Roberto Cardarelli

Systematic review: prevalence of malignant incidental thyroid nodules identified on fluorine-18 fluorodeoxyglucose positron emission tomography.

PurposeTo review current literature and determine the prevalence of malignant incidental focal hypermetabolic thyroid lesions detected by fluorine-18 fluorodeoxyglucose positron emission tomography (18F-FDG-PET). Materials and methodsStudies evaluating thyroid carcinomas discovered incidentally on 18F-FDG-PET were systematically searched in the MEDLINE, CINAHL, and Evidence-Based Medicine (EBM) Reviews from 1998 to 2007. Studies were eligible for inclusion with the following criteria: 18F-FDG-PET studies carried out on humans, long-term clinical follow-up or presence of histological confirmation of thyroid disease, and if studies reported the prevalence of abnormal 18F-FDG-PET scans with thyroid lesions and confirmed pathological thyroid disease. Studies were excluded if (1) there was no confirmed diagnosis, (2) there was a history of thyroid cancer, (3) they were carried out for diagnoses of thyroid abnormalities, or (4) they were case series. Two reviewers independently reviewed each studys eligibility and abstracted the data. ResultsEighteen articles met criteria resulting in a total of 55 160 patients with 571 patients (1%) having an unexpected focal abnormality in the thyroid gland. Diagnostic confirmations were obtained in 322 patients. Among the confirmed diagnoses, 200 (62.1%) were benign, 107 (33.2%) were malignant, and 15 (4.7%) were indeterminate or a patient without a clear diagnosis. Papillary thyroid carcinoma was the most prevalent thyroid malignancy (82.2%). Eight studies reporting individual maximum standard uptake values were included in a subanalysis. The mean maximum standard uptake value for 73 benign lesions was 4.6±2.1, and for the 52 malignant lesions was 6.8±4.6 (P<0.001). ConclusionThe high prevalence of malignancy associated with focal hypermetabolic thyroid nodules found on 18F-FDG-PET warrants further evaluation when detected.

Having a Personal Healthcare Provider and Receipt of Adequate Cervical and Breast Cancer Screening

Introduction: The purpose of this study was to assess the relationship between having a personal health care provider and adequate cervical and breast cancer screening behavior. Methods: Cross-sectional data were obtained from the 2004 Behavior Risk Factor Surveillance System. For cervical cancer, female respondents 18 years of age and older who did not have hysterectomy were included (n = 130,359); for breast cancer, female respondents 40 years of age or older were included (n = 129,929). Multiple logistic regression analyses were performed to determine the association between having a personal health care provider, specific demographics, and health insurance status with adequate cervical and breast cancer screening behavior. Results: Approximately 9% and 14% of the study population for the breast cancer and cervical cancer analyses, respectively, did not have a personal health care provider. Having at least one personal health care provider was significantly associated with adequate cervical cancer screening behavior (odds ratio, 2.37; 95% CI, 2.08–2.70) and breast cancer screening behavior (odds ratio, 2.86; 95% CI, 2.54–3.24) in multivariate analyses. Both multivariate analyses were adjusted for age, race/ethnicity, education, income, and health insurance. Conclusion: Having at least one personal health care provider was associated with adequate cervical and breast cancer screening behavior. Efforts to increase primary care access are a necessary part of the plan to increase preventive health services utilization.

Recruiting Practice-based Research Network (PBRN) physicians to be research participants: lessons learned from the North Texas (NorTex) needs assessment study.

