Post-Mastectomy Tissue Expander Placement Followed by Radiation Therapy: A Cost-Effectiveness Analysis of Staged Autologous Versus Implant-Based Unilateral Reconstruction.

BACKGROUND: There is no preferred approach to breast reconstruction for patients with locally advanced breast cancer (LABC) who require post-mastectomy radiation therapy (PMRT). Staged implant and autologous reconstruction both have unique risks and benefits. No previous study has compared their cost-effectiveness with utility scores. METHODS: A literature review determined the probabilities and outcomes for mastectomy and staged implant or autologous reconstruction. Utility scores were used to calculate the quality-adjusted life years (QALYs) associated with successful surgery and postoperative complications. Medicare billing codes were used to assess costs. A decision analysis tree was constructed with rollback and incremental cost-effectiveness ratio (ICER) analyses. Sensitivity analyses were performed to validate results and account for uncertainty. RESULTS: Mastectomy with staged deep inferior epigastric perforator (DIEP) flap reconstruction is costlier ($14,104.80 vs $3216.93), but more effective (QALYs, 29.96 vs 24.87). This resulted in an ICER of 2141.00, favoring autologous reconstruction. One-way sensitivity analysis showed that autologous reconstruction was more cost-effective if less than $257,444.13. Monte Carlo analysis showed a confidence of 99.99% that DIEP flap reconstruction is more cost-effective. CONCLUSIONS: For patients with LABC who require PMRT, staged autologous reconstruction is significantly more cost-effective than reconstruction with implants. Despite the decreased morbidity, staged implant reconstruction has greater rates of complication.

Plastic Surgery Patient Expectations for Postoperative Opioid Prescriptions.

BACKGROUND: The opioid epidemic is a healthcare crisis perpetuated by analgesic overprescribing. Despite public health attention on this issue, expectations for pain management and opioid use by plastic surgery patients are poorly understood. This study aimed to evaluate patient expectations of postoperative pain, concern for opioid dependence, and anticipated analgesic plan after plastic surgery. METHODS: New patients presenting to an academic plastic surgery clinic were prospectively enrolled from November 2017 to September 2018. These patients completed a preconsultation survey regarding their pain history and anticipated postoperative pain and analgesics regimens. Responses between cohorts expecting and not expecting postoperative opioids were compared using descriptive and univariate analyses. RESULTS: A total of 168 patients (63.9% female, 36.1% male; mean ± SD age 46 ± 17 years) completed the survey before breast (21.9%), cosmetic (5.3%), craniofacial (3.0%), general reconstruction (13.0%), hand (3.0%), and skin and soft tissue (49.1%) surgeries. Twenty-eight percent of patients expected opioid prescriptions. On a standard visual analog scale, patients who expected opioids anticipated greater postoperative pain (6.9 vs 4.6, P < 0.05). They were more concerned about experiencing pain (5.8 vs 4.9, P < 0.05), expected a longer duration of opioid use (63.0% vs 37.0%, P < 0.05), and were less interested in nonnarcotic analgesic alternatives (57.9% vs 19.8%, P < 0.05). CONCLUSIONS: Less than one-third of plastic surgery patients in this study expect opioid pain medications after surgery. This supports broader use of nonopioid, multimodal pain regimens. Identification and management of patient pain expectations, especially among those anticipating a need for opioids, provide a critical opportunity for preoperative education on the benefits of nonopioid analgesics, thus minimizing opiate prescribing.

TikTok: Is It Time to Start Trending with #PlasticSurgery?

