Among patients with spondylolisthesis and lumbar spinal stenosis, laminectomy with fusion was associated with modestly greater improvement in physical health–related quality of life than laminectomy ...alone but not with significantly greater reduction in disability related to back pain.
The increased use of the lumbar spinal fusion procedure in the United States, along with the wide variation in practice, is attracting interest from multiple stakeholders, including patients, physicians, payers, and policymakers. In a report published in 2014, spinal fusion (465,000 hospital-based procedures in 2011) accounted for the highest aggregate hospital costs ($12.8 billion in 2011) of any surgical procedure performed in U.S. hospitals.
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The randomized, controlled Spine Patient Outcomes Research Trial (SPORT) showed that surgery was superior to nonoperative care for the management of lumbar degenerative spondylolisthesis.
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In SPORT, most patients in the surgical group were treated by means . . .
In November 2013, the American College of Cardiology and American Heart Association (ACC/AHA) released a clinical practice guideline on the treatment of blood cholesterol to reduce cardiovascular ...risk in adults. This synopsis summarizes the major recommendations.
In 2008, the National Heart, Lung, and Blood Institute convened the Adult Treatment Panel (ATP) IV to update the 2001 ATP-III cholesterol guidelines using a rigorous process to systematically review randomized, controlled trials (RCTs) and meta-analyses of RCTs that examined cardiovascular outcomes. The panel commissioned independent systematic evidence reviews on low-density lipoprotein cholesterol and non-high-density lipoprotein cholesterol goals in secondary and primary prevention and the effect of lipid drugs on atherosclerotic cardiovascular disease events and adverse effects. In September 2013, the panel's draft recommendations were transitioned to the ACC/AHA.
This synopsis summarizes key features of the guidelines in 8 areas: lifestyle, groups shown to benefit from statins, statin safety, decision making, estimation of cardiovascular disease risk, intensity of statin therapy, treatment targets, and monitoring of statin therapy.
The Precision Medicine Initiative’s advances may add complexity to delivering high-quality, cost-effective care in keeping with patients’ values. A complementary effort could investigate ...delivery-system interventions that are tailored to individual needs and wishes.
In 2015, President Barack Obama launched the Precision Medicine Initiative (PMI), aimed at enabling “a new era of medicine through research, technology, and policies that empower patients, researchers, and providers to work together toward development of individualized care.”
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He requested $215 million for the initiative in his 2016 budget — public research funding dedicated to creating diagnostics and treatments tailored to individual patients’ biologic (genetic and molecular) profiles.
All physicians aspire to individualize medical care, yet patients often receive care that’s not aligned with their preferences and generally have inadequate access to their health information. The PMI’s scientific advances may . . .
Medical cost analysis is increasingly important, but the methodology is complex and varied.
To illustrate how different cost analysis methodologies influence conclusions generated from data from a ...prospective nonrandomized trial for treatment of cervical spondylotic myelopathy.
Patients 40 to 85 years of age with degenerative cervical spondylotic myelopathy were enrolled from 7 sites over 2 years (2007-2009). Patients were treated with ventral or dorsal fusion surgery, and outcomes were measured to 1 year postoperatively. A hospital-based cost analysis was performed using Medicare cost-to-charge ratios (CCRs) multiplied by hospital charges from the index hospitalization (CCR method). A society-based cost analysis was performed by estimating costs from the index hospitalization using Medicare coding reimbursement (the Medicare reimbursement method). A separate outpatient cost analysis was performed on a subset of 20 patients.
Of the 85 patients analyzed, 72 had 1-year follow-up. The CCR method showed a difference in upfront direct costs between the dorsal and ventral approaches ($27,942 ± 14,220 vs $21,563 ± 8721; P = .02). Overall upfront direct costs with the Medicare reimbursement method were not different. With the CCR method, the ventral approach dominates an incremental cost-effectiveness ratio analysis. With the Medicare reimbursement method, the incremental cost-effectiveness ratio for ventral surgery is $34,533, the cost of 1 additional quality-adjusted life-year gained by using ventral instead of dorsal surgery. In the subanalysis, outpatient costs were less after ventral surgery than dorsal surgery ($1997 ± 1211 vs $4734 ± $2874; P = .006).
The choice of cost methodology may substantially influence the final results of an economic study.
IMPORTANCE: Cervical spondylotic myelopathy is the most common cause of spinal cord dysfunction worldwide. It remains unknown whether a ventral or dorsal surgical approach provides the best results. ...OBJECTIVE: To determine whether a ventral surgical approach compared with a dorsal surgical approach for treatment of cervical spondylotic myelopathy improves patient-reported physical functioning at 1 year. DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial of patients aged 45 to 80 years with multilevel cervical spondylotic myelopathy enrolled at 15 large North American hospitals from April 1, 2014, to March 30, 2018; final follow-up was April 15, 2020. INTERVENTIONS: Patients were randomized to undergo ventral surgery (n = 63) or dorsal surgery (n = 100). Ventral surgery involved anterior cervical disk removal and instrumented fusion. Dorsal surgery involved laminectomy with instrumented fusion or open-door laminoplasty. Type of dorsal surgery (fusion or laminoplasty) was at surgeon’s discretion. MAIN OUTCOMES AND MEASURES: The primary outcome was 1-year change in the Short Form 36 physical component summary (SF-36 PCS) score (range, 0 worst to 100 best; minimum clinically important difference = 5). Secondary outcomes included 1-year change in modified Japanese Orthopaedic Association scale score, complications, work status, sagittal vertical axis, health resource utilization, and 1- and 2-year changes in the Neck Disability Index and the EuroQol 5 Dimensions score. RESULTS: Among 163 patients who were randomized (mean age, 62 years; 80 49% women), 155 (95%) completed the trial at 1 year (80% at 2 years). All patients had surgery, but 5 patients did not receive their allocated surgery (ventral: n = 1; dorsal: n = 4). One-year SF-36 PCS mean improvement was not significantly different between ventral surgery (5.9 points) and dorsal surgery (6.2 points) (estimated mean difference, 0.3; 95% CI, −2.6 to 3.1; P = .86). Of 7 prespecified secondary outcomes, 6 showed no significant difference. Rates of complications in the ventral and dorsal surgery groups, respectively, were 48% vs 24% (difference, 24%; 95% CI, 8.7%-38.5%; P = .002) and included dysphagia (41% vs 0%), new neurological deficit (2% vs 9%), reoperations (6% vs 4%), and readmissions within 30 days (0% vs 7%). CONCLUSIONS AND RELEVANCE: Among patients with cervical spondylotic myelopathy undergoing cervical spinal surgery, a ventral surgical approach did not significantly improve patient-reported physical functioning at 1 year compared with outcomes after a dorsal surgical approach. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02076113
The article discusses the findings of a study to evaluate and compare the content on the American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) Examination with conditions seen ...in practice by general internists, which reveal that 69% were concordant with conditions seen in general medicine practices, although some areas of discordance were identified. The need for the ABIM to strive for continuous improvement and become more relevant and useful is highlighted.
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