Chief complaints and feedback from clinic satisfaction tool: Thematic analysis of a new outpatient communication tool.

OBJECTIVES: Up to half of all patients leave their outpatient clinic visit with an uncommunicated need. We designed the clinic satisfaction tool (CST) as a low-cost, highly utilised assessment of the spine clinic experience that improved communication in our multidisciplinary spine practice. The purpose of this study was to qualitatively analyse chief complaints and feedback from the CSTs to determine how spine clinic patients used the form, identify the most prevalent concerns and mark areas for improvement. METHODS: Institutional retrospective review of CSTs. Chief complaints and feedback were inductively coded to create a framework for patient complaints. RESULTS: 832 patients presented to clinic, and 100 sets of chief complaints coded before reaching thematic saturation. Patients used the chief complaint section of CST to canvas four themes: symptoms, questions about their disease, management and treatment. Twenty-nine patients left mostly positive feedback but also wrote additional concerns about care. CONCLUSION: Spine patients have a predictable pattern of chief complaints and with the CST were able to have all these complaints addressed. The CST efficiently collects practice-specific chief complaints that can be used to guide physician behaviour and design educational clinical tools that are useful for patients.

Relationship between socioeconomic status, exposure to airborne pollutants, and chronic rhinosinusitis disease severity.

BACKGROUND: Air pollution directly interacts with airway mucosa, yet little is known about how pollutants affect upper airway inflammation. Studies have shown increased incidence of chronic rhinosinusitis (CRS), rhinitis, and asthma in areas with higher traffic pollution, and these neighborhoods are often associated with lower socioeconomic status (SES). The Area Deprivation Index (ADI) assesses neighborhood-level SES by zip code. The purpose of this study was to assess the relationship between SES and exposure to inhaled pollutants and CRS disease severity. METHODS: CRS patients with and without nasal polyps (CRSwNP and CRSsNP, respectively) were identified (total patients = 234; CRSwNP patients = 138; CRSsNP patients = 96). Pollutant concentrations, including particulate matter 2.5 (PM2.5 ), black carbon (BC), and nitrogen dioxide (NO2 ), were measured at 70 sites within the defined countywide sites and used to estimate patient exposures. SES was measured by ADI state deciles. Disease severity metrics included the modified Lund-Mackay score (LMS), the need for systemic steroids, and functional endoscopic sinus surgery (FESS). Associations were analyzed and identified using linear, logistic, and Poisson multivariable regression. RESULTS: The distribution of CRSsNP and CRSwNP patients across ADI state deciles was similar. ADI, however, was a predictor of exposure to airborne pollutants (PM2.5 , BC, and NO2 ) with a 1.39%, 2.39%, and 2.49% increase in PM2.5 , BC, and NO2 per increasing decile increment (p < 0.0001), respectively, which demonstrated a direct correlation between deprived neighborhoods and higher levels of exposure to PM2.5 , BC, and NO2 with an increase in pollutant levels per increase in ADI decile. Furthermore, ADI was a predictor for increased steroid treatment. CONCLUSION: Lower SES predicted higher exposure to air pollution and increased disease severity in patients with CRS as demonstrated by the increased need for steroid treatment.

The true penalty of the waiting room: the role of wait time in patient satisfaction in a busy spine practice.

OBJECTIVE: Most clinics collect routine data on performance metrics on physicians for outpatient visits. However, the relationship of these metrics with patient experience is unclear. The goal of this study was to investigate the relationships between the Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey (CG-CAHPS), the standard patient experience survey, and clinic performance metrics to understand the determinants of patient satisfaction and identify targets for improving patient experience. METHODS: The authors performed a retrospective single-institution cohort review of spine surgeon metrics over 15 months including demographics, waiting-room times, in-room times, lead times, timely note closure, timely MyChart responses, and monthly patient volume. Kruskal-Wallis tests and mixed-model regression were used to determine the predictors of 3 domains of patient satisfaction-Global, Access, and Communication. RESULTS: Over 15 months, 22 surgeons conducted 27,090 visits. The average clinic visit total time was 85.17 ± 25.75 minutes. Increased wait times were associated with poor Global (p = 0.008), Access (p < 0.001), and Communication scores (p = 0.003) in univariate analysis. Every 10-minute increase in waiting time was associated with a 3%, 9.8%, and 2.4% decrease in Global, Access, and Communication scores, respectively. Increased in-room time was also an independent predictor of poor Access scores (p < 0.001). In multivariate analysis, increased wait times were negative predictors of Global (p = 0.005), Access (p < 0.001), and Communication (p = 0.002) scores. CONCLUSIONS: Excessive waiting-room time significantly impacts unexpected dimensions of the patient experience and impacts communication with patients. Understanding the complex relationship between the factors that inform the patient experience will help target effective interventions to improve clinic efficiency and patient satisfaction.

