Tertiary Care Practice Research Articles

Tertiary Care Center Trends in Colonic Stent Placement over the Past Decade.

Colonic endoluminal stent placement is a commonly utilized and effective endoscopic approach for the management of malignant large bowel obstruction and is an emerging approach for the management of some benign etiologies of large bowel obstruction. However, recent studies evaluating the evolution of clinical scenarios and patient populations for which stenting is performed in real-world practice are lacking. We assessed colonic stent utilization patterns in a tertiary care academic medical center over the past 10 years. We analyzed the demographics and patient and procedure characteristics of the initial (first half of study period) and latter (second half of the study period) procedures to assess trends over time using standard descriptive statistics. Our analysis was notable due to its provision of some novel insights. The frequency of colonic stent placement procedures increased significantly over time by comparison of the procedure volume for the initial 5-year interval (22 colonic stent procedures) relative to the latter 5-year interval (49 colonic stent procedures) (p = 0.03). The median age of patients who underwent colonic stent placement was significantly lower in the latter 5 years, compared with the initial 5 years of the study period (mean of 81.41 vs. 58.73 years, respectively, p < 0.001). The increased diversity of indications for colonic stent placement was also noted over time. Our data highlight the evolution of colonic stent placement in tertiary care practice over time and are notable for some interesting trends, including the increased utilization of colonic stent placement over time, the broadening of indications for colonic stent placement to include benign indications, and lower patient age at the time of colonic stent placement over time. These findings will help inform the clinical practice of colonic stent placement and provide a foundation to guide future research on the topic.

Sustaining private eye care practices during initial days of the coronavirus pandemic

Background: The coronavirus disease 2019 (COVID-19) pandemic created new challenges for private eye care practices. Safety issues were encountered by both the healthcare workers and patients. This short communication addresses the changes made in our private eye care practice during the pandemic and the valuable lessons learned for the future. Methods: We describe the challenges faced in our tertiary private eye care practice in India with respect to treating patients and preventing the transmission of COVID-19, considering the economic hardship within this area. We discuss the emerging economic, medical, legal, educational, and psychological issues and their solutions, which eye care hospitals could follow in the future to ensure safety without compromising quality of care. Results: Hospitals required efficient operation with reduced fixed expenses. Clinical practices were followed in the hospital as per the recommendations of the country’s apex ophthalmic body. Proper triage and prescreening of patients at the entrance, digitalization, teleophthalmology, staggered appointments, and role-appropriate personal protective equipment were important preventive measures. The operating room protocols were modified to ensure the safety of the operating staff. Special consent was obtained from patients to safeguard against legal repercussions arising from the pandemic. The training of residents and fellows led to new avenues, including the use of digital tools. Hospitals attempted to provide counseling and psychological support to their doctors and staff during these trying times. Conclusions: The COVID-19 pandemic will not be the last pandemic to occur in an ever-changing world. This event provided us with many new insights into the economic, clinical, legal, and psychological challenges of the COVID-19 pandemic and with ways to overcome these challenges and emerge intact. Clinical and surgical training suffered during the pandemic; however, the impact was only temporary. Clinical research gained respect because of the efforts undertaken during the pandemic. The pandemic was exceptionally harsh on many private eye care practices, and we hope to provide useful and comprehensive solutions on how to successfully navigate a similar situation if encountered in the future.

Relevance of BEST-CLI trial endpoints in a tertiary care limb preservation program

