Health Literacy and Time Spent With a Hand Surgeon.

PURPOSE: To characterize the relationship between health literacy and duration of new hand surgery office visits. METHODS: Using a stopwatch from outside the room, we measured the duration of the visit (minutes of face-to-face contact between attending surgeon and patient) for 224 new patients presenting to 1 of 5 orthopedic hand surgeons (D.R.). Directly after the visit, patients were asked to complete the Newest Vital Sign (NVS) health literacy test, a sociodemographic survey, and 3 Patient-Reported Outcomes Measurement Information System-based questionnaires: Pain Interference, Upper Extremity Function, and Depression. The Newest Vital Sign scores were divided into limited (0-3) and adequate (4-6) health literacy. Medical records were reviewed to collect data on diagnosis, visit type, management, and whether patients were first seen by a resident/fellow. Multiple linear regression modeling was used to characterize the association between health literacy and duration of visit while controlling for the effect of other patient and visit characteristics. RESULTS: The unadjusted mean visit duration was 1.9 minutes shorter in patients with limited health literacy (9.4 minutes) than in patients with adequate health literacy (11.3 minutes), and this difference persisted after adjustment for a broad range of patient and visit characteristics. Greater magnitude of disability was associated with longer visits, as were second-opinion appointments, a diagnosis of nonspecific arm pain or compression neuropathy, and appointments in which operative management was chosen. Visits in which a resident/fellow saw the patient first were shorter than visits without resident/fellow assistance. CONCLUSIONS: The finding that limited health literacy correlated with shorter visits may suggest that patients who may stand to benefit the most from detailed health education and counseling received less. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Patient Satisfaction and its Relation to Perceived Visit Duration With a Hand Surgeon.

PURPOSE: To determine whether patient perception of time spent with a hand surgeon relates to patient satisfaction after a single new-patient office visit. METHODS: Prior to each visit, 112 consecutive new patients predicted how much time they expected to spend with the surgeon. Following the visit, patients were asked to estimate the time spent with the surgeon, indicate whether the surgeon appeared rushed, and rate their overall satisfaction with the surgeon. Wait time and actual visit duration were measured. Patients also completed a sociodemographic survey, the Consultation and Relational Empathy Measure, the Newest Vital Sign Health Literacy test, and 3 Patient-Reported Outcomes Measurement Information System-based questionnaires: Upper Extremity Function, Pain Interference, and Depression. Multivariable logistic and linear regression models were used to determine predictors of patient satisfaction, patient-perceived surgeon rush, and high previsit expectations of visit duration. RESULTS: Patient satisfaction was not associated with perceived visit duration but did correlate strongly with patient-rated surgeon empathy and symptoms of depression. Neither visit duration nor previsit expectations of visit length were determinants of patient-perceived surgeon rush. Only surgeon empathy was associated. Less-educated patients anticipated needing more time with the surgeon. CONCLUSIONS: Patient satisfaction with the surgeon and with the time spent during the office visit was primarily linked to surgeon empathy rather than to visit duration or previsit expectation of visit length. Efforts to make hand surgery office visits more patient-centered should focus on improving dialogue quality, and not necessarily on making visits longer.

Experimental coevolution: rapid local adaptation by parasites depends on host mating system.

Host-parasite interactions can drive rapid, reciprocal genetic changes (coevolution), provided both hosts and parasites have high heritabilities for resistance/infectivity. Similarly, the host's mating system should also affect the rate of coevolutionary change in host-parasite interactions. Using experimental coevolution, we determined the effect of obligate outcrossing verses partial self-fertilization (mixed mating) on the rate of evolutionary change in a nematode host (Caenorhabditis elegans) and its bacterial parasite (Serratia marcescens). Bacterial populations were derived from a common ancestor. We measured the effects of host mating system on host adaptation to the parasite. We then determined the extent of parasite adaptation to their local host populations. Obligately outcrossing hosts exhibited more rapid adaptation to parasites than did mixed mating hosts. In addition, most of the parasites became adapted to infecting their local hosts, but parasites from obligately outcrossing hosts showed a greater level of local adaptation. These results suggest that host populations evolved along separate trajectories and that outcrossing host populations diverged further than partially selfing populations. Finally, parasites tracking outcrossing host populations diverged further than parasites tracking the partially selfing host populations. These results show that the evolutionary trajectories of both hosts and parasites can be shaped by the host's mating system.

