Socioeconomic and ethnic disparities associated with access to cochlear implantation for severe-to-profound hearing loss: A multicentre observational study of UK adults.

BACKGROUND: Patients with severe-to-profound hearing loss may benefit from management with cochlear implants. These patients need a referral to a cochlear implant team for further assessment and possible surgery. The referral pathway may result in varied access to hearing healthcare. This study aimed to explore referral patterns and whether there were any socioeconomic or ethnic associations with the likelihood of referral. The primary outcome was to determine factors influencing referral for implant assessment. The secondary outcome was to identify factors impacting whether healthcare professionals had discussed the option of referral. METHODS AND FINDINGS: A multicentre multidisciplinary observational study was conducted in secondary care Otolaryngology and Audiology units in Great Britain. Adults fulfilling NICE (2019) audiometric criteria for implant assessment were identified over a 6-month period between 1 July and 31 December 2021. Patient- and site-specific characteristics were extracted. Multivariable binary logistic regression was employed to compare a range of factors influencing the likelihood of implant discussion and referral including patient-specific (demographics, past medical history, and degree of hearing loss) and site-specific factors (cochlear implant champion and whether the hospital performed implants). Hospitals across all 4 devolved nations of the UK were invited to participate, with data submitted from 36 urban hospitals across England, Scotland, and Wales. Nine hospitals (25%) conducted cochlear implant assessments. The majority of patients lived in England (n = 5,587, 86.2%); the rest lived in Wales (n = 419, 6.5%) and Scotland (n = 233, 3.6%). The mean patient age was 72 ± 19 years (mean ± standard deviation); 54% were male, and 75·3% of participants were white, 6·3% were Asian, 1·5% were black, 0·05% were mixed, and 4·6% were self-defined as a different ethnicity. Of 6,482 submitted patients meeting pure tone audiometric thresholds for cochlear implantation, 311 already had a cochlear implant. Of the remaining 6,171, 35.7% were informed they were eligible for an implant, but only 9.7% were referred for assessment. When adjusted for site- and patient-specific factors, stand-out findings included that adults were less likely to be referred if they lived in more deprived area decile within Indices of Multiple Deprivation (4th (odds ratio (OR): 2·19; 95% confidence interval (CI): [1·31, 3·66]; p = 0·002), 5th (2·02; [1·21, 3·38]; p = 0·05), 6th (2·32; [1·41, 3·83]; p = 0.05), and 8th (2·07; [1·25, 3·42]; p = 0·004)), lived in London (0·40; [0·29, 0·57]; p < 0·001), were male (females 1·52; [1·27, 1·81]; p < 0·001), or were older (0·97; [0·96, 0·97]; p < 0·001). They were less likely to be informed of their potential eligibility if they lived in more deprived areas (4th (1·99; [1·49, 2·66]; p < 0·001), 5th (1·75; [1·31, 2·33], p < 0·001), 6th (1·85; [1·39, 2·45]; p < 0·001), 7th (1·66; [1·25, 2·21]; p < 0·001), and 8th (1·74; [1·31, 2·31]; p < 0·001) deciles), the North of England or London (North 0·74; [0·62, 0·89]; p = 0·001; London 0·44; [0·35, 0·56]; p < 0·001), were of Asian or black ethnic backgrounds compared to white patients (Asian 0·58; [0·43, 0·79]; p < 0·001; black 0·56; [0·34, 0·92]; p = 0·021), were male (females 1·46; [1·31, 1·62]; p < 0·001), or were older (0·98; [0·98, 0·98]; p < 0·001). The study methodology was limited by its observational nature, reliance on accurate documentation of the referring service, and potential underrepresentation of certain demographic groups. CONCLUSIONS: The majority of adults meeting pure tone audiometric threshold criteria for cochlear implantation are currently not appropriately referred for assessment. There is scope to target underrepresented patient groups to improve referral rates. Future research should engage stakeholders to explore the reasons behind the disparities. Implementing straightforward measures, such as educational initiatives and automated pop-up tools for immediate identification, can help streamline the referral process.

Litigation in thyroid surgery: a pan-specialty review of National Health Service (UK) data.

