Nonclinical Factors Research Articles

Social determinants of physicians’ treatment recommendation in early glottic cancer.

65 Background: Glottic cancer is often diagnosed early due to its deleterious effects on the voice. National cancer treatment guidelines recommend larynx preserving treatment, either surgery or radiation, since both modalities have similar rates of local control and recurrence. Without any survival advantage for either treatment modality, physicians may make treatment recommendations based on other clinical or nonclinical factors. Methods: Using the National Cancer Database, a national hospital-based cancer registry data, this retrospective cohort analysis included adult patients, aged 18 years and older, with clinically confirmed diagnosis of early-stage (T1 and T2) glottic cancer between 2004 and 2017 (n = 27,632). The outcome of interest was physicians’ treatment recommendation of surgery or radiation therapy. Main measures included social determinants of health variables, including race/ethnicity, urban/rural status, health insurance status, and income. We further adjusted for covariates, including age and gender. Logistic regression analysis estimated odds of physicians’ recommendation of radiation versus Surgery, based on social determinants of health factors and adjusting for all covariates in the model. Results: More patients received recommendation for radiation treatment vs surgery (78% vs 22%). Female patients were less likely to receive a recommendation of radiation (aOR = 0.90; 95% CI 0.82, 0.98), while Black patients had increased odds of being recommended radiation compared to White patients (aOR = 1.16, 95% CI 1.04, 1.29). Both facility type and location, and patients’ urban vs. rural status were all associated with treatment recommendation, and individuals residing in rural areas had 32% increased odds of being recommendation radiation treatment vs surgery (aOR = 1.32; 95% CI 1.06, 1.64). Conclusions: Radiation treatment is prevalent in early-glottic cancer care, and we found an association between social determinants of health and physician recommendation of treatment. Further research should examine concordance of patient treatment preference vs physician recommendation.

Fostering Excellence in Obstetrical Surgery.

This obstetric surgery review is directed toward the common obstetrical surgeries (caesarean delivery, VBAC/TOLAC, operative vaginal delivery, placenta accreta spectrum) with evidence for quality and safety to allow for obstetrical outcome excellence. This focused scoping review has used a structured process for article identification and inclusion for each of the focused surgeries. The review results provide an obstetrical surgery (OS) overview for caesarean delivery, vaginal birth after caesarean delivery and/or trial of labor after caesarean delivery, operative vaginal delivery, placenta accreta spectrum; considerations for quality and safety variance due to non-clinical human factors; quality improvement (QI) tools; OS QI implementation cohorts; implementation considering certain barriers and solutions. Administrative health care systems and obstetrical surgery care providers cannot afford, not to consider and implement, certain evidenced-based "bottom-up/top-down" processes for quality and safety, as the patients will demand the quality and the safety, but the lawyers should not have to enforce it.

Social determinants of health and lung cancer surgery: a qualitative study.

Social determinants of health (SDOH) are non-clinical factors that may affect the outcomes of cancer patients. The purpose of this study was to describe the influence of SDOH factors on quality of life (QOL)-related outcomes for lung cancer surgery patients. Thirteen patients enrolled in a randomized trial of a dyadic self-management intervention were invited and agreed to participate in semi-structured key informant interviews at study completion (3 months post-discharge). A conventional content analysis approach was used to identify codes and themes that were derived from the interviews. Independent investigators coded the qualitative data, which were subsequently confirmed by a second group of independent investigators. Themes were finalized, and discrepancies were reviewed and resolved. Six themes, each with several subthemes, emerged. Overall, most participants were knowledgeable about the concept of SDOH and perceived that provider awareness of SDOH information was important for the delivery of comprehensive care in surgery. Some participants described financial challenges during treatment that were exacerbated by their cancer diagnosis and resulted in stress and poor QOL. The perceived impact of education varied and included its importance in navigating the healthcare system, decision-making on health behaviors, and more economic mobility opportunities. Some participants experienced barriers to accessing healthcare due to insurance coverage, travel burden, and the fear of losing quality insurance coverage due to retirement. Neighborhood and built environment factors such as safety, air quality, access to green space, and other environmental factors were perceived as important to QOL. Social support through families/friends and spiritual/religious communities was perceived as important to postoperative recovery. Among lung cancer surgery patients, SDOH factors can impact QOL and the patient's survivorship journey. Importantly, SDOH should be assessed routinely to identify patients with unmet needs across the five domains. SDOH-driven interventions are needed to address these unmet needs and to improve the QOL and quality of care for lung cancer surgery patients.

