Characterizing the lack of diversity in musculoskeletal urgent care website content.

BACKGROUND: Musculoskeletal urgent care centers (MUCCs) are becoming an alternative to emergency departments for non-emergent orthopedic injuries as they can provide direct access to orthopedic specialty care. However, they tend to be located in more affluent geographies and are less likely to accept Medicaid insurance than general urgent care centers. MUCCs utilize websites to drive patients to their centers, and the content may influence patients' consumer behaviors and perceptions of the quality and accessibility of the MUCCs. Given that some MUCCs target insured patient populations, we evaluated the racial, gender, and body type diversity of website content for MUCCs. METHODS: Our group conducted an online search to create a list of MUCCs in the United States. For each MUCC, we analyzed the content featured prominently on the website (above the fold). For each website, we analyzed the race, gender, and body type of the featured model(s). MUCCs were classified according to their affiliation (i.e. academic versus private) and region (i.e. Northeast versus South). We performed chi-squared and univariate logistic regression to investigate trends in MUCC website content. RESULTS: We found that 14% (32/235) of website graphics featured individuals from multiple racial groups, 57% (135/235) of graphics featured women, and 2% (5/235) of graphics featured overweight or obese individuals. Multiracial presence in website graphics was associated with the presence of women on the websites and Medicaid acceptance. CONCLUSION: MUCC website content has the potential to impact patients' perceptions of medical providers and the medical care they receive. Most MUCC websites lack diversity based on race and body type. The lack of diversity in website content at MUCCs may introduce further disparities in access to orthopedic care.

Preoperative Risk Management Programs at the Top 50 Orthopaedic Institutions Frequently Enforce Strict Cutoffs for BMI and Hemoglobin A1c Which May Limit Access to Total Joint Arthroplasty and Provide Limited Resources for Smoking Cessation and Dental Care.

BACKGROUND: Performing elective orthopaedic surgery on patients with high BMI, poorly controlled hyperglycemia, and who use tobacco can lead to serious complications. Some surgeons use cutoffs for BMI, hemoglobin A1c, and cigarette smoking to limit surgery to patients with lower risk profiles rather than engaging in shared decision-making with patients about those factors. Other studies have suggested this practice may discriminate against people of lower income levels and women. However, the extent to which this practice approach is used by orthopaedic surgeons at leading hospitals is unknown. QUESTIONS/PURPOSES: (1) How often are preoperative cutoffs for hemoglobin A1c and BMI used at the top US orthopaedic institutions? (2) What services are available at the top orthopaedic institutions for weight loss, smoking cessation, and dental care? (3) What proportion of hospital-provided weight loss clinics, smoking cessation programs, and dental care clinics accept Medicaid insurance? METHODS: To investigate preoperative cutoffs for hemoglobin A1c and BMI and patient access to nonorthopaedic specialists at the top orthopaedic hospitals in the United States, we collected data on the top 50 orthopaedic hospitals in the United States as ranked by the 2020 US News and World Report 's "Best Hospitals for Orthopedics" list. We used a surgeon-targeted email survey to ascertain information regarding the use of preoperative cutoffs for hemoglobin A1c and BMI and availability and insurance acceptance policies of weight loss and dental clinics. Surgeons were informed that the survey was designed to assess how their institution manages preoperative risk management. The survey was sent to one practicing arthroplasty surgeon, the chair of the arthroplasty service, or department chair, whenever possible, at the top 50 orthopaedic institutions. Reminder emails were sent periodically to encourage participation from nonresponding institutions. We received survey responses from 70% (35 of 50) of hospitals regarding the use of preoperative hemoglobin A1c and BMI cutoffs. There was no difference in the response rate based on hospital ranking or hospital region. Fewer responses were received regarding the availability and Medicaid acceptance of weight loss and dental clinics. We used a "secret shopper" methodology (defined as when a researcher calls a facility pretending to be a patient seeking care) to gather information from hospitals directly. The use of deception in this study was approved by our institution's institutional review board. We called the main telephone line at each institution and spoke with the telephone operator at each hospital asking standardized questions regarding the availability of medical or surgical weight loss clinics, smoking cessation programs, and dental clinics. When possible, researchers were referred directly to the relevant departments and asked phone receptionists if the clinic accepted Medicaid. We were able to contact every hospital using the main telephone number. Our first research question was answered using solely the surgeon survey responses. Our second and third research questions were addressed using a combination of the responses to the surgeon surveys and specific hospital telephone calls. RESULTS: Preoperative hemoglobin A1c cutoffs were used at 77% (27 of 35) of responding institutions and preoperative BMI cutoffs were used at 54% (19 of 35) of responding institutions. In the secret shopper portion of our study, we found that almost all the institutions (98% [49 of 50]) had a medical weight loss clinic, surgical weight loss clinic, or combined program. Regarding smoking cessation, 52% (26 of 50) referred patients to a specific department in their institution and 18% (9 of 50) referred to a state-run smoking cessation hotline. Thirty percent (15 of 50) did not offer any internal resource or external referral for smoking cessation. Regarding dental care, 48% (24 of 50) of institutions had a dental clinic that performed presurgical check-ups and 46% (23 of 50) did not offer any internal resource or external referral for dental care. In the secret shopper portion of our study, for institutions that had internal resources, we found that 86% (42 of 49) of weight loss clinics, 88% (23 of 26) of smoking cessation programs, and 58% (14 of 24) of dental clinics accepted Medicaid insurance. CONCLUSION: Proceeding with TJA may not be the best option for all patients; however, surgeons and patients should come to this consensus together after a thoughtful discussion of the risks and benefits for that particular patient. Future research should focus on how shared decision-making may influence patient satisfaction and a patient's ability to meet preoperative goals related to weight loss, glycemic control, smoking cessation, and dental care. Decision analyses or time trade-off analyses could be implemented in these studies to assess patients' tolerance for risk. CLINICAL RELEVANCE: Orthopaedic surgeons should engage in shared decision-making with patients to develop realistic goals for weight loss, glycemic control, smoking cessation, and dental care that consider patient access to these services as well as the difficulties patients experience in losing weight, controlling blood glucose, and stopping smoking.

