Standardized Script Research Articles

Consumer Prices for Surgical Management of End-Stage Hallux Rigidus

Category:Midfoot/Forefoot, Healthcare economicsIntroduction/Purpose:Hallux rigidus is the most prevalent arthritic condition of the foot. Treatment of end-stage disease traditionally consists of a first metatarsophalangeal joint (MTPJ) arthrodesis, however the use of a synthetic cartilage implant is becoming more common. With the high prevalence of disease and implementation of new treatment modalities, healthcare consumers should be aware of the costs associated with management. The purpose of this study was to determine access to the cost and variability in price of first MTPJ arthrodesis and synthetic cartilage implantation.Methods:Forty academic centers were contacted using a standardized patient script. The patient was a 59-year-old female who had failed conservative treatment of hallux rigidus. Each institution was contacted up to three times in an attempt to obtain a full bundled operative quote for a first MTPJ arthrodesis and synthetic cartilage implantation.Results:Twenty centers (50%) provided a quote for first MTPJ arthrodesis and 15 centers (38%) provided a quote for synthetic cartilage implantation. Only 14 centers (35%) were able to provide a quote for both procedures. The mean bundled price for MTPJ arthrodesis was $21,767 (range, $8,417 – $39,265). The mean bundled price for synthetic cartilage implantation was $21,546 (range, $4,903 – $74,145). There was no statistically significant difference between the bundled price for first MTPJ arthrodesis and synthetic cartilage implantation.Conclusion:There was limited availability of consumer prices for first MTPJ arthrodesis and synthetic implantation, therefore impeding healthcare consumers’ decision making. There was a wide range of quotes for both procedures, indicating potential cost savings.

Critical errors in infrequently performed trauma procedures after training

BackgroundCritical errors increase postoperative morbidity and mortality. A trauma readiness index was used to evaluate critical errors in 4 trauma procedures. In comparison to practicing and expert surgeon benchmarks, we hypothesized that pretraining trauma readiness index including both vascular and nonvascular trauma surgical procedures can identify residents who will make critical errors. MethodsIn a prospective study, trained evaluators used a standardized script to evaluate performance of brachial, axillary, and femoral artery exposure and proximal control and lower-extremity fasciotomy on unpreserved cadavers. Forty residents were evaluated before and immediately after Advanced Surgical Skills for Exposure in Trauma training, and 38 were re-evaluated 14 months later. Residents were compared to 34 practicing surgeons evaluated once 30 months after training, and 10 experts. ResultsResident trauma readiness index increased with training (P < .001), remained unchanged 14 month later and was higher, with lower variance than practicing surgeons (P < .05). Expert trauma readiness index was higher than residents (P < .004) and practicing surgeons (P < .001). Resident training decreased critical errors when evaluated immediately and 14 months after Advanced Surgical Skills for Exposure in Trauma training. Practicing surgeons had more critical errors and performance variability than residents or experts. Experts had 5 to 7 times better error recovery than practicing surgeons or residents. Trauma readiness index area under the receiver operating curve with Youden Index <0.60 or <6 decile in their cohort, predicts a surgeon will make a critical error. ConclusionLow trauma readiness index was associated with critical errors occurring in all surgeon cohorts and can identify surgeons in need of remedial intervention.

Consumer Prices for Surgical Management of Ankle Arthritis: Limited Availability and Wide Variability.

Background:Healthcare costs for the surgical management of ankle arthritis continue to rise. Patients are generally unaware of the prices of the services they use. Understanding the costs associated with surgical management of ankle arthritis is an important facet of patient care. The purposes of this study were to (1) determine the access to the surgical cost of total ankle arthroplasty (TAAs) and ankle arthrodesis and (2) the variability of the price between the two procedures.Methods:Fifty foot and ankle centers (25 academic, 25 private) that perform TAAs and ankle arthrodeses were contacted using a standardized patient script. The described patient was a 63-year-old man who had failed conservative treatment of ankle arthritis. Each institution was contacted up to three times in an attempt to obtain a full-bundled surgical quote for a TAA and an ankle arthrodesis.Results:Twenty-one centers (42%, 14 academic, 7 private) were able to provide a quote for a TAA and an ankle arthrodesis. The mean bundled price for a TAA was $50,332 (SD ± $25,744), with the mean academic and private center quote being $56,529 and $37,937, respectively. The mean bundled price for an ankle arthrodesis was $41,756 (SD ± $26,033), with the mean academic and private center quote being $48,116 and $29,037, respectively. No statistically significant difference was found between the bundled prices for TAA and ankle arthrodesis.Discussion:This study demonstrated limited availability of consumer prices for TAA and ankle arthrodesis. When comparing different institutions for surgical management of ankle arthritis, there was a wide range of quotes for both TAA and ankle arthrodesis. When comparing the choice of surgical management for ankle arthritis, no statistically significant difference was observed in price between TAA and ankle arthrodesis.

