Inappropriate wrist MRI: did guidelines have an impact?

OBJECTIVES: To assess the national prevalence and cost of inappropriate MRI in patients with wrist pain prior to and following American College of Radiology (ACR) guideline publication. STUDY DESIGN: We used administrative claims from the IBM MarketScan Research Databases to evaluate the appropriateness of wrist MRI in a national cohort of patients with commercial insurance or Medicare Advantage. METHODS: Adult patients with a diagnosis of wrist pain between 2016 and 2019 were included and followed for 1 year. We made assessments of appropriateness based on ACR guidelines for specific wrist pain etiologies. We tabulated the total costs and out-of-pocket expenses associated with inappropriate MRI studies using weighted mean payments for facility and professional fees. We performed segmented logistic regression on interrupted time series data to identify predictors of receiving inappropriate imaging and the impact of guideline publication on MRI use. RESULTS: The study cohort consisted of 867,119 individuals. Of these, 40,164 individuals (4.6%) had MRI, of whom 52.6% received an inappropriate study. Inappropriate studies accounted for $44,493,234 in total payments and $8,307,540 in out-of-pocket expenses. The interrupted time series found an approximately 1% monthly decrease in the odds of receiving an inappropriate study after guideline dissemination. CONCLUSIONS: MRI as a diagnostic tool for wrist pain is often inappropriate and expensive. Our findings support interventions to increase guideline adherence, such as integrated clinical decision support tools.

Post-Bariatric Panniculectomy: Postoperative Complications by Weight Loss Surgery Type.

BACKGROUND: Over 250,000 patients undergo bariatric surgery each year in the United States. Approximately 21% will undergo subsequent body contouring after massive weight loss. Patients with prior bariatric surgery are at a greater risk for complications relative to the general population. However, it is unknown if bariatric surgery type is associated with differential complication risk after panniculectomy. METHODS: A retrospective chart review of post-bariatric who underwent abdominal panniculectomy at a single large quaternary care center was performed. Postoperative complications were graded according to the Clavien-Dindo classification. Descriptive statistics, multivariable logistic regression, and power calculations were performed. RESULTS: In total, 216 patients were included. Restrictive bariatric surgery accounted for 48.6% while 51.3% had a history of malabsorptive bariatric surgery. The overall rate of complications was 34.3% (restrictive: 36.2%; malabsorptive: 32.8%, p=0.66). Wound complications were observed in 25.5% (n=55) of patients. Systemic complications occurred in 11.1% of patients overall, with statistically similar rates between restrictive and malabsorptive groups. After adjusting for both patient and operative factors, no significant difference in total complications (OR=1.15, 95% CI: 0.47 to 2.85, p=0.76), systemic complications (OR=0.26, 95% CI: 0.05 to 1.28, p=0.10), or wound complications (OR=2.31, 95% CI: 0.83 to 6.41, p=0.11) was observed. CONCLUSIONS: Complications following panniculectomy in bariatric surgery patients is high and predominantly related to wound healing. No significant difference between type of bariatric surgery and complication risk was found.

Harnessing the potential of large language models in medical education: promise and pitfalls.

OBJECTIVES: To provide balanced consideration of the opportunities and challenges associated with integrating Large Language Models (LLMs) throughout the medical school continuum. PROCESS: Narrative review of published literature contextualized by current reports of LLM application in medical education. CONCLUSIONS: LLMs like OpenAI's ChatGPT can potentially revolutionize traditional teaching methodologies. LLMs offer several potential advantages to students, including direct access to vast information, facilitation of personalized learning experiences, and enhancement of clinical skills development. For faculty and instructors, LLMs can facilitate innovative approaches to teaching complex medical concepts and fostering student engagement. Notable challenges of LLMs integration include the risk of fostering academic misconduct, inadvertent overreliance on AI, potential dilution of critical thinking skills, concerns regarding the accuracy and reliability of LLM-generated content, and the possible implications on teaching staff.

Medicare Eligibility and Racial and Ethnic Disparities in Operative Fixation for Distal Radius Fracture.

