Cost-Effectiveness of Diffusion-Weighted Magnetic Resonance Imaging Versus Second-Look Surgery in Treating Cholesteatoma: A Modeling Study.

OBJECTIVE: To evaluate whether canal wall-up (CWU) tympanomastoidectomy with diffusion-weighted magnetic resonance imaging (DW-MRI) is a cost-effective method of treating cholesteatoma compared with CWU with second-look surgery. DESIGN AND SETTING: Cost-effectiveness analysis was conducted using a Markov state transition model. The simulation model adhered to the Panel Recommendations on Cost-Effectiveness in Health and Medicine established by the US Public Health Service. One-way and Monte Carlo probability sensitivity analyses were conducted for validation. INTERVENTIONS: Tympanomastoidectomy with DW-MRI versus tympanomastoidectomy with second-look surgery. MAIN OUTCOME MEASURES: Effectiveness and health utility were measured using quality-adjusted life years (QALYs). Costs were derived from Medicare reimbursement using the perspective of the payer. Probabilities for outcomes and complications were taken from existing literature. Cost-effectiveness was assessed using the incremental cost-effectiveness ratio. RESULTS: With base case analysis, the total cost was $15,069 when treated with CWU and second-look surgery versus $13,126 when treated with CWU and DW-MRI. The second-look treatment pathway yielded 17.05 QALYs, whereas the DW-MRI pathway yielded 16.91 QALYs in terms of health benefit accrued across the lifetime of the patient. The cost-effectiveness incremental cost-effectiveness ratio was $21,800/QALY. Using the conventional $50,000 willingness-to-pay threshold, second-look surgery was the more cost-effective approach 63.7% of the time by simulation. CONCLUSIONS: Both treatment pathways were found to be cost-effective, with second-look surgery incrementally cost-effective 63.7% of the time. Assumptions were validated by one-way and Monte Carlo probability sensitivity analysis. PROFESSIONAL PRACTICE GAP AND EDUCATIONAL NEED: There is ample variation in treatment pathways regarding usage of DW-MRI and second-look surgery for cholesteatoma. LEARNING OBJECTIVE: To evaluate the cost-effectiveness of DW-MRI and second-look surgery approaches, accounting for health-related quality-of-life outcomes and costs for the duration of the patient lifetimes. DESIRED RESULT: To inform the discussion on the treatment for cholesteatoma given emergent noninvasive technologies.Level of Evidence: Level III.Indicate IRB or IACUC: Exempt.

Cost-effectiveness of Canal Wall-Up vs Canal Wall-Down Mastoidectomy: A Modeling Study.

OBJECTIVE: To assess the relative lifetime costs, benefits, and cost-effectiveness between the 2 approaches, canal wall-up (CWU) and canal wall-down (CWD) tympanomastoidectomy, used in the treatment of cholesteatomas. STUDY DESIGN: Markov state transition model. SETTING: Tertiary academic health system. METHODS: A Markov state transition model was used to simulate outcomes across the patient lifetime. Outcome and complication probabilities were obtained from the existing literature. Costs were calculated from the payer perspective, with procedure, hospital, clinic, and physician cost derived from Medicare reimbursement. Quality-adjusted life years (QALYs) were used to represent effectiveness and utility. One-way and probability sensitivity analyses (PSAs) were conducted. RESULTS: The base case analysis, assuming a 40-year-old patient, yielded a lifetime cost of $14,214 for a patient treated with the CWU approach assuming second-look surgery and $22,290 with a CWD approach. CWU and CWD generated a benefit of 17.11 and 17.30 QALYs, respectively. The incremental cost-effectiveness ratio for CWU was $43,237 per QALY. The Monte Carlo PSA validated the base case scenario. Using a standard $50,000 willingness-to-pay threshold, CWD was the more cost-effective approach and was selected 54.8% of the time by the simulation. CONCLUSION: Both CWU and CWD were found to be cost-effective, with CWD being cost-effective 54.8% of the time at a WTP threshold of $50,000. The assumptions used in the analysis were validated by the results of 1-way and PSA.

The Price of Otologic Procedures: Variation in Markup by Surgical Procedure and Geography in the United States.

