By Y. Trompok. Paine College. 2018.
Supporting Evidence: Recently generic accutane 40 mg with visa acne 8 dpo, BCBSA Medical Advisory Panel made the following judgments about whether 1H MRS for evaluation of suspected brain tumors meets the BCBSA TEC criteria based on the available evidence (58) purchase accutane 40mg on line skin care while pregnant. The advisory panel reviewed seven published studies that included up to 271 subjects (59–65). These seven studies were selected for inclusion in the review of evidence because (1) the sample size was at least 10; (2) the criteria for a positive test were speciﬁed; (3) there was a method to conﬁrm 1H MRS diagnosis; and (4) the report provided sufﬁcient data to calculate diagnostic test performance (sensitivity and speciﬁcity). The reviewers speciﬁcally addressed whether 1H MRS for evaluation of suspected brain tumors meets the following ﬁve TEC criteria: 1. The technology must have approval from the appropriate governmen- tal regulatory bodies. The scientiﬁc evidence must permit conclusions concerning the effect of the technology on health outcomes. With the exception of the ﬁrst criterion, the reviewers concluded that the available evidence on 1H MRS in the evaluation of brain neoplasm was insufﬁcient. The TEC also concluded that the overall body of evidence does not provide strong and consistent evidence regarding the diagnostic test characteristics of MRS in determining the presence or absence of brain neo- plasm, both for differentiation of recurrent/residual tumor vs. Assessment of the health beneﬁt of MRS in avoiding brain biopsy was evaluated in two studies (59,64), but the studies had limitations. However, other human studies conducted on the use of MRS for brain tumors demonstrate that this noninvasive method is techni- cally feasible and suggest potential beneﬁts for some of the proposed indi- cations. But there is a paucity of high-quality direct evidence demonstrating the impact on diagnostic thinking and therapeutic decision making. What Is the Cost-Effectiveness of Imaging in Patients with Suspected Primary Brain Neoplasms or Brain Metastatic Disease? Summary of Evidence: Routine brain CT in all patients with lung cancer has a cost-effectiveness ratio of $69,815 per quality-adjusted life year (QALY). However, the cost per QALY is highly sensitive to variations in the nega- tive predictive value of a clinical evaluation, as well as to the cost of CT. Chapter 6 Imaging of Brain Cancer 113 Cost-effectiveness analysis (CEA) of patients with headache suspected of having a brain neoplasm are presented in Chapter 10. For a hypothetical cohort of patients, it was assumed that all primary lung carcinomas were potentially resectable. If no brain metastasis were detected by CT, the primary lung tumor would be resected. Brain metastasis as detected by CT would disqualify the patient for resection of the primary lung tumor. Costs were taken from the payer’s perspective and based on prevailing Medicare payments. The rates of false- positive and false-negative ﬁndings were also considered in the calculation of the effectiveness of CT. The cost of the CT-ﬁrst strategy was $11,108 and the cost for the CT-deferred strategy $10,915; however, the CT-ﬁrst strat- egy increased life expectancy by merely 1. The cost per QALY is highly sen- sitive to variations in the negative predictive value of a clinical evaluation, as well as to the cost of CT. This study is instructive because it highlights the importance of considering false-positive and false-negative ﬁndings and performing sensitivity analysis. For a detailed discussion of the speciﬁcs of the decision-analytic model and sensitivity analysis, the reader is referred to the articles by Colice et al. Take-Home Figure Patients with suspected brain cancer based on clinical examination ·Acute focal neurologic deficit ·Nonchronic seizure or headache ·Progressive personality or cognitive changes Nonanatomic imaging: ·Proton spectroscopy ·Perfusion/diffustion MRI Laboratory test: · ·SPECT or PET Blood ·Cerebrospinal fluid ·EEG/EMG Figure 6. In patients with presenting with an acute neurologic event such as seizure or focal deﬁcit, noncontrast head CT examination should be done expeditiously to exclude any life-threatening conditions such as hemorrhage or herniation. Cha Imaging Case Studies Several cases are shown to illustrate the pros and cons of different neu- roimaging modalities differentiating true neoplasms from lesion mimick- ing neoplasms. Case 1 A 54-year-old man with headache and seizures and a pathologic diagno- sis of glioblastoma multiforme (GBM) (Figure 6.