OBJECTIVE: Thyroid surgery carries risks that significantly impact patients. This paper describes the landscape of thyroid surgery related litigation claims in the National Health Service from April 2015 to April 2020, to establish learning points in order to improve patient care and minimise litigation risk. METHODS: Data were requested from National Health Service Resolution and Hospital Episode Statistics. Claims were classified into operative and non-operative causes. Subspecialty information, incident details and claim costings were analysed. RESULTS: Sixty claims were identified. Thirty-eight claims (63.3 per cent) were closed, with an average total claim cost of £68 816 and average damages paid of £36 349. Claims related to diagnostic issues were most common (n = 19); of claims associated with operative causes (n = 30), those relating to nerve injury were most common (n = 8), with issues of nerve monitoring and consent being cited. CONCLUSION: Utilisation of well-established protocols will likely reduce litigation in thyroid surgery, as we move towards a landscape in which the patient journey is thoroughly scrutinised for targeted improvements.

Litigation in Septorhinoplasty Surgery: A Pan-Specialty Review of National Health Service (the United Kingdom) Data.

Success in septorhinoplasty surgery can be difficult to assess due to a lack of objective and measurable outcomes. If patients' expectations are not met, it places surgeons performing septorhinoplasty at risk of litigation which can be stressful and costly. The National Institute of health (NHS) Resolution is a government-funded organization in the United Kingdom that provides expertise to the NHS on resolving patient concerns. Data were requested from NHS Resolution for claims involving septorhinoplasty surgery over a period of 5 years between April 2015 and April 2020. Rhinoplasty claims performed by all specialties were included. Data included the claim status, incident details, alleged injury, damages claimed, and damages paid. A total of 31 claims were identified by the study, equating to a total cost of £1,347,336.10. Of the 31 claims for rhinoplasty or septorhinoplasty, 9 cases were open (29%, £962,361.00) and 22 cases were closed (71%, £384,975.10). The common causes for claims were "intraoperative problems (32%)," "failure to warn-informed consent (19%)," and "foreign body left in situ (13%)." The most common injuries were "cosmetic disfigurement (39%)," "unnecessary pain (29%)," and "additional/ unnecessary operation (29%)." This study highlights the need for improved awareness of clinical negligence claims among surgeons who perform septorhinoplasty. Results are applicable to all specialties who perform the procedure. The study highlights the importance of assessing patients' motives and expectations prior to surgery and emphasizes the need for a well-documented rigorous consent process.

Long-term oncological outcomes after haemorrhagic apoplexy in pituitary adenoma managed operatively and non-operatively.

INTRODUCTION: Depending on severity of presentation, pituitary apoplexy can be managed with acute surgery or non-operatively. We aim to assess long-term tumour control, visual and endocrinological outcomes following pituitary apoplexy with special emphasis on patients treated non-operatively. METHODS: Multicentre retrospective cohort study. All patients with symptomatic pituitary apoplexy were included. Patients were divided into 3 groups: group 1: surgery within 7 days; group 2: surgery 7 days-3 months; group 3: non-operative. Further intervention for oncological reasons during follow-up was the primary outcome. Secondary outcome measures included visual and endocrinological function at last follow-up. RESULTS: One hundred sixty patients were identified with mean follow-up of 48 months (n = 61 group 1; n = 34 group 2; n = 64 group 3). Factors influencing decision for surgical treatment included visual acuity loss (OR: 2.50; 95% CI: 1.02-6.10), oculomotor nerve palsy (OR: 2.80; 95% CI: 1.08-7.25) and compression of chiasm on imaging (OR: 9.50; 95% CI: 2.06-43.73). Treatment for tumour progression/recurrence was required in 17%, 37% and 24% in groups 1, 2 and 3, respectively (p = 0.07). Urgent surgery (OR: 0.16; 95% CI: 0.04-0.59) and tumour regression on follow-up (OR: 0.04; 95% CI: 0.04-0.36) were independently associated with long-term tumour control. Visual and endocrinological outcomes were comparable between groups. CONCLUSION: Urgent surgery is an independent predictor of long-term tumour control following pituitary apoplexy. However, 76% of patients who successfully complete 3 months of non-operative treatment may not require any intervention in the long term.

The Educational Value and Emotional Impact on Medical Students After Participating in Transplant Organ Retrieval.