Host DNA depletion on frozen human respiratory samples enables successful metagenomic sequencing for microbiome studies.

Background: Most respiratory microbiome studies have focused on amplicon rather than metagenomics sequencing due to high host DNA content. We evaluated efficacy of five host DNA depletion methods on previously frozen human bronchoalveolar lavage (BAL), nasal swabs, and sputum prior to metagenomic sequencing. Results: Median sequencing depth was 76.4 million reads per sample. Untreated nasal, sputum and BAL samples had 94.1%, 99.2%, and 99.7% host-reads. The effect of host depletion differed by sample type. Most treatment methods increased microbial reads, species richness and predicted functional richness; the increase in species and predicted functional richness was mediated by higher effective sequencing depth. For BAL and nasal samples, most methods did not change Morisita-Horn dissimilarity suggesting limited bias introduced by host depletion. Conclusions: Metagenomics sequencing without host depletion will underestimate microbial diversity of most respiratory samples due to shallow effective sequencing depth and is not recommended. Optimal host depletion methods vary by sample type.

Variation in Physician Charges and Medicare Payments for Hand Surgery.

Purpose To assess national and state-level variation in physician charges (full amounts requested before payments are negotiated) and Medicare payments for common hand procedures. Materials and Methods Using the Medicare Provider Utilization and Payment Data Public Use File for 2012, we evaluated national and state variations in physician charges and Medicare payments for carpal tunnel release, trigger finger release, trigger finger injection, closed treatment of distal radius fracture, and interposition arthroplasty, intercarpal or carpometacarpal joints. We assessed variation, using the coefficient of variation. We also determined the correlation between charges and payments, as well as the association of patient volume with charges and payments. Results There was wide state-level variation in physician charges for carpal tunnel release (11-fold), trigger finger release (9.6-fold), and trigger finger injection (5.5-fold). On a national level, physician charges varied substantially for carpal tunnel release, trigger finger release, trigger finger injection, closed treatment of distal radius fracture, and interposition arthroplasty, intercarpal or carpometacarpal joints. Medicare payments varied to a lesser extent. The correlations between physician charges and Medicare reimbursements were not strong. Weak to no correlations were noted between patient volume and both charges and payments. Conclusion Physician charges for hand surgery vary substantially across states and nationally, and they do not correlate well with Medicare payments and surgeon volume. As the health care market transitions toward more restrictive physician networks and high-deductible plans, protecting uninsured and out-of-network patients from unexpected, high medical bills should be a policy priority. Type of Study/Level of Evidence Economic/Decision Analysis, Level III study.

The Integral Role of Genetic Variation in the Evolution of Outcrossing in the Caenorhabditis elegans-Serratia marcescens Host-Parasite System.

Outcrossing is predicted to facilitate more rapid adaptation than self-fertilization as a result of genetic exchange between genetically variable individuals. Such genetic exchange may increase the efficacy of selection by breaking down Hill-Robertson interference, as well as promoting the maintenance of within-lineage genetic diversity. Experimental studies have demonstrated the selective advantage of outcrossing in novel environments. Here, we assess the specific role of genetic variation in the evolution of outcrossing. We experimentally evolved genetically variable and inbred populations of mixed mating (outcrossing and self-fertilizing) Caenorhabditis elegans nematodes under novel ecological conditions-specifically the presence of the virulent parasite Serratia marcescens. Outcrossing rates increased in genetically variable host populations evolved in the presence of the parasite, whereas parasite exposure in inbred populations resulted in reduced rates of host outcrossing. The host populations with genetic variation also exhibited increased fitness in the presence of the parasite over eight generations, whereas inbred populations did not. This increase in fitness was primarily the result of adaptation to the parasite, rather than recovery from initial inbreeding depression. Therefore, the benefits of outcrossing were only manifested in the presence of genetic variation, and outcrossing was favored over self-fertilization as a result. As predicted, the benefits of outcrossing under novel ecological conditions are a product of genetic exchange between genetically diverse lineages.

