Don't chase the adenoma: A probabilistic approach to imaging before parathyroidectomy.

BACKGROUND: Preoperative imaging before parathyroidectomy can localize adenomas and reduce unnecessary bilateral neck explorations. We hypothesized that (1) the utility of preoperative imaging varies substantially depending on the preoperative probability of having adenoma(s) and (2) that a selective imaging approach based on this probability could avoid unnecessary patient costs and radiation. METHODS: We analyzed 3,577 patients who underwent parathyroidectomy for primary hyperparathyroidism from 2001 to 2022. The predicted probability of patients having single or double adenoma versus hyperplasia was estimated using logistic regression. We then estimated the relationship between the predicted probability of single/double adenoma and the likelihood that sestamibi or 4-dimensional computed tomography was helpful for operative planning. Current Medicare costs and published data on radiation dosing were used to calculate costs and radiation exposure from non-helpful imaging. RESULTS: The mean age was 62 ± 13 years; 78% were women. Adenomas were associated with higher mean calcium (11.2 ± 0.74 mg/dL) and parathyroid hormone levels (140.6 ± 94 pg/mL) than hyperplasia (9.8 ± 0.52 mg/dL and 81.4 ± 66 pg/mL). The probability that imaging helped with operative planning increased from 12% to 65%, as the predicted probability of adenoma increased from 30% to 90%. For every 10,000 patients, a selective approach to imaging that considered the preoperative probability of having adenomas could save patients up to $3.4 million and >239,000 millisieverts of radiation. CONCLUSION: Rather than imaging all patients with primary hyperparathyroidism, a selective strategy that considers the probability of having adenomas could reduce costs and avoid excess radiation exposure.

Quantifying Faculty Perception of Diversity, Equity, and Inclusion Within Academic Otolaryngology-Head and Neck Surgery Departments.

OBJECTIVE: Investigating faculty perceptions of diversity, equity, and inclusion (DEI) among academic otolaryngology programs. STUDY DESIGN: Quantitative survey. SETTING: Academic otolaryngology departments. METHODS: The DEI Inventory was developed by a multi-institutional health equity consortium and disseminated within 16 academic otolaryngology programs. The inventory consisted of 25 items graded on a 5-point Likert scale (strongly disagree to strongly agree), 2 yes/no questions, and 5 items reflecting overall DEI, stress, and burnout among academic otolaryngologists. Validated imposter phenomenon and personality trait measures were also included. RESULTS: The inventory received 158 (31.0%) partial and 111 (21.8%) full responses. No significant differences were identified in DEI scores by race. Compared to males, females reported lower scores on the overall DEI Inventory (3.6 vs 4.3, p < .001). Female respondents also reported greater levels of imposter phenomenon than their male counterparts (53.2 vs 47.5, p = .049). CONCLUSION: Preliminary responses to our DEI Inventory suggest that faculty perception of DEI is not impacted by race. Female faculty report considerably lower perceptions of DEI than their male counterparts and experience greater levels of imposter phenomenon. The results of the DEI Inventory can help departments design meaningful interventions to improve levels of DEI among faculty.

Sex, Race, Insurance, and Pain: Do Patient Sociodemographics Influence Postoperative Opioid Prescriptions Among Hand Surgeons?

BACKGROUND: Social and demographic factors may influence patient treatment by physicians. This study analyzes the influence of patient sociodemographics on prescription practices among hand surgeons. METHODS: We performed a retrospective analysis of all hand surgeries (N = 5278) at a single academic medical center from January 2016 to September 2018. The average morphine milligram equivalent (MME) prescribed following each surgery was calculated and then classified by age, race, sex, type of insurance, and history of substance use or chronic pain. Multivariate linear regression was used to compare MME among groups. RESULTS: Overall, patients with a history of substance abuse were prescribed 31.2 MME more than those without (P < .0001), and patients with a history of chronic pain were prescribed 36.7 MME more than those without (P < .0001). After adjusting for these variables and the type of procedure performed, women were prescribed 11.2 MME less than men (P = .0048), and Hispanics were prescribed 16.6 MME more than whites (P = .0091) overall. Both Hispanic and black patients were also prescribed more than whites following carpal tunnel release (+19.0 and + 20.0 MME, respectively; P < .001). Patients with private insurance were prescribed 24.5 MME more than those with Medicare (P < .0001), but 25.0 MME less than those with Medicaid (P < .0001). There were no differences across age groups. CONCLUSIONS: Numerous sociodemographic factors influenced postoperative opioid prescription among hand surgeons at our institution. These findings highlight the importance of establishing more uniform, evidence-based guidelines for postoperative pain management, which may help minimize subjectivity and prevent the overtreatment or undertreatment of pain in certain patient populations.

