Documentation of International Classification of Headache Disorders Criteria in Patient Medical Records: A Retrospective Cohort Analysis.

OBJECTIVE: To determine headache diagnosis and treatment patterns in the outpatient setting, focusing on documentation of the International Classification of Headache Disorders (ICHD) criteria. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort data were collected from electronic medical records of adults aged 18-35 who presented to resident-staffed family medicine outpatient clinics in the Midwest, USA, for a new or worsening headache between 2015 and 2016. Diagnosis codes were used to summarize the overall nature and prevalence of headaches. A random subset of 30 patients each for migraine headache (MGH) with and without aura and tension-type headache (TTH) were reviewed to determine how many of the five possible ICHD criteria were documented. Demographics/clinical characteristics, ICHD criteria, number and type of medications, and healthcare utilization (imaging, primary and emergency department care) through one year following the initial visit were summarized and compared across headache types. RESULTS: There were 716 unique patients during the study period (414 MGH, 227 unspecified headaches, 75 TTH, or others). Complete ICHD criteria were documented for two patients in total. There was partial documentation (e.g., one to four of the possible five) for 30% of TTH, 63% of MGH without aura, and 77% of MGH with aura (p<0.05). Across headache types, patients were prescribed an average of 2.3 to 3.3 medications over one year, with MGH patients generally trying more medications (up to eight for those with aura and up to 12 for those without). Abortive or rescue medications were prescribed to nearly all patients; prophylactics were prescribed for 50% of MGH with aura, 66.7% of MGH without aura, and 53.3%. Non-pharmacologic interventions were less prescribed: 33.3% of TTH patients and 3.3% of MGH types combined (p<0.05). Healthcare utilization was highest for MGH with aura (ED visits) and without aura (clinic visits) patients compared to TTH (p<0.001). CONCLUSION: Headache-related documentation is often incomplete, which may limit interpretation and associations between diagnoses, prescribing patterns, and healthcare utilization. Future studies should evaluate the use of electronic medical records (EMR)-based templates to improve documentation, and additional detailed studies are needed in the local setting to determine whether treatment, including the use of non-pharmacologic and prophylactic methods of treatment, is optimal.

Plastic Surgery Tourism: Complications, Costs, and Unnecessary Spending?

Background: The liability of plastic surgery tourism in patient health and postoperative resource allocation is significant. Procedures completed within the context of medical tourism often lack rigorous quality assurance and provide limited preoperative evaluation or postoperative care. Not only does this jeopardize the patient's well-being, but it also increases the financial burden and redirects invaluable resources domestically through often unnecessary diagnostic tests and hospitalizations. Objectives: This manuscript will examine the complications and associated costs following plastic surgery tourism and highlight unnecessary expenses for patients with outpatient complications. Methods: A retrospective review was conducted of all patients 18 years or older who underwent destination surgery and were seen within 1 year postoperatively in consultation with plastic surgery at our health system between January 11, 2015 and January 7, 2022. Patient admissions were reviewed and deemed necessary or unnecessary after review by 2 physicians. Results: The inclusion criteria were met by 41 patients, of whom hospitalization was deemed necessary in 28 patients vs unnecessary in 13 patients. The most common procedures included abdominoplasty, liposuction, breast augmentation, and "Brazilian butt lift." The most common complications were seroma and infection. Patients deemed to have a necessary admission often required at least 1 operation, were more likely to need intravenous antibiotics, were less likely to have the diagnosis of "pain," necessitated a longer hospitalization, and incurred a higher cost. The total financial burden was $523,272 for all 41 patients. Conclusions: Plastic surgery tourism poses substantial health risks, the morbidities are expensive, and it strains hospital resources.

Use of Low-Cost Task Trainer for Emergency Department Thoracotomy Training in General Surgery Residency Program.

