NSAIDs do not reduce severity among post-ERCP pancreatitis patients

OBJECTIVE

Non-steroidal anti-inflammatory drugs (NSAIDs) are the most studied chemoprophylaxis for post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). While previous systematic reviews have shown NSAIDs reduce PEP, their impact on moderate to severe PEP (MSPEP) is unclear. We conducted a systematic review and meta-analysis to understand the impact of NSAIDs on MSPEP among patients who developed PEP. We later surveyed physicians' understanding of that impact.

DESIGN

A systematic search for randomized trials using NSAIDs for PEP prevention was conducted. Pooled-prevalence and Odds-ratio of PEP, MSPEP were compared between treated vs. control groups. Analysis was performed using R software. Random-effects model was used for all variables. Physicians were surveyed via email before and after reviewing our results.

RESULTS

7688 patients in 25 trials were included. PEP was significantly reduced to 0.598 (95%CI, 0.47-0.76) in the NSAIDs group. Overall burden of MSPEP was reduced among all patients undergoing ERCP: OR 0.59 (95%CI, 0.42-0.83). However, NSAIDs didn't affect the proportion of MSPEP among those who developed PEP (p = 0.658). Rectal Indomethacin and diclofenac reduced PEP but not MSPEP. Efficacy didn't vary by risk, timing of administration, or bias-risk. Survey revealed a change in the impression of the effect of NSAIDs on MSPEP after reviewing our results.

CONCLUSIONS

Rectal diclofenac or indomethacin before or after ERCP reduce the overall burden of MSPEP by reducing the pool of PEP from which it can arise. However, the proportion of MSPEP among patients who developed PEP is unaffected. Therefore, NSAIDs prevent initiation of PEP, but do not affect severity among those that develop PEP. Alternative modalities are needed to reduce MSPEP among patients who develop PEP.

Days Alive and Out of the Hospital After Heart Transplantation: A Retrospective Cohort Study

OBJECTIVE

Evaluate days alive and out of the hospital (DAOH) as an outcome measure after orthotopic heart transplantation in patients with mechanical circulatory support (MCS) as a bridge to transplant compared to those patients without prior MCS.

DESIGN

A retrospective observational study of adult patients who underwent cardiac transplantation between January 1, 2015, and January 1, 2020. The primary outcome was DAOH at 365 days (DAOH365) after an orthotopic heart transplant. A Poisson regression model was fitted to detect the association between independent variables and DAOH365.

SETTING

An academic tertiary referral center.

PARTICIPANTS

A total of 235 heart transplant patients were included-103 MCS as a bridge to transplant patients, and 132 direct orthotopic heart transplants without prior MCS.

MEASUREMENTS AND MAIN RESULTS

The median DAOH365 for the entire cohort was 348 days (IQR 335.0-354.0). There was no difference in DAOH365 between the MCS patients and patients without MCS (347.0 days [IQR 336.0-353.0] v 348.0 days [IQR 334.0-354.0], p = 0.43). Multivariate analysis identified patients who underwent a transplant after the 2018 heart transplant allocation change, pretransplant pulmonary hypertension, and increased total ischemic time as predictors of reduced DAOH365.

CONCLUSIONS

In this analysis of patients undergoing orthotopic heart transplantation, there was no significant difference in DAOH365 in patients with prior MCS as a bridge to transplant compared to those without MCS. Incorporating days alive and out of the hospital into the pre-transplant evaluation may improve understanding and conceptualization of the post-transplantation patient experience and aid in shared decision-making with clinicians.

The influence of operating room temperature and humidity on surgical site infection: A multisite ACS-NSQIP analysis

BACKGROUND

Literature evaluating intraoperative temperature/humidity and risk of surgical site infection (SSI) is lacking.

METHODS

All operations at three centers reported to the ACS-NSQIP were reviewed (2016-2020); ambient intraoperative temperature (⁰F) and relative humidity (RH) were recorded in 15-min intervals. The primary endpoint was superficial SSI, which was evaluated with multi-level logistic regression.

RESULTS

14,519 operations were analyzed with 179 SSIs (1.2%). The lower/upper 10th percentiles for temperature and RH were 64.4/71.4 °F and 33.5/55.5% respectively. Low or high temperature carried no significant increased risk for SSI (Low ⁰F OR = 0.95, 95% CI 0.51-1.77, P = 0.86; High ⁰F OR = 1.13, 95% CI = 0.69-1.86, P = 0.63). This was also true for low and high RH (Low RH OR = 0.96, 95% CI 0.58-1.61, p = 0.88; High RH OR = 0.61, 95% CI = 0.33-1.14, P = 0.12). Analysis of combined temperature/humidity showed no increased risk for SSI.

CONCLUSION

Significant deviations in intraoperative temperature/humidity are not associated with increased risk of SSI.

Surgical Site Infections in Open and Laparoscopic Operations in Rooms With Open-floor Drainage Systems

INTRODUCTION

Surgical site infections are common postoperative complications. Some operating rooms have open-floor drainage systems for fluid disposal during endourologic cases, although nonendoscopy cases are not always allowed in these rooms. We hypothesized that operating rooms with open-floor drainage systems would not materially affect risk of surgical site infections for patients undergoing open and laparoscopic procedures.

METHODS

Patients who had surgical site infections from 2016 through 2020 were identified from data of the National Surgical Quality Improvement Program. Patients without surgical incisions, with open wounds, and with surgical site infections at surgery were excluded. The primary outcome was surgical site infection occurrence within 30 days of surgery. Multilevel multivariable logistic regression was used to estimate the observed-to-expected surgical site infection ratio for each operating room (2 with and 23 without open-floor drainage systems).

RESULTS

We identified 8,419 surgical cases, of which 802 (9.5%) were performed in operating rooms with open-floor drainage systems; 166 patients (2.0%) had surgical site infections. Of the surgical site infections, 7 (4.2%) occurred in operating rooms with open-floor drainage systems. Surgical specialty, American Society of Anesthesiologists physical status, higher case acuity, dyspnea, immunosuppression, longer surgical duration, and wound classification were associated with surgical site infections (P < .05 for all). The observed-to-expected ratios of surgical site infections occurring in the 2 operating rooms with open-floor drainage systems were 0.85 and 1.15. The odds ratio of surgical site infections for urologic cases performed in room with vs without open-floor drainage systems was 1.30 (P = .65).

CONCLUSIONS

Urology operating room designs often include open-floor drainage systems for water-based cases. These drainage systems were not associated with an increased risk of surgical site infections.

Avoiding Blunders When Analyzing Correlated Data, Clustered Data, or Repeated Measures

Rheumatology research often involves correlated and clustered data. A common error when analyzing these data occurs when instead we treat these data as independent observations. This can lead to incorrect statistical inference. The data used are a subset of the 2017 study from Raheel et al consisting of 633 patients with rheumatoid arthritis (RA) between 1988 and 2007. RA flare and the number of swollen joints served as our binary and continuous outcomes, respectively. Generalized linear models (GLM) were fitted for each, while adjusting for rheumatoid factor (RF) positivity and sex. Additionally, a generalized linear mixed model with a random intercept and a generalized estimating equation were used to model RA flare and the number of swollen joints, respectively, to take additional correlation into account. The GLM's β coefficients and their 95% confidence intervals (CIs) are then compared to their mixed-effects equivalents. The β coefficients compared between methodologies are very similar. However, their standard errors increase when correlation is accounted for. As a result, if the additional correlations are not considered, the standard error can be underestimated. This results in an overestimated effect size, narrower CIs, increased type I error, and a smaller P value, thus potentially producing misleading results. It is important to model the additional correlation that occurs in correlated data.