Asian American Pacific Islander Representation in Outcomes Research: NSQIP Scoping Review.

BACKGROUND: If Asian American and Pacific Islanders (AAPIs) are not recognized within patients in health services research, we miss an opportunity to ensure health equity in patient outcomes. However, it is unknown what the rates are of AAPIs inclusion in surgical outcomes research. STUDY DESIGN: Through a scoping review, we used Covidence to search MEDLINE, EMBASE, PsycINFO, Web of Science, Scopus, and CINAHL for studies published in 2008-2018 using NSQIP data. NSQIP was chosen because of its national scope, widespread use in research, and coding inclusive of AAPI patients. We examined the proportion of studies representing AAPI patients in the demographic characteristics and Methods, Results, or Discussion section. We then performed multivariable logistic regression to examine associations between study characteristics and AAPI inclusion. RESULTS: In 1,264 studies included for review, 62% included race. Overall, only 22% (n = 278) of studies included AAPI patients. Of studies that included race, 35% represented AAPI patients in some component of the study. We found no association between sample size or publication year and inclusion. Studies were significantly more likely to represent AAPI patients when there was a higher AAPI population in the region of the first author's institution (lowest vs highest tercile; p < 0.001). Studies with a focus on disparities were more likely to include AAPI patients (p = 0.001). CONCLUSIONS: Our study is the first to examine AAPI representation in surgical outcomes research. We found < 75% of studies examine race, despite availability within NSQIP. Little more than one-third of studies including race reported on AAPI patients as a separate group. To provide the best care, we must include AAPI patients in our research.

The Unintended Consequences of Nonoperative Management of Acute Appendicitis.

BACKGROUND: Appendicitis has traditionally been treated surgically. Recently, nonoperative management is emerging as a viable alternative to the traditional operative approach. This raises the question of what are the unintended consequences of nonoperative management of appendicitis with respect to cost and patient burden. METHODS: National Readmissions Database was queried between 2010 and 2014. Patients who were admitted with acute appendicitis between January and June of each year were identified. Patients who underwent appendectomy were compared with those treated nonoperatively. Six-month all-cause readmission rates and aggregate costs between index hospitalization and readmissions were calculated. RESULTS: We identified 438,995 adult admissions for acute appendicitis. Most cases were managed with appendectomy (93.2%). There was a significant increase in the rate of nonoperative management, from 3.6% in 2010 to 6.8% in 2014 (P value for trend <0.01). Discharges receiving nonoperative management tended to be older and have more comorbidities. There was a 59% decreased adjusted odds of readmission within 6 mo among patients receiving appendectomy in comparison to those managed nonoperatively. Despite this, in multivariable linear regression, there was an adjusted $2900 cost increase associated with surgical management (P < 0.01). CONCLUSIONS: This study shows that nonoperative management is increasing. Patients treated nonoperatively may have an increased risk of readmission within 6 mo but incur a decreased average adjusted total cost. Given this, it is important that surgeons critically assess patients who are being considered for nonoperative management of appendicitis.

The effect of sociodemographic factors on outcomes and time to discharge after bariatric operations.

