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Claus LE, Amos JM, Links AR, Beach MC, Boss EF. Surgeon Information-Sharing, Parent Verbal Engagement, and Parent Knowledge of Pediatric Adenotonsillectomy. Otolaryngol Head Neck Surg 2024; 170:552-559. [PMID: 37811575 PMCID: PMC11066756 DOI: 10.1002/ohn.549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/18/2023] [Accepted: 09/02/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVE We characterize clinician information-sharing and parent verbal engagement during pediatric adenotonsillectomy consultations and evaluate whether these behaviors relate to disease-specific knowledge for parents of children with obstructive sleep-disordered breathing (OSDB). STUDY DESIGN Mixed-methods sequential explanatory analysis. SETTING Outpatient otolaryngology clinics. METHODS We analyzed audio-recorded communication during outpatient encounters for children undergoing initial evaluation for adenotonsillectomy. We identified discrete triadic instances of clinician discussion of individual risks and benefits, parent verbal responses coded as passive ("Right") or active ("Would that repeat the recovery time?"), and corresponding parent answer (correct or incorrect) on a postconsult knowledge questionnaire. Primary outcomes included parent knowledge and decisional conflict. We qualitatively analyzed substantive questions asked by parents during the encounter. RESULTS In 30 consults, clinicians (n = 8) provided 156 instances of discussion (101 risk, 55 benefit), to which parents provided 34% active responses. Clinician discussion of risks and benefits was associated with greater parent knowledge (odds ratio [OR] = 3.70, 95% confidence interval [CI]: 2.25-6.09; P < .001), however parent active engagement was not associated with greater parent knowledge (OR = 1.04, 95% CI: 0.42-2.58, P = .93). Parents demonstrated greater knowledge of benefits than risks (χ2 = 23.16, V = 1.13; P < .001). Parents who responded actively (OR = 0.26, 95% CI: 0.09-0.72; P = .010) or had greater knowledge (OR = 0.41, 95% CI: 0.21-0.81; P = .010) had less decisional conflict. CONCLUSION Clinician information-sharing was associated with greater parent knowledge about OSDB treatment. Greater parent engagement and knowledge were independently associated with less decisional conflict. These findings may inform clinicians' approaches to counseling and engaging parents in decisions for surgery.
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Affiliation(s)
- Lauren E. Claus
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Janine M. Amos
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Anne R. Links
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Mary Catherine Beach
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland
| | - Emily F. Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
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Huang EY, Hairston TK, Walsh J, Ballard ME, Boss EF, Jenks CM. Evaluation of Parental Perspectives and Concerns about Pediatric Cochlear Implantation: A Social Media Analysis. Otol Neurotol 2023; 44:e715-e721. [PMID: 37758320 DOI: 10.1097/mao.0000000000004024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
OBJECTIVE Parents often experience uncertainty during decision-making for their child's cochlear implantation (CI) surgery, and online forums provide insight on parental opinions that might not be expressed in clinic. This study aims to evaluate parental perspectives and concerns about pediatric CI using social media analysis. STUDY DESIGN Qualitative study. SETTING Three online forums involving parental posts about pediatric CI. INTERVENTION/METHODS Forums were queried using keywords (e.g., "cochlear implant") to gather all U.S. parent-initiated posts about pediatric CI from 2006 to 2021. Thematic content analysis was performed to classify posts by overarching domain, themes, and subthemes. Posts were reviewed for thematic synthesis and double coded. Descriptive statistics were calculated for each theme by unique users. RESULTS A total of 79 posts by 41 unique users were analyzed. Themes relating to decision for CI included facilitators, inhibitors, resources, and feelings. Parents posted about lack of benefit from hearing aids promoting decision for CI and high cost as an inhibitor. Some expressed concern about making a major decision for a minor. Parents often mentioned their child's healthcare providers and social media as resources. CONCLUSION Through social media posts, parental priorities and concerns for decision-making of CI surgery were identified. Findings may guide discussions between physicians and parents and facilitate shared decision-making about CI.
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Affiliation(s)
- Emily Y Huang
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tai K Hairston
- Johns Hopkins University School of Medicine, Department of Pediatrics, Baltimore, Maryland
| | - Jonathan Walsh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Megan E Ballard
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carolyn M Jenks
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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3
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Balakrishnan K, Faucett EA, Villwock J, Boss EF, Esianor BI, Jefferson GD, Graboyes EM, Thompson DM, Flanary VA, Brenner MJ. Allyship to Advance Diversity, Equity, and Inclusion in Otolaryngology: What We Can All Do. Curr Otorhinolaryngol Rep 2023; 11:201-214. [PMID: 38073717 PMCID: PMC10707492 DOI: 10.1007/s40136-023-00467-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 01/31/2024]
Abstract
Purpose of review To summarize the current literature on allyship, providing a historical perspective, concept analysis, and practical steps to advance equity, diversity, and inclusion. This review also provides evidence-based tools to foster allyship and identifies potential pitfalls. Recent findings Allies in healthcare advocate for inclusive and equitable practices that benefit patients, coworkers, and learners. Allyship requires working in solidarity with individuals from underrepresented or historically marginalized groups to promote a sense of belonging and opportunity. New technologies present possibilities and perils in paving the pathway to diversity. Summary Unlocking the power of allyship requires that allies confront unconscious biases, engage in self-reflection, and act as effective partners. Using an allyship toolbox, allies can foster psychological safety in personal and professional spaces while avoiding missteps. Allyship incorporates goals, metrics, and transparent data reporting to promote accountability and to sustain improvements. Implementing these allyship strategies in solidarity holds promise for increasing diversity and inclusion in the specialty.
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Affiliation(s)
- Karthik Balakrishnan
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Erynne A. Faucett
- Department of Otolaryngology-Head and Neck Surgery, University of CA-Davis , Sacramento, USA
| | - Jennifer Villwock
- Department of Otolaryngology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Emily F. Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Brandon I. Esianor
- Department of Otolaryngology-Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gina D. Jefferson
- Department of Otolaryngology-Head and Neck Surgery, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Evan M. Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, USA
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, USA
| | - Dana M. Thompson
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
- Feinberg School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Northwestern University, Chicago, IL, USA
| | - Valerie A. Flanary
- Division of Pediatric Otolaryngology, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael J. Brenner
- Department of Otolaryngology–Head & Neck Surgery, University of Michigan medical School, 1500 East Medical Center Drive, 48108 Ann Arbor, MI, USA
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Saraswathula A, Roy S, Blythe WR, Gourin CG, Boss EF. The Unrealized Potential of the Reg-ent ENT Clinical Data Registry. JAMA Otolaryngol Head Neck Surg 2023; 149:659-661. [PMID: 37382937 DOI: 10.1001/jamaoto.2023.1389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Affiliation(s)
- Anirudh Saraswathula
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
| | - Soham Roy
- Department of Pediatric Otolaryngology-Head and Neck Surgery, Children's Hospital Colorado, Denver
| | | | - Christine G Gourin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
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Ikeda AK, McShay C, Marsh R, Saini S, Sardesai MG, Weaver EM, Boss EF. Patient Factors and Preferences in Choosing Sleep Surgery for Obstructive Sleep Apnea: A Qualitative Study. Otolaryngol Head Neck Surg 2023; 168:514-520. [PMID: 35671145 DOI: 10.1177/01945998221105404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 05/18/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE There are several obstructive sleep apnea (OSA) treatment options available to patients, including surgery and less invasive therapies. Little is known about the factors that influence patient preferences for treatment. We aimed to understand factors influencing patient experience and decision making for undergoing sleep surgery. STUDY DESIGN Retrospective qualitative study. SETTING Tertiary sleep surgery clinic. METHODS We conducted semistructured interviews with adults who previously underwent any nasal and/or pharyngeal sleep surgery. We asked open-ended questions about their decision-making process within a preconceived thematic framework of chief OSA symptoms, expectations for recovery, and sources of information. The interviews were audio recorded and transcribed, and content was analyzed for defined, emergent, and prevalent themes. RESULTS Ten patients were interviewed from December 11, 2020 through January 29, 2021. Six patients underwent nasal surgery, 1 underwent pharyngeal surgery, and 3 underwent staged nasal and pharyngeal procedures. All patients were beyond the acute recovery phase. Reasons for pursuing surgical consultation varied from sleep apnea burden to external factors, such as recommendations from significant others. Duration of sleep surgery consideration varied from months to years. Major concerns about sleep surgery involved anesthesia and postoperative pain. External factors influencing patients' decisions to pursue sleep surgery included family and friend support. Postoperative outcomes of surgery included patient satisfaction with decision for surgery, given OSA improvements. CONCLUSION Understanding patient factors that influence decision making for sleep surgery may guide clinicians in patient-centered counseling that engages patients in decision making, aligning with clinical symptoms and patient preferences.
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Affiliation(s)
- Allison K Ikeda
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Crystina McShay
- Department of Human Centered Design and Engineering, University of Washington, Seattle, Washington, USA
| | - Robin Marsh
- Department of Human Centered Design and Engineering, University of Washington, Seattle, Washington, USA
| | - Shireen Saini
- Department of Human Centered Design and Engineering, University of Washington, Seattle, Washington, USA
| | - Maya G Sardesai
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Edward M Weaver
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
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Ikeda AK, McShay C, Marsh R, Saini S, Sardesai M, Boss EF, Weaver EM. Barriers and communication behaviors impacting referral to sleep surgery: qualitative patient perspectives. J Clin Sleep Med 2023; 19:111-117. [PMID: 36591793 PMCID: PMC9806776 DOI: 10.5664/jcsm.10260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 08/19/2022] [Accepted: 08/23/2022] [Indexed: 02/01/2023]
Abstract
STUDY OBJECTIVES Physician-patient interactions influence the immediate encounter and leave lasting impressions for future health care encounters. We aimed to understand patient experiences and decision-making for considering sleep surgery, in terms of barriers and communication behaviors that facilitate or hinder referral for consideration of sleep surgery management of obstructive sleep apnea (OSA) when continuous positive airway pressure (CPAP) therapy has failed. METHODS We employed qualitative methods, using semistructured interviews of adults with OSA who presented for sleep surgery consultation after unsatisfactory therapy with CPAP. Open-ended questions traced symptoms and progression of sleep apnea burden, trials of noninvasive OSA therapies, outcomes, and patient expectations and concerns. The interviews were audio-recorded, transcribed, and analyzed using content analysis to identify themes. RESULTS Ten adult patients with OSA were enrolled March through April 2021 and reached predominant thematic saturation. Barriers to sleep surgery consultation included: (1) delays in OSA diagnosis due to limited OSA awareness among patients or primary providers and patients' perceived inconvenience of sleep testing, (2) patients faulted for slow progress, (3) patient-reported lack of urgency by providers in troubleshooting noninvasive management options, (4) scheduling delays and waitlists, and (5) cost. Patients were receptive to noninvasive treatment options, but inadequate improvement led to frustration after multiple encounters. Patients appreciated empathetic providers who shared information through transparent and understandable explanations and who presented multiple treatment options. CONCLUSIONS Experiences of patients with OSA highlight the need for shared decision-making through improved communication of unresolved concerns and alternative management options, including timely referral for sleep surgery consultation when indicated. CITATION Ikeda AK, McShay C, Marsh R, et al. Barriers and communication behaviors impacting referral to sleep surgery: qualitative patient perspectives. J Clin Sleep Med. 2023;19(1):111-117.
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Affiliation(s)
- Allison K. Ikeda
- University of Washington, Department of Otolaryngology–Head and Neck Surgery, Seattle, Washington
| | - Crystina McShay
- University of Washington, Department of Human Centered Design and Engineering, Seattle, Washington
| | - Robin Marsh
- University of Washington, Department of Human Centered Design and Engineering, Seattle, Washington
| | - Shireen Saini
- University of Washington, Department of Human Centered Design and Engineering, Seattle, Washington
| | - Maya Sardesai
- University of Washington, Department of Otolaryngology–Head and Neck Surgery, Seattle, Washington
| | - Emily F. Boss
- Johns Hopkins University, Department of Otolaryngology–Head and Neck Surgery, Baltimore, Maryland
| | - Edward M. Weaver
- University of Washington, Department of Otolaryngology–Head and Neck Surgery, Seattle, Washington
- Seattle Veterans Affairs Medical Center, Surgery Service, Seattle, Washington
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George JA, Salazar AJG, Irfan A, Prichett L, Nasr IW, Garcia AV, Boss EF, Jelin EB. Effect of implementing an enhanced recovery protocol for pediatric colorectal surgery on complication rate, length of stay, and opioid use in children. J Pediatr Surg 2022; 57:1349-1353. [PMID: 35153077 DOI: 10.1016/j.jpedsurg.2022.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/05/2022] [Accepted: 01/10/2022] [Indexed: 12/20/2022]
Abstract
Introduction In the past two decades, Enhanced Recovery After Surgery (ERAS) pathways for adults have improved efficiency of care and decreased length of stay (LOS) without increasing postoperative complications. The effects of enhanced recovery pathways for children are less well known. In this retrospective cohort study, we evaluated the effects of an enhanced recovery protocol (ERP) implementation in children undergoing colorectal surgery. Methods We introduced a colorectal ERP in 2017. Children and young adults (ages 2-22 years) were divided into pre-intervention (2014-2016) and post-intervention groups (2017-2019) for analysis. We abstracted data, including demographics, primary surgery, LOS, postoperative pain scores, and postoperative complications. Results A total of 432 patients were included. Of those,148 (34%) were pre-ERP implementation and 284 (66%) were post-ERP implementation. Post-ERP patients experienced significantly shorter LOS (5.7 vs. 8.3 days, p<0.01); required less intraoperative local anesthetic (9.5% vs. 38.5%, p<0.01) because 55% of patients received an epidural and 18% received an abdominal plane block; and used less postoperative opioid (62.5% vs. 98.7%, p<0.01) than did pre-ERAS patients. After protocol implementation, average pain scores were lower on postoperative day 1 (3.6 vs. 4.5, p<0.05) and across the hospitalization (3.0 vs. 4.0, p<0.01). Conclusion Enhanced recovery pathways decrease LOS, opioid use, and postoperative pain scores for children undergoing colorectal surgery and should be considered for this patient population.
