Nonclinical Factors Research Articles

Understanding the complexity of decision-making for mothers of young children with ambulatory cerebral palsy: A qualitative phenomenological study.

To investigate non-clinical factors that affect health-related decision-making in mothers with young ambulatory children living with cerebral palsy (CP). Guided by phenomenology, we asked parents to describe early experiences of raising a young ambulatory child living with CP. Conversations were audio-recorded, transcribed, coded, and analysed using a qualitative inductive approach. Eighteen parents (all mothers) of 20 children participated. Five themes emerged related to decision-making, each influencing goal setting, prioritization, and health service use. Mothers had to balance both child and family well-being. Acceptance of their child's diagnosis and abilities changed over time, partially influenced by their child's emerging voice. Uncertainty arose when weighing multiple factors regarding child, family, and what the future held. Experiences were laden with system-level burdens related to underinsurance and care coordination. Themes regularly overlapped and persisted. Our findings highlight the complexity of the decision-making experienced by mothers of young ambulatory children living with CP. Probing this information can inform appropriate shared care planning that meets the preferences and circumstances of mothers and their families.

Revealing the impact of social circumstances on the selection of cancer therapy through natural language processing of social work notes.

We aimed to investigate the impact of social circumstances on cancer therapy selection using natural language processing to derive insights from social worker documentation. We developed and employed a Bidirectional Encoder Representations from Transformers (BERT) based approach, using a hierarchical multi-step BERT model (BERT-MS), to predict the prescription of targeted cancer therapy to patients based solely on documentation by clinical social workers. Our corpus included free-text clinical social work notes, combined with medication prescription information, for all patients treated for breast cancer at UCSF between 2012 and 2021. We conducted a feature importance analysis to identify the specific social circumstances that impact cancer therapy regimen. Using only social work notes, we consistently predicted the administration of targeted therapies, suggesting systematic differences in treatment selection exist due to non-clinical factors. The findings were confirmed by several language models, with GatorTron achieving the best performance with an area under the receiver operating characteristic curve (AUROC) of 0.721 and a Macro F1 score of 0.616. The UCSF BERT-MS model, capable of leveraging multiple pieces of notes, surpassed the UCSF-BERT model in both AUROC and Macro-F1. Our feature importance analysis identified several clinically intuitive social determinants of health that potentially contribute to disparities in treatment. Leveraging social work notes can be instrumental in identifying disparities in clinical decision-making. Hypotheses generated in an automated way could be used to guide patient-specific quality improvement interventions. Further validation with diverse clinical outcomes and prospective studies is essential. Our findings indicate that significant disparities exist among breast cancer patients receiving different types of therapies based on social determinants of health. Social work reports play a crucial role in understanding these disparities in clinical decision-making.

Uncovering neural substrates across Alzheimer's disease stages using contrastive variational autoencoder.

Alzheimer's disease is the most common major neurocognitive disorder. Although currently, no cure exists, understanding the neurobiological substrate underlying Alzheimer's disease progression will facilitate early diagnosis and treatment, slow disease progression, and improve prognosis. In this study, we aimed to understand the morphological changes underlying Alzheimer's disease progression using structural magnetic resonance imaging data from cognitively normal individuals, individuals with mild cognitive impairment, and Alzheimer's disease via a contrastive variational autoencoder model. We used contrastive variational autoencoder to generate synthetic data to boost the downstream classification performance. Due to the ability to parse out the nonclinical factors such as age and gender, contrastive variational autoencoder facilitated a purer comparison between different Alzheimer's disease stages to identify the pathological changes specific to Alzheimer's disease progression. We showed that brain morphological changes across Alzheimer's disease stages were significantly associated with individuals' neurofilament light chain concentration, a potential biomarker for Alzheimer's disease, highlighting the biological plausibility of our results.

