Legal Services for Veterans (LSV): Protocol for evaluating the grant-based LSV initiative supporting community organizations' delivery of legal services to veterans.

BACKGROUND: 1.8 million Veterans are estimated to need legal services, such as for housing eviction prevention, discharge upgrades, and state and federal Veterans benefits. While having one's legal needs met is known to improve one's health and its social determinants, many Veterans' legal needs remain unmet. Public Law 116-315 enacted in 2021 authorizes VA to fund legal services for Veterans (LSV) by awarding grants to legal service providers including nonprofit organizations and law schools' legal assistance programs. This congressionally mandated LSV initiative will award grants to about 75 competitively selected entities providing legal services. This paper describes the protocol for evaluating the initiative. The evaluation will fulfill congressional reporting requirements, and inform continued implementation and sustainment of LSV over time. METHODS: Our protocol calls for a prospective, mixed-methods observational study with a repeated measures design, aligning to the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) and Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) frameworks. In 2023, competitively selected legal services-providing organizations will be awarded grants to implement LSV. The primary outcome will be the number of Veterans served by LSV in the 12 months after the awarding of the grant. The evaluation has three Aims. Aim 1 will focus on measuring primary and secondary LSV implementation outcomes aligned to RE-AIM. Aim 2 will apply the mixed quantitative-qualitative Matrixed Multiple Case Study method to identify patterns in implementation barriers, enablers, and other i-PARIHS-aligned factors that relate to observed outcomes. Aim 3 involves a mixed-methods economic evaluation to understand the costs and benefits of LSV implementation. DISCUSSION: The LSV initiative is a new program that VA is implementing to help Veterans who need legal assistance. To optimize ongoing and future implementation of this program, it is important to rigorously evaluate LSV's outcomes, barriers and enablers, and costs and benefits. We have outlined the protocol for such an evaluation, which will lead to recommending strategies and resource allocation for VA's LSV implementation.

Trends in functional outcome measures in orthopedic oncology.

The purpose of this study was to identify trends in the use of functional outcome measures within orthopedic oncology. The search engine, PubMed, was reviewed for all articles over an 11-year period from 2011 to 2021 from five major journals that publish in the field of orthopedic oncology. The functional outcome measures used in the articles were recorded along with study date, study design, clinical topic/pathology, and level of evidence. Out of 5968 musculoskeletal tumor-focused articles reviewed, 293 (4.9%) included at least one outcome measure. A total of 28 different outcome tools were identified. The most popular were Musculoskeletal Tumor Society (MSTS) score (61.1%) and Toronto Extremity Salvage (TESS) score (14.0%), followed by 36-Item Short Form Survey (SF-36) (4.1%) and Patient-Reported Outcomes Measurement Information System (PROMIS) (3.8%). The use of MSTS scores decreased by 0.7% each year, whereas PROMIS increased by 1.2% each year. Seventy-four articles used more than one outcome measure. Of these 74 articles, 61 had the MSTS as one of the outcome measures. Orthopedic oncology utilizes functional outcome measures less commonly in comparison to other orthopedic subspecialties. However, this may be due in large part to orthopedic oncologists putting more emphasis on outcomes such as local recurrence, implant failure, and mortality. MSTS score is the most widely used functional outcome measure, but the utilization of PROMIS has increased recently, and could be the next step in evaluating outcomes in orthopedic oncology as it is patient-derived rather than physician-derived.

Operative Treatment of Ulnar Collateral Ligament Injury in Female Athletes.

