. Other areas in which the respondents felt ill-prepared included identifying victims of IPV (61.5%) and appropriate referrals to social services (64%). Only 7 to 9% screen new patients or those with abuse indicators on the history or exam.Conclusion: This study explored OHCPs' attitudes and knowledge of IPV and provided insight into IPV screening practices and management in dental care settings. Because injuries to the head, neck, and face are very common in IPV, OHCPs have the opportunity to play a key role in managing "the silent epidemic" of domestic violence by routinely including screening of new and returning patients and having a referral resources available.
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Conocimientos, Actitudes y Práctica en Salud , Personal de Salud , Maltrato Conyugal , Recursos en Salud , Humanos , Encuestas y CuestionariosRESUMEN
BACKGROUND: Clinical trials demonstrated the efficacy of carotid artery stenting (CAS) relative to carotid endarterectomy when performed by physicians with demonstrated proficiency. It is unclear how CAS performance may be influenced by the diversity in CAS and non-CAS provider volumes in routine clinical practice. METHODS AND RESULTS: We linked Medicare claims to the Centers for Medicare and Medicaid Services' CAS Database (2005-2009). We assessed the association between 30-day mortality and past-year physician (0, 1-4, 5-9, 10-19, ≥20) and hospital (<10, 10-19, 20-39, ≥40) CAS volumes and past-year hospital coronary and peripheral stenting volumes (<200, 200-399, 400-849, ≥850) among beneficiaries at least 66 years of age. Unadjusted 30-day mortality risk was 1.8% (95% confidence interval [CI], 1.6-2.0) for 19 724 patients undergoing CAS by 2045 physicians in 729 hospitals. Median past-year CAS volume was 9 (interquartile range, 4-19) for physicians and 23 (interquartile range, 12-41) for hospitals. Compared to physicians performing ≥20 CAS in the past year, lower CAS volumes were associated with higher adjusted risks of 30-day morality (P value for trend < 0.05): 1.4 (95% CI, 0.9-2.3) for 0 past-year CAS, 1.3 (95% CI, 0.9-1.8) for 1 to 4, 1.1 (95% CI, 0.8-1.6) for 5 to 9, and 0.9 (95% CI, 0.7-1.4) for 10 to 19. An inverse relationship between 30-day mortality and past-year CAS hospital volume as well as past-year hospital non-CAS volume, past-year hospital non-CAS volume, and 30-day mortality was also noted. CONCLUSIONS: Among Medicare patients, an inverse relationship exists between physician and hospital CAS volumes and hospital non-CAS stenting volume and 30-day mortality, even after adjusting for all pertinent patient- and hospital-level factors.
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Implantación de Prótesis Vascular , Arterias Carótidas/cirugía , Estenosis Carotídea/epidemiología , Hospitales de Alto Volumen/estadística & datos numéricos , Médicos/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Implantación de Prótesis Vascular/mortalidad , Estenosis Carotídea/mortalidad , Estenosis Carotídea/cirugía , Ensayos Clínicos como Asunto , Estudios de Cohortes , Endarterectomía Carotidea , Femenino , Humanos , Masculino , Medicare , Selección de Paciente , Práctica Profesional , Stents/estadística & datos numéricos , Análisis de Supervivencia , Estados UnidosRESUMEN
The aim of this study was to examine the association between distance education (DE) and students' sense of classroom community (SCC) in U.S. dental hygiene programs. The concept of SCC is recognized to have an influence on students' educational outcomes. With the goal of increasing diversity among future dental professionals, there comes a need to accommodate students of various backgrounds through the use of DE. The impact of DE on students' SCC has not been studied in previous research. This 2014 cross-sectional survey study looked at a convenience sample of dental hygiene students finishing their first or second clinical year to assess their SCC. Participating programs had both host and satellite campuses and utilized DE for didactic course delivery at the remote sites. To calculate the students' sense of community, Rovai's Classroom Community Scale (CCS) was utilized, and demographic information was collected. Six of the 13 eligible programs agreed to participate; the overall response rate for individual students was 25%. When evaluated on their sense of community, the satellite college-based students scored 26.47 CCS units and 14.51 learning subscale units lower than the host college-based students. These results suggested a negative association between the students' sense of community and their affiliation with satellite campuses when controlled for demographic variables. The findings suggest a negative trend in the SCC for dental hygiene students on remote campuses and utilizing DE for a portion of their curriculum. This trend can potentially decrease students' educational success and satisfaction and should be addressed.
