MedPAC to Congress: Eliminate MIPS

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The Medicare Payment Advisory Commission has formally recommended to Congress that it repeal the Merit-based Incentive Payment System track of Medicare’s Quality Payment Program.

MedPAC “has concluded that ... the Merit-based Incentive Payment System (MIPS) will not fulfill its goals and therefore should be eliminated,” the commission said in its March 15 report to Congress. MedPAC added that the “basic design of MIPS is fundamentally incompatible with the goals of a beneficiary-focused approach to quality measurement.”

TheaDesign/Thinkstock
The commission notes that the design of MIPS measures quality and adjusts payments based on measures chosen by the individual physician. “But a system built on this design will be inequitable, because clinicians will be evaluated and compared on dissimilar measures. In addition, many clinicians will not be evaluated at all because, as individuals, they will not have a sufficient number of cases for statistically reliable scores.”

MedPAC adds that, by the Centers for Medicare & Medicaid Services’ own estimates, more than half of clinicians will be exempt from reporting on MIPS, based on the low-volume threshold that exempts providers who bill for $90,000 or less in Medicare claims or see 200 or fewer Medicare patients.

 

 


The advisory panel also highlighted other flaws. Those include MIPS’ onerous reporting burden; measures that do not allow for meaningful comparisons among clinicians; differing rules for clinicians depending on location, practice size, and other factors; and payment adjustments that could vary wildly from year to year, creating financial uncertainty for physicians.

The commission, which voted 14-2 in favor of eliminating MIPS, also recommended it be replaced with a “voluntary value program.” But it has offered Congress only a conceptual direction for that replacement program.



“This voluntary value program (VVP) is based on the premise that patient outcomes rely on the combined contributions of clinicians and emphasizes that quality improvement is a collective effort,” according to the report.

The VVP would measure all clinicians based on the same set of measures: clinical quality, patient experience, and value. And it would do so on a population level, rather than the individual patient level.

 

 


MedPAC sees the VVP not as an end goal in the transition to paying for value, but rather a stepping stone to get clinicians more comfortable with value-based payments en route to moving into the QPP’s advanced alternative payment model (A-APM) track.

“A VVP’s penalties and rewards might not be significant enough to meaningfully change clinician behavior,” the report stated. “However, the intent is to get clinicians comfortable with being measured in a manner similar to the way they would be in A-APMs. With that experience, clinicians would be poised to form or join robust A-APMs, under which the risk and reward are more meaningful, and the potential for true delivery system reform is within reach.”

There was a near unanimous consensus among MedPAC commissioners that MIPS is flawed, but not all commissioners were ready to give up on it – especially considering how much clinicians have already invested in the program.

MedPAC also heard from the American Medical Association, which voiced opposition to the idea of ending MIPS. In addition, the commission received written feedback from physicians against its proposal.

 

 


Other experts support preserving MIPS. Gail R. Wilensky, PhD, economist and senior fellow at Project Hope and a former top health aide to President George H.W. Bush, wrote in the New England Journal of Medicine that MIPS should be fixed rather than scrapped.

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The Medicare Payment Advisory Commission has formally recommended to Congress that it repeal the Merit-based Incentive Payment System track of Medicare’s Quality Payment Program.

MedPAC “has concluded that ... the Merit-based Incentive Payment System (MIPS) will not fulfill its goals and therefore should be eliminated,” the commission said in its March 15 report to Congress. MedPAC added that the “basic design of MIPS is fundamentally incompatible with the goals of a beneficiary-focused approach to quality measurement.”

TheaDesign/Thinkstock
The commission notes that the design of MIPS measures quality and adjusts payments based on measures chosen by the individual physician. “But a system built on this design will be inequitable, because clinicians will be evaluated and compared on dissimilar measures. In addition, many clinicians will not be evaluated at all because, as individuals, they will not have a sufficient number of cases for statistically reliable scores.”

MedPAC adds that, by the Centers for Medicare & Medicaid Services’ own estimates, more than half of clinicians will be exempt from reporting on MIPS, based on the low-volume threshold that exempts providers who bill for $90,000 or less in Medicare claims or see 200 or fewer Medicare patients.

 

 


The advisory panel also highlighted other flaws. Those include MIPS’ onerous reporting burden; measures that do not allow for meaningful comparisons among clinicians; differing rules for clinicians depending on location, practice size, and other factors; and payment adjustments that could vary wildly from year to year, creating financial uncertainty for physicians.

The commission, which voted 14-2 in favor of eliminating MIPS, also recommended it be replaced with a “voluntary value program.” But it has offered Congress only a conceptual direction for that replacement program.



“This voluntary value program (VVP) is based on the premise that patient outcomes rely on the combined contributions of clinicians and emphasizes that quality improvement is a collective effort,” according to the report.

The VVP would measure all clinicians based on the same set of measures: clinical quality, patient experience, and value. And it would do so on a population level, rather than the individual patient level.

 

 


MedPAC sees the VVP not as an end goal in the transition to paying for value, but rather a stepping stone to get clinicians more comfortable with value-based payments en route to moving into the QPP’s advanced alternative payment model (A-APM) track.

“A VVP’s penalties and rewards might not be significant enough to meaningfully change clinician behavior,” the report stated. “However, the intent is to get clinicians comfortable with being measured in a manner similar to the way they would be in A-APMs. With that experience, clinicians would be poised to form or join robust A-APMs, under which the risk and reward are more meaningful, and the potential for true delivery system reform is within reach.”

There was a near unanimous consensus among MedPAC commissioners that MIPS is flawed, but not all commissioners were ready to give up on it – especially considering how much clinicians have already invested in the program.