An initial exploration of factors that may impact radiographer performance in reporting mammograms

ObjectivesIn the United Kingdom, radiographers with a qualification in image interpretation have interpreted mammograms since 1995. These radiographers work under the title of radiography advanced practitioners (RAP) or Consultant Radiographer. This study extends upon what has been very recently published by exploring further clinical, non-clinical and experiential factors that may impact the reporting performance of RAPs. MethodsFifteen RAPs interpreted an image test set of 60 2D mammograms of known truth using the Detected-X software platform. Unknown to the reader, twenty cases contained a malignancy. Sensitivity, specificity, lesion sensitivity, receiver operating characteristic (ROC) and jack-knife free response operating characteristic (AFROC) values were established for each RAP. Specific features that had significant impact on accuracy were identified using Student's-T and Mann Whitney tests. ResultsRAPs with more than 10 years' experience in image interpretation, compared to those with less than 10 years’ experience, demonstrated lower specificity (51.3% vs 84.8%, p = 0.0264), ROC (0.83 vs 0.91, p = 0.0264) and AFROC (0.75 vs 0.87, p = 0.0037) values. Further, higher sensitivity values of 90.7% were seen in those RAPs who had an eye test in the last year compared to those who had not, 82% (p = 0.021). Other changes are presented in the paper. ConclusionThese data reveal previously unidentified factors that impact the diagnostic efficacy of RAPs when interpreting mammographic images. Highlighting such findings will empower screening authorities to better examine ways of standardising performance and offer a baseline for performance benchmarks. Implications for practiceThis study for the first time performs an initial exploration of the factors that may be associated with RAP performance when interpreting screening mammograms.

Non-receipt of targeted and immunotherapies in diverse patients with metastatic cancers.

93 Background: The rapid evolution of molecularly targeted kinase inhibitors (TKIs) and immune checkpoint inhibitors (ICIs) in the treatment of metastatic cancer, coupled with high drug costs, raises potential for unwarranted variation in patient management. We evaluated correlates of non-receipt of TKIs and ICIs in a diverse, population-based sample of patients with metastatic non-small cell lung cancer (NSCLC), kidney and bladder (GU) cancer, and melanoma. Methods: We identified 2240 patients diagnosed in 2019 with metastatic NSCLC, GU cancer, or melanoma and reported to the Georgia or Los Angeles SEER registries. Using SEER registry data, we linked all patients to a managing oncology physician. We collected data from the managing physician regarding receipt of TKIs and ICIs. We used bivariate analyses and multivariable logistic regression models to assess associations between non-receipt of TKIs and ICIs and patient-level factors. Results: We present results for a preliminary sample (N=894). About half (55%) of the patients had NSCLC, 31% had GU cancer, and 14% had melanoma. The mean age was 62 (SD 12); 59% were male; 65% were White, 16% were Black, 11% were Hispanic, and 7% were Asian; 52% had Medicare, 29% had private insurance, 9% had Medicaid, and 4% had no insurance; 89% resided in urban areas, 11% resided in rural areas. 22% lived in a census tract area with >20% of the population living below the poverty level. The Table shows that in bivariate analyses, non-receipt of TKIs was associated with NSCLC, older age, male sex, non-white race, and non-private or no insurance (all p<0.05). After adjustment, non-receipt of TKIs was associated with NSCLC, older age, male sex, and race. Asian and Hispanic patients had lower rates of non-receipt, and Black patients had higher rates. In bivariate analyses, non-receipt of ICIs was associated with NSCLC and GU cancer (p=0.004); this association remained significant after adjustment. Conclusions: Non-receipt of TKIs was associated with important non-clinical factors including race and sex. Non-receipt of ICIs was associated only with cancer type. These findings suggest that policy-relevant factors such as out-of-pocket costs for oral cancer therapies and differential access to molecular sequencing may contribute to unwarranted variation in receipt of TKIs. Bivariate analyses of non-receipt. Did not Receive TKI Did not Receive ICI % P % P Cancer type NSCLC GU Melanoma 786572 0.002 313015 0.004 Age <50 50-64 65-74 75-84 85+ 5471757986 <0.001 2625302940 0.385 Sex Male Female 7670 0.048 2631 0.085 Race & Ethnicity White Black Hispanic Asian Other 7579655860 0.002 2329312927 0.981 Marital Status Married Unmarried 7373 0.645 2630 0.158 Insurance Medicare Medicaid Private Other government None 7075637080 <0.001 3130215031 0.101 Geography Urban Rural 7375 0.784 2826 0.567 % population below poverty level 0-5% 5-<10% 10-<20% 20-100% 69717774 0.314 29273222 0.138