Minor complications and failures occurred early in the author’s experience and were seen in fewer than 1% of patients 5mg accutane visa acne yahoo. Radiographs demonstrate opac- ification of the right L4 nerve root with min- imal epidural reflux: (A) oblique and (B) AP views discount accutane 30mg without prescription skin care must haves. Radiographs following in- jection of 1 mL of nonionic contrast showing (A) oblique and (B) AP views. A B 166 Complications 167 epidurography prior to injection of therapeutic substances significantly minimizes the risks of procedures. Allergic reaction to contrast material is a known risk when iodinated contrast is used. Complications or side effects specific to epidural steroid injections include headache, which is most likely following thecal punc- ture. When a dural puncture occurs, it is easy to recognize after con- trast administration, and neither steroid nor local anesthetic should be administered at that level. Instead, the needle is removed, and the epidural space is accessed at another level. The possibility of intrathe- cal injection is the reason for using a nonionic contrast medium that has been approved for myelography. If dural puncture occurs, the patient is given postmyelogram instructions (oral hydration and 12- to 24-hour bed rest). By diagnosing a thecal puncture and avoiding intrathecal steroid administration, significant side effects may be avoided. In fact, intrathecal injections of steroids were once used to treat certain conditions such as multiple sclerosis. Nonetheless, the precau- tions described earlier for avoiding intrathecal steroid injections are im- portant, since arachnoiditis may be a devastating clinical condition. More acutely, injection of local anesthetic into the thecal sac may result in pro- found hypotension and transient anesthesia. Transient anesthesia in the lumbar area will wear off in 1 to 3 hours and is usually only inconve- nient. In the cervical region, this effect may result in respiratory arrest, necessitating intubation and respiratory support. This is generally avoided by not using anesthetics in cervical epidural injections. Infection (epidural empyema/abscess or meningitis) is a potential and serious complication that may occur from contamination follow- ing skin puncture. Meningitis may result, with the potential for rapid dissemina- tion within the central nervous system. Obviously, the same meticu- lous attention to sterile technique that is used for myelography must be exercised for epidural injections. High volumes of injectate into the epidural space may result in vit- real hemorrhage. Transient paral- ysis also has been described following lumbar epidural injection, but this is extremely rare. The subsequent injection into the cord produced intrinsic spinal cord injury with permanent symptoms. Fluoroscopy and constant awareness of needle tip position, performing epidurog- raphy before steroid injection, and interaction with an awake patient will significantly decrease the chance of such misadventure. Of course, the use of fluoroscopy alone will not ensure against cord injury or the- cal sac puncture. Additional complications may result in anterior radicular arteries due to injection or injury of major feeding anterior radicular arteries to the spinal cord. This is likely the cause of profound complications, such as spinal cord infarction. Use of the techniques described in this chapter will minimize rates of both minor and serious complication. The au- thor has performed several thousand procedures in an outpatient set- ting without any serious complications. Several studies have demonstrated the difficulty and uncertainty of obtaining an accurate injection without imaging guidance.