OBJECTIVE: Emergency department thoracotomy (EDT) is an uncommon but potentially lifesaving procedure that warrants familiarity with anatomy, instruments, and indications necessary for completion. To address this need, we developed a low-cost EDT trainer. The primary objective of this study was to compare the effectiveness of a low-cost EDT trainer to teach emergency department thoracotomy with a discussion-based teaching session. Secondary objective was to study the face validity of the low-cost EDT trainer. DESIGN: A prospective 2-phase randomized control study was conducted. Participants were randomly divided into two groups. In phase one, baseline medical knowledge for both groups was assessed using a multiple-choice question pretest. In Group 1, each participant was taught EDT using a one-on-one discussion with a trauma surgeon, whereas Group 2 used the EDT trainer and debriefing for training. In phase 2 (1 month later), all participants completed a knowledge retention test and performed a videoed EDT using our EDT trainer, the video recordings were later reviewed by content experts blinded to the study participants using a checklist with a maximum score of 22. The participants also completed a reaction survey at the end of phase 2 of the study. SETTING: OhioHealth Riverside Methodist Hospital, an urban tertiary care academic hospital in Columbus, Ohio. PARTICIPANTS: Nine senior surgery residents from training years 3 to 5. RESULTS: The mean score for the performance of the procedure for the simulation-based (Group 2) was significantly higher than that of the discussion-based (Group 1) (Rater 1: 21.2 ± 0.8 vs. 19.0 ± 2.0, p = 0.05, Rater 2: 20.4 ± 1.5 vs. 18.3±1.0, p = 0.04). Group 2 also was quicker than Group 1 in deciding to start the procedure by approximately 56 seconds. When comparing the mean pretest knowledge score to the mean knowledge retention score 30 days after training, the discussion-based group improved from 58.33% to 81.25% (p = 0.01); the simulation-trained group's scores remained at 68.33%. All the participants agreed or strongly agreed that the simulator provided a realistic opportunity to perform EDT and improved their confidence. CONCLUSIONS: The results of this pilot study support our hypothesis that using a low-cost EDT trainer effectively improves general surgery residents' confidence and procedural skills scores in a simulated environment. Further training with low-cost simulators may provide surgical residents with deliberate practice opportunities and improve performance when learning low-frequency procedures.

Factors Associated With No-Show to Ambulatory Tele-Video Neurology Visits.

Introduction Telehealth visits (TH) have become an important pillar of healthcare delivery during the COVID pandemic. No-shows (NS) may result in delays in clinical care and in lost revenue. Understanding the factors associated with NS may help providers take measures to decrease the frequency and impact of NS in their clinics. We aim to study the demographic and clinical diagnoses associated with NS to ambulatory telehealth neurology visits. Methods We conducted a retrospective chart review of all telehealth video visits (THV) in our healthcare system from 1/1/2021 to 5/1/2021 (cross-sectional study). All patients at or above 18 years of age who either had a completed visit (CV) or had an NS for their neurology ambulatory THV were included. Patients having missing demographic variables and not meeting the ICD-10 primary diagnosis codes were excluded. Demographic factors and ICD-10 primary diagnosis codes were retrieved. NS and CV groups were compared using independent samples t-tests and chi-square tests as appropriate. Multivariate regression, with backward elimination, was conducted to identify pertinent variables. Results Our search resulted in 4,670 unique THV encounters out of which 428 (9.2%) were NS and 4,242 (90.8%) were CV. Multivariate regression with backward elimination showed that the odds of NS were higher with a self-identified non-Caucasian race OR = 1.65 (95%, CI: 1.28-2.14), possessing Medicaid insurance OR = 1.81 (95%, CI: 1.54-2.12) and with primary diagnoses of sleep disorders OR = 10.87 (95%, CI: 5.55-39.84), gait abnormalities (OR = 3.63 (95%, CI: 1.81-7.27), and back/radicular pain OR = 5.62 (95%, CI: 2.84-11.10). Being married was associated with CVs OR = 0.74 (95%, CI: 0.59-0.91) as well as primary diagnoses of multiple sclerosis OR = 0.24 (95%, CI: 0.13-0.44) and movement disorders OR = 0.41 (95%, CI: 0.25-0.68). Conclusion Demographic factors, such as self-identified race, insurance status, and primary neurological diagnosis codes, can be helpful to predict an NS to neurology THs. This data can be used to warn providers regarding the risk of NS.