BACKGROUND: TikTok is a short-form video social media platform created in 2016 that has rapidly grown in popularity. The aim of this study was to examine trending plastic surgery videos on TikTok and to understand the dynamics of the #PlasticSurgery conversation on this relatively new social media platform. METHODS: A prospective analysis of TikTok videos identified by directly querying the platform using #PlasticSurgery was performed during November of 2020. Top trending videos at time of data collection, defined as having more than 100,000 likes, were included. Videos were analyzed for user credentials, video engagement (number of views, likes, shares, and comments), associated hashtags, and video purpose and content. RESULTS: The top 376 trending videos were viewed a total of 1,680,910,700 times at time of analysis. Videos made by board-certified plastic surgeons were, on average, more popular than videos made by non-plastic surgeons [490.4 versus 378.6 million likes ( P = 0.006); 5.1 versus 3.8 billion views ( P = 0.046)]. The most popular procedures featured were augmentation mammaplasty (531,143,800 views; 42,825,400 likes), followed by body contouring procedures such as liposuction and abdominoplasty (276,810,500 views; 22,362,000 likes) and rhinoplasty (243,724,100 views; 27,588,200 likes). Educational videos on average had significantly higher levels of engagement than entertainment-focused videos [549,336 versus 340,163 likes ( P = 0.002); 6.3 versus 2.9 million views ( P < 0.001)]. CONCLUSIONS: Videos about plastic surgery, particularly educational videos by board-certified plastic surgeons, perform exceptionally well on the TikTok platform. TikTok presents an opportunity for plastic surgeons to educate patients about plastic surgery procedures and to present themselves as board-certified plastic surgeons.

Board Certification in Cosmetic Surgery: An Evaluation of Training Backgrounds and Scope of Practice.

BACKGROUND: The American Board of Cosmetic Surgery (ABCS) offers a certification process for physicians desiring third-party credentials in aesthetic surgery. This study aims to examine the training backgrounds and scope of practice of ABCS-certified physicians. METHODS: The ABCS online directory was used to identify diplomates. Additional board certifications were identified using the American Board of Medical Specialties physician database. Scope of training was defined using American Council for Graduate Medical Education or Commission on Dental Accreditation requirements for residency training programs. Scope of practice was determined using ABCS physician profiles and professional websites. RESULTS: Three hundred forty-two ABCS-certified physicians were included in the study. Two-hundred twelve (60.2 percent) also held American Board of Medical Specialties board certifications. Over half (62.6 percent) of ABCS diplomates advertised surgical operations beyond the scope of their American Council for Graduate Medical Education or Commission on Dental Accreditation training. Specialties with the highest prevalence of practicing beyond scope of training were internal medicine [n = 2 (100 percent)], general surgery [n = 69 (95.8 percent)], obstetrics and gynecology [n = 17 (85 percent)], otolaryngology [n = 65 (59.1 percent)], dermatology [n = 16 (51.6 percent)], and oral and maxillofacial surgery [n = 30 (50 percent)]. The most commonly offered out-of-scope procedures were liposuction (59.6 percent), abdominoplasty (50.0 percent), breast augmentation (49.7 percent), and buttock augmentation (36.5 percent). CONCLUSIONS: ABCS-certified physicians include internists and dermatologists, who market themselves as board-certified cosmetic surgeons, and the majority of ABCS members perform complex aesthetic procedures outside the scope of their primary residency training. Patients who rely on ABCS certification when selecting a cosmetic surgeon may not understand the scope of that physician's training experience and qualifications.

Comparison Between Quality of Care Provided by Trained Feeding Assistants and Certified Nursing Assistants During Between-Meal Supplementation in Long-Term Care Settings.

The purpose of this study was to compare the quality of feeding assistance provided by trained non-nursing staff with care provided by certified nursing assistants (CNAs). Research staff provided an 8-hr training course that met federal and state requirements to non-nursing staff in five community long-term care facilities. Trained staff were assigned to between-meal supplement and/or snack delivery for 24 weeks. Using standardized observations, research staff measured feeding assistance care processes between meals across all study weeks. Trained staff, nurse aides, and upper level staff were interviewed at 24 weeks to assess staff perceptions of program impact. Trained staff performed significantly better than CNAs for 12 of 13 care process measures. Residents also consumed significantly more calories per snack offer from trained staff ( M = 130 ± 126 [ SD] kcal) compared with CNAs ( M = 77 ± 94 [ SD] kcal). The majority of staff reported a positive impact of the training program.

The emerging impact of cell-free chemical biosynthesis.

Biomanufacturing has emerged as a promising alternative to chemocatalysis for green, renewable, complex synthesis of biofuels, medicines, and fine chemicals. Cell-free chemical biosynthesis offers additional advantages over in vivo production, enabling plug-and-play assembly of separately produced enzymes into an optimal cascade, versatile reaction conditions, and direct access to the reaction environment. In order for these advantages to be realized on the larger scale of industry, strategies are needed to reduce costs of biocatalyst generation, improve biocatalyst stability, and enable economically sustainable continuous cascade operation. Here we overview the advantages and remaining challenges of applying cell-free chemical biosynthesis for commodity production, and discuss recent advances in cascade engineering, enzyme immobilization, and enzyme encapsulation which constitute important steps towards addressing these challenges.