Introduction: The purpose of this study was to examine strategies for recruiting physician subjects in a practice-based research network continuing education research study, using different recruitment methods at four systems, or health plan arrangements. Methods: The North Texas Primary Care Practice-based Research Network Needs Assessment Study consisted of a survey and five self-directed medical record abstractions. Physicians were recruited to be research subjects from four systems, using different recruitment strategies. χ2 was used to determine differences in physicians consenting and completing the study between systems. Kruskal-Wallis was used to determine differences in time from first contact to consent and number of contacts required before consent between systems. Results: One hundred five of 211 physicians (49.8%) consented to participate, of which 90 (85.7%) completed the survey. There was a significant difference by system in the number of physicians who consented (P = .04) and number of contacts required pre-consent (P < .001) but not in the number of physicians completing the study or time from first contact to consent. Discussion/Conclusions: Success of recruiting physicians to be research subjects varied between systems using different recruitment methods. Lessons learned include using clinician champions to make initial contact, establishing a relationship with clinic personnel, distinguishing the research team from a pharmaceutical representative, establishing a preferred contact method, and collecting study materials on a set timeline.

The Association of Free Testosterone Levels in Men and Lifestyle Factors and Chronic Disease Status A North Texas Healthy Heart Study

Purpose: Hypogonadism is highly prevalent in men older than 45 years and is associated with an increased risk of chronic diseases, including obesity, metabolic syndrome, diabetes, and cardiovascular disease. The objective of this study was to determine whether lifestyle factors such as smoking, diet, and exercise are associated with reduced testosterone levels. Methods: In this cross-sectional study, 147 men older than 44 years were recruited from a collaborative network of primary care clinics in the Dallas/Fort Worth, Texas, metropolitan area. Free testosterone levels were measured in plasma samples via an enzyme-linked immunosorbent assay–based method, and analyzed by simple and multiple linear regression in relationship to age, race/ethnicity, smoking, diet, exercise, obesity, diabetes, hypertension, and dyslipidemia. Results: The participants had a mean free testosterone level of 3.1 ng/mL (standard deviation [SD] = 1.5) and mean age of 56.8 years (SD = 7.9). In simple regression analysis, free testosterone levels were associated with increased age (β = −0.04; P = .02), diet (β = −0.49; P = .05), diabetes (β = −0.9; P = .003), and hypertension (β = −0.55; P = .03) but not with race/ethnicity, smoking, exercise, obesity, or dyslipidemia. In multiple regression analysis, free testosterone values were significantly associated only with age (β = −0.05; P = .01) and diet (β = −0.72; P = .01). Conclusions: This study implicates diet, in addition to advanced age as a possible risk factor in the development of reduced testosterone levels.

Terminate lung cancer (TLC) study—A mixed-methods population approach to increase lung cancer screening awareness and low-dose computed tomography in Eastern Kentucky

For low dose CT lung cancer screening to be effective in curbing disease mortality, efforts are needed to overcome barriers to awareness and facilitate uptake of the current evidence-based screening guidelines. A sequential mixed-methods approach was employed to design a screening campaign utilizing messages developed from community focus groups, followed by implementation of the outreach campaign intervention in two high-risk Kentucky regions. This study reports on rates of awareness and screening in intervention regions, as compared to a control region.

The influence of research compensation options on Practice-based Research Network (PBRN) physician participation: a North Texas (NorTex) PBRN study.

Objective: To study the effect of two compensation approaches, continuing medical education (CME) credits (5 hours) or monetary (

Systematic Review of Ambulatory Transitional Care Management (TCM) Visits on Hospital 30-Day Readmission Rates.

150), on the participation rate of a physician needs assessment study. Methods: Physicians representing family medicine, internal medicine, pediatric, and geriatrics specialties, and practicing in ambulatory primary care clinics affiliated with the North Texas Primary Care (NorTex) PBRN clinics, were recruited to complete a survey relevant to their subspecialty and to conduct a self-audit/abstraction of five medical records. Physicians were recruited from four health care systems, and the recruiting methods varied by system. Study outcome was the rate of study completion by type of incentive. Results: One hundred five of 211 (49.8%) physicians approached to participate gave consent and 84 (39.8%) completed the study. There was no difference in the number of physicians randomly assigned to monetary compared with CME compensation for giving consent to participate (adjusted odds ratio = 1.42, confidence interval = 0.69, 2.93). However, physicians in the monetary compensation group were more likely to complete the study after giving consent (adjusted odds ratio = 4.70, confidence interval = 1.25, 17.58). This monetary effect was also significant from the perspective of all physicians approached initially (adjusted odds ratio = 2.78, confidence interval = 1.16, 6.67). Discussion: This study suggests that future PBRN investigators should receive monetary compensation for the opportunity cost of adding research activities to their already busy practices. This compensation may be especially vital for PBRNs to complete more ambitious projects requiring a significant time commitment from the participating physicians.