Recurrent and Progressive Facial Baroparesis on Flying Relieved by Eustachian Tube Dilation.

OBJECTIVES: Facial baroparesis is a rare phenomenon of seventh cranial nerve palsy traditionally reported in divers, with only 11 cases reported in aviation so far. It is important to correctly diagnose facial baroparesis given the differential diagnosis of stroke and decompression disease and offer appropriate treatment for recurrent cases. METHODS: The authors present the case of a patient with recurrent and progressive facial baroparesis treated with Eustachian tube balloon dilation. Institutional medical records were reviewed, and analysis of the current literature was performed. RESULTS: A 37-year-old woman experienced recurrent and progressive left facial paralysis on descent from altitude on commercial airline flights, with resolution between flights. The patient flew frequently for work-related trips and for the past 7 years had noted facial paralysis that began with mild asymmetry of the face and progressed to an inability to close her left eye. She denied any otologic symptoms other than ear fullness and pressure causing left otalgia. The right side was not involved. After treatment with Eustachian tube dilation, the patient has been on numerous flights with complete resolution of symptoms. CONCLUSIONS: This study presents a rare case of facial baroparesis on commercial flight descent that resolved after left Eustachian tube dilation. Although unilateral facial palsy can be concerning for stroke, a history of ear fullness and pressure may suggest facial baroparesis instead. For recurrent and progressive cases, Eustachian tube dilation should be considered for treatment.

Clinic Satisfaction Tool Improves Communication and Provides Real-Time Feedback.

BACKGROUND: Patient-reported assessments of the clinic experience are increasingly important for improving the delivery of care. The Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey is the current standard for evaluating patients' clinic experience, but its format gives 2-mo delayed feedback on a small proportion of patients in clinic. Furthermore, it fails to give specific actionable results on individual encounters. OBJECTIVE: To develop and assess the impact of a single-page Clinic Satisfaction Tool (CST) to demonstrate real-time feedback, individualized responses, interpretable and actionable feedback, improved patient satisfaction and communication scores, increased physician buy-in, and overall feasibility. METHODS: We assessed CST use for 12 mo and compared patient-reported outcomes to the year prior. We assessed all clinic encounters for patient satisfaction, all physicians for CG-CAHPS global rating, and physician communication scores, and evaluated the physician experience 1 yr after implementation. RESULTS: During implementation, 14 690 patients were seen by 12 physicians, with a 96% overall CST utilization rate. Physicians considered the CST superior to CG-CAHPS in providing immediate feedback. CG-CAHPS global scores trended toward improvement and were predicted by CST satisfaction scores (P < .05). CG-CAHPS physician communication scores were also predicted by CST satisfaction scores (P < .01). High CST satisfaction scores were predicted by high utilization (P < .05). Negative feedback dropped significantly over the course of the study (P < .05). CONCLUSION: The CST is a low-cost, high-yield improvement to the current method of capturing the clinic experience, improves communication and satisfaction between physicians and patients, and provides real-time feedback to physicians.

Factors associated with opioid use after endoscopic sinus surgery.

OBJECTIVES/HYPOTHESIS: Responsible prescribing of postoperative pain medications is necessary in combatting the current opioid epidemic in the United States. The goal of this study was to determine which clinical factors affect opioid usage following functional endoscopic sinus surgery (FESS). STUDY DESIGN: Retrospective medical records study. METHODS: This is a single-institution retrospective study of subjects undergoing FESS by the senior author between September 2016 and December 2017. Opioid usage was assessed for each patient at the first postoperative visit. Univariate and multivariable analyses were performed to investigate factors associated with pain medication usage. Patients using opioids prior to surgery were excluded. RESULTS: A total of 136 patients were stratified into three groups based on number of opioid tablets taken during the first week after surgery: 31 patients (23%) took no opioids, 61 patients (45%) took one to five tablets, and 44 patients (32%) took more than five tablets. Gender, extent of surgery, revision surgery, polyp status, and cystic fibrosis did not significantly vary between the three groups. Multinomial logistic regression analysis with backward stepwise variable selection method revealed that those who had septoplasty (odds ratio [OR]: 4.84, 95% confidence interval [CI]: 1.68-13.98; P < .01) or were of younger age (OR 0.96, 95% CI: 0.93-0.99; P = .01) had significantly higher odds of taking >5 tablets. CONCLUSIONS: The majority of patients undergoing FESS did not take more than 5 opioid tablets after surgery. Concurrent septoplasty and younger age were associated with increased opioid usage. Knowledge of such factors can help surgeons to assess opioid prescribing patterns and to counsel their patients on postoperative pain. Laryngoscope, 129:1751-1755, 2019.

Airway findings in children with tracheostomies: When is diagnostic bronchoscopy and laryngoscopy indicated?