INTRODUCTION: Bariatric surgery is an effective treatment for obesity resulting in both sustained weight loss and reduction in obesity-related comorbidities. It is uncertain how sociodemographic factors affect postoperative outcomes. METHODS: The National Inpatient Sample was queried for patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) from 2005 to 2014. Factors associated with selection of SG over RYGB, increased postoperative length of stay (LOS) greater than 3 days, and inpatient mortality were compared by race, insurance status, and other clinical and hospital factors. RESULTS: The database captured 781,413 patients, of which 525,986 had a RYGB and 255,428 had SG. There was an increase in the incidence of SG over RYGB over time. Among the self-pay/uninsured, the increased incidence began several years earlier than other groups. Black patients had greater odds of increased postoperative LOS (OR 1.40) and in-hospital mortality (OR 2.11). CONCLUSION: Sociodemographic factors are associated with differences in temporal trends in the adoption of SG versus RYGB for surgical weight loss.

Affordable Rapid Olfaction Measurement Array: A Novel, Essential Oil-Based Test Strongly Correlated with UPSIT and Subjective Outcome Measures.

BACKGROUND: Olfactory dysfunction is an important facet of numerous disease states ranging from sinonasal disease to neurocognitive disorders. Due to expense and/or logistical barriers, objective olfactory testing is not common. We describe the creation of a novel, essential oil-based smell test, Affordable Rapid Olfaction Measurement Array (AROMA), composed at 14 scents at different concentrations and demonstrate correlation of AROMA with the University of Pennsylvania Smell Identification Test (UPSIT), patient age, Sinonasal Outcomes Test (SNOT-22), and perceived loss of smell. METHODS: AROMA was developed for point-of-care olfactory testing and compared to the UPSIT, as well as subjective outcome measures as noted above. About 37 healthy controls were prospectively recruited to assess the reliability of AROMA using a test-retest protocol. An additional cohort of 38 participants with sinonasal disease were prospectively recruited to complete the AROMA and UPSIT, and were compared with a cohort of 30 healthy controls. Spearman correlation correlated AROMA and UPSIT results, patient age, SNOT-22, and perceived loss of smell. RESULTS: AROMA demonstrated good test-retest reliability (r = 0.85, P < .001). Spearman's rho correlation of AROMA to UPSIT was statistically significant at ρ = 0.75 (P < .001). SNOT-22, age, and perceived sense of smell were all significantly correlated with both AROMA (ρ = -0.548, -0.557, -0.642, respectively) and UPSIT (ρ = -0.367, -0.460, -0.552, respectively). CONCLUSION: AROMA has a strong correlation with UPSIT and may be more strongly correlated with sinonasal outcomes. Additionally, AROMA is reusable; level of odorant is not static; and AROMA can test both odor detection and identification. LEVEL OF EVIDENCE: 2b.

Hospital Variation in Spending for Lung Cancer Resection in Medicare Beneficiaries.

BACKGROUND: As cancer payment models transition from fee for service toward payment "bundles" based on episodes of care, a deeper understanding of the costs associated with stage I lung cancer treatment becomes increasingly relevant. To better understand costs in early lung cancer care, we sought to characterize hospital-level variation in Medicare expenditure after lobectomy for stage I non-small cell lung carcinoma. METHODS: Patients who were diagnosed with stage I non-small cell lung carcinoma from 2006 through 2011 and undergoing lobectomy were selected from the Surveillance, Epidemiology and End Results-Medicare linked database. We used Medicare claims to estimate costs of care in the 90 days after initial surgical hospitalization. Hospitals were grouped into quintiles of mean excess cost, calculated as the mean difference between observed costs and risk-adjusted predicted costs. The association between hospital factors and mean excess cost were compared across hospitals, including complication rates and hospital volume. RESULTS: A total of 3530 patients underwent lobectomy at 156 hospitals. Hospitals in the lowest cost quintile had index hospitalizations $6226 less costly than predicted. Conversely, the most expensive hospital quintile had index hospital costs that were $6151 costlier than predicted. Increased costs were positively associated with the number of complications per patient (P < .001), but not hospital volume (P = .85). CONCLUSIONS: Among Medicare beneficiaries undergoing lobectomy for stage I non-small cell lung carcinoma, the cost of perioperative care varied substantially across hospitals and was strongly associated with complication rate, but not hospital volume.

Differential Safety Between Top-Ranked Cancer Hospitals and Their Affiliates for Complex Cancer Surgery.

