Letter of recommendation characteristics associated with interview offer to a vascular surgery residency program.

BACKGROUND: Letters of recommendation (LORs) are considered by program directors (PDs) to be an integral part of the residency application. With the conversion of USMLE Step 1 to a binary pass/fail outcome, LORs will likely have higher important in the application process moving forward. However, their utility in securing an interview for a particular applicant remains undetermined. This study aims to identify the applicant and LOR characteristics associated with an interview invitation. METHODS: Letter writer (n=977) characteristics were abstracted from applications (n=264) to an individual integrated vascular surgery residency program over 2 application cycles. A validated text analysis program, Linguistic Inquiry and Word Count, was used to characterize LOR content. Applicant, letter writer, and LOR characteristics associated with an interview invitation was determined using multivariable analysis. RESULTS: Letter writers were 70.9% vascular surgeons (VS), 23.7% PDs, and 45.4% professors. Applicants offered an interview were more likely to come from a top 50 medical school (35.2% vs 25.8%, p=0.013) and an institution with a home vascular program (45.5% vs 34.1%, p=0.006). Alpha Omega Alpha membership was significantly associated with interview offer (28.4%, p<0.001). A greater proportion of letters from VS was associated with an interview offer (p <0.001) compared with letter writers of other specialties. One or more PD letters was significantly associated with an interview offer (79.55% vs 20.45%, p=0.008), whereas number of letters from APDs was not significantly associated with interview offer. Letters written by away institution faculty were significantly associated with interview offer (75%, p<0.001), whereas nonclinical letters were not. Presence of one or more letters from a chair (57.95% vs 42.05%, p=0.015) or chief (67.05% vs 32.95%, p=0.028) was significantly associated with interview offer. Letters for applicants offered an interview had more references to research and teaching, which were more common in letters written by VS. Letters written by PDs were more likely to use assertive, advertising language in favor of applicants. There were no significant applicant, letter writer, or LOR characteristics associated with a top 20 rank. CONCLUSION: Successful applicants were more likely to have LORs written by VS, PDs, and those of higher academic rank with references to research and teaching.

Definition and Perception of Autonomy in Vascular Surgery Training.

BACKGROUND: There is a lack of data evaluating operative autonomy within vascular surgery. This study aims to determine where discrepancies exist in the definition of autonomy between trainees and attending faculty. METHODS: An Institutional Review Board-approved, anonymous survey was e-mailed to vascular trainees and attending faculty at all Accreditation Council for Graduate Medical Education-approved vascular surgery training programs in the United States. Data were compared using chi-square statistical analysis. RESULTS: One-hundred forty-nine responses from vascular surgery trainees (n = 89) and faculty (n = 60) were obtained. The most highly ranked preoperative skill by trainees was Case Planning, at all post-graduate year-levels. Although a majority of trainees believe this skill is expected of them, only 36.1% of attendings responded that they expect all trainee levels to perform this task. Draping/positioning was ranked as the second most important intraoperative task for all post-graduate year-levels by attendings; however, only 32.8% of attendings expect trainees to perform this. Exposure of Critical Structures was ranked as the most important intraoperative task by both trainees and attendings at the Chief and Fellow level. However, responses by both trainees and attendings showed that this is expected <70% of the time. When asked about double-scrubbing independently of other tasks, most trainees assessed double-scrubbing as inherently important to autonomy at all levels of training and within all regions. Only 44.3% of attendings responded that they expect all trainees to double-scrub. Additionally, most trainees in all regions responded that they spend <25% of cases double-scrubbed. CONCLUSIONS: These responses show a discrepancy between the skills that both trainees and attendings deem important to autonomy versus what is being expected of trainees in reality.

Hospital Admissions Associated With Head and Neck Injuries From Olympic-style Sports and Activities Between 2010 and 2022.

The objective of this study was to evaluate which Olympic-style sports and activities are most likely to result in hospitalizations relating to head and neck injuries. This was a cross-sectional study using the National Electronic Injury Surveillance System (NEISS) database. Subjects with head and neck injuries from selected Olympic-style sports and activities between 2010 and 2022 were included. Independent variables were demographics and injury characteristics (injury location and sport). The primary outcome variable was hospitalization (yes/no). Survey-weighted descriptive, bivariate, and logistic regression statistics were computed to measure the association between demographic/injury variables and hospitalization. There were 175,995 subjects (national estimate, 5,922,584) meeting inclusion criteria. After adjusting for demographic and injury characteristics, head injuries (odds ratio [OR] = 2.17; 95% CI, 1.83-2.56; P<0.001) demonstrated higher odds of hospitalization compared with facial injuries. Injuries from cycling (OR = 2.52; 95% CI, 2.16-2.95; P<0.001), mountain biking (OR = 2.56; 95% CI, 1.80-3.65; P<0.001), and horseback riding (OR = 4.01; 95% CI, 2.76-5.83; P<0.001) demonstrated higher odds of hospitalization relative to baseball injuries. In conclusion, head and neck injuries associated with high velocity Olympic-style sports and activities such as cycling, mountain biking, and horseback riding had the highest odds of hospitalization.

