Demographic Practice Research Articles

Characteristics of medical oncologists participating in the Oncology Care Model.

e18017 Background: The Oncology Care Model (OCM) is Medicare’s first bundled payment program for patients with cancer. Because practices voluntarily enrolled in the OCM in 2016, there may be differences between OCM-participating and non-participating oncologists that impact the OCM’s generalizability. We examine baseline characteristics of OCM participants and markets with high OCM physician participation. Methods: In this cross-sectional study, we identified characteristics of US medical oncologists practicing in 2016 using a national telephone-verified physician database. We linked this data with Dartmouth Atlas and Medicare claims data to identify market characteristics of areas with high OCM participation. We used logistic regression to examine relationships between market characteristics and OCM participation. Results: Of 10428 US medical oncologists, 2605 (24.9%) were listed on an OCM-participating practice’s website. There were no differences in sex or medical training between OCM participants and non-participants, although OCM participants were younger. OCM participants were more likely to be affiliated with large, group, and urban practices that were not part of a health system (Table). Southwest, Southeast, and mid-Atlantic markets had higher OCM participation. Markets with high OCM physician participation had higher specialist density, Hospital Care Intensity Index, and acute care utilization at the end of life (all p < 0.001). Market penetration of Accountable Care Organizations (adjusted odds ratio [aOR] 4.65, 95% CI 3.31-6.56, p < 0.001) and Medicare Advantage (aOR 2.82, 95% CI 1.97-4.06, p < 0.001) were associated with higher OCM participation. Conclusions: We found differences in provider and practice demographics, care intensity, and prior exposure to alternative payment models between OCM-participants and non-participants. Differences in practice and market characteristics influence oncologists’ participation in alternative payment models and should be accounted for in Medicare’s OCM evaluation. [Table: see text]

Investigation of Radiation Oncologists' Awareness of Online Reputation Management.

BackgroundOnline reputation management (ORM) is an emerging practice strategy that emphasizes the systematic and proactive monitoring of online reviews relating to one’s professional reputation.ObjectiveWe developed this survey project to assess whether radiation oncologists are aware of ORM and how it is utilized in their practices. We hypothesized that ORM is largely unknown by most practicing radiation oncologists and that little time is spent actively managing their reputations.MethodsAn online survey was submitted to 1222 radiation oncologists using the Qualtrics research platform. Physician emails were gathered from the American Society for Radiation Oncology member directory. A total of 85 physicians initiated the survey, whereas 76 physicians completed more than or equal to 94% (15/16) of the survey questions and were subsequently used in our analyses. The survey consisted of 15 questions querying practice demographics, patient satisfaction determination, ORM understanding, and activities to address ORM and 1 question for physicians to opt-in to a US $50 Amazon gift card raffle. The survey data were summarized using a frequency table, and data were analyzed using the Chi-square test, Fisher exact test, and Spearman correlation coefficients.ResultsWe calculated a 7% (85/1222) response rate for our survey, with a completion rate of 89% (76/85). A majority of respondents (97%, 74/76) endorsed being somewhat or strongly concerned about patient satisfaction (P<.001). However, 58% (44/76) of respondents reported spending 0 hours per week reviewing or managing their online reputation and 39% (30/76) reported spending less than 1 hour per week (P<.001). A majority of physicians (58%, 44/76) endorsed no familiarity with ORM (P<.001) and 70% (53/76) did not actively manage their online reputation (P<.001). Although 83% (63/76) of respondents strongly or somewhat believed that patients read online reviews (P<.001), 57% (43/76) of respondents did not check their online reviews (P=.25) and 80% (61/76) endorsed never responding to online reviews (P<.001). Moreover, 58% (44/76) of the respondents strongly or somewhat supported the idea of managing their online reputation going forward (P=.001). In addition, 11 out of the 28 pairs of questions asked in our correlation studies reached statistical significance. Degree of concern for patient satisfaction and the notion of managing one’s ORM going forward were the 2 most frequently correlated topics of statistical significance in our analyses.ConclusionsORM is presently under-recognized in radiation oncology. Although most practitioners are concerned about patient satisfaction, little effort is directed toward the internet on this matter. ORM offers an area of practice improvement for many practicing radiation oncologists.

