Geographic variation in patient surveillance after radical prostatectomy

The AIMS65 score compared with the Glasgow-Blatchford score in predicting outcomes in upper GI bleeding

INTRODUCTION

We previously derived and validated the AIMS65 score, a mortality prognostic scale for upper GI bleeding (UGIB).

OBJECTIVE

To validate the AIMS65 score in a different patient population and compare it with the Glasgow-Blatchford risk score (GBRS).

DESIGN

Retrospective cohort study.

PATIENTS

Adults with a primary diagnosis of UGIB.

PRIMARY OUTCOME

inpatient mortality.

SECONDARY OUTCOMES

composite clinical endpoint of inpatient mortality, rebleeding, and endoscopic, radiologic or surgical intervention; blood transfusion; intensive care unit admission; rebleeding; length of stay; timing of endoscopy. The area under the receiver-operating characteristic curve (AUROC) was calculated for each score.

RESULTS

Of the 278 study patients, 6.5% died and 35% experienced the composite clinical endpoint. The AIMS65 score was superior in predicting inpatient mortality (AUROC, 0.93 vs 0.68; P < .001), whereas the GBRS was superior in predicting blood transfusions (AUROC, 0.85 vs 0.65; P < .01) The 2 scores were similar in predicting the composite clinical endpoint (AUROC, 0.62 vs 0.68; P = .13) as well as the secondary outcomes. A GBRS of 10 and 12 or more maximized the sum of the sensitivity and specificity for inpatient mortality and rebleeding, respectively. The cutoff was 2 or more for the AIMS65 score for both outcomes.

LIMITATIONS

Retrospective, single-center study.

CONCLUSION

The AIMS65 score is superior to the GBRS in predicting inpatient mortality from UGIB, whereas the GBRS is superior for predicting blood transfusion. Both scores are similar in predicting the composite clinical endpoint and other outcomes in clinical care and resource use.

Geographical variation in surveillance strategies after curative-intent surgery for upper aerodigestive tract cancer

BACKGROUND

Analysis of geographical variation in utilization of medical resources is often used to identify regions of overutilization or underutilization.

METHODS

We surveyed the membership of the American Head and Neck Society regarding their recommended frequency of office visits and 13 imaging studies and blood tests for their patients after potentially curative therapy for upper aerodigestive tract cancers.

RESULTS

Of the 1322 members surveyed, 610 (46%) responded: 420 responses (32%) were assessable. Responses were compared by US Census Region, Metropolitan Statistical Area, and managed care organization penetration rate. Overseas members (16% of assessable responses) comprised a separate category for the regional analysis. There were statistically significant variations in practice patterns among Census Regions for office visits, complete blood count, computed tomography of the head, sonography, and esophagoscopy. Non-US members recommended significantly more blood tests, imaging studies, and endoscopy than US members for routine cancer surveillance. Only the frequency of office visits differed significantly among Metropolitan Statistical Areas. Surprisingly, the penetration rate of managed care organizations had no significant effect on posttreatment surveillance intensity.

CONCLUSIONS

This analysis indicates that only a small portion of the wide variation in observed follow-up practice patterns can be explained by geographical determinants.

Social disparities and prostate cancer: mapping the gaps in our knowledge

To evaluate the current state of our knowledge regarding social disparities and prostate cancer and to map the domains where substantial knowledge has been acquired as well as those where little is known, with the purpose of identifying important areas for future research. A Medline research was conducted to identify published papers regarding social disparities in prostate cancer since 1990. The results of this review are presented in a social disparities and prostate cancer grid designed to highlight which domains of social disparities have been researched and which neglected. The major social disparity in prostate cancer concerns the extremely high prostate cancer incidence and mortality seen among black Americans. This is also the area where the most research has been performed. Low socioeconomic position is associated with poorer prostate cancer outcomes but not with higher prostate cancer incidence. It remains poorly defined to what extent racial/ethnic differences in prostate cancer result from differences in socioeconomic position (SEP). Understanding the causes of the high prostate cancer mortality seen among black men remains the major challenge in the area of social disparities and prostate cancer.

How do we manage breast cancer in the elderly patients? A survey among members of the British Association of Surgical Oncologists (BASO)

AIMS

To frame the attitude and perception of breast surgeons in the UK toward the increasing number of older breast cancer patients.

METHODS

A 15-item questionnaire was designed to inquire on the definition of elderly, clinical management, age-related differences in surgical treatment, interaction with geriatricians, operative risk assessment, and surveyed identification/descriptive data. The questionnaire was sent to all 350 ABS associates (Association of Breast Surgery) at the British Association of Surgical Oncology (BASO).

RESULTS

A 150 questionnaires were returned (compliance 43%) providing the largest sample of breast surgical specialist overview on this topic. The major part of the surveyed (44%) stated age does not stand as the most relevant factor on its own in identifying a patient as "elderly", nor in offering surgical management (98%) and in dealing with the axilla (75%). The surveyed are aware of the burden of this epidemiological problem and would rather finalise the decision-making process based on multiple factors. This is to tailor the most appropriate treatment aiming to improving quality of life (42%) and quality adjusted survival (40%). Although most breast surgeons are inclined to discuss their onco-geriatric patients with geriatricians on a regular (32%) or occasional (42%) basis, no geriatric assessment is routinely utilised (82%) and the operative risk is predicted with ASA (45%). These figures confirm the surveyed breast surgeons in the UK are not biased by an ageistic approach, and aim to achieve a global well-being to the older patients with breast cancer.

CONCLUSIONS

This survey confirms our lack of knowledge in the management of elderly patients affected by breast cancer. Taken into account the limitations of a survey, we are pleased to confirm the performance of the largest part of breast surgeons at BASO is not biased by an ageist mentality.

Geographic variation in posttreatment surveillance intensity for patients with cutaneous melanoma

BACKGROUND

We investigated whether geographic determinants could account for variation in posttreatment melanoma surveillance intensity among plastic surgeons.

METHODS

A custom-designed questionnaire was mailed to U.S. and non-U.S. members of the American Society of Plastic and Reconstructive Surgeons (ASPRS). Subjects were asked how they use 14 specific follow-up modalities during years 1 to 5 and 10 following primary treatment for patients with cutaneous melanoma. Repeated-measures analysis of variance was used to compare practice patterns by TNM stage, year postsurgery, U.S. census region, metropolitan statistical area (MSA), and managed care organization (MCO) penetration rate.

RESULTS

Of the 1,142 respondents, 395 were evaluable. Those who did not perform melanoma surgery or follow-up were excluded. Correlation analysis showed that mean follow-up intensity for the modalities surveyed was highly correlated across TNM stages and years postsurgery. Within MSAs, only chest radiograph utilization varied significantly. The pattern of testing varied significantly by geographic region for seven modalities (office visit, computed tomography scan of the brain and chest/abdomen, alpha-fetoprotein level, 5S-cysteinyl dopa level, abdominal ultrasonogram, bone scan); in each of these, utilization by non-U.S. surgeons exceeded utilization in any U.S. census region. The pattern of testing varied significantly by MCO penetration rate for chest radiograph (greater utilization in the lowest MCO penetration rate areas) and 5S-cysteinyl dopa level (greater utilization in the highest MCO penetration rate areas).

CONCLUSIONS

The intensity of posttreatment surveillance recommended by ASPRS members caring for patients with cutaneous melanoma varies markedly. This analysis provides the first evidence that geographic factors significantly affect the surveillance strategies of clinicians following patients with cutaneous melanoma. Variation by census region was most prominent, although the size of detected differences was small.