Importance: Leading cancer hospitals have increasingly shared their brands with other hospitals through growing networks of affiliations. However, the brand of top-ranked cancer hospitals may evoke distinct reputations for safety and quality that do not extend to all hospitals within these networks. Objective: To assess perioperative mortality of Medicare beneficiaries after complex cancer surgery across hospitals participating in networks with top-ranked cancer hospitals. Design, Setting, and Participants: A cross-sectional study was performed of the Centers for Medicare & Medicaid Services 100% Medicare Provider and Analysis Review file from January 1, 2013, to December 31, 2016, for top-ranked cancer hospitals (as assessed by U.S. News and World Report) and affiliated hospitals that share their brand. Participants were 29 228 Medicare beneficiaries older than 65 years who underwent complex cancer surgery (lobectomy, esophagectomy, gastrectomy, colectomy, and pancreaticoduodenectomy [Whipple procedure]) between January 1, 2013, and October 1, 2016. Exposures: Undergoing complex cancer surgery at a top-ranked cancer hospital vs an affiliated hospital. Main Outcomes and Measures: Risk-adjusted 90-day mortality estimated using hierarchical logistic regression and comparison of the relative safety of hospitals within each cancer network estimated using standardized mortality ratios. Results: A total of 17 300 patients (59.2%; 8612 women and 8688 men; mean [SD] age, 74.7 [6.2] years) underwent complex cancer surgery at 59 top-ranked hospitals and 11 928 patients (40.8%; 6287 women and 5641 men; mean [SD] age, 76.2 [6.9] years) underwent complex cancer surgery at 343 affiliated hospitals. Overall, surgery performed at affiliated hospitals was associated with higher 90-day mortality (odds ratio, 1.40; 95% CI, 1.23-1.59; P < .001), with odds ratios that ranged from 1.32 (95% CI, 1.12-1.56; P = .001) for colectomy to 2.04 (95% CI, 1.41-2.95; P < .001) for gastrectomy. When the relative safety of each top-ranked cancer hospital was compared with its collective affiliates, the top-ranked hospital was safer than the affiliates in 41 of 49 studied networks (83.7%; 95% CI, 73.1%-93.3%). Conclusions and Relevance: The likelihood of surviving complex cancer surgery appears to be greater at top-ranked cancer hospitals compared with the affiliated hospitals that share their brand. Further investigation of performance across trusted cancer networks could enhance informed decision making for complex cancer care.

Evaluating a novel surgical risk assessment curriculum for medical students.

PURPOSE: Predicting surgical risk is challenging. There is no curriculum to teach risk assessment to students. We hypothesize that a risk assessment curriculum will improve medical students' confidence in and familiarity with assessing risk, and help identify barriers to assessing risk. METHODS: Third year surgery clerkship students participated in a risk-assessment workshop. Students completed pre- and post-intervention surveys assessing their familiarity with models, and confidence in predicting postoperative complications. Additionally, they completed a retention survey 12-weeks following the session. RESULTS: Following the session, confidence in predicting post-operative morbidity and mortality improved from <1% to 21.9% and 19.05% respectively. The majority of students continued to feel more confident mortality 12-weeks following the session. Not seeing attendings/residents use the calculator was a significant barrier to use. CONCLUSIONS: This novel risk assessment curriculum improved student confidence towards assessing risk up to three months following the session. Additionally, this study highlights that barriers exist to using risk assessment tools clinically.

The Early Impact of Medicaid Expansion on Uninsured Patients Undergoing Emergency General Surgery.

BACKGROUND: Under the Affordable Care Act, eligibility for Medicaid coverage was expanded to all adults with incomes up to 138% of the federal poverty level in states that participated. We sought to examine the national impact Medicaid expansion has had on insurance coverage for patients undergoing emergency general surgery (EGS) and the cost burden to patients. MATERIALS AND METHODS: The National Inpatient Sample (NIS) was used to identify adults ≥18 y old who underwent the 10 most burdensome EGS operations (defined as a combination of frequency, cost, and morbidity). Distribution of insurance type before and after Medicaid expansion and charges to uninsured patients was evaluated. Weighted averages were used to produce nationally representative estimates. RESULTS: A total of 6,847,169 patients were included. The percentage of uninsured EGS patients changed from 9.4% the year before Medicaid expansion to 7.0% after (P < 0.01), whereas the percentage of patients on Medicaid increased from 16.4% to 19.4% (P < 0.01). The cumulative charges to uninsured patients for EGS decreased from $1590 million before expansion to $1211 million after. CONCLUSIONS: In the first year of Medicaid expansion, the number of uninsured EGS patients dropped by 2.4%. The cost burden to uninsured EGS patients decreased by over $300 million.

