Cost-effectiveness of Canal Wall-Up vs Canal Wall-Down Mastoidectomy: A Modeling Study.

OBJECTIVE: To assess the relative lifetime costs, benefits, and cost-effectiveness between the 2 approaches, canal wall-up (CWU) and canal wall-down (CWD) tympanomastoidectomy, used in the treatment of cholesteatomas. STUDY DESIGN: Markov state transition model. SETTING: Tertiary academic health system. METHODS: A Markov state transition model was used to simulate outcomes across the patient lifetime. Outcome and complication probabilities were obtained from the existing literature. Costs were calculated from the payer perspective, with procedure, hospital, clinic, and physician cost derived from Medicare reimbursement. Quality-adjusted life years (QALYs) were used to represent effectiveness and utility. One-way and probability sensitivity analyses (PSAs) were conducted. RESULTS: The base case analysis, assuming a 40-year-old patient, yielded a lifetime cost of $14,214 for a patient treated with the CWU approach assuming second-look surgery and $22,290 with a CWD approach. CWU and CWD generated a benefit of 17.11 and 17.30 QALYs, respectively. The incremental cost-effectiveness ratio for CWU was $43,237 per QALY. The Monte Carlo PSA validated the base case scenario. Using a standard $50,000 willingness-to-pay threshold, CWD was the more cost-effective approach and was selected 54.8% of the time by the simulation. CONCLUSION: Both CWU and CWD were found to be cost-effective, with CWD being cost-effective 54.8% of the time at a WTP threshold of $50,000. The assumptions used in the analysis were validated by the results of 1-way and PSA.

Non-resuscitative first aid training and assessment for junior secondary school students: A pre-post study.

ABSTRACT: School-based first aid interventions can contribute to the number of adults trained in first aid in the community over time but few studies have examined the effectiveness of teaching non-resuscitative first aid on knowledge, attitudes and skills. Currently, there is no consensus on the optimal content and duration of first aid training for junior secondary students. The aim of this study was to evaluated the effectiveness of a 2.5 hour introductory non-resuscitative first aid course for junior secondary students.This prospective, single-centre, pre-post study included 140 students (11-13 years old). Students completed a questionnaire on first aid knowledge, attitude towards first aid and self-confidence to perform first aid before and after a training session. Six emergency medicine physicians taught practical first aid skills training. A game-based formative assessment was undertaken where the instructors assessed small teams of students' role-playing injured classmates and first aid responders (and vice-versa) treating abrasions, ankle sprain, choking and a scald injury.Few students had prior first aid training (14%). After adjusting for student's age, sex, prior first aid training and format delivery, the course was associated with increased mean knowledge score (pre-training 53%, post-training 88%; mean difference [MD] 35%, 95% CI: 32% to 38%), positive attitudes and more confidence in performing first aid after training (all P < .001). All teams showed a good level of competency in treating simulated injuries with first aid kits.This brief non-resuscitative first aid course was associated with noticeable and valuable changes in knowledge score and self-confidence level in performing first aid. The game-based formative assessment facilitated a positive learning environment for skill competency evaluation.

Pediatric interventional radiology workforce in North America: a descriptive analysis of demographics, educational backgrounds and scholarly activities.

