Socioeconomic Status and Cochlear Implant Usage: A Datalogging Study.

OBJECTIVE: To evaluate the associations between proxy measures of socioeconomic status (SES) and usage of cochlear implants. STUDY DESIGN: Retrospective case series. METHODS: Usage outcomes were measured among patients with a cochlear implant and data logging at a tertiary care children's hospital between 2002 and 2017. Time per day with cochlear implant turned on, coil off, and listening to speech in noise and speech in quiet were extracted from audiology records, averaging right and left ear usage for those with bilateral implants. Associations between cochlear implant usage and demographic factors such as insurance type and median household income for zip code were assessed. RESULTS: There were 142 total patients; 74 had bilateral usage data. Mean on air time was 10.76 hours (SD: 4.4). Those with private insurance had 1.2 hour more on air time/day (P = .047) and 0.9 hour more quiet time/day (P = .011) compared to those with public insurance. Younger age at last visit was associated with increased speech in quiet (B = -.08; 95% CI: -0.12-[-0.05], P < .001) and coil off (B = -0.06; 95% CI: -0.11-[-0.02], P = .006). Younger age at implant was associated with longer duration since last data logging visit (B = -10.46; 95% CI: -18.41-[-2.51], P = .010), more daily use (on air; B = -0.23; 95% CI: -0.43-[-0.03], P = .026), and increased time spent listening to speech in noise (B = -0.07; 95% CI: -0.14-[-0.01], P = .024). No other significant associations between datalogging output and each proxy SES factor were found. CONCLUSIONS: Lack of private insurance and older age at implantation decreased access to binaural hearing for children and young adults with cochlear implants.

Droplet and Aerosol Generation With Mastoidectomy During the COVID-19 Pandemic: Assessment of Baseline Risk and Mitigation Measures With a High-performance Cascade Impactor.

HYPOTHESIS: Aerosols are generated during mastoidectomy and mitigation strategies may effectively reduce aerosol spread. BACKGROUND: An objective understanding of aerosol generation and the effectiveness of mitigation strategies can inform interventions to reduce aerosol risk from mastoidectomy and other open surgeries involving drilling. METHODS: Cadaveric and fluorescent three-dimensional printed temporal bone models were drilled under variable conditions and mitigation methods. Aerosol production was measured with a cascade impactor set to detect particle sizes under 14.1 µm. Field contamination was determined with examination under UV light. RESULTS: Drilling of cadaveric bones and three-dimensional models resulted in strongly positive aerosol production, measuring positive in all eight impactor stages for the cadaver trials. This occurred regardless of using coarse or cutting burs, irrigation, a handheld suction, or an additional parked suction. The only mitigation factor that led to a completely negative aerosol result in all eight stages was placing an additional microscope drape to surround the field. Bone dust was scattered in all directions from the drill, including on the microscope, the surgeon, and visually suspended in the air for all but the drape trial. CONCLUSIONS: Aerosols are generated with drilling the mastoid. Using an additional microscope drape to cover the surgical field was an effective mitigation strategy to prevent fine aerosol dispersion while drilling.

Advanced practice providers and children's hospital-based pediatric otolarynology practices.

INTRODUCTION: Advanced practice providers (APPs), including nurse practitioners and physician assistants, have been deployed in children's hospital-based academic pediatric otolaryngology practices for many years. However, this relationship in terms of prevalence, roles, financial consequences and satisfaction has not been examined. The objective of this study is to explore how APPs impact healthcare delivery in this setting. METHODS: Pediatric otolaryngology chiefs of all academic children's hospitals in the US were electronically surveyed about the ways APPs intersected clinically and financially in their respective practice. RESULTS: A total of 29 of 36 children's hospital-based pediatric otolaryngology practices completed the survey, of which 26 practices (90%) utilized APP. There were large variances within the APP practice cohort in faculty size (mean/median/range = 9.4/8.5/3-29); annual patient visits (mean/median = 18,373/17,600); number of practice site (mean/median/range = 4.3/4/2-9) and number of outpatient APP (mean/median/range = 6.3/5/1-30). No factors (faculty size, annual visits and number of practice sites) differentiated between the APP and non-APP practices. Among APP practices, significant correlation (p<.00001) was observed between size of APP cohort to faculty size and annual visits. 69% of the practices did not differentiate job functions of nurse practitioners and physician assistants. 85% of the practices utilized APPs in all practice sites and 19% utilized APPs in the operating room. 77% of APPs billed independently and 46% had on-site supervision. The most prevalent APP salary bracket based on 0-5, 6-10 and > 11 years of tenure were $76-100K (65%), $100-150K (77%) and $100-150K (86%), respectively. In 46% of the practices, APPs were able to generate enough revenue to cover more than 75% of their salary and 23% of practices generated a profit. 81% of the chiefs ranked the effectiveness of APPs as high (4 and 5) on a 5-point Likert scale. DISCUSSION: The majority of academic pediatric otolaryngology practices employed APPs. Despite the diversity seen in practice complexity, APP functionality and financial impact, most found the APP model to be beneficial in improving patient care, patient access and faculty productivity.