ObjectiveMajor adverse limb event-free survival (MALE-FS) differed significantly by initial revascularization approach in the BEST-CLI randomized trial. The BEST-CLI trial represented a highly selected subgroup of patients seen in clinical practice; thus, we examined the endpoint of MALE-FS in an all-comers tertiary care practice setting. MethodsThis is a single-center retrospective study of consecutive, unique patients who underwent technically successful infrainguinal revascularization for chronic limb-threatening ischemia (2011-2021). MALE was major amputation (transtibial or above) or major reintervention (new bypass, open bypass revision, thrombectomy, or thrombolysis). ResultsAmong 469 subjects, the mean age was 70 years, and 34% were female. Characteristics included diabetes (68%), end-stage renal disease (ESRD) (16%), Wound, Ischemia, and foot Infection (WIfI) stage 4 (44%), Global Limb Anatomic Staging System (GLASS) stage 3 (62%), and high pedal artery calcium score (pMAC) (22%). Index revascularization was autogenous vein bypass (AVB) (30%), non-autogenous bypass (NAB) (13%), or endovascular (ENDO) (57%). The composite endpoint of MALE or death occurred in 237 patients (51%) at a median time of 189 days from index revascularization. In an adjusted Cox model, factors independently associated with MALE or death included younger age, ESRD, WIfI stage 4, higher GLASS stage, and moderate-severe pMAC, whereas AVB was associated with improved MALE-FS. Freedom from MALE-FS, MALE, and major amputation at 30 days were 90%, 92%, and 95%; and at 1 year were 63%, 70%, and 83%, respectively. MALE occurred in 144 patients (31%) and was associated with ESRD, WIfI stage, GLASS stage, pMAC score, and index revascularization approach. AVB had superior durability, with adjusted 2-year freedom from MALE of 72%, compared with 66% for ENDO and 51% for NAB. Within the AVB group, spliced vein conduit had higher MALE compared with single-segment vein (hazard ratio, 1.8; 95% confidence interval, 0.9-3.7; P = .008 after inverse propensity weighting), but there was no statistically significant difference in major amputation. Of the 144 patients with any MALE, the first MALE was major reintervention in 47% and major amputation in 53%. Major amputation as first MALE was associated with non-AVB index approach. Indications for major reintervention were symptomatic stenosis/occlusion (54%), lack of clinical improvement (28%), asymptomatic graft stenosis (16%), and iatrogenic events (3%). Conversion to bypass occurred after 6% of ENDO cases, two-thirds of which involved distal bypass targets at the ankle or foot. ConclusionsIn this consecutive, all-comers cohort, disease complexity was associated with procedural selection and MALE-FS. AVB independently provided the greatest MALE-FS and freedom from MALE and major amputation. Compared with the BEST-CLI randomized trial, MALE after ENDO in this series was more frequently major amputation, with relatively few conversions to open bypass.

Prescription opioid use increases resource utilization following ventral hernia repair

Previous studies showed that preoperative opioid use is associated with increased postoperative opioid use and surgical site infection (SSI) in patients undergoing ventral hernia repair (VHR). Orthopedic surgery literature cites increased resource utilization with opioid use. This study aimed to determine the effect of preoperative opioid use on resource utilization after open VHR. A retrospective institutional review board-approved study of VHRs from a single tertiary care practice between 2013 and 2020 was performed. Medical records, the National Surgical Quality Improvement Program database, and Kentucky All Schedule Prescription Electronic Reporting data were reviewed for patient demographics, comorbidities, dispensed opiate prescriptions, hernia characteristics, and outcomes. Univariate logistic regression analyses assessed the effect of each patient's demographic and clinical characteristics. Multivariate logistic regression models analyzed significant factors from the univariate analyses. The primary outcome was resource utilization measured as readmission, emergency department visit, or >2 postoperative clinic visits within 45 days after VHR. Overall, 381 patients who underwent VHR were identified; of which 101 patients had preoperative dispensed opioids. Multivariate analysis demonstrated that patient gender at birth, any new-onset SSI, and any preoperative opioid use were associated with increased postoperative resource utilization (odds ratio, 1.76; P=.026). Preoperative opioid use was determined as a risk factor that increased resource utilization after open VHR. An understanding of the drivers of the increased use of resources is essential in developing strategies to improve healthcare value. Future research will focus on strategies to reduce the utilization of resources among patients who use opioids.