Testing the Usability of a Software for Geospatial and Transport Modeling in Acute Stroke Service Planning.

Introduction: Geographic visualizations have been used to understand disease since the nineteenth century. We developed a software that creates simple visualizations which can be used as a decision support tool for pre-hospital acute stroke transportation planning. In this study, we test the usability of this software to improve user experience and assess the interpretability of the visualizations it produces as it relates to planning and optimizing stroke systems of care.Materials and Methods: Healthcare practitioners and administrators working within the acute stroke system in Alberta, Canada were invited to participate. Participants were randomized to either the geographic visualization or 2-D temporospatial diagrams. Using a standardized script participants were asked to complete tasks and interpret the visualizations produced by the software. The computer screen and audio were recorded. Recordings were transcribed verbatim and analyzed using inductive thematic analyses. The number of errors made and time to task completion were also analyzed.Results: Eighteen participants (8 physicians, 5 healthcare administrators, 3 paramedics, and 2 nurses) were enrolled. Mean age was 41.22 years (SD: 10.55) and 8 participants were female. It took users a mean of 1.59 min (SD: 0.71) to complete all 10 tasks for the geographic visualizations and a mean of 1.08 min (SD: 0.33) to complete all 15 tasks for the 2-D temporospatial diagrams. Map users made a median of 2 errors (IQR: 4), 2-D temporospatial diagram users also made a median of 2 errors (IQR: 1.5). All but one map user correctly interpreted all maps, only three of the eight 2-D temporospatial diagram correctly interpreted all diagrams. In the qualitative analysis three common themes were identified: comments on the user interface, comments on the visualization tool(s), and suggestions for improvement. Most study participants mentioned that the software would be useful in their work.Conclusions: Healthcare professional from several different aspects of stroke care see geographic visualizations in transport decision making to be a useful tool. The software demonstrated high usability. However, several suggestions were made to improve user experience as well as additional features which could be developed and become the subject of future studies.

Simultaneous Evaluation of Communication Skills by Standardized Patients and Medical Evaluators

Abstract Introduction: The present study analyzes the evaluation of communication skills by standardized patients (SPs) and medical evaluators (Es) in an OSCE setting. Methods: The OSCE involved 189 sixth-year medical students, as well as 34 SPs and 63 Es. Communications skills were evaluated in 8 stations, simultaneously by SPs and Es. The SPs were actors who had been trained in the clinical case and who acted in accordance with a standardized script in a simulated clinical situation. The evaluators, also standardized, were Resident Doctors or staff Doctors from the Hospital Services involved. Results: The global scores awarded to students for communication skills were very similar in both groups, although the score awarded by Es was significantly higher, and a direct relationship was also observed between the mean scores awarded by both groups. Evaluators awarded significantly higher scores than SPs in 7 out of the 10 items on the checklist. Female medical students also scored significantly higher than their male counterparts in many items, including external appearance, listening, cordiality, optimism, interest, expression and empathy. Discussion: Our data indicate that SPs and Es evaluated communication skills in a similar manner in an OSCE setting, a finding which suggests that health-related professionals can be used as an alternative to SPs, thus helping to lower economic costs. Our study also confirms a gender difference (in favor of women) in the evaluation of communications skills by both groups.

