Satisfaction With Quality of Health Care Among Medicare Beneficiaries With Functional Hearing Loss.

BACKGROUND/OBJECTIVES: Nearly 38 million Americans have hearing loss. Understanding how sensory deficits such as hearing loss, which limit communication, impact satisfaction has implications for Medicare value-based reimbursement mechanisms. The aim of this study was to characterize the association of functional hearing loss and dissatisfaction with quality of health care over the past year among Medicare beneficiaries. METHODS: Cross-sectional study of satisfaction with quality of health care among Medicare beneficiaries with self-reported trouble hearing from the 2015 Medicare Current Beneficiaries Survey. There were 11,441 Medicare beneficiaries representing a 48.6 million total weighted nationally representative sample. RESULTS: Forty-eight percent of Medicare beneficiaries reported a little or a lot of trouble hearing. Medicare beneficiaries with a little trouble hearing (odds ratio=1.496; 95% confidence interval, 1.079-2.073; P=0.016) and a lot of trouble hearing (odds ratio=1.769; 95% confidence interval, 1.175-2.664; P=0.007) had 49.6% and 76.9% higher odds of being dissatisfied with the quality of their health care over the previous year, respectively. CONCLUSIONS: Medicare beneficiaries with functional hearing loss had higher odds of dissatisfaction with health care over the past year compared to those without functional hearing loss. Given Medicare's reliance on patient satisfaction as a value-based measure for hospital reimbursement, interventions to address hearing loss in the health care system are needed.

Caregiver perceptions and attitudes associated with oral immunotherapy on social media.

Background: Caregiver values and preferences with regard to oral immunotherapy (OIT) for treatment of food allergies are not widely reported. Understanding caregiver perspectives is integral to establishing shared decision-making in the treatment of food allergy. Objective: We aimed to understand caregiver opinions that may influence caregivers in their decisions about OIT through social media. Methods: We searched a popular parenting web site for posts related to OIT from December 2008 to September 2019. We applied a Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework to review posts for inclusion, performed thematic content analysis to determine common themes, and calculated frequencies for each theme and subtheme. Posts and comments were included if they contained discussions about OIT for immunoglobulin E-mediated food allergy and were excluded if they were duplicates, comments from an original post from the original user, or comments on a nonrelevant original post. Results: Of 1300 posts and comments retrieved, 174 were included (13%). Most were excluded because they did not directly address OIT for food allergy. Relevant posts could fall into multiple themes and were categorized under three main themes: attitudes (n = 128, "I am scared to do OIT but scared not to!"), logistics (n = 168, "We will be doing this once LO [little one] is a little older"), and questions (n = 32, "How does it work?"). Conclusion: Caregivers communicate with each other through social media, expressing attitudes, logistics, and questions about OIT. Understanding these lay perspectives may help guide clinicians in counseling and engage caregivers in decision-making.

Differences in Tonsillectomy Use by Race/Ethnicity and Type of Health Insurance Before and After the 2011 Tonsillectomy Clinical Practice Guidelines.

OBJECTIVE: To evaluate whether differences in pediatric tonsillectomy use by race/ethnicity and type of insurance were impacted by the American Academy of Otolaryngology-Head and Neck Surgery's 2011 tonsillectomy clinical practice guidelines. STUDY DESIGN: We included children aged <15 years from Florida or South Carolina who underwent tonsillectomy in 2004-2017. Annual tonsillectomy rates within groups defined by race/ethnicity and type of health insurance were calculated using US Census data, and interrupted time series analyses were used to compare the guidelines' impact on utilization across groups. RESULTS: The average annual tonsillectomy rate was greater among non-Hispanic white children (66 procedures per 10 000 children) than non-Hispanic black (38 procedures per 10 000 children) or Hispanic children (41 procedures per 10 000 children) (P < .001). From the year before to the year after the guidelines' release, tonsillectomy use decreased among non-Hispanic white children (-11.1 procedures per 10 000 children), but not among non-Hispanic black (-0.9 procedures per 10 000 children) or Hispanic children (+3.9 procedures per 10 000 children) (P < .05). Use was greater among publicly than privately insured children (75 vs 52 procedures per 10 000 children, P < .001). The guidelines were associated with a reversal of the upward trend in use seen in 2004-2010 among publicly insured children (-5.5 procedures per 10 000 children per year, P < .001). CONCLUSIONS: Tonsillectomy use is greatest among white and publicly insured children. However, the American Academy of Otolaryngology-Head and Neck Surgery's 2011 clinical practice guideline statement was associated with an immediate decrease and change in use trends in these groups, narrowing differences in utilization by race/ethnicity and type of insurance.