The Fate of the Inconclusive Periprosthetic Joint Infection Workup and Reliability of Data Points

In 2018, periprosthetic joint infection (PJI) criteria were revised to include a new category labeled "inconclusive." The purpose of this study was to characterize and describe the fate of the inconclusive PJI workup and to analyze preoperative factors associated with outcomes. We reviewed all PJI workups at our institution during a 3-year period (426 patients). Patients were labeled "infected," "not infected," or "inconclusive" according to 2018 PJI preoperative criteria. In addition to standard diagnostic variables, the presence or absence of clinical elements that increase the pretest probability of infection were collected. Patients with any missing preoperative diagnostic test results and those with clinical follow-up less than 30 days were excluded. Logistic regression was used to identify the factors associated with infection. Two hundred ninety-six workups remained after exclusion criteria were applied, consisting of 66 (22.2%) with a preoperative score of 6 or greater defined as infected, 52 (17.6%) inconclusive (score 2-5), and 178 (60.1%) not infected (score 0-1). Postoperative re-scoring of the inconclusive group based on intraoperative findings as per the 2018 criteria identified 6 of 52 (11.5%) as infected, 12 (23.1%) inconclusive, and 34 (65.4%) not infected. Among those preoperatively scored as inconclusive, variables statistically correlated with the presence of infection included history of PJI, factors that increase skin barrier penetration (eg, psoriasis and venous stasis), and presence of comorbidities predisposing to infection. For patients labeled inconclusive, clinical elements of the pretest probability for infection (eg, history of prior PJI) were as reliable as any diagnostic test, including alpha-defensin, in the diagnosis of PJI. [Orthopedics. 2023;46(5):e291-e297.].

Operating in an Opioid Crisis: A Temporal Analysis of Pain Medication Prescribing Practices in Plastic Surgery

BACKGROUND

In response to the opioid epidemic, the United States declared a public health emergency in 2017. We evaluated pain medication prescribing practices among plastic and reconstructive surgeons, assessing pain medication prescription rates and opioid-related mortality both nationally and regionally within the United States.

METHODS

A retrospective analysis of Medicare Part D prescriber data among plastic surgeons from 2013 through 2017 was conducted. Pain medications were categorized as opioid and nonopioid medications. Trends in surgeon prescribing habits were evaluated using the Cochrane-Armitage trend test.

RESULTS

A total of 708,817 pain medication claims were identified: 612,123 claims (86%) were for opioid pain medications and 96,694 claims (14%) were for nonopioid pain medications. Total pain medication claims decreased from 44% of all medications in 2013 to 37% in 2017 (P < 0.001). Opioid medications decreased from 37% of total medication claims to 32% (P < 0.001). The overall opioid prescription rate fell from 1.53 claims per beneficiary in 2013 to 1.32 in 2017 (P < 0.001). Nonopioid pain medications decreased from 7% in 2013 to 6% in 2017 (P < 0.001); nonsteroidal anti-inflammatory drug claims increased by 44%. The prescription rate of nonopioid medications decreased from 2.40 claims per beneficiary in 2013 to 2.32 in 2017 (P < 0.001). An overall increase in opioid-related mortality was observed. Trends in pain medication prescriptions varied significantly among US regions and divisions.

CONCLUSIONS

Plastic surgeons are prescribing less opioids and relying more on nonopioid pain medications. Increased adoption of multimodal pain treatment approaches among surgeons is a likely explanation for this trend in face of the current opioid crisis.

Ethics Education in U.S. Allopathic Medical Schools: A National Survey of Medical School Deans and Ethics Course Directors

AbstractPurpose: to characterize ethics course content, structure, resources, pedagogic methods, and opinions among academic administrators and course directors at U.S. medical schools.

METHOD

An online questionnaire addressed to academic deans and ethics course directors identified by medical school websites was emailed to 157 Association of American Medical Colleges member medical schools in two successive waves in early 2022. Descriptive statistics were utilized to summarize responses.

RESULTS

Representatives from 61 (39%) schools responded. Thirty-two (52%) respondents were course directors; 26 (43%) were deans of academic affairs, medical education, or curriculum; and 3 with other roles also completed the survey (5%). All 61 schools reported some form of formal ethics education during the first year of medical school, with most (n = 54, 89%) reporting a formal mandatory introductory course during preclinical education. Schools primarily utilized lecture and small-group teaching methods. Knowledge-based examinations, attendance, and participation were most commonly used for assessment. A large majority regarded ethics as equally or more important than other foundational courses, but fewer (n = 37, 60%) provided faculty training for teaching ethics.

CONCLUSIONS

Despite a response rate of 39 percent, the authors conclude that medical schools include ethics in their curricula in small-group and lecture formats with heterogeneity regarding content taught. Preclinical curricular redesigns must innovate and implement best practices for ensuring sound delivery of ethics content in future curricula. Additional large-scale research is necessary to determine said best practices.

A comparison of naloxegol versus alvimopan at the time of cystectomy and urinary diversion

INTRODUCTION

The use of alvimopan at the time of cystectomy has been associated with improved perioperative outcomes. Naloxegol is a less costly alternative that has been used in some centers. This study aims to compare the perioperative outcomes of patients undergoing cystectomy with urinary diversion who receive the mu-opioid antagonist alvimopan versus naloxegol.

MATERIALS AND METHODS

This was a retrospective review that included all patients who underwent cystectomy with urinary diversion at our institution between 2007-2020. Comparisons were made between patients who received perioperative alvimopan, naloxegol and no mu-opioid antagonist (controls).

RESULTS

In 715 patients who underwent cystectomy, 335 received a perioperative mu-opioid antagonist, of whom 57 received naloxegol. Control patients, compared to naloxegol and alvimopan patients, experienced a significantly (p < 0.05) delayed return of bowel function (4.3 vs. 2.5 vs. 3.0 days) and longer hospital length of stay (7.9 vs. 7.5 vs. 6.5 days), respectively. The incidence of nasogastric tube use (14.2% vs. 12.5% vs. 6.5%) and postoperative ileus (21.6% vs. 21.1% vs. 13.3%) was also most common in the control group compared to the naloxegol and alvimopan cohorts, respectively. A multivariable analysis revealed that when comparing naloxegol and alvimopan, there was no difference in return of bowel function (OR 0.88, p = 0.17), incidence of postoperative ileus (OR 1.60, p = 0.44), or hospital readmission (OR 1.22, p = 0.63).

CONCLUSIONS

Naloxegol expedites the return of bowel function to the same degree as alvimopan in cystectomy patients. Given the lower cost of naloxegol, this agent may be a preferable alternative to alvimopan.

Use of the Electronic Health Record During Clinical Encounters: An Experience Survey

PURPOSE

Use of the electronic health record (EHR) during face-to-face clinical encounters affects communication, and prior research has been inconclusive regarding its effect. This survey study assessed health care practitioner use of EHR-specific communication skills and patient and practitioner experiences and attitudes regarding EHR use during clinical encounters.

METHODS

For this US-based study, we distributed previously validated surveys to practitioners and adult patients (aged >18 years) at academic primary care practices from July 1, 2018 through August 31, 2018. The electronic practitioner survey was completed first; a paper survey was administered to patients after appointments. Descriptive statistics were calculated, and the Cochran-Armitage test was used to assess for associations between key variables.

