Provider-Level Variation in Treatment Planning of Radiation Oncology Procedures in the United States

PURPOSE: Variation in the use of radiation oncology procedures and technologies is poorly characterized. We sought to identify associations between the treatment planning codes used to bill for radiotherapy procedures and the demographic characteristics of the radiation oncologists submitting them. METHODS: The Physician and Other Supplier Public Use File was linked to the Physician Compare database by using the physician National Provider Identifier for the year 2016. Analysis was stratified by practice setting, considering both the freestanding non–facility-based (NFB) setting and the facility-based (FB) setting. Multivariable logistic regression was used to determine provider characteristics (gender, practice rurality, and years since graduation) that predicted for the use of 3D-conformal RT (3DCRT) planning, intensity-modulated RT (IMRT) planning, and brachytherapy planning in the Medicare population. RESULTS: Three thousand twenty-nine physicians were linked for analysis. In both the FB and NFB settings together, male gender predicted for decreased likelihood of 3DCRT planning (OR, 0.70, 95% CI, 0.62 to 0.80, P < .001) and increased likelihood of IMRT planning (OR, 1.35, 95% CI, 1.19 to 1.54, P < .001). Brachytherapy planning was also more likely with increasing years since medical school graduation (OR, 1.03, 95% CI, 1.01 to 1.04, P < .001) in the combined FB and NFB settings. These significant associations persisted when examining the NFB and FB settings individually. In both settings overall, brachytherapy planning was more likely in male providers (OR, 1.75, 95% CI, 1.10 to 2.76, P = .02) and also more likely for providers practicing in metropolitan regions compared with those practicing in rural areas (OR, 3.01, 95% CI, 1.23 to 7.39, P = .02). CONCLUSION: Male gender predicts for utilization of IMRT planning, whereas female gender predicts for utilization of 3DCRT planning. Future research is warranted to better understand the role that provider gender and rurality play in the selection of radiation planning techniques for Medicare patients.

Alexander Béla (1857-1916), a magyar radiológia „nagy embere” emlékezete halála 105. évfordulóján

Béla Alexander, born in the historical Upper Hungary (Slovakia today) dedicated his whole life to X-rays discovered by Conrad Röntgen. After medical school graduation, he was known as a poet and a community activist as well. For more than ten years he was treating indigent people in Késmárk (Kežmarok today) in the daylight time and experimented with X-rays during the nights. Although Alexander gained an international reputation for his X-ray images and studies, made and written about upper and lower limbs’ bones, the scientific value of his stereoscopic X-rays was argued in Hungarian academic circles. Due to his successful struggles, Alexander moved up the career ladder in the capital Budapest from 1907. Milestones of his career: director of the X-ray lab between 1906 and 1907, then the director of the University Institute for X-rays between 1907 and 1916, which was established on his former X-ray lab.) After his death caused by X-rays, directors of the Institute continued Alexander’s work between the two World Wars.

Distribution of male and female procedural and surgical specialists in Australia

ObjectiveThis study examined the distribution of the sexes across Australian medical procedural specialties in 2017 and investigated the proportion of currently registered female specialists based on their graduation date from 1969 to 2008. MethodsA cross-sectional analysis of current Australian procedural and surgical specialists registered with the Australian Health Practitioner Registration Agency as of January 2017 was undertaken. Participants included 4851 surgical specialists (594 female, 4257 male) and 14948 specialists in specialties with high levels of procedural clinical work (4418 female, 10530 male). The number of male and female specialists across each procedural specialty and the medical school graduation date of current female specialists were analysed. ResultsIn 2017, female fellows represented only one in 10 surgeons and three in 10 procedural specialists. All surgical specialties are underrepresented by female specialists. Cardiology is least represented by female practitioners (one in 10), followed by intensive care and ophthalmology (two in 10). General surgery, otolaryngology and urology saw more female specialists with graduation dates between 1983 and 2003 compared with the other surgical specialties. ConclusionThe number of female practitioners registered as specialists is increasing, but they continue to be underrepresented at specialist level across many procedural and surgical specialties. What is known about the topic?Although the number of female students entering medical school now outnumbers that of males, female practitioners remain underrepresented at the specialist level. What does this paper add?Surgery continues to be underrepresented by female specialists, but general surgery, otolaryngology and urology have shown increases in females reaching specialist level. All procedural specialties have shown increasing numbers of female practitioners reaching the specialist level. What are the implications for practitioners?All surgical specialties and nearly all procedural specialties need to adopt evidence-based practices to make their training programs both appealing and sustainable to female trainees in order to work towards achieving gender parity.