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Affiliation(s)
- Jessica A George
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology, Johns Hopkins University, The Charlotte R. Bloomberg Children's Center, 1800 Orleans Street, Suite 6321, Baltimore, MD 21287, United States.
| | - Andres J Gonzalez Salazar
- Department of General Surgery, Johns Hopkins University, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Ahmer Irfan
- Department of Surgery, University of Alabama at Birmingham, 202 Boshell Diabetes Building, 1808 7th Avenue South, Birmingham, AL 35233, United States
| | - Laura Prichett
- Biostatistics, Epidemiology and Data Management (BEAD) Core, Department of Pediatrics, Johns Hopkins University School of Medicine, Mason F. Lord Bldg, Center Tower, Suite 4200, 5200 Eastern Ave., Baltimore, MD 21224, United States
| | - Isam W Nasr
- Department of General Pediatric Surgery, Johns Hopkins University, The Charlotte R. Bloomberg Children's Center, 1800 Orleans Street, Suite 7323, Baltimore, MD 21287, United States
| | - Alejandro V Garcia
- Department of General Pediatric Surgery, Johns Hopkins University, The Charlotte R. Bloomberg Children's Center, 1800 Orleans Street, Suite 7323, Baltimore, MD 21287, United States
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, The Charlotte R. Bloomberg Children's Center, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Eric B Jelin
- Department of General Pediatric Surgery, Johns Hopkins University, The Charlotte R. Bloomberg Children's Center, 1800 Orleans Street, Suite 7323, Baltimore, MD 21287, United States
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Leu GR, Links AR, Park J, Beach MC, Boss EF. Parental Expression of Emotions and Surgeon Responses During Consultations for Obstructive Sleep-Disordered Breathing in Children. JAMA Otolaryngol Head Neck Surg 2021; 148:145-154. [PMID: 34882170 DOI: 10.1001/jamaoto.2021.3530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Little is known about emotional communication between parents and surgeons. Understanding the patterns and correlates of emotional communication may foster collaboration during surgical consultations. Objective To describe the emotional expressions by parents when bringing their child for evaluation of obstructive sleep-disordered breathing (SDB) as well as surgeon responses to these emotional expressions and to evaluate the association between parental demographic characteristics and surgeon response types. Design, Setting, and Participants This cross-sectional study analyzed the audio-recorded consultations between otolaryngologists and parents of children who underwent their initial otolaryngological examination for obstructive SDB at 1 of 3 outpatient clinical sites in Maryland from April 1, 2016, to May 31, 2017. Data analysis was performed from November 1 to December 31, 2019. Main Outcomes and Measures Emotional expressions by parents and surgeon responses were audio recorded, transcribed, and coded using the Verona Coding Definitions of Emotional Sequences. Results A total of 59 consultations, of which 40 (67.8%) contained at least 1 emotional expression, were included. Participants included 59 parents (53 women [89.8%]; mean [SD] age, 33.4 [6.4] years) and 7 surgeons (4 men [57.1%]; mean [SD] age, 42.8 [7.9] years). Parents made 123 distinct emotional expressions (mean [SD], 3.08 [2.29] expressions per visit), which were often expressed as subtle cues (n = 103 of 123 [83.7%]) vs explicit concerns (n = 20 [16.3%]). Most expressions (n = 98 [79.7%]) were related to medical issues experienced by the child (eg, symptoms and surgical risks). Most surgeon responses provided parents space for elaboration of emotional expressions (n = 86 [69.9%]) and were nonexplicit (n = 55 [44.7%]). Surgeons were less likely to explore the emotions of parents from racial and ethnic minority groups compared with White parents (OR, 0.47; 95% CI, 0.18-0.98). Conclusions and Relevance This cross-sectional study found that emotional communication occurs between surgeons and parents of pediatric patients with obstructive SDB. However, surgeon responses varied according to parental race and ethnicity, suggesting the existence of implicit biases in surgeon-patient communication and calling for further research to inform efforts to promote family-centered, culturally competent communication in surgery.
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Affiliation(s)
- Grace R Leu
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Anne R Links
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jenny Park
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mary Catherine Beach
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Xie DX, Boss EF, Stewart CM. Audience of Academic Otolaryngology on Twitter: Cross-sectional Study. JMIR Med Educ 2021; 7:e25654. [PMID: 34889748 PMCID: PMC8701711 DOI: 10.2196/25654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/24/2021] [Accepted: 10/15/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Despite the ubiquity of social media, the utilization and audience reach of this communication method by otolaryngology-head and neck surgery (OHNS) residency programs has not been investigated. OBJECTIVE The purpose of this study was to evaluate the content posted to a popular social media platform (Twitter) by OHNS residency programs. METHODS In this cross-sectional study, we identified Twitter accounts for accredited academic OHNS residency programs. Tweets published over a 6-month period (March to August 2019) were extracted. Tweets were categorized and analyzed for source (original versus retweet) and target audience (medical versus layman). A random sample of 100 tweets was used to identify patterns of content, which were then used to categorize additional tweets. We quantified the total number of likes or retweets by health care professionals. RESULTS Of the 121 accredited programs, 35 (28.9%) had Twitter accounts. Of the 2526 tweets in the 6-month period, 1695 (67.10%) were original-content tweets. The majority of tweets (1283/1695, 75.69%) were targeted toward health care workers, most of which did not directly contain medical information (954/1283, 74.36%). These tweets contained information about the department's trainees and education (349/954, 36.6%), participation at conferences (263/954, 27.6%), and research publications (112/954, 11.7%). Two-thirds of all tweets did not contain medical information. Medical professionals accounted for 1249/1362 (91.70%) of retweets and 5616/6372 (88.14%) of likes on original-content tweets. CONCLUSIONS The majority of Twitter usage by OHNS residency programs is for intra and interprofessional communication, and only a minority of tweets contain information geared toward the public. Communication and information sharing with patients is not the focus of OHNS departments on Twitter.
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Affiliation(s)
- Deborah X Xie
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, United States
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, United States
| | - C Matthew Stewart
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, United States
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10
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Kochis S, Keet C, Claus LE, Hairston T, Links AR, Boss EF. Caregiver perceptions and attitudes associated with oral immunotherapy on social media. Allergy Asthma Proc 2021; 42:432-438. [PMID: 34474713 DOI: 10.2500/aap.2021.42.210050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: Caregiver values and preferences with regard to oral immunotherapy (OIT) for treatment of food allergies are not widely reported. Understanding caregiver perspectives is integral to establishing shared decision-making in the treatment of food allergy. Objective: We aimed to understand caregiver opinions that may influence caregivers in their decisions about OIT through social media. Methods: We searched a popular parenting web site for posts related to OIT from December 2008 to September 2019. We applied a Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework to review posts for inclusion, performed thematic content analysis to determine common themes, and calculated frequencies for each theme and subtheme. Posts and comments were included if they contained discussions about OIT for immunoglobulin E-mediated food allergy and were excluded if they were duplicates, comments from an original post from the original user, or comments on a nonrelevant original post. Results: Of 1300 posts and comments retrieved, 174 were included (13%). Most were excluded because they did not directly address OIT for food allergy. Relevant posts could fall into multiple themes and were categorized under three main themes: attitudes (n = 128, "I am scared to do OIT but scared not to!"), logistics (n = 168, "We will be doing this once LO [little one] is a little older"), and questions (n = 32, "How does it work?"). Conclusion: Caregivers communicate with each other through social media, expressing attitudes, logistics, and questions about OIT. Understanding these lay perspectives may help guide clinicians in counseling and engage caregivers in decision-making.
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Affiliation(s)
- Suzanne Kochis
- From the Division of Allergy/Immunology, Children's National Hospital, Washington, DC
| | - Corinne Keet
- Department of Pediatrics, Johns Hopkins School of Medicine, and
| | - Lauren E. Claus
- Department of Otolaryngology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Tai Hairston
- Department of Pediatrics, Johns Hopkins School of Medicine, and
| | - Annie R. Links
- Department of Otolaryngology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Emily F. Boss
- Department of Otolaryngology, Johns Hopkins School of Medicine, Baltimore, MD
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11
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Exilus SD, Haut ER, Canner J, Boss EF, Rowan NR. Otolaryngologist Characteristics and Outlier Use of Balloon Sinuplasty in the Medicare Population. Laryngoscope 2021; 132:1340-1345. [PMID: 34405899 DOI: 10.1002/lary.29824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/28/2021] [Accepted: 08/08/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Balloon sinuplasty (BSP) is associated with varied practice patterns. This study sought to identify otolaryngologist characteristics associated with BSP utilization. STUDY DESIGN Retrospective analysis of Medicare claims data and the National Physician Compare database. METHODS Outlier otolaryngologists were compared to non-outliers. Otolaryngologist characteristics included sex, practice size, geographic setting, years of experience, procedure setting, 10 or fewer endoscopic sinus surgeries per year for 3 or more years, and high number of services per unique Medicare beneficiary. Outlier status was defined as performing an annual total of balloon procedures of 2 standard deviations (SDs) above the mean for all otolaryngologists in the same year. RESULTS Between January 2012 and December 2017, 1,408 otolaryngologists performed 101,662 endoscopic sinus surgeries and 97,680 BSP procedures. Sixty-six outlier otolaryngologists (4.7%) accounted for 44.3% of all BSP procedures. Outlier status was associated with practice size of 10 or fewer individual providers (OR, 5.15; 95% CI, 2.73-9.74; P < .001), performance of 10 or fewer total endoscopic sinus surgeries per year for 3 or more years (OR, 3.90; 95% CI, 1.59-9.57; P = .003), and high number of overall services per beneficiary (OR 6.70; 95% CI, 1.19-37.84; P = .031). Provider sex, years of experience, and geographic setting were not associated with outlier status. CONCLUSION Outlier BSP patterns are associated with a few otolaryngologists who are more likely to be identified in small practices and record low numbers of endoscopic surgeries. Although BSP is an appropriate and effective tool, identification of outlier patterns may help to facilitate peer-to-peer counsel. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Smirnov D Exilus
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A.,The Johns Hopkins Surgery Center for Outcomes Research, Baltimore, Maryland, U.S.A
| | - Elliot R Haut
- The Johns Hopkins Surgery Center for Outcomes Research, Baltimore, Maryland, U.S.A
| | - Joe Canner
- The Johns Hopkins Surgery Center for Outcomes Research, Baltimore, Maryland, U.S.A
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Nicholas R Rowan
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
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12
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Cooper JN, Taylor HG, Boss EF. Early Tonsillectomy for Mild Obstructive Sleep Apnea: Too Early to Draw Conclusions. Pediatrics 2021; 148:peds.2021-050761. [PMID: 34257147 DOI: 10.1542/peds.2021-050761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jennifer N Cooper
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio .,Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio
| | - H Gerry Taylor
- Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Emily F Boss
- Center for Biobehavioral Health, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
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13
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Cooper JN, Koppera S, Boss EF, Lind MN. Differences in Tonsillectomy Utilization by Race/Ethnicity, Type of Health Insurance, and Rurality. Acad Pediatr 2021; 21:1031-1036. [PMID: 33207221 DOI: 10.1016/j.acap.2020.11.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Tonsillectomy is one of the most common pediatric surgical procedures. In previous decades, large geographic variation and racial disparities in its use have been reported. We aimed to compare contemporary rates of pediatric tonsillectomy utilization in the United States by child race/ethnicity, type of health insurance, and metropolitan/nonmetropolitan residence. METHODS We performed a cross-sectional study using the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project State Ambulatory Surgery and Services Databases and State Inpatient Databases of 8 US states. We included all children aged <15 years who underwent tonsillectomy in 2013 to 2017. Annual population-level tonsillectomy rates across states and sociodemographic groups overall and by surgical indication were calculated using US Census data. Negative binomial regression models were used to compare rates between groups. RESULTS In all states evaluated, tonsillectomy utilization was higher in non-Hispanic white children than non-Hispanic black or Hispanic children, higher in publicly insured than privately insured children, and higher in children residing in nonmetropolitan areas as compared to metropolitan areas (all P < .05). Tonsillectomy use was highest among white children from nonmetropolitan areas, both overall and for each indication (all P < .05). CONCLUSIONS Tonsillectomy utilization is higher in US children who are white, publicly insured, and who live in nonmetropolitan areas. Future research should identify multilevel factors, such as those at the patient, family, primary care provider, otolaryngologist, health care delivery system, interpersonal and community levels, that explain these differences in utilization in order to improve the appropriateness and equity of tonsillectomy use in children.