The epidemiology of work-related musculoskeletal injuries among chiropractors in the eThekwini municipality

BackgroundChiropractors are a unique group of health care professionals who are at risk for developing work-related musculoskeletal injuries. Diversity of daily practice imposes different physical demands on the chiropractor. This study aimed to determine the prevalence of work-related musculoskeletal injuries in chiropractors in eThekwini municipality and selected risk factors associated with these work-related musculoskeletal injuries.MethodsThe design was a quantitative, cross-sectional, descriptive study utilising a self-administered questionnaire, developed specifically for this research. The questionnaire contained sections on personal and practice demographics, with questions pertaining to the single most severe work-related musculoskeletal injury, as well as the second and third most severe work-related musculoskeletal injury.ResultsA response rate of 64% was obtained (n = 62). The life-time prevalence of work-related musculoskeletal injuries was 69% with a predominance of injuries to the upper extremity (50%) and lower back (28.3%). The hand/wrist was the most common anatomical site of injury (31.5%) followed by the lower back (28.3%). Number of years in practice was considered a risk factor as most injuries occurred within the first five years of practice (41.6%). The majority of injuries affected the soft tissue, including ligament sprains (27.5%) and muscle strains (26.6%) and occurred while the practitioner was performing manipulation (38.2%) of the lumbosacral (80.8%) area with the patient in the side posture (61.5%).ConclusionsThe results concur with other studies on work-related musculoskeletal injuries in chiropractors and add insight into risk factors predisposing this population to injury.

VARIATION IN PREFERRED TECHNIQUE FOR ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN THE SKELETALLY IMMATURE: WHERE DO WE STAND?

Purpose: Despite several well-described operative techniques, the optimal management of anterior cruciate ligament (ACL) injuries in pediatric patients remains unclear. The goal of this study was to identify preferred techniques in skeletally immature patients of various ages and analyze differences in operative strategy based on surgeon and practice demographics. Methods: An electronic survey was administered to members of the Pediatric Research in Sports Medicine society, a cohort of experienced surgeons who perform a high volume of pediatric ACL reconstructions. The survey presented a scenario of a patient who had a physical exam and imaging consistent with an acute, isolated ACL tear. The respondent was asked to select their preferred reconstruction technique for females and males at consecutive skeletal ages from 8 to 15 years. Surgeon and practice demographic information was recorded. Univariate analysis was followed by stepwise multinominal logistic regression to control for confounders. Results: Eighty-eight of 103 surgeons (85%) responded to the survey, the majority of whom (68%) performed more than 25 pediatric ACL reconstructions annually. The greatest variation in technique was from ages 11 to 13 in females and 11 to 14 in males. The modified MacIntosh was the most frequently utilized from ages 8 to 10. An all-epiphyseal technique was preferred over a broader age range in males than females, with peak utilization at age 11 in both. A partial trans-physeal (hybrid) technique was preferred in slightly older patients, with peak utilization at age 12 in females and 13 in males. The trans-physeal technique was most widely used at age 13 and up in females and 14 and up in males. The impact of fellowship training on technique preference was statistically significant for males ages 11-13 and females 11 and 12 (p&lt;0.05 for all). Surgeons with pediatric orthopaedic training tended to prefer an all-epiphyseal reconstruction, while those with both pediatric and sports training preferred the modified MacIntosh. Conclusions: The preferred ACL reconstruction technique for skeletally immature patients varied considerably, especially in the 11-13 year-old age range, highlighting a lack of consensus among orthopedic surgeons for the optimal ACL reconstruction strategy in skeletally immature patients. Surgeon’s fellowship training was significantly associated with their preferred surgical technique.

Defining the Critical Elements of the Most Common Arthroscopic Procedures: A Consensus of Orthopaedic Sports Medicine Surgeons.