Transfusions in Children's Surgery: Characterization and Development of a Model for Benchmarking.

BACKGROUND: Perioperative blood transfusions in children are associated with patient morbidity and are often overutilized. In this study, we identify procedures most commonly associated with the use of red blood cells (RBC) in childrens surgery and develop risk-adjusted models for benchmarking. METHODS: Data from the 2012-2015 National Surgical Quality Improvement Program-Pediatric participant use data files were used. CPT (Current Procedural Terminology) codes were grouped to identify the procedures where transfusions were allocated and associated patient demographics and comorbidities. Patients were stratified in two age groups (0-3 mo and 3 mo to 18 y), and a logistic regression model was developed for each age group. RESULTS: Of 369,176 total cases, 21,410 (5.8%) were associated with a perioperative transfusion. 659 CPT codes were grouped in 207 clusters according to their similarities. The most common procedures associated with transfusion were arthrodesis for spinal deformity (n = 9533, 44.5%), followed by craniectomy for craniosynostosis (n = 1853, 8.7%). The logistic regression model for patients <3 mo included 18 variables and had excellent discriminatory performance (area under the curve 0.866). The model for patients ≥3 mo to 18 y had 21 variables and an area under the curve of 0.911. CONCLUSIONS: The majority of transfusions used in children's surgery are concentrated within a relatively few procedural groups. These findings can help centers in focusing blood optimization efforts on common surgeries with high transfusion rates. In addition, multiple preoperative factors have been built into a risk-adjusted model that can be used for benchmarking blood transfusions among hospitals.

Evaluation of Anemia and Nutritional Status on Children Undergoing Resection of Primary Liver Tumors.

INTRODUCTION: Complete tumor resection of primary malignant liver tumors offers the best chance of survival. However, many of these children may experience anemia and failure to thrive. This study analyzes the association of preoperative anemia and nutritional support with outcomes in children undergoing major resection of primary malignant liver tumors. METHODS: Using the National Surgical Quality Improvement Program Pediatric database from 2012 to 2015, children undergoing major liver resections for primary malignant hepatic tumors were selected. Patient demographics, comorbidities, and 30-d outcomes were compared with respect to the presence of preoperative anemia and the need for nutritional support. Outcomes included 30-d postoperative complications, perioperative blood transfusions, and hospital readmissions. Propensity score matching was performed to control for significant confounders. RESULTS: One hundred ten children were included, 76 (69.1%) with preoperative anemia, and 36 (32.7%) receiving nutritional support. Anemia was associated with preoperative chemotherapy (P = 0.02) and steroids (P = 0.03). Nutritional support was associated with cardiac (P = 0.01), respiratory (P < 0.01), neurologic (P < 0.01), and hematologic comorbidities (P = 0.02). There were 20 (18.2%) postoperative complications and 6 (5.5%) hospital readmissions. After propensity score matching, there was no difference in complications between anemic and nonanemic patients (P = 0.13). Preoperative nutritional support was associated with an increased rate of complications (P < 0.01). Neither anemia (P = 1.00) nor nutritional support (P = 0.49) were associated with readmissions. CONCLUSIONS: The need for nutritional support is common in children undergoing resection of primary malignant hepatic tumors. Anemia was not significantly associated with postoperative complications. In this study, nutritional support was associated with an increased risk of postoperative complications. The need for nutritional support may warrant special attention to the patient's overall conditioning during operative planning.

Review of the enhanced recovery pathway for children: perioperative anesthetic considerations.