Pelvic Floor Dysfunction: A Common Cause of Chronic Orchialgia

Purpose: We determined the prevalence of pelvic floor dysfunction (PFD) as an etiology for chronic orchialgia in a single tertiary care practice and characterized the presenting symptoms of chronic orchialgia patients with PFD. Materials and Methods: An IRB-approved retrospective review was performed for patients diagnosed with chronic orchialgia from 2016 to 2021 using CPT codes N50.82 (scrotal pain), N50.819 (testicle pain), and G89.29 (chronic pain in testicle). Patients with acute orchialgia (&lt;3 months) were excluded. PFD was diagnosed on a 360-degree digital rectal examination when increased tone or pain to palpation of the levator ani muscle group was noted. Suspected etiology of the orchialgia and accompanying urinary, bowel, or sexual symptoms were recorded. Unpaired t-tests were used to determine significant associations while accounting for differences in sample size. Results: Of 136 patients with chronic orchialgia, the most common etiologies were classified as idiopathic (37.7%); prior surgery (32.1%); varicocele, hydrocele, or spermatocele (28.3%); PFD (17.6%); and postinfection (11.3%). Chronic orchialgia patients with PFD (n = 24) were significantly more likely to present with accompanying urinary (P &lt; .01), bowel (P &lt; .01), and sexual dysfunction (P = .04) symptoms. Orchialgia patients with PFD were more likely to report symptoms of functional obstruction, particularly urinary hesitancy (P &lt; .01), constipation (P &lt; .01), and painful ejaculation (P &lt; .01), compared with patients without PFD. Conclusions: PFD was determined to be the etiology in 1 in 6 patients with chronic orchialgia. All patients presenting with chronic orchialgia and obstructive symptoms warrant a 360-degree rectal examination as part of their initial evaluation. IRB Protocol Number: 10677.

A Comparison of Voice Therapy Attendance Rates Between In-Person and Telepractice

This study sought to investigate whether a significant difference exists in attendance, cancellations, and no-shows between in-person therapy and telepractice. The authors hypothesized that telepractice no-show and cancellation rates would be less than in-person no-show and cancellation rates. This retrospective study manually reviewed and analyzed attendance, no-show, and cancellation data over a 3-month span of in-person-only visits (September 2019-November 2019) and a 3-month span of telepractice visits (September 2020-November 2020) conducted at the Emory Voice Center, a tertiary care practice in urban Atlanta, Georgia. Additionally, data were collected for each patient's full course of therapy outside of the 3-month windows and analyzed for attendance, no-show, and cancellation patterns. Data from 521 patients were available for review from the selected time frame. In 2019 (in-person), 157 patients met inclusion criteria, and in 2020 (telepractice), 176 patients were included. Therapy initiation, therapy attendance, and no-show rates had significant increases in the telepractice year, and cancellations made greater than 24 hr before the appointments had a significant decrease in the telepractice year. Furthermore, the overall course of therapy showed significantly fewer missed appointments and more attended appointments in the telepractice year. Patients participating in voice therapy via telepractice are more likely to initiate treatment and attend treatment and less likely to cancel sessions compared with patients receiving treatment in person. These data combined with extant data on telepractice treatment efficacy indicate that telepractice should be considered standard of care and offered to all patients seeking treatment, as it removes many reported barriers to treatment.

Communication Preferences of Parents and Caregivers of Children and Youth With Special Healthcare Needs During a Hypothetical Infectious Disease Emergency.

Children and youth with special healthcare needs are at risk for severe consequences during infectious disease emergencies. Messages for parents and caregivers from trusted sources, via preferred channels, that contain the information they need, may improve health outcomes for this population. In this mixed methods study, we conducted a survey (N = 297) and 80 semistructured interviews, with 70 caregivers of children and youth and 10 young adults with special healthcare needs, between April 2018 and June 2019 in Pennsylvania. The survey presented 3 scenarios (ie, storm, disease outbreak, radiation event); the interviews included questions about storms and an outbreak. This article addresses only the disease outbreak data from each set. Participants were recruited through convenience samples from an urban tertiary care children's hospital and practices in a statewide medical home network. In this article, we summarize the preferred information sources, channels, and content needs of caregivers of children and youth with special healthcare needs during an infectious disease emergency. Nearly 84% of caregivers reported that they believe their child's doctor is the best source of information. Other preferred sources include medical experts (31%); the US Centers for Disease Control and Prevention (30%); friends, family, and neighbors (21%); and local or state health and emergency management (17%). Pediatric healthcare providers play an important role in providing information to parents and caregivers of children and youth with special healthcare needs during an infectious disease emergency. Public health agencies can establish health communication plans that integrate medical practices and other reliable sources to promote the dissemination of accurate information from trusted messengers.