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Affiliation(s)
- Jennifer N Cooper
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, Abigail Wexner Research Institute at Nationwide Children's Hospital (JN Cooper and S Koppera), Columbus, Ohio; Department of Pediatrics, The Ohio State University College of Medicine (JN Cooper), Columbus, Ohio; Division of Epidemiology, The Ohio State University College of Public Health (JN Cooper), Columbus, Ohio.
| | - Swapna Koppera
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, Abigail Wexner Research Institute at Nationwide Children's Hospital (JN Cooper and S Koppera), Columbus, Ohio
| | - Emily F Boss
- Department of Otolaryngology, Johns Hopkins University School of Medicine (EF Boss), Baltimore, Md
| | - Meredith N Lind
- Department of Otolaryngology, Nationwide Children's Hospital (MN Lind), Columbus, Ohio; Department of Otolaryngology, The Ohio State University College of Medicine (MN Lind), Columbus, Ohio
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Xie DX, Boss EF, Stewart CM. An Exploration of Otolaryngology in the Reddit Community. Laryngoscope 2021; 132:284-286. [PMID: 34319587 DOI: 10.1002/lary.29696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/24/2021] [Accepted: 06/09/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Deborah X Xie
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - C Matthew Stewart
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
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Links AR, Callon W, Wasserman C, Beach MC, Ryan MA, Leu GR, Tunkel D, Boss EF. Treatment recommendations to parents during pediatric tonsillectomy consultations: A mixed methods analysis of surgeon language. Patient Educ Couns 2021; 104:1371-1379. [PMID: 33342578 DOI: 10.1016/j.pec.2020.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/19/2020] [Accepted: 11/11/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE A deeper understanding of the dialogue clinicians use to relay treatment recommendations is needed to fully understand their influence on patient decisions about surgery. We characterize how otolaryngologists provide treatment recommendations and suggest a classification framework. METHODS We qualitatively analyzed surgeon recommendations from 55 encounters between otolaryngologists and parents of children evaluated for tonsillectomy, and classified recommendation types by phrasing. Multilevel logistic regression identified predictors of recommendation phrasing. RESULTS Clinicians provided 183 recommendations (mean/visit = 3.3). We identified four domains of recommendation-phrasing (direct, passive, acceptable, parent-oriented). Direct recommendations (n = 68, 37%) included presumptive statements phrasing intentions as inevitable. Passive recommendations (n = 65, 36%) included practice-based recommendations utilizing general statements. Acceptable recommendations (n = 29, 16%) included speaking positively about treatment options. Parent-oriented recommendations (n = 21, 11%) included parent choice statements. Clinicians more commonly made direct recommendations to parents who were racial minorities (OR = 2.7, p = .02, 95% CI [1.7, 5.9]) or had an annual income <$50,000 (OR = 2.2, p = .03, 95% CI [1.1, 4.4]). CONCLUSION Clinicians provide treatment recommendations in a variety of ways that may introduce more or less certainty and choice to parental treatment decisions. PRACTICE IMPLICATIONS Findings may be implemented into training which increases clinician awareness of dialogue use when recommending treatment alternatives to patients.
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Affiliation(s)
- Anne R Links
- Johns Hopkins University School of Medicine, Department of Otolaryngology, Baltimore, USA.
| | - Wynne Callon
- Harvard Medical School, Boston Children's Hospital, Boston, USA
| | - Carly Wasserman
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, USA
| | - Mary Catherine Beach
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, USA
| | - Marisa A Ryan
- Johns Hopkins University School of Medicine, Department of Otolaryngology, Baltimore, USA
| | - Grace R Leu
- Johns Hopkins University School of Medicine, Department of Otolaryngology, Baltimore, USA
| | - David Tunkel
- Johns Hopkins University School of Medicine, Department of Otolaryngology, Baltimore, USA
| | - Emily F Boss
- Johns Hopkins University School of Medicine, Department of Otolaryngology, Baltimore, USA
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Leu GR, Links AR, Ryan MA, Walsh JM, Tunkel DE, Beach MC, Boss EF. Assessment of Parental Choice Predisposition for Tonsillectomy in Children. JAMA Otolaryngol Head Neck Surg 2021; 147:263-270. [PMID: 33377933 DOI: 10.1001/jamaoto.2020.5031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance The decision to proceed with tonsillectomy to treat pediatric obstructive sleep-disordered breathing (OSDB) often falls on individual families. Despite emphasis on shared decision-making between parents and surgeons about tonsillectomy for OSDB, the extent to which parents have already decided about surgery prior to the child's consultation is not known. Objective To identify predictors of parent choice predisposition for surgical treatment of OSDB with tonsillectomy and describe its association with parent-clinician communication. Design, Setting, and Participants Observational cohort study conducted at 3 outpatient clinical sites (urban-based outpatient center, suburban off-site outpatient center, and community-based medical center) associated with a large academic center. A total of 149 parents of children undergoing their initial otolaryngology consultation for OSDB were identified through clinic scheduling records and deemed eligible for participation in this study. Of the 149 parents, a volunteer sample of 64 parents (42.9%) agreed to participate and have their consultation audiorecorded. Of these 64 participants, 12 parents were excluded because their child had previously been evaluated for OSDB by a specialist. Main Outcomes and Measures The primary outcomes and measures were treatment choice predisposition scale (a measure of the strength of a patient's treatment decision prior to entering a medical consultation), parent communication behaviors coded in consultation audiorecordings (substantive questions asked, introduced medical jargon, expression of treatment preference, and scores on the OSDB and Adenotonsillectomy Knowledge Scale for parents). Results A total of 52 parent participants were included in the final analysis. Most parent participants were female (n = 48; 92%); 50% (n = 26) of parents were non-Hispanic White, 37% (n = 19) were Black, 10% (n = 5) were Hispanic/Latino, and 4% (n = 2) self-reported race/ethnicity as "Other." Mean (range) choice predisposition was 6.84 (2-10), with 22 parents (42%) more predisposed to choose tonsillectomy. Parents more predisposed to choose tonsillectomy used more medical jargon during the consultation (odds ratio [OR], 3.95; 95% CI, 1.16-15.15) and were less likely to ask questions (OR, 0.22; 95% CI, 0.05-0.87). Parental predictors of greater predisposition toward choosing surgery were White race (OR, 7.31; 95% CI, 1.77-39.33) and prior evaluation by a pediatrician for OSDB (OR, 6.10; 95% CI, 1.44-33.34). Conclusions and Relevance In this cohort study of parents of children with OSDB, many parents were predisposed to choose treatment with tonsillectomy prior to initial surgical consultation, which may lessen engagement and influence 2-way communication. In this cohort, greater predisposition for tonsillectomy was observed in non-Hispanic White parents and parents of patients who had been previously evaluated by a pediatrician for OSDB. Understanding parent choice predisposition for surgery may promote improved communication and parental engagement during surgical consultations. It may also help direct education about sleep and tonsillectomy to nonsurgical forums.
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Affiliation(s)
- Grace R Leu
- Tufts University School of Medicine, Boston, Massachusetts
| | - Anne R Links
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marisa A Ryan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan M Walsh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David E Tunkel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mary Catherine Beach
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland.,Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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17
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Reed NS, Assi L, Horiuchi W, Hoover-Fong JE, Lin FR, Ferrante LE, Inouye SK, Miller ER, Boss EF, Oh ES, Willink A. Medicare Beneficiaries With Self-Reported Functional Hearing Difficulty Have Unmet Health Care Needs. Health Aff (Millwood) 2021; 40:786-794. [PMID: 33939509 PMCID: PMC8323057 DOI: 10.1377/hlthaff.2020.02371] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Hearing loss is associated with higher health care spending and use, but little is known about the unmet health care needs of people with hearing loss or difficulty. Analysis of 2016 Medicare Current Beneficiary Survey data for beneficiaries ages sixty-five and older reveals that those who reported a lot of trouble hearing in the past year were 49 percent more likely than those who reported no trouble hearing to indicate not having a usual source of care. Compared with those who reported no trouble hearing, those who reported some trouble hearing were more likely to indicate not having obtained medical care in the past year when they thought it was needed, as well as not filling a prescription, with the risk for both behaviors being greater among those reporting a lot of trouble hearing versus a little. Interventions that improve access to hearing services and aid communication may help older Medicare beneficiaries meet their health care needs.
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Affiliation(s)
- Nicholas S. Reed
- Department of Epidemiology and in the Cochlear Center for Hearing and Public Health, both at the Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland
| | - Lama Assi
- Cochlear Center for Hearing and Public Health, Johns Hopkins Bloomberg School of Public Health
| | - Wakako Horiuchi
- John A. Burns School of Medicine, University of Hawaii, in Honolulu, Hawaii
| | - Julie E. Hoover-Fong
- McKusick-Nathans Institute of Genetic Medicine, Department of Genetic Medicine, and the director of the Kathryn and Alan C. Greenberg Center for Skeletal Dysplasias, both at Johns Hopkins School of Medicine, in Baltimore, Maryland
| | - Frank R. Lin
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins School of Medicine, and director of the Cochlear Center for Hearing and Public Health, Johns Hopkins Bloomberg School of Public Health
| | - Lauren E. Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, in New Haven, Connecticut
| | - Sharon K. Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, and the director of the Aging Brain Center in the Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, both in Boston, Massachusetts
| | | | - Emily F. Boss
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins School of Medicine
| | - Esther S. Oh
- Department of Medicine, Johns Hopkins School of Medicine
| | - Amber Willink
- Menzies Centre for Health Policy and Economics, University of Sydney, in New South Wales, Australia
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18
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Clements AC, Walsh JM, Dai X, Skinner ML, Sterni LM, Tunkel DE, Boss EF, Ryan MA. Cardiopulmonary Testing before Pediatric Adenotonsillectomy for Severe and Very Severe Obstructive Sleep Apnea Syndrome. Laryngoscope 2021; 131:2361-2368. [PMID: 33704794 DOI: 10.1002/lary.29480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 02/08/2021] [Accepted: 02/12/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS Adenotonsillectomy is first-line treatment for pediatric obstructive sleep apnea syndrome (OSAS) when not otherwise contraindicated. There is concern severe OSAS increases risk of comorbid cardiopulmonary abnormalities, such as ventricular hypertrophy or pulmonary hypertension, which preoperative testing could detect. Our objective is to determine if there is a severity of pediatric OSAS where previously undetected cardiopulmonary comorbidities are likely. STUDY DESIGN Retrospective chart review. METHODS We performed a retrospective review of 358 patients ≤21 years with severe OSAS who underwent adenotonsillectomy at a tertiary hospital June 1, 2016 to June 1, 2018. We extracted demographics, comorbidities, polysomnography, and preoperative tests. Wilcoxon rank-sum and logistic regression estimated associations of OSAS severity (based on obstructive apnea-hypopnea index [OAHI], hypoxia, hypercarbia) with preoperative echocardiograms and chest X-rays (CXRs). RESULTS Mean age was 5.9 (±3.6) years and 52% were male. Mean OAHI and oxygen saturation nadir were 30.3 (±23.8) and 80.7% (±9.2), respectively. OAHI ≥60 was associated with having a preoperative echocardiogram (OR, 3.8; 95% CI, 1.7-8.5) or CXR (OR, 3.0; 95% CI, 1.4-6.8) compared to OAHI 10-59. There were no significant associations between OSAS severity and test abnormalities. The presence of previously diagnosed cardiopulmonary comorbidities was associated with abnormalities on echocardiogram (OR, 36; 95% CI, 4.1-320.1) and CXR (OR, 4.1; 95% CI, 1.2-14.4). CONCLUSIONS Although pediatric patients with very severe OSAS (OAHI ≥60) underwent more pre-adenotonsillectomy cardiopulmonary tests, OSAS severity did not predict abnormal findings. Known cardiopulmonary comorbidities may be a better indication for cardiopulmonary testing than polysomnographic parameters, which could streamline pre-adenotonsillectomy evaluation and reduce cost. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
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Affiliation(s)
| | - Jonathan M Walsh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Xi Dai
- Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Margaret L Skinner
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Laura M Sterni
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - David E Tunkel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Marisa A Ryan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
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Zhang L, Links AR, Boss EF, White A, Walsh J. Identification of Potential Barriers to Timely Access to Pediatric Hearing Aids. JAMA Otolaryngol Head Neck Surg 2021; 146:13-19. [PMID: 31600386 DOI: 10.1001/jamaoto.2019.2877] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Despite various barriers identified to early pediatric access to cochlear implantation, barriers to timely access to pediatric hearing aids are not well characterized. Objective To identify socioeconomic, demographic, and clinical factors that may be associated with pediatric access to hearing aids. Design, Setting, and Participants This retrospective cohort study included 90 patients aged 1 to 15 years who were referred for auditory brainstem response (ABR) testing and evaluation for hearing aids at a single tertiary care academic medical center from March 2004 to July 2018. Children who did not receive both ABR testing and hearing aids at the same center were excluded from analysis. Main Outcomes and Measures Associations of insurance type (private vs public), race/ethnicity (white vs other), primary language (English vs other), cause of hearing loss (complex vs not complex), zip code, hearing aid manufacturer, and severity of hearing loss (in decibels) with the duration of intervals from newborn hearing screening to ABR testing, from ABR testing to ordering of hearing aids, and from ABR testing to dispensing of hearing aids. Results Of the 90 patients, mean (SD) age was 5.6 (3.7) years, 56% were female, and 77 (86%) were non-Hispanic. Results of χ2 tests indicated significant assocations existed between public insurance and race/ethnicity and between public insurance and primary language other than English. Variables associated with the interval from newborn hearing screening to ABR testing included insurance type (mean difference, 7.4 months; 95% CI, 2.6-12.2 months) and race/ethnicity (mean difference, 6.9 months; 95% CI, 2.7-11.1 months). Increased delays between birth and a child's first ABR test were associated with public insurance (mean difference, 6.0 months; 95% CI, 1.8-10.2 months) and race/ethnicity other than white (mean difference, 6.0 months; 95% CI, 2.3-9.7 months). The mean time from birth to initial ABR testing was a mean of 6 months longer for patients from non-English-speaking families than for those from English-speaking families (mean [SD] interval, 14.9 [16.3] months vs 9.0 [8.5] months), although the difference was not statistically significant. Severity of hearing loss was associated with a decrease in the interval from ABR testing to ordering of hearing aids after accounting for other potential barriers (odds ratio, 0.6; 95% CI, 0.4-0.9). Zip code and complexity of the child's medical condition did not appear to be associated with timely access to pediatric hearing aids. Conclusions and Relevance This study's findings suggest that insurance type, race/ethnicity, and primary language may be barriers associated with pediatric access to hearing aids, with the greatest difference observed in time to initial ABR testing. Clinical severity of hearing loss appeared to be associated with a significant decrease in time from ABR testing to ordering of hearing aids. Greater efforts to assist parents with ABR testing and coordination of follow-up may help improve access for other at-risk children.