The inefficient effects of non-clinical factors on health care costs.

We use Benford's law to examine the non-random elements of health care costs. We find that as health care expenditures increase, the conformity to the expected distribution of naturally occurring numbers worsens, indicating a tendency towards inefficient treatment. Government insurers follow Benford's law better than private insurers indicating more efficient treatment. Surprisingly, self-insured patients suffer the most from non-clinical cost factors. We suggest that cost saving efforts to reduce non-clinical expenses should be focused on more severe, costly encounters. Doing so focuses cost reduction efforts on less than 10% of encounters that constitute over 70% of dollars spent on health care treatment.

The Factors Associated With Mutant Epidermal Growth Factor Receptor Positivity in Patients With Lung Cancer: A Study From a Tertiary Care Center in Pakistan.

Objective In this study, we sought to elucidate the relationship between demographic and clinical factors and epidermal growth factor receptor tyrosine kinase (EGFR-TK) positivity in patients with advanced-stage lung cancer at a tertiary care center in Pakistan. Methods This analytical cross-sectional study was conducted from February 2020 to July 2023 at Shaikh Zayed Hospital, Lahore, Pakistan, in collaboration with the Centre of Excellence in Molecular Biology (CEMB), University of the Punjab. The study included 70 consecutive patients with advanced-stage lung cancer, and aimed to identify common EGFR mutations (Exon 19 deletion and Exon 21 L858R mutation), determine their frequency, and correlate EGFR-TK mutation positivity with clinical and non-clinical factors. Tissue acquisition and processing involved bronchoscopy, pleuroscopy, or percutaneous ultrasound-guided lung mass biopsy, followed by molecular analysis using polymerase chain reaction (PCR) extraction, amplification, and sequencing. The study employed convenient sampling and included adults aged over 18 years with histologically confirmed lung cancer. Results We enrolled 70 lung cancer patients, with a mean age of 60.87 years, and a male-to-female ratio of 1.4:1. The majority (61.4%) had adenocarcinoma, and 34.3% harbored a mutant EGFR-TK. EGFR mutations were more common in adenocarcinoma (91.7%) and associated with female non-smokers. Binary logistic regression analysis revealed that age <50 years and adenocarcinoma type were significant predictors of EGFR mutations. We found no significant associations with gender, smoking status, or other variables. These findings have implications for personalized treatment approaches in lung cancerpatients. Conclusions Our study reveals a high frequency of occult EGFR mutations (Exon 19 deletion and Exon 21 L858R mutation) in non-small cell lung cancer (NSCLC) patients, particularly among male smokers and female non-smokers. These findings emphasize the importance of routine EGFR mutation testing to identify patients who may benefit from targeted therapies, ultimately improving treatment outcomes.

SP2.3 - Environmental and non-technical factors influence surgical trainees involvement in laparoscopic appendectomy in Northern Italy: a propensity score matching and survey based multicenter analysis

