Urban Tertiary Academic Center Research Articles

A Single Institution 19 Year Comparison of Furlow and Straight Line Palatoplasty Techniques in Bilateral Cleft Lip and Palate.

This study aims to compare patients' speech correcting surgery and fistula rates between the Furlow and Straight Line (SLR) palatoplasty techniques when combined with greater palatine flaps for complete bilateral cleft lip and palate (BCLP) repair. This was a single-center IRB approved retrospective cohort study. This study took place at an urban tertiary academic center. All patients with BCLP anomalies that underwent repair between January 2003 and August 2022 were included. Patients with index operations at an outside institution or incomplete medical charting were excluded. A total of 1552 patients underwent palatoplasty during the study period. Of these, 192 (12.4%) met inclusion criteria with a diagnosis of BCLP. Primary outcomes of this study included rate of fistula and incidence of speech correcting surgery. Secondary outcomes included rate of surgical fistula repair. One hundred patients underwent SLR (52.1%) and 92 Furlow repair (47.9%). There was no significant difference in fistula rates between the SLR and Furlow repair cohorts (20.7% vs. 15.0%; p = 0.403). However, SLR was associated with lower rates of speech correcting surgery when compared to the Furlow repair (12.5% vs. 29.6%; p = 0.011). This study compares the effect of Furlow and SLR on speech outcomes and fistula rates in patients with BCLP. Our findings suggest that SLR resulted in an almost three times lower rate of velopharyngeal dysfunction requiring surgical intervention in patients with BCLP, while fistula rates remained similar.

Preoperative Oswestry Disability Index Should not be Utilized to Determine Surgical Eligibility for Patients Requiring Lumbar Fusion for Degenerative Lumbar Spine Disease.

Retrospective cohort study. To evaluate how preoperative Oswestry Disability Index (ODI) thresholds might affect minimal clinically important difference (MCID) achievement following lumbar fusion. As payers invest in alternative payment models, some are suggesting threshold cutoffs of patient-reported outcomes (PROMs) in reimbursement approvals for orthopedic procedures. The feasibility of this has not been investigated in spine surgery. We included all adult patients undergoing one to three-level primary lumbar fusion at a single urban tertiary academic center from 2014 to 2020. ODI was collected preoperatively and one year postoperatively. We implemented theoretical threshold cutoffs at increments of 10. MCID was set at 14.3. The percent of patients meeting MCID were determined among patients "approved" or "denied" at each threshold. At each threshold, the positive predictive value (PPV) for MCID attainment was calculated. A total 1368 patients were included and 62.4% (N=364) achieved MCID. As the ODI thresholds increased, a greater percent of patients in each group reached the MCID. At the lowest ODI threshold, 6.58% (N=90) of patients would be denied, rising to 20.2%, 39.5%, 58.4%, 79.9%, and 91.4% at ODI thresholds of 30, 40, 50, 60, and 70, respectively. The PPV increased from 0.072 among patients with ODI>20 to 0.919 at ODI>70. The number of patients denied a clinical improvement in the denied category per patient achieving the MCID increased at each threshold (ODI>20: 1.96; ODI>30: 2.40; ODI>40: 2.75; ODI>50: 3.03; ODI>60: 3.54; ODI>70: 3.75). Patients with poorer preoperative ODI are significantly more likely to achieve MCID following lumbar spine fusion at all ODI thresholds. Setting a preoperative ODI threshold for surgical eligibility will restrict access to patients who may benefit from spine fusion despite ODI>20 demonstrating the lowest predictive value for MCID achievement. 3.