Importance: Medicare provides near-universal health insurance to US residents aged 65 years or older. How eligibility for Medicare coverage affects racial and ethnic disparities in operative management after orthopedic trauma is poorly understood. Objective: To assess the association of Medicare eligibility with racial and ethnic disparities in open reduction and internal fixation (ORIF) after distal radius fracture (DRF). Design, Setting, and Participants: This retrospective cohort study with a regression discontinuity design obtained data from the Healthcare Cost and Utilization Project all-payer statewide databases for Florida, Maryland, and New York. These databases contain encounter-level data and unique patient identifiers for longitudinal follow-up across emergency departments, outpatient surgical centers, and hospitals. The cohort included patients aged 57 to 72 years who sustained DRFs between January 1, 2016, and November 30, 2019. Data analysis was performed between March 1 and October 15, 2023. Exposure: Eligibility for Medicare coverage at age 65 years. Main Outcomes and Measures: Type of management for DRF (closed treatment, external fixation, percutaneous pinning, and ORIF). Time to surgery was ascertained in patients undergoing ORIF. Multivariable logistic regression and regression discontinuity design were used to compare racial and ethnic disparities in patients who underwent ORIF before or after age 65 years. Results: A total of 26 874 patients with DRF were included (mean [SD] age, 64.6 [4.6] years; 22 359 were females [83.2%]). Of these patients, 2805 were Hispanic or Latino (10.4%; hereafter, Hispanic), 1492 were non-Hispanic Black (5.6%; hereafter, Black), and 20 548 were non-Hispanic White (76.5%; hereafter, White) and 2029 (7.6%) were individuals of other races and ethnicities (including Asian or Pacific Islander, Native American, and other races). Overall, 32.6% of patients received ORIF but significantly lower use was observed in Black (20.2% vs 35.4%; P < .001) and Hispanic (25.8% vs 35.4%; P < .001) patients compared with White individuals. After adjusting for potential confounders, multivariable logistic regression analysis confirmed the disparity in ORIF use in Black (odds ratio [OR], 0.60; 95% CI, 0.50-0.72) and Hispanic patients (OR, 0.82; 95% CI, 0.72-0.94) compared with White patients. No significant difference in ORIF use was found among racial and ethnic groups at age 65 years. The expected disparity in ORIF use between White and Black patients at age 65 years without Medicare coverage was 12.6 percentage points; however, the actual disparity was 22.0 percentage points, 9.4 percentage points (95% CI, 0.3-18.4 percentage points) greater than expected, a 75% increase (P = .04). In the absence of Medicare coverage, the expected disparity in ORIF use between White and Hispanic patients was 8.3 percentage points, and this result persisted without significant change in the presence of Medicare coverage. Conclusions and Relevance: Results of this study showed that surgical management for DRF was popular in adults aged 57 to 72 years, but there was lower ORIF use in racial or ethnic minority patients. Medicare eligibility at age 65 years did not attenuate race and ethnicity-based disparities in surgical management of DRFs.

Impact of consensus guideline publication on the timing of elective pediatric umbilical hernia repair.

BACKGROUND: The American Academy of Pediatrics published consensus guidelines advising observation of asymptomatic umbilical hernias until age 4 or 5, given unnecessary risks of early intervention and substantial practice variation. Yet, the impact of guidelines on early repair (age <4) or if certain groups remain at risk for avoidable intervention is unclear. METHODS: This retrospective study used data from children's hospitals participating in the Pediatric Health Information System database. Children aged 17 years and younger who underwent umbilical hernia repair from July 2017 to August 2022 were eligible for inclusion. Children with recurrent hernias, an emergency, or urgent presentation were excluded. An interrupted time series using segmented multivariable logistic regression estimated the association of guideline publication in November 2019 with the odds of guideline-adherent repair (age ≥4) after adjusting for sociodemographic characteristics and hospital-level random effects. RESULTS: 16,544 children underwent repair, of which 3,115 (18.8%) were children <4 years old. After adjustment, guideline publication was associated with an immediate increase in guideline-adherent repairs (odds ratio = 1.25 95% confidence interval = 1.05-1.49). The interrupted time series found that each month after publication was associated with a 2% increase in the odds of guideline-adherent repair (odds ratio = 1.02, 95% confidence interval = 1.01-1.03). Children with public insurance were nearly 20% less likely to receive guideline-adherent repair than privately insured children (odds ratio = 0.82, 95% confidence interval = 0.74-0.91). Children in the Midwest had lower odds of guideline-adherent repair (Midwest versus Northeast: odds ratio = 0.45. 95% confidence interval = 0.24-0.84). CONCLUSION: Guideline publication was associated with greater odds of guideline-adherent repair, yet public insurance coverage and Midwest location remain significant predictors of early repair against recommendations.

Efficacy of an Introductory Nail Disorder Learning Module to Supplement the Medical School Curriculum: Experience from One United States Medical School.

Introduction: Dermatologic and systemic conditions affecting nails are common, but nail pathology education in medical school curricula is limited. We created and evaluated the efficacy of a case-based module on nail pathologies in a medical student cohort from one well-respected US medical school. Methods: We developed a module consisting of five cases: melanonychia, onychomycosis, nail psoriasis, Beau's lines/onychomadesis, and apparent leukonychia. Participants completed a pre-module questionnaire prior to completing the module and another questionnaire directly following completion. Results: Sixty-two clinical medical students completed the pre-module questionnaire, the module, and the post-module questionnaire. 59.68% of participants reported they had evaluated 1-5 patients with nail findings. However, 43.55% of study participants denied receiving any lectures on nail pathologies in their medical education. On average, the module took 13.73 min to complete. Student-reported confidence in both identifying and treating common nail disorders significantly increased from to pre- to post-module responses for both identification (p < 0.001) and treatment (p < 0.001) of common nail pathologies. Discussion/Conclusion: Nail findings are prevalent in all medical specialties, and improved medical student education on nail pathologies is necessary. Our introductory, case-based module on pathologies is an effective way to improve student confidence in identifying and treating nail disorders.