Coevolutionary interactions with parasites constrain the spread of self-fertilization into outcrossing host populations.

Given the cost of sex, outcrossing populations should be susceptible to invasion and replacement by self-fertilization or parthenogenesis. However, biparental sex is common in nature, suggesting that cross-fertilization has substantial short-term benefits. The Red Queen hypothesis (RQH) suggests that coevolution with parasites can generate persistent selection favoring both recombination and outcrossing in host populations. We tested the prediction that coevolving parasites can constrain the spread of self-fertilization relative to outcrossing. We introduced wild-type Caenorhabditis elegans hermaphrodites, capable of both self-fertilization, and outcrossing, into C. elegans populations that were fixed for a mutant allele conferring obligate outcrossing. Replicate C. elegans populations were exposed to the parasite Serratia marcescens for 33 generations under three treatments: a control (avirulent) parasite treatment, a fixed (nonevolving) parasite treatment, and a copassaged (potentially coevolving) parasite treatment. Self-fertilization rapidly invaded C. elegans host populations in the control and the fixed-parasite treatments, but remained rare throughout the entire experiment in the copassaged treatment. Further, the frequency of the wild-type allele (which permits selfing) was strongly positively correlated with the frequency of self-fertilization across host populations at the end of the experiment. Hence, consistent with the RQH, coevolving parasites can limit the spread of self-fertilization in outcrossing populations.

Temporal dynamics of outcrossing and host mortality rates in host-pathogen experimental coevolution.

Cross-fertilization is predicted to facilitate the short-term response and the long-term persistence of host populations engaged in antagonistic coevolutionary interactions. Consistent with this idea, our previous work has shown that coevolving bacterial pathogens (Serratia marcescens) can drive obligately selfing hosts (Caenorhabditis elegans) to extinction, whereas the obligately outcrossing and partially outcrossing populations persisted. We focused the present study on the partially outcrossing (mixed mating) and obligately outcrossing hosts, and analyzed the changes in the host resistance/avoidance (and pathogen infectivity) over time. We found that host mortality rates increased in the mixed mating populations over the first 10 generations of coevolution when outcrossing rates were initially low. However, mortality rates decreased after elevated outcrossing rates evolved during the experiment. In contrast, host mortality rates decreased in the obligately outcrossing populations during the first 10 generations of coevolution, and remained low throughout the experiment. Therefore, predominant selfing reduced the ability of the hosts to respond to coevolving pathogens compared to outcrossing hosts. Thus, we found that host-pathogen coevolution can generate rapid evolutionary change, and that host mating system can influence the outcome of coevolution at a fine temporal scale.

Running with the Red Queen: host-parasite coevolution selects for biparental sex.

Most organisms reproduce through outcrossing, even though it comes with substantial costs. The Red Queen hypothesis proposes that selection from coevolving pathogens facilitates the persistence of outcrossing despite these costs. We used experimental coevolution to test the Red Queen hypothesis and found that coevolution with a bacterial pathogen (Serratia marcescens) resulted in significantly more outcrossing in mixed mating experimental populations of the nematode Caenorhabditis elegans. Furthermore, we found that coevolution with the pathogen rapidly drove obligately selfing populations to extinction, whereas outcrossing populations persisted through reciprocal coevolution. Thus, consistent with the Red Queen hypothesis, coevolving pathogens can select for biparental sex.