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Affiliation(s)
- Lisa Zhang
- Medical student, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Anne R Links
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alicia White
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan Walsh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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20
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Leu GR, Links AR, Tunkel DE, Walsh JM, Ryan MA, DiCarlo H, Jelin EB, Beach MC, Boss EF. Understanding Bias in Surgery: Perceived Cultural Similarity Between Surgeons and Patient Families. Otolaryngol Head Neck Surg 2021; 165:282-289. [PMID: 33430701 DOI: 10.1177/0194599820982639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We describe surgeon and parent perceptions of similarity toward each other and evaluate differences in the perceptions of similarity by race. STUDY DESIGN Observational cohort analysis. SETTING Three outpatient sites. METHODS Following consultations for children undergoing evaluation for 1 of 3 surgical procedures (tonsillectomy, hernia repair, circumcision), surgeons and parents rated their perception of cultural similarity toward each other on a 6-point Likert scale. Surgeon evaluation of 9 parent characteristics was measured with 7-point Likert scales. Regression analyses were performed to identify predictors of greater surgeon-perceived similarity and to assess associations of perceived similarity with evaluation of parent characteristics. RESULTS Most parents were women (n = 38, 84%), whereas surgeons were primarily men (n = 7, 54%). Of 45 parents, 23 (51%) were non-White, whereas only 4 of 13 clinicians (31%) were non-White. Mean perceived similarity score was 21.7 for parents (range, 10-24) and 18.2 for surgeons (range, 10-24). There was no difference in parent-perceived similarity based on race (White vs non-White parents, mean [SD] = 22.3 [3.4] vs 21.1 [3.0]; P = .26). Surgeons perceived greater similarity with White parents (odds ratio = 4.78; 95% CI, 1.02-22.54; P = .04) and parents with higher income (odds ratio = 11.84; 95% CI, 1.32-106.04; P = .03). Greater perceived similarity by the surgeons was associated with more positive assessments of parent personality characteristics. CONCLUSION Surgeons perceived similarity more commonly with White parents, while parents' perception of similarity to surgeons was uniform regardless of parent race. Elucidating biases of surgeons may help to tailor interventions promoting culturally competent, equitable communication and decision making for elective surgery.
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Affiliation(s)
- Grace R Leu
- School of Medicine, Tufts University, Boston, Massachusetts, USA
| | - Anne R Links
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - David E Tunkel
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jonathan M Walsh
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Marisa A Ryan
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Heather DiCarlo
- Department of Pediatric Urology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Eric B Jelin
- Department of Pediatric Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Mary Catherine Beach
- Department of Internal Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Sidell DR, Balakrishnan K, Best SR, Zur K, Buckingham J, De Alarcon A, Baroody FM, Bock JM, Boss EF, Bower CM, Campisi P, Chen SF, Clarke JM, Clarke KD, Cocciaglia A, Cotton RT, Cuestas G, Davis KL, DeFago VH, Dikkers FG, Dossans I, Florez W, Fox E, Friedman AD, Grant N, Hamdi O, Hogikyan ND, Johnson K, Johnson LB, Johnson RF, Kelly P, Klein AM, Lawlor CM, Leboulanger N, Levy AG, Lam D, Licameli GR, Long S, Lott DG, Manrique D, McMurray JS, Meister KD, Messner AH, Mohr M, Mudd P, Mortelliti AJ, Novakovic D, Ongkasuwan J, Peer S, Piersiala K, Prager JD, Pransky SM, Preciado D, Raynor T, Rinkel RNPM, Rodriguez H, Rodríguez VP, Russell J, Scatolini ML, Scheffler P, Smith DF, Smith LP, Smith ME, Smith RJH, Sorom A, Steinberg A, Stith JA, Thompson D, Thompson JW, Varela P, White DR, Wineland AM, Yang CJ, Zdanski CJ, Derkay CS. Systemic Bevacizumab for Treatment of Respiratory Papillomatosis: International Consensus Statement. Laryngoscope 2021; 131:E1941-E1949. [PMID: 33405268 DOI: 10.1002/lary.29343] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/08/2020] [Accepted: 12/17/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES/HYPOTHESIS The purpose of this study is to develop consensus on key points that would support the use of systemic bevacizumab for the treatment of recurrent respiratory papillomatosis (RRP), and to provide preliminary guidance surrounding the use of this treatment modality. STUDY DESIGN Delphi method-based survey series. METHODS A multidisciplinary, multi-institutional panel of physicians with experience using systemic bevacizumab for the treatment of RRP was established. The Delphi method was used to identify and obtain consensus on characteristics associated with systemic bevacizumab use across five domains: 1) patient characteristics; 2) disease characteristics; 3) treating center characteristics; 4) prior treatment characteristics; and 5) prior work-up. RESULTS The international panel was composed of 70 experts from 12 countries, representing pediatric and adult otolaryngology, hematology/oncology, infectious diseases, pediatric surgery, family medicine, and epidemiology. A total of 189 items were identified, of which consensus was achieved on Patient Characteristics (9), Disease Characteristics (10), Treatment Center Characteristics (22), and Prior Workup Characteristics (18). CONCLUSION This consensus statement provides a useful starting point for clinicians and centers hoping to offer systemic bevacizumab for RRP and may serve as a framework to assess the components of practices and centers currently using this therapy. We hope to provide a strategy to offer the treatment and also to provide a springboard for bevacizumab's use in combination with other RRP treatment protocols. Standardized delivery systems may facilitate research efforts and provide dosing regimens to help shape best-practice applications of systemic bevacizumab for patients with early-onset or less-severe disease phenotypes. LEVEL OF EVIDENCE 5 Laryngoscope, 131:E1941-E1949, 2021.
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Affiliation(s)
- Douglas R Sidell
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A.,Aerodigestive and Airway Reconstruction Center, Lucile Packard Children's Hospital Stanford, Stanford, California, U.S.A
| | - Karthik Balakrishnan
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A.,Aerodigestive and Airway Reconstruction Center, Lucile Packard Children's Hospital Stanford, Stanford, California, U.S.A
| | - Simon R Best
- Department of Otolaryngology-Head and Neck Surgery, Division of Laryngology, and, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Karen Zur
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Julia Buckingham
- Maternal and Child Health Research Institute, Lucile Packard Children's Hospital, Stanford University School of Medicine, Stanford University, Stanford, California, U.S.A
| | - Alessandro De Alarcon
- Department of Otolaryngology, Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Fuad M Baroody
- Section of Otolaryngology-Head and Neck Surgery and Department of Pediatrics, University of Chicago Medicine and The Comer Children's Hospital, Chicago, Illinois, U.S.A
| | - Jonathan M Bock
- Department of Otolaryngology and Communication Sciences, Division of Laryngology and Professional Voice, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery and the Department of Health Policy and Management, Division of Pediatric Otolaryngology, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Charles M Bower
- Department of Otolaryngology Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Arkansas for Medical Sciences (UAMS), Arkansas Children's Hospital, Little Rock, Alaska, U.S.A
| | - Paolo Campisi
- Department of Otolaryngology - Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Sharon F Chen
- Department of Pediatrics, Division of Infectious Diseases, Lucile Packard Children's Hospital Stanford, Stanford, California, U.S.A
| | - Jeffrey M Clarke
- Department of Medicine, Division of Oncology, Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, U.S.A
| | - Kevin D Clarke
- Pediatric Otolaryngology, Division of Otolaryngology Head and Neck Surgery, University of British Columbia (UBC, UVIc), Victoria General Hospital, Victoria, British Columbia, Canada
| | - Alejandro Cocciaglia
- ENT-Respiratory Endoscopy Department, Garrahan Children's Hospital, Buenos Aires, Argentina
| | - Robin T Cotton
- Department of Otolaryngology, Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Giselle Cuestas
- Respiratory Endoscopy Section, ENT Department, Hospital General de Niños "Dr. Pedro de Elizalde", Buenos Aires, Argentina
| | - Kara L Davis
- Department of Pediatrics, Division of Pediatric Oncology, Bass Center for Childhood Cancer and Blood Disorders, Stanford University, Stanford, California, U.S.A
| | - Victor H DeFago
- Pediatric Surgery, Sanatorio del Salvador Privado SA, Cordoba, Argentina
| | - Frederik G Dikkers
- Department of Otorhinolaryngology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Ines Dossans
- Otolaryngology-Head and Neck Surgery, Hospital Pereira Rossell, Montevideo, Uruguay
| | - Walter Florez
- Department of Otolaryngology, Instituto Nacional de Salud del Niño de San Borja, Lima, Peru
| | - Elizabeth Fox
- Comprehensive Cancer Center, St Jude Children's Research Hospital, Memphis, Tennessee, U.S.A
| | - Aaron D Friedman
- Department of Otolaryngology, Head and Neck Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio, U.S.A
| | - Nazaneen Grant
- Department of Otolaryngology, Division of Laryngology, Medstar Georgetown University Hospital, Georgetown, Washington, District of Columbia, U.S.A
| | - Osama Hamdi
- Howard University College of Medicine, Washington, District of Columbia, U.S.A
| | - Norman D Hogikyan
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, U.S.A
| | - Kaalan Johnson
- University of Washington School of Medicine, Department of Otolaryngology Head and Neck Surgery, Division of Pediatric Otolaryngology, Seattle, Washington, District of Columbia, U.S.A
| | - Liane B Johnson
- Department of Surgery, Dalhousie University, Division of Paediatric Otolaryngology-Head and Neck Surgery, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Romaine F Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Texas (UT) Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Peggy Kelly
- Department of Otolaryngology, Head and Neck Surgery, Division of Pediatric Otolaryngology, Children's Hospital Colorado affiliated with University of Colorado, Anschutz, Aurora, Colorado, U.S.A
| | - Adam M Klein
- Department of Otolaryngology-Head and Neck Surgery, Division of Laryngology, Emory Voice Center, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Claire M Lawlor
- Department of Otolaryngology, Division of Pediatric Otolaryngology, Children's National Health System, George Washington University School of Medicine, Washington, District of Columbia, U.S.A
| | - Nicolas Leboulanger
- Head and Neck Surgery, Pediatric Otolaryngology, Necker Enfants Malades Hospital, Paris University, Paris, France
| | - Alejandro G Levy
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Arnold Palmer Hospital Center for Children's Cancer and Blood Disorders, Orlando Health, Orlando, Florida, U.S.A
| | - Derek Lam
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Greg R Licameli
- Department of Otolaryngology, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Steve Long
- Department of Head and Neck Surgery, Kaiser Permanente, Hillsboro, Oregon, U.S.A
| | - David G Lott
- Department of Otorhinolaryngology, Division of Laryngology, Mayo Clinic Arizona, Phoenix, Arizona, U.S.A
| | - Dayse Manrique
- Department of Otorhinolaryngology, Universidad Federal de Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - James Scott McMurray
- Pediatric Otolaryngology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Kara D Meister
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A.,Aerodigestive and Airway Reconstruction Center, Lucile Packard Children's Hospital Stanford, Stanford, California, U.S.A
| | - Anna H Messner
- Department of Otolaryngology/Head and Neck Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, U.S.A
| | - Michael Mohr
- Department of Hematology, Oncology and Respiratory Medicine, University Hospital Muenster, Muenster, Germany
| | - Pamela Mudd
- Department of Otolaryngology, Division of Pediatric Otolaryngology, Children's National Health System, George Washington University School of Medicine, Washington, District of Columbia, U.S.A
| | - Anthony J Mortelliti
- Department of Otolaryngology-Head and Neck Surgery, State University of New York (SUNY) Upstate Medical University, Syracuse, New York, U.S.A
| | - Daniel Novakovic
- Department of Otolaryngology, Head and Neck Surgery, Central Clinical School, Faculty of Medicine and Health, University of Sydney, The Canterbury Hospital, Sydney, New South Wales, Australia
| | - Julian Ongkasuwan
- Department of Otolaryngology, Division of Adult and Pediatric Laryngology, Bobby R. Alford Department of Otolaryngology Head and Neck Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, U.S.A
| | - Shazia Peer
- Division of Otorhinolaryngology, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Krysztof Piersiala
- Division of Ear, Nose and Throat Diseases, Karolinska Institutet, Karolinksa University Hospital, Stockholm, Sweden
| | - Jeremy D Prager
- Department of Otolaryngology, Head and Neck Surgery, Division of Pediatric Otolaryngology, Children's Hospital Colorado affiliated with University of Colorado, Anschutz, Aurora, Colorado, U.S.A
| | | | - Diego Preciado
- Department of Otolaryngology, Division of Pediatric Otolaryngology, Children's National Health System, George Washington University School of Medicine, Washington, District of Columbia, U.S.A
| | - Tiffany Raynor
- Department of Otolaryngology, Head and Neck Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Rico N P M Rinkel
- Department of Otolaryngology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Hugo Rodriguez
- Respiratory Endoscopy Department, Hospital de Pediatria Prof Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Verónica P Rodríguez
- Respiratory Endoscopy Section, ENT Department, Hospital General de Niños "Dr. Pedro de Elizalde", Buenos Aires, Argentina
| | - John Russell
- Department of Paediatric Otolaryngology, Children's Health Ireland, Dublin, Ireland
| | - María Laura Scatolini
- Respiratory Endoscopy Department, Hospital de Pediatria Prof Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Patrick Scheffler
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - David F Smith
- Divisions of Pediatric Otolaryngology, Pulmonary Medicine, and the Sleep Center, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Lee P Smith
- Division of Otolaryngology-Head and Neck Surgery, Pediatric Otolaryngology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Steven and Alexandra Cohen Children's Medical Center of New York, New Hyde Park, New York, U.S.A
| | - Marshall E Smith
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, U.S.A
| | - Richard J H Smith
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Abraham Sorom
- Otolaryngology, Head and Neck Surgery, Confluence Health, Wenatchee, Washington, District of Columbia, U.S.A
| | - Amalia Steinberg
- Otolaryngology, Head and Neck Surgery, Alaska Native Medical center, Anchorage, Alaska, U.S.A
| | - John A Stith
- Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, SSM Cardinal Glennon Children's Hospital Medical Center, St. Louis, Missouri, U.S.A
| | - Dana Thompson
- Division of Pediatric Otolaryngology Head and Neck Surgery Ann and Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Jerome W Thompson
- Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric ENT, LeBonheur Children's Hospital, College of Medicine, University of Tennnessee, Memphis, Tennessee, U.S.A
| | - Patricio Varela
- Pediatric Surgery Department, Universidad de Chile, Mackenna Children Hospital, Clinica Las Condes Medical center, Santiago, Chile
| | - David R White
- Division of Pediatric Otolaryngology, Medical University of South Carolina (MUSC) Shawn Jenkins Children's Hospital, Charleston, South Carolina, U.S.A
| | - Andre M Wineland
- Department of Otolaryngology-Head and Neck Surgery and the Department of Health Policy and Management, Division of Pediatric Otolaryngology, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Christina J Yang
- Department of Otolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Children's Hospital at Montefiore, New York, New York, U.S.A
| | - Carlton J Zdanski
- Department of Otolaryngology/Head and Neck Surgery, Division of Pediatric Otolaryngology/Head and Neck Surgery, North Carolina Children's Hospital, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Craig S Derkay
- Department of Otolaryngology-Head and Neck Surgery, Eastern Virginia Medical School, Children's Hospital of the King's Daughters, Norfolk, Virginia, U.S.A
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Abstract
BACKGROUND/OBJECTIVES Nearly 38 million Americans have hearing loss. Understanding how sensory deficits such as hearing loss, which limit communication, impact satisfaction has implications for Medicare value-based reimbursement mechanisms. The aim of this study was to characterize the association of functional hearing loss and dissatisfaction with quality of health care over the past year among Medicare beneficiaries. METHODS Cross-sectional study of satisfaction with quality of health care among Medicare beneficiaries with self-reported trouble hearing from the 2015 Medicare Current Beneficiaries Survey. There were 11,441 Medicare beneficiaries representing a 48.6 million total weighted nationally representative sample. RESULTS Forty-eight percent of Medicare beneficiaries reported a little or a lot of trouble hearing. Medicare beneficiaries with a little trouble hearing (odds ratio=1.496; 95% confidence interval, 1.079-2.073; P=0.016) and a lot of trouble hearing (odds ratio=1.769; 95% confidence interval, 1.175-2.664; P=0.007) had 49.6% and 76.9% higher odds of being dissatisfied with the quality of their health care over the previous year, respectively. CONCLUSIONS Medicare beneficiaries with functional hearing loss had higher odds of dissatisfaction with health care over the past year compared to those without functional hearing loss. Given Medicare's reliance on patient satisfaction as a value-based measure for hospital reimbursement, interventions to address hearing loss in the health care system are needed.
