The Association Between Sociodemographic Factors, Social Determinants of Health, and Spine Surgical Patient Portal Utilization.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To examine patient portal use among the surgical spine patient population across different sociodemographic groups and assess the impact of patient portal use on clinical outcomes. SUMMARY OF BACKGROUND DATA: Patient portals (PP) have been shown to improve outcomes and quality of care. Engaging them requires internet access, technological literacy, and dexterity, which may serve as access barriers. METHODS: After exclusion criteria were applied, the study included data for 9211 encounters from 7955 patients. PP utilization was defined as having activated and used the Duke University Medical Center patient portal system, MyChart, at least once. Sociodemographic characteristics included urbanicity, age, race, ethnicity, language, employment, and primary insurer. Clinical outcomes included the length of hospital stay during the procedure, 30-day return to the emergency department, 30-day readmission, and being discharged somewhere other than home. RESULTS: Being older than 65, non-White, unemployed, non-English-speaking, male, not-partnered, uninsured or publicly insured (Medicaid, Medicare and under 65 years of age, or other government insurance), and living in a rural environment were all risk factors for decreased PP utilization among surgical spine patients. A one-risk factor decrease in the number of social risk factors was associated with a 78% increase in the odds of PP utilization [odds ratio (OR): 1.78; 95% Confidence interval (CI): 1.69-1.87; P <0.001]. Patients not utilizing the portal at the time of their procedure had higher odds of 30-day readmission (OR: 1.59; 95% CI: 1.26-2.00), discharge somewhere other than home (OR: 2.41, 95% CI: 1.95-2.99), and an increased length of hospital stay (geometric mean ratio: 1.21; 95% CI: 1.12-1.30) compared with those who utilized it. CONCLUSIONS: In patients undergoing spine procedures, PPs are not equally utilized among different sociodemographic groups. PP utilization is also associated with better outcomes. Interventions aimed at increasing PP uptake may improve care for certain patients.

Cystic fibrosis learning network telehealth innovation lab during the COVID-19 pandemic: a success QI story for interdisciplinary care and agenda setting.

INTRODUCTION: The Cystic Fibrosis Foundation chronic care guidelines recommend monitoring clinical status of a patient with cystic fibrosis (CF) through quarterly interdisciplinary visits. At the beginning of the COVID-19 pandemic, the Cystic Fibrosis Learning Network (CFLN) designed and initiated a telehealth (TH) innovation lab (TH ILab) to support transition from the classic CF care model of quarterly in-person office visits to a care model that included TH. AIM: The specific aims of the TH ILab were to increase the percentage of virtual visits with interdisciplinary care (IDC) from 60% to 85% and increase the percentage of virtual visits in which patients and families participated in shared agenda setting (AS) from 52% to 85% by 31 December 2020. METHODS: The model for improvement methodology was used to determine the ILab aims, theory, interventions and measures. In the testing phase of the ILab, data related to process and outcome measures as well as learnings from plan-do-study-act cycles were collected, analysed and shared weekly with the TH ILab teams. Participating centres created processes for IDC and AS for TH visits and developed and shared quality improvement tools specific to their local context with other centres during the ILab weekly meetings and via a secure CFLN-maintained platform. RESULTS: Both specific aims were achieved ahead of the expected target date. By August 2020, 85% of the TH ILab visits provided IDC and 92% of patients were seen for CF care by teams from the TH ILab that participated in AS. CONCLUSION: Shared learning through a collaborative, data-driven process in the CFLN TH ILab rapidly led to standardised TH IDC and AS, which achieved reliable and sustainable processes which could be reproduced by other networks.

Differences in comorbidities on low back pain and low back related leg pain.

