The Association of Season of Surgery and Patient Reported Outcomes following Total Hip Arthroplasty

Background

Understanding the impact of situational variables on surgical recovery can improve outcomes in total hip arthroplasty (THA). Literature examining hospital outcomes by season remains inconclusive, with limited focus on patient experience. The aim of this study is to investigate if there are differences in hospital and patient-reported outcomes measures (PROMS) after THA depending on the season of the index procedure to improve surgeon preoperative counseling.

Methods

A retrospective chart review was performed on patients undergoing primary THA at a single large academic center between January 2013 and August 2020. Demographic, operative, hospital, and PROMs were gathered from the institutional electronic medical record and our institutional joint replacement outcomes database.

Results

6418 patients underwent primary THA and met inclusion criteria. Of this patient population, 1636 underwent surgery in winter, 1543 in spring, 1811 in summer, and 1428 in fall. PROMs were equivalent across seasons at nearly time points. The average age of patients was 65 (+/- 10) years, with an average BMI of 29.3 (+/- 6). Rates of complications including ED visits within 30 days, readmission within 90 days, unplanned readmission, dislocation, fracture, or wound infection were not significantly different by season (P > .05).

Conclusion

Our findings indicate no differences in complications and PROMs at 1 year in patients undergoing THA during 4 distinct seasons. Notably, patients had functional differences at the second follow-up visit, suggesting variation in short-term recovery. Patients could be counseled that they have similar rates of complications and postoperative recovery regardless of season.

Rural-Urban Differences in Hospital and Patient-Reported Outcomes Following Total Hip Arthroplasty

Background

Rural patients have unique health-care factors influencing outcomes of arthroplasty, hypothetically putting these patients at increased risk for complications following total joint arthroplasty. The aim of this study is to better understand differences in patient outcomes and satisfaction between rural and urban patients receiving care in an urban setting and to provide more equitable care.

Methods

A retrospective chart review was performed on patients undergoing primary total hip arthroplasty at a single large academic center between January 2013 and August 2020. Demographic, operative, and hospital outcomes were obtained from the institutional electronic medical record. Rurality was determined by rural-urban code (RUC) classifications by zip code with RUC codes 1-3 defined as urban and RUC 4-10 defined as rural.

Results

Patients from urban areas were more likely to visit the emergency department within 30 days postoperatively (P = .006) and be readmitted within 90 days (P < .001). However, unplanned (P < .001) admissions were higher in the rural group. There was no statistical difference in postoperative complications (P = .4). At 6 months, rural patients had higher patient-reported outcome measures (PROMs) including Hip Disability and Osteoarthritis Outcome Score total (P = .05), Hip Disability and Osteoarthritis Outcome Score interval (P = .05), self-reported functional improvement (P < .05), improvements in pain (P < .05), and that the surgery met expectations (P < .05). However, these values did not reach minimal clinically important difference.

Conclusions

There may be differences in emergency department visits, readmissions, and PROMs in rural vs urban populations undergoing total hip arthroplasty in an urban setting. Patient access to care and attitudes of rural patients toward health care may underlie these findings. Understanding differences in PROMs, satisfaction, and hospital-based outcomes based on rurality is essential to provide equitable arthroplasty care.

Impact of Dermoscopy Training for Primary Care Practitioners on Number Needed to Biopsy to Detect Melanoma

Introduction

The incidence of melanoma is on the rise. In trained hands, dermoscopy aids in the differentiation of melanoma from benign skin growths, including melanocytic nevi. This study evaluated the impact of dermoscopy training for primary care practitioners (PCPs) on the number of nevi needed to biopsy (NNB) to detect a melanoma.

Methods

We conducted an educational intervention that included a foundational dermoscopy training workshop and subsequent monthly telementoring video conferences. We performed a retrospective observational study to evaluate the impact of this intervention on the number of nevi needed to biopsy to detect a melanoma.

Results

The number of nevi biopsied to detect one melanoma decreased from 34.3 to 11.3 following the training intervention.

Conclusion

Dermoscopy training for primary care practitioners resulted in a significant reduction in the NNB to detect melanoma.

"I know my body better than anyone else": a qualitative study of perspectives of people with lived experience on antimicrobial treatment decisions for injection drug use-associated infections

Background

People who inject drugs (PWID) are at risk for severe bacterial and fungal infections including skin and soft tissue infections, endocarditis, and osteomyelitis. PWID have high rates of self-directed discharge and are often not offered outpatient antimicrobial therapies, despite studies showing their efficacy and safety in PWID. This study fills a gap in knowledge of patient and community partner perspectives on treatment and discharge decision making for injection drug use (IDU)-associated infections.