OBJECTIVE: To characterize and analyze variation in price markup of seven common otologic surgeries by procedure and geographic region. STUDY DESIGN: Retrospective Analysis of the Centers for Medicare and Medicaid Services database of 2017 Medicare Provider Utilization and Payment Public File. SETTING: Inpatient and outpatient centers delivering Medicare-reimbursed services. PATIENTS: Full sample of patients undergoing procedures with Medicare fee-for-service final action claims during 2017. INTERVENTIONS: Seven procedures (myringotomy, tympanoplasty, mastoidectomy, tympanomastoidectomy stapedotomy/stapedectomy, cochlear implant, bone-anchored hearing aid). MAIN OUTCOME MEASURES: Markup ratio (MUR) is defined as the ratio of total charges to Medicare-allowable-costs; Variation in MUR was measured using coefficient of variation (CoV). RESULTS: Among all providers, the median MUR was 2.4 (interquartile range: 1.9-3.1). MUR varied significantly by procedure, from 2.3 for myringotomy to 8.7 for mastoidectomy (p < 0.01). MUR also varied significantly within procedure, with the least variation found in myringotomy (CoV = 0.46), and the greatest in cochlear implants (CoV = 0.92). Using the national average as baseline, MUR varied 71% between states, ranging from 1.75 to 6.24. Within the same state, significant variation was also noted, varying by 4% (CoV = 0.04) in Montana compared with 138% (CoV = 1.38) in Pennsylvania. MUR was not significantly correlated with patient comorbidity or Centers for Medicare and Medicaid Services risk scores. CONCLUSIONS: There was significant variation in the price of otologic surgery across geographic regions and procedures. The MUR for otology is lower or comparable to that reported in other surgical fields.

The utility of augmented reality in lateral skull base surgery: A preliminary report.

OBJECTIVE: To discuss the utility of augmented reality in lateral skull base surgery. PATIENTS: Those undergoing lateral skull base surgery at our institution. INTERVENTION(S): Cerebellopontine angle tumor resection using an augmented reality interface. MAIN OUTCOME MEASURE(S): Ease of use, utility of, and future directions of augmented reality in lateral skull base surgery. RESULTS: Anecdotally we have found an augmented reality interface helpful in simulating cerebellopontine angle tumor resection as well as assisting in planning the incision and craniotomy. CONCLUSIONS: Augmented reality has the potential to be a useful adjunct in lateral skull base surgery, but more study is needed with large series.

Lymph Node Ratio in HPV-Associated Oropharyngeal Cancer: Identification of a Prognostic Threshold.

OBJECTIVE: To evaluate the utility of lymph node ratio (LNR) as a prognostic factor for survival and recurrence in surgically treated patients with human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC). STUDY DESIGN: Retrospective cohort study. METHODS: In this retrospective cohort study of a tertiary healthcare system in a major metropolitan area, we reviewed 169 consecutive patients with HPV-related OPSCC treated using transoral robotic surgery. Univariable and multivariable Cox proportional hazards regression analysis with stratified models were used to compare LNR with other traditional clinicopathologic risk factors forrecurrence and survival. An LNR cutoff was found using the minimal P approach. RESULTS: Multivariable Cox regression models showed that each additional percentage increase in LNR corresponded to an adjusted hazard ratio (HR) of 1.04 (confidence interval [CI] 1.02-1.07). LNR was more significant when adjusted for adequate lymph node yield of ≥ 18 nodes (HR 5.05, 95% confidence interval [CI] 1.38-18.47). The minimal P generated cutoff point at LNR ≥ 17% demonstrated a HR 4.34 (95% CI 1.24-15.2) for disease-free survival. CONCLUSION: For HPV-related OPSCC, continuous LNR and an LNR threshold of 17% could be helpful in identifying recurrent disease in addition to measures such as lymph node number alone. LEVEL OF EVIDENCE: 4.

Assessment of Changes in Rural and Urban Primary Care Workforce in the United States From 2009 to 2017.

Importance: Access to primary care clinicians, including primary care physicians and nonphysician clinicians (nurse practitioners and physician assistants) is necessary to improving population health. However, rural-urban trends in primary care access in the US are not well studied. Objective: To assess the rural-urban trends in the primary care workforce from 2009 to 2017 across all counties in the US. Design, Setting, and Participants: In this cross-sectional study of US counties, county rural-urban status was defined according to the national rural-urban classification scheme for counties used by the National Center for Health Statistics at the Centers for Disease Control and Prevention. Trends in the county-level distribution of primary care clinicians from 2009 to 2017 were examined. Data were analyzed from November 12, 2019, to February 10, 2020. Main Outcomes and Measures: Density of primary care clinicians measured as the number of primary care physicians, nurse practitioners, and physician assistants per 3500 population in each county. The average annual percentage change (APC) of the means of the density of primary care clinicians over time was calculated, and generalized estimating equations were used to adjust for county-level sociodemographic variables obtained from the American Community Survey. Results: The study included data from 3143 US counties (1167 [37%] urban and 1976 [63%] rural). The number of primary care clinicians per 3500 people increased significantly in rural counties (2009 median density: 2.04; interquartile range [IQR], 1.43-2.76; and 2017 median density: 2.29; IQR, 1.57-3.23; P < .001) and urban counties (2009 median density: 2.26; IQR. 1.52-3.23; and 2017 median density: 2.66; IQR, 1.72-4.02; P < .001). The APC of the mean density of primary care physicians in rural counties was 1.70% (95% CI, 0.84%-2.57%), nurse practitioners was 8.37% (95% CI, 7.11%-9.63%), and physician assistants was 5.14% (95% CI, 3.91%-6.37%); the APC of the mean density of primary care physicians in urban counties was 2.40% (95% CI, 1.19%-3.61%), nurse practitioners was 8.64% (95% CI, 7.72%-9.55%), and physician assistants was 6.42% (95% CI, 5.34%-7.50%). Results from the generalized estimating equations model showed that the density of primary care clinicians in urban counties increased faster than in rural counties (ß = 0.04; 95% CI, 0.03 to 0.05; P < .001). Conclusions and Relevance: Although the density of primary care clinicians increased in both rural and urban counties during the 2009-2017 period, the increase was more pronounced in urban than in rural counties. Closing rural-urban gaps in access to primary care clinicians may require increasingly intensive efforts targeting rural areas.