Early medical school graduation during the COVID-19 pandemic: preliminary assessment

Introduction: The current outbreak of the new coronavirus or SARS-CoV-2, which causes COVID-19, was first reported to the World Health Organization on December 31, 2019, being declared a pandemic on March 11, 2020. As for the clinical spectrum of SARS-CoV-2 infection, it is a broad one, ranging from asymptomatic, mild upper respiratory tract disease to severe viral pneumonia with respiratory failure and death. With a chance of severe clinical presentation close to 25%, SARS-CoV-2 infection can lead to health service overload and increase the demand for material and human resources. Aiming to increase the availability of health professionals directly involved in care during the pandemic, the Ministry of Education authorized the early graduation for students pursuing careers in health, including medicine. Objective: The aim of this article is to obtain preliminary results of the impact of early graduation for medical students during the COVID-19 pandemic. Method: Observational and cross-sectional study, carried out by applying a questionnaire with 13 questions, five of which used a Likert scale of assessment, six in multiple choice format and two descriptive, via Google Forms, applied to medical students from the universities of Curitiba-PR that graduated earlier in mid-year 2020, due to the COVID-19 pandemic. Results: 113 recently graduated students answered the questionnaire.101 participants reported that they are working as physicians and, among them, 63.36% stated that they are working directly in the treatment of COVID-19 cases. Regarding the importance of an early graduation, most participants fully agree or agree, while only three participants totally disagree. More than half of the interviewees do not feel harmed by the early graduation. However, 43.3% believe they have failed to acquire important information for their training. Finally, regarding their performance in the pandemic, 79.6% consider important their role in the fight against COVID-19 pandemic. Conclusion: The study shows that, at first, the efforts to give the Class of 2020 an early graduation were successful, since these new physicians are contributing to alleviate workforce shortages and provide better care for patients during the pandemic.

Leadership, recognition awards, and publication by men and women in the American Academy of Neurology

ObjectiveTo study sex differences with respect to publications, leadership, and recognition awards in the American Academy of Neurology (AAN) in light of recent research highlighting inequities in these domains.MethodsWe examined medical school graduation, neurology residency (using American Medical Association and American Council for Graduate Medical Education data), membership in the AAN, first and last authorship in Neurology®, membership on AAN committees, and AAN recognition awards by sex for 1997, 2007, and 2017.ResultsFemale medical students were less likely to enter neurology residency in 1997 only. In 2007 and 2017, there was no proportionate difference between men and women as last author, a surrogate for senior member of the author panel. In 2017, women were proportionately more likely to be first authors than men, a surrogate for principal investigator of the study. Committee membership was less for women in 1997 and 2007 (p < 0.001) but was not proportionately different in 2017 (p = 0.534). Women were proportionately more likely to receive recognition awards in all years studied (1997 p = 0.008, 2007 p < 0.001, 2017 p < 0.001), although absolute numbers of women were lower.ConclusionsFemale membership, leadership (through committee membership), and publications as last author were lower in 1997 in the AAN. These same metrics demonstrated substantial proportionate changes, with no differences in last authorship in 2007 and 2017, greater likelihood for women to be first author in 2017, no differences in committee membership in 2017, and greater likelihood of receiving awards determined by merit in all 3 years.

New generation of medical students: what they are looking for?