Background: Ulnar collateral ligament (UCL) reconstruction has been the standard surgical intervention for elite male athletes with UCL insufficiency. Recently, UCL repair and augmentation with an internal brace has been increasingly performed. Purpose: To evaluate the clinical and functional outcomes as well as return-to-sport rate after UCL repair in female athletes. Study Design: Case series; Level of evidence, 4. Methods: Included were 15 female athletes (mean age, 16.5 ± 3.5 years) who underwent UCL repair between 2011 and 2021 at a single institution. Data collected included age, sport played, competition level, symptom onset, previous surgeries, mechanism of injury, surgical intervention, and return to sport. Patients were contacted via phone at minimum 24-month follow-up, and postoperative outcomes were evaluated using the Mayo Elbow Performance Score (MEPS) and the Single Assessment Numeric Evaluation (SANE). Results: Of the 15 female athletes, there were 4 cheerleaders, 3 softball players, 2 volleyball players, 2 soccer players, 1 gymnast, 1 tennis player, 1 dancer, and 1 javelin thrower. Ten of the 15 athletes (67%) competed at the high school level, 4 (26%) at the collegiate level, and 1 patient (7%) was a recreational volleyball player. In all patients, there was an acute onset of symptoms after injury. Ten patients underwent UCL repair with an internal brace (67% of athletes), while 5 underwent standard UCL repair. The median MEPS for athletes with and without an internal brace was 100 (range, 80-100). There was no significant difference of MEPS (P = .826) or SANE scores (P = .189) between the patients who received an internal brace and those who did not. Thirteen of the 15 athletes (86.7%) returned to sport. Conclusion: The UCL injuries in the female athletes in this study were the result of acute trauma. Primary UCL repair, both with and without internal bracing, was an effective surgical treatment for returning these athletes to sport.

Instagram Outperforms Twitter in Driving Social Media Engagement Among Sports Medicine Orthopaedic Surgeons.

Purpose: To determine the content posted by sports medicine orthopaedic surgeons on Instagram and Twitter and to evaluate the associated engagement. Methods: Data were collected from sports medicine orthopaedic surgeons' Instagram profiles and Twitter profiles between December 2020 and June 2022. The median number of total number of likes, comments, and retweets was calculated. The content of posts from both platforms was divided into the following categories: personal life, research, patient testimony, day in the life, pathway to becoming a physician, clinical cases, medical facts, and team coverage. Results: Data from 71 Instagram profiles and 39 Twitter profiles were used in this study. A total of 1,193 posts were identified on Instagram and 1,284 posts were identified on Twitter. The personal life category had the greatest number of posts on Instagram (303, 25.4%), whereas the medical facts category had the greatest number of posts on Twitter (251, 19.5%). Pathway to becoming a physician had the greatest median number of likes on both Instagram (97.5, range 48-2,467) and Twitter (19, range 0-50) and the greatest median number of comments on Instagram at 16 (range 1-203). The team coverage category on Instagram had the greatest percentage of likes per follower at 9.9%. A significantly greater percentage of orthopaedic surgeons posted about day in the life content, medical facts, and research on Twitter in comparison with Instagram. Instagram resulted in significantly more social media engagement than Twitter in all 8 categories (P < .05). Conclusions: Instagram resulted in significantly more social media engagement across all categories in comparison with Twitter with team coverage, personal life, and pathway to becoming a physician being the most popular categories. Clinical Relevance: The information learned in this study may help sports surgeons understand how they may best utilize social media to engage with others and enhance their clinical practice.

Implementing a virtual emergency department to avoid unnecessary emergency department presentations.

OBJECTIVE: EDs are necessary for urgent health concerns; however, many physical ED visits could be better treated in alternate settings. The present study aimed to describe the feasibility, acceptability and effectiveness of a Virtual ED to reduce unnecessary physical ED presentations at a large tertiary health service in Australia. METHODS: This observational study using the RE-AIM framework (Reach, Efficacy, Adoption, Implementation and Maintenance) evaluated the feasibility of a Virtual ED using routinely collected health service data and process-evaluation to assess intervention fidelity and adherence between April 2020 and 31 March 2022. The primary outcome for the present study was the feasibility of the Virtual ED model of care. RESULTS: The Virtual ED received 2080 direct calls for patients with a mean age of 50.3 years, with 70.4% managed in the Virtual ED alone and 29.6% referred for physical ED presentation. Of the 2080 direct referrals, 95.8% were potentially avoidable ED presentations. Of those referred, 28.3% required an admission. Of calls managed entirely by Virtual ED, 18 (1.2%) unexpectedly required a hospital admission within 48 h. General practitioner respondents rated the Virtual ED service as helpful to very helpful. The service had an average of 212 referrals per month, with a 65.2% average growth rate. The Virtual ED service was considered helpful and clinically appropriate, with a high level of ED avoidance. CONCLUSION: The Virtual ED prevented 70% of community triaged patients from presenting to the physical ED, with good uptake from all referrers, supporting the use of virtual care pathways in emergency care management.

High Incidence of Acute Kidney Injury Following Antibiotic-Loaded Spacer Insertion for Periprosthetic Joint Infection: An Updated Review of the Literature.