INTRODUCTION: Medical students and healthcare professionals lack knowledge and confidence in organ transplantation which stems in part from a lack of exposure to transplant surgery at medical school. To address this, we developed a program that allowed students to attend organ retrievals and assessed its efficacy as an educational intervention. METHODS: Students were invited to attend organ retrievals through a voluntary program. Students then completed an anonymous, self-administered questionnaire (n = 40) designed to capture the perceived educational value and emotive impact of attending an organ retrieval, and its effect on career aspirations. Quantitative and qualitative data were analyzed. RESULTS: 100% of students would recommend attending an organ retrieval to a colleague. Students strongly agreed that attending an organ retrieval was a useful learning experience (87.5%) and 90% of students felt more confident discussing organ donation with patients and relatives. 50% of students were more likely to pursue a career in transplant surgery. Students recognized a number of difficulties associated with the emotive impact of organ procurement. CONCLUSION: An organ retrieval program for medical students offers a novel learning opportunity, and may increase knowledge and improve attitudes toward transplantation in future healthcare professionals. However, the emotive impact of exposing students to organ retrievals must also be recognized.

Medical Student Schwartz Rounds: A Powerful Medium for Medical Student Reflective Practice.

PURPOSE: Reflection is a core component of good medical practice and of growing importance given increasing rates of burnout in the field of medicine. Schwartz Rounds (SRs) are a group-based model of reflective practice. This study explored the utility of student-specific Schwartz Rounds as a medium for reflective practice amongst medical students entering their first year of clinical attachments, and how effective these are compared to standard organisation-wide Schwartz Rounds. METHODS: Three Medical Student Schwartz Rounds (MSSRs) were piloted over the course of a year at a major teaching hospital, focussed on the theme: "Is this what I signed up for?" Participants were asked to complete a questionnaire following the session, and this data was then analysed. RESULTS: Feedback was obtained from 93% (42/45) students who attended. Ninety per cent of students rated the sessions as "excellent or exceptional", 93% felt the MSSRs added to their "insight and self-awareness", and 90% plan to attend SRs again in the future. A thematic analysis of the qualitative feedback highlighted three broad themes from the pilot; group reflection is more profound than individual reflection, sharing experiences facilitated a greater sense of belonging, and group reflective practice can be intimidating. There was a statistically significant difference between students' ratings of MSSRs, rated 8.67/10, versus written reflection, rated 4.64/10 (p<0.01). CONCLUSION: Students were overwhelmingly positive about their experiences in this pilot, with response ratings commensurate with those from organisation-wide Schwartz Rounds. Therefore, MSSRs should be considered as a valid alternative form of reflective practice.

Specialty Showcase Days: Can Specialist Careers Workshops Improve The Consideration Of ENT For Medical Students?

OBJECTIVE: We hypothesize that poor consideration of specialist surgery is due to a lack of exposure to information about careers and practice itself. Ear, Nose, and Throat (ENT) surgery is given little weight in medical school curricula, despite ENT problems being extremely common. Our objective is to assess whether a specialty showcase day was sufficient to boost informed consideration of this career. DESIGN: We designed a half-day course involving an interactive careers workshop exploring ENT as a specialty choice, alongside simulation stations of commonly presenting ENT problems led by ENT doctors. We used pre- and post-course evaluation sheets to explore factors that encourage and discourage students from surgical careers and perceptions of ENT. SETTING: A large proportion of UK medical schools do not offer ENT placements, and of those that do, nearly half are not compulsory. This leaves students unaware of ENT as a career option and unclear about what an ENT career comprises. Our half-day course took place in the simulation suite at St Mary's Hospital, London. PARTICIPANTS: Medical students were mainly in their third year of study and had aspirations towards a variety of surgical and non-surgical careers, with a minority aspiring towards ENT before the course. RESULTS: Our results demonstrate that all students found the session useful and had a much better understanding of ENT practice, with almost all students leaving more likely to consider a career in ENT. CONCLUSION: We would like to repeat this session in different student year groups and compare their perceptions with our results. We find our results a good case for including informative careers workshops as part of medical school teaching. We pose that interactive workshops exploring specialist surgical careers are a valid way to enable students in making informed career decisions - particularly in specialties that are under-represented at medical school.