Abstract Aims Laparoscopic appendectomy (LA) is an index procedure for surgical residents (R). The trends of R involvement in LA can be a quality benchmark for residency programs. The impact of clinical and non-clinical factors on such trends is still undisclosed. We aimed to investigate the prevalence of LA performed by R in the largest Italian educational network and explore the decision-making behind R involvement in LA. Methods We extracted data from the RESIDENT-1 (R1) multicenter trial registry and performed a propensity score matching (PSM) analysis to identify clinical and environmental differences according to the operator, surgeons(S) vs R. Additionally, to explore environmental and non-technical factors influencing the choice of the primary operator, we administered a survey to S and R in the R1 network. Results We enrolled 653 LA from October 2019 to October 2022, 234 (35.89%) were performed by R. We compared 231 per group after PSM. In academic hospitals and dedicated emergency surgery units LA were more frequently approached by R (57.14%vs26.84%, 51.08%vs19.05% p&amp;lt;0.001, respectively). The survey showed discrepant perspectives, R prioritize clinical factors, as the presence of complicated disease (25.53%vs.8.33%, p&amp;lt;0.015), whilst non-technical and environmental factors such as year of residency (63.1%vs.44.7%,p=0.05) and punctuality (47.2%vs.23.4%,p=0.041) were more important for S. Both groups agreed that a perioperative feedback system would improve the process of R involvement in LA. Conclusion Our study report a low rate of LA performed by R in northern Italy, primarily influenced by non-clinical factors. Furthermore, dedicated pathways and a well-structured perioperative teaching method could optimize the teaching process.

PROGNOSTIC FACTORS FOR ORCHIDECTOMY IN TESTICULAR TORSION PATIENTS AT TERTIARY HOSPITAL

Objective: This study was conducted to analyze the prognostic factors for orchidectomy in testicular torsion patients. Material &amp; Methods: From January 2001 to December 2021, 100 cases of testicular torsion cases were retrospectively collected. Data were described and analyzed based on clinical factors (age, duration of symptoms, scrotal swelling, high-riding testis, Prehn test, cremasteric reflex, leukocytosis, degree of twisting) and non-clinical factors (distance from hospital, duration of travel to hospital, education level and employment status) for each surgical procedure. Then logistic regression analysis was performed. Results: There were 88 testicular torsion patients (88%) underwent orchidectomy and 12 patients (12%) underwent orchidopexy. There was no significant relationship between age, duration of symptoms, scrotal swelling, Prehn test, cremasteric reflex, leukocytosis, distance from hospital, duration of travel to hospital, education level and employment status with orchidectomy (p&gt;0.05). Significant prognostic factors for orchidectomy in testicular torsion patients were high-riding testis (OR = 0.06; 95% CI = 0.01-0.37; p = 0.002) and degree of twisting (OR = 0.04; 95% CI = 0.006-0.24; p = 0.000). Conclusion: High-riding testis and degree of twisting are prognostic factors for orchidectomy in testicular torsion patients. Keywords: Orchidectomy, prognostic factors, testicular torsion.

Frailty in Persons with Down Syndrome: Results from the REVIVIS Study

ObjectivesTo determine frailty prevalence and identify possible nonclinical factors associated with this condition in community-dwelling individuals with Down syndrome (DS). DesignCross-sectional analysis of the registry study REVIVIS, a single-center, prospective study on the geriatric management of persons with DS. Setting and ParticipantsIndividuals with DS (n = 139) referred to a geriatric clinic. MethodsFrailty was assessed through a 38-item Frailty Index (FI). A multivariable linear regression model was performed to assess the relationship between frailty and different variables of interest: age, number of prescribed drugs, and employment status (unemployed vs employed). ResultsAmong 139 subjects (54.5% male), mean (SD) aged 42.9 (6.9) years, the median (interquartile range) FI was 0.24 (0.16-0.30) with 60 participants (43.2%) classified as frail. The number of prescribed medications was associated with higher FI levels (P < .001), whereas being employed was associated with lower FI levels (P < .001) compared with being unemployed. No association was found between chronological age and FI. Conclusions and ImplicationsOur findings suggest that chronological age is insufficient to encompass the complexity of a subject with DS, underscoring the importance of a standardized evaluation of the FI among this population. Access to geriatric care might become an important opportunity for people with DS, a population characterized by high vulnerability (or frailty).