PURPOSE: Enhanced recovery after surgery (ERAS) pathways have been used for two decades to improve perioperative recovery in adults. Nevertheless, little is known about their effectiveness in children. The purpose of this review was to consider pediatric ERAS pathways, review the literature concerned with their potential benefit, and compare them with adult ERAS pathways. SOURCE: A PubMed literature search was performed for articles that included the terms enhanced recovery and/or fast track in the pediatric perioperative period. Pediatric patients included those from the neonatal period through teenagers and/or youths. PRINCIPAL FINDINGS: The literature search revealed a paucity of articles about pediatric ERAS. This lack of academic investigation is likely due in part to the delayed acceptance of ERAS in the pediatric surgical arena. Several pediatric studies examined individual components of adult-based ERAS pathways, but the overall study of a comprehensive multidisciplinary ERAS protocol in pediatric patients is lacking. CONCLUSION: Although adult ERAS pathways have been successful at reducing patient morbidity, the translation, creation, and utility of instituting pediatric ERAS pathways have yet to be realized.

Analysis of risk factors for morbidity in children undergoing the Kasai procedure for biliary atresia.

OBJECTIVE: To evaluate the perioperative risk factors for 30-day complications of the Kasai procedure in a large, cross-institutional, modern dataset. STUDY DESIGN: The 2012-2015 National Surgical Quality Improvement Program Pediatric database was used to identify patients undergoing the Kasai procedure. Patients' characteristics were compared by perioperative blood transfusions and 30-day outcomes, including complications, reoperations, and readmissions. Multivariable logistic regression was used to identify risk factors predictive of outcomes. Propensity matching was performed for perioperative blood transfusions to evaluate its effect on outcomes. RESULTS: 190 children were included with average age of 62 days. Major cardiac risk factors were seen in 6.3%. Perioperative blood transfusions occurred in 32.1%. The 30-day post-operative complication rate was 15.8%, reoperation 6.8%, and readmission 15.3%. After multivariate analysis, perioperative blood transfusions (OR 3.94; p < 0.01) and major cardiac risk factors (OR 7.82; p < 0.01) were found to increase the risk of a complication. Perioperative blood transfusion (OR 4.71; p = 0.01) was associated with an increased risk of reoperation. Readmission risk was increased by prematurity (OR 3.88; p = 0.04) and 30-day complication event (OR 4.09; p = 0.01). After propensity matching, perioperative blood transfusion was associated with an increase in complications (p < 0.01) and length of stay (p < 0.01). CONCLUSION: Major cardiac risk factors and perioperative blood transfusions increase the risk of post-operative complications in children undergoing the Kasai procedure. Further research is warranted in the perioperative use of blood transfusions in this population. LEVEL OF EVIDENCE: IV.

Outcomes after endoscopic dilation of laryngotracheal stenosis: an analysis of ACS-NSQIP.

IMPORTANCE: Endoscopic management of pediatric subglottic stenosis (SGS) is common, however no multi-institutional studies have assessed its perioperative outcomes. The American College of Surgeon's National Surgical Quality Improvement Program - Pediatric (ACS-NSQIP-P) represents a source of such data. DESIGN: Current procedural terminology (CPT) codes were queried for endoscopic or open airway reconstruction in the ACS-NSQIP-P Public Use File (PUF). Demographics and 30-day events were abstracted to compare open to endoscopic techniques and to assess for risk factors for varied outcomes after endoscopic dilation. SETTING: National database. PARTICIPANTS: Patients with data reported in the 2015 ACS-NSQIP-P PUF. MEASUREMENTS: Length of stay (LOS), 30-day rates of reintubation, readmission and reoperation. RESULTS: 171 endoscopic and 116 open procedures were identified. Mean age at endoscopic and open procedures was 4.1 (SEM = 0.37) and 5.4 years (SEM = 0.40) respectively. Mean LOS was shorter after endoscopic procedures (5.5 days, SEM = 1.13 vs. 11.3 days SEM = 1.01, p = 0.0003). Open procedures had higher rates of reintubation (OR = 7.41, p = .026) and reoperation (OR = 3.09, p = .009). In patients undergoing endoscopic dilation, children <1 year were more likely to require readmission (OR=4.21, p=0.03) and reoperation (OR=4.39, p=0.03) when compared to older children. CONCLUSION: Open airway reconstruction is associated with longer LOS and increased reintubations and reoperations, suggesting a possible opportunity to improve value in healthcare in the appropriately selected patient. Reoperations and readmissions following endoscopic dilation are more prevalent in children less than one year.

Use of risk stratification indices to predict mortality in critically ill children.