RESULTS

The practitioner response was 72.9% (43/59); patient response, 45.2% (452/1,000). Practitioners reported maintaining less eye contact (79.1%), listening less carefully (53.5%), focusing less on patients (65.1%), and visits feeling less personal (62.8%). However, patients reported that practitioners provided sufficient eye contact (96.8%) and listened carefully (97.0%); they disagreed that practitioners focused less on them (86.7%) or that visits felt less personal (87.2%). Patients thought EHR use was positive (91.7%); only one-third of practitioners (37.2%) thought that patients would agree with that statement. Practitioners reported stress, burnout, and a lack of sufficient time for EHR documentation.

CONCLUSIONS

A discrepancy existed in this study between patient and practitioner experiences and attitudes about EHR use, which appeared to negatively affect the experience of health care practitioners but not patients. Organizations should adopt formal strategies to improve practitioner experiences with EHR use.

Variation in Lymph Node Yield After Radical Cystectomy

OBJECTIVES

To test the hypothesis that lymph node yield will vary by pathology assistant (PA) in patients undergoing radical cystectomy (RC) with pelvic lymph node dissection (PLND).

METHODS

This is a single-institution retrospective review that included patients who underwent an RC with PLND for bladder cancer from January 1, 2007, to January 1, 2018. Predicted mean lymph node counts were generated using multivariable regression analysis.

RESULTS

In a total of 430 patients who underwent RC with PLND, the median lymph node count (interquartile range) was 15.0 (11.0-21.0). The frequency of the limits of lymphadenectomy was as follows: external iliac, internal iliac, and obturator (true pelvis) (33.3%); true pelvis plus common iliac to the level of the aortic bifurcation (47.9%); and inferior mesenteric artery (18.8%). On descriptive analysis, there were differences in lymph node yield when evaluating the following variables: level of dissection, clinical stage, neoadjuvant chemotherapy, surgical approach, surgeon, pathologist, and PA (P < .05). On multivariable analysis, adjusted lymph node counts varied between surgeons, pathologists, clinical stage, and level of dissection but not by PA (P = .18).

CONCLUSIONS

Lymph node yield after RC varies on several known levels, including surgeon, extent of lymphadenectomy, clinical stage, and pathologist. This study found no significant variation in lymph node yield according to PA.

Identifying the Optimal case-volume threshold for pancreatectomy in contemporary practice

BACKGROUND

The volume-mortality association led to regionalization recommendations for pancreatic surgery. Mortality following pancreatectomy has declined, but case-volume thresholds remain unchanged.

METHODS

Patients undergoing pancreatectomy from 2004 to 2013 were identified in the National Cancer Database (NCDB). Hospitals were divided into low (LV), medium (MV), and high-volume (HV) strata using 30-day mortality quartiles and logistic regression with cubic splines. Adjusted absolute difference and odds of 30-day mortality between strata were calculated.

RESULTS

Annual volumes for LV, MV, and HV were <4, 4-18 and > 18 cases using quartiles and <6, 6-18 and > 18 using cubic splines. Absolute 30-day mortality trended downwards, with differential improvements for MV and LV. Benchmark 30-day mortality for hospitals with >18 cases was 2.8%. For this benchmark, the case-volume threshold decreased from 31 in 2004 to 6 in 2013.

CONCLUSION

Differential improvement in 30-day mortality at LV and MV hospitals led to similar 30-day mortality odds at MV and HV hospitals by 2013.

Is There an Optimal Cutoff for Aspiration Fluid Volume in the Diagnosis of Periprosthetic Joint Infection?

BACKGROUND

The diagnosis of periprosthetic joint infection is often challenging in the setting of low aspiration volumes, or in the presence of infection with a slow-growing organism. We sought to determine if an optimal threshold of aspiration fluid volume exists when cultures from the preoperative aspiration are compared to intraoperative cultures.

METHODS

All revision total hip and knee arthroplasty procedures over 5 years at our institution were reviewed. Cases were excluded if they underwent joint lavage during aspiration, had an antibiotic spacer in place, were suspected of adverse local tissue reaction to metal debris, did not have an accurate aspiration volume recorded, or if there were no aspiration or operative cultures available. Receiver operating characteristic curves were used to evaluate aspiration volume for identifying cases with identical aspiration and culture results.

RESULTS

A total of 857 revision cases were reviewed, among which 294 met inclusion criteria. There were 45 cases (15.3%) with discordant aspiration and operative cultures. The mean aspiration volume for identical cases was significantly higher than for discordant cases (19.1 vs 10.2 mL, P = .02). The proportion of slow-growing organisms was significantly greater among discordant compared to identical operative cultures (52.4% for discordant cases vs 8.2% for identical cases, P < .001). The optimal cutoff value for predicting identical cultures was 3.5 mL for typical organisms and 12.5 mL for slow-growing organisms.

CONCLUSION

Aspiration cultures are more likely to correlate with intraoperative cultures with higher aspiration volumes, and the optimal aspiration volume is higher for slow-growing organisms.

Using evidence to direct quality improvement efforts: Defining the highest impact complications after complex cytoreductive surgery for ovarian cancer

OBJECTIVE

We sought to identify postoperative complications with the greatest impact on patient-centric outcomes to serve as high yield QI targets in ovarian cancer (OC) surgery.

METHODS

Women undergoing complex CRS (defined as cytoreductive surgery with colon resection) for OC between January 1, 2012 and 12/31/2016 were identified from the National Surgical Quality Improvement Program (NSQIP) database. We determined the population attributable fraction (PAF) to quantify the contribution of each major complication towards adverse outcomes. PAF represents the burden of adverse outcomes that could be eliminated if the corresponding complication was prevented. Organ space surgical site infection (SSI) was used as a surrogate for anastomotic leak (AL).

RESULTS

A total of 1434 women met inclusion criteria. Any adverse clinical outcome (composite of death, reoperation, or end organ dysfunction) occurred in 9.1% of women, and AL was the largest contributor to adverse clinical outcomes [PAF = 33.4% (95%CI: 22.3%-45.6%)]. The rates of increased resource utilization were as follows; prolonged hospitalization in 23.7%, non-home discharge in 10.7% and unplanned readmission in 14.8% of women. AL was the largest contributor to prolonged hospitalizations [PAF = 75.7% (95%CI: 51.4%-90.0%)] and readmissions [PAF = 17.1% (95%CI: 11.5%-22.6%)]; while transfusion was the largest contributor to non-home discharge [PAF = 22.8% (95%CI: 0.7%-42.4%)]. By comparison, the impact of other complications, including those targeted by the Surgical Care Improvement Project (SCIP), such as incisional SSI, venous thromboembolism, myocardial infarction, and urinary infection, was small.

CONCLUSIONS

Anastomotic leak is the largest contributor to adverse clinical outcomes and increased resource utilization after complex cytoreductive surgery. Quality improvement efforts to reduce AL and its impact should be of highest priority in OC surgery.

Single-dose perioperative mitomycin-C versus thiotepa for low-grade noninvasive bladder cancer

INTRODUCTION

Mitomycin-C (MMC) and thiotepa are intravesical agents effective in reducing the recurrence of low-grade noninvasive bladder cancer when instilled perioperatively. No studies have compared these agents as a single-dose perioperative instillation. This study tests whether there is a difference in recurrence-free survival in patients with low-grade noninvasive bladder cancer who received intravesical MMC versus thiotepa.