MedPAC also heard from the American Medical Association, which voiced opposition to the idea of ending MIPS. In addition, the commission received written feedback from physicians against its proposal.

 

 


Other experts support preserving MIPS. Gail R. Wilensky, PhD, economist and senior fellow at Project Hope and a former top health aide to President George H.W. Bush, wrote in the New England Journal of Medicine that MIPS should be fixed rather than scrapped.

 

The Medicare Payment Advisory Commission has formally recommended to Congress that it repeal the Merit-based Incentive Payment System track of Medicare’s Quality Payment Program.

MedPAC “has concluded that ... the Merit-based Incentive Payment System (MIPS) will not fulfill its goals and therefore should be eliminated,” the commission said in its March 15 report to Congress. MedPAC added that the “basic design of MIPS is fundamentally incompatible with the goals of a beneficiary-focused approach to quality measurement.”

TheaDesign/Thinkstock
The commission notes that the design of MIPS measures quality and adjusts payments based on measures chosen by the individual physician. “But a system built on this design will be inequitable, because clinicians will be evaluated and compared on dissimilar measures. In addition, many clinicians will not be evaluated at all because, as individuals, they will not have a sufficient number of cases for statistically reliable scores.”

MedPAC adds that, by the Centers for Medicare & Medicaid Services’ own estimates, more than half of clinicians will be exempt from reporting on MIPS, based on the low-volume threshold that exempts providers who bill for $90,000 or less in Medicare claims or see 200 or fewer Medicare patients.

 

 


The advisory panel also highlighted other flaws. Those include MIPS’ onerous reporting burden; measures that do not allow for meaningful comparisons among clinicians; differing rules for clinicians depending on location, practice size, and other factors; and payment adjustments that could vary wildly from year to year, creating financial uncertainty for physicians.

The commission, which voted 14-2 in favor of eliminating MIPS, also recommended it be replaced with a “voluntary value program.” But it has offered Congress only a conceptual direction for that replacement program.



“This voluntary value program (VVP) is based on the premise that patient outcomes rely on the combined contributions of clinicians and emphasizes that quality improvement is a collective effort,” according to the report.

The VVP would measure all clinicians based on the same set of measures: clinical quality, patient experience, and value. And it would do so on a population level, rather than the individual patient level.

 

 


MedPAC sees the VVP not as an end goal in the transition to paying for value, but rather a stepping stone to get clinicians more comfortable with value-based payments en route to moving into the QPP’s advanced alternative payment model (A-APM) track.

“A VVP’s penalties and rewards might not be significant enough to meaningfully change clinician behavior,” the report stated. “However, the intent is to get clinicians comfortable with being measured in a manner similar to the way they would be in A-APMs. With that experience, clinicians would be poised to form or join robust A-APMs, under which the risk and reward are more meaningful, and the potential for true delivery system reform is within reach.”

There was a near unanimous consensus among MedPAC commissioners that MIPS is flawed, but not all commissioners were ready to give up on it – especially considering how much clinicians have already invested in the program.

MedPAC also heard from the American Medical Association, which voiced opposition to the idea of ending MIPS. In addition, the commission received written feedback from physicians against its proposal.

 

 


Other experts support preserving MIPS. Gail R. Wilensky, PhD, economist and senior fellow at Project Hope and a former top health aide to President George H.W. Bush, wrote in the New England Journal of Medicine that MIPS should be fixed rather than scrapped.

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CDC: Beware Brazil yellow fever outbreak

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The Centers for Disease Control and Prevention recommends that travelers who haven’t been vaccinated against yellow fever should avoid travel to Brazil, according to a media teleconference by CDC officials.

“The most important new recommendation ... is that travelers should not go to these yellow fever hot spots in Brazil, unless they are vaccinated,” stated Martin Cetron, MD, director of the Division of Global Migration and Quarantine at the CDC. “Health officials in Brazil recently confirmed more than 920 cases of yellow fever, including more than 300 deaths, during this outbreak” he added.

©DamrongpanThongwat/thinkstock
Yellow fever is a fairly common infection in locations such as South America, and is spread by the bite of an infected mosquito, according to Dr. Cetron. He pointed out that Brazil’s yellow fever outbreak has been spreading into areas popular with tourists, including urban centers such as Rio De Janeiro.

Since the beginning of 2018, 10 travel-related cases of yellow fever have been reported among international travelers returning from Brazil. Four of these travelers died. All 10 travelers had not received the yellow fever vaccine. Of these 10 travelers, 8 acquired the disease on Ilha Grande, an island off the coast of Rio De Janeiro that is popular among tourists.

 

 


The CDC is urging travelers to get vaccinated because of the potentially fatal effects of yellow fever. Vaccinations are recommended for any eligible person 9 months of age or older traveling to Brazil, specifically Espírito Santo, São Paulo, and Rio de Janeiro states, and certain cities in Bahia state, as well as Ilha Grande in particular.

Individuals heading to Brazil should receive the vaccination at least 10 days before travel. If a traveler is unvaccinated and cannot get the vaccination in the appropriate amount of time, areas where vaccination is recommended should be avoided.

The Food and Drug Administration–approved yellow fever vaccine, YF-VAX, is not currently available because of manufacturing issues. Stamaril, another yellow fever vaccine, is available at a limited number of yellow fever vaccination clinics in the United States.

In light of these supply issues, the CDC has provided resources to locate yellow fever vaccination clinics.

 

 


Dr. Cetron reemphasized that unvaccinated individuals planning to vacation in Brazil may want to reconsider their travel plans.

“People who have never been vaccinated against yellow fever should not travel to the areas in Brazil affected by the outbreak. Particularly the hot spot of Ilha Grande.”

Information for clinicians and travelers is available on the travel notice portion of the CDC site. The travel notice for Brazil includes a map of the yellow fever–affected areas in Brazil, as well as other informational resources.