BACKGROUND: Pediatric interventional radiology has grown as an advanced subspecialty with increased demand, number and complexity of cases, and number of pediatric institutions offering a pediatric interventional radiology service. Despite the overall increase in the number of pediatric interventionalists over the past two decades, there is a heterogeneity in their academic backgrounds and a lack of uniform training pathways. OBJECTIVE: To analyze the demographics, academic backgrounds and scholarly activities of pediatric interventionalists across the United States (U.S.) and Canada. MATERIALS AND METHODS: A list of all members of the Society for Pediatric Interventional Radiology was obtained and pediatric interventionalists at academic and private practice institutions in the U.S. and Canada were included. Publicly available online sources were used to gather demographic and educational information about each pediatric interventionalist, which included the online curriculum vitae, the HealthGrades.com and Doximity.com websites, and Elsevier's Scopus database. Demographic and educational data including age, gender, educational background, additional degrees, academic rank, previous leadership positions, and metrics of scholarly activities were recorded. Fellowships in diagnostic pediatric radiology, adult interventional radiology and/or pediatric interventional radiology were recorded. Mann-Whitney U tests and Kruskal-Wallis tests were used to compare differences between groups. RESULTS: One hundred and twenty-five pediatric interventionalists were included, of whom 24 (19.2%) were female. The mean age was 48.6 years (standard deviation [SD]: 10.6, median: 45 years, range: 36-82 years). There was no statistical difference between median age for male versus female pediatric interventionalists (44.5 years vs. 45 years, P=0.89). A majority of pediatric interventionalists were American medical school graduates (96, 76.8%), while 29 (23.2%) were international medical graduates. Eighty-three percent (104) of the pediatric interventionalists completed diagnostic radiology residency training in the U.S., most commonly at the University of Cincinnati in Ohio (6.4%) and Washington University in St. Louis, MO (5.6%). Among fellowship training, pediatric interventionalists completed a pediatric radiology fellowship (61.6%), adult interventional radiology fellowship (40%) and/or a dedicated pediatric interventional radiology fellowship (57.6%). The mean±SD (median) publications, citations and Hirsch index (h-index) for pediatric interventionalists were 32±45 (12), 68±1,317 (120) and 9±10 (5), respectively. There was a statistically higher number of publications, citations and h-index with increasing academic rank at the assistant, associate and professor levels (P<0.001 for all groups). International medical graduate pediatric interventionalists had a higher, but not statistically significant, median publication count (26 vs. 11, P=0.0.25), citation count (236 vs. 93, P=0.36) and h-index (9.0 vs. 5, P=0.24) compared to pediatric interventional radiologists from American medical schools. CONCLUSION: Pediatric interventionalists in North America are predominantly male, with about a quarter having graduated from international medical schools. Pediatric radiology fellowship, followed by pediatric interventional radiology fellowship, was the most frequently pursued training pathway.

Influence of Insurance Status and Demographic Factors on Outcomes Following Tracheostomy.

OBJECTIVES/HYPOTHESIS: Little data exists regarding the relationship between socioeconomic and demographic factors and tracheostomy outcomes. The goal of this study was to determine associations between socioeconomic status (SES), demographic factors, and insurance status with hospital length of stay (LOS), intensive care unit (ICU) LOS, and mortality following tracheostomy. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective analysis of all patients who underwent tracheostomy at an urban tertiary-care academic hospital from 2016 to 2017 was performed. Patients were aggregated into low-, middle-, and high-income brackets. Other variables included age, sex, race, ethnicity, body mass index, and Charlson Comorbidity Index (CCI). Outcomes included hospital and ICU LOS, in-hospital mortality, and 30-day mortality following tracheostomy. Outcomes were compared using Kruskal-Wallis tests for continuous variables and χ2 or Fisher exact tests for categorical variables. The α level was set to .05. RESULTS: In total, 523 patients were included in the study. Patients from high-income areas were more likely to be male (P < .01), white (P < .01), and had lower body mass index (P = .04). On multiple regression analysis, Hispanic or Latino ethnicity was associated with an increased odds of 30-day mortality (odds ratio [OR]: 4.43, P = .020). CCI was also associated with increased odds of 30-day mortality (OR: 1.12, P = .039). CONCLUSIONS: Lower SES was not associated with increased morbidity or mortality after tracheostomy. Although Hispanic patients tended to have a lower CCI score, they had increased 30-day mortality, suggesting there are factors specific to this population that may influence outcomes, and future targeted studies are warranted to study these relationships. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1463-1467, 2021.

Banana fruit: An "appealing" alternative for practicing suture techniques in resource-limited settings.