Effectiveness of Netarsudil versus Brimonidine in Eyes already Being Treated with Glaucoma Medications at a Single Academic Tertiary Care Practice: A Comparative Study

Rho kinase inhibitors, such as netarsudil, are a relatively new class of medications recently introduced into the market for the treatment of glaucoma, the leading cause of irreversible blindness in the world. Previous clinical trials have studied netarsudil's efficacy when used as a first- or second-line agent but limited studies have investigated its effectiveness in the real world where it is more commonly used as a third, fourth, or fifth agent in combination with other topical medications. Equally important, prior studies have not compared its effectiveness to its peer medications in these settings. To compare intraocular pressure (IOP) lowering after initiation of netarsudil or brimonidine therapy in patients with glaucoma using >2 medications for IOP management. A chart review of 369 eyes from 279 patients followed at a single academic tertiary practice was performed with an institutional review board waiver of consent to compare IOP lowering after prescription of netarsudil (n = 176) versus brimonidine (n = 193) as a third, fourth, or fifth IOP-lowering agent. Patients were identified by querying the electronic medical record for those with a glaucoma-related diagnosis who were prescribed either medication. Five sequential IOP measurements were obtained to determine the mean change in IOP before and after treatment (ΔIOP = mean IOP4,5 - mean IOP1,2,3). A multilevel linear mixed-effects model assessed the influence of medication (independent variable) on ΔIOP (dependent variable). Additional independent variables of interest included the number of glaucoma medications at baseline, age, sex, glaucoma type and severity, race, and pretreatment IOP. Bootstrap analysis was performed to remove sampling bias and confirm mixed-effects model findings. Kaplan-Meier survival analysis evaluated the probability of requiring additional intervention within 3 years following the date of medication prescription. The unadjusted mean (SD) ΔIOP for netarsudil and brimonidine was -2.20 (4.11) mm Hg and -2.21 (3.25) mm Hg, respectively (P = 0.484). The adjusted linear mixed-effects models and bootstrap analysis demonstrated that there was no statistical difference in IOP-lowering effectiveness between the medications. Netarsudil and brimonidine failed to adequately control IOP at similar rates with 42% and 47% probabilities of survival respectively by the 3-year follow-up (P = 0.520). When escalating pharmacologic therapy, the IOP-lowering effect of netarsudil appeared to be similar to that produced by brimonidine. (Curr Ther Res Clin Exp. 2023; 84:XXX-XXX).

Exploring Gap in Adherence to ASGE Quality Metrics of EUS Examination for Pancreatic Lesions: A Quality Improvement Initiative

ASGE proposed dedicated quality metrics for EUS examination. Overall adherence to this quality metrics remains unknown in both academic center as well as in community practice. We aimed to conduct retrospective analysis of EUS practice for pancreatic lesions in our hospital system that comprises of both academic tertiary care practice as well as community based EUS practice.