Driving Impairment and Healthcare Provider Counseling in Rheumatoid Arthritis and Osteoarthritis Patients: A Cross-Sectional Survey.

BACKGROUND/OBJECTIVE: To examine rates of counseling on driving for individuals with osteoarthritis (OA) and/or rheumatoid arthritis (RA) and evaluate the Health Assessment Questionnaire Disability Index (HAQ-DI) as a screening tool for further driving evaluation. METHODS: A cross-sectional survey was completed by individuals recruited via ResearchMatch (a national web-based recruitment tool) between March 5 and April 20, 2020. Individuals with a current US driver's license, ≥18 years old, with self-reported OA and/or RA diagnosis were surveyed about driving difficulty and vehicle modification and completed a HAQ-DI assessment. Respondents were dichotomized based on reporting vehicle modification(s) due to arthritis versus no modification(s) for univariate and multivariate analyses. RESULTS: Of 4,435 recruited patients, 304 (6.9%) met inclusion/exclusion criteria and completed the surveys. Of all respondents, 259 (85.2%) reported at least some difficulty with one or more driving activities, but only 47 (15.5%) reported discussion with a physician and/or healthcare professional. A total of 184 (60.5%) respondents had HAQ-DI ≥ 1 and were more likely to report vehicle modification(s) compared to respondents with HAQ-DI score < 1 (OR = 5.00, 95% CI = 2.69-9.32, p < 0.011) after controlling for age, gender, type of arthritis, and driving behaviors. CONCLUSION: Few respondents report discussion of driving difficulties with healthcare providers, although many report driving-related impairments, particularly those with HAQ-DI scores ≥ 1. Our data suggest a strong association between HAQ-DI scores and vehicle modification. The HAQ-DI may serve as a screening tool to predict a patient's need for driving evaluation and vehicle modification(s).

Airway Obstacle Course for Teaching Prehospital Providers Airway Techniques.

BACKGROUND:  Early airway intervention is a vital step in the management of critically ill patients. Emergency medical service (EMS) providers are often first in the chain of survival with equipment to manage airway problems that arise. Therefore, it is paramount that they receive thorough training in aspects of airway management. Often, the training providers currently undergo does not reflect the environmental challenges inherent in EMS. Our obstacle course not only offers trainees a situational environment that simulates common challenges associated with the prehospital environment, but also provides a break from traditional tabletop and lecture-based training methods. METHODS:  An airway obstacle course was created that comprised four different "obstacles". Each obstacle was a patient in a precarious position requiring airway management, and the trainees could manage the obstacles in the order of their choosing. Trainees could choose from four different airway devices based on the local protocol. Once the device was used successfully, it could no longer be implemented in the course, and thus each device was used once. A validated return on the learning model was used for evaluating learning. RESULTS:  Immediately following training, 95.1% (78) trainees felt they were more confident with airway management. Nearly all, 96.4% (79), agreed that the scenarios in the obstacle course were realistic. Participants retained confidence gains in resource management for intubation at the six-month follow-up (p=0.010). In the six months following training, there was a doubling in the number of intubation attempts (24 to 48) and an overall drop in the success rate (75% to 63%). At the six-month follow-up, participants were able to describe specific events where the training helped them with patient management. CONCLUSIONS:  The model of an intubation obstacle course as a means of training EMS providers is both realistic to the participants and provides lasting effects to their confidence in resource management skills. Further studies are needed to determine its effects on intubation success rates and patient outcomes.

Simulation Improves Internal Medicine Resident Confidence With Defibrillation, Cardioversion, and Transcutaneous Pacemaker Use.