ObjectiveTo define the critical elements of common procedures in arthroscopic surgery.MethodsA survey was administered to surgeons associated with the American Orthopaedic Society for Sports Medicine (AOSSM) to determine the critical elements for four common arthroscopic procedures: anterior cruciate ligament (ACL) reconstruction, knee arthroscopy with meniscal debridement or repair, rotator cuff repair (RCR), and capsulorrhaphy for anterior glenohumeral instability (Bankart repair). Respondents were asked which steps necessitated their direct supervision. The level of experience and practice demographics were also recorded.ResultsFor all applicable procedures, patient positioning and closure were not considered critical steps. Establishing arthroscopic portals was critical for all procedures, except knee arthroscopy. Diagnostic arthroscopy was only critical in ACL reconstruction. Private practice surgeons considered every step of these common procedures to be critical elements. Less experienced surgeons were more likely to regard certain aspects of a procedure critical. Surgeons with >15 years of experience considered diagnostic arthroscopy critical to all procedures, whereas those with <15 years of experience did not. Unlike surgeons with a resident as first assist, surgeons with a physician assistant (PA) or nurse practitioner (NP) found every step of each procedure to be critical except closure and positioning.ConclusionAcross all procedures, only patient positioning and closure were consistently regarded as non-critical elements. There were significant differences in responses according to experience and practice setting. Future research is necessary to determine the implications of these findings and guide the definition of the “critical portions” of surgery.

2017 Infectious Diseases Society of America Physician Compensation Survey: Results and Analysis.

Analyzing health care reimbursement is a dynamic process. Infectious Diseases (ID) physicians have careers in diverse practice models. With current compensation models focusing on value and quality metrics, ID physicians are poised to be at the forefront of these delivery models. Monitoring and disseminating the current status of ID physician compensation are priorities of the Infectious Diseases Society (IDSA). In 2015, the IDSA conducted the largest ID physician compensation survey to date. The data were analyzed and disseminated, and the society subsequently responded with a plan to continue to develop and collect the most comprehensive and accurate data on ID physician compensation. Therefore, from May to June 2017, the IDSA conducted a follow-up compensation survey of its members. This survey resulted in the largest number of respondents of any ID compensation survey. It revealed that compensation across the different practice demographics had increased since the 2015 survey and is generally higher than salaries published in other comparable surveys. These data and the subsequent analyses focus on physicians who report patient care as their primary responsibility; they are presented by members of the IDSA’s Clinical Affairs Committee.

Bariatric Surgery Worldwide: Baseline Demographic Description and One-Year Outcomes from the Fourth IFSO Global Registry Report 2018.

Since 2014, the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has produced an annual report of all bariatric surgery submitted to the Global Registry. We describe baseline demographics of international practice from the 4th report. The IFSO Global Registry amalgamated data from 51 different countries, 14 of which provided data from their national registries. Data were available from 394,431 individual records, of which 190,177 were primary operations performed since 2014. Data were submitted on 72,645 Roux en Y gastric bypass operations (38.2%), 87,467 sleeve gastrectomy operations (46.0%), 14,516 one anastomosis gastric bypass procedures (7.6%) and 9534 gastric banding operations (5.0%) as the primary operation since 2014. The median patient body mass index (BMI) pre-surgery was 41.7kgm2 (inter-quartile range: 38.3-46.1kgm2). Following gastric bypass, 84.1% of patients were discharged within 2days of surgery; and 84.5% of sleeve gastrectomy patients were discharged within 3days. Assessing operations performed between 2012 and 2016, at one year after surgery, the mean recorded percentage weight loss was 28.9% and 66.1% of those taking medication for type 2 diabetes were recorded as not using them. The proportion of patients no longer receiving treatment for diabetes was highly dependent on weight loss achieved. There was marked variation in access and practice. A global description of patients undergoing bariatric surgery is emerging. Future iterations of the registry have the potential to describe the operated patients comprehensively.

Associations Between Integrated Care Practice and Burnout Factors of Primary Care Physicians.

Physician burnout is increasingly problematic across many health care settings. Despite this trend, little is known about whether the type of collaboration in these settings may potentially help curb this trend. We explored whether higher levels of integrated care practice are associated with reduced burnout for physicians across settings. A national survey was sent to health care professionals who work in a variety of medical settings. Primary care physicians (n=288) were a subset of this sample and were asked about their practice demographics and perceptions of burnout. A shortened version of the Maslach Burnout Inventory (MBI) assessed for areas of burnout in physicians. Higher levels of integrated care were associated with higher personal accomplishment (B=1.89, 95% CI:0.47, 3.31) and lower depersonalization (B=-2.48, 95% CI:-4.54, -0.42) in routine practice on the MBI. No significant associations were found between MBI scores and both years of practice at a current site or number of providers at the site. While physician burnout continues to be a worsening problem, integrated care may be an additional strategy to help curb this trend. Administrators need to consider the value of integrated practice in addressing physician wellness-the potentially next big aim of health care.

