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.

Reducing medical errors and adverse events.

Medical errors account for ∼98,000 deaths per year in the United States. They increase disability and costs and decrease confidence in the health care system. We review several important types of medical errors and adverse events. We discuss medication errors, healthcare-acquired infections, falls, handoff errors, diagnostic errors, and surgical errors. We describe the impact of these errors, review causes and contributing factors, and provide an overview of strategies to reduce these events. We also discuss teamwork/safety culture, an important aspect in reducing medical errors.

Influence of obesity on in-hospital and midterm outcomes after endovascular repair of abdominal aortic aneurysm.

PURPOSE: To evaluate the influence of obesity on outcomes after endovascular aneurysm repair (EVAR). METHODS: A retrospective analysis was conducted of 80 patients (77 men; mean age 75.0+/-7.6 years) undergoing elective EVAR for abdominal aortic aneurysm (AAA) between 2001 and 2008. Patients were stratified on presence of obesity [body mass index (BMI) >or=30 kg/m(2)). Outcomes in-hospital and during follow-up were compared between obese and non-obese patients. RESULTS: In this cohort, 26 (33%) patients had a BMI >or=30 kg/m(2). Mean BMI in the non-obese group was 25.6 kg/m(2) versus 34.1 kg/m(2) in the obese group (p<0.001). In obese patients, EVAR operating time was longer compared to non-obese patients: 217 versus 177 minutes (p = 0.006). One obese patient died after EVAR (p = 0.325); the combined operative mortality and major complication rate was 8% (n = 2) in the obese group versus 7% (n = 4) in the non-obese group (p = NS). Endoleak occurred in 25% (n = 6) of the obese group versus 14% (n = 7) of the non-obese group (p = 0.261). Postoperative intensive care for >24 hours (65% versus 70%, p = 0.796) and overall length of stay (3.9 versus 3.8 days, p = 0.845) did not differ significantly; neither did all-cause mortality during 2 years of follow-up (p = 0.688). CONCLUSION: Obesity is associated with extended operation times during EVAR, but increasing BMI appears to have little influence on outcomes after EVAR. A preferential approach to offering EVAR for obese patients may be reasonable.

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.

Impact of pharyngeal closure technique on fistula after salvage laryngectomy.

IMPORTANCE: No consensus exists as to the best technique, or techniques, to optimize wound healing, decrease pharyngocutaneous fistula formation, and shorten both hospital length of stay and time to initiation of oral intake after salvage laryngectomy. We sought to combine the recent experience of multiple high-volume institutions, with different reconstructive preferences, in the management of pharyngeal closure technique for post-radiation therapy salvage total laryngectomy in an effort to bring clarity to this clinical challenge. OBJECTIVE: To determine if the use of vascularized flaps in either an onlay or interposed fashion reduces the incidence or duration of pharyngocutaneous fistula after salvage laryngectomy compared with simple primary closure of the pharynx. DESIGN: Multi-institutional retrospective review of all patients undergoing total laryngectomy after having received definitive radiation therapy with or without chemotherapy between January 2005 and January 2012, conducted at 7 academic medical centers. SETTING: Academic, tertiary referral centers. PATIENTS: The study population comprised 359 patients from 8 institutions. All patients had a history of laryngeal irradiation and underwent laryngectomy between 2005 and 2012. They were grouped as primary closure, pectoralis myofascial onlay flap, or interposed free tissue. All patients had a minimum of 4 months follow-up. MAIN OUTCOMES AND MEASURES: Fistula incidence, severity, and predictors of fistula. RESULTS: Of the 359 patients, fistula occurred in 94 (27%). For patients with fistula, hospital stay increased from 8.9 to 12.1 days (P < .001) and oral diet initiation was delayed from 10.5 days to 29.9 days (P < .001). Patients were grouped according to closure technique: primary closure (n = 99), pectoralis onlay flap (n = 40), and interposed free tissue (n = 220). Incidence of fistula with primary closure was 34%. For the interposed free flap group, the fistula rate was lower at 25% (P = .07). Incidence of fistula was the lowest for the pectoralis onlay group at 15% (P = .02). Multivariate analysis confirmed a significantly lower fistula rate with either flap technique. For patients who developed fistula, mean duration of fistula was significantly prolonged with primary closure (14.0 weeks) compared with pectoralis flap (9.0 weeks) and free flap (6.5 weeks). CONCLUSIONS AND RELEVANCE: Pharyngocutaneous fistula remains a significant problem following salvage laryngectomy. Use of nonirradiated, vascularized flaps reduced the incidence and duration of fistula and should be considered during salvage laryngectomy.