BACKGROUND: The use of antibiotic-impregnated cement during 2-stage revision arthroplasty for periprosthetic joint infection poses a risk of renal complications following spacer insertion. This systematic review aimed to investigate the rate of acute kidney injury (AKI) following antibiotic-loaded spacer insertion and to identify risk factors associated with this complication. METHODS: A systematic review was performed using PubMed, Cochrane Central, and Scopus databases. All clinical studies that documented renal complications following antibiotic-loaded spacer insertion for periprosthetic knee (total knee arthroplasty [TKA]) or hip (total hip arthroplasty [THA]) infection were included. Articles that combined THA and TKA outcomes were also included and labeled "THA + TKA." Descriptive statistics were analyzed when data were available. RESULTS: There were 24 studies (9 THA, 7 TKA, 8 THA + TKA) included. The mean incidences of spacer-related AKI across THA, TKA, and THA + TKA cohorts were 4.2 (range, 0 to 10%), 14 (range, 0 to 19%), and 27% (range, 0 to 35%), respectively. The most common patient-related risk factors for AKI were underlying chronic kidney disease or high baseline creatinine, low preoperative hemoglobin, and blood transfusion requirement. Spacer-related risk factors included high antibiotic dosage (>3.6 g/cement batch) and antibiotic type. While most recovered without complication, select patients required hemodialysis for acute management (2 THA, 18 THA + TKA) and/or developed chronic kidney disease (8 TKA, 8 THA). CONCLUSION: The rate of AKI following spacer insertion was high and likely under-reported in the literature. Surgeons should be cognizant of this devastating complication and should closely monitor at-risk patients for AKI following antibiotic-loaded spacer insertion.

In vivo selection in non-human primates identifies superior AAV capsids for on-target CSF delivery to spinal cord.

Systemic administration of adeno-associated virus (AAV) vectors for spinal cord gene therapy has challenges including toxicity at high doses and pre-existing immunity that reduces efficacy. Intrathecal delivery of AAV vectors into the cerebral spinal fluid (CSF) can avoid many of the issues of systemic delivery, although achieving broad distribution of the vector and transgene expression throughout the spinal cord is challenging and vector entry to the periphery occurs, sometimes initiating hepatotoxicity. Here we performed two rounds of in vivo biopanning in non-human primates (NHPs) with an AAV9 peptide display library injected intrathecally and performed insert sequencing on DNA isolated from either whole tissue (conventional selection), isolated nuclei, or nuclei from transgene-expressing cells. A subsequent barcoded pool of candidates and AAV9 was compared at the DNA (biodistribution) and RNA (expression) level in spinal cord and liver of intrathecally injected NHPs. Most of the candidates displayed enhanced biodistribution compared to AAV9 at all levels of spinal cord ranging from 2 to 265-fold. Nuclear isolation or expression-based selection yielded 4 of 7 candidate capsids with enhanced transgene expression in spinal cord (up to 2.4-fold), while no capsid obtained by conventional selection achieved that level. Furthermore, several capsids displayed lower biodistribution to the liver of up to 1,250-fold, compared to AAV9, providing a remarkable on target/off target biodistribution ratio. These capsids may have potential for gene therapy programs directed at the spinal cord and the selection method described here should be useful in clinically relevant large animal models.

How often does homelessness precede criminal arrest in veterans? Results from the U.S. survey of prison inmates.

Research has shown links between homelessness and criminal legal involvement in military veterans. The present study aimed to determine the magnitude and directionality of this association by investigating the incidence of, and factors associated with, homelessness preceding criminal arrest among veterans. Data on incarcerated veterans (N = 1,602) were analyzed from the 2016 Survey of Prison Inmates conducted by the U.S. Bureau of Justice Statistics. In this survey, 27% of incarcerated veterans reported homelessness 12 months before criminal arrest. In multivariable logistic regression analyses, higher odds of experiencing homelessness preceding criminal arrest were associated with younger age, non-White race, substance use disorder (with or without serious mental illness [SMI]), history of previous arrests, parental history of incarceration, and history of homelessness before age 18. These factors were found to be the same for nonveterans, as were rates of homelessness before arrest. However, incarcerated veterans were more likely to have mental disorders, including SMI, posttraumatic stress disorder (PTSD), and personality disorders. In contrast, incarcerated nonveterans were more likely to have a criminal history, including past arrests, parental incarceration, and juvenile detention. Although policymakers may be aware that some veterans they serve are at risk of criminal legal involvement, these national data reveal the magnitude and directionality of this problem: more than one in four incarcerated veterans experienced homelessness before criminal arrest. Identifying characteristics of veterans who experienced homelessness before criminal arrest directly informs service providers of demographic, historical, and clinical factors to evaluate and address to prevent criminal legal involvement. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Brain Health Indicators Following Acute Neuro-Exergaming: Biomarker and Cognition in Mild Cognitive Impairment (MCI) after Pedal-n-Play (iPACES).