Reliability of Telephone Interview for Assessment of Long-Term Stroke Outcomes: Evidence from Interrater Analysis

Background: A comprehensive evaluation of interrater reliability is crucial when it comes to multiple coders assessing the stroke outcomes using telephone interview. The reliability between telephone raters is important, as it could affect the accuracy of the findings published. Objective: This study aimed to establish the interrater reliability between multiple telephone interviewers when assessing long-term stroke outcomes. Methods: Patients alive at discharge selected in a retrospective cohort stroke project were recruited in this study. Their contact numbers were obtained from the medical record unit. The patients and/or proxies were interviewed based on a standardized script in Malay or English. Stroke outcomes assessed were modified Rankin Scale (mRS) and Barthel Index (BI) at 1-year post discharge. Fully crossed design was applied and 3 assessors collected the data simultaneously. Data was analysed using the software R version 3.4.4. Results: Out of 207 subjects recruited, 132 stroke survivors at the time of interview were analysed. We found a significant excellent interrater reliability between telephone interviewers assessing BI, with intraclass correlation coefficient at 0.996 (95% CI 0.995–0.997). Whereas substantial agreement between the telephone interviewers was revealed in assessing mRS, with Fleiss’, Conger’s and Light’s Kappa statistics reporting 0.719 and the Nelson’s model-based κ_m kappa statistic reporting 0.689 (95% CI 0.667–0.711). Conclusion: It is reliable to get multiple raters in assessing mRS and BI using the telephone system. It is worthwhile to make use of a telephone interview to update clinicians on their acute clinical management towards long-term stroke prognosis.

Service Providers' Perception of Barriers to Access Mental Health Services

Background: The literature shows that mental health services are yet not adequate and whatever is available is underutilized in India. The aim of the study was to identify the available mental health services; barriers to utilize and deliver mental health service and explore the strategies for effective delivery of mental health services. Methodology: The Expert Interview and Key Informant Interview were the methods of data collection. A standardized script for conducting the interviews was developed based on literature review and discussion with experienced qualitative researchers as per the objectives of the study. Results: The main themes identified under the study were - mental health services, services & facilities under District Mental Health Programme, mental health services in primary health centres, barriers to utilizing mental health services, policy-level barriers to provide mental health services, recommendations and suggestions from service providers to improve mental health service system. Conclusion: There are multiple barriers, which need to be addressed effectively. There is a need to create a network among all stakeholders. Keywords: Mental health service, district mental health programme, India

Evaluation of a call center to assess post-discharge maternal and early neonatal outcomes of facility-based childbirth in Uttar Pradesh, India.

BackgroundMaternal and neonatal outcomes in the immediate post-delivery period are critical indicators of quality of care. Data on childbirth outcomes in low-income settings usually require home visits, which can be constrained by cost and access. We report on the use of a call center to measure post-discharge outcomes within a multi-site improvement study of facility-based childbirth in Uttar Pradesh, India.MethodsOf women delivering at study sites eligible for inclusion, 97.9% (n = 157,689) consented to follow-up. All consenting women delivering at study facilities were eligible to receive a phone call between days eight and 42 post-partum to obtain outcomes for the seven-day period after birth. Women unable to be contacted via phone were visited at home. Outcomes, including maternal and early neonatal mortality and maternal morbidity, were ascertained using a standardized script developed from validated survey questions. Data Quality Assurance (DQA) included accuracy (double coding of calls) and validity (consistency between two calls to the same household). Regression models were used to identify factors associated with inconsistency.FindingsOver 23 months, outcomes were obtained by the call center for 98.0% (154,494/157,689) consenting women and their neonates. 87.9% of call center-obtained outcomes were captured by phone call alone and 12.1% required the assistance of a field worker. An additional 1.7% were obtained only by a field worker, 0.3% were lost-to-follow-up, and only 0.1% retracted consent. The call center captured outcomes with a median of 1 call (IQR 1–2). DQA found 98.0% accuracy; data validation demonstrated 93.7% consistency between the first and second call. In a regression model, significant predictors of inconsistency included cases with adverse outcomes (p<0.001), and different respondents on the first and validation call (p<0.001).ConclusionsIn areas with widespread mobile cell phone access and coverage, a call center is a viable and efficient approach for measurement of post-discharge childbirth outcomes.

