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Our study supports the need for minimizing contrast dose in patients with renal dysfunction. A contrast dose on the basis of estimated renal function with a planned contrast volume restricted to less than thrice and preferably twice the CCC might be valuable in reducing the risk of CIN and NRD.

ITH RATES INCREASINGover the last decade, 1 bariatric surgery has become the second most common abdominal operation in the United States. Despite trends toward declining mortality rates, 2 payers and patient advocacy groups remain concerned about the safety of bariatric surgery and uneven quality across hospitals. In response, 2 major professional organizations-the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery-have implemented programs for accrediting hospitals as centers of excellence (COE) in bariatric surgery. Standards for COE accreditation vary somewhat between the programs, but they generally include minimum procedure volume standards, availability of specific protocols and resources for managing morbidly obese patients, and submission of outcomes data to a central registry.Context Despite the growing popularity of bariatric surgery, there remain concerns about perioperative safety and variation in outcomes across hospitals.Objective To assess complication rates of different bariatric procedures and variability in rates of serious complications across hospitals and according to procedure volume and center of excellence (COE) status.Design, Setting, and Patients Involving 25 hospitals and 62 surgeons statewide, the Michigan Bariatric Surgery Collaborative (MBSC) administers an externally audited, prospective clinical registry. We evaluated short-term morbidity in 15 275 Michigan patients undergoing 1 of 3 common bariatric procedures between 2006 and 2009. We used multilevel regression models to assess variation in risk-adjusted complication rates across hospitals and the effects of procedure volume and COE designation (by the American College of Surgeons or American Society for Metabolic and Bariatric Surgery) status.Main Outcome Measure Complications occurring within 30 days of surgery.Results Overall, 7.3% of patients experienced perioperative complications, most of which were wound problems and other minor complications. Serious complications were most common after gastric bypass (3.6%; 95% confidence interval [CI], 3.2%-4.0%), followed by sleeve gastrectomy (2.2%; 95% CI, 1.2%-3.2%), and laparoscopic adjustable gastric band (0.9%; 95% CI, 0.6%-1.1%) procedures (PϽ.001). Mortality occurred in 0.04% (95% CI, 0.001%-0.13%) of laparoscopic adjustable gastric band, 0 sleeve gastrectomy, and 0.14% (95% CI, 0.08%-0.25%) of the gastric bypass patients. After adjustment for patient characteristics and procedure mix, rates of serious complications varied from 1.6% (95% CI, 1.3-2.0) to 3.5% (95% CI, 2.4-5.0) (risk difference, 1.9; 95% CI, 0.08-3.7) across hospitals. Average annual procedure volume was inversely associated with rates of serious complications at both the hospital level (Ͻ150 cases, 4.

With better weight loss than LAGB and lower complication rates than RYGB, SG is a reasonable choice for the treatment of morbid obesity and should be covered by both public and private payers.

There is evidence that collaborations between hospitals and physicians in particular regions of the country have led to improvements in the quality of care. Even so, there have not been many of these collaborations. We review one, the Michigan regional collaborative improvement program, which was paid for by a large private insurer, has yielded improvements for a range of clinical conditions, and has reduced costs in several important areas. In general and vascular surgery alone, complications from surgery dropped almost 2.6 percent among participating Michigan hospitals-a change that translates into 2,500 fewer Michigan patients with surgical complications each year. Estimated annual savings from this one collaborative are approximately $20 million, far exceeding the cost of administering the program. Regional collaborative improvement programs should become increasingly attractive to hospitals and physicians, as well as to national policy makers, as they seek to improve health care quality and reduce costs.

ORONARY ARTERY DISEASE REmains the most frequent cause of death and disability in the developed world and rates are increasing among developing nations. 1 As the population at risk has increased, national health care systems are under financial pressure to deliver cost-effective diagnosis and risk stratification of symptomatic patients suspected of having coronary ischemia. Noninvasive multislice cardiac computed tomography angiography (CCTA) has emerged since 2000 as a new diagnostic test with the potential to efficiently address this challenge. 2,3 Multiple studies of the accuracy of CCTA compared with invasive coronary angiography in thousands of patients have documented sensitivities and negative predictive values in the range of 90%. 4-6 This suggests that CCTA may definitively exclude the diagnosis of coronary artery disease in a substantial proportion of appropriately selected patients, allowing scarce

A B S T R A C T PurposeGene expression profile (GEP) testing is a relatively new technology that offers the potential of personalized medicine to patients, yet little is known about its adoption into routine practice. One of the first commercially available GEP tests, a 21-gene profile, was developed to estimate the benefit of adjuvant chemotherapy for hormone receptor-positive breast cancer (HR-positive BC). Patients and MethodsBy using a prospective registry data set outlining the routine care provided to women diagnosed from 2006 to 2008 with HR-positive BC at 17 comprehensive and community-based cancer centers, we assessed GEP test adoption and the association between testing and chemotherapy use. Overall, testing was associated with lower odds of chemotherapy use (OR, 0.70; 95% CI, 0.62 to 0.80). Stratified analyses demonstrated that for small, node-negative cancers, testing was associated with higher odds of chemotherapy use (OR, 11.13; 95% CI, 5.39 to 22.99), whereas for node-positive and large node-negative cancers, testing was associated with lower odds of chemotherapy use (OR, 0.11; 95% CI, 0.07 to 0.17). Results ConclusionThere has been a progressive increase in use of this GEP test and an associated shift in the characteristics of and overall reduction in the proportion of women with HR-positive BC receiving adjuvant chemotherapy.

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