Introduction While many graduate medical education programs require residents to be certified in advanced cardiac life support, this does not cover all aspects of cardiac stabilization in patients with a pulse. Residents are often on the front lines of providing care to patients with life-threatening dysrhythmias. Our residents expressed a lack of confidence in their ability to provide this care. Methods A convenience sample of internal medicine, preliminary medicine, and transitional year residents from our large community-based tertiary care hospital participated in our survey and training. We utilized a pre-post survey method of our residents' confidence in domains that are critical to caring for patients requiring cardiac resuscitation and stabilization. Our pre-post survey was a modified Likert scale. Our training consisted of a 1-hour faculty-led hands-on training session focused on these critical domains in our hospital's simulation suites. Follow-up survey data were collected immediately after the training and at six and 11 months after the training using mean confidence across all five domains as the study variable. Results Resident mean confidence in the five domains (placing leads and pads, manipulating defibrillator controls, performing defibrillation, performing synchronized cardioversion, and performing transcutaneous pacemaker use) increased immediately after our training compared to before the training (p<0.001). This increase in confidence from before the training was sustained at six and 11 months after the training (p=0.001 and p=0.002, respectively). Confidence was lower at six and 11 months than immediately after training (p=0.01 and p=0.004, respectively). Conclusion Our project showed that simulation-based training was effective in improving our trainee's confidence in providing care to patients with life-threatening dysrhythmias. As with previous studies in simulation, confidence degradation was seen over time and likely mirrors skill degradation in these low-frequency encounters. As such, future aims include identification of ideal time intervals between training.

Cervical cancer radiation therapy compliance rates based on location of radiation therapy.

OBJECTIVE: Completion of radiation therapy (RT) within 60 days has been proposed as a national quality measure for patients with carcinoma of the cervix as protracted RT has been associated with worse oncologic outcomes. The objective of this study was to compare compliance rates based on location of RT administration. METHODS: This was a retrospective chart review of patients diagnosed with cervical cancer between January of 2000 to December of 2016 who were planned to undergo primary treatment with sensitizing chemotherapy and RT. Patients who completed both external beam radiation therapy (EBRT) and brachytherapy (BT) at the primary institution were compared to patients who completed a portion or all of their RT elsewhere. The primary outcome measured was completion of RT within 60 days. Secondary outcomes included compliance with sensitizing chemotherapy, total radiation dose, recurrence rate, progression free survival (PFS) and overall survival (OS). The groups were compared using standard statistical analysis. RESULTS: This study included 100 patients, 75 of which received all of their RT at the primary institution. These patients were more likely to complete RT within 60 days when compared to patients who underwent RT at different facilities (58.7% vs 24%, respectively; p = 0.005). Patients who underwent all of their RT at the primary institution completed their therapy an average of 16.4 days sooner (75.1 ±â€¯21.3 days versus 58.7 ±â€¯13.2 days; p = 0.001). Overall survival was significantly improved in this group (p = 0.03). CONCLUSION: Women who complete EBRT and BT at different institutions are more likely to have a protracted RT course (>60 days). These patients should be identified at diagnosis and efforts made to coordinate their care to avoid delays in treatment.

The effect of art therapy on the quality of life in patients with a gynecologic cancer receiving chemotherapy.

OBJECTIVES: Most art therapy research has involved patients with malignancies other than gynecologic cancer. The current study aimed to assess the impact of an art therapy intervention on the quality of life (QOL) in patients with gynecologic cancer who were receiving chemotherapy. METHODS: This was a prospective, non-randomized, pilot study. Eligible patients had a primary or recurrent gynecologic malignancy scheduled to be treated with at least 6 cycles of chemotherapy over 18 weeks. The intervention consisted of five sessions of art therapy during the chemotherapy. Patients completed a Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire prior to starting chemotherapy, and again at completion of the fifth session. Differences between the FACT-G scores were examined by paired t-tests. An increase in the mean FACT-G score indicated an improvement in QOL. At each session, the patients completed a separate, supplemental questionnaire to subjectively rate the benefit of the session and to express their experience with the art intervention. RESULTS: Twenty-four patients enrolled. Eight did not complete the study, leaving 16 evaluable patients. The mean FACT-G score pre-chemotherapy was 82.3 (95% CI: 75.5, 89.2), and post-art therapy was 78.6 (95% CI: 71.7, 85.5). The mean change in QOL was -3.7 points (95% CI: -10.7, 3.2, p = 0.270). A supplemental questionnaire indicated that 15 of 16 patients felt that art therapy was beneficial at each session. CONCLUSIONS: FACT-G scores did not significantly change over the course of chemotherapy in patients with gynecologic cancers receiving art therapy. Several published studies have indicated that chemotherapy is associated with a decline in QOL. Our results suggest art therapy may help to prevent or mitigate this decline.