MATERIALS AND METHODS

A retrospective review was performed of patients who underwent cystoscopic excision of a bladder mass identified as a small, low-grade, treatment-naïve, noninvasive, wild-type urothelial carcinoma of the bladder and who received either intravesical thiotepa (30 mg/15 cc) or MMC (40 mg/20 cc) between January 1, 2002, and January 1, 2016. Data were collected for demographic characteristics, comorbid conditions, operative information, surveillance, and recurrence. The primary outcome was disease-free survival. Cohorts were compared via the doubly robust estimation approach, which used logistic regression to model the probability of recurrence.

RESULTS

Of 154 total patients, 84 received intravesical MMC; 70, thiotepa. No statistical differences were shown between groups for age, sex, race, body mass index, smoking status, or baseline comorbid conditions; mass size, tumor multifocality, or tumor grade; and unadjusted recurrence rates (MMC, 36.0%; thiotepa, 46.0%; p = .33) at similar median follow up (MMC, 20.4; thiotepa, 22.8 months; p = .46). The robust logistic regression analysis yielded no differences in recurrence rates between MMC and thiotepa (OR, 0.65 [95% CI, 0.33-1.31]; p = .23). No episodes of myelosuppression or frozen pelvis were identified.

CONCLUSIONS

As single-dose perioperative agents, both thiotepa and MMC were associated with similar recurrence-free survival rates.

Robotic vs. open cystectomy: How length-of-stay differences relate conditionally to age

OBJECTIVES

The length-of-stay (LOS) benefit of minimally invasive cystectomy varies in the published literature, potentially because of subgroup effects. Here, we investigated the effect of minimally invasive cystectomy on LOS among different age groups.

METHODS AND MATERIALS

Adult patients who underwent cystectomy (open or minimally invasive) from January 1, 2012, to December 31, 2016, were identified from the National Surgical Quality Improvement Program database. Multivariable linear regression was used to evaluate the adjusted association between the surgical approach and LOS after stratifying patients by age (40-64, 65-79, and ≥80 years). A sensitivity analysis was performed after multiple imputation by using age as a continuous variable with a third-order polynomial term.

RESULTS

Of the 5,561 patients identified, 640 underwent minimally invasive cystectomy and 4,921 had open cystectomy. The unadjusted analysis showed that minimally invasive cystectomy was associated with a shorter mean LOS compared with the open approach (8.0 vs. 9.7 days; P < 0.001). The predicted difference in LOS between the 2 approaches was 0.72 days (95% confidence interval (CI), -0.28 to 1.72; P = 0.16) for patients aged 40 to 64 years, 1.48 days (95% CI, 0.73-2.23; P < 0.001) for 65 to 79 years, and 2.56 days (95% CI, 0.84-4.29; P = 0.01) for ≥80 years favoring the minimally invasive approach. The sensitivity analysis did not materially change the results.

CONCLUSIONS

Older patients may derive more LOS benefit from minimally invasive approaches than younger patients. Given the greater expense associated with the minimally invasive approach, an age-adapted strategy to using this technology may be reasonable.

Evidence of Pent-Up Demand for Total Hip and Total Knee Arthroplasty at Age 65

BACKGROUND

Despite efforts to curtail the economic burden of total joint arthroplasty (TJA), utilization of these successful procedures continues to increase. Previous studies have provided evidence for pent-up demand (delaying necessary medical care until financially feasible) in health care as insurance status changes. We sought to determine whether evidence exists for pent-up demand in the TJA population when patients become eligible for Medicare enrollment.

METHODS

The 2014 Nationwide Readmission Database was used to determine the incidence of TJA. The observed increase in incidence from age 64 to 65 was compared to the expected increase. Pent-up demand was calculated by subtracting the expected from the observed difference in frequency of TJA, and excess cost was determined by multiplying this value by the median cost of a primary TJA. The Medicare Expenditure Panel Survey Household Component was used to compare out-of-pocket (OOP) costs, access to care, and insurance coverage among patients aged 60-64 (group 1) and 66-70 (group 2).

RESULTS

The expected and observed increases in TJA procedures from age 64 to 65 were 595 and 5211, respectively, resulting in pent-up demand of 4616 joint arthroplasties (1273 THA and 3343 TKA), and an excess cost of $55 million (range, $33 million-$70 million). Mean total OOP expenses for patients in group 1 were significantly greater ($1578.39) than patients in group 2 ($1143.63, P < .001). Despite spending more money OOP, the proportion of patients who were unable to obtain necessary medical care was significantly higher in group 1 than group 2 (4.9% vs 2.4%, P < .0001). This discrepancy was most prominent among patients with public insurance (10.6% vs 2.5%, P < .0001).

CONCLUSION

The findings of this study suggest that patients with hip and knee osteoarthritis likely delay elective TJA until they are eligible for Medicare enrollment, resulting in significant additional financial burden to the public health system. As the population ages, it will become increasingly important for stakeholders and policy-makers to be aware of this pent-up demand for TJA procedures.

LEVEL OF EVIDENCE

Therapeutic level IV.

Comparison of Stroke Outcomes of Hub and Spoke Hospital Treated Patients in Mayo Clinic Telestroke Program

PURPOSE

To examine telemedicine as it applies to acute ischemic stroke care at a spoke hospital and the effect on patient outcomes, including the timeliness of response, quality of care, safety, morbidity, and mortality when compared to standard hub hospital stroke center care.

METHODS

Retrospective review of prospectively entered quality/performance stroke/telestroke patient catalog data were completed for 1000 adult patients who presented with an acute ischemic stroke to the Mayo Clinic Hospitals (500 patients) or to one of thirteen Mayo Clinic affiliated telestroke spoke hospitals in the regions (500 patients). The primary outcome of interest was the percentage of accurate decision making for eligibility of IV alteplase administration assessed by blinded adjudication and the secondary outcomes pertained to complications, discharge parameters, and standard quality metrics.

RESULTS

There was no difference in the spoke hospital versus hub hospital groups in identifying and making the correct decision regarding which patients were eligible for IV alteplase administration (96% [95% confidence interval (CI): 94%-97%] versus 97% [95% CI: 95%-98%]; P = 0.32). There was no difference among the groups in proportion receiving IV alteplase, sustaining symptomatic intracranial hemorrhage, and mortality. Patients in the spoke group were less likely to have a favorable outcome at discharge, as defined by National Institutes of Health Stroke Scale (NIHSS): 0-1 or mRS: 0-1 or Glasgow Outcome Scale (GOS): 0-1 (21% versus, 35%; P < 0.001), were less likely to have venous thromboembolism prophylaxis (46% versus 63%; P < 0.01), were less likely to have received antithrombotic therapy (85% versus 90%; P = .02), were less likely to be discharged on anticoagulation when indicated (56% versus 64%; P = .01), and were less likely to be prescribed cholesterol reducing treatment (68% versus 72%; P < .001). The initial acute care hospital length of stay was longer for the spoke hospital group by one day (median: 4 versus 3; P < .001).

CONCLUSION

The key findings were that evidence-based stroke thrombolysis eligibility decision making, thrombolysis administration, and thrombolysis emergency stroke metrics were uniformly excellent for the spoke hospital group when compared to the standard hub hospital group. However, evidence-based stroke hospitalization and discharge metrics were inferior for the spoke hospital group when compared to the standard hub hospital.