PURPOSE: Suturing is an important core surgical competency that requires continued practice. The purpose of this study was to evaluate bananas as a medium for practicing suture techniques in resource-limited settings. MATERIALS AND METHODS: Using a crossover design, 20 University of Rwanda medical students practiced suturing on banana peels and commercial foam boards. Students were randomized into 2 groups: group A practiced on foam boards first and then bananas, and group B practiced on banana peels first and then foam boards. A post-workshop survey was then administered to students to gauge their attitude towards banana peels as a suturing practice material. Suture performance for each student was graded by three fellowship-trained facial plastic surgeons based on consistent spacing, knot location, appropriate knot, absence of air knots, and adequate bite size. RESULTS: Suture performance graded by facial plastic surgeons demonstrated that suturing outcomes with bananas were equal or superior to foam in 56.7% of instances. Twenty students participated in the workshop; 16 students responded to the survey (response rate = 80%). Students were comfortable practicing suturing with banana peels (Mdn = 4, IQR = 1) and strongly agreed that suturing banana peels was a useful activity (Mdn = 5, IQR = 1). Students thought banana peels and foam were comparable learning platforms (Mdn = 3.5, IQR = 1) and felt their suturing abilities improved with practice on banana peels (Mdn = 4, IQR = 1.3). CONCLUSIONS: Banana peels are a low cost, equally viable alternative to synthetic suture media.

Patient education materials assessment tool for laryngectomy health information.

BACKGROUND: The decision to undergo laryngectomy carries medical, social, and emotional consequences. This study evaluates the understandability and actionability of current laryngectomy information. METHODS: Laryngectomy-related educational materials from an online search were evaluated using the validated Patient Education Materials Assessment Tool (PEMAT). Reading difficulty was calculated using the Flesch-Kincaid Level, Flesch Reading Ease, Gunning-Fog Index (GFI), Coleman-Liau Index, Automated Readability Index, and Simple Measure of Gobbledygook (SMOG) score. Interrater agreement was assessed using Cohen's kappa. Pearson's correlation coefficient was used to determine the relationship among readability, understandability, and actionability. RESULTS: Forty-four articles were included. Interrater agreement was substantial (κ = 0.71). Mean understandability was 68.3% ± 17% and mean actionability was 66.3% ± 24%. Average reading difficulty exceeded the ability of an average American adult. There was a negative correlation between readability and understandability (R = -0.49; P < .05). CONCLUSION: Most laryngectomy information is too difficult for the average person to read, understand, or act upon. Revisions may be warranted to benefit a larger readership.

Resident Involvement in Professional Otolaryngology Organizations: Current Trends in the United States.

Involvement by residents in professional medical organizations can enrich their training, but little data exist regarding the number and types of involvement opportunities available to otolaryngology residents. We sought to fill this gap in knowledge by quantifying the extent to which major otolaryngology-related organizations in the United States provide involvement opportunities to otolaryngology residents. Our analysis included 23 organizations and subspecialty societies. Results showed that many opportunities exist for residents to attend conferences and present research; however, fewer involvement and funding opportunities existed in any other leadership, health policy, or service-learning experiences. These findings were consistent across general and subspecialty societies. Given the many purported benefits of resident involvement in otolaryngology outside of the standard training environment, future efforts may be warranted to increase the number and type of involvement opportunities currently available in professional societies.

Quantifying Medical Student Education and Exposure to Otolaryngology.

OBJECTIVES: Evaluate the educational and exposure opportunities provided to students by national otolaryngology organizations. METHODS: Twenty-four otolaryngology organizations and subspecialty societies were reviewed for medical student involvement opportunities, educational and enrichment opportunities, costs of involvement, and available research and travel scholarships. RESULTS: Nine organizations (37.5%) offered membership; 6 charged a membership fee, averaging $73 ± $30 (mean ± SD). Membership was limited to associate status for 7 organizations (77.8%; 7/9). Three organizations (12.5%) provided service opportunities, 4 (16.7%) allowed students to vote, and 1 (4.2%) allowed students to endorse others for membership. Most organizations allowed students to attend conferences (95.8%), and 19 (79.2%) allowed students to present research. Twenty-one (87.5%) organizations charged a conference registration fee ($366 ± $300). Seven organizations (29.2%) offered research scholarships, and 5 (20.8%) offered travel awards. CONCLUSIONS: Opportunities exist for medical students to attend conferences and present research; however, educational and enrichment activities in other areas were limited. Future efforts may be warranted to increase the number and type of opportunities for students.

Variable Reporting by Authors Presenting Arthroplasty Research at Multiple Annual Conferences.