A Quality Improvement Project to Increase the Rate of HPV Vaccination Initiation in Adolescents

The vaccination rate of the human papilloma virus vaccine [9vHPV] is low, with only 63% of eligible females and 50% eligible males receiving the vaccine in 2016. The aim of this quality improvement project was to increase the initiation rate of HPV vaccination at Smyrna Pediatrics by 20%, from 3.6% to 4.3% over four weeks. Two physicians, one nurse practitioner, and two medical assistants implemented this quality improvement initiative. There is a lack of education and standardized communication about HPV and 9vHPV to prevent against the virus. A standardized script was created so that all conversations between healthcare professionals and patients and their parents or guardians included the wording of the 9vHPV being recommended rather than optional. Educational material from the CDC was the standard handout given to each adolescent and their parent or guardian. Standardized education and communication was to be provided at each adolescent visit of the 125 eligible adolescents seen during the four-week implementation period, 4% (n = 5) agreed to receive the 9vHPV vaccine. With a baseline of 3.6% (n = 4), there was an 11.1% increase of initiation of 9vHPV. The use of standardized education documents presented to all patients and their parents or guardians established health education as the mainstay of the project and provided information about the importance of prevention and protection from the virus that the vaccine prevents. The implementation of results over a longer period of time may prove to be more effective for the practice’s increase of vaccination rates overall.

Deciding to lead: a qualitative study of women leaders in emergency medicine

BackgroundThe aim of this study is to highlight career paths of senior women leaders in academic emergency medicine (EM) to encourage younger women to pursue leadership.MethodsThis was a qualitative study using semi-structured interviews with female EM leaders. We interviewed 22 recognized female leaders selected using criterion-based sampling and a standardized script of open-ended questions derived from the Intelligent Career Model. Questions were related to job purpose, skills, and networking. Interviews were transcribed verbatim and three trained reviewers analyzed transcripts following grounded theory principles and using Dedoose®. Researchers used an iterative process over several meetings to produce the final set of codes and themes.ResultsOur iterative process identified four themes: women leaders made an intentional decision to pursue opportunities to influence emergency medicine, women sought out natural mentors and sponsors to facilitate career development, women leaders intentionally planned their out of work life to support their leadership role, and an important focus for their work was to help others achieve excellence.ConclusionsOur study provides insights from senior female leaders in EM; supporting the value of women pursuing leadership. There is a widely acknowledged need to diversify leadership and support gender-specific needs to develop women leaders in medicine. Becoming a woman leader in EM means making intentional decisions and taking risks. Leaders found benefits in natural mentors and sponsors. Those relationships have power to change the trajectory of emerging women leaders by identifying and reinforcing potential. Work/life balance remains an area which requires intentional planning. Woman leaders encourage succession planning and corroborate the need for increasing the percentage of women leaders to benefit the organizational culture. Leadership in academic medicine is changing with reorientation of a largely autocratic, vertically oriented hierarchy into a more democratic, consensus-driven, and horizontally organized management structure which should complement the strengths women bring to the leadership table.

Social anxiety and employment interviews: does nonverbal feedback differentially predict cortisol and performance?

ABSTRACTBackground & Objectives: Interviewers often provide positive nonverbal feedback to reduce interviewees’ anxiety. Socially anxious individuals typically harbor negative self-views discrepant with positive feedback. We examined whether nonverbal feedback and social anxiety jointly influence cortisol responses to, and performance during, interviews.Design: An experimental between-subjects design randomly assigned participants to feedback condition.Methods: Undergraduate students (N = 130) provided saliva and completed social anxiety, interview anxiety, and affective measures before a simulated interview. Following a standardized script, a confederate interviewer provided positive, ambiguous, or negative nonverbal feedback. Participants then provided saliva and completed self-focused attention and self-awareness measures. Confederate interviewers and an external rater evaluated participants’ anxiety displays, assertive behavior, and performance.Results: Positive feedback decreased cortisol and improved performance for low social anxiety participants. Socially anxious participants exhibited higher cortisol but did not exhibit significant differences in performance after positive compared to negative feedback.Conclusions: Consistent with previous findings, positive feedback did not benefit socially anxious interviewees. Positive feedback increased physiological arousal relative to negative feedback but did not hinder performance among people high in social anxiety. These results provide novel information about the interactive influence of social anxiety and nonverbal interviewer feedback on arousal, self-focus, and interview performance.