Background Changes in technologies and standards of life leads to the fact that each generation is very different from the previous one. Modification of generations affects the quality and the development of medicine. Current medical students are our future doctors. And changes in health care will be made by them soon. So, their views will influence the development of health care system in the future. Therefore, it is important for us to understand how today's graduates see their future work and what is important for them. Methods The opinions of 720 final year medical students were investigated using an anonymous questionnaire in Krasnoyarsk, Russia. Data were analyzed using SPSS 22 program by the following methods (p &lt; 0.05): descriptive statistics, decision trees analysis, χ2-test. Results Medicine have to change rapidly in accordance with the demands of new generations. Only in such case, current graduates of medical schools would like to work in practice medicine in the future. In this work, factors that are important for the work of modern students were investigated. Such posers were examined: the opportunities to work in rural areas and the basis for such decisions, the choice of future doctors' specialty, the young doctors' self-confidence and how much time they need experienced doctors' support as mentors. To avoid further staff shortages, we have to take into account the needs and priorities of today's graduates. Conclusions Practically all of the graduates are not ready to work alone immediately after medical school graduation - 97.0% of them report that they need a mentor. In addition, the majority of them prefer to work with mentor for a year or more (80.5%). Practically half of the students are ready to work in rural areas (49.5%); the most important factors that influence their decision are salary, free housing and clinic's equipment (important for 53.4%, 35.9% and 26.5% of the graduates, respectively). Key messages The majority of the graduates are not ready to work alone immediately after medical school graduation and need a mentor for a year or more. Increased salary, free housing and good clinic’s equipment may attract the medical graduates to work in rural areas.

Physician Practice Variability in the Use of Extended-Fraction Radiation Therapy for Bone Metastases: Are We Choosing Wisely?

PURPOSE: Routine use of extended-fraction (> 10 fractions) radiation therapy (RT) for palliation of bone metastases is recognized as a low-value intervention by the American Society for Radiation Oncology. We examined contemporary practice patterns of, and physician characteristics associated with extended-fraction RT use. MATERIALS AND METHODS: We conducted a retrospective cohort study using Medicare fee-for-service data. We included patients who underwent 2- or 3-dimensional external-beam RT for bone metastases between January 1, 2016, and December 31, 2018. Physicians treating > 10 patients over the study period were analyzed for their individual practice. Hierarchic logistic regression modeling was used to identify patient- and physician-level factors associated with extended-fraction RT use. RESULTS: A total of 12,221 patients (median age, 75.6 years; 40.9% women, 87.6% white) were included. The rate of extended-fraction RT was 23.4%. A total of 1,432 physicians treated any patient. Among the 382 physicians treating > 10 patients, 127 (33.2%) used extended-fraction RT > 30% (consensus threshold). Physician factors associated with decreased odds of extended-fraction RT were years since medical school graduation (≤ 10 years and 11-20 years v ≥ 31 years: adjusted odds ratio [aOR], 0.32 [95% CI, 0.20 to 0.51] and 0.64 [95% CI, 0.44 to 0.93]) and practicing in the Northeast or Midwest versus the South (aOR, 0.36 [95% CI, 0.22 to 0.58] and 0.48 [95% CI, 0.31 to 0.74]). Physicians treating > 20 patients ( v 11-14 patients) over the study period had increased odds of delivering extended-fraction RT (aOR, 1.53 [95% CI, 1.10 to 2.12]). CONCLUSION: In this study, almost one fourth of patients received extended-fraction RT, and one third of physicians had an extended-fraction RT use rate of > 30%. Personalized feedback of performance data, clinical pathways and peer review, and updated reimbursement models are potential mechanisms to address this low-value care.

