Vestibular-Evoked Myogenic Potential Outcomes Associated with Pediatric Sports-Related Concussion.

OBJECTIVES/HYPOTHESIS: To 1) characterize vestibular-evoked myogenic potential responses in children and young adults with sports-related concussion (SRC) histories as compared with a normal healthy control group, and 2) correlate VEMP characteristics to SRC/sport history outcomes. STUDY DESIGN: Prospective cohort study. METHODS: Seventy-six children and young adults with and without a history of SRC received cervical and ocular VEMP testing using a 500 Hz tone burst air conduction stimuli. VEMP response parameters (response rates, peak latencies, and peak-to-peak amplitudes) were assessed. Other clinical vestibular measures were performed. In the SRC group, sport history outcomes including number of SRC sustained over a lifetime, years of playing contact sports, and length of time playing contact sports were collected via in-person questionnaire. RESULTS: Children and young adults with SRC had significantly reduced oVEMP responses and peak-to-peak amplitudes and greater amplitude response asymmetries between left and right ear. There was no effect of group on cVEMP findings. A greater frequency of SRCs sustained throughout a lifetime, a greater number of contact sports played, and a longer duration of playing a contact sport correlated with significantly poorer VEMP response characteristics. CONCLUSIONS: Our results suggest that SRC and repeated subclinical head impact events have an effect on oVEMP outcomes. SRC may affect the utricle, superior vestibular nerve, and/or brainstem-mediated vestibular-ocular-reflex pathway. The prevalence of post-concussion-related dizziness is becoming increasingly common in a pediatric-otology clinic, thus performing VEMP testing in youth post-SRC provides an objective, noninvasive, and cost-effective method for monitoring the effects of sports-related impact on the vestibular system and related neural pathways. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:436-442, 2022.

Resource Utilization and Billing in a Resident-Managed Inpatient Consult Service.

OBJECTIVE: Patient care delivered by residents is an educational opportunity to foster autonomy. These services, however, may not be billed without direct faculty supervision. This quality improvement project analyzes descriptive data, procedures, and billing from an academic otolaryngology-head and neck surgery department's inpatient consult service. METHODS: This prospective cohort study collected descriptive and billing data on all consults over 30 consecutive days. Data collected described bedside procedures and operative interventions. Encounters were Current Procedural Terminology coded and equivalent work relative value unit (wRVU) calculated. Codes submitted for billing were reviewed to identify opportunities for inpatient billing improvement. RESULTS: Ninety-eight new consults were included, and 105 bedside procedures were performed. Flexible laryngoscopy (n = 27), I&D (incision and drainage; n = 11), and suturing (n = 11) were the most performed bedside procedures. Operative intervention was required in 15 encounters. The inpatient consult team provided the equivalent of 391.39 wRVU. Seventy-three percent of operative compared to 3% of bedside procedures were submitted for billing. DISCUSSION: The productivity of our team approximated 61.8% of a full-time general otolaryngologist but with decreased billing submissions. Balance between resident autonomy, education, quality patient care, and the ability to capture service revenue is complex. Strategies other institutions have used to capture missed billing opportunities have included a hospitalist model, mid-level providers, and resident billing. IMPLICATIONS FOR PRACTICE: This study characterizes an academic inpatient consult service. Results describe a case for improving the structure of the inpatient consult service, caution that studies collecting data via department billing may underrepresent services, and suggest alternative service structures to overcome identified billing limitations.