Exploring Perfusion Safety: A Review of Clinical and Non-Clinical Factors with Emphasis on Quality Improvement

This literature review examines perfusion safety in cardiothoracic surgery, with a primary focus on cardiopulmonary bypass (CPB) and circulatory devices. PRISMA guidelines were followed and various databases, including PubMed, MEDLINE, and Google Scholar, were searched using relevant keywords to identify pertinent studies and literature on the subject. The review traces the historical development of perfusion techniques and underscores the importance of equipment factors, personnel considerations, and perfusion management strategies in ensuring patient safety during CPB and circulatory device usage. Clinical aspects of perfusion safety, encompassing equipment safety features, temperature management, anticoagulation, and blood conservation, are discussed. Non-clinical aspects, including the implementation of standardized protocols, robust training structures, positive team dynamics, and the fostering of a safety-oriented culture, are also examined. Quality improvement initiatives for blood conservation, monitoring, and incident reporting are explored, along with an acknowledgment of the significant contributions of major perfusion societies and boards (AmSECT, SCPS, EBCP) in establishing standards and promoting excellence in the field. Challenges related to device design, patient selection, and perioperative management are addressed, highlighting the need for standardized practices and ongoing research to enhance perfusion safety. This comprehensive review underscores the enduring commitment to advancing perfusion safety and quality through systematic research, education, and collaborative efforts in cardiothoracic surgery.

Socioeconomic Disparities Affecting the Presentation and Outcomes in Pediatric Subdural Empyema Patients.

Pediatric subdural empyemas (SDE) carry significant morbidity and mortality, and prompt diagnosis and treatment are essential to ensure optimal outcomes. Nonclinical factors affect presentation, time to diagnosis, and outcomes in several neurosurgical conditions and are potential causes of delay in presentation and treatment for patients with SDE. To evaluate whether socioeconomic status, race, and insurance status affect presentation, time to diagnosis, and outcomes for children with subdural empyema. We conducted a retrospective cohort study with patients diagnosed with SDE between 2005 and 2020 at our institution. Information regarding demographics (age, sex, zip code, insurance status, race/ethnicity) and presentation (symptoms, number of prior visits, duration of symptoms) was collected. Outcome measures included mortality, postoperative complications, length of stay, and discharge disposition. 42 patients were diagnosed with SDE with a mean age of 9.5 years. Most (85.7%) (n = 36) were male ( P = .0004), and a majority, 28/42 (66.7%), were African American ( P < .0001). There was no significant difference in socioeconomic status based on zip codes, although a significantly higher number of patients were on public insurance ( P = .015). African American patients had a significantly longer duration of symptoms than their Caucasian counterparts (8.4 days vs 1.8 days P = .0316). In total, 41/42 underwent surgery for the SDE, most within 24 hours of initial neurosurgical evaluation. There were no significant differences in the average length of stay. The average length of antibiotic duration was 57.2 days and was similar for all patients. There were no significant differences in discharge disposition based on any of the factors identified with most of the patients (52.4%) being discharged to home. There was 1 mortality (2.4%). Although there were no differences in outcomes based on nonclinical factors, African American men on public insurance bear a disproportionately high burden of SDE. Further investigation into the causes of this is warranted.

Factors affecting timing of loop ileostomy closure: a regional centre's experience with 106 patients.