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Affiliation(s)
- Nicholas S Reed
- Cochlear Center for Hearing and Public Health, Johns Hopkins University Bloomberg School of Public Health
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health
| | | | - Frank R Lin
- Cochlear Center for Hearing and Public Health, Johns Hopkins University Bloomberg School of Public Health
- Departments of Otolaryngology
| | - Esther S Oh
- Cochlear Center for Hearing and Public Health, Johns Hopkins University Bloomberg School of Public Health
- Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine
| | - Amber Willink
- Cochlear Center for Hearing and Public Health, Johns Hopkins University Bloomberg School of Public Health
- Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
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23
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Dai X, Ryan MA, Clements AC, Tunkel DE, Links AR, Boss EF, Walsh JM. The Effect of Language Barriers at Discharge on Pediatric Adenotonsillectomy Outcomes and Healthcare Contact. Ann Otol Rhinol Laryngol 2020; 130:833-839. [PMID: 33319598 DOI: 10.1177/0003489420980176] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Effective delivery of discharge instructions and access to postoperative care play a critical role in outcomes after pediatric surgery. Previous studies in the pediatric emergency department suggest that caregivers with language barriers have less comprehension of discharge instructions despite use of interpretation services. However, the impact of language barriers during discharge on surgical outcomes in a pediatric surgical setting has not been studied. This study examined the effect of parental language during discharge on number and mode of healthcare contact following pediatric adenotonsillectomy. METHODS A retrospective cohort study was conducted on children who underwent adenotonsillectomy at a tertiary care pediatric academic medical center from July 1, 2016 to June 1, 2018. Data were collected on consecutive patients with non-English-speaking caregivers and a systematic sampling of patients with English-speaking caregiver. Surgery-related complications and healthcare contacts within 90 days after discharge were collected. Two-tailed t tests, χ2 tests, and logistic regression were performed to assess the association between parental primary language and incidence of healthcare contact after surgery. RESULTS A total of 136 patients were included: 85 English-speaking and 51 non-English-speaking. The groups were comparable in age, sex, and comorbidities. The non-English group had more patients with public insurance (86% vs. 56%; P < .001). Number of encounters and types of complications following discharge were similar, but the non-English group was more likely to utilize the emergency department compared to phone calls (OR, 9.3; 95% CI, 2.3-38.2), even after adjustment for insurance type (OR, 7.9; 95% CI, 1.6-39.4). CONCLUSION Language barriers at discharge following pediatric otolaryngology surgery is associated with a meaningful difference in how patients utilized medical care. Interventions to improve comprehension and access may help reduce preventable emergency department visits and healthcare costs.
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Affiliation(s)
- Xi Dai
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marisa A Ryan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, USA
| | | | - David E Tunkel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Anne R Links
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Jonathan M Walsh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, USA
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24
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Cramer JD, Balakrishnan K, Roy S, David Chang CW, Boss EF, Brereton JM, Monjur TM, Nussenbaum B, Brenner MJ. Intraoperative Sentinel Events in the Era of Surgical Safety Checklists: Results of a National Survey. OTO Open 2020; 4:2473974X20975731. [PMID: 33344877 PMCID: PMC7731722 DOI: 10.1177/2473974x20975731] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 10/26/2020] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Despite the implementation of advanced health care safety systems including checklists, preventable perioperative sentinel events continue to occur and cause patient harm, disability, and death. We report on findings relating to otolaryngology practices with surgical safety checklists, the scope of intraoperative sentinel events, and institutional and personal response to these events. STUDY DESIGN Survey study. SETTING Anonymous online survey of otolaryngologists. METHODS Members of the American Academy of Otolaryngology-Head and Neck Surgery were asked about intraoperative sentinel events, surgical safety checklist practices, fire safety, and the response to patient safety events. RESULTS In total, 543 otolaryngologists responded to the survey (response rate 4.9% = 543/11,188). The use of surgical safety checklists was reported by 511 (98.6%) respondents. At least 1 patient safety event in the past 10 years was reported by 131 (25.2%) respondents; medication errors were the most commonly reported (66 [12.7%] respondents). Wrong site/patient/procedure events were reported by 38 (7.3%) respondents, retained surgical items by 33 (6.4%), and operating room fire by 18 (3.5%). Although 414 (79.9%) respondents felt that time-outs before the case have been the single most impactful checklist component to prevent serious patient safety events, several respondents also voiced frustrations with the administrative burden. CONCLUSION Surgical safety checklists are widely used in otolaryngology and are generally acknowledged as the most effective intervention to reduce patient safety events; nonetheless, intraoperative sentinel events do continue to occur. Understanding the scope, causes, and response to these events may help to prioritize resources to guide quality improvement initiatives in surgical safety practices.
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Affiliation(s)
- John D. Cramer
- Department of Otolaryngology–Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Karthik Balakrishnan
- Department of Otolaryngology–Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Soham Roy
- Department of Otorhinolaryngology–Head and Neck Surgery, University of Texas Medical School at Houston, Houston, Texas, USA
| | - C. W. David Chang
- Department of Otolaryngology–Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Emily F. Boss
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jean M. Brereton
- American Academy of Otolaryngology–Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Taskin M. Monjur
- American Academy of Otolaryngology–Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Brian Nussenbaum
- American Board of Otolaryngology—Head & Neck Surgery, Houston, Texas, USA
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Ryan MA, Leu GR, Upchurch PA, Tunkel DE, Walsh JM, Boss EF. Systemic Bevacizumab (Avastin) for Juvenile-Onset Recurrent Respiratory Papillomatosis: A Systematic Review. Laryngoscope 2020; 131:1138-1146. [PMID: 32959914 DOI: 10.1002/lary.29084] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/31/2020] [Accepted: 08/12/2020] [Indexed: 11/12/2022]
Abstract
OBJECTIVES Juvenile onset recurrent respiratory papillomatosis (JORRP) can cause severe or disseminated disease. Surgical treatment may be inadequate. Systemic bevacizumab has shown initial success for severe JORRP. The objective of this systematic review was to assess usage, effectiveness, and safety of this treatment. METHODS We searched PubMed, Embase, and Web of Science for studies of humans with JORRP treated with systemic bevacizumab. Two researchers independently reviewed the studies to determine inclusion and aggregate data on patient characteristics, dosing protocols, treatment response, adverse events, and level of evidence. RESULTS Of 80 identified articles, 12 studies were included detailing 20 distinct cases. At a mean age of 12.8 years (range = 1-43 years) patients received initial dosing of 5 to 10 mg/kg of bevacizumab followed by ongoing doses at a mean 3-week intervals (range = 2-5 weeks). All patients had clinically significant disease reduction with reduced need for surgery. Six patients (30%) had complete response in at least one involved anatomic site. Eleven (55%) required no surgery after initiating treatment. There was recurrence in all four patients whose treatment was stopped, but had rapid improvement with treatment resumption. Six (30%) experienced mild or moderate adverse events. CONCLUSIONS Marked improvement in severe JORRP has been reported from systemic bevacizumab. Treatment protocols vary, and treatment discontinuation was not feasible in any reported patient. Based on currently available data, systemic bevacizumab can be considered for severe JORRP as it appears to be well tolerated and effective. A clinical trial could enhance the understanding of its safety and efficacy for this indication. Laryngoscope, 131:1138-1146, 2021.
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Affiliation(s)
- Marisa A Ryan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Grace R Leu
- Tufts University School of Medicine, Boston, Massachusetts, U.S.A
| | - Patrick A Upchurch
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, U.S.A.,Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - David E Tunkel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Jonathan M Walsh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
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26
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Salazar JH, Goldstein SD, Swarup A, Boss EF, Van Arendonk KJ, Abdullah F. Transfusions in Children’s Surgery: Characterization and Development of a Model for Benchmarking. J Surg Res 2020; 252:47-56. [DOI: 10.1016/j.jss.2019.11.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 11/05/2019] [Accepted: 11/23/2019] [Indexed: 11/25/2022]
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27
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Clements AC, Dai X, Walsh JM, Sterni LM, Prichett L, Boss EF, Seal SM, Ryan MA. Outcomes of Adenotonsillectomy for Obstructive Sleep Apnea in Prader-Willi Syndrome: Systematic Review and Meta-analysis. Laryngoscope 2020; 131:898-906. [PMID: 33026674 DOI: 10.1002/lary.28922] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/27/2020] [Accepted: 06/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Prader-Willi syndrome (PWS) increases the risk of obstructive sleep apnea (OSA) due to obesity, hypotonia, and abnormal ventilatory responses. We evaluated post-adenotonsillectomy complications, polysomnography changes, and quality of life in children with OSA and PWS. STUDY DESIGN Systematic review and meta-analysis. METHODS We conducted a systematic review and meta-analysis by searching PubMed, Embase, Cochrane, Web of Science, and Scopus. Two researchers independently reviewed studies about adenotonsillectomy for OSA in patients <21 years with PWS. We extracted study design, patient numbers, age, complications, polysomnography, and quality of life. We pooled postoperative changes in apnea hypopnea index (AHI) for meta-analysis. We applied Methodological Index for Nonrandomized Studies (MINORS) criteria to assess study quality. RESULTS The initial search yielded 169 studies. We included 68 patients from eight studies with moderate to high risk of bias. Six studies reported on complications and 12 of 51 patients (24%) had at least one. Velopharyngeal insufficiency was the most commonly reported complication (7/51, 14%). We included seven studies in meta-analysis. Mean postoperative improvement in AHI was 7.7 (95% CI: 4.9-10.5). Postoperatively 20% (95% CI: 3%-43%) had resolution of OSA with AHI < 1.5 while 67% (95% CI: 50%-82%) had improvement from severe/moderate OSA to mild/resolved (AHI < 5). Two studies evaluated quality of life and demonstrated improvement. CONCLUSIONS Children with PWS undergoing adenotonsillectomy for OSA have a substantial risk of postoperative complications that may require additional interventions, especially velopharyngeal insufficiency. Despite improvements in polysomnography and quality of life, many patients had residual OSA. This information can be used to counsel families when considering OSA treatment options. Laryngoscope, 131:898-906, 2021.