The related CDC Morbidity and Mortality Weekly Report is available online.

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The Centers for Disease Control and Prevention recommends that travelers who haven’t been vaccinated against yellow fever should avoid travel to Brazil, according to a media teleconference by CDC officials.

“The most important new recommendation ... is that travelers should not go to these yellow fever hot spots in Brazil, unless they are vaccinated,” stated Martin Cetron, MD, director of the Division of Global Migration and Quarantine at the CDC. “Health officials in Brazil recently confirmed more than 920 cases of yellow fever, including more than 300 deaths, during this outbreak” he added.

©DamrongpanThongwat/thinkstock
Yellow fever is a fairly common infection in locations such as South America, and is spread by the bite of an infected mosquito, according to Dr. Cetron. He pointed out that Brazil’s yellow fever outbreak has been spreading into areas popular with tourists, including urban centers such as Rio De Janeiro.

Since the beginning of 2018, 10 travel-related cases of yellow fever have been reported among international travelers returning from Brazil. Four of these travelers died. All 10 travelers had not received the yellow fever vaccine. Of these 10 travelers, 8 acquired the disease on Ilha Grande, an island off the coast of Rio De Janeiro that is popular among tourists.

 

 


The CDC is urging travelers to get vaccinated because of the potentially fatal effects of yellow fever. Vaccinations are recommended for any eligible person 9 months of age or older traveling to Brazil, specifically Espírito Santo, São Paulo, and Rio de Janeiro states, and certain cities in Bahia state, as well as Ilha Grande in particular.

Individuals heading to Brazil should receive the vaccination at least 10 days before travel. If a traveler is unvaccinated and cannot get the vaccination in the appropriate amount of time, areas where vaccination is recommended should be avoided.

The Food and Drug Administration–approved yellow fever vaccine, YF-VAX, is not currently available because of manufacturing issues. Stamaril, another yellow fever vaccine, is available at a limited number of yellow fever vaccination clinics in the United States.

In light of these supply issues, the CDC has provided resources to locate yellow fever vaccination clinics.

 

 


Dr. Cetron reemphasized that unvaccinated individuals planning to vacation in Brazil may want to reconsider their travel plans.

“People who have never been vaccinated against yellow fever should not travel to the areas in Brazil affected by the outbreak. Particularly the hot spot of Ilha Grande.”

Information for clinicians and travelers is available on the travel notice portion of the CDC site. The travel notice for Brazil includes a map of the yellow fever–affected areas in Brazil, as well as other informational resources.

The related CDC Morbidity and Mortality Weekly Report is available online.

 

The Centers for Disease Control and Prevention recommends that travelers who haven’t been vaccinated against yellow fever should avoid travel to Brazil, according to a media teleconference by CDC officials.

“The most important new recommendation ... is that travelers should not go to these yellow fever hot spots in Brazil, unless they are vaccinated,” stated Martin Cetron, MD, director of the Division of Global Migration and Quarantine at the CDC. “Health officials in Brazil recently confirmed more than 920 cases of yellow fever, including more than 300 deaths, during this outbreak” he added.

©DamrongpanThongwat/thinkstock
Yellow fever is a fairly common infection in locations such as South America, and is spread by the bite of an infected mosquito, according to Dr. Cetron. He pointed out that Brazil’s yellow fever outbreak has been spreading into areas popular with tourists, including urban centers such as Rio De Janeiro.

Since the beginning of 2018, 10 travel-related cases of yellow fever have been reported among international travelers returning from Brazil. Four of these travelers died. All 10 travelers had not received the yellow fever vaccine. Of these 10 travelers, 8 acquired the disease on Ilha Grande, an island off the coast of Rio De Janeiro that is popular among tourists.

 

 


The CDC is urging travelers to get vaccinated because of the potentially fatal effects of yellow fever. Vaccinations are recommended for any eligible person 9 months of age or older traveling to Brazil, specifically Espírito Santo, São Paulo, and Rio de Janeiro states, and certain cities in Bahia state, as well as Ilha Grande in particular.

Individuals heading to Brazil should receive the vaccination at least 10 days before travel. If a traveler is unvaccinated and cannot get the vaccination in the appropriate amount of time, areas where vaccination is recommended should be avoided.

The Food and Drug Administration–approved yellow fever vaccine, YF-VAX, is not currently available because of manufacturing issues. Stamaril, another yellow fever vaccine, is available at a limited number of yellow fever vaccination clinics in the United States.

In light of these supply issues, the CDC has provided resources to locate yellow fever vaccination clinics.

 

 


Dr. Cetron reemphasized that unvaccinated individuals planning to vacation in Brazil may want to reconsider their travel plans.

“People who have never been vaccinated against yellow fever should not travel to the areas in Brazil affected by the outbreak. Particularly the hot spot of Ilha Grande.”

Information for clinicians and travelers is available on the travel notice portion of the CDC site. The travel notice for Brazil includes a map of the yellow fever–affected areas in Brazil, as well as other informational resources.

The related CDC Morbidity and Mortality Weekly Report is available online.

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Match Day 2018: A slow year for dermatology

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Dermatology saw modest gains in residency slots and matches in what was the largest Match Day on record, according to the National Resident Matching Program (NRMP).

Available dermatology PGY-2 slots rose 0.7% to 426 for 2018, and total slots filled were up just 1.2% to 420, for an overall fill rate of 98.6%. The fill rate for U.S. graduates, however, slipped from 81.8% last year to 81.7%, which continues a decline that started in 2015. For all specialties, U.S. graduates filled 58.7% of the record-high 30,232 available PGY-1 spots, and the overall fill rate was 96.1%, the NRMP said in its 2018 Main Residency Match report.



