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INTRODUCTION: Frailty and cognitive function are often measured during kidney transplant evaluation. However, patient perspectives on the ethical considerations of this practice are unclear. RESEARCH QUESTION: What are patient perspectives on the use of aging metrics in kidney transplant decision-making? DESIGN: One hundred participants who were evaluated for kidney transplantation and were enrolled in an ongoing prospective cohort study (response rate = 61.3%) were surveyed. Participants were informed of the definitions of frailty and cognitive impairment and then asked survey questions regarding the use of these measures of aging to determine kidney transplant candidacy. RESULTS: Participants (75.6%) thought it was unfair to prevent older adults from receiving a kidney transplant based on age, but there was less agreement on whether it was fair to deny frail (46.5%) and cognitively impaired (45.9%) patients from accessing kidney transplantation. Compared to older participants, younger participants had 5.36-times (95%CI:1.94-14.81) the odds of choosing a hypothetical younger, frail patient to list for kidney transplantation than an older, non-frail patient; they also had 3.56-times (95%CI:1.33-9.56) the odds of choosing the hypothetical frail patient with social support rather than a non-frail patient without social support. Participants disagreed on the use of patient age as a listing criterion; 19.5% ranked it as the fairest and 28.7% as the least fair. CONCLUSION: The patient views highlighted in this study are an important step toward developing ethical guidelines to ensure fair use of frailty, cognitive function, and chronological age for kidney transplant decision-making.
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The COVID-19 pandemic has caused changes in health care as well as human suffering, and consideration of the principles of ethics can build a foundation to consider dilemmas that have arisen. Diversity, equity, and inclusion have become key issues. Simulation training and the related ethics of its application have taken on new meaning. Access to health care continues to evolve and will need further evaluation in the years following the COVID-19 pandemic.
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COVID-19 , Procedimentos Ortopédicos , Humanos , SARS-CoV-2 , Pandemias , Atenção à SaúdeRESUMO
BACKGROUND: Advanced imaging modalities are expensive, and access to advanced imaging services may vary by socioeconomic factors, creating the potential for unwarranted variations in care. Ankle sprains are a common injury for which variations in MRI use can occur, both via underuse of indicated MRIs (appropriate use) and overuse of nonindicated MRIs (inappropriate use). High-value, equitable healthcare would decrease inappropriate use and increase appropriate use of MRI for this common injury. It is unknown whether socioeconomic factors are associated with underuse of indicated MRIs and overuse of nonindicated MRIs for ankle sprains. QUESTIONS/PURPOSES: Using ankle sprains as a paradigm injury, given their high population incidence, we asked: (1) Does MRI use for ankle sprains vary by insurance type? (2) After controlling for relevant confounding variables, did patients who received an MRI have higher odds of undergoing ankle surgery? METHODS: Between 2011 and 2019, a total of 6,710,223 patients were entered into the PearlDiver Mariner Patient Records Database with a diagnosis of ankle sprain. We considered patients with continuous enrollment in the database for at least 1 year before and 2 years after the diagnosis as potentially eligible. Based on that, 68% (4,567,106) were eligible; a further 20% (1,372,478) were excluded because of age younger than 18 years, age at least 65 years with Medicaid insurance, or age < 65 years with Medicare insurance. Another 0.1% (9169) had incomplete data, leaving 47% (3,185,459) for analysis here. Patients with Medicaid insurance differed from patients with Medicare Advantage or private insurance with respect to age, gender, region, and comorbidity burden. The primary outcome was ankle MRI occurring within 12 months after diagnosis. The use of ankle surgery after MRI in each cohort was measured as a secondary outcome. We used multivariable logistic regression models to evaluate the association between insurance type and MRI use while adjusting for age, gender, region, and comorbidity burden. Separate multivariable regression models were created to evaluate the association between receiving an MRI and subsequent ankle surgery for each insurance type, adjusting for age, gender, region, and comorbidity burden. Within 12 months of an ankle sprain diagnosis, 1% (3522 of 339,457) of patients with Medicaid, 2% (44,793 of 2,627,288) of patients with private insurance, and 1% (1660 of 218,714) of patients with Medicare Advantage received an MRI. RESULTS: After controlling for age, gender, region, and comorbidity burden, patients with Medicaid had lower odds of receiving an MRI within 12 months after ankle sprain diagnosis than patients with private insurance (odds ratio 0.60 [95% confidence interval 0.57 to 0.62]; p < 0.001). Patients with Medicaid who received an MRI had higher adjusted odds of undergoing subsequent ankle surgery (OR 23 [95% CI 21 to 26]; p < 0.001) than patients with private insurance (OR 12.7 [95% CI 12 to 13]; p < 0.001). CONCLUSION: Although absolute MRI use was generally low, there was substantial relative variation by insurance type. Given the high incidence of ankle sprains in the general population, these relative differences can translate to tens of thousands of MRIs. Further studies are needed to evaluate the reasons for decreased appropriate MRI use in patients with Medicaid and overuse of MRI in patients with private insurance. The establishment of clinical practice guidelines by orthopaedic professional societies and more stringent gatekeeping for MRI use by health insurers could reduce unwarranted variations in MRI use. LEVEL OF EVIDENCE: Level III, prognostic study.
