Development and Implementation of an Inpatient Otolaryngology Consultation Service at an Academic Medical Center.

OBJECTIVES: To design and implement a formal otolaryngology inpatient consultation service that improves satisfaction of consulting services, increases educational opportunities, improves the quality of patient care, and ensures sustainability after implementation. METHODS: This was a retrospective cohort study in a large academic medical center encompassing all inpatient otolaryngology service consultations from July 2005 to June 2014. Staged interventions included adding fellow coverage (July 2007 onward), intermittent hospitalist coverage (July 2010 onward), and a physician assistant (October 2011 onward). Billing data were collected for incidences of new patient and subsequent consultation charges. The 2-year preimplementation period (July 2005-June 2007) was compared with the postimplementation periods, divided into 2-year blocks (July 2007-June 2013). Outcome measures of patient encounters and work relative value units were compared between pre- and postimplementation blocks. RESULTS: Total encounters increased from 321 preimplementation to 1211, 1347, and 1073 in postimplementation groups (P < 0.001). Total work relative value units increased from 515 preimplementation to 2090, 1934, and 1273 in postimplementation groups (P < 0.001). CONCLUSIONS: A formal inpatient consultation service was designed with supervisory oversight by non-Accreditation Council for Graduate Medical Education fellows and then expanded to include intermittent hospitalist management, followed by the addition of a dedicated physician assistant. These additions have led to the formation of a sustainable consultation service that supports the mission of high-quality care and service to consulting teams.

Association of Midlife Hypertension with Late-Life Hearing Loss.

OBJECTIVE: To investigate the association of midlife hypertension with late-life hearing impairment. STUDY DESIGN: Data from the Atherosclerosis Risk in Communities study, an ongoing prospective longitudinal population-based study (baseline, 1987-1989). SETTING: Washington County, Maryland, research field site. SUBJECTS AND METHODS: Subjects included 248 community-dwelling men and women aged 67 to 89 years in 2013. Systolic blood pressure (SBP) and diastolic blood pressure were measured at each of 5 study visits from 1987-1989 to 2013. Hypertension was defined by elevated systolic or diastolic blood pressure or antihypertensive medication use. A 4-frequency (0.5-4 kHz) better-hearing ear pure tone average in decibels hearing loss (dB HL) was calculated from pure tone audiometry measured in 2013. A cutoff of 40 dB HL was used to indicate clinically significant moderate to severe hearing impairment. Hearing thresholds at 5 frequencies (0.5-8 kHz) were also considered separately. RESULTS: Forty-seven participants (19%) had hypertension at baseline (1987-1989), as opposed to 183 (74%) in 2013. The SBP association with late-life pure tone average differed by the time of measurement, with SBP measured at earlier visits associated with poorer hearing; the difference in pure tone average per 10-mm Hg SBP measured was 1.43 dB HL (95% CI, 0.32-2.53) at baseline versus -0.43 dB HL (95% CI, -1.41 to 0.55) in 2013. Baseline hypertension was associated with higher thresholds (poorer hearing) at 4 frequencies (1, 2, 4, 8 kHz). CONCLUSION: Midlife SBP was associated with poorer hearing measured 25 years later. Further analysis into the longitudinal relationship between hypertension and hearing impairment is warranted.

Pilot Study of Audiometric Patterns in Fuchs Corneal Dystrophy.

Purpose: Although Fuchs corneal dystrophy (FCD) is considered an eye disease, a small number of studies have identified genes related to both FCD and hearing loss. Whether FCD is related to hearing loss is unknown. Method: This is a case-control study comparing pure-tone audiometry hearing thresholds in 180 patients with FCD from a hospital-based ophthalmology clinic with 2,575 population-based controls from a nationally representative survey, the National Health and Nutrition Examination Survey (from cycles 2005-06 and 2009-10). Generalized estimating equations were used to compare mean better-hearing ear thresholds in the 2 groups adjusted for age, sex, race, and noise exposure. Results: Patients with FCD had higher hearing thresholds (worse hearing) in lower frequencies (mean difference at 0.5 kHz = 3.49 dB HL) and lower hearing thresholds (better hearing) in higher frequencies (difference at 4 kHz = -4.25 dB HL) compared with population-based controls. Conclusion: In the first study to use objectively measured hearing, FCD was associated with poorer low-frequency and better high-frequency audiometric thresholds than population controls. Further studies are needed to characterize this relationship.

The Economic Impact of Adult Hearing Loss: A Systematic Review.