Venous Thromboembolism after Inpatient Surgery in Administrative Data vs NSQIP: A Multi-Institutional Study

BACKGROUND

Previous studies have documented significant differences between administrative data and registry data in the determination of postoperative venous thromboembolism (VTE). The goal of this study was to characterize the discordance between administrative and registry data in the determination of postoperative VTE.

STUDY DESIGN

This study was performed using data from the American College of Surgeons NSQIP merged with administrative data from 8 different hospitals (5 different medical centers) between 2013 and 2015. Occurrences of postoperative vein thrombosis (VT) and pulmonary embolism (PE) as ascertained by administrative data and NSQIP data were compared. In each situation where the 2 sources disagreed (discordance), a 2-clinician chart review was performed to characterize the reasons for discordance.

RESULTS

The cohort used for analysis included 43,336 patients, of which 53.3% were female and the mean age was 59.5 years. Concordance between administrative and NSQIP data was worse for VT (κ 0.57; 95% CI 0.51 to 0.62) than for PE (κ 0.83; 95% CI 0.78 to 0.89). A total of 136 cases of discordance were noted in the assessment of VT; of these, 50 (37%) were explained by differences in the criteria used by administrative vs NSQIP systems. In the assessment of postoperative PE, administrative data had a higher accuracy than NSQIP data (odds ratio for accuracy 2.86; 95% CI 1.11 to 7.14) when compared with the 2-clinician chart review.

CONCLUSIONS

This study identifies significant problems in ability of both NSQIP and administrative data to assess postoperative VT/PE. Administrative data functioned more accurately than NSQIP data in the identification of postoperative PE. The mechanisms used to translate VTE measurement into quality improvement should be standardized and improved.

Speaker Introductions at Internal Medicine Grand Rounds: Forms of Address Reveal Gender Bias

BACKGROUND

Gender bias has been identified as one of the drivers of gender disparity in academic medicine. Bias may be reinforced by gender subordinating language or differential use of formality in forms of address. Professional titles may influence the perceived expertise and authority of the referenced individual. The objective of this study is to examine how professional titles were used in the same and mixed-gender speaker introductions at Internal Medicine Grand Rounds (IMGR).

METHODS

A retrospective observational study of video-archived speaker introductions at consecutive IMGR was conducted at two different locations (Arizona, Minnesota) of an academic medical center. Introducers and speakers at IMGR were physician and scientist peers holding MD, PhD, or MD/PhD degrees. The primary outcome was whether or not a speaker's professional title was used during the first form of address during speaker introductions at IMGR. As secondary outcomes, we evaluated whether or not the speakers professional title was used in any form of address during the introduction.

RESULTS

Three hundred twenty-one forms of address were analyzed. Female introducers were more likely to use professional titles when introducing any speaker during the first form of address compared with male introducers (96.2% [102/106] vs. 65.6% [141/215]; p < 0.001). Female dyads utilized formal titles during the first form of address 97.8% (45/46) compared with male dyads who utilized a formal title 72.4% (110/152) of the time (p = 0.007). In mixed-gender dyads, where the introducer was female and speaker male, formal titles were used 95.0% (57/60) of the time. Male introducers of female speakers utilized professional titles 49.2% (31/63) of the time (p < 0.001).

CONCLUSION

In this study, women introduced by men at IMGR were less likely to be addressed by professional title than were men introduced by men. Differential formality in speaker introductions may amplify isolation, marginalization, and professional discomfiture expressed by women faculty in academic medicine.

Hepatitis E virus serum antibodies and RNA prevalence in patients evaluated for heart and kidney transplantation

BACKGROUND

Acute hepatitis E virus (HEV) infection in solid organ transplant recipients is rare, but can cause severe hepatic and extrahepatic complications. We sought to identify the pretransplant prevalence of HEV infection in heart and kidney candidates and any associated risk factors for infection.

MATERIAL AND METHODS

Stored frozen serum from patients undergoing evaluation for transplant was tested for HEV immunoglobulin G (IgG) antibodies and HEV RNA. All patients were seen at Mayo Clinic Hospital, Phoenix, Arizona, with 333 patients evaluated for heart (n = 132) or kidney (n = 201) transplant. HEV IgG antibodies (anti-HEV IgG) were measured by enzyme-linked immunosorbent assay, and HEV RNA by a noncommercial nucleic acid amplification assay.

RESULTS

The prevalence of anti-HEV IgG was 11.4% (15/132) for heart transplant candidates and 8.5% (17/201) for kidney transplant candidates, with an overall seroprevalence of 9.6% (32/333). None of the patients tested positive for HEV RNA in the serum. On multivariable analysis, age older than 60 years was associated with HEV infection (adjusted odds ratio, 3.34; 95% CI, 1.54-7.24; P = 0.002).

CONCLUSIONS

We conclude that there was no evidence of acute HEV infection in this pretransplant population and that older age seems to be associated with positive anti-HEV IgG.

Simple Moving Average: A Method of Reporting Evolving Complication Rates

Surgeons often cite published complication rates when discussing surgery with patients. However, these rates may not truly represent current results or an individual surgeon's experience with a given procedure. This study proposes a novel method to more accurately report current complication trends that may better represent the patient's potential experience: simple moving average. Reverse shoulder arthroplasty (RSA) is an increasingly popular and rapidly evolving procedure with highly variable reported complication rates. The authors used an RSA model to test and evaluate the usefulness of simple moving average. This study reviewed 297 consecutive RSA procedures performed by a single surgeon and noted complications in 50 patients (16.8%). Simple moving average for total complications as well as minor, major, acute, and chronic complications was then calculated using various lag intervals. These findings showed trends toward fewer total, major, and chronic complications over time, and these trends were represented best with a lag of 75 patients. Average follow-up within this lag was 26.2 months. Rates for total complications decreased from 17.3% to 8% at the most recent simple moving average. The authors' traditional complication rate with RSA (16.8%) is consistent with reported rates. However, the use of simple moving average shows that this complication rate decreased over time, with current trends (8%) markedly lower, giving the senior author a more accurate picture of his evolving complication trends with RSA. Compared with traditional methods, simple moving average can be used to better reflect current trends in complication rates associated with a surgical procedure and may better represent the patient's potential experience. [Orthopedics.2016; 39(5):e869-e876.].

Accuracy and confidence in the clinical diagnosis of basal cell cancer using dermoscopy and reflex confocal microscopy

BACKGROUND

Diagnosis of suspected basal cell carcinoma (BCC) is typically confirmed with incisional biopsy before referral to final surgery.

OBJECTIVE

To investigate the clinical confidence and accuracy of physicians making a diagnosis of BCC based on dermoscopic and reflectance confocal microscopy (RCM) features.

METHODS

This study was designed as a simulation to determine the certainty and willingness to refer to surgery without previous biopsy confirmation of BCC. Study subjects were identified with suspected BCC. Dermoscopic and RCM lesion images were obtained before biopsy. Eight clinicians with various expertise levels blindly interpreted these images and chose among four hypothetical treatment options: definite BCC, refer directly to surgery without biopsy; other malignancy, perform biopsy for diagnosis; uncertain diagnosis, perform biopsy; benign, do not biopsy. Decisions for treatment were based on dermoscopic images alone and, subsequently, on dermoscopic and RCM images combined.