Delayed discharge does not decrease the cost of readmission after pulmonary lobectomy.

BACKGROUND: Readmission after pulmonary lobectomy has become a potentially avoidable source of excess health care costs. Initiatives that focus on expedited discharge after lobectomy may decrease costs, but a criticism of this approach is that expedited discharge may be associated with more frequent and more expensive readmissions. We explored whether patients are at greater risk for costly readmission after expedited discharge. METHODS: The Nationwide Readmission Database was queried for cases of lobectomy for lung cancer between 2010 and 2014. Patients 65 years of age and older were categorized into three groups: patients discharged between hospital day 1 and 3 (expedited), between hospital days 4 and 7 (routine), or discharge after day 8 (late). Risk-adjusted 90-day readmission rates and hospital costs for readmission were compared among groups. RESULTS: A total of 104,905 patients underwent lobectomy for lung cancer during the study period. There were 18,652 (17.8%) expedited discharges, 54,551 (52.0%) routine discharges, and 31,702 (30.2%) late discharges. Compared with the expedited group, patients in the routine discharge group had a 3.2% greater risk-adjusted readmission rate (P < .0001), and patients in the late discharge group had 12.7% greater risk-adjusted readmission rate (P < .0001). After adjustment, expedited discharge was associated with a $4,066 decrease in index hospital costs compared with routine discharge, and a $19,233 decrease compared with late discharges (both P < .0001) but was not associated with costlier readmission (routine mean -$24 ± standard error $153, P = .87; late mean +$2,528 ± standard error $178; P < .0001). CONCLUSION: Expedited discharge after lobectomy is associated with a greater risk-adjusted readmission rate and greater index hospital costs over routine and late discharge, with no increased costs for readmission. These data demonstrate that prolonged hospital duration of stay does not decrease the risk of 90-day readmission after lobectomy, providing support for protocols that expedite patient discharge and decrease overall health care utilization.

The influence of sociodemographic factors on operative decision-making in small bowel obstruction.

BACKGROUND: Current guidelines for small bowel obstruction (SBO) recommend a limited trial of nonoperative management of no more than 3-5 d. For patients requiring surgery, it is uncertain if sociodemographic factors are associated with disparities in the duration of the trial of nonoperative therapy. METHODS: The Healthcare Cost and Utilization Project National Inpatient Sample from 2012 to 2014 was queried for discharges with a primary diagnosis of SBO. Primary outcomes of interest were the effects of sociodemographic factors, including race, insurance status, and income on the rate of receiving any operative management for SBO, and subsequently, among patients managed surgically, the risk of operative delay, defined as operative management ≥ 5 d after admission. We did this by using logistic hierarchical generalized linear models, accounting for hospital clustering and adjusted for sex, age, comorbidity, and hospital factors. RESULTS: Of the 589,850 admissions for SBO between 2012 and 2014, 22.0% underwent operations. Overall, 26.2% were non-White, including 12.2% Black and 8.6% Hispanic patients, and the majority (56.0%) had Medicare insurance coverage. Income quartiles were evenly distributed across the overall study population. In adjusted logistic regression, operative delay was associated with increased odds of in-hospital mortality (odds ratio 1.30 95% confidence interval [1.10, 1.54]). Adjusted for patient and hospital factors, Black patients were significantly more likely to receive operations for SBO, whereas Medicaid and Medicare patients were significantly less likely. However, Black, Medicaid, and Medicare patients who were managed operatively were significantly more likely to have an operative delay of 5 or more d. There was no significant association between income and operative management in adjusted regression models. CONCLUSIONS: Significant disparities in the operative management were based on race and insurance status. Further research is warranted to understand the causes of, and solutions to, these sociodemographic disparities in care.

