ObjectiveTo examine the hypothesis that elective laparoscopic repair should be routinely performed on patients with asymptomatic or minimally symptomatic paraesophageal hernias. Summary Background DataThe management of asymptomatic paraesophageal hernias is a controversial issue. Most surgeons believe that all paraesophageal hernias should be corrected electively on diagnosis, irrespective of symptoms, to prevent the development of complications and avoid the risk of emergency surgery. MethodsA Markov Monte Carlo decision analytic model was developed to track a hypothetical cohort of patients with asymptomatic or minimally symptomatic paraesophageal hernia and reflect the possible clinical outcomes associated with two treatment strategies: elective laparoscopic paraesophageal hernia repair (ELHR) or watchful waiting (WW). The input variables for ELHR were estimated from a pooled analysis of 20 published studies, while those for WW and emergency surgery were derived from the 1997 HCUP-NIS database and surgical literature published from 1964 to 2000. Outcomes for the two strategies were expressed in quality-adjusted lifeyears (QALYs). ResultsAnalysis of the HCUP-NIS database showed that published studies overestimate the mortality of emergency surgery (17% vs. 5.4%). The mortality rate of ELHR was 1.4%. The annual probability of developing acute symptoms requiring emergency surgery with the WW strategy was 1.1%. For patients 65 years of age, ELHR resulted in reduction of 0.13 QALYs (10.78 vs. 10.65) compared with WW. The model predicted that WW was the optimal treatment strategy in 83% of patients and ELHR in the remaining 17%. The model was sensitive only to alterations of the mortality rates of ELHR and emergency surgery. ConclusionsIf ELHR is routinely recommended, it would be more beneficial than WW in fewer than one of five patients. WW is a reasonable alternative for the initial management of patients with asymptomatic or minimally symptomatic paraesophageal hernias, and even if an emergency operation is required, the burden of the procedure is not as severe as was thought in the past.The need for surgical correction of asymptomatic paraesophageal hernias is controversial. Many surgeons, citing the influential studies of Belsey 1 and Hill, 2 advocate elective repair of all paraesophageal hernias irrespective of symptoms. The rationale for this approach is prophylactic; that is, prevention of life-threatening complications such as obstruction and strangulation and avoidance of the significant morbidity and mortality of an emergency operation. The perception that laparoscopic techniques offer a less morbid approach to surgical correction of paraesophageal hernias is cited as an additional reason to support the elective repair of paraesophageal hernias. However, beliefs held by the surgical community about the natural history of paraesophageal hernias and the morbidity and mortality of both elective and emergency operations are based on relatively small patient series and anecdotal case reports. Several recent ...

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Among patients who died of cancer, chemotherapy was used frequently in the last 3 months of life. The cancer's responsiveness to chemotherapy does not seem to influence whether dying patients receive chemotherapy at the end of life.

Twenty-five to sixty percent of physicians report burnout across all specialties. Changes in the healthcare environment have created marked and growing external pressures. In addition, physicians are predisposed to burnout due to internal traits such as compulsiveness, guilt, and self-denial, and a medical culture that emphasizes perfectionism, denial of personal vulnerability, and delayed gratification. Professional coaching, long utilized in the business world, provides a results-oriented and stigma-free method to address burnout, primarily by increasing one’s internal locus of control. Coaching enhances self-awareness, drawing on individual strengths, questioning self-defeating thoughts and beliefs, examining new perspectives, and aligning personal values with professional duties. Coaching utilizes established techniques to increase one’s sense of accomplishment, purpose, and engagement, all critical in ameliorating burnout. Coaching presumes that the client already possesses strengths and skills to handle life’s challenges, but is not accessing them maximally. Although an evidence base is not yet established, the theoretical basis of coaching’s efficacy derives from the fields of positive psychology, mindfulness, and self-determination theory. Using a case example, this article demonstrates the potential of professional coaching to address physician burnout.

Medicare expenditures in the last year of life decrease with age, especially for those aged 85 years or older. This is in large part because the aggressiveness of medical care in the last year of life decreases with increasing age.

Medicare-insured decedents in California were more than 4 times more likely to be enrolled in MCOs, were 50% more likely to use a hospice, and had a 30% lower hospitalization rate than decedents in Massachusetts, yet there are few differences in out-of-hospital deaths or expenditures in the last year of life. However, patients with cancer using hospice did have significant savings.

Objectives Calibrating a disease simulation model’s outputs to existing clinical data is vital to generate confidence in the model’s predictive ability. Calibration involves two challenges: 1) defining a total goodness-of-fit score for multiple targets if simultaneous fitting is required; and 2) searching for the optimal parameter set that minimizes the total goodness-of-fit score (i.e., yields the best fit). To address these two prominent challenges, we have applied an engineering approach to calibrate a microsimulation model, the Lung Cancer Policy Model (LCPM). Methods First, eleven targets derived from clinical and epidemiological data were combined into a total goodness-of-fit score by a weighted-sum approach, accounting for the user-defined relative importance of the calibration targets. Second, two automated parameter search algorithms, Simulated Annealing (SA) and Genetic Algorithm (GA), were independently applied to a simultaneous search of 28 natural history parameters to minimize the total goodness-of-fit score. Algorithm performance metrics were defined for speed and model fit. Results Both search algorithms obtained total goodness-of-fit scores below 95 within 1,000 search iterations. Our results show that SA outperformed GA in locating a lower goodness-of-fit. After calibrating our LCPM, the predicted natural history of lung cancer was consistent with other mathematical models of lung cancer development. Conclusion An engineering-based calibration method was able to simultaneously fit LCPM output to multiple calibration targets, with the benefits of fast computational speed and reduced need for human input and its potential bias.

Actual implementation of probabilistic sensitivity analysis may lead to misleading or improper conclusions when it is applied to groups of patients rather than individual patients. The practice of combining first- and second-order simulations when modeling the outcome for a group of more than one patient yields an erroneous marginal distribution whenever the parameter values are randomly sampled for each patient while the results are presented as simulated means for the group of patients. This practice results in underrepresenting the second-order uncertainty. It may also distort the shape (especially the symmetry or extent of the tails) in the simulated distribution. As a result, it may lead to premature or incorrect conclusions of superiority. It may also result in inappropriate estimates of the value of further research to inform parameter values.