Facing an unrelenting rise in dementia cases worldwide, researchers are exploring non-pharmacological ways to ameliorate cognitive decline in later life. Twenty older adults completed assessments before and after a single bout of interactive physical and cognitive exercise, by playing a neuro-exergame that required pedaling and steering to control progress in a tablet-based video game tailored to impact executive function (the interactive Physical and Cognitive Exercise System; iPACES v2). This study explored the cognitive and biomarker outcomes for participants with mild cognitive impairment (MCI) and normative older adults after 20 min of pedal-to-play exercise. Neuropsychological and salivary assessments were performed pre- and post-exercise to assess the impact. Repeated-measures ANOVAs revealed significant interaction effects, with MCI participants experiencing greater changes in executive function and alpha-amylase levels than normative older adults; within-group changes were also significant. This study provides further data regarding cognitive effects and potential mechanisms of action for exercise as an intervention for MCI.

Suicide risk among veterans using VHA justice-involved services: a latent class analysis.

BACKGROUND: Justice-involved Veterans experience notable risk for psychosocial stressors (e.g., homelessness) and psychiatric multimorbidity, which can result in complex clinical presentations. However, research examining how such factors coalesce to impact risk for suicide remains limited. METHODS: We conducted a latent class analysis of 180,454 Veterans accessing Veterans Health Administration (VHA) justice-related services from 2005 to 2018. RESULTS: A four-model class membership solution was identified. Among these classes, risk for suicide was highest among Veterans with greater psychiatric burden, with risk most notable among those with high VA service use. Veterans seeking healthcare primarily focused on substance use disorders or with low psychiatric burden and service use had a lower risk for suicide. CONCLUSIONS: Psychiatric multimorbidity is salient as it relates to suicide among Veterans accessing VHA justice-related services. Further evaluation of existing VHA services for this population and methods of augmenting and enhancing care for justice-involved Veterans with histories of co-occurring psychiatric conditions may be beneficial in facilitating suicide prevention efforts.

Incidental findings on CT scans for robot-assisted total joint arthroplasty.

INTRODUCTION: This study documented the incidence of incidental findings from preoperative computerized-tomography (CT) scans obtained for robotic-arm-assisted total joint arthroplasty (TJA) and its effect on patient management. METHODS: A retrospective review was conducted for patients who underwent robotic-arm assisted primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) from 2016 to 2020. All patients obtained preoperative CT scans which were formally read by fellowship-trained musculoskeletal radiologists. CT's were flagged with incidental findings and those requiring physician follow-up were identified as significant. RESULTS: A total of 1519 patients (mean age, 66 years ±9; 849 females) were evaluated. Seventy-three (4.81%) patients had incidental CT scan findings, and 25 (1.65%) patients had significant incidental findings. Four patients required additional imaging and two patients required intervention. CONCLUSION: This study found a 4.81% incidence of incidental findings from preoperative CT scans for robotic-arm-assisted THA and TKA. Of these findings, less than 2% required physician follow-up and less than 1% required intervention. With the increasing popularity of robotic-arm assisted total joint arthroplasty, it is important to consider the necessity of detection and management of associated incidental findings from preoperative CT scans.

Program and Faculty Reputation Are Valued Most by Applicants to Orthopaedic Sports Medicine Fellowships.