Opioid prescription and postoperative outcomes in pediatric patients.

OBJECTIVES/HYPOTHESIS: To determine if the amount of opioid prescribed and postoperative outcomes after adenotonsillectomy changed following implementation of mandated opioid consent forms. STUDY DESIGN: Retrospective cohort study. METHODS: Patients undergoing adenotonsillectomy 6 months before and after implementation of mandated opioid consent forms at a tertiary-care pediatric hospital were studied. Demographics, operative data, weight-based opioid dosage, and postoperative outcome measures, including nursing calls, emergency department (ED) visits, hospital readmission, and bleed rates, were collected and analyzed. RESULTS: Of 300 patients, opioid prescription was provided for 211 patients (70.3%), 112 preconsent (74.7%) and 99 postconsent (66.0%). Mean (standard deviation) total opioid prescribed (milligrams/kilogram) was significantly higher preconsent 4.8 (5.6) than postconsent 3.2 (4.7), (P = .003). There were no differences between number of nursing calls (P = .134) or ED visits (P = .083). Interestingly, preconsent patients had more hospital readmission for pain/dehydration (odds ratio OR: 368, P = .016) and bleeding concerns (OR: 244, P = .003). CONCLUSIONS: A mandated consent form prior to opioid prescription was associated with decreased overall opioid prescription without resultant increase in postoperative complications in pediatric patients. These data provide support for minimizing opioid prescription on a systems-based level. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1477-1481, 2019.

Quality Assessment of the Clinical Practice Guideline for Tympanostomy Tubes in Children.

OBJECTIVES: To determine the association between the introduction of statements 6 and 7 in the 2013 clinical practice guideline (CPG) for tympanostomy tubes in children and the identification of preoperative middle ear fluid (acute otitis media / otitis media with effusion [AOM/OME]) in children undergoing bilateral myringotomy and tube (BMT) placement. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care children's medical center. SUBJECTS AND METHODS: Patients who underwent BMT for recurrent AOM were retrospectively reviewed. We examined 240 patients before (BG; 2012) and 240 patients after (AG; 2014) the introduction of the CPG. RESULTS: The baseline characteristics of the 2 groups were comparable. The total annual number of BMT placements performed at our institution decreased from 3957 (BG) to 3083 (AG). There was no significant increase in the rate of preoperative AOM/OME identification following CPG introduction (BG 78.3% vs AG 83.3%, P = .164). The rate of identification of AOM/OME in the operating room (OR) increased from 54.2% (BG) to 71.3% (AG, P < .001). The rate of identification of AOM/OME both in the clinic and in the OR increased from 55.1% (BG) to 71.3% (AG, P < .001). Cases with concordant clinic and OR AOM/OME occurred among younger children ( P = .045), those with fewer episodes of AOM ( P = .043), and those with shorter time between the clinic and OR dates ( P = .008). CONCLUSIONS: Following the introduction of the CPG, there was no change in the rate of identification of AOM/OME prior to recommending BMT placement in children with recurrent AOM. The lack of improved compliance with statements 6 and 7 may be related to multiple clinician- and patient-derived factors.

Teach the teacher: Training otolaryngology fellows to become academic educators.

OBJECTIVES/HYPOTHESIS: Fellowship is the capstone of academic training and serves as preparation for an academic career. Fellows are expected to educate medical students and residents during and long after fellowship. However, little time is typically spent teaching fellows to become effective educators. We investigate a formal curriculum addressing teaching skills among fellows in otolaryngology-head and neck surgery (OHNS). STUDY DESIGN: E-mail survey. METHODS: We developed and implemented an educational program called Teach the Teacher to build skills as educators for fellows in OHNS. We conducted a survey of fellows from 2014 to 2017 in OHNS who participated in the course. The survey evaluated demographics, teaching experiences, and teaching limitations structured as yes/no and Likert-style questions (1 = strongly disagree, 5 = strongly agree). RESULTS: Thirty fellows were surveyed with a response rate was 80%. Fellowship was rated highly as an experience that will make fellows a better academic educator (mean ± standard deviation: 4.54 ± 0.64). The most important components of teaching during fellowship were role modeling (4.67 ± 0.62), followed by teaching psychomotor skills in the operating room (4.29 ± 0.89), diagnostic reasoning (4.25 ± 0.66), and evidence-based medicine (4.25 ± 0.83). The Teach the Teacher course specifically was rated as a helpful experience (4.00 ± 0.90). The primary limitations to developing teaching skills during fellowship identified were lack of time, patient safety, and inexperience with hospital culture. CONCLUSIONS: Fellowship is a key time to improve skills as academic educators. Fellows value formal efforts to teach academic skills. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:2034-2048, 2018.