2 Minute Medicine Rewind October 30, 2023

Racial differences in low-value care among older adult Medicare patients in US health systems: a retrospective cohort study

1. In this retrospective cohort study of Medicaid patients in the United States, Black participants were more likely than White participants to receive low-value diagnostic tests, while White participants were more likely than Black participants to receive low-value screening tests and interventions. 

Evidence Rating Level: 2 (Good)

Low-value medical care includes services that provide little benefit but have the potential for harm. These harms may be financial or physical. Researchers aimed to determine whether there are racial differences in the receipt of low-value care in the United States. 9,833,304 Medicare patients in the United States (6.8% Black, 57.9% female) aged 65 or older were included in this retrospective cohort study from 2016 to 2018. The researchers identified 40 low-value medical services. Black patients were more likely to receive low-value diagnostic tests in an acute setting compared to White participants, such as imaging for uncomplicated headaches (6.9% compared to 3.2%). White participants were more likely to receive low-value screening tests and treatments, such as prostate-specific antigen testing (31.0% compared to 25.7%) and antibiotics for upper respiratory tract infections (36.6% compared to 32.7%. P < 0.001 for all comparisons. These findings were attributed to Black and White participants receiving different care within systems, rather than participants seeking care from different systems. A limitation of this study is that racial groups other than Black and White participants were not included. Future research may examine whether there are racial differences in the harms that occur due to low-value medical services. As well, future work may focus on identifying policies to mitigate the provision of low-value care. 

Perinatal Trajectories of Maternal Depressive Symptoms in Prospective, Community-Based Cohorts Across 3 Continents

1. In this prospective cohort study, the maternal depressive symptoms were found to follow a stable trajectory from early pregnancy to two years postpartum. 

Evidence Rating Level: 1 (Excellent)

Maternal depressive symptoms during the peripartum period have a significant impact on the well-being of both mothers and their offspring. While postpartum depression is more commonly addressed in the literature, depressive symptoms during pregnancy are under-examined. Researchers aimed to assess the course of depressive symptoms across the perinatal period. This study uses data from 7 prospective cohorts across the United Kingdom, Canada, and Singapore. These cohorts spanned different time periods, collectively including 1991 to 2022. 11,563 women were included in the studies, (mean [SD] age, 29 [5] years). 4.9% of participants were East Asian, 2.6% were Southeast Asian, and 87.6% were White. Data were collected on self-reported depressive symptoms from early pregnancy to 2 years post-partum. Researchers used either the Edinburgh Postnatal Depression Scale or the Center for Epidemiological Studies Depression Scale to determine symptom severity. K-means clustering identified 3 trajectory groups of depressive symptoms (low, mild, and high) for each of the 7 cohorts. IRT analysis determined that the mean trajectory of depressive symptoms for all groups remained stable throughout the period from early pregnancy to 2 years postpartum. These findings conflict with the more typical emphasis on symptom onset in the post-partum period, which predominates in both research and clinical practice. The authors suggest that future research should not focus exclusively on the postpartum period. Patients would also likely benefit from greater screening for depressive symptoms throughout pregnancy, as well as earlier interventions. A limitation of this study is that the cohorts lacked racial diversity, and no data were collected from low or middle-income countries; therefore, the findings may not be generalizable to all populations.  

Efficacy of Testosterone Replacement Therapy in Correcting Anemia in Men With Hypogonadism, A Randomized Clinical Trial

1. In this randomized clinical trial, testosterone replacement therapy both treated and prevented anemia in middle and older men with hypogonadism. 

Evidence Rating Level: 1 (Excellent)

Testosterone deficiency is a known cause of mild normocytic anemia. Approximately 15% of older men with hypogonadism will develop anemia. In this randomized, placebo-controlled trial, researchers aimed to assess whether testosterone replacement therapy (TRT) can prevent or correct anemia in men with both hypogonadism. The trial took place across 316 sites, including 5204 men in the United States between May 2018 and February 2022. The study was conducted as part of the Testosterone Replacement Therapy for Assessment of Long-term Vascular Events and Efficacy Response in Hypogonadal Men (TRAVERSE) Study. Participants were aged 45 to 80, with testosterone levels below 300 ng/dL on two separate occasions, symptoms of hypogonadism, as well as cardiovascular disease (CVD) or increased CVD risk. 815 of the participants had anemia (mean [SD] age, 64.8 [7.7] years), while 4379 did not have anemia (mean [SD] age, 63.0 [7.9] years). Participants were randomized into two groups, with one group treated with 1.62% testosterone gel and the other with placebo gel. A significantly greater proportion of men in the treatment group had their anemia corrected compared to the placebo group at 6 months (41.0% vs 27.5%), 12 months (45.0% vs 33.9%), 24 months (42.8% vs 30.9%), 36 months (43.5% vs 33.2%), and 48 months (44.6% vs 39.2%) (P = .002). Similarly, for the participants without anemia, TRT resulted in a significantly smaller proportion of men developing anemia compared to placebo. This study demonstrates that TRT is effective for both treating and preventing anemia in men aged 45 to 80 with hypogonadism. A limitation of this study is that only men with CVD or risk factors for CVD were included, which limits the generalizability of this data. This study is clinically important, demonstrating that TRT benefits men with hypogonadism, both for preventing and treating anemia. 