Purpose: To determine the top orthopaedic surgery sports medicine fellowship programs in the United States and the most important aspects of fellowship programs as perceived by applicants. Methods: An anonymous survey was distributed via e-mail and text message to all current/former orthopaedic surgery residents who applied to one particular orthopaedic sports medicine fellowship program during the 2017-2018 through 2021-2022 application cycles. The survey asked applicants to rank what they considered to be the top-10 orthopaedic sports medicine fellowship programs in the United States before and after completion of their application cycle, based on operative and nonoperative experience, faculty, game coverage, research, and work-life balance. Final rank was calculated by awarding 10 points for a first-place vote, 9 points for a second-place vote, etc., with total number of points used to determine final ranking for each program. Secondary outcomes included rates of applying to perceived top-10 programs, relative importance of different fellowship program aspects, and preferred type of practice. Results: Seven-hundred sixty-one surveys were distributed with 107 applicants responding (14% response rate). Applicants voted the top orthopaedic sports medicine fellowships programs to be: (1) Steadman Philippon Research Institute, (2) Rush University Medical Center, and (3) Hospital for Special Surgery, both before and following the application cycle. When ranking fellowship program aspects, faculty members and fellowship reputation were most likely to be ranked highest in importance. Conclusions: This study demonstrates that most orthopaedic sports medicine fellowship applicants highly valued program reputation and faculty members when choosing a fellowship program and that the application/interview process did not have a substantial effect on how individuals perceived the top programs. Clinical Relevance: The findings of this study are important for residents applying to orthopaedic sports medicine fellowships and may have implications on fellowship programs and future application cycles.

Hospital presentations with diabetic ketoacidosis: A retrospective review.

BACKGROUND: Diabetic ketoacidosis (DKA) is a significant source of preventable episodes of care and cost. This study aimed to describe the demographic and clinical characteristics of people with type 1 diabetes (T1D) presenting to the Emergency Department (ED) with DKA in an area of socio-economic deprivation in metropolitan Queensland, Australia, and to describe factors associated with hospital admission and re-presentation in this population. METHODS: This was a retrospective descriptive analysis of routine healthcare record data for January 2015-December 2019. People with T1D were identified through hospital discharge codes. RESULTS: More than half (n = 165) the estimated local T1D population (n = 317) experienced an index ED presentation for DKA; mean±SD age at ED presentation was 31.1 + /- 19.3 years, 126 (76.4%) were aged ≥ 16 years and 20 (12.1%) were newly diagnosed. Index DKA presentation was significantly associated with female sex (p = 0.04) but no other demographic or geographic variables. More than half the presentations (n = 92, 55.8%) occurred outside regular business hours. Twenty-three representations occurred within 90 days, associated with older age (p = 0.045) and lower residential socio-economic score (p = 0.02). CONCLUSION: Findings highlight the frequent problem of DKA and the importance of socio-economic influences. This flags the need and opportunity to improve support to people with T1D to promote diabetes self-care.

Educational demographics of orthopaedic surgery department chairs.

Background: Becoming chair of an academic clinical department is a tremendous achievement that takes many years of experience and clinical excellence. Objective: The purpose of this study was to determine the educational demographics of current orthopaedic surgery department chairs in the United States. Methods: A complete list of orthopaedic surgery residency programs was obtained from the Accreditation Council for Graduate Medical Education (ACGME) 2019-2020 list of residency programs. Department chairs were identified through an online search. Educational data, including where the department chair went to medical school, residency, fellowship, and type of fellowship completed were obtained. Results: A total of 145 orthopaedic department chairs were identified. The most attended medical schools by department chairs were Baylor (6 of 145, 4.1%) and Northwestern (6 of 145, 4.1%). The University of Rochester was the most common orthopaedic residency attended (9 of 145, 6.2%) and Harvard was the most common orthopaedic clinical fellowship (20 of 133, 15.0%). On average, it took 17.9 years from completion of clinical training to being named department chair. Conclusion: This study provides insight into the academic credentials, length of clinical experience, and research productivity of current orthopaedic surgery department chairs. Certain training programs may be more likely to produce department chairs and, in general, an orthopaedic surgeon is more likely to become chair at an institution where he/she previously trained. Finally, research productivity is clearly an important factor in becoming chair, as most chairs have high h-indices and a consistent track record of research excellence.

Uncovering Ankylosing Spondylitis from a Diagnosis of Parsonage-Turner Syndrome: A Case Report of Bilateral Shoulder Pain and Weakness.