General practitioner attitudes and experiences of orthopaedic services in the Irish midlands.

Disorders of the musculoskeletal system are the main cause of disability and lost working days worldwide, and osteoarthritis affects almost half a million people in Ireland. Appropriate access and resourcing of general practice and orthopaedics is a necessary measure for the provision of a safe and efficient health service. One area that remains particularly challenging in Ireland is that of outpatient waiting lists, and the purpose of this study was to assess the attitudes and experiences of general practitioners in the Irish midlands with regard to orthopaedic services and to evaluate these in the context of national strategies and international best practice. A survey was sent to general practitioners in the midlands looking at five main areas: elective services, trauma services, allied health services, patient access and practice demographics. 98.7% of general practitioners surveyed stated they either agree or strongly agree that there is a significant difference in terms of access between public and private services. The average waiting time for an elective orthopaedic outpatient clinic is more than 1year as per 92.3% of GPs surveyed with 89.7% of GPs stating that the average waiting time for an elective private outpatient appointment being between 0 and 3months. Over three quarters of GPs surveyed either disagree or strongly disagree that there is adequate access to physiotherapy and occupational therapy services in the community with nearly 80% and 93.6% stating they have no physiotherapist or occupational therapist respectively attached to their practice. MSK disorders are a significant burden on the Irish health service and inadequate investment in general practice, allied health practitioner-led facilities and orthopaedic services remains a serious challenge that requires considerable attention to insure adequate patient care, safety and best practice.

Ethical conflict and moral distress in veterinary practice: A survey of North American veterinarians.

BackgroundConcerns about ethical conflicts, moral distress, and burnout in veterinary practice are steadily increasing. Root causes of these problems have not been rigorously identified. Little research has been done to evaluate the existence of moral distress in North American veterinarians or to explore its impact on career sustainability and poor well‐being.Hypothesis/ObjectivesEthical conflict and resultant moral distress are common occurrences in contemporary veterinary practice and negatively impact daily practice life, but may not be identified or labeled by veterinarians as such.AnimalsNo animals were used in this study.MethodsMixed methods sequential explanatory design; confidential and anonymous on‐line sampling of 889 veterinarians in North America.ResultsA majority of respondents reported feeling conflict over what care is appropriate to provide. Over 70% of respondents felt that the obstacles they faced that prevented them from providing appropriate care caused them or their staff moderate to severe distress. Seventy‐nine percent of participants report being asked to provide care that they consider futile. More than 70% of participants reported no training in conflict resolution or self‐care.Conclusions and Clinical ImportanceVeterinarians report widespread ethical conflict and moral distress across many practice types and demographics. Most veterinarians have little to no training on how to decrease the impact of these problems. Ethical conflict and resulting moral distress may be an important source of stress and poor well‐being that is not widely recognized or well defined. Well‐researched and effective tools used to decrease moral distress in human healthcare could be adapted to ameliorate this problem.

Integrating a nationally scaled workforce of community health workers in primary care: a modelling study.

To model cost and benefit of a national community health worker workforce. Modelling exercise based on all general practices in England. United Kingdom National Health Service Primary Care. Not applicable. Publicly available data on general practice demographics, population density, household size, salary scales and screening and immunisation uptake. We estimated numbers of community health workers needed, anticipated workload and likely benefits to patients. Conservative modelling suggests that 110,585 community health workers would be needed to cover the general practice registered population in England, costing £2.22bn annually. Assuming community health workerss could engage with and successfully refer 20% of eligible unscreened or unimmunised individuals, an additional 753,592 cervical cancer screenings, 365,166 breast cancer screenings and 482,924 bowel cancer screenings could be expected within respective review periods. A total of 16,398 additional children annually could receive their MMR1 at 12 months and 24,716 their MMR2 at five years of age. Community health workerss would also provide home-based health promotion and lifestyle support to patients with chronic disease. A scaled community health worker workforce integrated into primary care may be a valuable policy alternative. Pilot studies are required to establish feasibility and impact in NHS primary care.