Trends in management of odontoid fractures 2010–2021

Background ContextOdontoid fractures are relatively common. However, the literature is unclear how these fractures are best managed in many scenarios. As such, care is varied and poorly characterized. PurposeTo investigate the trends and predictive factors of surgical versus nonsurgical treatment and anterior versus posterior stabilization of odontoid fractures. Study Design/SettingRetrospective database cohort study. Patient SampleAdult patients with odontoid fractures between 2010 and 2021. Outcome MeasuresYearly trends and predictors of odontoid fracture management. MethodsAdult patients with odontoid fractures were abstracted from the large, national, administrative M161Ortho Pearldiver dataset. For operative versus nonoperative care of odontoid fractures, yearly rates were determined (since 2016 based on coding limitations). For anterior versus posterior stabilization, yearly rates were determined (2010-2021). Univariate and multivariable analyses were performed for both sets of comparisons. ResultsFor assessment of nonsurgical versus surgical management from 2016 to 2021, a total of 42,754 patients with odontoid fracture were identified, of which surgical intervention was done for 7.9%. Predictive factors of surgical intervention included being managed by a neurosurgeon (OR:1.29), being from Midwest United States (OR:1.35 relative to West), male sex (OR:1.20), and decreasing age (OR: 0.82 per decade) (p<0.001 for each). Of those undergoing surgical intervention, 33.6% had anterior surgery while 66.4% had posterior surgery (anterior surgery decreased from 36.4% in 2010 to 27.2% in 2021, p<0.001). Predictive factors of undergoing anterior versus posterior approach include having a neurosurgeon surgeon (OR:1.98), being from the Southern (OR:1.61 relative to Northeast), and having Medicare insurance (OR: 1.31) (p<0.001 for each). ConclusionsThe overall rate of surgery for odontoid fractures has remained similar over the past years. Of those undergoing surgery, less are being done from anterior. While these decisions were predicted by some clinical factors, both also correlated with non-clinical factors suggesting room for more consistent algorithms.

Negotiating grey areas: an interview-based analysis of paramedic uncertainty and decision-making in cardiac arrest events

BackgroundParamedics are responsible for critical resuscitation decisions when attending Out of Hospital Cardiac Arrests (OHCA). Existing research indicates that a range of clinical and non-clinical factors moderate their decision-making. Within the United Kingdom (UK), there is little evidence on how and why paramedics make their decisions at actual OHCA events.MethodsWe explored the experiences of UK paramedics using individually recalled OHCA events as catalysts for discussion. Pen portraits developed from semi-structured interviews with 31 paramedics across two UK ambulance services were thematically analysed, enabling cross-participant comparisons whilst retaining depth and context.ResultsWe identified four themes: uncertainties encountered in resuscitation guidelines, influences on decision-making, holistic perspectives, and indirect moderators. We found that paramedics experienced uncertainty at all stages of the resuscitation process. Uncertainties arose from indeterminate, ambiguous or complex information and were described as having both clinical and ethical dimensions. Whilst guidelines drove paramedics’ decisions, non-clinical personal, practical and relational factors moderated their assessments of survivability and decision-making, with attitudes to interactions between patient age, frailty and quality of life playing a substantial role. Coping strategies such as uncertainty reduction, assumption-based reasoning and weighing pros and cons were evident from interviews.ConclusionsThe complexity of interactions between clinical and non-clinical factors points to an element of variability in paramedics’ responses to uncertainty. Exploring UK paramedics’ uncertainties and decision-making during specific OHCA events can help acknowledge and address uncertainties in resuscitation guidelines and paramedic training, providing paramedics with the tools to manage uncertainty in a consistent and transparent way.

Factors behind Antibiotic Therapy: A Survey of Primary Care Pediatricians in Lombardy.