These steps are (1) prep- aration of a realistic action plan by each MTF that defines a focused strategy and sets of actions to introduce the guideline and to change clinic procedures (where needed) purchase 5 mg accutane mastercard acneorg, (2) performance of the defined actions by designated staff buy accutane 40 mg overnight delivery acne pregnancy, (3) ongoing monitoring of progress in making intended practice changes through the actions undertaken, and (4) adjustment of action strategies in response to monitoring findings. This process is based on the recognition that quality im- provement involves a series of manageable, incremental steps, each of which builds on previous steps over time to achieve continual improvements in health care processes and outcomes. Lessons from the Low Back Pain Demonstration 103 We list here some items that arose from the low back pain demon- stration, which are within the authority and responsibility of MEDCOM. Careful attention to the following should help build an effective program to support the MTFs in their implementation activities: • Commit corporate leadership to implementation of evidence- based best practices, which is essential to establishing a viable program across the AMEDD system. MEDCOM has eased the workload for MTFs by providing tools and techni- cal guidance, thus enhancing the potential to achieve practice improvements. Maintain a balance between flex- ibility for local MTF approaches and provision of sufficient policy direction to ensure that AMEDD is moving toward greater consistency in practices. This function should develop the data and analytic capa- bility to perform the measurement and report results to the MTFs, and it also should be equipped to provide training and support to MTFs for their local monitoring processes. Although the low back pain documentation form was shown to improve provider efficiency, it became a point of con- 104 Evaluation of the Low Back Pain Practice Guideline Implementation tention that often distracted from the real task at hand—the im- provement of low back pain care. The number of new forms will multiply as more guidelines are introduced, which could be a deterrent for the program if not presented appropriately. Con- tract providers resisted participation for the low back pain guideline, and similar resistance was observed in other demon- strations. These attitudes are due in part to financial incentives created by their contracts, where they are paid based on the number of visits they complete, and time spent on any other ac- tivities is unpaid time. Individual MTFs are not likely to take the lead in communicating information or ideas with others because each of them has a full set of work commitments that tend to discourage it from looking beyond the MTF boundaries. Examples of issues that oc- curred in the low back pain demonstration (as well as later in the asthma and diabetes guideline demonstrations) include how to handle patients presenting with multiple concerns or diagnoses, placement of documentation forms in the medical chart, proce- dures for use of diagnostic codes for visits, and the reading level for patient education materials. Thus, consider replacing traditional utilization review functions with this more proactive approach to achieve appropriate and consistent practices. Resource limitations inevitably define the scope of implementation any given MTF can undertake. Priorities for action should be consis- tent with available resources, and in turn, the needed resources Lessons from the Low Back Pain Demonstration 105 should be provided to support the agreed-upon actions. Both the ac- tions defined and the allocation of resources should be time limited, so that the desired new practices can be successfully integrated into a clinic’s routine and then these resources can be reallocated to other priorities. Appendix A EVALUATION METHODOLOGY PROCESS EVALUATION To capture the full dynamics of a process as complex as practice guideline implementation, it is important to take into account the roles and interactions of the many aspects of the system in which the guidelines are being implemented. A variety of stakeholders need to be considered to ensure that indi- viduals involved in implementing new practices anticipate possible effects on the stakeholders and responses that might be expected from them. These groups include treatment program leadership, middle management, the clinical and administrative staff working with program residents, and the clients themselves. The implemen- tation team consists of important stakeholders who not only are serving as team members but also have other job responsibilities. Information was collected about the actions involved in practice guideline implementation for participating MTFs, the dynamics of the change process, and responses of participants to their experi- ences with the process. Similarities and differences in the attitudes, motivations, and preferences of the stakeholders were considered as the process evaluation information was collected and results were synthesized. To capture changes in structures, processes, and issues as guideline implementation moved forward, site visits were con- 107 108 Evaluation of the Low Back Pain Practice Guideline Implementation ducted to collect information at baseline and at two follow-up times, as shown in Table A. A participant-observer approach was used throughout the imple- mentation process and evaluation. In addition to the site visits, we used routine progress reports and maintained an ongoing communi- cation process to provide a structure through which implementing MTFs could get assistance from each other, MEDCOM, or RAND. Both qualitative and quantitative data collection methods were used in the process evaluation to collect information on a set of questions that cover the dimensions shown in Table A. Focus groups were conducted with three groups: the im- plementation team, providers, and other clinic staff. Participants in each stakeholder group were asked questions regarding their atti- tudes toward guideline implementation, how they worked with the practice guideline, how they were affected by the implementation process, and issues or concerns they identified. Semi-structured in- terview methods were used for all interviews, group discussions, and focus groups, working from lists of questions to cover during each session.
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