Deep Learning Skin Disease Classifiers: Current Status and Future Prospects

Background Most studies on deep learning skin disease classifiers are done with binary classifications (ie, classifying lesions into malignant and benign). However, dermatology practice involves a large number of inflammatory and infective conditions that are not easily diagnosed by nondermatologist physicians. Objective The aim of this study is to develop a machine learning–based smartphone app for multiclass skin disease classification and evaluate its performance in different levels of dermatology practice. We will also explore similar studies in the literature. Methods We developed an artificial intelligence–driven smartphone app for 40 common skin diseases and tested it in primary care, tertiary care, and private practice settings. Results In the clinical study, the overall top-1 accuracy was 75.07% (95% CI 73.75%-76.36%), top-3 accuracy was 89.62% (95% CI 88.67%-90.52%), and the mean area under the curve was 0.90 (SD 0.07). Multimedia Appendix 1 shows the top-1 positive predictive values and negative predictive values from a clinical study of 35 diseases using the developed mobile health app on patients. In the literature, there are very few studies on image-based deep learning multiclass classification of common skin diseases and none of them included evaluations in actual clinical settings. Conclusions An artificial intelligence–driven smartphone app has the potential to improve the diagnosis and management of skin diseases in patients with skin of color. Nondermatologist, primary care physicians are likely to benefit from having access to such an app. Acknowledgments Nurithm Labs collaborated with the All India Institute Of Medical Science to develop this smartphone app. Other collaborators in this work include Rashi Pangti, Jyoti Mathur, Vikas Chouhan, Sharad Kumar, Lavina Rajput, Sandesh Shah, Atula Gupta, Ambika Dixit, Dhwani Dholakia, Sanjeev Gupta, Savera Gupta, Mariam George, and Vinod Kumar Sharma. Conflicts of Interest None declared.

S829 Racial Disparities in COVID-19 Vaccine Acceptance Are Not Present Among IBD Patients at an Urban Tertiary Care Practice

Introduction: Vaccine hesitancy among minorities remains a prevalent phenomenon stemming from several factors including underrepresentation in vaccine trials, systemic discrimination, historical racial injustices, and limited targeted education. Furthermore, it is well-established that COVID-19 infection disproportionately impacts minority patients. In this study, we sought to evaluate disparities in COVID-19 vaccine intention among a diverse urban population in effort to promote equitable, optimal care for our inflammatory bowel disease (IBD) patient cohort. Methods: A retrospective chart review of electronic medical records was conducted of all IBD patients seen from 1/1/2016 to 1/31/2021 by gastroenterologists at an urban university medical center. Patient gender, age, race, IBD subtype, and treatment regimen information were obtained. Phone-based surveys were conducted to determine patients’ intention to receive a COVID-19 vaccine. Patients were excluded if unable to contact or there was missing demographic data. A confidential database was created using Microsoft Excel Fischer exact tests were used with statistical significance set at p< 0.05. This study was approved by the university IRB. Results: 218 of 458 (47.6%) medical records were reviewed. 123 (56.4%) identified as White, 75 (34.4%) as Black, and 20 (9.2%) as Asian, Hispanic, or other. 195 (89.4%) received or intended to receive the COVID-19 vaccine. 112 (57.4%) Whites, 66 (33.8%) Blacks, and 17 (8.7%) Asian, Hispanics or other racial identity received or intended to receive COVID-19 vaccine. There was no significant difference (p=0.630) in vaccine intention in IBD patients based upon race. Conclusion: While the literature indicates several stark racial differences in COVID-19 vaccine perceptions, this study did not reveal any disparities in vaccine receipt nor intention among our diverse, urban IBD patient cohort. Our findings contradict the accepted concept that minority patients, particularly Black patients, tend to reject COVID-19 vaccination. It is possible that regardless of race, patients with chronic immune dysregulation, as in IBD, are more accepting of vaccination as a protective measure. However, these results emphasize the need to identify factors that encourage vaccination practices to guide development of interventions that increase widespread vaccine acceptance.