Incidental Computer Tomography Radiologic Findings through Research Participation in the North Texas Healthy Heart Study

To reduce readmission rates and prevent adverse outcomes after discharge, hospitals have begun implementing “transitional care” initiatives. This systematic review identifies research on the particular set of services now reimbursable by Medicare (transitional care management [TCM]) and evaluates the studies for program effectiveness. Results of 3 databases were screened for peer-reviewed journal articles published between January 2004 and 2015 that report on readmissions of adults in the US health care system under the Medicare TCM bundle. ClinicalTrials.gov was queried for funded studies. Of 969 identified studies, 77 met inclusion criteria for relevance to transitional care and appropriateness of population and setting. Of these, only 3 articles incorporated all required elements for TCM service. Although 2 were program improvement designs and none were randomized controlled studies, each report reduced readmission rates. Evidence for TCM effectiveness is limited. Additional study of TCM implementation and programmatic support for TCM is warranted.

Dissemination Approaches to Participating Primary Care Providers in a Quality Improvement Program Addressing Opioid Use in Central Appalachia.

Background: Although variation exists in the classification and practice of managing clinical findings in research, emerging views suggest that researchers bear some responsibility in the management of incidental findings. This study contributes to the documentation of the population characteristics and prevalence of medical findings incidental to research participation, specifically findings related to coronary calcium scores and computed tomography (CT) scans that investigated cardiovascular disparities in an asymptomatic population. Methods: A total of 571 asymptomatic adult participants were recruited in the North Texas Healthy Heart Study. Participants completed a 16-slice CT scan of the heart and abdomen. Findings of radiology reports and 3 years of follow-up documentation were reviewed. Results: A total of 246 clinically apparent findings were identified in 169 asymptomatic participants (32.9% of participants who completed a CT scan). Another 245 participants (48%) had findings of unknown significance, a total of 307 findings. At least 4 cases in this study led to a clinically significant intervention. Conclusion: Although CT scans were completed for research purposes, study procedures resulted in the diagnosis and treatment of individuals who were previously asymptomatic. Potential clinical benefits in imaging research are moderated by considerations regarding possible harm and costs resulting from uncertain findings and the use of CT scans for nonclinical purposes. The continued development of protocols for the handling of incidental findings in research and the establishment of guidelines are needed to ensure that research procedures mirror the best interests of participants.

Improving Chronic Pain Management Processes in Primary Care Using Practice Facilitation and Quality Improvement: The Central Appalachia Inter-Professional Pain Education Collaborative

Objectives Practice-based research networks (PBRNs) have been described as new clinical laboratories for primary care research and dissemination. PBRNs, however, have struggled to disseminate research results in a meaningful way to participating providers and clinics. Methods The Central Appalachia Inter-Professional Pain Education Collaborative was developed to work with PBRN clinics using quality improvement methods, deliver statewide continuing education activities to address the issue of opioid use in patients with chronic pain, and develop a multimodal mechanism to disseminate project results to clinics and participating providers. Results Successful change in the delivery of chronic pain care was dependent on the clinic’s commitment to a team-based, patient-centered approach. Statistically significant improvements were shown in 10 of 16 process measures, and 80% of the participants agreed that the quality improvement process activity increased their knowledge and would improve their performance in managing patients with chronic pain, as well as patient outcomes in their practice. Conclusions The Central Appalachia Inter-Professional Pain Education Collaborative project used an extensive and innovative dissemination plan under the rubric of “continual dissemination.” Unlike traditional dissemination efforts that focus on summary presentations, this initiative used a continual dissemination approach that updated participants quarterly through multiple means throughout the project, which improved engagement in the project.