UNLABELLED: The complexity and high cost of neonatal and pediatric intensive care has generated increasing interest in developing measures to quantify the severity of patient illness. While these indices may help improve health care quality and benchmark mortality across hospitals, comprehensive understanding of the purpose and the factors that influenced the performance of risk stratification indices is important so that they can be compared fairly and used most appropriately. In this review, we examined 19 indices of risk stratification used to predict mortality in critically ill children and critically analyzed their design, limitations, and purposes. Some pediatric and neonatal models appear well-suited for institutional benchmarking purposes, with relatively brief data acquisition times, limited potential for treatment-related bias, and reliance on diagnostic variables that permit adjustment for case mix. Other models are more suitable for use in clinical trials, as they rely on physiologic variables collected over an extended period, to better capture the interaction between organ systems function and specific therapeutic interventions in acutely ill patients. Irrespective of their clinical or research applications, risk stratification indices must be periodically recalibrated to adjust for changes in clinical practice in order to remain valid outcome predictors in pediatric intensive care units. Longitudinal auditing, education, training, and guidelines development are also critical to ensure fidelity and reproducibility in data reporting. CONCLUSION: Risk stratification indices are valid tools to describe intensive care unit population and explain differences in mortality.

Validating computer-generated measures of linguistic style matching and accommodation in patient-clinician communication.

OBJECTIVE: To explore the validity of computer-analyzed linguistic style matching (LSM) in patient-clinician communication. METHODS: Using 330 transcribed HIV patient encounters, we quantified word use with Linguistic Inquiry and Word Count (LIWC), a dictionary-based text analysis software. We measured LSM by calculating the degree to which clinicians matched patients in the use of LIWC "function words" (e.g., articles, pronouns). We tested associations of different LSM metrics with patients' perceptions that their clinicians spoke similiarly to them. RESULTS: We developed 3 measures of LSM: 1) at the whole-visit level; (2) at the turn-by-turn level; and (3) using a "rolling-window" approach, measuring matching between clusters of 8 turns per conversant. None of these measures was associated with patient-rated speech similarity. However, we found that increasing trajectories of LSM, from beginning to end of the visit, were associated with higher patient-rated speech similarity (ß 0.35, CI 0.06, 0.64), compared to unchanging trajectories. CONCLUSIONS: Our findings point to the potential value of clinicians' adapting their communication style to match their patients, over the course of the visit. PRACTICE IMPLICATIONS: With further validation, computer-based linguistic analyses may prove an efficient tool for generating data on communication patterns and providing feedback to clinicians in real time.

Surgeon Information-Sharing, Parent Verbal Engagement, and Parent Knowledge of Pediatric Adenotonsillectomy.

OBJECTIVE: We characterize clinician information-sharing and parent verbal engagement during pediatric adenotonsillectomy consultations and evaluate whether these behaviors relate to disease-specific knowledge for parents of children with obstructive sleep-disordered breathing (OSDB). STUDY DESIGN: Mixed-methods sequential explanatory analysis. SETTING: Outpatient otolaryngology clinics. METHODS: We analyzed audio-recorded communication during outpatient encounters for children undergoing initial evaluation for adenotonsillectomy. We identified discrete triadic instances of clinician discussion of individual risks and benefits, parent verbal responses coded as passive ("Right") or active ("Would that repeat the recovery time?"), and corresponding parent answer (correct or incorrect) on a postconsult knowledge questionnaire. Primary outcomes included parent knowledge and decisional conflict. We qualitatively analyzed substantive questions asked by parents during the encounter. RESULTS: In 30 consults, clinicians (n = 8) provided 156 instances of discussion (101 risk, 55 benefit), to which parents provided 34% active responses. Clinician discussion of risks and benefits was associated with greater parent knowledge (odds ratio [OR] = 3.70, 95% confidence interval [CI]: 2.25-6.09; P < .001), however parent active engagement was not associated with greater parent knowledge (OR = 1.04, 95% CI: 0.42-2.58, P = .93). Parents demonstrated greater knowledge of benefits than risks (χ2 = 23.16, V = 1.13; P < .001). Parents who responded actively (OR = 0.26, 95% CI: 0.09-0.72; P = .010) or had greater knowledge (OR = 0.41, 95% CI: 0.21-0.81; P = .010) had less decisional conflict. CONCLUSION: Clinician information-sharing was associated with greater parent knowledge about OSDB treatment. Greater parent engagement and knowledge were independently associated with less decisional conflict. These findings may inform clinicians' approaches to counseling and engaging parents in decisions for surgery.