Trends and sociodemographic disparities in sugary drink consumption among adults in New York City, 2009-2017.

Despite efforts to decrease sugary drink consumption, sugary drinks remain the largest single source of added sugars in diets in the United States. This study aimed to examine trends in sugary drink consumption among adults in New York City (NYC) over the past decade by key sociodemographic factors. We used data from the 2009-2017 NYC Community Health Survey to examine trends in sugary drink consumption overall, and across different age, gender, and racial/ethnic subgroups. We conducted a test of trend to examine the significance of change in mean sugary drink consumption over time. We also conducted multiple zero-inflated negative binomial regression to identify the association between different sociodemographic and neighborhood factors and sugary drink consumption. Sugary drink consumption decreased from 2009 to 2014 from 0.97 to 0.69 servings per day (p < 0.001), but then plateaued from 2014 to 2017 (p = 0.01). Although decreases were observed across all age, gender and racial/ethnic subgroups, the largest decreases over this time period were observed among 18-24 year old (1.75 to 1.22 servings per day, p < 0.001); men (1.12 to 0.86 servings per day, p < 0.001); Blacks (1.45 to 1.14 servings per day, p < 0.001); and Hispanics (1.26 to 0.86 servings per day, p < 0.001). Despite these decreases, actual mean consumption remains highest in these same sociodemographic subgroups. Although overall sugary drink consumption has been declining, the decline has slowed in more recent years. Further, certain age, gender and racial/ethnic groups still consume disproportionately more sugary drinks than others. More research is needed to understand and address the root causes of disparities in sugary drink consumption.

The National Landscape of Acute Mastoiditis: Analysis of the Nationwide Readmissions Database.

OBJECTIVE: To determine risk factors for readmission, prolonged length of stay, and discharge to a rehabilitation facility in patients with acute mastoiditis. Trends in treatment and complication rates were also examined. STUDY DESIGN: Retrospective cohort study. SETTING: Nationwide Readmissions Database (2013, 2014). PATIENTS: Pediatric and adult patients in the Nationwide Readmissions Database with a primary diagnosis of acute mastoiditis. INTERVENTIONS: Medical treatment, surgical intervention. OUTCOME MEASURES: Rates of and risk factors for readmission, prolonged length of stay, and discharge to a rehabilitation facility. Procedure and complication rates were also examined. RESULTS: Four thousand two hundred ninety-five pediatric and adult admissions for acute mastoiditis were analyzed. The overall rates of readmission, prolonged length of stay, and discharge to a rehabilitation facility were 17.0, 10.4, and 10.2%, respectively. Children 4 to 17 years of age had the highest rates of intracranial complications, and children ≤3 years were most likely to undergo operative intervention. Any procedure was performed in 31.2% of cases, and undergoing myringotomy or mastoidectomy was associated with lower rates of readmission but higher rates of prolonged length of stay. Those with intracranial complications and subperiosteal abscesses had the highest surgical intervention rates. CONCLUSIONS: Readmission, prolonged length of stay, and discharge to a rehabilitation facility are common in patients with acute mastoiditis with various sociodemographic and disease-related risk factors. While once a primarily surgical disease, a minority of patients in our cohort underwent procedures. Undergoing a surgical procedure was protective against readmission but a risk factor for prolonged length of stay.

Achieving Value in Population Health Big Data.

Several population health big data projects have been initiated in the USA recently. These include the County Health Rankings & Roadmaps (CHR) initiated in 2010, the 500 Cities Project initiated in 2016, and the City Health Dashboard project initiated in 2017. Such projects provide data on a range of factors that determine health-such as socioeconomic factors, behavioral factors, health care access, and environmental factors-either at the county or city level. They provided state-of-the-art data visualization and interaction tools so that clinicians, public health practitioners, and policymakers can easily understand population health data at the local level. However, these recent initiatives were all built from data collected using long-standing and extant public health surveillance systems from organizations such as the Centers for Disease Control and Prevention and the U.S. Census Bureau. This resulted in a large extent of similarity among different datasets and a potential waste of resources. This perspective article aims to elaborate on the diminishing returns of creating more population health datasets and propose potential ways to integrate with clinical care and research, driving insights bidirectionally, and utilizing advanced analytical tools to improve value in population health big data.