OBJECTIVE: Investigate the influence of external factors such as depression and BMI among subjects with primary severe low back pain (LBP) and low back related leg pain (LBLP). BACKGROUND: The report of disability in patients with LBP may be significantly influenced by confounding and moderating variables. No similar studies have examined the influence of these factors on LBLP. METHODS: This study included 1,448 consecutive subjects referred to a tertiary spine clinic. Unconditional binary logistic regression was used to determine the influence of comorbidities on the relationship between self-reported back and leg pain. A change in estimate formula was used to quantify this relationship. RESULTS: Among those subjects with primary LBP the unadjusted odds ratio was 8.58 (95% CI 4.87, 15.10) and when adjusting for BMI, depression and smoking was 5.94 (95% CI 3.04, 11.60) resulting in a 36.7% change due to confounding by these comorbidities. Among those with primary LBLP, the unadjusted odds ratio was 4.49 (95% CI 2.78, 7.27) and when adjusting for BMI and depression was 4.60 (95% CI 2.58, 8.19) resulting in a 1.7% change due to confounding by these comorbidities. CONCLUSION: The disability statuses of the patients with primary LBP in this study were more significantly affected by comorbidities of BMI, depression and smoking than patients with report of LBLP. However, these comorbidities contribute little to the relationship of primary low back related leg pain and Oswestry scores ≥ 40.

Telehealth transformation: COVID-19 and the rise of virtual care.

The novel coronavirus disease-19 (COVID-19) pandemic has altered our economy, society, and healthcare system. While this crisis has presented the U.S. healthcare delivery system with unprecedented challenges, the pandemic has catalyzed rapid adoption of telehealth, or the entire spectrum of activities used to deliver care at a distance. Using examples reported by U.S. healthcare organizations, including ours, we describe the role that telehealth has played in transforming healthcare delivery during the 3 phases of the U.S. COVID-19 pandemic: (1) stay-at-home outpatient care, (2) initial COVID-19 hospital surge, and (3) postpandemic recovery. Within each of these 3 phases, we examine how people, process, and technology work together to support a successful telehealth transformation. Whether healthcare enterprises are ready or not, the new reality is that virtual care has arrived.

Reliability and diagnostic accuracy of clinical special tests for myelopathy in patients seen for cervical dysfunction.

STUDY DESIGN: Case control study. BACKGROUND: Myelopathy is a clinical diagnosis based largely on initial examination findings during a clinical screen, followed by imaging verification of cord injury or compression. At present, few studies have examined the reliability and diagnostic accuracy of clinical examination measures. OBJECTIVES: To determine the reliability and diagnostic accuracy of neurological tests associated with the diagnosis of myelopathy. METHODS AND MEASURES: Reliability and diagnostic accuracy of 7 frequently used tests and measures and subjective findings associated with myelopathy were examined on consecutive patients with cervical pain. Interrater reliability and diagnostic accuracy values, including posttest probability, based on a pretest probability of 40%, were calculated for each test and for combinations of tests and measures. RESULTS: Four of the 7 diagnostic tests were found to have a substantial interrater reliability. None of the single or clusters of tests yielded low negative likelihood ratios. Of the individual tests, the Babinski sign demonstrated the highest positive likelihood ratio (LR+, 4.0; 95% CI: 1.1-16.6) and posttest probability (73%) for diagnosis, but yielded only a moderate negative likelihood ratio (LR-, 0.7; 95% CI: 0.6-0.9). Combinations of tests did not yield improved accuracy values over single test results. CONCLUSION: This study demonstrated that 4 of 7 tests used to screen for myelopathy offered substantial levels of interrater agreement when used on individuals with cervical dysfunction. None of the tests when performed individually or in combinations are effective for screening; however, the Babinski sign did alter posttest probability more significantly than combinations of test findings. LEVEL OF EVIDENCE: Diagnosis, Level 2b.

A case of chronic progressive lyme encephalitis as a manifestation of late lyme neuroborreliosis.

A 54-year-old female living in Europe presented with gait ataxia, dizziness, and bilateral hearing loss. Magnetic resonance imaging (MRI) revealed non-specific white matter changes. The patient's condition gradually deteriorated over two years without diagnosis. The patient continued to decline cognitively and neurologically with worsening ataxia and upper motor neuron signs. Repeat MRI showed worsening white matter changes. Lumbar puncture, not previously done, showed positive Lyme testing. Treatment with intravenous ceftriaxone resulted in marked neurological improvement. Four years after symptom, the patient has short-term memory deficits and chronic fatigue, but is otherwise neurologically, cognitively, and functionally intact. Follow up MRI findings remain largely unchanged. Because cases of intraparenchymal or encephalopathic neuroborreliosis in America are lacking, so are treatment options. We present a rare case and discuss our experience with antibiotic treatment. This case lends evidence to define optimal treatment of this disease, imperative for hastening neurological recovery.

The clinical value of a cluster of patient history and observational findings as a diagnostic support tool for lumbar spine stenosis.