S827 Assessing COVID-19 Vaccine Intention Among IBD Patients in an Urban University Tertiary Care Practice

Introduction: Widespread administration of COVID-19 vaccination can potentially limit the spread and devastation of infection in the United States. Despite the availability of safe and effective vaccines against COVID-19, there continues to be multifaceted hesitancy towards it. In this present study, we evaluated our inflammatory bowel disease (IBD) patient cohort’s acceptance of the COVID-19 vaccine at an urban university medical center. Methods: A retrospective chart review using an electronic medical record was conducted of all IBD patients seen from 1/1/2016 to 1/31/2021 by gastroenterologists at an urban, tertiary care, university medical center. Patient gender, age, race, IBD subtype, and medication regimen were obtained. Phone-based surveys were conducted to determine patients’ acceptance of COVID vaccine. Patients were excluded if they were unable to be contacted or there was missing demographic data. A confidential database was created using Microsoft Excel. Fischer exact tests were used with statistical significance set at p< 0.05. This study was approved by the university IRB. Results: 218 of 458 (47.6%) medical records were reviewed. There were 127 (58.3%) women, 91 (41.7%) men, with mean age of 44.4 years. 123 (56.4%) had ulcerative colitis, 93 (42.7%) Crohn’s disease, 2 (0.9%) with indeterminate colitis. 91 (41.7%) were on biologic therapy. 195 (89.4%) of our IBD patient cohort received or intended to receive the COVID vaccine. There was no significant difference in the rate of vaccine acceptance based upon age (p=0.212), gender (p=1.000), IBD type (p=0.150) or medication regimen (p=0.623). Conclusion: The findings of this study are reassuring in demonstrating similar intention of vaccine receipt across age, gender, disease subtype, and treatment regimen in IBD patients. It is also important to highlight that vaccination intent is significantly higher among IBD patient cohort than the general US population (defined as roughly 50% in December 2020). While this study is limited due to size, the rate of patient vaccine acceptance is encouraging since guidelines strongly support vaccination of IBD patients regardless of medication regimen. Further research is warranted to determine whether significant correlations exist between demographic groups and vaccine concerns.

Balloon dilation of the Eustachian tube with a seeker-based device: A registry of 169 patients.

ObjectiveTo collect real‐world data on the safety and effectiveness of balloon dilation of the Eustachian tube using a seeker‐based device in patients with persistent/chronic symptoms of Eustachian tube dysfunction.MethodsA multicenter, prospective, single‐arm registry was conducted from June 2018 through August 2020 at 10 US centers, including tertiary care and private practices. Primary endpoints included mean change from baseline in the 7‐item Eustachian Tube Dysfunction Questionnaire (ETDQ‐7) and the serious related adverse event rate. Secondary endpoints include changes in middle ear assessments, surgical intervention rate, and changes in Sino‐Nasal Outcome Test and Work and Activity Impairment (WPAI) questionnaires.ResultsA total of 169 participants were treated with balloon dilation of the Eustachian tube, with 166 and 154 participants completing the 6‐week and 6‐month follow‐ups, respectively. Repeated measures analysis of the change in ETDQ‐7 scores indicated statistically significant improvement (−2.1; 95% CI −2.40, −1.84; P < .0001) at 6‐month follow‐up. The minimum clinically important difference of improvement was achieved by 85% of participants at 6 months. Four nonserious adverse events were reported. Middle ear functional assessments were improved in the majority of participants with abnormal baseline findings. There were no statistically significant differences in the change from baseline ETDQ‐7 scores between participants who had concurrent procedures and those who did not. WPAI scores demonstrated significant improvement.ConclusionReal‐world evidence supports the clinical studies demonstrating that balloon dilation of the Eustachian tube with a seeker‐based device is a safe and effective procedure to treat ETD symptoms.Level of evidence3