The 2018 Match also set new highs for total positions offered (up 4.4% over last year), total positions filled (up 4.7%), PGY-1 positions (up 4.9%) filled, and total applicants (up 1.7%). “The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.

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Dermatology saw modest gains in residency slots and matches in what was the largest Match Day on record, according to the National Resident Matching Program (NRMP).

Available dermatology PGY-2 slots rose 0.7% to 426 for 2018, and total slots filled were up just 1.2% to 420, for an overall fill rate of 98.6%. The fill rate for U.S. graduates, however, slipped from 81.8% last year to 81.7%, which continues a decline that started in 2015. For all specialties, U.S. graduates filled 58.7% of the record-high 30,232 available PGY-1 spots, and the overall fill rate was 96.1%, the NRMP said in its 2018 Main Residency Match report.



The 2018 Match also set new highs for total positions offered (up 4.4% over last year), total positions filled (up 4.7%), PGY-1 positions (up 4.9%) filled, and total applicants (up 1.7%). “The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.

 

Dermatology saw modest gains in residency slots and matches in what was the largest Match Day on record, according to the National Resident Matching Program (NRMP).

Available dermatology PGY-2 slots rose 0.7% to 426 for 2018, and total slots filled were up just 1.2% to 420, for an overall fill rate of 98.6%. The fill rate for U.S. graduates, however, slipped from 81.8% last year to 81.7%, which continues a decline that started in 2015. For all specialties, U.S. graduates filled 58.7% of the record-high 30,232 available PGY-1 spots, and the overall fill rate was 96.1%, the NRMP said in its 2018 Main Residency Match report.



The 2018 Match also set new highs for total positions offered (up 4.4% over last year), total positions filled (up 4.7%), PGY-1 positions (up 4.9%) filled, and total applicants (up 1.7%). “The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.

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CT angiography boosts success in chronic total occlusion revascularization

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– When performed prior to revascularization, CT angiography almost doubles the likelihood of successful revascularization of chronic total occlusion relative to no CT angiography, according to a meta-analysis.

Because the meta-analysis relied primarily on retrospective data, the conclusion was characterized as hypothesis-generating. But the author, Wael Abuzeid, MD, an interventional cardiologist and assistant professor at Queen’s University, Kingston, Ont., suggested that there are several arguments to be made for pursuing a randomized trial.

Ted Bosworth/Frontline Medical News
Dr. Wael Abuzeid
When percutaneous intervention revascularization is conducted on the basis of coronary angiography alone, “there are important characteristics of CTO [chronic total occlusion] that are difficult to evaluate. These include proximal and distal vessel ambiguity, the extent to calcification, negative distal remodeling, and degree of tortuosity,” Dr. Abuzeid explained at CRT 18, sponsored by the Cardiovascular Research Institute at Washington Hospital Center. CT angiography (CTA) “provides a tremendous amount of information” on these and other characteristics that could help the operator anticipate problems and prepare strategies in advance of the procedure.

This is not a new idea, according to results of a systematic review of the literature. Although only four articles met prespecified criteria for entry into the meta-analysis that was eventually conducted, Dr. Abuzeid and his coauthors found 424 articles on this subject in a search of three literature databases.
 

 


Only one of the four studies entered into the meta-analysis involved prospective data collection, but three of the four found a significant advantage for preprocedural CTA when compared with no CTA for procedural success, meaning restoration of blood flow in the target CTO. The fourth study also associated preprocedural CTA with improved procedural success, but the advantage did not reach statistical significance.

When the data were combined for a meta-analysis, the odds ratio for procedural success for conducting a preprocedural CTA relative to no preprocedural CTA was 1.89 with a significant 95% confidence interval (1.18-3.04; P less than .05).

The four studies were published during 2012-2015. Two of them used CTA with only a 64-slice capacity, raising the possibility that an even greater improvement in results would have been achieved with CTA using the greater resolutions now available.

There were several important limitations of the study, particularly the potential for selection bias from the nonrandomized designs in the studies evaluated, Dr. Abuzeid acknowledged. However, the most likely selection bias would be funneling of more challenging cases to preprocedural CTA, a potential disadvantage for CTA if this resulted in a patient population likely to have a poor outcome.

Currently, few centers employ preprocedural CTA in routine management of CTO, according to Dr. Abuzeid.
 

 


“CTA prior to revascularization in CTO is not a standard approach even in complex patients,” Dr. Abuzeid said. However, he believes an argument can already be made for preprocedural CTA in some types of challenging patients, such as those with particularly long target lesions. In such cases, CTA could provide advance information about negative distal remodeling and the likelihood that a retrograde approach might be needed.

“For the junior operator, I think the information provided by preprocedural CTA could be very useful in planning,” Dr. Abuzeid said.

The arguments against preprocedural CTA include higher radiation exposure and a delay in the time to procedure by adding the extra step of first conducting the imaging study. In addition to verifying that procedural success is achieved with preprocedural CTA, these issues are among those that deserve evaluation in a prospective study.

“The appropriate randomized trial would be conducted at high-volume centers with all comers, not just complex patients, randomized to undergo a preprocedural CTA or no preprocedural imaging,” Dr. Abuzeid suggested. He said the appropriate primary outcome is relative success at restoring Thrombolysis in Myocardial Infarction grade 2 flow, but suggested that other endpoints, such as procedure time and rate of complications, would be useful for determining the value of this approach.

Dr. Abuzeid reports having no financial relationships.

SOURCE: Abuzeid W. CRT 18.

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– When performed prior to revascularization, CT angiography almost doubles the likelihood of successful revascularization of chronic total occlusion relative to no CT angiography, according to a meta-analysis.