Multidisciplinary Approach to Improve Sepsis Outcomes.

Severe sepsis and septic shock cause significant morbidity and mortality with health care costs approximating $17 billion annually. The Surviving Sepsis Campaign 2012 recommended time-sensitive care bundles to improve outcomes for patients with sepsis. At our community teaching hospital, a review of sepsis management for patients admitted to a medical intensive care unit (ICU) between December 2015 and March 2016 found 70.8% compliance with timing of lactate draw, 65.3% compliance for blood cultures, and 51.4% compliance with antibiotic administration recommendations. Thus, a quality improvement initiative to improve detection and time to bundle completion for ICU-level patients was designed. Previous studies suggest that utilization of sepsis alert systems and sepsis response teams in the emergency department setting is associated with improved compliance with recommended sepsis bundles and improved hospital mortality. Therefore, a "sepsis alert" protocol was implemented that used both an electronic alert and an overhead team alert that mobilized nursing, pharmacy, phlebotomy, and a senior internal medicine resident to bedside. In addition, a template to document sepsis diagnosis and bundle adherence was created. After implementation, we noted improvement in appropriately timed serum lactate, 88.6% versus 70.8% (p = .008) with no significant improvements in blood cultures, antibiotic administration, or mortality.

The Effect of an Educational Pamphlet on Patient Knowledge of and Intention to Discuss Screening for Obstructive Sleep Apnea in the Acute Ischemic Stroke Population.

BACKGROUND: The relationship between obstructive sleep apnea (OSA) and stroke is well established, thus supporting the importance of secondary prevention via screening and treatment for acute ischemic stroke survivors. Educational pamphlets are commonly used for patient education; however, none currently available on OSA have evaluated. The aim of this study was to evaluate the effect of a brief educational intervention on patient knowledge and interest in OSA screening. METHODS: Adult acute ischemic stroke patients were enrolled into a nonrandomized, single-group, pretest and posttest study. Inclusion criteria included minor or moderate stroke per the National Institutes of Health Stroke Scale score of 1 to 15, with a level of consciousness score of 0. Patients with known dementia or OSA were excluded. After the preintervention survey, patients were given an educational pamphlet reviewing OSA and stroke. A postintervention survey was administered 24 to 72 hours later. Outcomes included an 8-question knowledge test standardized to percentiles, intention to speak with a physician about screening on a 7-point scale (1, not at all likely, to 7, very likely), and perception of the pamphlet's educational value on a 7-point scale (1, not valuable, to 7, quite valuable). RESULTS: Of 124 eligible patients, 36 consented and 26 completed both preintervention and postintervention surveys. Preintervention knowledge scores averaged 69.7% (SD, 21.3%), postintervention scores averaged 80.8% (SD, 21.0%), P = .005, with an effect size of 1.00. Likelihood of speaking with a physician about OSA testing improved from 3.5 (SD, 2.0) to 5.0 (SD, 1.8), P = .001, with an effect size of 0.89. Pamphlet educational value was scored at 5.2 (SD, 1.7). CONCLUSIONS: A brief educational pamphlet written using health literacy concepts was considered valuable and improved patient knowledge and intention to discuss OSA screening with a physician. Further work is needed to determine whether the pamphlet can promote a discussion and referral for OSA screening at the primary care level.

Impact of a telemedicine eICU cart on sepsis management in a community hospital emergency department.