The Effect of Achieving Target Intraocular Pressure on Visual Field Worsening

To estimate the effect of achieving target intraocular pressure (IOP) values on visual field (VF) worsening in a treated clinical population. Retrospective analysis of longitudinal data. A total of 2852 eyes of 1688 patients with glaucoma-related diagnoses treated in a tertiary care practice. All included eyes had at least 5 reliable VF tests and 5 IOP measures on separate visits along with at least 1 target IOP defined by a clinician on the first or second visit. The primary dependent variable was the slope of the mean deviation (MD) over time (decibels [dB]/year). The primary independent variable was mean target difference (measured IOP - target IOP). We created simple linear regression models and mixed-effects linear models to study the relationship between MD slope and mean target difference for individual eyes. In the mixed-effects models, we included an interaction term to account for disease severity (mild/suspect, moderate, or advanced) and a spline term to account for thediffering effects of achieving target IOP (target difference ≤0) and failing to achieve target IOP (target difference >0). Rate of change in MD slope (changes in dB/year) per 1 mmHg change in target difference at different stages of glaucoma severity. Across all eyes, a simple linear regression model demonstrated that a 1 mmHg increase in target difference had a-0.018 dB/year (confidence interval [CI],-0.026 to-0.011; P < 0.05) effect on MD slope. The mixed-effects model shows that eyes with moderate disease that fail to achieve their target IOP experience the largest effects, with a 1 mmHg increase in target difference resulting in a -0.119 dB/year (CI,-0.168 to-0.070; P< 0.05) worse MD slope. The effects of missing target IOP on VF worsening were more pronounced than the effect of absolute level of IOP on VF worsening, where a 1 mmHg increase in IOP had a-0.004 dB/year (CI,-0.011 to 0.003; P > 0.05) effect on the MD slope. In treated patients, failing to achieve target IOP was associated with more rapid VF worsening. Eyes with moderate glaucoma experienced the greatest VF worsening from failing to achieve target IOP.

Medical Cannabis to Treat Symptoms From Head and Neck Radiation Therapy

I am a head and neck radiation oncologist in a tertiary care practice in Minnesota. I am credentialed in the state of Minnesota to certify patients for medical cannabis. Over the last 6 years, I have certified select patients for medical cannabis as part of management of their cancer-related symptoms and effects of treatment. In this paper, I review my approach to incorporating medical cannabis into the management of patients with head and neck cancer.

Awareness of health care workers regarding COVID-19 vaccine in a tertiary care hospital-a knowledge, attitude, and practice study

Awareness of health care workers regarding COVID-19 vaccine in a tertiary care hospital-a knowledge, attitude, and practice study

Open Reduction and Primary Subtalar Arthrodesis for Acute Intra-articular Displaced Calcaneal Fractures.

To evaluate the rate of subtalar arthrodesis based on a computed tomography (CT) scan after open reduction and primary subtalar arthrodesis for acute, displaced, intra-articular calcaneal fractures. Retrospective chart review. Single tertiary care practice. A retrospective chart review was performed to identify patients who sustained an acute, displaced, intra-articular calcaneal fracture and underwent open reduction and primary subtalar arthrodesis. Thirty-five patients participated in the study. Each patient included in the study was treated with open reduction and primary subtalar arthrodesis. All patients were evaluated with CT for arthrodesis of the posterior facet of the subtalar joint, which was quantitated. Other outcome measures included radiographic parameters, the Veterans RAND Item Health Survey, and the Foot and Ankle Ability Measure. The median patient age was 47.8 years (range 21.5-79.5 years). The median patient follow-up was 34.4 months (range 4.6-104.1 months). The Sanders classification was as follows: 3% (1/35) type II, 40% (14/35) type III, and 57% (20/35) type IV. Based on a CT scan, primary subtalar union occurred in 94.3% (33/35) of patients. Open reduction and primary subtalar arthrodesis for acute, displaced, intra-articular calcaneus fractures has a high rate of union and good pain and function outcomes. It should be strongly considered for patients with significant cartilage injury and comminution of the posterior facet. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Design and rationale of DUTCH-AF: a prospective nationwide registry programme and observational study on long-term oral antithrombotic treatment in patients with atrial fibrillation

IntroductionAnticoagulation therapy is pivotal in the management of stroke prevention in atrial fibrillation (AF). Prospective registries, containing longitudinal data are lacking with detailed information on anticoagulant therapy, treatment adherence and...