Methods

We conducted semi-structured interviews with patients (n = 10) hospitalized with IDU-associated infections and community partners (n = 6) in the Portland, Maine region. Community partners include peer support workers at syringe services programs (SSPs) and outreach specialists working with PWID. We transcribed and thematically analyzed interviews to explore perspectives on three domains: perspectives on long-term hospitalization, outpatient treatment options, and patient involvement in decision making.

Results

Participants noted that stigma and inadequate pain management created poor hospitalization experiences that contributed to self-directed discharge. On the other hand, patients reported hospitalization provided opportunities to connect to substance use disorder (SUD) treatment and protect them from outside substance use triggers. Many patients expressed interest in outpatient antimicrobial treatment options conditional upon perceived efficacy of the treatment, perceived ability to complete treatment, and available resources and social support. Finally, both patients and community partners emphasized the importance of autonomy and inclusion in medical decision making. Although some participants acknowledged their SUD, withdrawal symptoms, or undertreated pain might interfere with decision making, they felt these medical conditions were not justification for health care professionals withholding treatment options. They recommended open communication to build trust and reduce harms.

Conclusion

Patients with IDU-associated infections desire autonomy, respect, and patient-centered care from healthcare workers, and may self-discharge when needs or preferences are not met. Involving patients in treatment decisions and offering outpatient antimicrobial options may result in better outcomes. However, patient involvement in decision making may be complicated by many contextual factors unique to each patient, suggesting a need for shared decision making to meet the needs of hospitalized patients with IDU-associated infections.

Thematic analyses of participant survey responses following dermatology ECHO programs with dermoscopy: Practical tips and lessons learned

Introduction

Skin cancer is a major public health concern in the United States, reflecting approximately one in every three cancer diagnoses. Despite the high incidence of skin cancer, access to dermatologists is limited, especially in rural areas. Primary care physicians play a pivotal role in the evaluation of skin conditions, but dermatology training gaps exist in primary care training programs.

Objectives

This study examines the use of the Project ECHO (Extension for Community Healthcare Outcomes) knowledge-sharing framework to provide dermoscopy and skin cancer detection training to primary care providers (PCPs).

Methods

Responses to surveys administered to participants in two separate dermoscopy-focused Project ECHO courses were analyzed. Survey responses were collected over a 4-year period for the two courses, which were delivered in Maine and Texas. Thematic analysis of the qualitative data was performed, revealing codes and subcodes that indicated several overall trends.

Results

Overall, most respondents indicated the ECHO sessions to be helpful, reporting an increase in confidence and knowledge in dermoscopy. Other codes reflected a positive reception of the learning materials and teaching styles. Furthermore, participant survey analyses highlighted areas of improvement for future ECHO course sessions.

Conclusions

This thematic analysis of Project ECHO courses in dermatology with dermoscopy demonstrates the feasibility of using virtual educational platforms to effectively teach PCPs about dermoscopy and skin cancer, with high levels of participant satisfaction. The need to keeping the educational sessions brief, avoid scheduling sessions on high-volume patient care days, and provide a means for participants to obtain hands-on training in the operation of a dermatoscope were among the top lessons learned.

'I feel like they're actually listening to me': a pilot study of a hospital discharge decision-making conversation guide for patients with injection drug use-associated infections

Background

The prevalence of injection drug use (IDU)-associated infections and associated hospitalizations has been increasing for nearly two decades. Due to issues ranging from ongoing substance use to peripherally inserted central catheter safety, many clinicians find discharge decision-making challenging. Typically, clinicians advise patients to remain hospitalized for several weeks for intravenous antimicrobial treatment; however, some patients may desire other antimicrobial treatment options. A structured conversation guide, delivered by infectious disease physicians, intended to inform hospital discharge decisions has the potential to enhance patient participation in decisions. We developed a conversation guide in order to: (1) investigate its feasibility and acceptability and (2) examine experiences, outcomes, and lessons learned from use of the guide.

Methods

We interviewed physicians after they each piloted the conversation guide with two patients. We interviewed patients immediately after the conversation and again 4-6 weeks later. Two analysts indexed transcriptions and used the framework method to identify and organize relevant information. We conducted retrospective chart review to corroborate and contextualize qualitative data.