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Actitud del Personal de Salud , Higienistas Dentales/educación , Educación a Distancia , Estudiantes/psicología , Adulto , Factores de Edad , Estudios Transversales , Higienistas Dentales/psicología , Empleo , Femenino , Humanos , Relaciones Interpersonales , Aprendizaje , Masculino , Satisfacción Personal , Distancia Psicológica , Factores Sexuales , Estados Unidos , Adulto JovenRESUMEN
IMPORTANCE: Despite increased carotid artery stenting (CAS) dissemination following the 2005 National Coverage Determination, to our knowledge, periprocedural and long-term outcomes have not been described among Medicare beneficiaries. OBJECTIVE: To describe the incidence of outcomes during and after the periprocedural period among Medicare beneficiaries undergoing CAS. DESIGN, SETTING, AND PARTICIPANTS: Observational study with a mean follow-up time of approximately 2 years among 22,516 fee-for-service Medicare beneficiaries at least 66 years old undergoing CAS (2005-2009) who were linked to the Centers for Medicare & Medicaid Services' CAS database. Database procedure dates were required to fall during a Medicare hospitalization for CAS. MAIN OUTCOMES AND MEASURES: Periprocedural (30-day) and long-term risks of mortality and stroke or transient ischemic attack, as well as periprocedural myocardial infarction. Subgroups were based on sociodemographic, clinical, and center-level factors, as well as the Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial or Carotid Revascularization Endarterectomy vs Stenting Trial (CREST) enrollment criteria. RESULTS: The mean patient age was 76.3 years, 60.5% were male, 93.8% were of white race, 91.2% were at high surgical risk, 47.4% were symptomatic, and 97.4% had carotid stenosis of at least 70%. Crude 30-day mortality, stroke or transient ischemic attack, and myocardial infarction risks were 1.7% (95% CI, 1.5%-1.8%), 3.3% (95% CI, 3.0%-3.5%), and 2.5% (95% CI, 2.3%-2.7%), respectively. Mortality during a mean follow-up time of 2 years was 32.0% (95% CI, 31.0%-33.0%), with rates of 37.3% (95% CI, 35.8%-38.7%) among symptomatic patients and 27.7% (95% CI, 26.4%-28.9%) among asymptomatic patients. Older age, symptomatic carotid stenosis, and nonelective hospital admission were associated with increased adjusted hazards of mortality and stroke or transient ischemic attack during and after the periprocedural period. The presence of a stroke center, government ownership, and a hospital bed capacity of 500 or more were associated with increased adjusted hazards of periprocedural mortality and stroke or transient ischemic attack. Few patients met the SAPPHIRE trial or CREST enrollment criteria primarily because physicians did not meet proficiency requirements either due to exceeding periprocedural complication trial thresholds or not meeting minimum CAS volume requirements. CONCLUSIONS AND RELEVANCE: Competing risks may limit the benefits of CAS in certain Medicare beneficiaries, particularly among older and symptomatic patients who have higher periprocedural and long-term mortality risks. The generalizability of trials like the SAPPHIRE or CREST to the Medicare population may be limited, underscoring the need to evaluate real-world effectiveness of carotid stenosis treatments.
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Estenosis Carotídea/mortalidad , Estenosis Carotídea/cirugía , Beneficios del Seguro/tendencias , Medicare/tendencias , Stents , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Masculino , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
CONTEXT: The role of adjuvant chemotherapy remains poorly defined for the management of muscle-invasive bladder cancer (MIBC). The last meta-analysis evaluating adjuvant chemotherapy, conducted in 2005, had limited power to fully support its use. OBJECTIVE: To update the current evidence of the benefit of postoperative adjuvant cisplatin-based chemotherapy compared with control (ie, surgery alone) in patients with MIBC. EVIDENCE ACQUISITION: A comprehensive literature review was performed to identify all randomized controlled trials (RCTs) comparing adjuvant cisplatin-based chemotherapy with control for patients with MIBC. The search included the Medline, Embase, Cochrane Central Register of Controlled Trials databases, and abstracts from the American Society of Clinical Oncology meetings up to May 2013. An updated systematic review and meta-analysis was performed. EVIDENCE SYNTHESIS: A total of 945 patients included in nine RCTs (five previously analyzed, one updated, and three new) were examined. For overall survival, the pooled hazard ratio (HR) across all nine trials was 0.77 (95% confidence interval [CI], 0.59-0.99; p=0.049). For disease-free survival, the pooled HR across seven trials reporting this outcome was 0.66 (95% CI, 0.45-0.91; p=0.014). This disease-free survival benefit was more apparent among those with positive nodal involvement (p=0.010). CONCLUSIONS: This updated and improved meta-analysis of randomized trials provides further evidence of an overall survival and disease-free survival benefit in patients with MIBC receiving adjuvant cisplatin-based chemotherapy after radical cystectomy.