The burden of defunctioning ileostomy is significant with up to two thirds of patients reporting stoma-related morbidity. While timely reversal is safe and cost-effective, the time to reversal in regional Australian hospitals is not well described in professional publications. We aim to assess the current timeliness of ileostomy closure and identify possible reasons for delaying closure. A retrospective analysis of loop ileostomies created and reversed in Launceston General Hospital for both rectal cancer surgery and other benign indications was undertaken. Patients with loop ileostomy created between 2010 and 2020 were included. Clinical data of timing of events, complications, readmission and stoma follow-up were recorded; and analysed using multivariate regression analyses to identify clinically relevant risk factors for delayed closure. A total of 123 patients underwent loop-ileostomy formation during the study period, of which 106 patients (86.2%) were reversed. Median time to closure was 8.5 months (IQR 5.2-12.4) for patients with rectal cancers, compared to 5.2 months (IQR 3.6-9.3) for patients who did not have rectal cancer, with a difference of 3.4 months (95% CI 0.9, 5.9; P = 0.008). Adjuvant chemotherapy and unexpected readmission to hospital were associated with delayed reversal (P = 0.0081 and P = 0.0005, respectively). Stoma reversal is often scheduled 3-6 months after creation. More than two-thirds of patients experienced delays due to changing clinical concerns and non-clinical factors, such as unexpected delays at each stage of surgical planning. Early placement on the waiting list and better-coordinated follow-ups may expedite reversal surgery and reduce associated morbidities.

Association of Maternal Comorbidity Burden With Cesarean Birth Rate Among Nulliparous, Term, Singleton, Vertex Pregnancies

Cesarean birth rate among nulliparous, term, singleton, vertex (NTSV) pregnancies is a standard quality measure in obstetrical care. There are limited data on how the number and type of preexisting conditions affect mode of delivery among primigravidae, and it is also uncertain how maternal comorbidity burden differs across racial and ethnic groups and whether this helps to explain disparities in the NTSV cesarean birth rate. To determine the association between obstetric comorbidity index (OB-CMI) score and cesarean delivery among NTSV pregnancies and to evaluate whether disparities in mode of delivery exist based on race and ethnicity group after adjusting for covariate factors. This cross-sectional study of deliveries between January 2019 and December 2021 took place across 7 hospitals within a large academic health system in New York and included all NTSV pregnancies identified in the electronic medical record system. Exclusion criteria were fetal demise and contraindication to labor. The OB-CMI score. Covariate factors assessed included race and ethnicity group (American Indian or Alaska Native, Asian or Pacific Islander, Hispanic, non-Hispanic Black, non-Hispanic White, other or multiracial, and declined or unknown), public health insurance, and preferred language. Cesarean delivery. A total of 30 253 patients (mean [SD] age, 29.8 [5.4] years; 100% female) were included. Non-Hispanic White patients constituted the largest race and ethnicity group (43.7%), followed by Hispanic patients (16.2%), Asian or Pacific Islander patients (14.6%), and non-Hispanic Black patients (12.2%). The overall NTSV cesarean birth rate was 28.5% (n = 8632); the rate increased from 22.1% among patients with an OB-CMI score of 0 to greater than 55.0% when OB-CMI scores were 7 or higher. On multivariable mixed-effects logistic regression modeling, there was a statistically significant association between OB-CMI score group and cesarean delivery; each successive OB-CMI score group had an increased risk. Patients with an OB-CMI score of 4 or higher had more than 3 times greater odds of a cesarean birth (adjusted odds ratio, 3.14; 95% CI, 2.90-3.40) than those with an OB-CMI score of 0. Compared with non-Hispanic White patients, nearly all other race and ethnicity groups were at increased risk for cesarean delivery, and non-Hispanic Black patients were at highest risk (adjusted odds ratio, 1.43; 95% CI, 1.31-1.55). In this cross-sectional study of patients with NTSV pregnancies, OB-CMI score was positively associated with cesarean birth. Racial and ethnic disparities in this metric were observed. Although differences in the prevalence of preexisting conditions were seen across groups, this did not fully explain variation in cesarean delivery rates, suggesting that unmeasured clinical or nonclinical factors may have influenced the outcome.

Non-clinical factors and citizens’ satisfaction: A way to improve the quality of health systems

ABSTRACT Citzens’ self-reported satisfaction is often employed to assess the quality of health services and systems and guide actions for improvement. Health providers and policymakers are increasingly interested in identifying factors that promote higher satisfaction with health systems. Using data from the Spanish Healthcare Barometer survey, this paper aims at analysing the relationship between non-clinical factors of responsiveness and overall satisfaction with the public Spanish National Health System. Specifically, the study examines whether better experiences with aspects such as doctor-patient communication, dignity, or prompt attention are relevant in improving overall satisfaction with the health system. Factors that contribute most to satisfaction are also identified. The methodology relies on probit-adapted ordinary least squares, a method that is increasingly employed in the most recent subjective well-being literature. The findings show that non-clinical factors are relevant in reporting higher overall satisfaction with the health system. Factors related to prompt attention and dignity contribute most to increasing satisfaction. As our readings suggest, this is the first study to present empirical evidence on the relevance of non-clinical factors of responsiveness in improving users’ experience with the whole Spanish health system. These results provide health policymakers with information to improve the quality of the system.