Results

Eight patients and four infectious disease physicians piloted the conversation guide. All patients (N = 8) completed antimicrobial treatment. Nearly all participants believed the conversation guide was important for incorporating patient values and preferences. Patients reported an increased sense of autonomy, but felt post-discharge needs could be better addressed. Physician participants identified the guide's long length and inclusion of pain management as areas for improvement.

Conclusions

A novel conversation guide to inform hospital discharge decision-making for patients with IDU-associated infections was feasible, acceptable, and fostered the incorporation of patient preferences and values into decisions. While we identified areas for improvement, overall participants believed that this novel conversation guide helped to improve patient care and autonomy.

993. “I feel like they’re actually listening to me”: A Pilot Study of Hospital Discharge-Decision Making for Patients with Injection Drug Use-Associated Infections

Background

Conversation guides have the potential to transform care for patients hospitalized with injection drug use (IDU)-associated infections. This study’s objectives were to 1) pilot a structured conversation guide for hospital discharge decision making in patients with IDU-associated infections 2) investigate the guide’s feasibility and acceptability and 3) examine patient and provider experiences, patient outcomes, and lessons learned.

Methods

We developed a conversation guide and conducted semi-structured interviews with physicians and patients at a tertiary care center in Maine. We interviewed physicians after each piloted the guide with two patients. We interviewed patients less than one week after the conversation and again after 4-6 weeks. Two analysts indexed transcriptions and used the framework method to identify and organize relevant information. We conducted retrospective chart review to corroborate and contextualize qualitative data.

Results

Eight patients and four infectious disease physicians piloted the conversation guide. All patients (N=8) completed antimicrobial treatment and 88% were discharged on medication for opioid use disorder (Table 1). All providers and most patients stated that the conversation guide was important for incorporating patient preferences and antimicrobial treatment options. Patients appreciated more autonomy and their voices being included in their care. Providers felt the guide facilitated their understanding of patient values. Values and preferences between patients and providers were aligned. Participants identified the length of the guide, discussion of pain management, and addressing post-discharge needs such as housing as areas for improvement (Table 2).

Conclusion

The use of a conversation guide to inform hospital discharge decision making for patients with IDU-associated infections incorporates patient preferences and values into treatment decisions. While we identified areas for improvement, overall patients and providers believed that this novel conversation guide helped to improve patient care and autonomy.

Disclosures

Kinna Thakarar, DO, MPH, Maine Medical Center: Board Member|NIH: Grant/Research Support|University of New England: Board Member Monica K. Sikka, MD, F2G: Site research investigator Ellen Eaton, MD, MSPH, Gilead: Grant/Research Support.

Health care professional perspectives on discharging hospitalized patients with injection drug use-associated infections

Background:

Patients with injection drug use (IDU)-associated infections traditionally experience prolonged hospitalizations, which often result in negative experiences and bad outcomes. Harm reduction approaches that value patient autonomy and shared decision-making regarding outpatient treatment options may improve outcomes. We sought to identify health care professionals (HCPs) perspectives on the barriers to offering four different options to hospitalized people who use drugs (PWUD): long-term hospitalization, oral antibiotics, long-acting antibiotics at an infusion center, and outpatient parenteral antibiotics.

Methods:

We recruited HCPs (n = 19) from a single tertiary care center in Portland, Maine. We interviewed HCPs involved with discharge decision-making and other HCPs involved in the specialized care of PWUD. Semi-structured interviews elicited lead HCP values, preferences, and concerns about presenting outpatient antimicrobial treatment options to PWUD, while support HCPs provided contextual information. We used the iterative categorization approach to code and thematically analyze transcripts.

Results:

HCPs were willing to present outpatient treatment options for patients with IDU-associated infections, yet several factors contributed to reluctance. First, insufficient resources, such as transportation, may make these options impractical. However, HCPs may be unaware of existing community resources or viable treatment options. They also may believe the hospital protects patients, and that discharging patients into the community exposes them to structural harms. Some HCPs are concerned that patients with substance use disorder will not make ‘good’ decisions regarding outpatient antimicrobial options. Finally, there is uncertainty about how responsibility for offering outpatient treatment is shared across changing care teams.

Conclusion:

HCPs perceive many barriers to offering outpatient care for people with IDU-associated infections, but with appropriate interventions to address their concerns, may be open to considering more options. This study provides important insights and contextual information that can help inform specific harm reduction interventions aimed at improving care of people with IDU-associated infections.