Impacts of health insurance on tympanostomy tube outcomes in the pediatric population.

OBJECTIVES: Tympanostomy tube (TT) placement is a common surgical procedure for treating pediatric patients with chronic otitis media with effusion (COME) with or without recurrent acute otitis media (rAOM). Prior work suggests children from low-income families face significant disparities in access to care for rAOM or COME. The impact of these health disparities in the care of children with rAOM or COME has yet to be investigated in a state with an expanded public health insurance model. We seek to examine differences in care for patients with rAOM and COME based on insurance status and socioeconomic status (SES) in Massachusetts. METHODS: Retrospective review of 560 pediatric patients referred for TT insertion at a tertiary academic medical center between 2017 and 2019. Demographic data collected included age, ethnicity, insurance type (public, private, none) and zip code. Otologic history collected included prior AOM episodes, time to postoperative follow-up, postoperative "no-show" appointments, and number of postoperative audiograms. Multinomial logistic regression was used to isolate the effects of race and ethnicity. RESULTS: We found no major differences in preoperative outcome measures between cohorts. Postoperatively, public insurance was independently associated with decreased odds of undergoing an audiogram (OR 0.35, 95% Cl 0.16-0.76) and increased odds of "no-showing" for an appointment (OR 3.1, 95% CI 1.8-5.3). SES was not independently associated with differences in postoperative outcomes. CONCLUSION: In a state with an early expanded public health insurance model, access to care for rAOM and COME is comparable despite differences in insurance type and SES. However, enrollment in public health insurance is associated with worse measures of follow up care. Despite improvements in access to care with expanded health insurance models, retention continues to be a challenge for vulnerable populations.

The intestinal microbiota predicts COVID-19 severity and fatality regardless of hospital feeding method.

SARS-CoV-2-positive patients exhibit gut and oral microbiome dysbiosis, which is associated with various aspects of COVID-19 disease (1-4). Here, we aim to identify gut and oral microbiome markers that predict COVID-19 severity in hospitalized patients, specifically severely ill patients compared to moderately ill ones. Moreover, we investigate whether hospital feeding (solid versus enteral), an important cofounder, influences the microbial composition of hospitalized COVID-19 patients. We used random forest classification machine learning models with interpretable secondary analyses. The gut, but not the oral microbiota, was a robust predictor of both COVID-19-related fatality and severity of hospitalized patients, with a higher predictive value than most clinical variables. In addition, perturbations of the gut microbiota due to enteral feeding did not associate with species that were predictive of COVID-19 severity. IMPORTANCE SARS-CoV-2 infection leads to wide-ranging, systemic symptoms with sometimes unpredictable morbidity and mortality. It is increasingly clear that the human microbiome plays an important role in how individuals respond to viral infections. Our study adds to important literature about the associations of gut microbiota and severe COVID-19 illness during the early phase of the pandemic before the availability of vaccines. Increased understanding of the interplay between microbiota and SARS-CoV-2 may lead to innovations in diagnostics, therapies, and clinical predictions.

Prospective Evaluation of a Tiered Opioid Prescribing Guideline for Inpatient Colorectal Operations.

OBJECTIVE: This study sought to prospectively validate an institutional prescribing guideline based on previously defined opioid consumption patterns following inpatient colorectal operations. BACKGROUND: In light of the opioid epidemic, reducing excess prescription quantities is key while still tailoring to patient needs. METHODS: This is a cohort study of elective colorectal operations (colectomies, proctectomies, and ostomy reversals) at a single tertiary care medical center. Opioid prescribing and consumption patterns [quantified as Equianalgesic 5 mg Oxycodone Pills (EOP)] were compared before and after adoption of a tiered opioid prescribing guideline. Tiers were divided based on opioid consumption in the 24 hours before discharge: Tier 1 (0 EOP), Tier 2 (0.1-3 EOP), and Tier 3 (>3 EOP). Our guideline recommended maximum prescriptions of 0 EOP for Tier 1, 12 EOP for Tier 2, and 30 EOP for Tier 3. Results: The study included 100 patients before and 101 after guideline adoption. Demographic and operative characteristics were similar between cohorts. Guideline adherence was 85%. Overall, there was a 41%reduction in mean prescription quantity and 53% reduction in excess pills per prescription. No change in opioid consumption or refill rates was observed. CONCLUSIONS: Adoption of a tiered opioid prescribing guideline significantly reduced opioid prescription quantity with no change in consumption or refill rates. Standardization of discharge prescriptions based on patient consumption in the 24 hours before discharge may be an important step toward minimizing excess prescribing.