Antimicrobial resistance represents one of the most significant future health challenges in terms of both clinical and economic impacts on healthcare systems. The reason behind this issue is the misuse of antibiotics for the treatment of non-bacterial pathologies. The objective of this study is to investigate the factors underlying antibiotic prescription in pediatricians in the Lombardy region. The study was conducted by means of a 32-item questionnaire that investigated both pediatricians' knowledge of antimicrobial resistance and the factors determining the choice to prescribe antibiotic therapy. A total of 253 pediatricians participated in the survey. Most participants (71.6%) reported as highly relevant the need for a national plan against AMR. However, approximately half of the respondents declared the phenomenon of AMR as uncommon in pediatric settings. Among the identified associated factors, diagnostic uncertainty was associated with a stronger fear of legal repercussions and the influence of parental pressure when prescribing antibiotics. The inability to diagnose the bacterial origin of an infection might be the primary driver of prescribing choices, rather than other non-clinical factors, such as parental demands or a fear of lawsuits.

2165 Barriers perceived by medical students when considering a career in geriatric medicine.

Abstract Introduction Despite the UK’s increasing life expectancy, and increase in the elderly population, there is an overwhelming lack of Geriatricians in the UK; as of 2022, there is only 1 consultant Geriatrician per 8031 individuals over the age of 65 (BGS, 2023). To meet the complex care needs of this population, there must be a focus on increasing the interest that doctors have towards Geriatric Medicine, with the overall aim being to recruit more doctors into the speciality. Method The aim of this review was to investigate what factors medical students perceive as barriers to pursuing a career in Geriatric Medicine and then, from identifying these, generate a set of comprehensive suggestions as to how to tackle these barriers at a medical school level to increase the interest and ultimately uptake of Geriatric Medicine. The qualitative review contains literature published between 2003 and 2023 accessed using MedLine. Results Six themes were identified in answering our question: (a) high emotional burden, (b) caring for patients with complex needs, (c) negative preconceptions of non-clinical factors (prestige, salary, career progression), (d) negative influence of clinical educators, (e) lack of intellectual stimulation and (f) lack of exposure to the speciality and the elderly. Conclusion The barriers perceived by medical students when considering Geriatrics as a speciality are complex and multifaceted; these barriers must be tackled promptly in order to secure the next generation of Geriatricians. We suggest that this work can be used as a foundation for further qualitative studies with UK medical students to investigate barriers that are specific to UK students. From this, interventional courses designed to increase Geriatric Medicine uptake could be developed to strengthen the UK Geriatric Medicine workforce.

Assessing the Validity of the Centers for Medicare & Medicaid Services Measure in Identifying Potentially Preventable Emergency Department Visits by Patients With Cancer.

The Centers for Medicare & Medicaid Services (CMS) implemented chemotherapy measures (OP-35) to reduce potentially preventable emergency department visits (PPEDVs) and hospitalizations. This study evaluated the validity of the OP-35 measure in identifying PPEDVs among patients with cancer. This is a cross-sectional study, which used data from the 2012-2022 National Hospital Ambulatory Medical Care Survey. ED visits are assessed and compared on the basis of three measures: immediacy using Emergency Severity Index (ESI), disposition (discharge v hospitalization), and OP-35 criteria. Between 2012 and 2022, a weighted sample of 46,723,524 ED visits were made by patients with cancer. Among reported ESI cases, 25.2% (8,346,443) was high urgency. In addition, 30.3% (14,135,496) of ED visits among patients with cancer led to hospitalizations. Using the OP-35 measure, it was found that 20.85% (9,743,977) was PPEDVs. A 21.9% (10,232,102) discrepancy between discharge diagnosis (CMS billing codes) and chief complaints was identified. Further analysis showed that 19.2% (1,872,556) of potentially preventable ED visits (CMS OP-35) were high urgency and 32.6% (3,181,280) resulted in hospitalization. The CMS approach to identifying PPEDVs has limitations. First, it may overcount preventable visits by including high-urgency or hospitalization-requiring cases. Second, relying on final diagnoses for retrospective preventability judgment can be misleading as they may not reflect the initial reason for the visit. In addition, differentiating causes for ED visits in patients with cancer undergoing various treatments is challenging as the approach does not distinguish between chemotherapy-related complications and others. Identification inconsistencies arise because of varying coding practices and chosen preventable conditions, lacking consensus and alignment with specific hospital or patient needs. Finally, the model fails to consider crucial nonclinical factors like social support, economic barriers, and alternative care access, potentially unfairly penalizing hospitals serving underserved populations.