RESULTS

The sensitivity for referral to surgery without biopsy was 67.6% with the use of dermoscopy; the positive predictive value (PPV) was 97.0%. Adding RCM increased the sensitivity to 76.5% and the PPV to 98.6%.

CONCLUSIONS

Dermoscopy provides a high PPV for BCC. The addition of RCM to dermoscopy increases diagnostic sensitivity, particularly in less experienced dermoscopists. Physician behavior might be different if actual referrals were made for surgery without biopsy.

Factors Contributing to the Success of Ultrasound-Guided Native Renal Biopsy

OBJECTIVES

The purpose of this study was to evaluate factors contributing to the success of ultrasound-guided native renal biopsy.

METHODS

We retrospectively identified patients who had ultrasound-guided native renal biopsy at our institution over a 10-year period. We reviewed the imaging and electronic medical records to collect demographic information and clinical data, including pathologic results. Biopsy samples were categorized and compared on the basis of the number of glomeruli (optimal [≥20] versus suboptimal [<20]) and the pathologist's reported diagnostic confidence (high confidence versus limited confidence). Procedure details, including the operator and the use of the cortical tangential approach, were also obtained.

RESULTS

For 282 patients with biopsies using 18-gauge needles, the number of passes made was significantly higher for optimal (P < .001) and high-confidence (P < .001) specimens than for suboptimal and limited-confidence specimens. The cortical tangential approach was used more frequently for optimal (P< .001) and high-confidence (P = .01) specimens than for suboptimal and limited-confidence specimens. Radiologists routinely doing ultrasound-guided procedures of all types had significantly more optimal (P= .01) and high-confidence (P= .001) specimens than radiologists with limited ultrasound experience. The distance to the kidney, cortical thickness, glomerular filtration rate, and body mass index were not significant factors.

CONCLUSIONS

The ultrasound-guided procedural experience of the operator, taking more than 1 specimen, and the use of the cortical tangential approach significantly improved the pathologic material obtained during native renal biopsies.

Uphill both ways: Fatigue and quality of life in valley fever

Primary pulmonary coccidioidomycosis is characterized by prolonged respiratory and systemic symptoms and fatigue. We prospectively administered the fatigue severity scale (FSS) and Short Form-36 Health Status Questionnaire (SF-36) to patients with proven or probable primary pulmonary coccidioidomycosis to quantify disease effect on quality of life (QOL). The 24-week observational study did not specify whether antifungal treatment would be provided; the treating physician made treatment decisions. FSS and SF-36 were completed at 4-week intervals. Thirty-six patients participated, of whom 20 received antifungal treatment. At onset of coccidioidal illness, mean FSS score was higher (ie, more fatigue) in the treatment group. However, in early illness, both groups had higher fatigue levels than reference populations with other diseases (eg, multiple sclerosis). FSS scores gradually improved, and scores in each group were below the severe fatigue level at week 12 and week 16 in the nontreatment and treatment groups, respectively. By week 24, mean FSS score of the nontreatment group equaled the general population. SF-36 component and profile scores were lower (with more symptoms) in the treatment group at each time point than the nontreatment group; both groups showed similar improvement. Mental and emotional health SF-36 scores were not as severely affected as physical scores. Most patients reached a physical functioning level similar to the general population at week 12. Pulmonary coccidioidomycosis causes severe fatigue and substantially affects physical abilities. Fatigue was found to be prolonged, with gradual improvement in QOL, regardless of antifungal administration.

Distance from construction site and risk for coccidioidomycosis, Arizona, USA

Coccidioides spp. fungi, which are present in soil in the southwestern United States, can become airborne when the soil is disrupted, and humans who inhale the spores can become infected. In 2012, our institution in Maricopa County, Arizona, USA, began a building project requiring extensive excavation of soil. One year after construction began, we compared the acquisition of coccidioidomycosis in employees working adjacent to the construction site (campus A) with that of employees working 13 miles away (campus B). Initial testing indicated prior occult coccidioidal infection in 20 (11.4%) of 176 campus A employees and in 19 (13.6%) of 140 campus B employees (p = 0.55). At the 1-year follow-up, 3 (2.5%) of 120 employees from campus A and 8 (8.9%) of 90 from campus B had flow cytometric evidence of new coccidioidal infection (p = 0.04). The rate of coccidioidal acquisition differed significantly between campuses, but was not higher on the campus with construction.

Impact of Unaccounted Risk Factors on the Interpretation of Surgical Outcomes

BACKGROUND

Systems that report hospital-based risk-adjusted surgical outcomes are potentially sensitive to the underlying methods used for risk adjustment. If a body of operations has a true level of risk that is higher than the estimated risk, then these operations might generate bias in the output of these reports. The objective of this study was to quantify the impact of unaccounted risk on the results of a surgical outcomes report.

STUDY DESIGN

We constructed a model simulating a universe of 500 hospitals, each providing care to 1,500 patients in a given year. The likelihood of morbidity and mortality for each of these patients was drawn from a random sampling of patients in the American College of Surgeons NSQIP. A single additional hospital was also simulated, within which a certain proportion (proportion varied from 2% to 10%) of patients had a significantly higher (odds ratio varied from 1 to 5) actual likelihood of mortality.

RESULTS

The presence of even a small proportion (2%) of patients with unaccounted risk had the potential to greatly increase the likelihood of a hospital being considered a statistical outlier (poor performer). This impact was greater in the assessment of complications than mortality.

CONCLUSIONS

This study shows that even a small proportion of patients with substantial levels of unaccounted risk can have a dramatic impact on the assessment of hospital-level risk-adjusted surgical outcomes. To avoid the unintended consequences associated with risk-averse behavior from providers, policy should be constructed to address this potential source of bias.

Characteristics of patients with mild to moderate primary pulmonary coccidioidomycosis

In Arizona, USA, primary pulmonary coccidioidomycosis accounts for 15%-29% of community-acquired pneumonia. To determine the evolution of symptoms and changes in laboratory values for patients with mild to moderate coccidioidomycosis during 2010-2012, we conducted a prospective 24-week study of patients with primary pulmonary coccidioidomycosis. Of the 36 patients, 16 (44%) were men and 33 (92%) were White. Median age was 53 years, and 20 (56%) had received antifungal treatment at baseline. Symptom scores were higher for patients who received treatment than for those who did not. Median times from symptom onset to 50% reduction and to complete resolution for patients in treatment and nontreatment groups were 9.9 and 9.1 weeks, and 18.7 and 17.8 weeks, respectively. Median times to full return to work were 8.4 and 5.7 weeks, respectively. One patient who received treatment experienced disseminated infection. For otherwise healthy adults with acute coccidioidomycosis, convalescence was prolonged, regardless of whether they received antifungal treatment.

Use of FRAX as a determinant for risk-based osteoporosis screening may decrease unnecessary testing while improving the odds of identifying treatment candidates

PURPOSE

We have assessed the hypothetical impact of guideline-concordant osteoporosis screening on baseline behaviors utilizing two different guidelines and determined the relative ability of each to identify osteoporosis treatment candidates.

METHODS

We conducted secondary analyses from the Fracture Risk Perception Study, which enrolled patients aged 50 to 75 years to complete questionnaires about their bone health. We determined our baseline screening rates and detection of treatment candidates and then assessed the hypothetical impact of adherence to U.S. Preventive Services Task Force (USPSTF) and National Osteoporosis Foundation (NOF) criteria, particularly for women aged 50 to 64.