Evaluating musculoskeletal urgent care center triage and transfer of emergency conditions for emergency surgical assessment and intervention.

Musculoskeletal urgent care centers (MUCCs) are an alternative to emergency departments (EDs) for patients to seek care for low acuity orthopedic injuries such as ankle sprains or joint pain, but are not equipped to manage orthopedic emergencies that require a higher level of care provided in the ED. This study aims to evaluate telephone and online triage practices as well as ED transfer procedures for MUCCs for patients presenting with an orthopedic condition requiring urgent surgical intervention. We called 595 MUCCs using a standardized script presenting as a critical patient with symptoms of lower extremity compartment syndrome. We compared direct ED referral frequency and triage frequency for MUCCs for patients insured by either Medicaid or by private insurance. We found that patients presenting with an apparent compartment syndrome were directly referred to the ED by < 1 in 5 MUCCs. Additionally, < 5% of patients were asked additional triage questions that would increase clinician suspicion for compartment syndrome and allow MUCCs to appropriately direct patients to the ED. MUCCs provide limited telephone and online triage for patients, which may result in delays of care for life or limb threatening injuries that require ED resources such as sedation, reductions, and emergency surgery. However, when MUCCs did conduct triage, it significantly increased the likelihood that patients were appropriately referred to the ED. Level of Evidence: Level II, prognostic study.

Biological sex does not predict glymphatic influx in healthy young, middle aged or old mice.

Sexual dimorphism is evident in brain structure, size, and function throughout multiple species. Here, we tested whether cerebrospinal fluid entry into the glymphatic system, a network of perivascular fluid transport that clears metabolic waste from the brain, was altered between male and female mice. We analyze glymphatic influx in 244 young reproductive age (2-4 months) C57BL/6 mice. We found no male/female differences in total influx under anesthesia, or across the anterior/posterior axis of the brain. Circadian-dependent changes in glymphatic influx under ketamine/xylazine anesthesia were not altered by sex. This was not true for diurnal rhythms under pentobarbital and avertin, but both still showed daily oscillations independent of biological sex. Finally, although glymphatic influx decreases with age there was no sex difference in total influx or subregion-dependent tracer distribution in 17 middle aged (9-10 months) and 36 old (22-24 months) mice. Overall, in healthy adult C57BL/6 mice we could not detect male/female differences in glymphatic influx. This finding contrasts the gender differences in common neurodegenerative diseases. We propose that additional sex-dependent co-morbidities, such as chronic stress, protein misfolding, traumatic brain injury or other pathological mechanisms may explain the increased risk for developing proteinopathies rather than pre-existing suppression of glymphatic influx.

Circadian control of brain glymphatic and lymphatic fluid flow.

The glymphatic system is a network of perivascular spaces that promotes movement of cerebrospinal fluid (CSF) into the brain and clearance of metabolic waste. This fluid transport system is supported by the water channel aquaporin-4 (AQP4) localized to vascular endfeet of astrocytes. The glymphatic system is more effective during sleep, but whether sleep timing promotes glymphatic function remains unknown. We here show glymphatic influx and clearance exhibit endogenous, circadian rhythms peaking during the mid-rest phase of mice. Drainage of CSF from the cisterna magna to the lymph nodes exhibits daily variation opposite to glymphatic influx, suggesting distribution of CSF throughout the animal depends on time-of-day. The perivascular polarization of AQP4 is highest during the rest phase and loss of AQP4 eliminates the day-night difference in both glymphatic influx and drainage to the lymph nodes. We conclude that CSF distribution is under circadian control and that AQP4 supports this rhythm.