OBJECTIVE: The study aims to create a diagnostic support tool to indicate the likelihood of the presence of lumbar spinal stenosis (LSS) using a cluster of elements from the patient history and observational findings. DESIGN: The study is case based and case controlled. SETTING: The study was performed in the tertiary care of a medical center. SUBJECTS: There were a total of 1,448 patients who presented with a primary complaint of back pain with or without leg pain. METHODS: All patients underwent a standardized clinical examination. The diagnosis of LSS was made by one of two experienced orthopaedic surgeons based on clinical findings and imaging. Data from the patient history and observational findings were then statistically analysed using bivariate analysis and contingency tables. RESULTS: The most diagnostic combination included a cluster of: 1) bilateral symptoms; 2) leg pain more than back pain; 3) pain during walking/standing; 4) pain relief upon sitting; and 5) age>48 years. Failure to meet the condition of any one of five positive examination findings demonstrated a high sensitivity of 0.96 (95% CI=0.94-0.97) and a low negative likelihood ratio (LR-) of 0.19 (95% CI=0.12-0.29). Meeting the condition of four of five examination findings yielded a LR+ of 4.6 (95% CI=2.4-8.9) and a post-test probability of 76%. CONCLUSION: The high sensitivity of the diagnostic support tool provides the potential to reduce the incidence of unnecessary imaging when the diagnosis of LSS is statistically unlikely. In patients where the condition of four of the five findings was present, the post-test probability of 76% suggests that imaging and further workup are indicated. This is an inexpensive but powerful tool, with a potential to increase diagnostic efficiency and reduce cost by narrowing the indications for imaging.

The development of a clinical decision making algorithm for detection of osteoporotic vertebral compression fracture or wedge deformity.

The clinical diagnosis of an osteoporotic vertebral compression fracture (OVCF) is challenging and requires detailed assessment using comprehensive imaging methods. Further complicating matter is that the clinical sequelae associated with OVCF typically involves asymptomatic findings and variable pain patterns. The purpose of this study was to identify clinical characteristics and assessment findings that were associated with a diagnosis of OVCF. The study evaluated routine clinical findings in over 1400 subjects seen at an adult spine surgery clinic for thoracolumbar spine-related conditions within the years 2005-2009. All patients underwent a standardized clinical examination that included a self-report, observational, physical examination and imaging assessment. The diagnosis of OVCF was made after assessment of radiographic findings in sagittal alignment, vertebral body compression, and spinal canal dimensions. Data from the patient history and observational findings were then statistically analyzed and compared between those patients with a diagnosis of OVCF and those with an alternative diagnosis. Based on the results, a diagnostic support tool was created to predict the likelihood of OVCF. The most diagnostic combination included a cluster of: (1) age > 52 years; (2) no presence of leg pain; (3) body mass index ⩽ 22; (4) does not exercise regularly; and (5) female gender. A finding of two of five positive tests or less demonstrated high sensitivity of 0.95 (95% CI  =  0.83-0.99) and low negative likelihood ratio of 0.16 (95% CI  =  0.04-0.51), providing moderate value to rule out OVCF. Four of five yielded a positive likelihood ratio (LR+) of 9.6 (95% CI  =  3.7-14.9) providing moderate value in ruling in the diagnosis of OVCF. Further validation is necessary prospectively to determine the value of these findings on a disparate sample of patients in other unique environments.

Clustered clinical findings for diagnosis of cervical spine myelopathy.

Cervical spine myelopathy (CSM) is a clinical diagnosis made with imaging confirmation. At present, most clinical tests used to identify CSM are specific and no clusters of tests have proven more beneficial than stand alone tests in guiding treatment decision making. This study endeavored to produce a cluster of predictive clinical findings for a sample of patients using a clinical diagnosis/imaging confirmation as the reference standard for cervical spine myelopathy. Data from 249 patients with various conditions associated with cervical spine dysfunction were analyzed to determine which clinical tests and measures, when clustered together, were most diagnostic for CSM. Using multivariate regression analyses and calculations for sensitivity, specificity, and positive and negative likelihood ratios, a definitive cluster was identified. Thirteen clinical findings were investigated for capacity to diagnosis CSM. Five clinical: (1) gait deviation; (2) +Hoffmann's test; (3) inverted supinator sign; (4) +Babinski test; and (5) age >45 years, were demonstrated the capacity when clustered into one of five positive tests to rule out CSM (negative likelihood ratio = 0.18; 95% CI = 0.12-0.42), and when clustered into three of five positive findings to rule in CSM (positive likelihood ratio = 30.9; 95% CI = 5.5-181.8). This study found clustered combinations of clinical findings that could rule in and rule out CSM. These clusters may be useful in identifying patients with this complex diagnosis in similar patient populations.