Trends of ureteral stent usage in surgery for diverticulitis.

BACKGROUND: Many believe that the use of ureteral stents in colorectal surgery for diverticulitis aids prevention and easier identification of ureteral injuries; others argue that the added time, cost, and risks of stent placement negate potential benefits. Even among providers who use stents, selective use is common. Among unclear consensus, it remains unknown if the use of stents is growing. MATERIALS: Patients in the National Inpatient Sample who underwent a partial colectomy or anterior rectal excision for diverticulitis between 2000 and 2013 were included (n = 811,071). Trends in ureteral stent use, multivariate logistic regression of factors influencing stent placement, and linear regression of length of stay (LOS) and costs associated with stent use were examined. RESULTS: Usage of ureteral stents increased from 6.66% in 2000 to 16.30% in 2013 (P < 0.0001). Rates of stent usage were higher with laparoscopic surgery (19.31% versus 12.31% open, P < 0.0001). Regression demonstrated patients in the Northeast (Midwest odds ratio (OR) 0.49 [0.37-0.66] P < 0.0001, South OR 0.60 [0.45-0.80] P = 0.0004, West OR 0.30 [0.22-0.41], P < 0.0001), and those whose admission was elective (OR 2.37 [2.08-2.69], P < 0.0001) were more likely to receive stents. Stent use was associated with an increased LOS (0.55 days, P < 0.0001) and cost ($1,983, P < 0.0001). CONCLUSIONS: The use of ureteral stents in surgery for diverticulitis has steadily increased since 2000, despite the lack of consensus of their overall benefit. Stent usage is associated with laparoscopic surgery and varies widely among regions of the country. Further studies are required to truly understand the risk-benefit ratio of ureteral stenting and to determine if its increased use is warranted.

Trainees as Agents of Change in the Opioid Epidemic: Optimizing the Opioid Prescription Practices of Surgical Residents.

OBJECTIVE: Opioid abuse has become an epidemic in the United States, causing nearly 50,000 deaths a year. Postoperative pain is an unavoidable consequence of most surgery, and surgeons must balance the need for sufficient analgesia with the risks of overprescribing. Prescribing narcotics is often the responsibility of surgical residents, yet little is known about their opioid-prescribing habits, influences, and training experience. DESIGN: Anonymous online survey that assessed the amounts of postoperative opioid prescribed by residents, including type of analgesia, dosage, and number of pills, for a series of common general surgery procedures. Additional questions investigated influences on opioid prescription, use of nonnarcotic analgesia, degree of engagement in patient education on opioids, and degree of training received on analgesia and opioid prescription. SETTING: Accreditation Council for Graduate Medical Education accredited general surgery program at a university-based tertiary hospital. PARTICIPANTS: Categorical and preliminary general surgery residents of all postgraduate years. RESULTS: The percentage of residents prescribing opioids postprocedure ranged from 75.5% for incision and drainage to 100% for open hernia repair. Residents report prescribing 166.3 morphine milligram equivalents of opioid for a laparoscopic cholecystectomy, yet believe patients will only need an average of 113.9 morphine milligram equivalents. The most commonly reported influences on opioid-prescribing habits include attending preference (95.2%), concern for patient satisfaction (59.5%), and fear of potential opioid abuse (59.5%). Only 35.8% of residents routinely perform a narcotic risk assessment before prescribing and 6.2% instruct patients how to properly dispose of excess opioids. More than 90% of residents have not had formal training in best practices of pain management or opioid prescription. CONCLUSION AND RELEVANCE: Surgical trainees are relying almost exclusively on opioids for postoperative analgesia, often in excessive amounts. Residents are heavily influenced by their superiors, but are not receiving formal opioid-prescribing education, pointing to a great need for increased resident education on postoperative pain and opioid management to help change prescribing habits.

Optimizing Infant HIV Diagnosis in Resource-Limited Settings: Modeling the Impact of HIV DNA PCR Testing at Birth.