Preoperative Patient Education May Decrease Postoperative Opioid Use After Meniscectomy.

PURPOSE: To identify the current opioid prescribing and use practices after arthroscopic meniscectomy and to evaluate the role of preoperative patient education in decreasing postoperative opioid consumption. METHODS: Patients undergoing arthroscopic meniscectomy were prospectively identified for inclusion. They were placed into 1 of 2 groups: Group 1 received no education regarding opioid use after surgery, whereas group 2 received a standardized overview on postoperative opioid use. Patients were assigned to the groups consecutively: Patients treated at the beginning of the study were assigned to group 1, and patients treated at the end of the study were assigned to group 2. Data from group 1 were used to identify "normal" opioid prescribing and use practices and to guide patients in group 2 regarding normal postoperative opioid use. Patients were surveyed weekly for 4 weeks after surgery to determine the number of opioids taken. Postoperative opioid consumption was analyzed and compared between the 2 groups. RESULTS: A total of 62 patients completed the study (32 in group 1 and 30 in group 2). Patients in group 1 were prescribed an average of 42.0 opioid pills (95% confidence interval [CI], 34.0-51.0 pills) and used an average of 15.84 pills (95% CI, 9.26-22.4 pills) after surgery, whereas patients in group 2 used an average of 4.00 pills (95% CI, 2.12-5.88 pills) after surgery. Patients in group 2 used 11.84 fewer opioid pills (P = .001), a 296% decrease in postoperative opioid consumption. The number of patients who continued to take opioid pills 4 weeks after surgery was 7 patients (21.9%) in group 1 and 1 patient (3.3%) in group 2. CONCLUSIONS: Preoperative patient education regarding opioids may decrease postoperative opioid consumption and the duration for which patients take opioid pills after arthroscopic meniscectomy. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Biotin tagging of MeCP2 in mice reveals contextual insights into the Rett syndrome transcriptome.

Mutations in MECP2 cause Rett syndrome (RTT), an X-linked neurological disorder characterized by regressive loss of neurodevelopmental milestones and acquired psychomotor deficits. However, the cellular heterogeneity of the brain impedes an understanding of how MECP2 mutations contribute to RTT. Here we developed a Cre-inducible method for cell-type-specific biotin tagging of MeCP2 in mice. Combining this approach with an allelic series of knock-in mice carrying frequent RTT-associated mutations (encoding T158M and R106W) enabled the selective profiling of RTT-associated nuclear transcriptomes in excitatory and inhibitory cortical neurons. We found that most gene-expression changes were largely specific to each RTT-associated mutation and cell type. Lowly expressed cell-type-enriched genes were preferentially disrupted by MeCP2 mutations, with upregulated and downregulated genes reflecting distinct functional categories. Subcellular RNA analysis in MeCP2-mutant neurons further revealed reductions in the nascent transcription of long genes and uncovered widespread post-transcriptional compensation at the cellular level. Finally, we overcame X-linked cellular mosaicism in female RTT models and identified distinct gene-expression changes between neighboring wild-type and mutant neurons, providing contextual insights into RTT etiology that support personalized therapeutic interventions.

Whole blood treated with riboflavin and ultraviolet light: quality assessment of all blood components produced by the buffy coat method.

BACKGROUND: Pathogen inactivation (PI) technologies are currently licensed for use with platelet (PLT) and plasma components. Treatment of whole blood (WB) would be of benefit to the blood banking community by saving time and costs compared to individual component treatment. However, no paired, pool-and-split study directly assessing the impact of WB PI on the subsequently produced components has yet been reported. STUDY DESIGN AND METHODS: In a "pool-and-split" study, WB either was treated with riboflavin and ultraviolet (UV) light or was kept untreated as control. The buffy coat (BC) method produced plasma, PLT, and red blood cell (RBC) components. PLT units arising from the untreated WB study arm were treated with riboflavin and UV light on day of production and compared to PLT concentrates (PCs) produced from the treated WB units. A panel of common in vitro variables for the three types of components was used to monitor quality throughout their respective storage periods. RESULTS: PCs derived from the WB PI treatment were of significantly better quality than treated PLT components for most variables. RBCs produced from the WB treatment deteriorated earlier during storage than untreated units. Plasma components showed a 3% to 44% loss in activity for several clotting factors. CONCLUSION: Treatment of WB with riboflavin and UV before production of components by the BC method shows a negative impact on all three blood components. PLT units produced from PI-treated WB exhibited less damage compared to PLT component treatment.