ASO Visual Abstract: Open Versus Minimally Invasive Nephroureterectomy: Contemporary Analysis from a Wide National Population-Based Database.

Contemporary trend analysis of a large national data set confirms the occurrence of a significant shift toward minimally invasive nephroureterectomy (MINU), which is gradually replacing open nephroureterectomy (ONU). A minimally invasive approach is associated with a lower risk of complications. Social determinants of health (SDOH) are non-clinical factors that ultimately may have an impact on the outcomes of the nephroureterectomy (NU) procedure ( https://doi.org/10.1245/s10434-024-15565-6 ).

A Cross-Sectional Study on Patient Preferences for Selecting Surgeons for Joint Replacement Surgery in India.

Introduction This study aims to investigate the complex decision-making process of patients in India when choosing surgeons for joint replacement surgery, with a focus on both clinical and non-clinical factors influencing their preferences. Methods This was a cross-sectional observational study conducted at the KIMS-Sunshine Hospitals, Hyderabad, a high-volume tertiary care institute in India, in which patients with end-stage osteoarthritis requiring primary total knee arthroplasty were evaluated using a self-administered questionnaire, which assessed both patient-related and surgeon-related factors in choosing their joint replacement surgeon. Results A total of 210 participants were surveyed among whom the majority were females with an average age of 60.2 years with the majority belonging to the upper-middle-class socioeconomic status (48.6%, N=102). Fifty-nine percent preferred surgeons with over 20 years of experience, and 63.8% were willing to travel out-of-state for recognized expertise. Family recommendations (33.8%) and surgeon reputation (24.3%) were primary factors in surgeon selection. A vast majority (73.3%) preferred surgeons who were skilled in robotic surgery and had foreign training (32.9%). However, the majority (67.6%) did not express any gender preference.The survey highlighted a broad range of informational sources affecting decisions, including financial consideration (63.8%), personal referrals, and online platforms (17.1%). Preferences were also shaped by hospital reputation and insurance options (10.5%), illustrating a nuanced interplay of quality, cost, and personal connections in the selection process. Conclusion The findings of this survey illuminate the intricate and diverse preferences exhibited by patients when selecting a surgeon for joint replacement surgery. A significant rise in patient expectations is evident, underscoring a demand for more personalized, contemporary, and high-quality healthcare services. Importantly, geographical proximity appears to be a diminishing concern in their decision-making process. This trend presents an opportunity for centers of excellence to extend their influence and attract patients on both a regional and national level.

Accuracy of Electronic Health Record Documentation of Parental Presence: A Data Validation and Quality Improvement Analysis.

Parental presence in the neonatal intensive care unit (NICU) is known to improve the health outcomes of an admitted infant. The use of the electronic health record (EHR) to analyze associations between parental presence and sociodemographic factors could provide important insights to families at greatest risk for limited presence during their infant's NICU stay, but there is little evidence about the accuracy of nonvital clinical measures such as parental presence in these datasets. A data validation study was conducted comparing the percentage agreement of an observational log of parental presence to the EHR documentation. Overall, high accuracy values were found when combining two methods of documentation. Additional stratification using a more specific measure, each chart's complete accuracy, instead of overall accuracy, revealed that night shift documentation was more accurate than day shift documentation (76.3% accurate during night shifts, 55.2% accurate during day shifts) and that flowsheet (FS) recordings were more accurate than the free-text plan of care (POC) notes (82.4% accurate for FS, 75.1% accurate for POC notes). This research provides a preliminary look at the accuracy of EHR documentation of nonclinical factors and can serve as a methodological roadmap for other researchers who intend to use EHR data.