282 Impact of Emergency Medical Services Vehicle Use by Acute Ischemic Stroke Patients on Functional Outcomes: An Observational Study

Previous studies have documented the impact of emergency medical services (EMS) vehicle use on speedy thrombolytic treatment, but not on patient functional outcomes. We assessed the association of EMS use with likelihood and timeliness of intravenous (IV) thrombolytic treatment and functional outcomes at discharge and 90 days. Prospective observational study using Get With The Guidelines Stroke data on AIS patients with cerebrovascular imaging evidence, discharged 4/2016 to 10/2017 from a non-profit hospital’s primary stroke center unit in Columbia, South Carolina. Key outcomes of interest were: National Institutes of Health Stroke Scale (NIHSS) change from arrival to discharge (continuous variable), discharge disposition (discharged to home versus otherwise), and 90-day modified Rankin Scale, mRS 0-1 versus otherwise, (ascertained by phone calls to patients discharged from 4/2018 to 8/2017 within 75-105 days of discharge using a standardized script, supplemented by medical record data on neurology follow-up visits). Multiple logistic and linear regression analyses were used as appropriate. Of 1,166 total AIS discharges, 328 were excluded (transfer patients or hospice assigned pre-admission). Among 838 study-eligible patients, 52.4% were black, 72.2% arrived by EMS, mean admission NIHSS (available for 96.7% of patients) was 6.8 (±7.3; median 4.0, range 0 - 37), mean stroke-relevant comorbidities per patient 3.7 (±1.9), alteplase received 114 (13.6%), and 92 expired or assigned to hospice. Mean door to imaging (DTI) time was 98.8 minutes (±151.0; median 49), and mean door to needle (DTN) time for IV alteplase recipients, 46.2 minutes (±31.2; median 38.0). In bivariate analyses, EMS arrivals were older (mean age 70 years versus 63.6 for other transport), more severe (mean NIHSS 8.3 (±7.7) versus 2.9 (±3.7), more likely to have contraindications to alteplase, and had worse discharge outcomes. Adjusted for demographic and other factors, EMS use was highly associated with stroke severity (adjusted odds 4.1 for moderate stroke (NIHSS 6-15) versus mild stroke (NIHSS 0-5), and 12.3 for severe stroke (NIHSS>15), p<0.001). Adjusted for stroke severity, comorbidities, endovascular treatment and other relevant factors as appropriate, EMS arrival (relative to other transport) was associated with: 5-fold higher odds of IV alteplase, 88.5 minutes lower DTI (p<0.01; 57% reduction), and, among severe stroke patients, 5.7 points better improvement in discharge NHISS over admission NIHSS (all p<0.001). Insurance status and race were not significant factors in alteplase use, DTI or DTN. Discharge disposition was not significantly associated with arrival mode. 90-day mRS was ascertained for 430 patients (59.2% of eligible, despite 87.1% of eligibles fully pursued per protocol). The study lacked statistical power to assess EMS impact on 90-day mRS, given the effect magnitude of stroke severity on both EMS use and 90-day outcomes. However, discharge NIHSS accurately predicted 90-day mRS, (adjusted beta 0.20; score ranges of the 2 scales, 0-37 versus 0-6; model R2 = 0.42), supporting that EMS use may produce better long-term outcomes in severe stroke patients. This study breaks new ground, documenting a positive impact of EMS use on functional outcomes in severe stroke. Given evidence of equitable care regardless of insurance status/race at the study center, findings may be generalizable despite being a single-center observational study.

How Much Will My Child's Operation Cost? Availability of Consumer Prices From US Hospitals for a Common Pediatric Orthopaedic Surgical Procedure.

Price transparency allows patients to make value-based health care decisions and is particularly important for individuals who are uninsured or enrolled in high-deductible health care plans. The availability of consumer prices for children undergoing orthopaedic surgery has not been previously investigated. We aimed to determine the availability of price estimates from hospitals in the United States for an archetypal pediatric orthopaedic surgical procedure (closed reduction and percutaneous pinning of a distal radius fracture) and identify variations in price estimates across hospitals. This prospective investigation utilized a scripted telephone call to obtain price estimates from 50 "top-ranked hospitals" for pediatric orthopaedics and 1 "non-top-ranked hospital" from each state and the District of Columbia. Price estimates were requested using a standardized script, in which an investigator posed as the mother of a child with a displaced distal radius fracture that needed closed reduction and pinning. Price estimates (complete or partial) were recorded for each hospital. The number of calls and the duration of time required to obtain the pricing information was also recorded. Variation was assessed, and hospitals were compared on the basis of ranking, teaching status, and region. Less than half (44%) of the 101 hospitals provided a complete price estimate. The mean price estimate for top-ranked hospitals ($17,813; range, $2742 to $49,063) was 50% higher than the price estimate for non-top-ranked hospitals ($11,866; range, $3623 to $22,967) (P=0.020). Differences in price estimates were attributable to differences in hospital fees (P=0.003), not surgeon fees. Top-ranked hospitals required more calls than non-top-ranked hospitals (4.4±2.9 vs. 2.8±2.3 calls, P=0.003). A longer duration of time was required to obtain price estimates from top-ranked hospitals than from non-top-ranked hospitals (8.2±9.4 vs. 4.1±5.1 d, P=0.024). Price estimates for pediatric orthopaedic procedures are difficult to obtain. Top-ranked hospitals are more expensive and less likely to provide price information than non-top-ranked hospitals, with price differences primarily caused by variation in hospital fees, not surgeon fees. Level II-economic and decision analyses.