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Affiliation(s)
| | - Xi Dai
- Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Jonathan M Walsh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Laura M Sterni
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Laura Prichett
- Biostatistics, Epidemiology and Data Management (BEAD) Core, Johns Hopkins School of Medicine, Baltimore, Maryland, U.S.A
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Stella M Seal
- Johns Hopkins University School of Medicine, Welch Medical Library, Baltimore, Maryland, U.S.A
| | - Marisa A Ryan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
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Ryan MA, Leu GR, Boss EF, Raynor EM, Walsh JM. Adherence to American Academy of Otolaryngology-Head and Neck Surgery Clinical Practice Guidelines: A Systematic Review. Otolaryngol Head Neck Surg 2020; 163:626-644. [PMID: 32450772 DOI: 10.1177/0194599820922155] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Clinical practice guidelines synthesize and disseminate the best available evidence to guide clinical decisions and increase high-quality care. Since 2004, the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published 16 guidelines. The objective of this review was to evaluate clinicians' adherence to these guidelines' recommendations as measured in the literature. DATA SOURCES We searched PubMed, Embase, and Web of Science on August 29, 2019, for studies published after June 1, 2004. REVIEW METHODS We systematically identified peer-reviewed studies in English that reported clinician adherence to AAO-HNSF guideline recommendations. Two authors independently reviewed and abstracted study characteristics, including publication date, population, sample size, guideline adherence, and risk of bias. RESULTS The search yielded 385 studies. We excluded 331 studies during title/abstract screening and 32 more after full-text review. The remaining 22 studies evaluated recommendations from 8 of the 16 guidelines. The Otitis Media with Effusion, Polysomnography, Tonsillectomy, and Sinusitis guidelines were studied most. Study designs included retrospective chart reviews (7, 32%), clinician surveys (7, 32%), and health care database analyses (8, 36%). Studies reported adherence ranging from 0% to 99.8% with a mean of 56%. Adherence varied depending on the recommendation evaluated, type of recommendation, clinician type, and clinical setting. Adherence to the polysomnography recommendations was low (8%-65.3%). Adherence was higher for the otitis media with effusion (76%-90%) and tonsillectomy (43%-98.9%) recommendations. CONCLUSIONS Adherence to recommendations in the AAO-HNSF guidelines varies widely. These findings highlight areas for further guideline dissemination, research about guideline adoption, and quality improvement.
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Affiliation(s)
- Marisa A Ryan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Grace R Leu
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Eileen M Raynor
- Department of Head and Neck Surgery & Communication Sciences, Duke University Durham, North Carolina, USA
| | - Jonathan M Walsh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Heller MA, Lind MN, Boss EF, Cooper JN. Differences in Tonsillectomy Use by Race/Ethnicity and Type of Health Insurance Before and After the 2011 Tonsillectomy Clinical Practice Guidelines. J Pediatr 2020; 220:116-124.e3. [PMID: 32171561 DOI: 10.1016/j.jpeds.2020.01.061] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/02/2020] [Accepted: 01/29/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate whether differences in pediatric tonsillectomy use by race/ethnicity and type of insurance were impacted by the American Academy of Otolaryngology-Head and Neck Surgery's 2011 tonsillectomy clinical practice guidelines. STUDY DESIGN We included children aged <15 years from Florida or South Carolina who underwent tonsillectomy in 2004-2017. Annual tonsillectomy rates within groups defined by race/ethnicity and type of health insurance were calculated using US Census data, and interrupted time series analyses were used to compare the guidelines' impact on utilization across groups. RESULTS The average annual tonsillectomy rate was greater among non-Hispanic white children (66 procedures per 10 000 children) than non-Hispanic black (38 procedures per 10 000 children) or Hispanic children (41 procedures per 10 000 children) (P < .001). From the year before to the year after the guidelines' release, tonsillectomy use decreased among non-Hispanic white children (-11.1 procedures per 10 000 children), but not among non-Hispanic black (-0.9 procedures per 10 000 children) or Hispanic children (+3.9 procedures per 10 000 children) (P < .05). Use was greater among publicly than privately insured children (75 vs 52 procedures per 10 000 children, P < .001). The guidelines were associated with a reversal of the upward trend in use seen in 2004-2010 among publicly insured children (-5.5 procedures per 10 000 children per year, P < .001). CONCLUSIONS Tonsillectomy use is greatest among white and publicly insured children. However, the American Academy of Otolaryngology-Head and Neck Surgery's 2011 clinical practice guideline statement was associated with an immediate decrease and change in use trends in these groups, narrowing differences in utilization by race/ethnicity and type of insurance.
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Affiliation(s)
- Margaret A Heller
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Meredith N Lind
- Department of Otolaryngology, Nationwide Children's Hospital, Columbus, OH; Department of Otolaryngology, The Ohio State University College of Medicine, Columbus, OH
| | - Emily F Boss
- Department of Otolaryngology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH; Division of Epidemiology, The Ohio State University College of Public Health, Columbus, OH.
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Links AR, Callon W, Wasserman C, Walsh J, Tunkel DE, Beach MC, Boss EF. Parental role in decision-making for pediatric surgery: Perceptions of involvement in consultations for tonsillectomy. Patient Educ Couns 2020; 103:944-951. [PMID: 31866196 DOI: 10.1016/j.pec.2019.12.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 11/20/2019] [Accepted: 12/14/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Parental role in decision-making has implications for quality of care. We describe roles of parent participation in decision-making for tonsillectomy. METHODS Parents reported preferred role in decision-making before consultations for tonsillectomy and the role they experienced after their consult. Parents completed questionnaires, including items evaluating clinician/parent communication. Clinicians rated perception of parents' preferred role in decision-making. Congruence between parent and clinician responses was evaluated via kappa analysis. Logistic regression identified associations between decision-making roles and socioemotional and communication factors. RESULTS Consults between 63 parents and 8 otolaryngologists were analyzed.There was inadequate agreement between clinician and parent ratings of preferred roles (37%, p = 0.6, 95% CI [-0.09, 0.001]). Parents perceived greater involvement when clinicians discussed reasons to have (OR = 4.3, p = 0.03) or not have (OR = 4.1, p = 0.005) surgery. Parents perceived less involvement when clinicians used jargon (OR = 0.1, p = 0.03), and when parents trusted clinicians (OR = 0.4, p = 0.049), or experienced greater decisional conflict (OR = 0.9, p = 0.03). CONCLUSIONS Parents and clinicians perceived parental preference for decision-making involvement differently during consultations for tonsillectomy. Clinician information-sharing, jargon use, and parent trust in clinician predicted extent of perceived engagement. PRACTICE IMPLICATIONS Findings may enhance understanding of strategies to effectively communicate and engage parents in shared decision-making for pediatric surgical care.
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Affiliation(s)
- Anne R Links
- Johns Hopkins University School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Baltimore, USA.
| | - Wynne Callon
- Harvard Medical School, Boston Children's Hospital, Boston, USA
| | - Carly Wasserman
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, USA
| | - Jonathan Walsh
- Johns Hopkins University School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Baltimore, USA
| | - David E Tunkel
- Johns Hopkins University School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Baltimore, USA
| | - Mary Catherine Beach
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, USA
| | - Emily F Boss
- Johns Hopkins University School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Baltimore, USA
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Abstract
We evaluate maternal perspectives of frenotomy for ankyloglossia in newborns. We searched highly frequented forums like babycenter.com for comments related to frenotomy posted from 2012 to 2017. We applied modified grounded theory, reviewed posts for thematic synthesis, and calculated frequencies for each theme. High decisional conflict, low discussion of surgical complications, and an overall moderate positive experience were noted. Mothers posted about breastfeeding issues (n = 227, 74.7%) and overall experience (n = 229, 75.3%). Posts related to breastfeeding include discomfort ("I can no longer physically take the pain"; n = 93, 30.6%). Parents posted frequently about a satisfactory outcome ("It was so worth it to improve our nursing relationship"; n = 133, 43.8%), but dissatisfactory outcome ("I'm still having problems latching and am pumping. It's brutal"; n = 31) was present in 10.2%. These results aid in understanding parental thoughts of frenotomy. Physicians can use these self-reported maternal perspectives on frenotomy to guide counseling and improve shared decision making for parents.
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Affiliation(s)
- Shagnik Ray
- Johns Hopkins University, Baltimore, MD, USA
| | | | - Mark Giorgi
- Morehouse School of Medicine, Atlanta, GA, USA
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Kannan S, Seo J, Riggs KR, Geller G, Boss EF, Berger ZD. Surgeons' Views on Shared Decision-Making. J Patient Cent Res Rev 2020; 7:8-18. [PMID: 32002443 PMCID: PMC6988707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Abstract
PURPOSE Shared decision-making (SDM) has a significant role in surgical encounters, where decisions are influenced by both clinician and patient preferences. Herein, we sought to explore surgeons' practices and beliefs about SDM. METHODS We performed a qualitative study consisting of semi-structured individual interviews with 18 surgeons from private practice and academic surgery practices in Baltimore, Maryland. We purposively sampled participants to maximize diversity of practice type (academic vs private), surgical specialty, gender, and experience level. Interview topics included benefits and challenges to patient involvement in decision-making, communicating uncertainty to patients, and use of decision aids. Interviews were audio-recorded and transcribed. Transcripts were analyzed using content analysis to identify themes. RESULTS Surgeons were supportive of patients being involved in decision-making, particularly in cases with uncertainty about treatment options. However, surgeons identified SDM as being more appropriate for patients whom surgeons perceived as interested in decision-making involvement and for decisions in which surgeons did not have strong preferences. Additionally, surgeons reported typically presenting only a subset of available options, remaining confident in their ability to filter less suitable options based on intuitive risk assessments. Surgeons differed in their approach to making recommendations, with some guiding patients towards what they saw as the correct or optimal decision while others sought to maintain neutrality and support of the patients' chosen decision. CONCLUSIONS Many surgeons do not believe SDM is universally optimal for every surgical decision. They instead use assessments of patient disposition or potential clinical uncertainty to guide their perceived appropriateness of using SDM.
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Affiliation(s)
- Suraj Kannan
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jayhyun Seo
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kevin R. Riggs
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL
- Birmingham VA Medical Center, Birmingham, AL
| | - Gail Geller
- Division of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Emily F. Boss
- Pediatric Otolaryngology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Zackary D. Berger
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Hairston TK, Links AR, Harris V, Tunkel DE, Walsh J, Beach MC, Boss EF. Evaluation of Parental Perspectives and Concerns About Pediatric Tonsillectomy in Social Media. JAMA Otolaryngol Head Neck Surg 2019; 145:45-52. [PMID: 30452510 DOI: 10.1001/jamaoto.2018.2917] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Importance Tonsillectomy is common in children, but little is known about parental preferences and values concerning this surgical procedure. Twitter offers an opportunity to evaluate parental understanding and experience of tonsillectomy care. Objective To identify parental perspectives about tonsillectomy in children that may not be apparent in a routine clinical encounter. Design, Setting, and Participants In this qualitative study, social media platform Twitter was searched for posts (tweets) published between January 1, 2008, and December 31, 2017, by US-based parents about their child's tonsillectomy. Modified grounded theory was applied to develop a coding taxonomy to classify the tweets. Tweets were assessed for thematic synthesis and classification, and descriptive statistics were obtained for each theme. Main Outcomes and Measures Themes of parental experiences and perspectives about their child's tonsillectomy. Results Of the 5801 total tweets retrieved, 782 (13.5%) satisfied the inclusion criteria. Tweets were categorized under 2 overarching themes: procedural concerns (549 tweets [70.2%]) and attitudes or experiences (498 [63.7%]). Common tweets under procedural concerns mentioned surgical indication for tonsillectomy (55 tweets [7.0%]); eg, "strep-I think it's tonsil removing time…") and recovery (227 tweets [29.0%]), including child's attitude (89 tweets [11.4%]; eg, "so hard to get my daughter to eat") and parental experience (87 tweets [11.1%]; eg, "tonsillectomy recovery sucks for the parent as much as the kid!"). Common tweets regarding attitudes or experiences included the tenor of overall care (225 tweets [28.6%]; eg, "Tonsillectomy is a bear") and fears or apprehensions (209 tweets [26.6%]). Conclusions and Relevance These social media findings may be used to guide clinicians in educating and counseling parents as well as further engaging parents and children in shared decision making for tonsillectomy.
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Affiliation(s)
- Tai Kyung Hairston
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Anne R Links
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vandra Harris
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David E Tunkel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan Walsh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Abstract
This study uses National Vital Statistics System data to characterize trends in deaths among children and adolescents aged 0 to 17 years caused by object-related aspiration.
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Affiliation(s)
- John D. Cramer
- Department of Otolaryngology–Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan
| | - Taha Meraj
- Department of Otolaryngology–Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan
| | - Jennifer M. Lavin
- Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Emily F. Boss
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Aaronson NL, Cox CT, Boss EF. Parental health literacy in pediatric otolaryngology: A pilot study. Int J Pediatr Otorhinolaryngol 2019; 125:87-91. [PMID: 31271973 DOI: 10.1016/j.ijporl.2019.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 06/25/2019] [Accepted: 06/25/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Pediatric otolaryngology bears the highest frequency of elective surgical cases in children, but little is known regarding the health literacy of these children's parents. In a questionnaire-based pilot study, we assessed parental health literacy in our pediatric otolaryngology clinic and evaluated its relation to personal demographics. We also evaluated postoperative and diagnosis-based leaflets for readability using validated measures. METHODS Parents completed the Short Assessment of Health Literacy-English (SAHL-E) and were defined as low (0-14) or high (>14) literacy based on mean scores. RESULTS Fifty parents participated (mean SAHL-E score, 17.6), and all scored >14, indicating proficient health literacy. No differences existed in mean or median scores based on demographics. Continued education after high school was associated with higher scores (P = 0.003) and was the only significant variable in multivariable linear regression. All leaflets were at or below the recommended reading level for public health information. CONCLUSIONS Parents generally had high health literacy.