BACKGROUND: Early antiretroviral therapy (ART) initiation in HIV-infected infants significantly improves survival but is often delayed in resource-limited settings. Adding HIV testing of infants at birth to the current recommendation of testing at age 4-6 weeks may improve testing rates and decrease time to ART initiation. We modeled the benefit of adding HIV testing at birth to the current 6-week testing algorithm. METHODS: Microsoft Excel was used to create a decision-tree model of the care continuum for the estimated 1,400,000 HIV-infected women and their infants in sub-Saharan Africa in 2012. The model assumed average published rates for facility births (42.9%), prevention of mother-to-child HIV transmission utilization (63%), mother-to-child-transmission rates based on prevention of mother-to-child HIV transmission regimen (5%-40%), return of test results (41%), enrollment in HIV care (52%), and ART initiation (54%). We conducted sensitivity analyses to model the impact of key variables and applied the model to specific country examples. RESULTS: Adding HIV testing at birth would increase the number of infants on ART by 204% by age 18 months. The greatest increase is seen in early ART initiations (543% by age 3 months). The increase would lead to a corresponding increase in survival at 12 months of age, with 5108 fewer infant deaths (44,550, versus 49,658). CONCLUSION: Adding HIV testing at birth has the potential to improve the number and timing of ART initiation of HIV-infected infants, leading to a decrease in infant mortality. Using this model, countries should investigate a combination of HIV testing at birth and during the early infant period.

The Triple Aim and its implications on the management of chronic rhinosinusitis.

INTRODUCTION: Accountable care organizations (ACO) and alternative payment models are a sign of the change in reimbursement from fee-for-service to value-based reimbursement. The focus of health care under ACOs is represented by the Triple Aim: to improve the experience of health care, improve the health of populations, and reduce the per capita costs. Individuals with chronic rhinosinusitis (CRS) are heavy consumers of health care services. Results of recent studies have indicated that there is the potential for improved outcomes and cost savings from early surgical intervention. Adhering to the principles of the Triple Aim may signal a paradigm shift in regard to timing of intervention for CRS in certain patients. METHODS: A scoping review was performed to analyze the current literature related to management of CRS and the impact on cost, population health outcomes, and the patient's experience of health care. RESULTS: A growing body of literature indicates that, in appropriately selected patients, when compared with medical management, endoscopic sinus surgery has the potential to improve patient outcomes and reduce the long-term cost burden of CRS. CONCLUSION: With the advent of ACOs, a paradigm shift in the treatment of CRS is inevitable to better conform to the goals of the Triple Aim. Future treatment algorithms will need to account for the heterogeneity within CRS and seek to identify appropriate timing and interventions for patients on an individual basis if the value of health care is to be improved.

Reliability of preoperative assessment of cerebrospinal fluid pressure in the management of spontaneous cerebrospinal fluid leaks and encephaloceles.

BACKGROUND: The association of spontaneous cerebrospinal fluid (CSF) leaks with increased intracranial pressure (ICP) is well-documented. Accurate assessment of CSF pressure is paramount to optimal long-term outcomes, as failure of surgical repair or recurrent leaks may be associated with untreated intracranial hypertension. Many surgeons utilize a single opening pressure measured at the onset of the surgical procedure to determine if long-term acetazolamide or shunt placement will be necessary. However, preoperative measurement of CSF pressure may be inaccurate secondary to active drainage. The purpose of this study is to determine the accuracy of preoperative CSF pressure measurement in the setting of active CSF rhinorrhea. METHODS: Retrospective review of 65 cases of endoscopic repair of active spontaneous CSF rhinorrhea performed at a tertiary care institution from 2002 to 2009. A total of 16 cases in which reliable preoperative opening pressure and 48-hour to 72-hour postoperative CSF pressures were recorded were included in the analysis. Cases in which measurements were potentially unreliable or in which acetazolamide therapy was used were excluded from analysis. RESULTS: The average preoperative measurement was 26 ± 11 cm H20, and the average postoperative measurement was 15 ± 6 cm H20. The average change in CSF pressure from preoperative to postoperative was -10 ± 11 cm H20. Student paired t test was used to confirm statistical difference between the 2 sets of measurements. CONCLUSION: Our results suggest that a single preoperative measurement of CSF pressure in patients with active CSF rhinorrhea may not be sufficiently reliable to make subsequent long-term clinical decisions.