Electronic Informed Consent to Facilitate Recruitment of Pregnant Women Into Research

Methods to obtain informed consent digitally or electronically may increase the participation of racially and geographically diverse pregnant women in prospective research, which is essential to improve the evidence base for maternity care. We evaluated the feasibility and utility of e-consent in the first year of a multiyear clinical trial involving pregnant women. Of the 86 women screened, 71 were eligible, 65 (93% of eligible) agreed to review the e-consent form, and 61 (86% of eligible) completed the e-consent process. Of the interested women who were sent the e-consent link, all were able to complete the e-consent process, even those who reported low health literacy. Women of all racial and ethnic groups were equally likely to consent, and the sample of women who consented was consistent with practice demographics. E-consent is feasible and easy to use with pregnant women and may expedite enrollment of a representative sample.

Bridging the Gap in Global Advanced Radiation Oncology Training: Impact of a Web-Based Open-Access Interactive Three-Dimensional Contouring Atlas on Radiation Oncologist Practice in Russia.

Radiation oncologists in Russia face a number of unique professional difficulties including lack of standardized training and continuing medical education. To combat this, under the auspices of the Russian Society of Clinical Oncology (RUSSCO), our group has developed a series of ongoing in-person interactive contouring workshops that are held during the major Russian oncology conferences in Moscow, Russia. Since November 2016 during each workshop, we utilized a web-based open-access interactive three-dimensional contouring atlas as part of our didactics. We sought to determine the impact of this resource on radiation oncology practice in Russia. We distributed an IRB-approved web-based survey to 172 practicing radiation oncologists in Russia. We inquired about practice demographics, RUSSCO contouring workshop attendance, and the clinical use of open-access English language interactive contouring atlas (eContour). The survey remained open for 2months until November 2017. Eighty radiation oncologists completed the survey with a 46.5% response rate. Mean number of years in practice was 13.7. Sixty respondents (75%) attended at least one RUSSCO contouring workshop. Of those who were aware of eContour, 76% were introduced during a RUSSCO contouring workshop, and 81% continue to use it in their daily practice. The greatest obstacles to using the program were language barrier (51%) and internet access (38%). Nearly 90% reported their contouring practices changed since they started using the program, particularly for delineation of clinical target volumes (57%) and/or organs at risk (46%). More than 97% found the clinical pearls/links to cooperative group protocols in the software helpful in their daily practice. The majority used the contouring program several times per month (43%) or several times per week (41%). Face-to-face contouring instruction in combination with open-access web-based interactive contouring resource had a meaningful impact on perceived quality of radiation oncology contours among Russian practitioners and has the potential to have applications worldwide.