Because the meta-analysis relied primarily on retrospective data, the conclusion was characterized as hypothesis-generating. But the author, Wael Abuzeid, MD, an interventional cardiologist and assistant professor at Queen’s University, Kingston, Ont., suggested that there are several arguments to be made for pursuing a randomized trial.

Ted Bosworth/Frontline Medical News
Dr. Wael Abuzeid
When percutaneous intervention revascularization is conducted on the basis of coronary angiography alone, “there are important characteristics of CTO [chronic total occlusion] that are difficult to evaluate. These include proximal and distal vessel ambiguity, the extent to calcification, negative distal remodeling, and degree of tortuosity,” Dr. Abuzeid explained at CRT 18, sponsored by the Cardiovascular Research Institute at Washington Hospital Center. CT angiography (CTA) “provides a tremendous amount of information” on these and other characteristics that could help the operator anticipate problems and prepare strategies in advance of the procedure.

This is not a new idea, according to results of a systematic review of the literature. Although only four articles met prespecified criteria for entry into the meta-analysis that was eventually conducted, Dr. Abuzeid and his coauthors found 424 articles on this subject in a search of three literature databases.
 

 


Only one of the four studies entered into the meta-analysis involved prospective data collection, but three of the four found a significant advantage for preprocedural CTA when compared with no CTA for procedural success, meaning restoration of blood flow in the target CTO. The fourth study also associated preprocedural CTA with improved procedural success, but the advantage did not reach statistical significance.

When the data were combined for a meta-analysis, the odds ratio for procedural success for conducting a preprocedural CTA relative to no preprocedural CTA was 1.89 with a significant 95% confidence interval (1.18-3.04; P less than .05).

The four studies were published during 2012-2015. Two of them used CTA with only a 64-slice capacity, raising the possibility that an even greater improvement in results would have been achieved with CTA using the greater resolutions now available.

There were several important limitations of the study, particularly the potential for selection bias from the nonrandomized designs in the studies evaluated, Dr. Abuzeid acknowledged. However, the most likely selection bias would be funneling of more challenging cases to preprocedural CTA, a potential disadvantage for CTA if this resulted in a patient population likely to have a poor outcome.

Currently, few centers employ preprocedural CTA in routine management of CTO, according to Dr. Abuzeid.
 

 


“CTA prior to revascularization in CTO is not a standard approach even in complex patients,” Dr. Abuzeid said. However, he believes an argument can already be made for preprocedural CTA in some types of challenging patients, such as those with particularly long target lesions. In such cases, CTA could provide advance information about negative distal remodeling and the likelihood that a retrograde approach might be needed.

“For the junior operator, I think the information provided by preprocedural CTA could be very useful in planning,” Dr. Abuzeid said.

The arguments against preprocedural CTA include higher radiation exposure and a delay in the time to procedure by adding the extra step of first conducting the imaging study. In addition to verifying that procedural success is achieved with preprocedural CTA, these issues are among those that deserve evaluation in a prospective study.

“The appropriate randomized trial would be conducted at high-volume centers with all comers, not just complex patients, randomized to undergo a preprocedural CTA or no preprocedural imaging,” Dr. Abuzeid suggested. He said the appropriate primary outcome is relative success at restoring Thrombolysis in Myocardial Infarction grade 2 flow, but suggested that other endpoints, such as procedure time and rate of complications, would be useful for determining the value of this approach.

Dr. Abuzeid reports having no financial relationships.

SOURCE: Abuzeid W. CRT 18.

 

– When performed prior to revascularization, CT angiography almost doubles the likelihood of successful revascularization of chronic total occlusion relative to no CT angiography, according to a meta-analysis.

Because the meta-analysis relied primarily on retrospective data, the conclusion was characterized as hypothesis-generating. But the author, Wael Abuzeid, MD, an interventional cardiologist and assistant professor at Queen’s University, Kingston, Ont., suggested that there are several arguments to be made for pursuing a randomized trial.

Ted Bosworth/Frontline Medical News
Dr. Wael Abuzeid
When percutaneous intervention revascularization is conducted on the basis of coronary angiography alone, “there are important characteristics of CTO [chronic total occlusion] that are difficult to evaluate. These include proximal and distal vessel ambiguity, the extent to calcification, negative distal remodeling, and degree of tortuosity,” Dr. Abuzeid explained at CRT 18, sponsored by the Cardiovascular Research Institute at Washington Hospital Center. CT angiography (CTA) “provides a tremendous amount of information” on these and other characteristics that could help the operator anticipate problems and prepare strategies in advance of the procedure.

This is not a new idea, according to results of a systematic review of the literature. Although only four articles met prespecified criteria for entry into the meta-analysis that was eventually conducted, Dr. Abuzeid and his coauthors found 424 articles on this subject in a search of three literature databases.
 

 


Only one of the four studies entered into the meta-analysis involved prospective data collection, but three of the four found a significant advantage for preprocedural CTA when compared with no CTA for procedural success, meaning restoration of blood flow in the target CTO. The fourth study also associated preprocedural CTA with improved procedural success, but the advantage did not reach statistical significance.

When the data were combined for a meta-analysis, the odds ratio for procedural success for conducting a preprocedural CTA relative to no preprocedural CTA was 1.89 with a significant 95% confidence interval (1.18-3.04; P less than .05).

The four studies were published during 2012-2015. Two of them used CTA with only a 64-slice capacity, raising the possibility that an even greater improvement in results would have been achieved with CTA using the greater resolutions now available.

There were several important limitations of the study, particularly the potential for selection bias from the nonrandomized designs in the studies evaluated, Dr. Abuzeid acknowledged. However, the most likely selection bias would be funneling of more challenging cases to preprocedural CTA, a potential disadvantage for CTA if this resulted in a patient population likely to have a poor outcome.