Introduction: Parsonage-Turner syndrome is a rare condition that is often misdiagnosed by physicians due to the overlapping symptoms with other conditions such as rotator cuff injury and cervical radiculopathy. The etiology of the Parsonage-Turner syndrome is unknown, but has been associated with an immune-mediated response to rheumatic disease, infection, surgery, and immunizations. Case Presentation: A 18-year-old female former tennis player with a history of complex regional pain syndrome (CRPS), Ehler-Danlos syndrome (EDS), and two prior right shoulder surgeries presented to the orthopaedic clinic with bilateral shoulder pain. After a third surgery on the right shoulder, the patient later developed constant burning and sharp pain around the right shoulder that radiated toward the chest. She also experienced numbness, tingling, and weakness in the right shoulder along with pain and weakness in the left shoulder. The patient was tender over the right musculocutaneous nerve and both shoulders were inflamed on ultrasound. Electromyography (EMG) and nerve conduction studies were performed, which were consistent with a bilateral subacute on chronic brachial plexopathy, suggestive of Parsonage-Turner syndrome. Rheumatology was consulted due to an extensive family history of autoimmune diseases, leading to an additional diagnosis of ankylosing spondylitis. The patient's bilateral shoulder pain slowly improved over the following year with physical therapy and prolotherapy treatments. Conclusion: The case described, herein, represents a unique patient who presents with the rare conditions of ankylosing spondylitis, CRPS, EDS, and Parsonage-Turner syndrome. EMG was critical to differentiate Parsonage-Turner syndrome from the overlapping CRPS symptoms and without this, the diagnosis of ankylosing spondylitis may have been delayed. It is imperative physicians take a thorough history, include uncommon or rare conditions as a potential diagnosis, and undergo thorough testing while evaluating a patient to avoid unnecessary treatment therapies and patient dissatisfaction.

Activity Measure for Post-acute Care Mobility Scoring System: Comparison of Nursing and Physical Therapy Evaluation for Primary Hip and Knee Arthroplasty Patients.

BACKGROUND: Optimizing resource utilization after total joint arthroplasty (TJA) has become increasingly vital. The Activity Measure for Post-acute Care (AM-PAC) "6-clicks" scoring system is a validated, physical therapist (PT)-administered metric of patient basic mobility and predicts discharge disposition. This study aimed to determine whether the use of AM-PAC scoring by nurses in the postoperative period could (1) substitute for AM-PAC scoring by therapists and (2) predict 90-day outcomes in TJA patients. METHODS: We retrospectively reviewed all primary TJAs conducted by two surgeons at a single institution from 2019 to 2021. Patients underwent postoperative AM-PAC evaluation by nursing and physical therapy within 24 hours of surgery, and specific timing of nursing and PT scores was determined. Inter-rater reliability between therapy and nursing scores was analyzed. Multiple regression was used to determine the association between AM-PAC scores and readmissions, complications, length of stay, and nonhome discharge. RESULTS: In total, 1,119 patients were included. Agreement testing between therapy and nursing scores was weak for all six AM-PAC components, with a Spearman correlation of 0.437. Nursing scores were typically conducted earlier than therapist scores (204.0 ± 249.9 minutes versus 523.5 ± 449.4 minutes; P < 0.001). Therapy and nursing scores were not notable predictors for 90-day complications or readmissions. However, higher therapy and nursing scores were predictors of less than 2-day hospitalization (odds ratio [OR] 0.63, P < 0.001; OR 0.88, P < 0.001) and fewer nonhome discharges (OR 0.62, P < 0.001; OR 0.84, P < 0.001). CONCLUSION: Although nursing-driven mobility assessments could potentially improve efficiency of patient discharge and control costs, nursing AM-PAC scoring did not serve as an appropriate substitute for PT scoring in patients undergoing primary total hip and knee arthroplasty at our institution.

Collaborative improvement on acute opioid prescribing among diverse health systems.

BACKGROUND: Despite broad awareness of the opioid epidemic and the understanding that patients require much fewer opioids than traditionally prescribed, improvement efforts to decrease prescribing have only produced modest advances in recent years. METHODS AND FINDINGS: By using a collaborative model for shared expertise and accountability, nine diverse health care systems completed quality improvement projects together over the course of one year to reduce opioid prescriptions for acute pain. The collaborative approach was flexible to each individual system's goals, and seven of the nine participant institutions definitively achieved their desired results. CONCLUSIONS: This report demonstrates the utility of a collaborative model of improvement to bring about real change in opioid prescribing practices and may inform quality improvement efforts at other institutions.

Virtual Interviews for Sports Medicine Fellowship Positions Save Time and Money but Don't Replace In-Person Meetings.