An anesthesiologist-led inpatient buprenorphine initiative.

Hospitalized patients with opioid use disorder who present with acute pain are challenging to manage. Without any treatment, their mortality in the first 28 days after discharge is substantially increased. Unlike extended-release naltrexone, which requires a period of withdrawal, or methadone, which can cause prolonged corrected QT (QTc) and carries a higher risk of respiratory depression, buprenorphine provides potent analgesia with low respiratory risk. Hospitalization provides a unique opportunity for clinicians to perform buprenorphine induction, which could potentially reduce mortality without affecting analgesia. Our acute pain management service uses multimodal analgesia to maintain adequate analgesia and minimize withdrawal during buprenorphine induction in the hospital. With the assistance of narcotics addiction rehabilitation program specialists, we help link patients to outpatient buprenorphine providers and maximize the chance of successful recovery. The primary outcome of this study was to determine the percentage of patients who filled an outpatient buprenorphine prescription after undergoing inpatient induction.

Does Fee-for-Service Medicare Reimbursement Incentivize Volume Over Value Among Oral and Maxillofacial Surgeons?

PURPOSE: National health care payment models have begun transitioning from fee-for-service to value-based reimbursement because of criticism of the former incentivizing quantity over quality. However, there has yet to be an evaluation of the influence of fee-for-service incentives among oral and maxillofacial surgery services. This study characterized service intensity among oral and maxillofacial surgeons (OMSs) serving Medicare beneficiaries in 2017 to determine if higher Medicare income among OMSs arises from higher service intensity or a higher volume of patients treated. PATIENTS AND METHODS: This cross-sectional study was composed of Medicare Provider Utilization and Payment Data from 2017. Providers were included if their specialty type was listed as "maxillofacial surgery." The predictor variables included service intensity, defined as the number of health care services administered per Medicare beneficiary, and Medicare beneficiary volume. The primary outcome variable was Medicare income. Descriptive statistics and pair-wise comparisons were computed at an α level of .05. RESULTS: The analysis cohort was composed of 696 distinct OMSs. A total of 69,959 services were recorded for 53,245 Medicare beneficiaries, with a mean service intensity of 1.12 services per beneficiary. A statistically significant difference in service intensity was found between Medicare payment deciles (P = .002). The magnitude of this difference was less relative to the difference in all medical specialties. CONCLUSIONS: There is a statistically significant difference in service intensity between low and high earners in oral-maxillofacial surgery; however, the magnitude of the difference is unlikely to be clinically or economically meaningful. Variation in service intensity is lower in oral-maxillofacial surgery relative to all medical specialties in aggregate. Given the changing reimbursement landscape in medicine and surgery, it is important to evaluate existing billing practices within the specialty to advocate for the profession in discussions of payment reform and ensure that patients are receiving only necessary services.

Rural Oral and Maxillofacial Surgeon Case Mix Leads to Lower Medicare Reimbursement.

PURPOSE: A relative paucity of literature exists analyzing rural-urban differences in Medicare insurance claims by oral and maxillofacial surgeons (OMSs). The purpose of this study is to compare Medicare utilization, billing practices, and reimbursement rates between rural OMSs and their urban counterparts. METHODS: This cross-sectional study examines Medicare claims data from the 2017 Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File. The primary predictor variable was the provider Rural-Urban Commuting Area Code (rural vs urban). The primary outcome variable was the total Medicare standardized payment amount per OMS. Additional variables include total number of services provided, total unique Healthcare Common Procedure Coding System codes submitted, total submitted charge amount for all services, mean beneficiary hierarchical condition category, and the total Medicare allowed/payment amount for all services. Descriptive statistics were calculated and continuous variables were compared using nonparametric Mann-Whitney U tests. RESULTS: The analysis cohort had 921 OMSs who recorded 114,169 Part B services in 2017. Urban OMSs billed more services compared to rural OMSs, saw patients with a higher average hierarchical condition category score, and submitted more claims per beneficiary. The mean reimbursement-to-charge ratio was higher among rural OMSs, although the mean payment per service was higher among urban surgeons. CONCLUSIONS: Rural OMSs bill fewer unique codes and treat less medically complex patients compared with their urban counterparts. Rural surgeons were reimbursed proportionally higher for their total submitted charges than urban surgeons; however, they were reimbursed less for each individual service provided. These differences may be attributable to the Centers for Medicare & Medicaid Services Multiple Procedure Payment Reduction policy and provider case mix.

Clinical Productivity and Medicare Payments Among Female and Male Oral and Maxillofacial Surgeons.