Cardiovascular and blood glucose parameters in infants during propranolol initiation for treatment of symptomatic infantile hemangiomas.

OBJECTIVES: We sought to determine the effect of propranolol on cardiovascular and blood glucose parameters in infants with symptomatic infantile hemangiomas who were hospitalized for initiation of treatment, and to analyze adverse effects of propranolol throughout the course of inpatient and outpatient treatment. METHODS: A retrospective cohort analysis was performed on 50 infants (age less than 12 months) with symptomatic infantile hemangiomas who were hospitalized for propranolol initiation between 2008 and 2012. Demographic data and disease characteristics were recorded. Systolic and diastolic blood pressures, heart rate, blood glucose values, and adverse events recorded during hospitalization were analyzed. An additional cohort of 200 consecutively treated children was also assessed for adverse events associated with outpatient propranolol use. RESULTS: The median age among the inpatient cohort was 3.4 months (range, 0.8 to 12.0 months). Infants older than 6 months were more likely to exhibit bradycardia than were younger infants (p < 0.001). Hypotensive and/or bradycardic periods were infrequent and were not associated with observable clinical symptoms. The mean systolic and diastolic blood pressures and the mean heart rate decreased significantly from day 1 of hospitalization to day 2 (p = 0.004; p = 0.008; p < 0.001), but not from day 2 to day 3, when the propranolol dose was increased to target. Hypoglycemia was rare (0.3% incidence.) Among the 250 outpatients, 2 infants developed lethargy and hypoglycemia during a viral illness and recovered without sequelae. One infant experienced recurrent bronchospasm with viral illnesses and required concomitant bronchodilator therapy. CONCLUSIONS: Frequent deviations from normal ranges of blood pressure and heart rate occur upon initiation of propranolol, but are clinically asymptomatic. These findings support that outpatient initiation of propranolol in healthy, normotensive infants appears to be a relatively safe alternative to inpatient initiation. Hypoglycemia is rare, but can occur throughout the treatment period; parent counseling is of paramount importance.

Association of dysglycemia with post-operative outcomes in pediatric surgery.

BACKGROUND: Perioperative dysglycemia is associated with adverse surgical outcomes in adults. We sought to determine the association between perioperative dysglycemia and 30-day adverse surgical events in pediatric patients undergoing non-cardiac surgery. METHODS: We analyzed records from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS-NSQIP-P) database from 2016 to 2021 at two academic tertiary care hospitals. The primary outcomes were individual 30-day adverse events, composite serious adverse events, composite hospital acquired infections and composite morbidity. RESULTS: A total of 5410 records were analyzed: the cohort was 52.6% male and 52.6% non-Hispanic White, and 1472 (27.2%) had dysglycemia. Children undergoing procedures in general surgery (48.4%), neurosurgery (25.4%), and orthopedic surgery (16.0%) had higher rates of dysglycemia compared to other surgical specialties. Patients with dysglycemia were more likely to have surgical site infection (4.3% dysglycemic vs. 3.1% normoglycemic, p = 0.028), cardiac arrest (2.6% vs. 0.1%, p < 0.001), and sepsis (3.7% vs. 1.3%, p < 0.001); more likely to undergo reoperation (11.3% vs. 5.8%, p < 0.001); and more likely to remain hospitalized after 30 days (33.0% vs. 6.1%, p < 0.001). After controlling for patient and case demographics, perioperative dysglycemia was associated with more composite serious adverse events (OR 1.85, 95% CI 1.49-2.29, p = 0.000), composite hospital acquired infections (OR 1.42, 95% CI 1.04-1.93, p = 0.026), and composite morbidity (OR 2.52, 95% CI 2.13-2.97, p = 0.000). CONCLUSIONS: Perioperative dysglycemia in children undergoing non-cardiac surgery is associated with increased risk of adverse events and outcomes. Interventions that screen and normalize blood glucose in the perioperative period may mitigate risk and improve quality of care.

Patient Factors and Preferences in Choosing Sleep Surgery for Obstructive Sleep Apnea: A Qualitative Study.