Factors affecting the use of magnetic resonance imaging in a Southern European region: a qualitative study

ObjectivesThe use of Magnetic Resonance Imaging (MRI) has increased significantly in recent years. Superior diagnostic capability and extension of criteria for the performance of MRI may explain this increase, but there are also non-clinical factors that influence doctors’ decisions. We aim to describe the views of doctors in the Basque Country (Spain) regarding factors affecting MRI orders. MethodsWe conducted a qualitative study using semi-structured interviews with doctors based on intentional sampling to cover a diverse range of interviewees according to personal and professional characteristics (sex, workplace, post of responsibility). We analyzed transcript content using an inductive approach. ResultsFactors identified by doctors were classified into three themes: 1) superior diagnostic capability of the MRI compared to other imaging modalities has favoured MRI use and inclusion in Clinical Practice Guidelines; 2) patient demands, owing to lower trust and acceptance of doctors’ judgment than to technology-based medicine, leads to patient-doctor relationships that result unnecessary MRI test; 3) structural or contextual aspects of the health system, such as excessive rotation of doctors or a lack of time to carry out a thorough patient examination, which disempower doctors and favour overuse. ConclusionsDoctors identified non-clinical factors that affect MRI use and that lead to unintended consequences both for the healthcare system and for patients. We recommend an organizational approach to give doctors enough resources to overcome non-clinical factors that lead to excessive MRI orders in order to optimize its use.

Differential Utilization Patterns of Total Ankle Arthroplasty vs Arthrodesis: A United States National Ambulatory Database Analysis.

End-stage ankle osteoarthritis is a condition that can be treated with ankle arthrodesis (AA) or total ankle arthroplasty (TAA). The goal of this study is to estimate the 2016-2017 United States' utilization of TAA and AA in specific ambulatory settings and delineate patient and hospital factors associated with the selection of TAA vs AA for treatment of ankle osteoarthritis. TAA and AA procedures performed for ankle osteoarthritis were identified in the 2016-2017 Nationwide Ambulatory Surgery Sample (NASS) Database. Notably, the NASS database only examines instances of ambulatory surgery encounters at hospital-owned facilities. As such, instances of TAA and AA performed at privately owned or freestanding ambulatory surgical centers or those performed inpatient are excluded from this analysis. Cases were weighted using nationally representative discharge weights. Univariate analyses and a combined multiple logistic regression model were used to compare demographic, hospital-related, and socioeconomic factors associated with TAA vs AA. In total, 6577 cases were identified, which represents 9072 cases after weighting. Of these, TAA was performed for 2233 (24.6%). Based on the logistic regression model, several factors were associated with increased utilization of TAA vs AA. With regard to patient factors, older patients were more likely to undergo TAA, as well as females. Conversely, patients with a higher comorbidity burden were less likely to receive TAA over AA.With regard to socioeconomic factors, urban teaching and urban nonteaching hospitals were significantly more likely to use TAA compared to rural hospitals. Similarly, privately insured patients and those with a median household income of $71 000 or more were also more likely to receive TAA over AA. Private hospitals ("not-for-profit" and "investor-owned") were significantly more likely to offer TAA over AA. Using a large nationally representative cohort, the current data revealed that during 2016-2017, 24.6% of operatively treated cases of end-stage ankle osteoarthritis in the ambulatory setting are treated with TAA. Associations between socioeconomic and hospital-level factors with TAA utilization suggest that nonclinical factors may influence surgical treatment choice for ankle osteoarthritis. Level III, retrospective cohort study.