PURPOSE: To characterize and compare clinical productivity and payments between female and male oral and maxillofacial surgeons (OMSs) serving Medicare beneficiaries in 2017. MATERIALS AND METHODS: This cross-sectional study was composed of Medicare Provider Utilization and Payment Data from 2017. Providers were included if they were labeled as maxillofacial surgeons. The primary outcome variable was Medicare payment. Secondary outcome variables included clinical productivity (number of charges), unique billing codes, mean payment per charge, and beneficiary hierarchical condition category. Descriptive statistics and pair-wise comparisons were computed at an α level of .05. RESULTS: The analysis cohort was composed of 737 distinct OMSs, of whom 58 were women. Although female surgeons recorded higher mean clinical productivity, total Medicare payments, and number of unique Healthcare Common Procedure Coding System billing codes relative to male surgeons in both the facility and office settings, the differences were not statistically different. Payment per charge did not differ significantly between genders in the office setting. In the facility setting, women were reimbursed $63.74 per charge whereas men were reimbursed $109.69 per charge (P < .02). Female OMSs treated more medically complex patients relative to male OMSs (P < .02). CONCLUSIONS: Clinical productivity and total Medicare payments were similar between genders in both the facility and office settings, disputing prior surveys that illustrated bias about the productivity and ability of female OMSs. Female OMSs earned, on average, less per submitted charge in facility settings, which may be due to differences in documentation. The reason for this difference warrants further study.

Five-Year Comparative Analysis of Medicare Opioid Prescription Volume Among Oral and Maxillofacial Surgeons.

PURPOSE: To examine the volume and variation in opioid prescribing practices among oral and maxillofacial surgeons (OMSs) serving Medicare beneficiaries from 2013 to 2017 and identify the practice-level features that correlate with the opioid prescription volume. MATERIALS AND METHODS: The present cross-sectional study included Medicare Provider Utilization and Payment Data from 2013 to 2017. Providers were included if they were labelled as OMSs. The primary outcome variable was the opioid claim volume. The predictor variables included provider and beneficiary gender, beneficiary age, and beneficiary hierarchical condition category (HCC). The secondary outcome variables included mean opioid prescriptions per beneficiary and opioid days' supply per claim. Descriptive statistics and regression analyses were computed at an α level of 0.05. RESULTS: The 5-year analysis cohort included 2071 distinct providers; 605,593 total opioid prescription claims were recorded for 516,217 Medicare beneficiaries, with an average supply of 3.54 days of opioids per patient. From 2013 to 2017, a significant increase had occurred in the number of mean opioid claims per provider (P < .001) and a significant decrease in both the mean opioid claims per beneficiary (P < .001) and the days' supply per opioid claim per beneficiary (P < .001). Male provider gender (P < .001), lower beneficiary age (P < .001), percentage of female beneficiaries seen by a provider (P < .001), and lower HCC risk score (P < .001) all correlated with an increased opioid claim volume. Finally, a significant difference was found in the opioid claim volume among OMSs between the states (P < .001) and between oral and maxillofacial surgery and other surgical subspecialties (P < .001). CONCLUSIONS: Although the total number of opioids prescribed by OMSs has increased over time, the prescribing practices have, on the aggregate, become more responsible. The extreme cases of opioid prescribing and variations in state-level opioid claim volumes warrant additional investigation.

Canadian national survey of family medicine residents on point-of-care ultrasound training.

OBJECTIVE: To assess the quality of point-of-care ultrasound (POCUS) training in family medicine residency programs and to obtain the opinions of current family medicine residents on the role of ultrasound in primary care. DESIGN: A 23-question online survey conducted using SurveyMonkey between March 15 and June 30, 2017. SETTING: Canada. PARTICIPANTS: All family medicine residents of the 17 Canadian family medicine residency programs were included in the study but all enhanced skills residents were excluded. MAIN OUTCOME MEASURES: The quality and relevance of POCUS to primary care as perceived by residents and reported in the survey. RESULTS: A total of 854 Canadian family medicine residents responded, for a national response rate of 32.3%. Most respondents (94.3%) believe that POCUS training should be included in family medicine residency programs; however, only 18.4% of respondents currently receive formal training within their residency. Among those without POCUS training, 91.7% are interested in receiving formal training and 29.7% resorted to taking external POCUS courses. Most (77.5%) would consider using ultrasound in their future practice if they were competent in POCUS. The most useful applications for family medicine were considered to be the FAST (Focused Assessment with Sonography in Trauma) examination for free fluid and ascites (95.1%), procedural guidance (92.4%), and identifying an intrauterine pregnancy (88.6%). CONCLUSION: This is the largest survey identifying the perceived needs of family medicine residents for POCUS. Very few Canadian family medicine residents currently receive POCUS training. Consistent with our recent family medicine program director survey, there is overwhelming interest by family medicine residents to begin incorporating POCUS training into the family medicine curriculum.

WITHDRAWN: Health Policy Research May Ensure the Future of Oral and Maxillofacial Surgery.

The Publisher regrets that this article is an accidental duplication of an article that has already been published, https://doi.org/10.1016/j.joms.2017.03.056. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.