OBJECTIVE: There are several obstructive sleep apnea (OSA) treatment options available to patients, including surgery and less invasive therapies. Little is known about the factors that influence patient preferences for treatment. We aimed to understand factors influencing patient experience and decision making for undergoing sleep surgery. STUDY DESIGN: Retrospective qualitative study. SETTING: Tertiary sleep surgery clinic. METHODS: We conducted semistructured interviews with adults who previously underwent any nasal and/or pharyngeal sleep surgery. We asked open-ended questions about their decision-making process within a preconceived thematic framework of chief OSA symptoms, expectations for recovery, and sources of information. The interviews were audio recorded and transcribed, and content was analyzed for defined, emergent, and prevalent themes. RESULTS: Ten patients were interviewed from December 11, 2020 through January 29, 2021. Six patients underwent nasal surgery, 1 underwent pharyngeal surgery, and 3 underwent staged nasal and pharyngeal procedures. All patients were beyond the acute recovery phase. Reasons for pursuing surgical consultation varied from sleep apnea burden to external factors, such as recommendations from significant others. Duration of sleep surgery consideration varied from months to years. Major concerns about sleep surgery involved anesthesia and postoperative pain. External factors influencing patients' decisions to pursue sleep surgery included family and friend support. Postoperative outcomes of surgery included patient satisfaction with decision for surgery, given OSA improvements. CONCLUSION: Understanding patient factors that influence decision making for sleep surgery may guide clinicians in patient-centered counseling that engages patients in decision making, aligning with clinical symptoms and patient preferences.

Barriers and communication behaviors impacting referral to sleep surgery: qualitative patient perspectives.

STUDY OBJECTIVES: Physician-patient interactions influence the immediate encounter and leave lasting impressions for future health care encounters. We aimed to understand patient experiences and decision-making for considering sleep surgery, in terms of barriers and communication behaviors that facilitate or hinder referral for consideration of sleep surgery management of obstructive sleep apnea (OSA) when continuous positive airway pressure (CPAP) therapy has failed. METHODS: We employed qualitative methods, using semistructured interviews of adults with OSA who presented for sleep surgery consultation after unsatisfactory therapy with CPAP. Open-ended questions traced symptoms and progression of sleep apnea burden, trials of noninvasive OSA therapies, outcomes, and patient expectations and concerns. The interviews were audio-recorded, transcribed, and analyzed using content analysis to identify themes. RESULTS: Ten adult patients with OSA were enrolled March through April 2021 and reached predominant thematic saturation. Barriers to sleep surgery consultation included: (1) delays in OSA diagnosis due to limited OSA awareness among patients or primary providers and patients' perceived inconvenience of sleep testing, (2) patients faulted for slow progress, (3) patient-reported lack of urgency by providers in troubleshooting noninvasive management options, (4) scheduling delays and waitlists, and (5) cost. Patients were receptive to noninvasive treatment options, but inadequate improvement led to frustration after multiple encounters. Patients appreciated empathetic providers who shared information through transparent and understandable explanations and who presented multiple treatment options. CONCLUSIONS: Experiences of patients with OSA highlight the need for shared decision-making through improved communication of unresolved concerns and alternative management options, including timely referral for sleep surgery consultation when indicated. CITATION: Ikeda AK, McShay C, Marsh R, et al. Barriers and communication behaviors impacting referral to sleep surgery: qualitative patient perspectives. J Clin Sleep Med. 2023;19(1):111-117.

Evaluation of Parental Perspectives and Concerns about Pediatric Cochlear Implantation: A Social Media Analysis.

OBJECTIVE: Parents often experience uncertainty during decision-making for their child's cochlear implantation (CI) surgery, and online forums provide insight on parental opinions that might not be expressed in clinic. This study aims to evaluate parental perspectives and concerns about pediatric CI using social media analysis. STUDY DESIGN: Qualitative study. SETTING: Three online forums involving parental posts about pediatric CI. INTERVENTION/METHODS: Forums were queried using keywords (e.g., "cochlear implant") to gather all U.S. parent-initiated posts about pediatric CI from 2006 to 2021. Thematic content analysis was performed to classify posts by overarching domain, themes, and subthemes. Posts were reviewed for thematic synthesis and double coded. Descriptive statistics were calculated for each theme by unique users. RESULTS: A total of 79 posts by 41 unique users were analyzed. Themes relating to decision for CI included facilitators, inhibitors, resources, and feelings. Parents posted about lack of benefit from hearing aids promoting decision for CI and high cost as an inhibitor. Some expressed concern about making a major decision for a minor. Parents often mentioned their child's healthcare providers and social media as resources. CONCLUSION: Through social media posts, parental priorities and concerns for decision-making of CI surgery were identified. Findings may guide discussions between physicians and parents and facilitate shared decision-making about CI.