Correlation of magnetic resonance imaging findings and reported symptoms in patients with chronic cervical dysfunction.

Information gathered from the patient history, physical examination, and advanced testing augments the decision-making process and is proposed to improve the probability of diagnostic and prognostic accuracy. However, these findings may provide inconsistent results and can lead to errors in decision-making. The purpose of this study was to examine the relationship between common clinical complaints and specific findings on magnetic resonance imaging (MRI) in patients with chronic neck dysfunction. Forty-five English-speaking participants (25 female), with mean age of 52 (SD = 13.4), were evaluated by a neurosurgeon for complaints of symptoms related to the cervical spine. All participants answered a subjective questionnaire and received an MRI of the cervical spine. Cramer's V nominal correlation was performed to explore the relationship between the targeted variables. The correlation matrix calculations captured three significant findings. Evidence of spinal cord compression was significantly correlated to 1) anteroposterior canal diameter of less than or equal to 9 mm (r = .31; p<0.05) and 2) diminished subarachnoid fluid around the cord (r = .48; p<0.01). Report of loss of dexterity was significantly correlated with 3) report of lower extremity clumsiness (r = .33; p<0.05). In this study, no definitive relationships were found between the clinical complaints of neck pain, hand function, or clumsiness and specific MRI findings of spinal cord compression. Further research is needed to investigate the diagnostic utility of subjective complaints and their association with advanced testing.

Functional movement training for recurrent low back pain: lessons from a pilot randomized controlled trial.

OBJECTIVE: Despite considerable effort to reduce low back pain (LBP), approximately 60% of patients have recurrence after their first episode. The high rate of recurrence suggests that more effective intervention approaches are needed. This randomized, controlled feasibility trial was designed to compare disability, physical functional capacity, and pain outcomes at 2, 6, and 12 months for 2 conventional and 1 novel physical therapy (functional movement training) intervention for recurrent LBP. DESIGN: Randomized, controlled feasibility trial. SETTING: University hospital outpatient physical therapy clinic. PARTICIPANTS: Sixty-one participants (60% female) with recurrent LBP. INTERVENTIONS: Subjects were randomized to 1 of 3 intervention groups: group 1 had a single session consisting of standard back pain education; group 2 had 6 sessions in 8 weeks of conventional physical therapy; and group 3 had 6 sessions in 8 weeks of a novel method of functional movement training. Change from baseline was used to determine within-group changes and between-group differences for participants who finished each time point (2, 6, and 12 months). Changes were evaluated using analysis of variance and Newman-Keuls post hoc analysis. MAIN OUTCOME MEASURES: The primary outcome measure was the novel Continuous Scale Physical Functional Performance test (CS-PFP), a measure of actual physical functional capacity. Secondary measures included the revised Oswestry Disability Index, a measure of pain-related disability, the Roland Morris Disability Questionnaire, and a standard visual analogue pain scale. RESULTS: Of the participants, 67% provided data at 2 months and 44% provided information at 12 months. Raw change scores were evaluated at 2, 6, and 12 months. While no statistical significance was reached with any outcome measure, the trends suggested little change for group 1 (education) and suggested that greatest improvement in function may occur in group 3 (functional movement training). In particular, at 2 months, the CS-PFP change scores revealed a trend (P=.072) toward greater improvement in groups 2 (conventional physical therapy) and 3 (functional movement training) compared with group 1. At 12 months, Oswestry Disability Index and CS-PFP scores also trended toward significance for groups 2 and 3 (P=.7 and .9, respectively). Mean change scores were also calculated and revealed groups 2 and 3 had improved by 2 months and this improvement remained stable at the 1-year mark. Trends in the direction of best improvement occurred for those in the functional movement training group. CONCLUSION: A large-scale randomized, controlled trial is warranted to determine whether an intervention based on functional movement training is superior to conventional, impairment-based intervention for individuals with recurrent LBP.