Introduction Intensivist involvement for patients with sepsis is associated with decreased complications and mortality, and lower hospital resource utilization, but few studies have evaluated outcomes for patients exposed to electronic intensive care unit (eICU) telemedicine sepsis management in the emergency department (ED). In this study, we assess whether eICU cart exposure in the ED improved compliance with components of the 2010 Surviving Sepsis Campaign bundles, length of stay (LOS), disposition and hospital costs. Methods An institutional review board-approved, retrospective cohort study was completed on patients with confirmed sepsis who presented to our ED from July 2010 through February 2013. Results Of 711 patient ED encounters, 314 cases met criteria for analysis (95 exposed and 219 non-exposed). Patient cohorts had similar demographics and comorbid International Classification of Diseases, Ninth Edition (ICD-9) diagnoses. The exposed cohort received antibiotics more quickly (122.3 minutes ±83.3 versus 163.4 minutes ±204.4, p = 0.043) and were more likely to have lactic acid levels drawn within six hours (98.9% vs. 90%, p = 0.019). The exposed cohort had a shortened ED LOS (in days) 0.08 ± 0.28 versus 0.16 ± 0.37, p = 0.036. Hospital LOS, disposition and death were similar in both cohorts. Total hospital costs for the exposed cohort were lower and less variable (US$19,713 ± 16,550 vs. US$24,364 ± 25068), but this was not significant ( p = 0.274). Discussion Our findings suggest that in individuals with confirmed sepsis, ED exposure to a telemedicine-based eICU cart impacted adherence to aspects of the Surviving Sepsis Campaign recommended bundle, but did not impact overall survival and medical costs.

Oral Ketorolac for Pain Relief During Intrauterine Device Insertion: A Double-Blinded Randomized Controlled Trial.

OBJECTIVE: To evaluate if oral ketorolac provides effective pain relief during placement of an IUD for contraception. METHODS: We conducted a double-blinded randomized controlled trial in a community hospital in Columbus, Ohio. Participants that met eligibility criteria were consented and randomized to receive either oral ketorolac 20 mg or placebo 40 to 60 minutes before IUD placement. Both participants and providers were blinded to the randomization group. The primary outcome was pain reduction (measured on a 0-10 numerical rating scale) during IUD placement. Data was analyzed using a two-sided independent samples t-test. An a priori sample size was calculated to detect a clinically meaningful difference of 2 points with 80% power. The type I error probability was α = 0.05. RESULTS: Seventy-two participants were enrolled and randomized between May 2014 until March 2016. Thirty-five in the ketorolac group and 36 in the placebo group were analyzed. There were no differences in baseline characteristics between participants or providers, as well as pain ratings prior to the procedure, at tenaculum placement, or at uterine sounding. There was a significant decrease in the pain of the ketorolac versus the placebo group rating at IUD deployment (4.2 vs. 5.7, P = 0.031), overall pain rating (3.6 vs. 4.9, P = 0.047), and pain 10 minutes after the procedure (1.1 vs, 2.5, P = 0.007). CONCLUSION: Oral ketorolac given 40 to 60 minutes prior to IUD insertion is effective in reducing pain during IUD deployment, overall pain, and pain 10 minutes after IUD placement.

Twenty-Four-Hour Voiding Diaries Versus 3-Day Voiding Diaries: A Clinical Comparison.

OBJECTIVE: This study aimed to determine if 24-hour versus 3-day voiding diary affects medical decision making for women with urinary incontinence. METHODS: A retrospective chart review was conducted of patients presenting to the OhioHealth Urogynecology Physician group for urinary incontinence from 2009 to 2011. Practice protocol includes patient completion of a 3-day voiding diary before their appointment. Diagnostic and treatment plans were extracted based on the initial patient encounter and 3-day voiding diary. A chart review was then completed with the first 24 hours of the same diaries, principal history, and physical examination data compiled into a separate chart. These charts were then reevaluated by the same physician who initially provided care to the patient but were blinded to their previous orders, impressions, and plans. New plans were then created based on the 24-hour diaries and compared with the original plans. RESULTS: One hundred eighty-six charts were reviewed. There was good agreement between 24-hour and 3-day diaries in recommendations for first-line behavioral modifications (Κ > 0.6) and moderate agreement between diaries in initiation of medical therapy or trial of incontinence pessary (Κ > 0.4). However, 24-hour diaries resulted in a statistically significant increase in invasive diagnostic tests (P < 0.019) and other treatment recommendations when compared with 3-day diaries. CONCLUSIONS: Use of 24-hour diaries may result in increased testing when compared with 3-day diaries. It may be prudent to postpone invasive testing in those patients who initially are noncompliant with a longer diary until a more complete history can be obtained.