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The purpose of this study is to develop a wearable paradigm to accurately monitor Achilles tendon loading and walking speed using wearable sensors that reduce subject burden. Ten healthy adults walked in an immobilizing boot under various heel wedge conditions (30°, 5°, 0°) and walking speeds. Three-dimensional motion capture, ground reaction force, and 6-axis inertial measurement unit (IMU) signals were collected. We used a Least Absolute Shrinkage and Selection Operator (LASSO) regression to predict peak Achilles tendon load and walking speed. The effects of altering sensor parameters were also explored. Walking speed models (mean absolute percentage error (MAPE): 8.81 ± 4.29%) outperformed tendon load models (MAPE: 34.93 ± 26.3%). Models trained with subject-specific data performed better than models trained without subject-specific data. Removing the gyroscope, decreasing the sampling frequency, and using combinations of sensors did not change the usability of the models, having inconsequential effects on model performance. We developed a simple monitoring paradigm that uses LASSO regression and wearable sensors to accurately predict (MAPE ≤ 12.6%) Achilles tendon loading and walking speed while ambulating in an immobilizing boot. This paradigm provides a clinically implementable strategy to longitudinally monitor patient loading and activity while recovering from Achilles tendon injuries.
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Tendão do Calcâneo , Dispositivos Eletrônicos Vestíveis , Adulto , Humanos , Velocidade de Caminhada , Caminhada , Aprendizado de Máquina , Fenômenos Biomecânicos , MarchaRESUMO
There remains a high prevalence and substantial risks of opioid utilization amongst orthopedic patients. The goal of this review is to discuss strategies for responsible opioid use in the perioperative setting following foot and ankle orthopedic surgeries. We will highlight 1) education interventions, 2) risk identification, and 3) non-opioid alternatives for postoperative pain management.
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Analgesia , Ortopedia , Humanos , Tornozelo/cirurgia , Manejo da Dor , Extremidade Inferior , Analgésicos Opioides/uso terapêuticoAssuntos
Tomada de Decisões , Virtudes , Humanos , Incerteza , Medição de Risco , Assistência ao PacienteRESUMO
As surgical care continues to transition to an outpatient setting, ambulatory surgery centers (ASCs) present favorable options for physician investment. As of 2017, more than 90% of ASCs have at least some physician ownership, with 64% solely physician-owned. Yet, physician ownership creates an inherent conflict of interest known as dual agency, where clinicians have a personal financial stake in addition to their obligation towards patient well-being. Here, we assess the ethical considerations surrounding dual agency in the setting of ASCs through the lens of beneficence, nonmaleficence, autonomy, and justice. We further propose strategies for appropriate navigation of such situations, including disclosure of ownership status, instruction on unfamiliar techniques, and adherence to accepted clinical practice guidelines for materials selection and surgical indications.
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Propriedade , Cirurgiões , Procedimentos Cirúrgicos Ambulatórios , Beneficência , Revelação , Humanos , Investimentos em Saúde , Autonomia PessoalRESUMO
BACKGROUND: Among adult kidney transplant (KT) candidates, 21% are frail and 55% have cognitive impairment, increasing the risk of pre- and post-KT mortality. Centers often assess frailty status and cognitive function during transplant evaluation to help identify appropriate candidate. Yet, there are no ethical guidelines regarding the use of frailty and cognitive function during this evaluation. We seek to develop a clinical consensus on balancing utility and justice in access to KT for frail and cognitively impaired patients. METHODS: Twenty-seven experts caring for ESRD patients completed a two-round Delphi panel designed to facilitate consensus (> 80% agreement). RESULTS: Experts believed that denying patients transplantation based solely on expected patient survival was inequitable to frail or cognitively impaired candidates; 100% agreed that frailty and cognitive impairment are important factors to consider during KT evaluation. There was consensus that health related quality of life and social support are important to consider before waitlisting frail or cognitively impaired patients. Experts identified important factors to consider before waitlisting frail (likely to benefit from KT, frailty reversibility, age, and medical contraindications) and cognitively impaired (degree of impairment and medication adherence) patients. CONCLUSIONS: Clinical experts believed it was ethically unacceptable to allocate organs solely based on patients' expected survival; frailty and cognitive impairment should be measured at evaluation when weighed against other clinical factors. Ethical guidelines regarding the use of frailty and cognitive function during KT evaluation ought to be developed.
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Disfunção Cognitiva , Fragilidade , Transplante de Rim , Idoso , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/terapia , Técnica Delphi , Idoso Fragilizado/psicologia , Fragilidade/diagnóstico , Fragilidade/terapia , Humanos , Qualidade de VidaRESUMO
BACKGROUND: The allocation of scarce deceased donor kidneys is a complex process. Transplant providers are increasingly relying on constructs such as frailty and cognitive function to guide kidney transplant (KT) candidate selection. Patient views of the ethical issues surrounding the use of such constructs are unclear. We sought to assess KT candidates' attitudes and beliefs about the use of frailty and cognitive function to guide waitlist selection. METHODS: KT candidates were randomly recruited from an ongoing single-center cohort study of frailty and cognitive function. Semi-structured interviews were conducted, and thematic analysis was performed. Inductively derived themes were mapped onto bioethics principles. RESULTS: Twenty interviews were conducted (65% contact rate, 100% participation rate) (60% male; 70% White). With respect to the use of frailty and cognitive function in waitlisting decisions, four themes emerged in which participants: (1) valued maximizing a scarce resource (utility); (2) prioritized equal access to all patients (equity); (3) appreciated a proportional approach to the use of equity and utility (precautionary utility); and (4) sought to weigh utility- and equity-based concerns regarding social support. While some participants believed frailty and cognitive function were useful constructs to maximize utility, others believed their use would jeopardize equity. Patients were uncomfortable with using single factors such as frailty or cognitive impairment to deny someone access to transplantation; participants instead encouraged using the constructs to identify opportunities for intervention to improve frailty and cognitive function prior to KT. CONCLUSIONS: KT candidates' values mirrored the current allocation strategy, seeking to balance equity and utility in a just manner, albeit with conflicting viewpoints on the appropriate use of frailty and cognitive impairment in waitlisting decisions.