Allyship to Advance Diversity, Equity, and Inclusion in Otolaryngology: What We Can All Do.

Purpose of review: To summarize the current literature on allyship, providing a historical perspective, concept analysis, and practical steps to advance equity, diversity, and inclusion. This review also provides evidence-based tools to foster allyship and identifies potential pitfalls. Recent findings: Allies in healthcare advocate for inclusive and equitable practices that benefit patients, coworkers, and learners. Allyship requires working in solidarity with individuals from underrepresented or historically marginalized groups to promote a sense of belonging and opportunity. New technologies present possibilities and perils in paving the pathway to diversity. Summary: Unlocking the power of allyship requires that allies confront unconscious biases, engage in self-reflection, and act as effective partners. Using an allyship toolbox, allies can foster psychological safety in personal and professional spaces while avoiding missteps. Allyship incorporates goals, metrics, and transparent data reporting to promote accountability and to sustain improvements. Implementing these allyship strategies in solidarity holds promise for increasing diversity and inclusion in the specialty.

Outpatient tonsillectomy in children: demographic and geographic variation in the United States, 2006.

OBJECTIVES: To examine geographic and demographic variation for outpatient tonsillectomy in children nationally. STUDY DESIGN: The 2006 National Survey of Ambulatory Surgery was analyzed to describe outpatient tonsillectomy in children. Rates by age, sex, region, urban/rural residence, and payment source were calculated with 2006 population estimates from the Census Bureau and the National Health Interview Survey as denominators. Rates were compared with Z tests. RESULTS: In 2006, approximately 583 000 (95% CI, 370 000-796 000) outpatient tonsillectomy procedures were performed in children in the United States. Rates per 10 000 children were lower in children 13 to 17 years old (33.8 per 10 000) than in both children 7 to 12 years old (91.3; P < .05) and children 0 to 6 years old (102.9; P < .001). Compared with the South, tonsillectomy rates were lower in the West (29 per 10 000 versus 125 per 10 000; P < .01) and not significantly different in other regions. Compared with large central metropolitan areas, tonsillectomy rates were higher in small/medium metropolitan areas (118 per 10 000 versus 42 per 10 000; P < .05), and not significantly different in large fringe or non-metropolitan areas. Tonsillectomy rates were similar for children insured by Medicaid compared with those insured by private sources. Compared with older children (13-17 years), children in the younger age groups (0-6 years, 7-12 years) underwent tonsillectomy more commonly for airway obstruction (69.5% and 59.2% versus 34.3%, P < .05 for both). Compared with older children, younger children (0-6 years) underwent tonsillectomy less commonly for infection (40.4% versus 61.0% [7-12 years] and 72.2% [13-17 years], P < .001 for both). CONCLUSIONS: Use of tonsillectomy in the ambulatory setting varies across age groups, geographic regions, levels of urbanization, and indication. Further research is warranted to examine these differences.

Current Clinical Concepts: Management of Common Lumbar Spine Posterior Column Disorders in Young, Active Individuals.

Although posterior column disorders, such as spondylolysis and spondylolisthesis, are not commonly encountered in the general population, athletic trainers frequently see these conditions in athletic and active individuals due to the repetitive spinal extension and rotational loads placed on the pars interarticularis while participating in sport. Athletic trainers can successfully evaluate patients with posterior column disorders by performing a complete and comprehensive clinical examination to identify the location of pain, test spinal stability, and recognize compensatory movement patterns. Conservative management typically leads to a successful outcome in this population, with rest, bracing, and the use of therapeutic exercise having the best supporting evidence. In this Current Clinical Concepts review, we outlined the etiology and risk factors frequently associated with disorders of the posterior column. Additionally, we synthesized the literature for common evaluation techniques and interventions associated with the posterior column and provided a proposed rehabilitation progression to use in a younger, athletic population.