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Affiliation(s)
- Nicole Leigh Aaronson
- Nemours/Alfred I. duPont Hospital for Children, Department of Surgery, Section of Otolaryngology, Wilmington, DE, USA; Thomas Jefferson University School of Medicine, Departments of Otolaryngology and Pediatrics, Philadelphia, PA, USA.
| | - Courtney T Cox
- Nemours/Alfred I. duPont Hospital for Children, Department of Surgery, Section of Otolaryngology, Wilmington, DE, USA.
| | - Emily F Boss
- Johns Hopkins University Departments of Otolaryngology and Health Policy & Management, Baltimore, MD, USA.
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Kim SJ, Walsh J, Tunkel DE, Boss EF, Ryan M, Lee AH. Frequency of post-tonsillectomy hemorrhage relative to time of day. Laryngoscope 2019; 130:1823-1827. [PMID: 31566748 DOI: 10.1002/lary.28302] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 08/05/2019] [Accepted: 08/27/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Postoperative hemorrhage is a serious complication of tonsillectomy, with secondary bleeding rates affecting up to 0.8% to 3% of patients. Although these bleeds are anecdotally perceived as occurring more frequently at night, the occurrence of hemorrhage relative to the time of day has not been investigated. We measured the frequency of post-tonsillectomy hemorrhage onset relative to the time of day. METHODS We reviewed electronic medical records of all patients who experienced postprocedural hemorrhage (International Classification of Disease, Ninth Edition [ICD-9] 998.11, ICD-10 J95.830 at two hospitals within a tertiary academic health system in a 10-year period). Patient demographics, time of bleed onset, emergency room [ED] arrival time, and management (operating room vs. observation) were abstracted. Patients without a recorded bleeding time were excluded. Time of bleed onset was categorized as morning (6:01 am-12 pm), afternoon (12:01 pm-6 pm), evening (6:01 pm-12 am), or overnight (12:01 am-6 am). Chi-square goodness of fit test was used to assess the distribution of hemorrhage timing (P ≤ 0.05). RESULTS A total of 7,396 patients underwent tonsillectomy May 2008 through May 2018, among whom 121 (2%) post-tonsillectomy hemorrhage patients were identified. Among the 104 patients with ED arrival times, 29 (28%) arrived in the morning; 15 (14%) arrived in the afternoon; 40 (38%) arrived in the evening; and 20 (19%) arrived overnight (P = 0.003). Sixty patients (mean age 17.1 years, standard deviation 16.6) had a recorded timing of bleed onset. Bleed onset occurred most commonly overnight (24, 40%), followed by evening (21, 35%), afternoon (11, 18%), and morning (4, 7%) (P = 0.0007). CONCLUSION In this cohort, post-tonsillectomy hemorrhage occurred most frequently between midnight and 6 am. Our findings confirm anecdotal experience and provide data in setting caregiver expectations. LEVEL OF EVIDENCE 4 Laryngoscope, 130:1823-1827, 2020.
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Affiliation(s)
- Sun Joo Kim
- Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Jonathan Walsh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - David E Tunkel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Marisa Ryan
- Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Andrew H Lee
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
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Brenner MJ, Chang CWD, Boss EF, Goldman JL, Rosenfeld RM, Schmalbach CE. Patient Safety/Quality Improvement Primer, Part I: What PS/QI Means to Your Otolaryngology Practice. Otolaryngol Head Neck Surg 2019; 159:3-10. [PMID: 29968525 DOI: 10.1177/0194599818779547] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Patient safety/quality improvement (PS/QI) is the cornerstone of 21st-century health care. Otolaryngology-Head and Neck Surgery is excited to provide a dedicated PS/QI primer. The overarching goal for this PS/QI series is to provide a comprehensive and practical resource that assists readers, authors, and peer reviewers in understanding PS/QI research, its unique methodology, and the associated reporting standards for trustworthy performance measures. The target audience includes resident and fellows, faculty from the private sector and academia, and allied health professionals. This inaugural primer reviews PS/QI background as it relates to otolaryngology practice. It explores the history, goals, and development of performance measurement. In addition, it highlights opportunities for integrating PS/QI into otolaryngology practice. Payers will drive patients to quality care based on outcomes. Otolaryngologists have a responsibility to embrace a culture of PS/QI. In doing so, we will define optimal, quality otolaryngology care through objective data and metrics.
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Affiliation(s)
- Michael J Brenner
- 1 School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Emily F Boss
- 3 School of Medicine Johns Hopkins University, Baltimore, Maryland, USA
| | - Julie L Goldman
- 4 School of Medicine, University of Louisville, Louisville, Kentucky, USA
| | | | - Cecelia E Schmalbach
- 6 Roudebush Veterans Medical Center, School of Medicine, Indiana University, Indianapolis, Indiana, USA
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Links AR, Callon W, Wasserman C, Walsh J, Beach MC, Boss EF. Surgeon use of medical jargon with parents in the outpatient setting. Patient Educ Couns 2019; 102:1111-1118. [PMID: 30744965 PMCID: PMC6525640 DOI: 10.1016/j.pec.2019.02.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/13/2018] [Accepted: 02/01/2019] [Indexed: 05/05/2023]
Abstract
OBJECTIVE Unexplained medical terminology impedes clinician/parent communication. We describe jargon use in a pediatric surgical setting. METHODS We evaluated encounters between parents of children with sleep-disordered breathing (SDB; n = 64) and otolaryngologists (n = 8). Participants completed questionnaires evaluating demographics, clinical features, and parental role in decision-making via a 4-point categorical item. Two coders reviewed consultations for occurrence of clinician and parent utterance of medical jargon. Descriptive statistics established a profile of jargon use, and logistic regression evaluated associations between communication factors with jargon use. RESULTS Unexplained medical jargon was common (mean total utterances per visit = 28.9,SD = 19.5,Range = 5-100), including SDB-specific jargon (M = 8.3,SD = 8.8), other medical terminology (M = 13.9,SD = 12) and contextual terms (M = 3.8,SD = 4). Parents used jargon a mean of 4.3 times (SD = 4.6). Clinicians used more jargon in consults where they perceived parents as having greater involvement in decision-making (OR = 3.4,p < 0.05) and when parents used more jargon (OR = 1.2,p < 0.05). CONCLUSIONS Jargon use in pediatric surgical consultations is common and could serve as a barrier to informed or shared parent decision-making. This study provides a foundation for further research into patterns of jargon use across surgical populations. PRACTICE IMPLICATIONS Results will be integrated into communication training to enhance clinician communication, foster self-awareness in language use, and create strategies to evaluate parental understanding.
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Affiliation(s)
- A R Links
- Johns Hopkins School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Baltimore, MD, United States
| | - W Callon
- Johns Hopkins School of Medicine, Department of Medicine, Baltimore, MD, United States
| | - C Wasserman
- Johns Hopkins School of Medicine, Department of Medicine, Baltimore, MD, United States
| | - J Walsh
- Johns Hopkins School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Baltimore, MD, United States
| | - M C Beach
- Johns Hopkins School of Medicine, Department of Medicine, Baltimore, MD, United States
| | - E F Boss
- Johns Hopkins School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Baltimore, MD, United States.
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Leeds IL, Ladd MR, Sundel MH, Fannon ML, George JA, Boss EF, Jelin EB. Process measures facilitate maturation of pediatric enhanced recovery protocols. J Pediatr Surg 2018; 53:2266-2272. [PMID: 29801659 PMCID: PMC8710141 DOI: 10.1016/j.jpedsurg.2018.04.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 04/05/2018] [Accepted: 04/28/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND/PURPOSE The role of process measures used to predict quality in pediatric colorectal surgery enhanced recovery protocols has not been described. The purpose of this study was to demonstrate the feasibility of abstracting and monitoring process measures over protocol improvement iteration. METHODS Patients enrolled in the Pediatric Colorectal Enhanced Recovery After Surgery pathway at our institution were grouped by stage of implementation. We used a quality improvement database to compare multistage enhanced recovery process measures and 30-day patient outcomes. RESULTS We identified 58 surgical patients with 28(48%) cases enrolled in the pathway. There was increased use of regional anesthesia techniques in pathway patients (83% versus 20%, p < 0.001). All preoperative process measures clinically improved between early and full implementation. Improvements included a dramatic increase in formal preoperative education (56% versus 0%, p = 0.004) and administration of preoperative medication (p = 0.025). Overall, 12 (21%) patients experienced postoperative complications, which were similarly distributed between implementation groups. Readmissions were highest during the early implementation phase (40%, p = 0.029). Children in the late implementation group experienced fewer complications, which clinically correlated with process measure adherence. CONCLUSIONS Process measures complement outcome measures in assessing quality and effectiveness of a pediatric colorectal recovery protocol. Adherence to processes may reduce complications. LEVEL OF EVIDENCE Treatment study, Level III.
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Affiliation(s)
- Ira L Leeds
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mitchell R Ladd
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Margaret H Sundel
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Jessica A George
- Johns Hopkins Children's Center, Baltimore, MD; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Emily F Boss
- Johns Hopkins Children's Center, Baltimore, MD; Department of Otolaryngology and Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eric B Jelin
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Children's Center, Baltimore, MD.
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Aaronson NL, Joshua CL, Boss EF. Health literacy in pediatric otolaryngology: A scoping review. Int J Pediatr Otorhinolaryngol 2018; 113:252-259. [PMID: 30173996 DOI: 10.1016/j.ijporl.2018.08.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 08/09/2018] [Accepted: 08/09/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To review research on status and outcomes of health literacy in pediatric otolaryngology and identify opportunities for quality improvement. METHODS We performed a scoping review, adhering to methodologic standards. A combination of MeSH terms and keywords related to health literacy in otolaryngology was used to conduct a search. Relevant studies were identified using PubMed, Ovid MEDLINE, and Google Scholar databases. Studies were selected for inclusion by two authors if they addressed the domains of pediatric otolaryngology as well as health literacy. Data were abstracted from each study on the number of participants, the setting, the study design, the outcome measure, the intervention used, and the overall theme. Authors identified prominent overarching themes and grouped studies accordingly. Results were then tabulated for further review and to discern implications for future practice and research. RESULTS Of 1046 articles identified, 20 articles were included. Studies fell into three major themes: readability of patient materials, patient recall after informed consent, and optimal patient education. Prominent findings included the following: 1. Much of the printed and electronic educational material in otolaryngology is above the recommended reading level for public health information; 2. Parents do not easily recall information provided verbally or in written form; and 3. Adding visual and multimodal components improves the success of parental education. CONCLUSION Health literacy in pediatric otolaryngology may influence comprehension of educational materials and adequacy of informed consent. Future research may address whether patient health literacy affects clinical outcomes.
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Affiliation(s)
- Nicole Leigh Aaronson
- Division of Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.
| | - Catherine L Joshua
- Health Sciences Library, University of Virginia, Charlottesville, VA, USA
| | - Emily F Boss
- Departments of Otolaryngology and Health Policy & Management, Johns Hopkins University, Baltimore, MD, USA
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Abstract
Patient race/ethnicity affects health care utilization, provider trust, and treatment choice. It is uncertain how these influences affect pediatric care. We performed a systematic review (PubMed, Scopus, Web of Science, PsycINFO, Cochrane, and Embase) for articles examining race/ethnicity and parental treatment decision-making, adhering to PRISMA methodology. A total of 9200 studies were identified, and 17 met inclusion criteria. Studies focused on treatment decisions concerning end-of-life care, human papillomavirus vaccination, urological surgery, medication regimens, and dental care. Findings were not uniform between studies; however, pooled results showed (1) racial/ethnic minorities tended to prefer more aggressive end-of-life care; (2) familial tradition of neonatal circumcision influenced the decision to circumcise; and (3) non-Hispanic Whites were less likely to pursue human papillomavirus vaccination but more likely to complete the vaccine series if initiated. The paucity of studies precluded overarching findings regarding the influence of race/ethnicity on parental treatment decisions. Further investigation may improve family-centered communication, parent engagement, and shared decision-making.
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Affiliation(s)
- Vandra C. Harris
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Anne R. Links
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Jonathan Walsh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Desi P. Schoo
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Andrew H. Lee
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - David E. Tunkel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Emily F. Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland,Department of Health Policy and Management, Johns Hopkins Medical Institutions, Baltimore, Maryland
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Abstract
OBJECTIVES (1) Describe outcomes of bronchoscopy with foreign body removal among children on the basis of a large standardized multi-institutional data set. (2) Identify factors associated with 30-day adverse events. STUDY DESIGN Cross-sectional analysis of a US national database. SETTING Public data set from the ACS NSQIP-P (American College of Surgeons National Surgical Quality Improvement Program-Pediatric) from 2012 to 2015. SUBJECTS AND METHODS Children <18 years old who underwent bronchoscopy with removal of foreign body were identified. Patient demographics, comorbidities, hospitalization factors, surgical characteristics, and 30-day postoperative adverse events, including complication and readmission, were analyzed. Multivariate logistic regression identified predictive factors for postoperative complications and prolonged length of stay. RESULTS A total of 275 children underwent bronchoscopic foreign body removal (n = 165 male, 60%; n = 75 nonwhite and/or Hispanic, 27%; mean age, 3.5 years [range, 0.63-17.9; median, 2.0]). Adverse events occurred among 10 children (4%). Seven had pulmonary-related complications, and 1 patient died. Three patients were readmitted; there were no reoperations. On multivariate analysis, preoperative pulmonary disease or need for pulmonary support (odds ratio [OR], 6.42; P = .04) predicted postoperative complications. Preoperative pulmonary compromise (OR, 8.10; P < .01), American Society of Anesthesiologists class 3 or 4 (OR, 4.13; P < .01), and prolonged operative time (OR, 3.05; P = .01) were associated with prolonged hospital stay. CONCLUSION Bronchoscopy for retrieval of foreign body among children has an overall low incidence of 30-day adverse events. Children with preoperative pulmonary compromise have a significantly higher risk of postoperative complications. These findings may be applied to optimize perioperative care and counsel parents and families.