Training Nonnursing Staff to Assist with Nutritional Care Delivery in Nursing Homes: A Cost-Effectiveness Analysis.

OBJECTIVES: To determine the effect and cost-effectiveness of training nonnursing staff to provide feeding assistance for nutritionally at-risk nursing home (NH) residents. DESIGN: Randomized, controlled trial. SETTING: Five community NHs. PARTICIPANTS: Long-stay NH residents with an order for caloric supplementation (N = 122). INTERVENTION: Research staff provided an 8-hour training curriculum to nonnursing staff. Trained staff were assigned to between-meal supplement or snack delivery for the intervention group; the control group received usual care. MEASUREMENTS: Research staff used standardized observations and weighed-intake methods to measure frequency of between-meal delivery, staff assistance time, and resident caloric intake. RESULTS: Fifty staff (mean 10 per site) completed training. The intervention had a significant effect on between-meal caloric intake (F = 56.29, P < .001), with the intervention group consuming, on average, 163.33 (95% CI = 120.19-206.47) calories per person per day more than the usual care control group. The intervention costs were $1.27 per person per day higher than usual care (P < .001). The incremental cost-effectiveness ratio for the intervention was 134 kcal per dollar. The increase in cost was due to the higher frequency and number of snack items given per person per day and the associated staff time to provide assistance. CONCLUSION: It is cost effective to train nonnursing staff to provide caloric supplementation, and this practice has a positive effect on residents' between-meal intake.

Preventability of Hospital Readmissions From Skilled Nursing Facilities: A Consumer Perspective.

Purpose of the Study: A structured interview was conducted with Medicare patients readmitted to a private, tertiary teaching hospital from skilled nursing facilities (SNFs) to assess their perspectives of readmission preventability and their role in the readmission. Design and Methods: Data were collected at Vanderbilt University Medical Center using a 6-item interview administered at the bedside to Medicare beneficiaries with unplanned hospital readmissions from 23 SNFs within 60 days of a previous hospital discharge. Mixed analytical methods were applied, including a content analysis that evaluated factors contributing to hospital readmission as perceived by consumers. Results: Among 208 attempted interviews, 156 were completed, of which 53 (34%) respondents rated their readmission as preventable. 28.3% of the 53 consumers attributed the readmission to hospital factors, 52.8% attributed it to the SNF, and 18.9% believed both sites could have prevented the readmission. The primary driver of the readmission was a family member/caregiver in 31 cases and the patient in 24 of the 156 cases, amounting to 55 (35.3%) consumer-driven readmissions. Contributing factors included: premature hospital discharge (16.3%); poor discharge planning (16.3%); a clinical issue not resolved in the hospital (14.3%); inadequate treatment at the SNF (69.4%); improper medication management at the SNF (20.4%); and poor decision-making regarding the transfer (14.3%). Conclusions and Implications: Interviewing readmitted patients provides information relevant to reducing readmissions that may otherwise be omitted from hospital and SNF records. Consumers identified quality issues at both the hospital and SNF and perceived themselves as initiating a significant number of readmissions.

Potentially Avoidable Readmissions of Patients Discharged to Post-Acute Care: Perspectives of Hospital and Skilled Nursing Facility Staff.

BACKGROUND: Hospital readmissions from skilled nursing facilities (SNFs) are common. Previous research has not examined how assessments of avoidable readmissions differ between hospital and SNF perspectives. OBJECTIVES: To determine the percentage of readmissions from post-acute care that are considered potentially avoidable from hospital and SNF perspectives. DESIGN: Prospective cohort study. SETTING: One academic medical center and 23 SNFs. PARTICIPANTS: We included patients from a quality improvement trial aimed at reducing hospital readmissions among patients discharged to SNFs. We included Medicare patients who were discharged to one of 23 regional SNFs between January 2013 and January 2015, and readmitted to the hospital within 30 days. MEASUREMENTS: Hospital-based physicians and SNF-based staff performed structured root-cause analyses (RCA) on a sample of readmissions from a participating SNF to the index hospital. RCAs reported avoidability and factors contributing to readmissions. RESULTS: The 30-day unplanned readmission rate to the index hospital from SNFs was 14.5% (262 hospital readmissions of 1,808 discharges). Of the readmissions, 120 had RCA from both the hospital and SNF. The percentage of readmissions rated as potentially avoidable was 30.0% and 13.3% according to hospital and SNF staff, respectively. Hospital and SNF ratings of potential avoidability agreed for 73.3% (88 of the 120 readmissions), but readmission factors varied between settings. Diagnostic problems and improved management of changes in conditions were the most common avoidable readmission factors by hospitals and SNFs, respectively. CONCLUSION: A substantial percentage of hospital readmissions from SNFs are rated as potentially avoidable. The ratings and factors underlying avoidability differ between hospital and SNF staff. These data support the need for joint accountability and collaboration for future readmission reduction efforts between hospitals and their SNF partners.