Evaluating risk factors associated with poor removable prosthesis hygiene in community-dwelling elders: A cross-sectional study

Removable dental prosthesis cleanliness is multifactorial, and key clinical and nonclinical factors associated with prosthesis hygiene should be identified to inform practice, particularly given the dearth of studies relating specifically to prosthetic factors and prosthesis cleanliness. The purpose of this cross-sectional clinical study was to evaluate removable dental prosthesis cleanliness among community-dwelling elders by using a semi-automated planimetric assessment and to determine factors associated with removable prosthesis cleanliness. The cross-sectional study was conducted among community-dwelling elders wearing removable prostheses. Digital images of plaque on removable prostheses were made after staining with a plaque-disclosing agent by using a single-lens reflex camera with a standardized arrangement. The area of plaque coverage was quantified by using a semi-automated planimetric assessment method. Participant profiles were recorded, including sociodemographic and prosthesis-related variables. Variations in removable prosthesis cleanliness were determined in bivariate and regression analyses with the forward Wald test (α=.05). A total of 97 community-dwelling elders attending a hospital dental clinic were recruited (41 men and 56 women). The mean percentage of prostheses covered with plaque was 24.8%, and 42 (43.3%) were deemed 'unclean' (plaque coverage>25%). Bivariate analyses identified numerous prosthesis-related factors associated with prosthesis cleanliness (P<.05) including prosthesis age, prosthesis material, prosthesis retention and stability, prosthesis fit, and presence of denture stomatitis. Logistic regression analysis indicated that prosthesis fit was the key factor associated with prosthesis cleanliness, accounting for sociodemographic and other prosthesis-related factors (P<.001). Prostheses that were classified as completely ill-fitting were 12 times more likely to be unclean (OR=12.03; 95% CI 3.33-43.41) than those in the well-fitting group. Among a community-dwelling sample of older individuals attending a teaching hospital, approximately half had unclean prostheses as identified by the semi-automated planimetric method. Prosthesis fit was a key factor associated with prosthesis cleanliness. The findings have implications for maintaining removable prosthesis hygiene in the community.

Factors affecting the benefit of glasses alone in treating childhood amblyopia: an analysis of PEDIG data

BackgroundTo evaluate factors associated with better outcomes from optical treatment alone in amblyopic children from 3 up to 7 years.MethodsData extracted from two studies with similar protocols, Amblyopic Treatment Studies 5 (n = 152) and 13 (n = 128) from the Pediatric Eye Disease Investigator Group database, were used to determine by regression analysis the factors associated with improvements in visual acuity in the amblyopic eye, inter-ocular visual acuity difference and stereoacuity. Input variables were aetiology of amblyopia (anisometropic, strabismic and combined-mechanism amblyopia), treatment compliance, visual acuity, interocular visual acuity difference, stereoacuity, tropia size at distance and near, age and refractive error at baseline.ResultsDespite the range of clinical factors considered, our models explain only a modest proportion of the variance in optical treatment outcomes. The better predictors of the degree of optical treatment success in amblyopic children are visual acuity of the amblyopic eye, interocular visual acuity difference, stereoacuity, treatment compliance and the amblyopic eye spherical-equivalent refractive error. While the aetiology of the amblyopia does not exert a major influence upon treatment outcome, combined-mechanism amblyopes experience the smallest improvement in visual acuity, tropia and stereoacuity and may need longer optical treatment periods.ConclusionsWhile results identify the factors influencing optical treatment outcome in amblyopic children, clinicians will be unable to predict accurately the benefits of optical treatment in individual patients. Whether this is because relevant clinical or non-clinical factors (e.g. nature and volume of daily activities undertaken) influences the outcomes from optical treatment has not yet been identified and remains to be discovered.

Predicting Return to Work after Head and Neck Cancer Treatment Is Challenging Due to Factors That Affect Work Ability.