Currently, few centers employ preprocedural CTA in routine management of CTO, according to Dr. Abuzeid.
 

 


“CTA prior to revascularization in CTO is not a standard approach even in complex patients,” Dr. Abuzeid said. However, he believes an argument can already be made for preprocedural CTA in some types of challenging patients, such as those with particularly long target lesions. In such cases, CTA could provide advance information about negative distal remodeling and the likelihood that a retrograde approach might be needed.

“For the junior operator, I think the information provided by preprocedural CTA could be very useful in planning,” Dr. Abuzeid said.

The arguments against preprocedural CTA include higher radiation exposure and a delay in the time to procedure by adding the extra step of first conducting the imaging study. In addition to verifying that procedural success is achieved with preprocedural CTA, these issues are among those that deserve evaluation in a prospective study.

“The appropriate randomized trial would be conducted at high-volume centers with all comers, not just complex patients, randomized to undergo a preprocedural CTA or no preprocedural imaging,” Dr. Abuzeid suggested. He said the appropriate primary outcome is relative success at restoring Thrombolysis in Myocardial Infarction grade 2 flow, but suggested that other endpoints, such as procedure time and rate of complications, would be useful for determining the value of this approach.

Dr. Abuzeid reports having no financial relationships.

SOURCE: Abuzeid W. CRT 18.

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REPORTING FROM CRT 2018

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Key clinical point: Preprocedure CT angiography is linked with a greater rate of successful revascularization of chronic total occlusion.

Major finding: In a meta-analysis of data from four studies, CT angiography almost doubled the likelihood of procedural success (OR 1.89; P less than .05).

Study details: A systematic review and meta-analysis of four studies.

Disclosures: Dr. Abuzeid reports having no financial relationships.

Source: Abuzaid W. CRT 18.

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Match Day 2018: Internal medicine increases positions, matches

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Internal medicine helped to make the 2018 Main Residency Match the largest ever as the specialty offered and filled about 4% more residency slots than in 2017, according to the National Resident Matching Program (NRMP).

Internal medicine brought 7,542 PGY-1 positions – more than any other specialty – to the Match Day party this year and filled 44.9% of them with U.S. graduates and 96.7% overall. Despite the increase in IM residency slots, however, the number and percentage of U.S. seniors matching declined, as it has done each year since 2015. For all specialties, U.S. graduates filled 58.7% of the record-high 30,232 available spots, and the overall fill rate was 96.1%, the NRMP said in its 2018 Main Residency Match report.

The 2018 Match also set new highs for total positions offered (up 4.4% over last year), total (up 4.7%) and PGY-1 positions (up 4.9%) filled, and total applicants (up 1.7%). “The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.

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Internal medicine helped to make the 2018 Main Residency Match the largest ever as the specialty offered and filled about 4% more residency slots than in 2017, according to the National Resident Matching Program (NRMP).

Internal medicine brought 7,542 PGY-1 positions – more than any other specialty – to the Match Day party this year and filled 44.9% of them with U.S. graduates and 96.7% overall. Despite the increase in IM residency slots, however, the number and percentage of U.S. seniors matching declined, as it has done each year since 2015. For all specialties, U.S. graduates filled 58.7% of the record-high 30,232 available spots, and the overall fill rate was 96.1%, the NRMP said in its 2018 Main Residency Match report.

The 2018 Match also set new highs for total positions offered (up 4.4% over last year), total (up 4.7%) and PGY-1 positions (up 4.9%) filled, and total applicants (up 1.7%). “The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.

 

Internal medicine helped to make the 2018 Main Residency Match the largest ever as the specialty offered and filled about 4% more residency slots than in 2017, according to the National Resident Matching Program (NRMP).

Internal medicine brought 7,542 PGY-1 positions – more than any other specialty – to the Match Day party this year and filled 44.9% of them with U.S. graduates and 96.7% overall. Despite the increase in IM residency slots, however, the number and percentage of U.S. seniors matching declined, as it has done each year since 2015. For all specialties, U.S. graduates filled 58.7% of the record-high 30,232 available spots, and the overall fill rate was 96.1%, the NRMP said in its 2018 Main Residency Match report.

The 2018 Match also set new highs for total positions offered (up 4.4% over last year), total (up 4.7%) and PGY-1 positions (up 4.9%) filled, and total applicants (up 1.7%). “The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.

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Match Day 2018: Psychiatry increases positions and matches

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Psychiatry helped to make the 2018 Main Residency Match the largest ever as the specialty increased residency slots by 4.1% and accepted 3.3% more applicants, compared with 2017, according to the National Resident Matching Program.

Psychiatry brought 1,556 PGY-1 positions to the Match Day table this year and filled 63.1% of them with U.S. graduates – up for the fourth consecutive year – and 99.0% overall. For all specialties, U.S. graduates filled 58.7% of the record-high 30,232 available spots, and the overall fill rate was 96.1%, the NRMP said in its 2018 Main Residency Match report.

The 2018 Match also set new highs for total positions offered (up 4.4% over last year), total (up 4.7%) and PGY-1 positions (up 4.9%) filled, and total applicants (up 1.7%). “The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.

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Psychiatry helped to make the 2018 Main Residency Match the largest ever as the specialty increased residency slots by 4.1% and accepted 3.3% more applicants, compared with 2017, according to the National Resident Matching Program.

Psychiatry brought 1,556 PGY-1 positions to the Match Day table this year and filled 63.1% of them with U.S. graduates – up for the fourth consecutive year – and 99.0% overall. For all specialties, U.S. graduates filled 58.7% of the record-high 30,232 available spots, and the overall fill rate was 96.1%, the NRMP said in its 2018 Main Residency Match report.