Purpose: To understand the perceptions of program directors (PDs) and fellowship applicants regarding the virtual interview process for orthopaedic surgery sports medicine fellowship programs. Methods: An anonymous online survey was distributed through the American Orthopaedic Society for Sports Medicine (AOSSM) to applicants and PDs of orthopaedic surgery sports medicine fellowship programs following the 2020-2021 fellowship application cycle. Results: A total of 40 responses were received from PDs for a response rate of 47% (40 of 85) and 72 responses were received from applicants for a response rate of 27% (72 of 271). All of the surveyed PDs (40/40, 100%) agreed/strongly agreed that the applicant's interview carries significant weight in determining where an applicant is ranked on the match list. Fifty-eight percent (23 of 40) of PDs agreed/strongly agreed that virtual interviews negatively affected their personal connection with the fellowship interviewee. The presence of virtual interviews allowed 80% (57 of 71) of applicants to go on more interviews. Seventy-three percent (51 of 70) of applicants were able to save greater than $5,000 on travel expenses and 63% (25 of 40) of fellowship programs were able to save greater than $2,500 by conducting virtual interviews. Conclusions: Virtual interviews allowed fellowship programs and applicants to complete more interviews, but both PDs and applicants stated that interviewing in-person was important for applicants to meet faculty and tour the institution where they may be spending a year. In contrast, significant financial savings resulted due to the transition to virtual interviews. Finally, both PDs and applicants were in favor of having the option of interviewing virtually, suggesting that virtual interviews may continue to play a role in future application cycles. Clinical Relevance: This study may be valuable to fellowship programs that will continue to implement virtual interviews into future application cycles.

More Shots in Arms: Scalable Learnings From a Continuous Improvement Effort to Deliver COVID-19 Vaccinations in Small Community-Based Clinics.

Existing mass vaccination clinic guidance calls for staffing and resource requirements that may not be achievable in smaller settings. Practical and scalable solutions to these problems were developed by a volunteer group of continuous improvement professionals, working to assist 2 non-governmental organizations engaged in coordinating refugee health services: the Somali Health Board of Seattle, WA and Community Health Services Inc. of Rochester, MN. Our shared goal was to get more shots in arms by bringing vaccines to small communities through pop-up clinics that are quick to set-up and require minimal resources. The clinics were developed using continuous improvement methods, thereby yielding a 2-minute vaccine administration time and an 8-fold improvement in productivity as a result of Federal Emergency Management Agency (FEMA) guidance. This report details our field-tested methods and achieved results. The relevance and benefits of this approach deserve attention as pandemic response needs continue to evolve and vaccines become more globally available.

The Paradox of Patient-Reported Outcome Measures: Should We Prioritize "Feeling Better" or "Feeling Good" After Total Knee Arthroplasty?

BACKGROUND: The use of preoperative patient-reported outcome measure (PROM) thresholds for patient selection in arthroplasty care has been questioned recently. This study aimed to identify factors affecting achievement of the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) after total knee arthroplasty (TKA) and determine the overlap between the two outcomes. METHODS: We identified 1,239 primary, unilateral TKAs performed at a single institution in 2015-2019. PROMs including the Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and 12-item Short Form Health Survey (SF-12) were collected preoperatively and 1-year postoperatively. The likelihood of attaining PASS as per attainment of MCID was assessed. A multivariable regression was used to identify predictors of MCID and PASS. RESULTS: In total, 71.3% achieved MCID and 75.5% achieved PASS for KOOS-JR. Only 7.7% achieved MCID but not PASS, whereas almost twice this number did not achieve MCID but did achieve PASS (11.9%). Poorer preoperative KOOS-JR (OR 0.925), better SF-12 physical (OR 1.025), and mental (OR 1.027) were associated with MCID attainment. In contrast, better preoperative KOOS-JR (OR 1.030) and SF-12 mental (OR 1.025) were associated with PASS attainment. Age, gender, race, ethnicity, body mass index, Charlson index, American Society of Anesthesiologists classification, and smoking status were not significant predictors. CONCLUSION: Preoperative PROMs were associated with achieving MCID and PASS after TKA, albeit some positively and some negatively. In the era of value-based care, clinicians should not only strive to help patients "feel better" but also ensure that patients "feel good" after surgery. This study does not support the use of PROMs in prioritizing access to care.