Tu1914 PRACTICE PATTERNS IN BARIATRIC ENDOSCOPY: A SURVEY OF THE MEMBERS OF THE ASSOCIATION FOR BARIATRIC ENDOSCOPY

A wide range of endoscopic bariatric technologies (EBT) have been introduced in the United States in the past two years with many others in various phases of development. Endoscopic bariatric procedures have demonstrated safety and efficacy in achieving weight loss in conjunction with diet and lifestyle interventions in a clinical trial setting. Limited data exists on the adoption of EBT in clinical practice. To report current practice patterns and perceived barriers to wider adoption of EBT among members of the Association for Bariatric Endoscopy (ABE). All members of the ABE were invited to complete an anonymous electronic survey of domains relevant to knowledge, practice patterns and barriers to wider adoption of EBT. Participants were queried on the following: a) personal and practice demographics b) familiarity with current availability of EBT, c) practice patterns in EBT, d) barriers to wider adoption of EBT. Content validity was established by survey review by 4 experts in EBT. The survey response rate was 5.8% (28/480). The majority of responders had been in practice for >10 years (57.1%), were gastroenterologists (92.8%) and were in private practice (78.5%). Eighty two percent of responders performed >50 endoscopic procedures per month and a majority (60.7%) performed ERCP; 32.1% had been involved in pre-approval studies of EBT. Sixty percent of responders offered medical weight management in their practice and 39.3% prescribed weight loss medications. A majority of responders received education and training in EBT from the ABE (75%) as well as industry (71.4%) and rated there familiarity with EBT as 8.6±18.3 on a 10 cm VAS scale. Table 1 describes EBT practices among responders. The EBT most frequently offered was Orbera® intragastric balloon (IGB) (57.1%), while Aspire Assist® was the least utilized EBT (10.7%). Endoscopic sleeve gastroplasty and transoral outlet reduction were offered by 35.7%. In the 12 months prior to the survey, 35.7% of responders had performed NO endoscopic bariatric procedures, while 25% had performed >20. The most frequently cited barrier to wider adoption of EBT was lack of insurance reimbursement/cost (85.7%), followed by lack of physician awareness (50%). Members of the ABE are familiar with the available EBT, and most obtain education and training in EBT from professional societies and industry. Intragastric balloons are currently the most widely utilized EBT. Despite enthusiasm from physicians and professional societies, EBT volumes among responders are low, with 36% having performed NO endoscopic bariatric procedures in the past 12 months. Lack of insurance reimbursement/cost is felt to be the most significant barrier to wider adoption of EBT.Tabled 1Table 1: Baseline demographics and EBT practice patternsYears in practice<59 (32.1%)5-103 (10.7%)>1016 (57.2%)How do you obtain education about EBTASGE/ABE21 (75%)Industry20 (71.4%)Other professional society7 (25%)Perform ERCP17 (60.7%)Offer medical weight management17 (60.7%)Prescribe weight loss medications11 (39.3%)EBT Offered in PracticeOrbera IGB16 (57.1%)ReShape Duo IGB5 (20.8%)Obalon IGB4 (16.7%)Aspire Assist3 (12.5%)Endoscopic sleeve gastroplasty10 (41.7%)Volume Endoscopic Bariatric Procedures in the past 12 monthsNone10 (35.7%)10-2011 (39.3%)>207 (25%)Barriers to wider adoption of EBT in your practicePatient awareness11 (39.3%)Physician awareness14 (50%)Poor weight loss efficacy7 (25%)Concern for complications8 (28.6%)Lack of insurance coverage/cost24 (85.7%)Lack of infrastructure for weight loss program12 (42.9%) Open table in a new tab

Tu1043 RISK OF SERIOUS ADVERSE REACTIONS IN ANESTHESIA-ASSISTED ROUTINE AND COMPLEX LUMINAL ENDOSCOPY PROCEDURES DONE WITHOUT A REGISTERED NURSE IN AN INPATIENT ENDOSCOPY UNIT: EVALUATING MINIMAL STAFFING IN GI ENDOSCOPY

Anesthesia assisted (AA) Propofol based sedation is increasing utilized in GI endoscopy across the United States. Paradigm shift from moderate sedation to AA sedation has limited the role of a registered nurse in the procedure room, although they continue to be most important team member in pre-procedure and post-procedure care of the patient. The Society of Gastroenterology Nurses and Associates (SGNA) endorses the presence of at least one RN regardless of anesthesia assistance during all cases. However, this is counter to the recommendations of the American Society of Gastrointestinal Endoscopy (ASGE). Studies looking at the appropriate RN staffing needs in such circumstances are lacking. Primary aim of our study was to evaluate the safety of routine and complex upper and lower luminal endoscopy procedures done with anesthesia help, but without an RN, in an IP endoscopy unit. Retrospective chart review was done of all procedures done between June 2015 and July 2017. Data regarding procedure related serious complications, requiring hospitalization or cardiopulmonary resuscitation (CPR), was manually abstracted reviewed. Relevant Current Procedural Terminology (CPT) codes were used to identify all routine and complex luminal endoscopy procedures. All procedures in the study period were performed with anesthesia assistance with sedation and an endoscopy technician. Routine Luminal Procedures: A total of 3988 routine procedures (2752 upper; 1236 lower endoscopies) were performed in the IP endoscopy unit. Analysis of these procedures showed: 1131 (28.4%) done in ASA-I or ASA-II grade; 2629 (65.9%) in ASA-III or higher grade and ASA was not documented in 228 (5.7%) procedures. Only one (0.025%) patient (ASA-IV) undergoing colonoscopy had serious adverse reaction requiring CPR. Complex Luminal Procedures: A total of 1612 complex procedures (1561 upper; 50 lower) were performed in the IP endoscopy unit (Table 2). Analysis of these procedures showed: 541 (33.6%) done in ASA-I or higher; 958 (59.4%) in ASA-III or higher and ASA documentation could not be found in 113 (7.0%) procedures. One (0.06%) inpatient (ASA-III) required CPR following cardiac arrest during an EGD for GI bleeding. He was intubated and managed in the intensive care unit. The risk of serious adverse reactions remains low for the IP anesthesia-assisted routine and complex endoscopy procedures even in the absence of an RN during the procedure. Adding an additional staff member may add to the healthcare costs. Additional studies from different practice setting and demographics are needed to assess the patient safety, high quality patient care and optimal utilization of resources.