Striving to return to work is of great importance to many cancer survivors. The purpose of the study is to prospectively investigate the factors that hinder and facilitate return to work (RTW) at 3 and 12 months after the end of treatment in head and neck cancer (HNC) survivors and whether these factors influence the ability to continue working after treatment. Participants (n = 227) aged ≤ 65 years at diagnosis with HNC were included. Data were collected before the start of treatment and at 3 and 12 months after the end of treatment. The Rubin causal model was used for statistical analysis. Within the 3-month follow-up period, 92 participants had RTW and 30 had retired. At the 12-month follow-up, 80 of these participants were still working, another 51 participants had RTW, and five participants working still suffered from cancer. The hindrance to RTW within 3 months was advanced tumour stage (stage III and IV) (p = 0.0038). Hindrances to RTW at the 12-month follow-up were oral cancer (p = 0.0210) and larynx cancer (p = 0.0041), and facilitators were living in a relationship (p = 0.0445) and a white-collar job (p = 0.00267). Participants with early tumour stage (stage I and II) (p = 0.0019) and a white-collar job (p = 0.0185) had earlier RTW. The conclusion is that disease factors were the most important hindrances to RTW, and type of work and living with a spouse or partner were nonclinical factors influencing RTW.

Timeliness of diagnostic evaluation for postmenopausal bleeding: A retrospective cohort study using claims data.

Postmenopausal bleeding (PMB) is a common gynecologic condition. Although it can be a sign of uterine cancer, most patients have benign etiology. However, research on quality of diagnostic evaluation for PMB has been limited to cancer patients. To extend this research, we examined the timeliness of diagnostic evaluation for PMB among patients with benign conditions. Using the 2008-2019 MarketScan Research Databases, we identified 499176 patients (456741 with commercial insurance and 42435 with Medicaid insurance) who presented with PMB but did not have gynecologic cancer. For each patient, we measured the time from their PMB reporting to the date of their first diagnostic procedure. The association between patient characteristics and time to first diagnostic procedure was examined using Cox proportional hazards models (for the overall sample and then stratified by insurance type). Overall, 54.3% of patients received a diagnostic procedure on the same day when they reported PMB and 86.6% received a diagnostic procedure within 12 months after reporting PMB. These percentages were 39.4% and 77.1%, respectively, for Medicaid patients, compared to 55.7% and 87.4%, respectively, for commercially insured patients (p<0.001 for both). Medicaid patients had an 18% lower rate of receiving a diagnostic procedure at any given time point than commercially insured patients (adjusted hazard ratio = 0.82, 95% CI: 0.81-0.83). Meanwhile, older age and non-gynecologic comorbidities were associated with a lower rate whereas concomitant gynecologic conditions and recent use of preventive care were associated with a higher rate of receiving diagnostic procedures. Analysis stratified by insurance type identified additional risk factors for delayed diagnostic procedures (e.g., non-metropolitan versus metropolitan location for commercially insured patients and Black versus White race for Medicaid patients). A sizable proportion of patients did not receive prompt diagnostic evaluation for PMB. Both clinical and non-clinical factors could affect timeliness of evaluation.

Preventing Avoidable Rehospitalizations through Standardizing Management of Chronic Conditions in Skilled Nursing Facilities

ObjectivesThis study evaluated the impact of standardized care protocols, as a part of a quality improvement initiative (J10ohns Hopkins Community Health Partnership, J-CHiP), on hospital readmission rates for patients with a diagnosis of congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD) after being discharged to skilled nursing facilities (SNFs). DesignA retrospective study comparing 30-day hospital readmission rates the year before and 2 years following the implementation of the care protocol interventions. Settings and ParticipantsPatients discharged from Johns Hopkins Hospital or Johns Hopkins Bayview Medical Center to the participating SNFs diagnosed with CHF and/or COPD. MethodsThe standardized protocols included medical provider or nurse assessments on SNF admission, multidisciplinary care planning, and medication management to avoid unplanned readmissions to the hospital. Descriptive analyses were conducted to illustrate the 30-day readmission rates before and after protocol implementation. ResultsThere were 1128 patients in the pre-J-CHiP cohort and 2297 patients in the J-CHiP cohort. About half of the patients with a recorded diagnosis of CHF without COPD had the standardized protocol initiated, whereas 47% of the patients with a recorded diagnosis of COPD without CHF had the standardized protocol initiated. Of patients with recorded diagnoses of COPD and CHF, 49% had both protocols initiated. A reduction in the readmission rate was observed for patients with COPD protocols, from 23.5% in 2011 to 12.1% in 2015. However, fluctuations in the readmission rates were observed for patients who initiated the CHF protocols. Conclusions and ImplicationsThere were improvements in the readmission rates in this study, especially for patients who had initiated standardized care protocols in the SNFs. Our findings demonstrate great value in standardizing care management and strengthening collaboration with chronic care settings to facilitate a smooth transition of medically complex patients discharged from large health care systems. Future interventions could consider assessing nonclinical factors that may impact preventable hospital readmissions.