The 2018 Match also set new highs for total positions offered (up 4.4% over last year), total (up 4.7%) and PGY-1 positions (up 4.9%) filled, and total applicants (up 1.7%). “The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.

 

Psychiatry helped to make the 2018 Main Residency Match the largest ever as the specialty increased residency slots by 4.1% and accepted 3.3% more applicants, compared with 2017, according to the National Resident Matching Program.

Psychiatry brought 1,556 PGY-1 positions to the Match Day table this year and filled 63.1% of them with U.S. graduates – up for the fourth consecutive year – and 99.0% overall. For all specialties, U.S. graduates filled 58.7% of the record-high 30,232 available spots, and the overall fill rate was 96.1%, the NRMP said in its 2018 Main Residency Match report.

The 2018 Match also set new highs for total positions offered (up 4.4% over last year), total (up 4.7%) and PGY-1 positions (up 4.9%) filled, and total applicants (up 1.7%). “The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.

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Match Day 2018: Big increases for neurology

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Neurology helped to make the 2018 Main Residency Match the largest ever as the specialty offered and filled over 12% more residency slots than in 2017, according to the National Resident Matching Program (NRMP).

The third consecutive year with a double-digit increase in PGY-1 positions enabled neurology to bring 552 slots to the Match Day party this year: 50.7% were filled with U.S. graduates and the overall fill rate was 97.6%. For all specialties, U.S. graduates filled 58.7% of the record-high 30,232 available spots, and the overall fill rate was 96.1%, the NRMP said in its 2018 Main Residency Match report.

Graduate programs also offered 287 PGY-2 neurology positions, filling 66.2% with U.S. graduates and 98.6% overall. An additional 18 of 20 PGY-2 physician positions for neurology were filled as well.

The total number of child neurology PGY-1 positions offered rose to 134, of which 96.3% were filled (75.4% by U.S. graduates). Another seven of eight PGY-2 child neurology positions were filled. Of 26 PGY-2 physician positions offered for child neurology, 12 were filled.



The 2018 Match also set new highs for total positions offered (up 4.4% over last year), total (up 4.7%) and PGY-1 positions (up 4.9%) filled, and total applicants (up 1.7%). “The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.

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Neurology helped to make the 2018 Main Residency Match the largest ever as the specialty offered and filled over 12% more residency slots than in 2017, according to the National Resident Matching Program (NRMP).

The third consecutive year with a double-digit increase in PGY-1 positions enabled neurology to bring 552 slots to the Match Day party this year: 50.7% were filled with U.S. graduates and the overall fill rate was 97.6%. For all specialties, U.S. graduates filled 58.7% of the record-high 30,232 available spots, and the overall fill rate was 96.1%, the NRMP said in its 2018 Main Residency Match report.

Graduate programs also offered 287 PGY-2 neurology positions, filling 66.2% with U.S. graduates and 98.6% overall. An additional 18 of 20 PGY-2 physician positions for neurology were filled as well.

The total number of child neurology PGY-1 positions offered rose to 134, of which 96.3% were filled (75.4% by U.S. graduates). Another seven of eight PGY-2 child neurology positions were filled. Of 26 PGY-2 physician positions offered for child neurology, 12 were filled.



The 2018 Match also set new highs for total positions offered (up 4.4% over last year), total (up 4.7%) and PGY-1 positions (up 4.9%) filled, and total applicants (up 1.7%). “The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.

 

Neurology helped to make the 2018 Main Residency Match the largest ever as the specialty offered and filled over 12% more residency slots than in 2017, according to the National Resident Matching Program (NRMP).

The third consecutive year with a double-digit increase in PGY-1 positions enabled neurology to bring 552 slots to the Match Day party this year: 50.7% were filled with U.S. graduates and the overall fill rate was 97.6%. For all specialties, U.S. graduates filled 58.7% of the record-high 30,232 available spots, and the overall fill rate was 96.1%, the NRMP said in its 2018 Main Residency Match report.

Graduate programs also offered 287 PGY-2 neurology positions, filling 66.2% with U.S. graduates and 98.6% overall. An additional 18 of 20 PGY-2 physician positions for neurology were filled as well.

The total number of child neurology PGY-1 positions offered rose to 134, of which 96.3% were filled (75.4% by U.S. graduates). Another seven of eight PGY-2 child neurology positions were filled. Of 26 PGY-2 physician positions offered for child neurology, 12 were filled.



The 2018 Match also set new highs for total positions offered (up 4.4% over last year), total (up 4.7%) and PGY-1 positions (up 4.9%) filled, and total applicants (up 1.7%). “The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.

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Match Day 2018: A slow year for pediatrics

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Pediatrics saw modest gains in residency slots and matches in what was the largest Match Day on record, according to the National Resident Matching Program (NRMP).

Available pediatric PGY-1 slots rose 1.1% to 2,768 for 2018, and total slots filled were up just 0.7% to 2,711 – those totals ranked third among all specialties in each category. The fill rate for U.S. graduates dropped for the third year in a row to 63.1%, and the overall fill rate was 97.9%. For all specialties, U.S. graduates filled 58.7% of the record-high 30,232 available spots, and the overall fill rate was 96.1%, the NRMP reported.



The 2018 Match also set new highs for total positions offered (up 4.4% over last year), total positions and PGY-1 positions filled (up 4.7% and 4.9%, respectively), and total applicants (up 1.7%). “The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.

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Pediatrics saw modest gains in residency slots and matches in what was the largest Match Day on record, according to the National Resident Matching Program (NRMP).