2666. Rates of STI Testing and Diagnoses among Patients with Mpox in New York City, 2022

Abstract Background The 2022 global mpox outbreak occurred in the context of rising rates of sexually transmitted infections (STIs). We hypothesize that concurrent STI rates were underestimated due to inadequate testing during virtual visits and non-sexual health clinical settings. Methods We included data from all patients with confirmed mpox (through non-variola orthopoxviral PCR testing) from June 25 to October 17, 2022 at an urban tertiary academic center in New York. Manual chart review supplemented data extracted from the electronic medical record. We calculated descriptive statistics for HIV, syphilis, genitourinary, rectal, and pharyngeal gonorrhea/chlamydia (GC/CT) screening and diagnosis rates. We evaluated relationships between site-specific symptoms and extragenital testing. Results Of 228 individuals in the database, 98% were male at birth, the median age was 34 years. 40% were Hispanic and 27% Black. 50% were living with HIV. Only 41% were tested for other STIs in the two weeks prior to their mpox diagnosis. At the time of their mpox visit, 62.7% of patients were tested for syphilis, with 45.5% showing evidence of active or previously treated syphilis. 67 persons without known HIV were tested for HIV, resulting in 3 new diagnoses within 2 weeks of mpox diagnosis. 57.5% of patients were screened with a genitourinary GC/CT nucleic acid amplification testing (NAAT), with 2.3% and 3.8% positive for gonorrhea and chlamydia, respectively. 46.5% were screened with a rectal GC/CT NAAT, with 16.0% and 6.6% positive for gonorrhea and chlamydia, respectively. 47.4% of individuals were screened with a pharyngeal GC/CT NAAT, with 7.4% and 0.9% positive for gonorrhea and chlamydia, respectively. Site specific GC/CT NAATs were obtained from 52.2%, 55%, and 54% of patients with urinary, rectal and pharyngeal signs or symptoms, respectively. Without extragenital testing, 10 of 28 total gonorrhea cases (35.7%) and 3 of 13 total chlamydia cases (23.1%) would have been missed. Conclusion STI testing was insufficient in people with confirmed mpox, likely leading to under diagnosis of STIs. HIV testing was inadequate in at-risk individuals, and patients presenting with site-specific symptoms were too frequently not offered targeted testing. Disclosures All Authors: No reported disclosures

Predictors of Blood Transfusion in Patients Undergoing Lumbar Spinal Fusion

To determine risk factors for perioperative blood transfusion after lumbar fusion surgery. After institutional review board approval, a retrospective cohort study of adult patients who underwent lumbar fusion at a single, urban tertiary academic center was retrospectively retrieved. Our primary outcome, blood transfusion, was collected via chart query. A receiver operating characteristic curve was used to evaluate the regression model. A P-value < 0.05 was considered statistically significant. Of the 3,842 patients, 282 (7.3%) required a blood transfusion. For patients undergoing posterolateral decompression and fusion, predictors of transfusion included age (P < 0.001) and more levels fused (P < 0.001). A higher preoperative hemoglobin level (P < 0.001) and revision surgery (P= 0.005) were protective of blood transfusion. For patients undergoing transforaminal lumbar interbody fusion, greater Elixhauser comorbidity index (P < 0.001), longer operative time (P= 0.040), and more levels fused (P= 0.030) were independent predictors of the need for blood transfusion. Patients with a higher body mass index (P= 0.012) and preoperative hemoglobin level (P < 0.001) had a reduced likelihood of receiving a transfusion. For circumferential fusion, greater age (P= 0.006) and longer operative times (P= 0.015) were independent predictors of blood transfusion, while a higher preoperative hemoglobin level (P < 0.001) and male sex (P= 0.002) were protective. Our analysis identified older age, lower body mass index, greater Elixhauser comorbidity index, longer operative duration, more levels fused, and lower preoperative hemoglobin levels as independent predictors of requiring a blood transfusion following lumbar spinal fusion. Different surgical approaches were not found to be associated with transfusion.

Menstrual Health and Hygiene among Adolescents in the United States

Menstrual health in adolescents has been understudied in the United States. We aimed to assess patient and provider perspectives surrounding menstrual health management and screening. Our mixed-methods approach consisted of provider surveys, patient surveys, and patient interviews. Participants were recruited from a pediatric gynecology practice or an adolescent medicine clinic at an urban tertiary academic center. Providers were pediatrics faculty or residents. Patients aged 13-24 years were eligible. Participants completed an anonymous survey or semi-structured interview about their experiences with menstrual health. Descriptive statistics and thematic content analysis were used for quantitative and qualitative data, respectively. Convergent parallel analysis elucidated key findings in both data sets. The provider survey response rate was 65% (69/106); 15% (9/69) of providers consistently asked patients about menstrual products, whereas 44% (27/68) were concerned patients could not afford products. The patient survey response rate was 85% (101/119); 19% (19/101) of respondents reported menstrual hygiene insecurity, 55% (55/101) missed commitments during menses, and 45% (45/101) discussed menstrual products with providers. Fifteen patients were invited for qualitative interviews; 10 were conducted, and thematic saturation occurred. Interviews highlighted the importance of comprehensive early menstrual health education and providers' role in menstrual management. Adolescence is a crucial point of entry into health care. Because taboos surrounding menstruation could limit access to health care, menstrual health education must be emphasized. Menstrual health education is provided piecemeal by parents, schools, and providers. Current practice should be reevaluated to consider comprehensive educational approaches in which health care leads.

The Evolving Role of Medical Scribe: Variation and Implications for Organizational Effectiveness and Safety.

Increasing use of medical scribes is an unintended consequence of electronic health record adoption in the U.S. The role of scribe is not universally defined, leading to variations in scribe training and operations, as well as questions about scribe efficiency, effectiveness, and safety. Studies published since 2009 have primarily focused on the financial aspects of scribe use, but no published studies have taken an organizational view of this phenomenon. This paper describes stakeholder perspectives on scribes working in outpatient settings within an urban tertiary academic medical center. It places factors associated with of scribe systems within an eight-dimension sociotechnical framework for evaluating health information technology, and discusses key aspects of those perspectives.