Differences in Receipt of Immunotherapy Treatment Among Patients With Head and Neck Cancer

The US Food and Drug Administration approved immune checkpoint inhibitors (immunotherapy) for select cases of head and neck squamous cell carcinoma (HNSCC) in 2016. However, it is unclear whether there are clinical or sociodemographic differences among patients receiving immunotherapy as part of their care. Given the known disparities in head and neck cancer care, we hypothesized that there are differences in receipt of immunotherapy among patients with HNSCC based on clinical and nonclinical characteristics. To characterize clinical and nonclinical factors associated with receipt of immunotherapy among older patients with HNSCC. This retrospective cohort study included patients 65 years or older diagnosed with HNSCC (n = 4860) in a community oncology care setting. Electronic health records from Navigating Cancer were assessed from January 1, 2017, to April 30, 2022. Multivariable logistic regression was used to characterize clinical (tumor stage [localized vs advanced] and anatomical subsite [oropharyngeal vs nonoropharyngeal]) and nonclinical (age, smoking history, race and ethnicity, sex, and marital status) factors associated with receipt of immunotherapy. In the study cohort of 4860 patients, 3593 (73.9%) were men; 4230 (87.0%) were White and 630 (13.0%) were of other races. A total of 552 patients (11.4%) had received immunotherapy. After adjusting for covariates, in the final model, White patients with HNSCC had 80% increased odds of receiving immunotherapy (adjusted odds ratio [AOR], 1.80 [95% CI, 1.30-2.48]) compared with patients of other races. There were no statistically significant differences in the odds of receiving immunotherapy based on age, sex, or smoking history. Patients with nonoropharyngeal disease were significantly more likely to receive immunotherapy than those with oropharyngeal cancer (AOR, 1.29 [95% CI, 1.05-1.59]), as were those with advanced compared with local disease (AOR, 2.39 [95% CI, 1.71-3.34]). The findings of this cohort study suggest that among older patients with HNSCC, White patients may be more likely to receive immunotherapy as part of their care. Equitable access to immunotherapy and other treatment options will reduce cancer-related health disparities and improve survival of patients with HNSCC.

Physical therapy provision for patients with pneumonia in US hospitals.

Physical therapy (PT) appears beneficial for hospitalized patients. Little is known about PT practice patterns and costs across hospitals. To examine whether receiving PT is associated with specific patient and hospital characteristics for patients with pneumonia. We also explored the variability in PT service provision and costs between hospitals. We included administrative claims from 2010 to 2015 in the Premier Healthcare Database, inclusive of 644 US hospitals. We examined associations between receiving at least one PT visit and patient (age, race, insurance, intensive care utilization, comorbidity status, and length of stay) and hospital (academic status, rurality, size, and location) characteristics. Exploratory measures included timing and proportion of days with PT visits, and per-visit and per-admission costs. Of 768,010 patients, 49% had PT. After adjustment, older age most significantly increased the probability of receiving PT (+38.0% if >80 vs. ≤50 years). Higher comorbidity burden, longer length of stay, and hospitalization in an urban setting were also associated with higher probability. Hospitalization in the South most significantly decreased the probability (-9.1% vs. Midwest). Patients without Medicare and Non-White patients also had lower probability. Median (interquartile range) days to first visit was 2 (1-4). Mean proportion of days with a visit was 35% ± 20%. Median per-visit cost was $88.90 [$56.70-$130.90] and per-admission was $224.00 [$137.80-$369.20]. Both clinical (intensive care utilization and comorbidity status) and non-clinical (age, race, rurality, location) factors were associated with receiving PT. Within and between hospitals, there was high variability in the number and frequency of visits, and costs.

What Patients Say About Their Orthopaedic Hand and Wrist Surgeons: A Qualitative Analysis of Negative Reviews on Yelp.