Surgeons' experience and perceived barriers with outpatient shoulder arthroplasty

Recently, outpatient total shoulder arthroplasty (TSA) has been proposed as a safe and cost-effective alternative to the inpatient setting. This study evaluated the expert shoulder surgeon's experience with and perceived barriers to outpatient TSA. A secure web application was used to perform an online survey of 484 active American Shoulder and Elbow Surgeons members. The survey assessed surgeon practice demographics, experience with TSA/outpatient TSA, and perceived barriers to successful outpatient TSA. Simple descriptive statistics were performed to analyze the cohort. To identify differences between surgeons performing and not performing outpatient TSA, the Student t test and χ2 test were used in bivariate analysis. P < .05 was used for statistical significance. Of the 179 (37.0%) complete responses received, 20.7% perform outpatient TSA; of those, 78.4% reported an "excellent" experience. Outpatient surgeons were more likely to reside in the southern United States (P = .05) and performed a higher volume of TSAs annually (P = .03). Surgeons not performing outpatient TSA were more concerned with the potential of medical complications (P = .04). Perceived lack of experience (P = .002), low volume (P = .008), insurance contracts (P = .003), and reimbursement (P = .04) were less important barriers compared with outpatient TSA surgeons. Less than 25% of shoulder surgeons who completed survey are performing outpatient TSA, and those that do report an overall excellent experience. Volume of TSAs performed and practice location appear to play roles in the decision to perform outpatient TSA. As surgeons become more comfortable with outpatient TSA, there is a shift from concerns about medical complications to concerns about reimbursement.

Defining the "Critical Elements" for the Most Common Procedures in Spine Surgery: A Consensus of Orthopedic and Neurosurgical Surgeons.

Survey. To define the critical elements of common spine surgeries. Despite significant relevance to the field of spine surgery, the term "critical element" of surgery has not been clearly defined. Every surgical procedure involves numerous steps, each with its own potential for complications and harm to the patient. Despite its crucial role in surgical training, billing, and the ethicality of concurrent surgery, the term "critical element" of surgery has not been defined. A survey was administered to surgeons associated with AO Spine North America and the Society for Minimally Invasive Spine Surgery to determine the critical elements for four common spine procedures: open lumbar laminectomy and fusion, microdiscectomy, anterior cervical discectomy and fusion (ACDF), and posterior cervical laminectomy and fusion. Respondents were asked which steps necessitated their direct supervision. Surgical subspecialty, level of experience, and practice demographics were also recorded. For all applicable procedures, decompression, instrumentation, and fusion were designated as critical elements. Patient positioning and fascial closure were not. Radiographic localization was considered critical for all procedures, except posterior cervical laminectomy and fusion. Exposure was not considered critical for any procedures, except ACDF. Certain substeps of decompression in ACDF and open lumbar laminectomy and fusion were not considered critical. Orthopaedic surgeons considered exposure and fusion in ACDF procedures to be critical whereas neurosurgeons did not. Surgeons operating in private practice considered every step of these common procedures to be critical elements. Decompression, instrumentation, and fusion were considered critical elements of common spine surgeries. There were significant differences in responses according to surgical specialty and practice setting. Future research is necessary to determine the implications of these findings and guide the definition of the "critical portions" of surgery. 1.

Changes in the Practice Patterns and Demographics of Ontario Dermatologists.