Open versus Minimally Invasive Nephroureterectomy: Contemporary Analysis from a Wide National Population-Based Database.

It is generally perceived that minimally invasive nephroureterectomy (MINU), especially in the form of robotic-assisted laparoscopy, is gaining an increasing role in many institutions. The aim of our study was to investigate contemporary trends in the adoption of MINU in the United States compared with open nephroureterectomy (ONU). Patients who underwent ONU or MINU between 2011 and 2021 were retrospectively analyzed using PearlDiver Mariner, an all-payer insurance claims database. International Classification of Diseases diagnosis and procedure codes were used to identify the type of surgical procedure, patients' characteristics, social determinants of health (SDOH), and perioperative complications. The primary objective assessed different trends and costs in NU adoption, while secondary objectives analyzed factors influencing the postoperative complications, including SDOH. Outcomes were compared using multivariable regression models. Overall, 15,240 patients underwent ONU (n=7675) and MINU (n=7565). Utilization of ONU declined over the study period, whereas that of MINU increased from 29 to 72% (p=0.01). The 60-day postoperative complication rate was 23% for ONU and 19% for MINU (p<0.001). At multivariable analysis, ONU showed a significantly higher risk of postoperative complications (odds ratio 1.33, 95% CI 1.20-1.48). Approximately 5% and 9% of patients reported at least one SDOH at baseline for both ONU and MINU (p<0.001). Contemporary trend analysis of a large national dataset confirms that there has been a significant shift towards MINU, which is gradually replacing ONU. A minimally invasive approach is associated with lower risk of complications. SDOH are non-clinical factors that currently do not have an impact on the outcomes of nephroureterectomy.

Facility-Level and Racial Disparities in Access to Inpatient Psychiatric Occupational Therapy Services in the Veterans Health Administration.

Veterans receiving inpatient psychiatric services with limitations in activities of daily living (ADLs) benefit from occupational therapy, yet disparities in access are unknown. To investigate whether ADL limitations, an indicator of occupational therapy need, was associated with inpatient psychiatric occupational therapy utilization in the Veterans Health Administration (VHA) and whether this relationship differs by facility characteristics. Secondary analysis of VHA data. Modified Poisson regression modeled occupational therapy utilization as a function of ADL limitations, facility characteristics, and covariates. Interactions estimated whether the relationship between ADL limitations and occupational therapy utilization differed across facility characteristics. VHA inpatient psychiatric setting. Veterans receiving VHA inpatient psychiatric care from 2015 to 2020 (N = 133,844). Occupational therapy utilization. Veterans with ADL limitations were more likely to receive occupational therapy. Veterans receiving care in facilities with higher complexity and greater inpatient psychiatric care quality were more likely to receive occupational therapy. Additionally, Black veterans were less likely to receive occupational therapy relative to their White, non-Hispanic counterparts. Interactions indicated that the extent to which ADL limitations drove access to occupational therapy utilization was weaker within facilities with higher complexity and care quality. Veterans with ADL limitations were more likely to access inpatient psychiatric occupational therapy, suggesting that such services are generally allocated to veterans in need. However, findings indicate disparities in access across patient-level (e.g., Black race) and facility-level (e.g., facility complexity) factors, informing efforts to eliminate barriers to accessing these valuable services. Plain-Language Summary: This is the first study, to our knowledge, to examine disparities in access to inpatient psychiatric occupational therapy in the Veterans Health Administration (VHA). The study findings show that access to inpatient psychiatric occupational therapy is partly driven by the needs of the patient. However, nonclinical factors, such as a patient's race and the characteristics of the facility at which they receive care (complexity, number of psychiatric beds available, and the quality of psychiatric care), are also important drivers of access. Identifying factors influencing access to these valuable services is the first step in developing strategies that reduce barriers to access for veterans in need.