Hospitalist Versus Subspecialist Perspectives on Reasons, Timing, and Impact of Consultation.

BACKGROUND: Hospitalists frequently consult medical subspecialists in the management of inpatients. Given the potential impact on health resource utilization, it is important to understand the working relationship between these groups. METHODS: A cross-sectional survey of hospitalists, n = 655, and subspecialists across Ohio (nephrologists and endocrinologists), n = 293, was conducted to investigate perceptions and communication about reasons, timing, and impact of hospital consultations. RESULTS: Survey response rate was 13.3%. Hospitalists were more likely to report subspecialty request to serve as admitting physician with subsequent consultation 63.2% versus 26.7%, p < .001. Hospitalists with a daily workload ≥15 patients per day were more likely to report that this impeded their ability to manage details of patient care versus hospitalists with <15 patients per day, 53.2% versus 24.1%, p = .02, and resulted in subspecialty consultation for problems manageable by the hospitalist, 38.3% versus 6.9%, p = .003. Hospitalists were less likely than subspecialists to report major impact from consultation 50.0% versus 81.0%, p = .001 and they were more likely to report direct communication for urgent consults 97.3% versus 48.8%, p < .001. CONCLUSIONS: Future work should be aimed at addressing hospitalist workload, improving communication, and ensuring appropriate need and timing of consultation.

Patient characteristics, outcomes and costs following interhospital transfer to a tertiary facility for appendectomy versus patients who present directly.

BACKGROUND: Recent healthcare policy changes have emphasized pay-for-performance. Previous studies have not examined outcome differences between primary presenting appendicitis patients and transferred patients. METHODS: A retrospective cohort design examined appendicitis patients between March 2011 and 2013. Patients < age 18, were scheduled for an elective appendectomy, who were pregnant or had an interval appendectomy were excluded. RESULTS: The transfer cohort (n = 59) had more comorbidities, more severe American Society of Anesthesiologists status, a higher rate of pre-operative abscess/rupture as well as higher rates of perforation, gangrene, intra-operative drain placement and open conversion versus primary presenting patients (n = 622). After statistical regression adjustment, a higher open conversion rate in the transfer cohort, OR = 3.48 (95%CI: 1.04-11.61) and higher total costs $672.47 (95%CI: $68.75-$1276.19) remained. CONCLUSIONS: Adjustments in clinical outcome/reimbursement metrics may be needed to address the complexity of transfers and the subsequent higher in-hospital costs on tertiary facilities. LEVEL OF EVIDENCE: IV.

Associations with resident physicians' early adoption of electronic cigarettes for smoking cessation.

BACKGROUND: Use of the electronic cigarette for nicotine delivery has increased dramatically in recent years. Information continues to emerge on its role as a smoking cessation aid, but little is known about resident physician use of the device in clinical practice. METHODS: In 2015, an electronic survey was administered to resident physicians in one healthcare system in Columbus, Ohio. The survey included questions about personal smoking exposure, knowledge, beliefs, attitudes about electronic cigarettes and early adoption of electronic cigarettes with patients. Data were dichotomised based on a 'stages of change' model that assessed resident physician adoption of electronic cigarettes for therapeutic use. Data were analysed through χ2 tests and logistic regression using ORs and 95% CIs. RESULTS: Of 338 residents, 142 (42%) responded. Of all residents, 25 (17.7%) reported that they have been recommending electronic cigarettes to their patients for the past 6 months or longer. In the multivariate model, residents ≥postgraduate year (PGY)-3 (OR=3.68, 95% CI 1.20 to 11.29), peer-reviewed article exposure (OR=6.65, 95% CI 1.56 to 28.38) and the view that addictive potential is definitely or somewhat less than traditional cigarettes (OR=5.05, 95% CI 1.48 to 17.24) were associated with recommendation of electronic cigarettes. CONCLUSIONS: Few residents report recommending electronic cigarettes to patients who smoke. These residents consider the electronic cigarette less addicting than traditional cigarettes, supporting harm reduction strategies over strict abstinence. Most residents require further evidence-based education on efficacy and long-term safety of electronic cigarettes before recommending to their patients.