Available pediatric PGY-1 slots rose 1.1% to 2,768 for 2018, and total slots filled were up just 0.7% to 2,711 – those totals ranked third among all specialties in each category. The fill rate for U.S. graduates dropped for the third year in a row to 63.1%, and the overall fill rate was 97.9%. For all specialties, U.S. graduates filled 58.7% of the record-high 30,232 available spots, and the overall fill rate was 96.1%, the NRMP reported.



The 2018 Match also set new highs for total positions offered (up 4.4% over last year), total positions and PGY-1 positions filled (up 4.7% and 4.9%, respectively), and total applicants (up 1.7%). “The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.

 

Pediatrics saw modest gains in residency slots and matches in what was the largest Match Day on record, according to the National Resident Matching Program (NRMP).

Available pediatric PGY-1 slots rose 1.1% to 2,768 for 2018, and total slots filled were up just 0.7% to 2,711 – those totals ranked third among all specialties in each category. The fill rate for U.S. graduates dropped for the third year in a row to 63.1%, and the overall fill rate was 97.9%. For all specialties, U.S. graduates filled 58.7% of the record-high 30,232 available spots, and the overall fill rate was 96.1%, the NRMP reported.



The 2018 Match also set new highs for total positions offered (up 4.4% over last year), total positions and PGY-1 positions filled (up 4.7% and 4.9%, respectively), and total applicants (up 1.7%). “The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.

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Match Day 2018: Surgery increases positions and matches

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Surgery helped to make the 2018 Main Residency Match the largest ever as the specialty offered and filled 3% more residency slots than it did in 2017, according to the National Resident Matching Program (NRMP).

Surgery brought 1,319 PGY-1 positions to the Match Day table this year and filled 76.2% of them with U.S. graduates and 99.6% of them overall. For all specialties, U.S. graduates filled 58.7% of the record-high 30,232 available spots, and the overall fill rate was 96.1%, the NRMP reported.



The 2018 Match also set new highs for total positions offered (up 4.4% over last year), total positions and PGY-1 positions filled (up 4.7% and 4.9%, respectively), and total applicants (up 1.7%). “The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.

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Surgery helped to make the 2018 Main Residency Match the largest ever as the specialty offered and filled 3% more residency slots than it did in 2017, according to the National Resident Matching Program (NRMP).

Surgery brought 1,319 PGY-1 positions to the Match Day table this year and filled 76.2% of them with U.S. graduates and 99.6% of them overall. For all specialties, U.S. graduates filled 58.7% of the record-high 30,232 available spots, and the overall fill rate was 96.1%, the NRMP reported.



The 2018 Match also set new highs for total positions offered (up 4.4% over last year), total positions and PGY-1 positions filled (up 4.7% and 4.9%, respectively), and total applicants (up 1.7%). “The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.

 

Surgery helped to make the 2018 Main Residency Match the largest ever as the specialty offered and filled 3% more residency slots than it did in 2017, according to the National Resident Matching Program (NRMP).

Surgery brought 1,319 PGY-1 positions to the Match Day table this year and filled 76.2% of them with U.S. graduates and 99.6% of them overall. For all specialties, U.S. graduates filled 58.7% of the record-high 30,232 available spots, and the overall fill rate was 96.1%, the NRMP reported.



The 2018 Match also set new highs for total positions offered (up 4.4% over last year), total positions and PGY-1 positions filled (up 4.7% and 4.9%, respectively), and total applicants (up 1.7%). “The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.

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Match Day 2018: Family medicine increases positions, matches

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Family medicine helped to make the 2018 Main Residency Match the largest ever as the specialty increased residency slots by 8% and accepted 9% more applicants, compared with 2017, according to the National Resident Matching Program (NRMP).

Family medicine brought 3,629 PGY-1 positions to the Match Day table this year and filled 44.9% of them with U.S. graduates and 96.7% of them overall. “The number of U.S. allopathic seniors matching to family medicine has increased every year” since 2009, the NRMP reported. For all specialties, U.S. graduates filled 58.7% of the record-high 30,232 available spots, and the overall fill rate was 96.1%.



The 2018 Match also set new highs for total positions offered (up 4.4% over last year), total positions and PGY-1 positions filled (up 4.7% and 4.9%, respectively), and total applicants (up 1.7%). “The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.

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Family medicine helped to make the 2018 Main Residency Match the largest ever as the specialty increased residency slots by 8% and accepted 9% more applicants, compared with 2017, according to the National Resident Matching Program (NRMP).

Family medicine brought 3,629 PGY-1 positions to the Match Day table this year and filled 44.9% of them with U.S. graduates and 96.7% of them overall. “The number of U.S. allopathic seniors matching to family medicine has increased every year” since 2009, the NRMP reported. For all specialties, U.S. graduates filled 58.7% of the record-high 30,232 available spots, and the overall fill rate was 96.1%.



The 2018 Match also set new highs for total positions offered (up 4.4% over last year), total positions and PGY-1 positions filled (up 4.7% and 4.9%, respectively), and total applicants (up 1.7%). “The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.

 

Family medicine helped to make the 2018 Main Residency Match the largest ever as the specialty increased residency slots by 8% and accepted 9% more applicants, compared with 2017, according to the National Resident Matching Program (NRMP).

Family medicine brought 3,629 PGY-1 positions to the Match Day table this year and filled 44.9% of them with U.S. graduates and 96.7% of them overall. “The number of U.S. allopathic seniors matching to family medicine has increased every year” since 2009, the NRMP reported. For all specialties, U.S. graduates filled 58.7% of the record-high 30,232 available spots, and the overall fill rate was 96.1%.



The 2018 Match also set new highs for total positions offered (up 4.4% over last year), total positions and PGY-1 positions filled (up 4.7% and 4.9%, respectively), and total applicants (up 1.7%). “The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.

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