BACKGROUND: Prior studies have demonstrated discrepancies in financial conflict of interest (COI) disclosure among authors presenting research at multiple spine and sports medicine conferences. The purpose of this study was to quantify the variability of self-reported financial disclosures of individual authors presenting at multiple arthroplasty conferences during the same year. METHODS: The author disclosure information published for the 2012 annual meetings of the American Academy of Orthopaedic Surgeons (AAOS), American Association of Hip and Knee Surgeons, the Hip Society, and the Knee Society were compiled. We tabulated the author disclosures, the number of companies/entities represented, and the types of disclosures reported. The disclosures made by authors presenting at more than one meeting were then compared for discrepancies. RESULTS: Of the 209 authors who presented at both the AAOS and American Association of Hip and Knee Surgeons meetings, 79 (37.79%) demonstrated discrepancies in their disclosures with 7 (8.8%) reporting no disclosures to the AAOS. Of the 84 authors who presented at both the AAOS and Hip Society meetings, 1 (1.19%) had discrepancies in their disclosures. Of the 52 authors who presented at both the AAOS and Knee Society meetings, 2 (3.84%) had discrepancies in their disclosures. CONCLUSION: There is variability in reported financial COIs by authors presenting at multiple arthroplasty conferences within the same year. Further work is warranted to improve transparency of COI disclosures among arthroplasty surgeons presenting research at national meetings.

Cost-effectiveness of simultaneous versus sequential surgery in head and neck reconstruction.

OBJECTIVE: To determine whether simultaneous (ablation and reconstruction overlaps by two teams) head and neck reconstruction is cost effective compared to sequentially (ablation followed by reconstruction) performed surgery. STUDY DESIGN: Case-controlled study. SETTING: Tertiary care hospital. SUBJECTS: Oncology patients undergoing free flap reconstruction of the head and neck. METHODS: A match paired comparison study was performed with a retrospective chart review examining the total time of surgery for sequential and simultaneous surgery. Nine patients were selected for both the sequential and simultaneous groups. Sequential head and neck reconstruction patients were pair matched with patients who had undergone similar oncologic ablative or reconstructive procedures performed in a simultaneous fashion. A detailed cost analysis using the microcosting method was then undertaken looking at the direct costs of the surgeons, anesthesiologist, operating room, and nursing. RESULTS: On average, simultaneous surgery required 3 hours 15 minutes less operating time, leading to a cost savings of approximately $1200/case when compared to sequential surgery. This represents approximately a 15% reduction in the cost of the entire operation. CONCLUSION: Simultaneous head and neck reconstruction is more cost effective when compared to sequential surgery.

A systematic review of medication safety outcomes related to drug interaction software.

BACKGROUND: Adverse drug events (ADEs) represent an important problem for hospital and primary care. Software that detects potential adverse drug interactions has been widely implemented in an effort to reduce the rate of ADEs. However, the impact of drug interaction detection software (DIS) on patient safety outcomes remains unknown. OBJECTIVES: To systematically review the literature on DIS in preventing adverse drug events and determine the effectiveness and cost-effectiveness of DIS. METHODS: A literature search of MEDLINE, EMBASE, CINAHL, IPA and Healthstar, using terms "Computer, Software or Decision Support" combined with "Drug Interactions, Drug Errors or Drug Monitoring" sought English language, post-1990 prospective studies that examined drug interaction (drug-drug) software as an intervention and adverse drug interactions as an outcome. Relevant studies were analyzed using a Bayesian meta-analysis approach. RESULTS: Of 5848 citations, only four studies met our inclusion criteria. Most of the excluded studies were not prospective or measured only prescriber attitudes, implementation success or changes in workflow. No study examined the impact of drug interaction software exclusively, rather as a component of decision support software. A Bayesian meta-analysis of these studies showed no significant difference in event rate between intervention and control groups (relative risk 0.66, 95% CI 0.33 to 1.18). The posterior median I-squared was 52%. CONCLUSION: No good quality studies address the specific benefits and harms or cost-effectiveness of drug interaction software on medication safety or clinical outcomes. The evidence at present does not support a benefit for these systems or support any policy to widely disseminate their use.