Improved Resident Adherence to AAA Screening Guidelines via an Electronic Reminder.

The 2014 United States Preventive Services Task Force systematic review found abdominal aortic aneurysm (AAA) screening decreased related mortality by close to half. Despite the simplicity of screening, research suggests poor adherence to the recommended AAA screening guidelines. Using the quality improvement plan-study-do-act cycle, we retrospectively established poor adherence to AAA screening and poor documentation of smoking history in our resident clinic. An electronic reminder was prospectively implemented into our electronic medical record (EMR) with the goal of improving screening rates. After 1 year, a retrospective chart review was conducted. Comparisons of the pre- and post-electronic reminder intervention data were made using chi-square tests and odds ratios (OR). The purposeful AAA screening rate improved 27.8% during the intervention, 40.3% (95% confidence interval [CI]: 28.6-52.0%) versus 12.5% (95% CI: 3.1-21.9%), p = .002, suggesting patients were more likely to be screened as a result of the electronic reminder, OR = 4.73 (95% CI: 1.77-12.65). This improvement translates to a large effect size, Cohen's d = 0.86 (95% CI: 0.31-1.40). Electronic reminders are a simple EMR addition that can provide evidence-based education while improving adherence rates with preventive health screening measures.

A pilot study examining experiential learning vs didactic education of abdominal compartment syndrome.

BACKGROUND: Current surgical education relies on simulated educational experiences or didactic sessions to teach low-frequency clinical events such as abdominal compartment syndrome (ACS). The purpose of this pilot study was to evaluate if simulation would improve performance and knowledge retention of ACS better than a didactic lecture. METHODS: Nineteen general surgery residents were block randomized by postgraduate year level to a didactic or a simulation session. After 3 months, all residents completed a knowledge assessment before participating in an additional simulation. Two independent reviewers assessed resident performance via audio-video recordings. RESULTS: No baseline differences in ACS experience were noted between groups. The observational evaluation demonstrated a significant difference in performance between the didactic and simulation groups: 9.9 vs 12.5, P = .037 (effect size = 1.15). Knowledge retention was equivalent between groups. CONCLUSIONS: This pilot study suggests that simulation-based education may be more effective for teaching the basic concepts of ACS.

Effect of Maternal Retroplacental Leiomyomas on Fetal Growth.

OBJECTIVE: To evaluate the association between retroplacental leiomyoma identified on second trimester ultrasound and fetal growth. METHODS: We performed a retrospective study comparing the presence or absence of one or more retroplacental leiomyomas on birth weight in a cohort of women with singleton pregnancies undergoing second trimester fetal anatomic ultrasound at our institution between 2007 and 2012. The incidence of small for gestational age (SGA) infants was recorded. Secondary analysis evaluated the effect of number and size of retroplacental leiomyomas. RESULTS: Birth weight in women with at least one retroplacental leiomyoma was 177 grams less than in women without leiomyomas (95% CI -295 to -95, P = 0.003). There was a non-significant trend towards a higher incidence of SGA in infants born to women with retroplacental leiomyoma compared with women without leiomyoma (OR 2.84; 95% CI 0.97 to 6.84, P = 0.057). Women with a retroplacental leiomyoma > 4 cm in mean diameter were more likely to deliver an SGA infant than women without leiomyomas (OR 2.84, 95% CI 1.01 to 8.01; P = 0.048). Multiple retroplacental leiomyomas did not have a greater effect on pregnancy outcomes than single leiomyomas. CONCLUSION: Infants born to women with one or more retroplacental leiomyomas had a lower mean birth weight than infants born to women without leiomyomas. In addition, retroplacental leiomyomas > 4 cm in mean diameter were associated with an increased risk of delivering an SGA infant.