RESULTS

Of 144 women aged 50 to 64 years screened, 14 (9.7%) were treatment candidates. Screening based on identification of one or more risks (NOF) would lead to testing of 102 of the 144 patients (71%) to identify 12 of 14 treatment candidates (86%). Applying USPSTF criteria (9.3% FRAX threshold) would test 45 of the same 144 women (31%) to identify 11 of 14 treatment candidates (79%). NOF risk-based criteria would result in a moderate absolute screening rate reduction (16%, p = .0011; 95% CI, 7%-25%), but only marginal improvement in identifying treatment candidates (odds ratio, 2.67; 95% CI, 0.57-12.47). Applying the more selective USPSTF criteria greatly reduced unnecessary testing (56% absolute screening rate reduction; p < .0001; 95% CI, 47%-64%) while further improving the odds of identifying treatment candidates (odds ratio, 10.35; 95% CI, 2.72-39.35).

CONCLUSIONS

When contemplating screening younger patients, systematic calculation of FRAX and ordering only when the 9.3% fracture risk threshold is reached may decrease unnecessary screening for many women while still identifying appropriate osteoporosis treatment candidates.

Resident and hospitalist perspectives on the "great teaching case": Correlation with actual patient assignment decisions

BACKGROUND

With the advent of limits to resident duty hours and the size of teaching services, many academic institutions have introduced nonteaching services, often triaging perceived better teaching cases to the resident services.

OBJECTIVE

To compare resident versus faculty perceptions of ideal cases for teaching services and compare these perceptions with actual triage decisions made by faculty who assigned patients to either teaching or nonteaching services.

DESIGN

Residents and hospitalist faculty were surveyed about their perceptions of ideal and actual teaching admissions, first with qualitative, open-ended questions and then with quantitative, specific questions generated from responses to the first survey. Characteristics of patients admitted to teaching and nonteaching services were analyzed retrospectively and compared with resident and faculty perceptions.

RESULTS

Residents and faculty agreed that rare cases, patients with unique physical findings, and a variety of pathology were ideal for teaching services and that social admissions, benefactors, and patients with chronic or functional pain were not. Residents believed that traditional ("bread and butter") medicine cases were under-represented on the teaching services. Although residents perceived that they received a disproportionate number of older patients, outside transfers, patients with chronic pain, and patients with cancer, the only statistically significant difference was in patient age, with the teaching service actually receiving younger patients (66.7 vs 69.3 years; P=0.008).

CONCLUSIONS

Residents and faculty have similar views about ideal teaching cases, but a triage system based on perceived educational merit creates the possibility of resident misperceptions about their case mix, even if patients are distributed relatively equitably.

The accordion sign in the transplant ureter: ramifications during balloon dilation of strictures

PURPOSE

This study was designed to demonstrate the accordion sign within the transplant ureter and evaluate its ramifications during balloon dilation of strictures.

METHODS

A retrospective electronic chart and imaging review included demographic characteristics, procedure reports, and complications of 28 renal transplant patients having ureteral strictures treated with percutaneous balloon dilation reported in our transplant nephrology database during an 8-year period. The accordion sign was deemed present or absent on the basis of an imaging review and was defined as present when a tortuous ureter became kinked and irregular when foreshortened after placement of a wire or a catheter. Procedure-related urine leaks were categorized as occurring at the stricture if within 2 cm; otherwise, they were considered away from the stricture.

RESULTS

The accordion sign was associated with a significantly greater occurrence of leaks away from the stricture (P = 0.001) but not at the stricture (P = 0.34).

CONCLUSIONS

The accordion sign is an important consideration when performing balloon dilation procedures on transplant ureteral strictures, given the increased risk of leak away from the stricture. Its presence should prompt additional care during wire and catheter manipulations.

Gastric adenocarcinoma in common variable immunodeficiency: features of cancer and associated gastritis may be characteristic of the condition

Common variable immunodeficiency (CVID) is associated with an increased risk of gastric cancer. The aim of the study was to determine the morphological features of CVID-associated gastric adenocarcinoma (CAGA) and of the background gastritis. The population of gastric cancer patients with CVID of Mayo Clinic in the period 2000-2010 was studied; 6 cases of CVID (2 males, 4 females, average age 47 years, age range 26-71 years) were found in 5793 patients with gastric cancer in the study period. Each patient underwent gastric resection for which histology slides were reviewed. Chronic gastritis variables, CVID-related findings, and features of the adenocarcinoma were recorded. CAGA was of intestinal type, with high number of intratumoral lymphocytes (ITLs). Cancer was diagnosed in younger patients than in the overall population of gastric cancer. Severe atrophic metaplastic pangastritis with extensive dysplasia was present in the background in 4 cases, with features of lymphocytic gastritis in 2 cases. Features of CVID (plasma cells paucity in 4 of 6 cases, lymphoid nodules prominent in four cases) could be detected. In summary, gastric adenocarcinoma at young age with ITLs, accompanied by atrophic metaplastic pangastritis, should alert the pathologist of the possibility of CAGA. It follows that, in presence of those characteristics, the search of CVID-associated abnormalities should be undertaken in the nonneoplastic tissues.

Gender distribution of U.S. medical school faculty by academic track type

PURPOSE

Over the past 30 years, the number and type of academic faculty tracks have increased, and researchers have found differences in promotion rates between track types. The authors studied the gender distribution of medical school faculty on the traditional tenure track (TTT) and clinician-educator track (CET) types.

METHOD

The authors analyzed gender and academic track type distribution data from the March 31, 2011, snapshot of the Association of American Medical Colleges' Faculty Roster. Their final analysis included data from the 123 medical schools offering the TTT type and the 106 offering the CET type, which excluded any schools with 10 or fewer faculty on each track type.

RESULTS

The original dataset included 134 medical schools representing 138,508 full-time faculty members, 50,376 (36%) of whom were women. Of the 134 medical schools, 128 reported at least one of four track types: TTT, CET, research track, and other. Of the 83 medical schools offering the CET type, 64 (77%) had a higher proportion of female than male faculty on that track type. Of the 102 medical schools offering the TTT type, only 20 (20%) had a higher proportion of female than male faculty on that track type.

CONCLUSIONS

Medical schools offering the CET type reported higher proportions of female faculty on that track type. Given that faculty on the CET type lag behind their TTT colleagues in academic promotion, these findings may contribute to continued challenges in gaining academic and leadership parity for women in academic medicine.

Cost utility analysis of reverse total shoulder arthroplasty

BACKGROUND

Reverse shoulder arthroplasty provides satisfactory outcomes, but its cost-effectiveness is unproven. We prospectively analyzed outcomes and costs for primary reverse shoulder arthroplasty.

METHODS

Thirty serial patients (16 women and 14 men; mean age, 74.1 years [range, 61.1-87.3 years]) with rotator cuff arthropathy had active motion recorded and completed function tests (visual pain analog scale; Simple Shoulder Test; American Shoulder and Elbow Surgeons Shoulder Outcome score; EuroQol; and Short Form-36 Health Survey) preoperatively and postoperatively at 1 and 2 years. Costs included professional fees, operating room and supply costs, and hospital care. Changes were compared by the Wilcoxon signed rank test, and quality-adjusted life-years were calculated preoperatively and postoperatively.