Abdominal aortic aneurysm repair in obese patients: improved outcome after endovascular treatment compared with open surgery.

PURPOSE: To investigate outcomes in obese patients with abdominal aortic aneurysm (AAA) treated with elective open or endovascular repair (EVAR). STUDY DESIGN: We compared the outcomes of obese patients with AAA treated with elective open repair and EVAR. Obesity was defined as a body mass index (BMI) > or =30 kg/m( 2). RESULTS: A total of 56 patients with a BMI > or =30 kg/m(2) were identified for analysis (mean age 70 +/- 8 years; mean BMI 34 +/- 4 kg/m(2), and 95% [n = 53] were male). Open surgery was performed in 55% (n = 31). The in-hospital complication rate (including nonsurvivors) was significantly increased after open repair compared with EVAR (26% vs 4%, P = .033). Mortality did not differ significantly during 3 years of follow-up (P = .816). Length of stay, intensive care unit (ICU) stay, and need for ventilation were significantly increased after open surgery compared with EVAR. CONCLUSIONS: We observed improved short-term outcomes among obese AAA patients after EVAR compared to open repair. Endovascular repair may be preferable in obese patients with AAA.

Patients with abdominal aortic aneurysm and chronic obstructive pulmonary disease have improved outcomes with endovascular aneurysm repair compared with open repair.

The purpose of our study was to evaluate outcomes in abdominal aortic aneurysm (AAA) patients with chronic obstructive pulmonary disease (COPD) undergoing open or endovascular abdominal aortic aneurysm repair (EVAR). We retrospectively examined the records of consecutive patients with AAA and COPD who underwent either open repair or EVAR between 2001 and 2008. In-hospital and follow-up outcomes were compared between open repair and EVAR using SPSS (SPSS Inc, Chicago, IL). Sixty-nine patients were included for analysis (mean age 71 +/- 1.0 years; 93% [n = 64] male). Open surgery was performed in 63% (n = 43). In-hospital mortality was 4%. All-cause mortality did not differ significantly between the open repair and EVAR groups during 3 years of follow-up (p = .491). In-hospital death and major complications occurred in 30% (n = 13) after open repair compared with 12% (n = 3) after EVAR (p = .075). Pneumonia occurred in 19% (n = 8) after open repair and in 0% after EVAR (p = .019); pneumonia was associated with increased mortality during the first year after AAA repair (log-rank test p = .003). Hospital length of stay was increased in the open repair group compared with the EVAR group (16 vs 5 days, p < .001), as was intensive care unit length of stay (11 vs 2 days, p < .001) and need for ventilation (61% vs 12%, p < .001). Patients with COPD and anatomically suitable AAAs should be preferentially offered EVAR.

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.

Endovascular aneurysm repair is associated with less malnutrition than open abdominal aortic aneurysm repair.

BACKGROUND: Patients undergoing abdominal aortic aneurysm (AAA) repair have high rates of postoperative malnutrition. We examined whether endovascular aneurysm repair (EVAR) is associated with reduced postoperative malnutrition compared with open AAA repair. METHODS: The records of patients undergoing AAA repair in the Veterans Affairs (VA) Connecticut Healthcare System were reviewed. Primary outcomes were 30-day morbidity, lengths of hospitalization and intensive care unit stay, duration of intubation, and nutritional risk index scores. RESULTS: Sixty-two patients were included (open repair, 37; EVAR, 25). Nutritional parameters were comparable between groups before surgery. Patients treated with EVAR had improved postoperative nutritional profiles as determined by albumin level (3.7 +/- .08 vs 3.2 +/- .12; P = .003), and nutritional risk index (97.9 +/- 1.3 vs 88.9 +/- 1.8; P = .0006), compared with patients treated with open repair. CONCLUSIONS: Patients undergoing EVAR developed significantly less postoperative malnutrition compared with those having open repair. EVAR may be a strategy to avoid malnutrition and improve outcomes in patients at risk for malnutrition after undergoing AAA repair.

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.