Importance: Hearing impairment (HI) is highly prevalent in older adults and has been associated with adverse health outcomes. However, the overall economic impact of HI is not well described. Objective: The goal of this review was to summarize available data on all relevant costs associated with HI among adults. Evidence Review: A literature search of PubMed, Embase, the Cochrane Library, CINAHL, and Scopus was conducted in August 2015. For this systematic review, data extraction and quality assessment were performed by 2 independent reviewers. Eligibility criteria for included studies were presence of quantitative estimation of economic impact or loss of productivity of patients with HI, full-text English-language access, and publication in an academic, peer-reviewed journal or government report prior to August 2015. This review follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. A meta-analysis was not performed owing to the studies' heterogeneity in outcomes measures, methodology, and study country. Findings: The initial literature search yielded 4595 total references. After 2043 duplicates were removed, 2552 publications underwent title and abstract review, yielding 59 articles for full-text review. After full-text review, 25 articles were included. Of the included articles, 8 incorporated measures of disability; 5 included direct estimates of medical expenditures; 8 included other cost estimates; and 7 were related to noise-induced or work-related HI. Estimates of the economic cost of lost productivity varied widely, from $1.8 to $194 billion in the United States. Excess medical costs resulting from HI ranged from $3.3 to $12.8 billion in the United States. Conclusions and Relevance: Hearing loss is associated with billions of dollars of excess costs in the United States, but significant variance is seen between studies. A rigorous, comprehensive estimate of the economic impact of hearing loss is needed to help guide policy decisions around the management of hearing loss in adults.

Application of Lean Sigma to the Audiology Clinic at a Large Academic Center.

OBJECTIVE: To apply Lean Sigma--a quality improvement strategy to eliminate waste and reduce variation and defects--to improve audiology scheduling and utilization in a large tertiary care referral center. The project goals included an increase in utilization rates of audiology block time and a reduction in appointment lead time. STUDY DESIGN: Prospective quality improvement study. SETTING: Academic tertiary care center. SUBJECTS: All patients scheduling audiology clinic visits July 2013 to July 2014. METHODS: Value stream mapping was performed for the audiology scheduling process, and wasteful steps were identified for elimination. Interventions included a 2-week block release, audiology template revision, and reduction of underutilized blocks. Schedule utilization and lead time for new patient diagnostic audiogram were measured for 5 months postintervention and compared with 5 months preintervention. Overall, 2995 preintervention and 3714 postintervention booked appointments were analyzed. RESULTS: Block utilization increased from 77% to 90% after intervention (P < .0001). Utilization of joint-with-provider visits increased from 39% to 67% (P < .0001). Booked appointments increased from 2995 to 3714, with joint-with-provider booked appointments increasing from 317 to 1193. Appointment lead time averaged 24 days postintervention, compared with 29 days preintervention (P = .06). Average monthly relative value units measured 13,321 preintervention and 14,778 postintervention (P = .09). CONCLUSION: Lean Sigma techniques were successfully used to increase appointment block utilization and streamline scheduling practices.

Can laboratory tests predict the prognosis of patients after endovascular aneurysm repair? Current status and future directions.

The purpose of this study was to determine what laboratory values predict the prognosis of patients after endovascular aneurysm repair (EVAR). MEDLINE and Cochrane Library databases were searched. This resulted in 13 relevant articles. Data were pooled, and meta-analyses were performed. A meta-analysis including 5,655 patients showed that preoperative serum creatinine>1.5 mg/dL was a significant risk indicator for increased 30-day mortality (relative risk 3.0, 95% confidence interval 2.3-4.1, p<.0001). Four other studies showed that other cutoff values of creatinine or glomerular filtration rate can predict mortality and complications following EVAR. One study suggested that reduced preoperative hemoglobin is a risk indicator for reduced long-term survival. Increased serum creatinine, reduced glomerular filtration rate, and reduced hemoglobin are significant and strong predictors of mortality and complications after EVAR. Current evidence remains limited, and further research is needed to determine conclusively additional laboratory values that may predict the outcome of patients following EVAR.

Theory, technique, and practice of magnetic resonance angiography.

Magnetic resonance angiography (MRA) is now a widely accepted technique used to characterize vascular pathology such as stenosis, dissection, fistula, and aneurysms. Magnetic resonance techniques are increasingly driving clinical decision making by vascular physicians. The physics behind MRA can contribute to the general understanding and interpretation of the anatomic images. We seek to provide a window into how magnetic resonance images are generated, which techniques may be employed, and the potential advantages and limitations of various techniques and to discuss the future role MRA may have for the vascular physician.