RESULTS

Twenty-seven patients completed the study. Clinical and functional outcomes demonstrated significant improvement (P < .05). Significantly improved (P < .05) Short Form-36 subgroups included physical functioning, role limitations due to physical health, bodily pain, vitality, and physical composite score. EuroQol dimensions of usual activities and pain/discomfort improved significantly (P < .05). Calculations with the SF-6D showed that median QALYs improved from 6.56 preoperatively to 7.43 at 1-year follow-up (P <.09) and from 6.56 preoperatively to 7.58 at 2-year follow-up (P <.003). The increase in QALYs calculated from the EQ-5D was somewhat greater, changing from 6.21 preoperatively to 7.69 at 1-year follow-up (P <.0001) and from 6.13 to 8.10 at 2-year follow-up (P <.04). Mean cost was $21,536. Cost utility at 2 years was $26,920/quality-adjusted life-year by the Short Form 6 Dimensions and $16,747/quality-adjusted life-year by the EuroQol.

CONCLUSION

EuroQol and Short Form-36 results demonstrated modestly cost-effective (<$50,000/quality-adjusted life-year) improvement for cuff tear arthropathy patients after primary reverse shoulder arthroplasty.

LEVEL OF EVIDENCE

Level II, economic and decision analysis.

Attributes associated with patient perceived outcome in an academic chronic pain clinic

OBJECTIVES

Patient satisfaction is tied to outcome, but there is scant literature on the relationship of patient perceived outcome and attributes of the pain clinic visit, including the patient interaction with the pain management specialist. The primary purpose of this study is to identify attributes of the patient-provider interaction most strongly associated with patient perceived outcome of their clinic visit. The secondary aim is to correlate patient perceived outcome with patient self-rated overall health.

METHODS

A patient satisfaction survey conducted via phone approximately 3 weeks after the patient's pain clinic visit.

RESULTS

The response rate was 60.2%; 987 patient surveys collected between 2006 and 2010 were used in the analysis. Four factors were significantly associated with the outcome: (1) Explanations by the physician of the patient's condition and treatment, (2) clear instructions regarding post-appointment activities, (3) knowing the patient as a person, and (4) the patient's self-rated health. In terms of the secondary objective, those who answered very good/excellent regarding their self-rated health had an 87% increased odds of better (very good/excellent) outcome of their pain clinic visit (or 1.87 times the odds of better outcome) compared with those who answered poor/fair/good.

CONCLUSIONS

Our results suggest that pain physicians may positively impact patient perceived outcomes of clinic visits by explaining the patient's condition and treatment, providing instructions, and taking the time to understand the patient and their values.

The impact of early and brief corticosteroids on the clinical course of primary pulmonary coccidioidomycosis

OBJECTIVE

Primary pulmonary coccidioidomycosis can often be associated with hypersensitivity symptoms treatable with a short course of palliative corticosteroids. Long-term use of corticosteroids is a known risk factor for severe or disseminated infection but the effects of short-term use are not known.

METHODS

A retrospective review was conducted of immunocompetent patients with acute pulmonary coccidioidomycosis who received systemic corticosteroids for relief of coccidioidal-related symptoms. Age- and sex-matched controls were also reviewed. Predetermined end-points were assessed.

RESULTS

Seventy-four patients met inclusion criteria for the corticosteroid-treated group, and 74 controls were identified. Cumulative corticosteroid (prednisone-equivalent) doses were 10 mg → 3,600 mg (mean = 206 mg; median = 120 mg). Corticosteroids were prescribed most commonly for rash 43/74 [58%] or asthma/wheezing/cough 30/74 [41%]. Coccidioidal-related hospitalization occurred in 19 patients in the corticosteroid group vs. 22 in the control group (P = .58). Coccidioidal-related symptoms resolved within a mean of 19 weeks (median = 8 weeks [range = 2-208 weeks]) vs. 32.3 weeks (median = 8 weeks [range = 1-1040 weeks]) in the corticosteroid and control groups (P = .38). Relapse of symptoms occurred in 12% of both groups (P > .99). Extrapulmonary dissemination occurred in 3% vs. 4.0% (P > .99) in the corticosteroid and control groups, respectively.

CONCLUSION

This study found no adverse effects of short-term corticosteroid therapy for early symptomatic treatment in acute pulmonary coccidioidomycosis.

Surgeon fatigue and postural stability: is robotic better than laparoscopic surgery?

OBJECTIVE

To compare muscular fatigue and postural stability of surgeons before and after laparoscopic and robotic surgery.

SUBJECTS AND METHODS

The design of this study is Class II. A consecutive cohort of patients presenting at an academic tertiary-care center for scheduled gynecologic surgery was used. Routine surgical care was examined with testing of surgeon fatigue and postural measures before and after the procedure. Motor fatigue was measured using a quantitative grip dynamometer, and postural stability was measured using a nondominant, single-leg stance. A subjective fatigue score was recorded following surgery.

RESULTS

Primary surgeons completed testing before and after 56 surgeries. A trend toward decline in postural stability was observed more in the laparoscopy group than in the robotic group (P=.29). The fatigue index and subjective fatigue scores were not significantly different.

CONCLUSIONS

Similar changes in postural stability and muscular strength were observed following laparoscopic and robotic surgery. The optimal measurement tool to capture surgical fatigue remains elusive. Fatigue differences may have been more pronounced if surgical procedure degree of difficulty had been more consistent between groups.

Improving hypertension control in diabetes: a multisite quality improvement project that applies a 3-step care bundle to a chronic disease care model for diabetes with hypertension

Hypertension in diabetes patients leads to significant morbidity and mortality. Nonetheless blood pressure (BP) control in patients with diabetes remains disappointing. The authors applied a care bundle to decrease the proportion of patients with BP exceeding 130/80. Teams from 4 sites in 3 states (Minnesota, Florida, and Arizona) developed a bundle consisting of a standardized BP process, an order set, and a patient goal. Baseline data were collected in the first 12 weeks, followed by 6 weeks of implementing changes. The final 16 weeks represented the intervention. There was a statistically significant decrease in the proportion of patients with uncontrolled BP in 3 of 4 sites (P < .0001 in all 3 sites demonstrating improvement). There was a statistically significant improvement in the satisfaction survey (P = .0011). Implementing an evidence-based care bundle for hypertension in diabetes mellitus can improve BP outcomes.

Patient satisfaction in an academic chronic pain clinic

OBJECTIVES

Patient perception of healthcare quality is of growing interest. It has been shown that patient satisfaction is associated with compliance with medical advice and clinical outcome. The 3-fold purpose of this study was to identify which attributes of the patient-physician interaction most strongly correlated with patients' perceptions of provider quality of care, to identify key drivers that move patients' perception of overall provider quality from "very good" to "excellent," and to identify features of the pain clinic experience that were most important to patients but were simultaneously perceived as lacking.

METHODS

Randomized patient satisfaction survey conducted via telephone approximately 3 weeks after the patient's pain clinic visit.

RESULTS

A total of 999 patients participated in the survey over 5 years (estimated response rate 60.2%). Thoroughness, listening, and time spent with the provider were the 3 attributes most strongly associated with the patients' perceptions of provider quality of care, while thoroughness, listening, punctuality, and clear instructions were the drivers of "very good" vs. "excellent" patient perceived overall provider quality. Areas identified for clinic improvement include thoroughness, providing adequate explanations and instructions, and including patient preferences in decision making.

CONCLUSIONS

These results may guide pain clinic physicians as they seek to improve patient perceptions of their care and ultimately patient outcomes.