Abstract 230: Internal Medicine Trainee Understanding and Reaction to Out of Pocket Costs

Introduction: Out-of-pocket costs (OOPC) are a significant barrier to care and drive suboptimal medical therapy in ASCVD. Despite this, there is minimal attention paid to these costs in post-graduate education. To define a potential knowledge gap, we surveyed trainee understanding of OOPC. Methods: We surveyed Internal Medicine residents at a large academic program comprised of a large county safety-net hospital, a VA, and a private tertiary care hospital, about knowledge and practices surrounding patient OOPC. Residents rotate on services at all sites and the vast majority have primary care clinic at the county or VA hospital. Participants answered questions considering their most recent inpatient panel and their clinic patient panel. Familiarity was ranked on a 5-point Likert scale, and for the purposes of presentation, was divided into “Poor” and “Moderate or Better”. Non-parametric analysis was used to test differences between outpatients v inpatients and by year of training. Results: Of 159 residents, 106 (67%) responded. Familiarity with patient insurance status was moderate or better in 135 of 159 (85%). Moderate or better understanding of costs associated with medications (52% [83 of 159]), testing (19% [30 of 159]) and clinic visits (30% [48 of 159]) was less common. Respondents had higher familiarity with OOPC for clinic patients compared with their most recent inpatient panel: clinic visits (39% v 21% [62 v 33 of 159 p &lt; 0.005]), testing (25.7% v 12.4% [41 v 20 of 159 p = 0.002]), and medications (62% v 42% [99 v 67 of 159 p &lt;0.005]) Knowledge of cost of care was not an often-considered factor in decision making (27% “Often” or “Always” [43 of 159]). There was no significant difference in response by year of training. Discussion: Our survey demonstrates that trainee familiarity with OOPC was low overall but modestly higher for established clinic patients, perhaps reflecting longitudinal experience with them or the heterogeneity of admitted patient funding status. Familiarity with patient OOPC was not an often-considered factor in decision making and did not significantly improve over years of training. This suggests an important gap in trainee education. Teaching greater familiarity with patient OOPC during residency can increase awareness of the financial realities of patients, enabling more patient-centered care.

Impact of an electronic decision support rule on ESR/CRP co-ordering rates in a community health system and projected impact in the tertiary care setting and a commercially insured population

IntroductionErythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are common laboratory assays used as markers of inflammation. ESR suffers from higher false positive and false negative rates than CRP. To that end, the American Board of Internal Medicine's (ABIM's) Choosing Wisely campaign has recommended against ESR testing for those with undiagnosed conditions in favor of CRP testing. This study describes the impact of a computerized provider order entry (CPOE) decision support rule against ESR/CRP co-ordering within a community health system that predates the ABIM's Choosing Wisely national guidance. To demonstrate the potential impact of such a CPOE rule within other healthcare settings, ESR/CRP ordering data from a multi-site tertiary care practice and from the commercially insured population in the OptumLabs® Data Warehouse (OLDW) were analyzed and the relative reduction in ESR/CRP co-ordering achieved within the community health system was projected onto these populations. Materials and methodsESR and/or CRP orders from a community health system were assessed from 2012 to 2016. Co-ordering and test concordance rates between ESR and CRP were compared before and after CPOE decision support rule launch. Similarly, ESR/CRP co-ordering across three tertiary care sites from 2015 to 2016 and the OLDW from 2009 to 2013 were assessed and the co-ordering rate reduction achieved in the community health system was mathematically projected onto these populations. Estimated payer savings from the rule's effect were calculated within each population using Medicare reimbursement rates. ResultsThe CPOE decision support rule realized an unadjusted 42% relative rate reduction in ESR/CRP co-ordering within the community health system yielding an annual payer savings of $15,000 with a modest increase in ESR/CRP concordance rates. Projecting a 40% relative reduction in ESR/CRP co-ordering rates from a similarly effective CPOE rule, annual payer cost reductions exceeding $100,000 within a multi-site tertiary care setting and $1,000,000 within the OLDW would be expected. ConclusionESR/CRP co-ordering represents an opportunity to eliminate testing waste and reduce payer costs. A CPOE decision support rule stably reduces ESR/CRP co-ordering rates. Similar results may occur as one component of new commercially available decision support platforms.