Consumer Prices for Surgical Management of Ankle Arthritis

Category: Ankle Arthritis Introduction/Purpose: In the United States alone there are over 50,000 new cases of ankle arthritis every year. The financial healthcare burden for surgical management of ankle arthritis likely continues to rise with the volume of total ankle replacements (TAR) increasing 100-fold over the last 20 years. Healthcare consumers however are generally unaware of the costs of the services they use. Understanding the costs associated with operative management of ankle arthritis is an important facet of patient care although access to this information may not be readily available. The purpose of this study was to determine the access to the surgical cost of TARs and ankle arthrodesis and the variability of the cost between the two procedures. Methods: 50 foot and ankle centers (25 academic, 25 private) that perform TARs and ankle arthrodeses were contacted using a standardized patient script. The described patient was a healthy 63-year-old male who had failed conservative treatment of ankle arthritis. Each institution was contacted up to three times to attempt to obtain a full bundled operative quote for a TAR and an ankle arthrodesis. Results: 21 centers (42%, 14 academic, 7 private) were able to provide a quote for a TAR and ankle arthrodesis. The mean bundled price for a TAR was $50,332 (SD +/- $25,744) with the mean academic and private center quote being $56,529 and $37,937 respectively. The mean bundled price for an ankle arthrodesis was $41,756 (SD +/- $26,033) with the mean academic and private center quote being $48,116 and $29,037 respectively. There was no statistically significant difference between the bundled price for TAR and ankle arthrodesis. Conclusion: There was limited availability of consumer prices for TAR and ankle arthrodesis thus hindering healthcare consumers’ decision making. When comparing different institutions for surgical management of ankle arthritis, there was a wide range of quotes for both TAR and ankle arthrodesis. When comparing the choice of surgical management for ankle arthritis, there was no difference in price between TAR and ankle arthrodesis.

Mental health services for maternal depression: A need for system-level change

ABSTRACTIntroduction: Women who are impacted by poverty are at heightened risk for depression, yet are unlikely to engage in mental health services due to to practical and perceptual barriers about treatment, including transportation and childcare difficulties, and misperceptions about mental health providers and treatment. The mental health service system has also been shown to limit access due to a lack of providers, extensive wait lists for services, and language barriers. The purpose of this study was to examine agency-level barriers to treatment among a poverty-impacted sample of women with depressive symptoms, as well as any supports that agencies have implemented to engage consumers into services.Method: This study conducted an environmental scan of mental health agencies and practitioners within three districts comprising nine zip codes representing the most socioeconomically disadvantaged areas in Harlem, New York. Following a standardized script, 46 private practitioners (n=27) and agencies (n=19) located within these zip codes provided information about their services, wait times, and any supports they offered consumers to attend.Results: Private practitioners were statistically less likely to accept insurance than agencies, yet agencies had significantly greater waitlists for services, particularly for Spanish-speaking clients. Few private practitioners offered services in Spanish, or offered affordable treatment (less than $100 per session). Only two agencies offered transportation vouchers; no other supports were offered by either private practitioners or agencies.Discussion: Mental health care remains largely inaccessible for mothers living in poverty, particularly if they are Spanish speaking. Systems-level changes are needed in order to provider affordable, accessible treatment and ultimately reduce the risk of maternal depression upon the family.