OBJECTIVES: To determine the utility of diagnostic laryngoscopy and bronchoscopy in children with tracheostomies and to describe the incidence of airway findings. METHODS: Retrospective cohort study examining children with tracheostomies who underwent direct laryngoscopy and bronchoscopy (DLB) at Duke University Hospital between 2008 and 2016. RESULTS: A total of 81 patients who underwent 114 bronchoscopies met inclusion criteria. The median time between tracheostomy and first DLB was 13 months (IQR 4.25-14.75). Sixty-six patients were diagnosed with findings on DLB (81.5%). Suprastomal granulation tissue was the most common complication (59.0%), followed by increased tracheal secretions (23%), stomal and peristomal granulation (13.2%), tracheal ulcer (3.3%), and suprastomal collapse (1.6%). The proportion of patients with airway findings who underwent endoscopy >6 months post-tracheostomy was higher than those <6 months post-tracheostomy, although this did not reach statistical significance (90.6% vs. 75.5%, p = 0.087). However, when examining tracheostomy-related findings, the proportion of patients with airway findings who underwent DLB >6 months post-tracheostomy (61%) compared to <6 months post-tracheostomy (36%) was significantly different (p = 0.026). Patients who were symptomatic before bronchoscopy were more likely to have positive findings (91.9% vs. 72.7%, p = 0.027) and patients were more likely to be symptomatic if they had DLB >6 months after tracheostomy versus <6 months after tracheostomy (68.8% vs. 30.6%; p < 0.001). CONCLUSION: The high incidence of airway findings, especially tracheostomy-related findings, noted on DLB supports the continued use of airway endoscopies in children post-tracheostomy. Timing of DLB may play a role in determining utility with evaluation and symptomatic patients should be more closely monitored as they demonstrate higher rates of airway findings.

Sinonasal Quality of Life Outcomes After Extended Endonasal Approaches to the Skull Base.

Introduction Endoscopic endonasal skull base surgery (EESBS) leads to significant alterations in sinonasal anatomy and physiology. However, there is limited data available on quality of life (QOL) outcomes following EESBS. Methods A retrospective review of patients undergoing EESBS from January 2014 to April 2017 was performed. Records were reviewed for clinical history, operative details, and 22-item Sinonasal Outcomes Test (SNOT-22) scores. Unadjusted and adjusted linear regression models were utilized to compare change in SNOT-22 scores from baseline in patients who underwent a simple sella approach (SA) or an extended beyond sella approach (BSA). Results A total of 108 patients were in the SA group, while 61 patients were in the BSA group. SNOT-22 scores were available at baseline and 3 months for 84 patients, while 6-month scores were available for 49 patients. SNOT-22 scores for all patients were not significantly different at 3 months ( p = 0.40) or at 6 months ( p = 0.58). Unadjusted linear regression model did not show an association between the type of approach and change in SNOT-22 score at 3 months ( p = 0.07) and 6 months ( p = 0.28). Adjusted regression model showed a significant decrease in SNOT-22 scores at 3 months ( p = 0.04) for the BSA group, but there was no significant change in SNOT-22 score at 6 months ( p = 0.22). Conclusion Patients undergoing EESBS had no significant change in outcomes at 3 and 6 months. A more extensive BSA was not associated with worse QOL outcomes as measured by SNOT-22.

Correlation between sinus and lung cultures in lung transplant patients with cystic fibrosis.

BACKGROUND: Lung transplantation has revolutionized the treatment of end-stage pulmonary disease due to cystic fibrosis. However, infection of the transplanted lungs can lead to serious complications, including graft failure and death. Although many of these patients have concurrent sinusitis, it is unclear whether bacteria from the sinuses can infect the allograft. METHODS: This is a single-institution retrospective study of all patients who underwent lung transplantation for cystic fibrosis from 2005 to 2015 at Duke University Hospital. Pre- and posttransplant nasal and pulmonary cultures obtained via nasal endoscopy and bronchoalveolar lavage (BAL), respectively, were analyzed. RESULTS: A total of 141 patients underwent 144 lung transplants. Sinus cultures were available for 76 patients (12 pretransplant, 42 posttransplant, 22 both pre- and posttransplant). Pretransplant BAL cultures were available for 139 patients, and posttransplant BAL cultures were available for all patients. Pseudomonas aeruginosa (PsA) and methicillin-resistant Staphylococcus aureus (MRSA) were the most common organisms cultured. There was a significant correlation between pretransplant sinus and posttransplant BAL cultures for PsA (p = 0.003), MRSA (p = 0.013), and Burkholderia cepacia (p = 0.001). CONCLUSION: There was a high correlation between pretransplant sinus cultures and posttransplant BAL cultures for PsA, MRSA, and Burkholderia sp. This suggests that the paranasal sinuses may act as a reservoir for allograft colonization in patients with cystic fibrosis. Further studies are needed to determine whether treatment of sinusitis affects allograft colonization and transplant outcomes.