Stability of Geriatric Syndromes in Hospitalized Medicare Beneficiaries Discharged to Skilled Nursing Facilities.

OBJECTIVES: To assess multiple geriatric syndromes in a sample of older hospitalized adults discharged to skilled nursing facilities (SNFs) and subsequently to home to determine the prevalence and stability of each geriatric syndrome at the point of these care transitions. DESIGN: Descriptive, prospective study. SETTING: One large university-affiliated hospital and four area SNFs. PARTICIPANTS: Fifty-eight hospitalized Medicare beneficiaries discharged to SNFs (N = 58). MEASUREMENTS: Research personnel conducted standardized assessments of the following geriatric syndromes at hospital discharge and 2 weeks after SNF discharge to home: cognitive impairment, depression, incontinence, unintentional weight loss, loss of appetite, pain, pressure ulcers, history of falls, mobility impairment, and polypharmacy. RESULTS: The average number of geriatric syndromes per participant was 4.4 ± 1.2 at hospital discharge and 3.8 ± 1.5 after SNF discharge. There was low to moderate stability for most syndromes. On average, participants had 2.9 syndromes that persisted across both care settings, 1.4 syndromes that resolved, and 0.7 new syndromes that developed between hospital and SNF discharge. CONCLUSION: Geriatric syndromes were prevalent at the point of each care transition but also reflected significant within-individual variability. These findings suggest that multiple geriatric syndromes present during a hospital stay are not transient and that most syndromes are not resolved before SNF discharge. These results underscore the importance of conducting standardized screening assessments at the point of each care transition and effectively communicating this information to the next provider to support the management of geriatric conditions.

Medications associated with geriatric syndromes and their prevalence in older hospitalized adults discharged to skilled nursing facilities.

BACKGROUND: More than half of the hospitalized older adults discharged to skilled nursing facilities (SNFs) have more than 3 geriatric syndromes. Pharmacotherapy may be contributing to geriatric syndromes in this population. OBJECTIVES: Develop a list of medications associated with geriatric syndromes and describe their prevalence in patients discharged from acute care to SNFs. DESIGN: Literature review and multidisciplinary expert panel discussion, followed by cross-sectional analysis. SETTING: Academic medical center in the United States PARTICIPANTS: One hundred fifty-four hospitalized Medicare beneficiaries discharged to SNFs. MEASUREMENTS: Development of a list of medications that are associated with 6 geriatric syndromes. Prevalence of the medications associated with geriatric syndromes was examined in the hospital discharge sample. RESULTS: A list of 513 medications was developed as potentially contributing to 6 geriatric syndromes: cognitive impairment, delirium, falls, reduced appetite or weight loss, urinary incontinence, and depression. Medications included 18 categories. Antiepileptics were associated with all syndromes, whereas antipsychotics, antidepressants, antiparkinsonism, and opioid agonists were associated with 5 geriatric syndromes. In the prevalence sample, patients were discharged to SNFs with an overall average of 14.0 (±4.7) medications, including an average of 5.9 (±2.2) medications that could contribute to geriatric syndromes, with falls having the most associated medications at discharge at 5.5 (±2.2). CONCLUSIONS: Many commonly prescribed medications are associated with geriatric syndromes. Over 40% of all medications ordered upon discharge to SNFs were associated with geriatric syndromes and could be contributing to the high prevalence of geriatric syndromes experienced by this population. Journal of Hospital Medicine 2016;11:694-700. © 2016 Society of Hospital Medicine.