Background Patients often turn to online reviews as a source of information to inform their decisions regarding care. Existing literature has analyzed factors associated with positive online patient ratings among hand and wrist surgeons. However, there is limited in-depth analysis of factors associated with low patient satisfaction for hand and wrist surgeons. The focus of this study is to examine and characterize extremely negative reviews of hand and wrist surgeons on Yelp.com. Methods A search was performed using the keywords "hand surgery" on Yelp.com for eight major metropolitan areas including Washington DC, Dallas, New York, Phoenix, Los Angeles, San Francisco, Boston, and Seattle. Only single-star reviews (out of a possible 5 stars) of hand and wrist surgeons were included. The complaints in the 1-star reviews were then categorized into clinical and nonclinical categories. Result A total of 233 single-star reviews were included for analysis, which resulted in 468 total complaints. Of these complaints, 81 (18.8%) were clinically related and 351 (81.3%) were nonclinical in nature. The most common clinical complaints were for complication (24 complaints, 6%), misdiagnosis (16 complaints, 4%), unclear treatment plan (16 complaints, 4%), and uncontrolled pain (15 complaints, 3%). The most common nonclinical complaints were for physician bedside manner (93 complaints, 22%), financially related (80 complaints, 19%), unprofessional nonclinical staff (61 complaints, 14%), and wait time (46 complaints, 11%). The difference in the number of complaints for surgical and nonsurgical patients was statistically significant ( p < 0.05) for complication and uncontrolled pain. Clinical Relevance Patient satisfaction is dependent on a multitude of clinical and nonclinical factors. An awareness of online physician ratings is essential for hand and wrist surgeons to maintain and improve patient care and patient satisfaction. We believe the results of our study could be used to further improve the quality of care provided by hand and wrist surgeons.

Using advanced analytics to help identify women who are more likely to have a severe subjective experience of vulvovaginal atrophy: a modeling study

Objective To develop a model to identify women likely to be severely impacted by vulvovaginal atrophy (VVA), based on their experience of symptoms and non-clinical factors. Methods Multivariate statistics and machine-learning algorithms were used to develop models using data from a cross-sectional, observational, multinational European survey. A set of independent variables were chosen to assess subjective VVA severity and its impact on daily activities. Results A final composite model was selected that included three categories of variables: clinical severity, patient demographics/clinical characteristics and Day-to-Day Impact of Vaginal Aging (DIVA) variables related to emotion/mood, impact on lifestyle and frequency of sex. The model accurately classified 71% of women. Three DIVA variables (feeling bad about yourself, desire/interest in sex, physical comfort related to sitting) explained much of the variation in the dependent variable of the model. Over 90% of the impact of VVA relates to certain psychosocial and behavioral aspects that can be identified without the need to consider physical signs/symptoms. Conclusion Non-clinical factors can contribute significantly to the overall VVA burden. Questions used in developing the composite model could form the basis of an instrument to help screen women prior to clinical consultation and improve VVA management.

How surgeons use risk calculators and non-clinical factors for informed consent and shared decision making: A qualitative study

BackgroundThe discussion of risks, benefits, and alternatives to surgery with patients is a defining component of informed consent. As shared-decision making has become central to surgeon-patient communication, risk calculators have emerged as a tool to aid communication and decision-making. To optimize informed consent, it is necessary to understand how surgeons assess and communicate risk, and the role of risk calculators in this process. MethodsWe conducted interviews with 13 surgeons from two institutions to understand how surgeons assess risk, the role of risk calculators in decision-making, and how surgeons approach risk communication during informed consent. We performed a qualitative analysis of interviews based on SRQR guidelines. ResultsOur analysis yielded insights regarding (a) the landscape and approach to obtaining surgical consent; (b) detailed perceptions regarding the value and design of assessing and communicating risk; and (c) practical considerations regarding the future of personalized risk communication in decision-making. Above all, we found that non-clinical factors such as health and risk literacy are changing how surgeons assess and communicate risk, which diverges from traditional risk calculators. ConclusionPrincipally, we found that surgeons incorporate a range of clinical and non-clinical factors to risk stratify patients and determine how to optimally frame and discuss risk with individual patients. We observed that surgeons’ perception of risk communication, and the importance of eliciting patient preferences to direct shared-decision making, did not consistently align with patient priorities. This study underscored criticisms of risk calculators and novel decision-aids – which must be addressed prior to greater adoption.