The effect of insurance type on access to inguinal hernia repair under the Affordable Care Act

BackgroundThe expansion of Medicaid under the Affordable Care Act extended coverage to any individual with an income up to 138% of the federal poverty level. Our study of surgeon practice management investigated the impact of the type of insurance on access to elective inguinal hernia repair and the disparities in access between Medicaid expansion and nonexpansion states. MethodsPractices of 240 hernia repair surgeons across 8 states were randomly selected from the American College of Surgeons Find a Surgeon Database. Investigators posed as simulated patients seeking an evaluation for an inguinal hernia. Physician offices were contacted using a standardized script on separate occasions to assess appointment success rates and waiting periods for 3 different insurance types (BlueCross, Medicaid, Medicare). ResultsOf 240 surgical practices contacted, 75.4% scheduled appointments for Medicaid patients, compared to 98.8% for Medicare patients and 98.3% for those with private insurance. In states that expanded Medicaid, fewer offices accepted Medicaid patients compared to those in nonexpanded states. No differences in wait times between expanded and nonexpanded states were observed. Surgeons in either solo practices or urban settings were less likely to accept Medicaid patients than those in either group practices or non-urban offices. ConclusionsSimulated Medicaid patients were less successful at scheduling appointments for surgical consultation than BlueCross or Medicare patients. Fewer surgical practices in expansion states accepted Medicaid patients despite increased coverage due to Medicaid expansion. These findings should be further investigated amidst future changes in Medicaid to understand their impact on access to surgical care.

The Impact of Rural or Urban Location on Clinical Availability of the Copper IUD: A Mystery Caller Study [14F

INTRODUCTION: The copper IUD is the only highly effective non-hormonal method of contraception. It is also the most effective form of emergency contraception (EC), when placed within 5 days of unprotected intercourse, and is the only method of EC that provides ongoing contraception. For these reasons, local availability of the copper IUD to women is essential. METHODS: A mystery caller model was employed with a single caller making inquiries to urban and rural clinics in Washington state over a two-month period regarding availability of copper IUDs using a standardized script. Clinic types included OB/GYN, primary care, family planning and multispecialty. Clinics were identified using the HRSA 340B database, with allocation as urban vs rural based on the Office of Management and Budget county designations. The primary outcome was the reported availability of the copper IUD. Secondary outcomes included ability to schedule an appointment for copper IUD placement within 5 days. RESULTS: A total of 97 urban and 97 rural clinics were included in the analysis. A greater proportion of urban clinics reported availability of copper IUDs than rural clinics (78 vs 50%; p &lt;0.001). Only 19 urban clinics and 10 rural clinics were able to schedule an appointment for copper IUD placement within the 5 day window needed for EC use (19 vs 10%, p = 0.07). CONCLUSION: Rural clinics are less likely to have copper IUDs available, even when clinic type is taken into account. Efforts are needed to increase availability of this method, particularly in rural areas.

Comparing Digital Photography via Email Correspondence With Traditional Telephone Communication for Assessment of Postoperative Pediatric Urology Patients

Introduction Postoperative concerns are commonly managed by a nurse practitioner (NP) via traditional telephone conversation (TTC). In recent years, electronic interaction, including digital photographs sent via email (PEC), has become an alternative, novel strategy to evaluate surgical site concerns. Its use may result in fewer unplanned clinic or emergency room (ER) visits as well as improve patient satisfaction. Herein, we present a pilot a study to determine the feasibility of conducting a definitive trial comparing the effectiveness of PEC versus TTC in reducing the number of unplanned clinic and ER visits as well as improving patient experience. Materials and Methods Children &lt; 18 years old at the time of surgery and within the 30-day postoperative period were recruited from June 2015 to January 2016 at a tertiary children’s hospital. Exclusion criteria were concerns occurring outside the 30-day postoperative period and inability/unwillingness to email photographs. Patients were allocated to PEC or TTC after initiating contact with the NP through an electronic centralized blocked randomization system. A standardized telephone script was used to gather relevant clinical data for both groups. These data informed a clinical plan, with those randomized to the PEC group sending digital photographs of the surgical site in addition to the traditional telephone call. Within 48 hours, families were sent a link to an electronic survey measuring patient experience using a validated questionnaire. Feasibility data on recruitment rates, compliance with sending photographs, and completing patient experience questionnaires were collected. Secondary outcomes included number of unplanned clinic/ER visits, number of follow-up phone calls, and patient experience scores. Results Of the 328 children who underwent urological procedures during the recruitment period, 215 (66%) consented to participate in the study. Of these, 42(13%) contacted the NP with postoperative concerns and were randomized. Two patients in the PEC group were excluded after randomization (one for contacting on Postoperative Day 31 and one for not sending photographs), resulting in 19 patients in the PEC group and 21 patients in the TTC group. Penile surgeries (hypospadias repair and circumcisions [43%]) were the most common procedures with postoperative concerns. Ninety-eight percent of the PEC patients were compliant in sending photographs. Overall, 98% of surveys were completed. Twice as many unplanned clinic visits were observed in the TTC group when compared with the PEC group (p = .28), despite a similar number of follow-up phone calls between groups (Table 1). Patient experience scores were also comparable in both groups, with families scoring high satisfaction with the experience regardless of the modality of communication. Conclusions A definitive trial examining the effectiveness of PEC versus TTC appears feasible and safe as seen by the high recruitment, photographic compliance, hospital visits, and survey completion rates in this pilot study.