Do neurosurgeons receive more patient complaints than other physicians? Describing who is most at risk and how we can improve

OBJECTIVEThe number of unsolicited patient complaints (UPCs) about surgeons correlates with surgical complications and malpractice claims. Using a large, national patient complaint database, the authors sought to do the following: 1) compare the rates of UPCs for neurosurgeons to those for other physicians, 2) analyze the risk of UPCs with individual neurosurgeon characteristics, and 3) describe the types of UPCs made about neurosurgeons.METHODSPatient and family complaint reports among 36,265 physicians, including 423 neurosurgeons, 8292 other surgeons, and 27,550 nonsurgeons who practiced at 33 medical centers (22 academic and 11 regional) from January 1, 2014, to December 31, 2017, were coded with a previously validated Patient Advocacy Reporting System (PARS) algorithm.RESULTSAmong 423 neurosurgeons, 93% were male, and most (71%) practiced in academic medical centers. Neurosurgical subspecialties included general practice (25%), spine (25%), tumor (16%), vascular (13%), functional (10%), and pediatrics (10%). Neurosurgeons had more average total UPCs per physician (8.68; 95% CI 7.68–9.67) than nonsurgeons (3.40; 95% CI 3.33–3.47) and other surgeons (5.01; 95% CI 4.85–5.17; p < 0.001). In addition, a significantly higher percentage of neurosurgeons received at least one UPC (71.6%; 95% CI 67.3%–75.9%) than did nonsurgeons (50.2%; 95% CI 49.6%–50.8%) and other surgeons (58.2%; 95% CI 57.1%–59.3%; p < 0.001). Factors most associated with increased average UPCs were younger age, measured as median medical school graduation year (1990.5 in the 0-UPC group vs 1993 in the 14+-UPC group, p = 0.009) and spine subspecialty (13.4 mean UPCs in spine vs 7.9 mean UPCs in other specialties, 95% CI 2.3–8.5, p < 0.001). No difference in complaints was seen in those who graduated from non-US versus US medical schools (p = 0.605). The most common complaint types were related to issues surrounding care and treatment, communication, and accessibility, each of which was significantly more common for neurosurgeons than other surgical specialties (p < 0.001).CONCLUSIONSNeurosurgeons were more likely to generate UPCs than other surgical specialties, and almost 3 out of 4 neurosurgeons (71.6%) had at least one UPC during the study period. Prior studies have shown that feedback to physicians about behavior can result in fewer UPCs. These results suggest that neurosurgeons have opportunities to reduce complaints and potentially improve the overall quality of care delivered.

The association between drug industry payments and NCCN guideline panel membership.

2068 Background: The high frequency of financial relationships between the pharmaceutical industry and influential oncologists who author clinical practice guidelines may influence guideline recommendations. Therefore, we assessed the financial relationships held by NCCN Guidelines panelists before and after joining the panel, compared to those held by a matched set of oncologists. Methods: Membership of NCCN Guidelines panels for the 20 most common cancers was obtained from archival guidelines and linked manually to Open Payments records of industry payments. We identified physicians who newly joined an NCCN panel during the August 2013-December 2018 study period, and we included medical oncologists who had at least 1 year of Open Payments data before and after joining. These medical oncologists who joined an NCCN panel (panelists) were matched 1:2 to medical oncologists with the same gender, institutional affiliation, and medical school graduation year, who did not join an NCCN panel (non-panelists). The dollar value of industry payments was then calculated over the 1 year before (pre-join) and after (post-join) the date that each panelist joined. We used generalized linear models to assess differences in industry payments between the panelists and matched non-panelists in the pre-join period. We used difference-in-difference estimation (DiD) to assess whether joining an NCCN panel was associated with increased payments in the post-join period. Results: There were 54 panelists and 108 non-panelists (matched from 1447 eligible oncologists at NCCN institutions). Mean per-oncologist payments among panelists were greater than non-panelists in the pre-join period ($11,259 vs $3,427, p = 0.02). From the pre-join to post-join period there was a similar increase in mean per-oncologist payments among panelists and non-panelists ($2,236 vs. $1,569, DiD estimate +$667, p = 0.77). Conclusions: Medical oncologists who were selected to an NCCN Guidelines panel had greater financial ties to industry compared to peer oncologists who were not selected. This difference was present prior to joining; oncologists did not experience a greater increase in financial payments from industry in the 1-year period after joining an NCCN panel. These results suggest an opportunity to reduce the potential influence of industry in oncology clinical practice guidelines through the selection of guideline panelists with fewer ties to industry.