Changes in the practice patterns and demographics of Canadian dermatologists remain largely unknown and would be helpful in assessing the future practice of dermatology across Canada. To assess changes in the population of Ontario dermatologists over time and the factors that influence their practice patterns, caseload, and the procedures they perform. A retrospective population-based analysis was performed using comprehensive administrative data on Ontario Health Insurance Plan insured dermatology visits and procedures from April 1, 2009, to March 31, 2015. The number of dermatologists practicing in Ontario per 100 000 people increased from 1.52 (2009) to 1.62 (2014). During this period, the proportion of female dermatologists increased from 40% to 47%, and the proportion of male dermatologists decreased from 60% to 53%. The mean number of patient visits per dermatologist decreased from 6323 (2009) to 5877 (2014). Females saw a decrease from 4818 to 4181 visits, and males remained constant at 7274 to 7265 visits. Middle career dermatologists had more patient visits compared to those in their early or late career. A rural practice was associated with more patient visits compared to an urban one. The proportion of dermatologists providing nonemergency in-hospital patient services declined. The number of biopsies and malignant excisions performed increased. The number of dermatologists at the population level increased and the number of patient visits per dermatologist decreased. Career stage, physician sex, and practice location all affect the practice of dermatology. Future studies to assess underlying factors for these observations would be of value.

Caring for urologic transition patients: Current practice patterns and opinions

Congenitalism is an emerging field that recognizes the complex needs of adult patients with congenital urologic issues. Despite the onset of transitional care clinics, these patients remain difficult to care for due to resource availability, insurance coverage, and multi-disciplinary needs. The current study sought to characterize practice patterns and opinions regarding care for urologic transition patients. An anonymous 20-question survey was sent to members of the Society of Pediatric Urology listserv. Questions pertained to physician background, practice demographics, clinic structure, and quality. Five-point Likert scales were used to assess quality markers (5=most/best). Data were analyzed in R, and subgroup analyses were performed. Subgroups included presence of formal transition clinic, city size, and practice type. The response rate was 53%, with 124 respondents. A formal transition clinic was reported by 32%. Those with formal clinics reported higher enthusiasm (3.9 vs 3.4, P<0.01) for care of these patients and believed they provided better care compared to other institutions (P<0.001) Summart Table. There was no significant difference in perceived quality between respondents in academic vs other practices. There was a small trend towards higher-quality ratings in smaller cities (3.8 vs 3.5, P=0.13). The majority (64%) felt that transition patients are best cared for by specialized adult providers; however, these formalized clinics found to be staffed primarily by pediatric providers (54%). This study supported the general consensus in the literature that transition clinics improve care for urologic transition patients, while underlining discordance between current practice patterns and recommendations for optimal care. The majority of practices appeared to lack a formal transition clinic, and there was variation in their structure. Those with formal clinics tended to rate themselves as providing higher-quality care. The majority of respondents believed that adult specialists in either reconstructive or neuro-urology are best suited to care for these complex patients.

Assessment of Knowledge, Attitude and Practice (KAP) of Saudi Adult toward Blood Donation in Riyadh City, 2017

Background: Blood donation can save the lives of people who are in serious conditions thus it is a global concern of all societies. Objectives: Evaluating the knowledge, attitude and practice (KAP) of Saudi adult subjects toward blood donation in Riyadh City. Methods: A cross sectional community survey design was conducted among 500 adult Saudi subjects who were interviewed in shopping malls of Riyadh City during the period from May to July 2017. The questionnaire included interview regarding the demographics of respondents, knowledge, attitude and practice regarding blood donation. Results: All the participants had significant knowledge about their blood group and the importance of blood donation. Also, the majority of respondents had adequate knowledge about the most common site of blood donation, the specificity of blood groups and the dangerous of donation of subjects with infection. Also, a good knowledge was found among most of respondents regarding the time, the complications and the precautions of blood donation. The attitude and practice pattern of participants were good among most of the participants .The KAP was adequate among 71% of respondents regarding blood donation and there was a significant association between the respondents good KAP with young age, male gender and higher educational degree. Conclusion: The KAP of most of Saudi subjects was good and showed a high prevalence of blood donation among them with a favorable attitude to donate blood.