Shoulder replacement surgery’s rising demand, inequality of provision, and variation in outcomes: cohort study using Hospital Episode Statistics for England

1. In this retrospective cohort study, the incidence of shoulder replacement surgery was found to be rising in the United Kingdom, with regional inequalities in service provision, and increasing rates of serious adverse events. 

Evidence Rating Level: 2 (Good)

Most cases of shoulder pain occur due to degenerative and inflammatory conditions, which can be effectively managed with shoulder replacement surgery. There is little data regarding the incidence of and access to this surgery in the United Kingdom. In this cohort study, 77,613 elective primary and 5847 revision shoulder surgeries between 1999 and 2020 were included in the analysis. Over the study period, the incidence of primary shoulder replacements rose from 2.6 to 10.4 per 100,000 population. This increase mainly occurred in the demographic over the age of 65. Given that approximately 16.7% of participants needed to travel to a different region to have their surgery, researchers concluded that there is evidence of inequalities in regional service provision in the United Kingdom. The researchers also assessed trends in serious adverse events (SAEs) from shoulder replacement surgery. Over the study period, SAEs increased, with the 30-day risk increasing from 1.3 to 4.8% and the 90-day risk increasing from 2.4 to 6.0%. Participants of lower socioeconomic status were more likely to experience SAEs and require revision surgeries. The incidence of shoulder replacement surgery is projected to continue to increase in the United Kindom, with an expected increase of 234% by 2050. Overall, this study demonstrates that the incidence of shoulder replacement surgeries is rising in the United Kingdom, with regional inequalities in service provision, and an increasing rate of serious adverse events from these surgeries. This study demonstrates that policymakers will need to adequately plan for the required infrastructure and workforce needed to accommodate this projected demand for shoulder replacement surgery. Future research may examine why serious adverse events from this surgery are increasing, and whether there are any strategies that could be employed to mitigate these risks. 

Deep learning models of ultrasonography significantly improved the differential diagnosis performance for superficial soft-tissue masses: a retrospective multicenter study

1. In this retrospective study, the use of deep learning models improved the accuracy of radiologic diagnosis of benign and malignant superficial soft tissue masses. 

Evidence Rating Level: 2 (Good)

The majority of superficial soft tissue masses are benign tumors. Early detection and accurate diagnoses are necessary for determining treatment and prognosis for these masses. Diagnostic difficulties exist because there are over 70 different subtypes of benign superficial tumors, with few subtypes displaying the classic textbook signs. In this retrospective study, data were collected on 1615 patients with superficial soft tissue masses between January 2015 and December 2022. Two radiologists analyzed the ultrasound images of these masses and diagnosed them as either malignant or a subtype of a benign mass. Deep learning models (DLM) were also employed to analyze the images, with DLM-1 used to distinguish between benign and malignant masses, with an AUC of 0.992 (95% CI: 0.980, 1.0) and an ACC of 0.987 (95% CI: 0.968, 1.0), while DLM-2 was used to categorize the benign masses into the 5 most common subtypes. These subtypes are lipomyoma, hemangioma, neurinoma, epidermal cyst, and calcifying epithelioma, with AUCs of 0.986, 0.993, 0.944, 0.973, and 0.903, respectively. After referring to the DLM results, the radiologists re-evaluated their diagnoses. The initial diagnoses were then compared to the histopathological report for each mass. Using the DLMs, the radiologists improved their diagnostic accuracy. For the radiologist with 30 years of experience, using the DLMs improved their accuracy of diagnosing benign masses from 71.4% to 80.9% and malignant masses from 86.2% to 89.7%, while for the radiologist with 8 years of experience, the accuracy of diagnosing benign masses improved from 59.5% to 73.8% and malignant masses from 81% to 87.9%. A limitation of this study is that the radiologists only had access to images to make their diagnoses, while in clinical practice they can use information about patient history and presentation, which likely improves diagnostic accuracy. Overall, this study demonstrates that DLMs may be helpful in certain clinical settings for assisting radiologists with diagnosing soft tissue masses. 

Image: PD

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