Weight Gain Post‐tonsillectomy More Common in Young Children

Objective: Adenotonsillectomy (TA), performed for either obstructive sleep apnea (OSA) or recurrent tonsillitis (RT), has been associated with significant weight gain after surgery. The objective of this study was to look at a large population of children undergoing TA and the demographic factors which may contribute to weight gain. Method: Retrospective chart review of children undergoing TA at an urban tertiary-academic center between 2008 and 2011. Demographic data (including age, gender, and race), OSA disease severity, pre- and 6-month postoperative normalized body mass index (z scores), and changes in were compared. Results: One hundred fifteen children had complete data after TA; 85 of whom underwent surgery for OSA. There were no significant differences between OSA and RT patients in mean age (7.2 ± 4.3 vs 7.3 ± 4.4 years, P = .955) or gender (38% female vs 50%; P = .323). However, the OSA patients were more likely to be black (60% vs 33%) than RT patients ( P = .026). Overall, the preoperative BMI z scores increased from 0.98 ± 1.50 to 1.21 ± 1.25 ( P = .0009) with no significant difference by surgical indication ( P = .58). Multiple linear regression analysis found that only age was significantly, and negatively, associated with changes in BMI z scores ( P = .015). Conclusion: Similar to previous studies, children had significant weight gain after TA. This analysis suggests that younger age is a significant predictor of weight gain after surgery. Further investigation of the relationship between weight gain and demographic factors would benefit from prospective evaluation with special attention to the relationship with age.

Impact of Physician Screening in the Emergency Department on Patient Flow

BackgroundPhysician triage is one of many front-end interventions being implemented to improve emergency department (ED) efficiency. Study ObjectiveWe aim to determine the impact of this intervention on some key components of ED patient flow, including time to physician evaluation, treatment order entry, diagnostic order entry, and disposition time for admitted patients. MethodsWe conducted a 2-year before–after analysis of a physician triage system at an urban tertiary academic center with 90,000 annual visits. The goal of the physician in triage was to arrange safe disposition of straightforward patients as well as to initiate work-ups. All medium-acuity patients arriving during the hours of the intervention were impacted and thus included in the analysis. Our primary outcome was the time to disposition decision. In addition to before–after analysis, comparison was made with high-acuity patients, a group not impacted by this intervention. Patient flow data were extracted from the ED information system. Outcomes were summarized with medians and interquartiles. Multivariable regression analysis was performed to investigate the intervention effect controlling for potential confounding variables. ResultsThe median time to disposition decision decreased by 6min, and the time to physician evaluation, analgesia, antiemetic, antibiotic, and radiology order decreased by 16, 70, 66, 36, and 16min, respectively. These findings were all statistically significant. Similar results were observed from the multivariable regression models after controlling for potential confounding factors. ConclusionsPhysician triage led to earlier evaluation, physician orders, and a decrease in the time to disposition decision.

Operational and financial impact of physician screening in the ED

BackgroundPhysician screening is one of many front-end interventions being implemented to improve emergency department (ED) efficiency. Study objectiveWe aimed to quantify the operational and financial impact of this intervention at an urban tertiary academic center. MethodsWe conducted a 2-year before-after analysis of a physician screening system at an urban tertiary academic center with 90 000 annual visits. Financial impact consisted of the ED and inpatient revenue generated from the incremental capacity and the reduction in left without being seen (LWBS) rates. The ED and inpatient margin contribution as well as capital expenditure were based on available published data. We summarized the financial impact using net present value of future cash flows performing sensitivity analysis on the assumptions. Operational outcome measures were ED length of stay and percentage of LWBS. ResultsDuring the first year, we estimate the contribution margin of the screening system to be $2.71 million and the incremental operational cost to be $1.86 million. Estimated capital expenditure for the system was $1 200 000. The NPV of this investment was $2.82 million, and time to break even from the initial investment was 13 months. Operationally, despite a 16.7% increase in patient volume and no decrease in boarding hours, there was a 7.4% decrease in ED length of stay and a reduction in LWBS from 3.3% to 1.8%. ConclusionsIn addition to improving operational measures, the implementation of a physician screening program in the ED allowed for an incremental increase in patient care capacity leading to an overall positive financial impact.

Nutritional Support in Mild Acute Pancreatitis: A Review of Practice Patterns at an Urban Tertiary Academic Center

Nutritional Support in Mild Acute Pancreatitis: A Review of Practice Patterns at an Urban Tertiary Academic Center