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Affiliation(s)
- Grace X Tan
- 1 Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Emily F Boss
- 1 Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel S Rhee
- 2 Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Callon W, Beach MC, Links AR, Wasserman C, Boss EF. An expanded framework to define and measure shared decision-making in dialogue: A 'top-down' and 'bottom-up' approach. Patient Educ Couns 2018; 101:1368-1377. [PMID: 29550295 PMCID: PMC6475620 DOI: 10.1016/j.pec.2018.03.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 03/09/2018] [Accepted: 03/10/2018] [Indexed: 05/11/2023]
Abstract
OBJECTIVES We aimed to develop a comprehensive, descriptive framework to measure shared decision making (SDM) in clinical encounters. METHODS We combined a top-down (theoretical) approach with a bottom-up approach based on audio-recorded dialogue to identify all communication processes related to decision making. We coded 55 pediatric otolaryngology visits using the framework and report interrater reliability. RESULTS We identified 14 clinician behaviors and 5 patient behaviors that have not been previously described, and developed a new SDM framework that is descriptive (what does happen) rather than normative (what should happen). Through the bottom-up approach we identified three broad domains not present in other SDM frameworks: socioemotional support, understandability of clinician dialogue, and recommendation-giving. We also specify the ways in which decision-making roles are assumed implicitly rather than discussed explicitly. Interrater reliability was >75% for 92% of the coded behaviors. CONCLUSION/PRACTICE IMPLICATIONS This SDM framework allows for a more expansive understanding and analysis of how decision making takes place in clinical encounters, including new domains and behaviors not present in existing measures. We hope that this new framework will bring attention to a broader conception of SDM and allow researchers to further explore the new domains and behaviors identified.
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Affiliation(s)
- Wynne Callon
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Anne R Links
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carly Wasserman
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Emily F Boss
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Garcia AV, Ladd MR, Crawford T, Culbreath K, Tetteh O, Alaish SM, Boss EF, Rhee DS. Analysis of risk factors for morbidity in children undergoing the Kasai procedure for biliary atresia. Pediatr Surg Int 2018; 34:837-844. [PMID: 29915925 DOI: 10.1007/s00383-018-4298-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the perioperative risk factors for 30-day complications of the Kasai procedure in a large, cross-institutional, modern dataset. STUDY DESIGN The 2012-2015 National Surgical Quality Improvement Program Pediatric database was used to identify patients undergoing the Kasai procedure. Patients' characteristics were compared by perioperative blood transfusions and 30-day outcomes, including complications, reoperations, and readmissions. Multivariable logistic regression was used to identify risk factors predictive of outcomes. Propensity matching was performed for perioperative blood transfusions to evaluate its effect on outcomes. RESULTS 190 children were included with average age of 62 days. Major cardiac risk factors were seen in 6.3%. Perioperative blood transfusions occurred in 32.1%. The 30-day post-operative complication rate was 15.8%, reoperation 6.8%, and readmission 15.3%. After multivariate analysis, perioperative blood transfusions (OR 3.94; p < 0.01) and major cardiac risk factors (OR 7.82; p < 0.01) were found to increase the risk of a complication. Perioperative blood transfusion (OR 4.71; p = 0.01) was associated with an increased risk of reoperation. Readmission risk was increased by prematurity (OR 3.88; p = 0.04) and 30-day complication event (OR 4.09; p = 0.01). After propensity matching, perioperative blood transfusion was associated with an increase in complications (p < 0.01) and length of stay (p < 0.01). CONCLUSION Major cardiac risk factors and perioperative blood transfusions increase the risk of post-operative complications in children undergoing the Kasai procedure. Further research is warranted in the perioperative use of blood transfusions in this population. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Alejandro V Garcia
- Department of Surgery, Johns Hopkins School of Medicine, 1800 Orleans St., Baltimore, MD, 21287, USA.
| | - Mitchell R Ladd
- Department of Surgery, Johns Hopkins School of Medicine, 1800 Orleans St., Baltimore, MD, 21287, USA
| | - Todd Crawford
- Department of Surgery, Johns Hopkins School of Medicine, 1800 Orleans St., Baltimore, MD, 21287, USA
| | - Katherine Culbreath
- Department of Surgery, Johns Hopkins School of Medicine, 1800 Orleans St., Baltimore, MD, 21287, USA
| | - Oswald Tetteh
- Department of Surgery, Johns Hopkins School of Medicine, 1800 Orleans St., Baltimore, MD, 21287, USA
| | - Samuel M Alaish
- Department of Surgery, Johns Hopkins School of Medicine, 1800 Orleans St., Baltimore, MD, 21287, USA
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Daniel S Rhee
- Department of Surgery, Johns Hopkins School of Medicine, 1800 Orleans St., Baltimore, MD, 21287, USA
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Harris VC, Links AR, Kim JM, Walsh J, Tunkel DE, Boss EF. Follow-up and Time to Treatment in an Urban Cohort of Children with Sleep-Disordered Breathing. Otolaryngol Head Neck Surg 2018; 159:371-378. [PMID: 29685083 DOI: 10.1177/0194599818772035] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective To evaluate follow-up and timing of sleep-disordered breathing diagnosis and treatment in urban children referred from primary care. Study Design Retrospective longitudinal cohort analysis. Setting Tertiary health system. Subjects and Methods Pediatric outpatients with sleep-disordered breathing, referred from primary care for subspecialty appointment or polysomnography in 2014, followed for 2 years. Timing of polysomnography or subspecialty appointments, loss to follow-up, and sleep-disordered breathing severity were main outcomes. Chi-square and t-test identified differences in children referred for polysomnography, surgery, and loss to follow-up. Logistic regression identified predictors of loss to follow-up. Days to polysomnography or surgery were evaluated using the Kaplan-Meier estimator, with Cox regression comparing estimates by polysomnography receipt and disease severity. Results Of 216 children, 188 (87%) had public insurance. Half (109 [50%]) were lost to follow-up after primary care referral. More children were lost to follow-up when referred for polysomnography (50 [76%]) compared with subspecialty evaluation (35 [32%]; P < .001). Children referred to both polysomnography and subspecialty were more likely to be lost to follow-up (odds ratio = 2.73, 95% confidence interval = 1.29-5.78; P = .009). For children who obtained polysomnography, an asymmetric distribution of obstructive sleep apnea severity was not observed ( P = .152). Median time to polysomnography and surgery was 75 and 226 days, respectively. Obstructive sleep apnea severity did not influence time to surgery ( P = .410). Conclusion In this urban population, half of the children referred for sleep-disordered breathing evaluation are lost to follow-up from primary care. Obstructive sleep apnea severity did not predict follow-up or timeliness of treatment. These findings suggest social determinants may pose barriers to care in addition to the clinical burden of sleep-disordered breathing.
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Affiliation(s)
- Vandra C Harris
- 1 Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Anne R Links
- 1 Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Julia M Kim
- 2 Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Jonathan Walsh
- 1 Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - David E Tunkel
- 1 Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Emily F Boss
- 1 Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.,3 Department of Health Policy and Management, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Harris VC, Links AR, Hong P, Walsh J, Schoo DP, Tunkel DE, Stewart CM, Boss EF. Consulting Dr. Google: Quality of Online Resources About Tympanostomy Tube Placement. Laryngoscope 2018; 128:496-501. [PMID: 28842989 PMCID: PMC5771888 DOI: 10.1002/lary.26824] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 06/29/2017] [Accepted: 07/05/2017] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Tympanostomy tube (TT) placement is common in children; however, family-centeredness and utility of online information used for decision making and understanding is unknown. We evaluate the quality of leading Internet resources describing TT placement. STUDY DESIGN Cross-sectional descriptive design. METHODS We performed a Google (Menlo Park, CA) search for terms related to TTs. We defined quality using scaled readability measures (Flesch Reading Ease and Flesch-Kincaid Grade-Level), understandability and actionability (Patient Education Materials Assessment Tool), shared decision-making centrality (Center for Medicare and Medicaid Services informed consent guidelines), and clinical practice guideline (CPG) compatibility. Three reviewers coded each measure. Fleiss κ interrater reliability analysis was performed. RESULTS Ten most frequently encountered websites were analyzed. One of 10 met national health literacy standards (mean 10th-grade level reading, median 9th, range 6-15th). All sites were understandable (mean understandability 81.9%, range 73%-92%). Most had low actionability scores (7 of 10, median 47%, mean 44.6%, range 0-80). Shared decision-making centrality was high (mean 5, range 4-6), but most did not list alternative treatment options. Although CPG compatibility was high (mean 3.4, range 1-4), many websites contained inconsistent recommendations about tube duration, follow-up, and water precautions. There was inter-rater agreement for understandability scoring (κ = 0.20; P = 0.02). CONCLUSION Internet resources about TT placement vary in quality pertaining to health literacy, principles of shared decision making, and consistency with practice guidelines. With growing emphasis on patient-/family-centered engagement in healthcare decision making, standardization of content and improved usability of educational materials for common surgical procedures in children such as tympanostomy tube placement should be a public health priority. LEVEL OF EVIDENCE NA. Laryngoscope, 128:496-501, 2018.
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Affiliation(s)
- Vandra C. Harris
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Anne R. Links
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Paul Hong
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jonathan Walsh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Desi P. Schoo
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - David E. Tunkel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Charles M. Stewart
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Emily F. Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
- Department of Health Policy and Management, Johns Hopkins Medical Institutions, Baltimore, Maryland
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George JA, Koka R, Gan TJ, Jelin E, Boss EF, Strockbine V, Hobson D, Wick EC, Wu CL. Review of the enhanced recovery pathway for children: perioperative anesthetic considerations. Can J Anaesth 2017; 65:569-577. [PMID: 29270915 DOI: 10.1007/s12630-017-1042-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 11/22/2017] [Accepted: 11/25/2017] [Indexed: 01/08/2023] Open
Abstract
PURPOSE Enhanced recovery after surgery (ERAS) pathways have been used for two decades to improve perioperative recovery in adults. Nevertheless, little is known about their effectiveness in children. The purpose of this review was to consider pediatric ERAS pathways, review the literature concerned with their potential benefit, and compare them with adult ERAS pathways. SOURCE A PubMed literature search was performed for articles that included the terms enhanced recovery and/or fast track in the pediatric perioperative period. Pediatric patients included those from the neonatal period through teenagers and/or youths. PRINCIPAL FINDINGS The literature search revealed a paucity of articles about pediatric ERAS. This lack of academic investigation is likely due in part to the delayed acceptance of ERAS in the pediatric surgical arena. Several pediatric studies examined individual components of adult-based ERAS pathways, but the overall study of a comprehensive multidisciplinary ERAS protocol in pediatric patients is lacking. CONCLUSION Although adult ERAS pathways have been successful at reducing patient morbidity, the translation, creation, and utility of instituting pediatric ERAS pathways have yet to be realized.
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Affiliation(s)
- Jessica A George
- The Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University and School of Medicine, Baltimore, MD, USA. .,SOM Anes Pediatric Anesthesiology, Bloomberg Children's Bldg 6339, 1800 Orleans Street, Baltimore, MD, 21287, USA.
| | - Rahul Koka
- The Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University and School of Medicine, Baltimore, MD, USA.,SOM Anes Pediatric Anesthesiology, Bloomberg Children's Bldg 6339, 1800 Orleans Street, Baltimore, MD, 21287, USA
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University, Stony Brook, NY, USA
| | - Eric Jelin
- Department of General Pediatric Surgery, Johns Hopkins Bloomberg Children's Center and Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery and Health Policy & Management, Johns Hopkins University, School of Medicine and Bloomberg School of Public Health, Baltimore, MD, USA
| | - Val Strockbine
- Department of General Pediatric Surgery, Johns Hopkins Bloomberg Children's Center and Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Deborah Hobson
- Department of Surgery, The Johns Hopkins Hospital and Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Elizabeth C Wick
- Department of Surgery, The Johns Hopkins Hospital and Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Christopher L Wu
- The Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University and School of Medicine, Baltimore, MD, USA
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Abstract
Sleep-disordered breathing (SDB) is prevalent in children and most commonly treated by surgery with adenotonsillectomy. We aimed to learn physician perspectives of social and communication factors that influence decision making for treatment of pediatric SDB. Purposive sampling identified 10 physician key informants across disciplines and practice settings, who participated in semistructured interviews regarding SDB care experiences and communication with parents. Interviews were analyzed using directed qualitative content analysis. Physicians provided a variety of perspectives on decision making for treatment that fell into 3 overarching themes: approach to surgery and alternatives, communication and decision making with families, and sociocultural factors/barriers to care. Perspectives were moderately heterogeneous, suggesting that individual social and relational elements may significantly influence how physicians refer patients and recommend treatment, and how parents choose surgery for this prevalent condition. These findings will inform development of culturally competent communication strategies and support tools to enhance shared decision making for physicians treating children with SDB.
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Affiliation(s)
- Emily F. Boss
- Johns Hopkins University School of Medicine Department of Otolaryngology—Head and Neck Surgery Baltimore, USA
| | - Anne R. Links
- Johns Hopkins University School of Medicine Department of Otolaryngology—Head and Neck Surgery Baltimore, USA
| | - Ron Saxton
- Johns Hopkins University School of Medicine Department of Otolaryngology—Head and Neck Surgery Baltimore, USA
| | - Tina L. Cheng
- Johns Hopkins University School of Medicine Department of Pediatrics, Baltimore, USA
| | - Mary Catherine Beach
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
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Leeds IL, Ladd MR, Fannon ML, Boss EF, George J, Jelin EB. Enhanced Recovery after Surgery Pathway for Pediatric Surgery: Initial Experience. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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