98: Global climate change: Decreasing hot air emissions at the SGS annual clinical meeting

To evaluate time “lost” associated with oral, oral poster, and video presentation introductions and pleasantries at the SGS annual clinical meeting. The 2017 SGS abstract supplement was reviewed and the median word and character counts for titles of oral, oral poster, and video presentations were collected. Titles in each category that were equal to the median were identified and utilized for timing analyses. A standardized script for presenter introduction and pleasantries was created. This included the presenter name, current position and hospital affiliation. Additionally, it included a disclosure statement and a sentence thanking coauthors and the society for allowing them to present their research/video. Six physicians were instructed to read the script aloud as if standing at the presenter podium and timing was recorded. They were also timed when verbalizing a variety of oral, oral poster and video presentation titles. This was used to calculate overall meeting time utilized. Seventy-five presentations from the 2017 SGS Annual Scientific Meeting were reviewed and included in the analysis: 20 oral presentations, 26 oral posters, 8 podium videos, and 21 videofest videos. The median character and word counts for oral presentation titles were 95 and 13, for oral poster titles 91 and 14, and for video titles 62 and 9, respectively. The mean introduction time was 13.5 seconds. The mean times to verbalize titles for oral, oral poster and video presentations using median character count was 10.3, 9.5, and 8.1 seconds. The mean times to verbalize titles for oral, oral poster and video presentations using median word count was 7.4, 10.1, and 7.35 seconds. The resultant total time of seventy-five presentations using the standard script for introductions and the average character count of the titles is 3105 seconds (51.8 minutes). Similarly, the total time using the average word count is 2876.25 seconds (47.9 minutes). A mean of 49.85 minutes could be saved if these statements were omitted. Fifty minutes, almost 1 hour, could be saved if self-introductions and general pleasantries were omitted from the SGS Annual Scientific Meeting. This could be utilized to allow additional research presentations, social activities or to wait in line at Space Mountain. Let’s be honest, we are all thankful to the society for hosting an outstanding annual meeting and allowing us to present our research, however, self-introductions and pleasantries may not be necessary. We believe our findings are generalizable and may be applied to other scientific/clinical meetings within and outside our surgical specialty.

Single-Dose Levonorgestrel Emergency Contraception and Silent Barriers to Its Access: Is It Really Just One Step?

Single-dose levonorgestrel has been legally available over the counter in the United States without age restriction since 2013. The objective of this study was to discover if there are barriers to access and to determine if such barriers vary based on the gender of the person making the purchase. A male and female caller contacted 146 Richmond, Virginia pharmacies listed on the Plan B One Step® website. Ultimately, these callers interviewed 90 pharmacies via phone and used a rehearsed standardized script to ask eight questions regarding emergency contraception (EC) in relation to availability, age restrictions, parental consent, counseling requirements, and a male's ability to purchase the product. The statistical data were analyzed using Fisher's exact test. Pharmacy employees provided incorrect information to both men and women regarding age restrictions for purchasing Plan B One Step 51% of the time. However, only seven of the pharmacy employees counseled that males were unable to purchase the medication. Both callers received correct information regarding parental consent and in-store counseling at the time of purchase. Pharmacy technicians provided the majority of information, and the male caller was more likely to be transferred to another person when requesting the medication (9 vs. 0 transfers for the male and female callers, respectively). Given the inconsistent data provided to the public regarding the purchase of EC, clinicians are obligated to convey accurate up-to-date information to patients about emergency contraceptive products as part of their counseling and should not assume that consumers receive accurate information when inquiring about over-the-counter EC.