How Patients Choose a Laryngologist: A Pilot Stated Preference Study.

OBJECTIVE: Patients consider many factors when deciding how to receive medical care. This study used best-worst scaling (BWS), a technique novel to otolaryngology, to quantitatively examine preferences among patients choosing a laryngologist. Our objective was to quantify in a pilot cohort the relative importance patients place on a variety of attributes when seeking a laryngologist. STUDY DESIGN: BWS survey. SETTING: Academic voice clinic. METHODS: New patients were recruited to take a computerized BWS survey developed using attributes derived from patient input, expert opinion, and literature review. Attributes were grouped into 4 categories: physician reputation, physician qualifications, hospital-related factors, and other nonclinical factors. Responses were analyzed using multinomial logit regression to determine importance scores and associations with other variables. RESULTS: Eighty-seven of 93 patients recruited participated (93.5% response rate). Physician qualifications were the most important attributes to patients, with specialty laryngology training receiving the highest importance score (20.8; 95% CI, 20.2 to 21.5; P < .0001). Recommendations from referring physicians (15.6; 95% CI, 14.3 to 16.9) and use of cutting-edge technology (11.9; 95% CI, 10.7 to 13.1) were the second and third most important, respectively. Least important were nonclinical factors, including wait time to get an appointment (4.3; 95% CI, 2.8 to 5.8) and convenience of office location (1.5; 95% CI, 0.9 to 2.1). Just over half of patients (51.2%) reported willingness to wait 4 weeks for an appointment with a laryngologist. Older patients were less concerned with convenience-related factors. CONCLUSION: Nonclinical factors were less important to patients than clinical factors, and laryngology-specific training was paramount. Stated preference methodologies can elucidate underlying preferences and help providers make care more patient centered.

A Bioresorbable Fiducial for Head and Neck Cancer.

We aim to evaluate a novel bioresorbable fiducial for marking tumor bed margins in head and neck cancers (HNCs) to improve upon current use of nonresorbable materials. A feasibility test was done placing the marker (L-lactide and ε-caprolactone) in an orange for computed tomography (CT) and applesauce for T1-, T2-, and PD-weighted magnetic resonance imaging (MRI) image acquisition, using routine clinical parameters. The resulting CT and MRI images showed excellent delineation of the marker with all of its margins well seen without adjacent artifact. The marker appeared similar to air on CT and MRI, surrounded by fluid-like appearance of the medium. Surgical bed appearance when radiotherapy is planned should not produce any artifact near the marker, and there should be no inherent marker-related artifact. These pilot CT and MR images show clinical utility for intraoperative marking of positive margins in the skull base or neck to guide future treatment and monitoring.

Global Burden of Head and Neck Cancer: Economic Consequences, Health, and the Role of Surgery.

OBJECTIVE: We aimed to describe the mortality burden and macroeconomic effects of head and neck cancer as well as delineate the role of surgical workforce in improving head and neck cancer outcomes. STUDY DESIGN: Statistical and economic analysis. SETTING: Research group. SUBJECTS AND METHODS: We conducted a statistical analysis on data from the World Development Indicators and the 2016 Global Burden of Disease study to describe the relationship between surgical workforce and global head and neck cancer mortality-to-incidence ratios. A value of lost output model was used to project the global macroeconomic effects of head and neck cancer. RESULTS: Significant differences in mortality-to-incidence ratios existed between Global Burden of Disease study superregions. An increase of surgical, anesthetic, and obstetric provider density by 10% significantly correlated with a reduction of 0.76% in mortality-to-incidence ratio (P < .0001; adjusted R2 = 0.84). There will be a projected global cumulative loss of $535 billion US dollars (USD) in economic output due to head and neck cancer between 2018 and 2030. Southeast Asia, East Asia, and Oceania will suffer the greatest gross domestic product (GDP) losses at $180 billion USD, and South Asia will lose $133 billion USD. CONCLUSION: The mortality burden of head and neck cancer is increasing and disproportionately affects those in low- and middle-income countries and regions with limited surgical workforces. This imbalance results in large and growing economic losses in countries that already face significant resource constraints. Urgent investment in the surgical workforce is necessary to ensure access to timely surgical services and reverse these negative trends.

Neurological Pupil Index and Pupillary Light Reflex by Pupillometry Predict Outcome Early After Cardiac Arrest.

BACKGROUND: The absence of the pupillary light reflex (PLR) 3 days after cardiac arrest predicts poor outcome, but quantitative PLR assessment with pupillometry early after recovery of spontaneous circulation (ROSC) and throughout targeted temperature management (TTM) has rarely been evaluated. METHODS: Fifty-five adult patients treated with TTM with available pupillometry data from the NeurOptics NPi-200 were studied. Discharge outcome was classified good if the cerebral performance category score was 1-2, poor if 3-5. Pupil size, PLR percent constriction (%PLR), and constriction velocity (CV) were determined at TTM start and 6 (± 2)-h post-ROSC ("early"), and throughout TTM using data from the worst eye at each assessment. The Neurological Pupil index (NPi) was also determined at each pupil assessment; the NPi is scored from 0 (nonreactive) to 5 (brisk) with values < 3 considered sluggish or abnormal. Prognostic performance to predict poor outcome was assessed with receiver operator characteristic curves. RESULTS: All nine patients with ≥ 1 nonreactive pupil (NPi = 0) within 6 (± 2) h after ROSC died, and 12/14 (86%) with sluggish pupils (0 < NPi < 3) had poor outcomes. 15/29 (52%) patients with normal pupil reactivity (NPi ≥ 3) had poor outcomes, four survived with cerebral performance category = 3, three died of cardiac causes, and eight died of neurologic causes. During TTM, 20/21 (95%) patients with nonreactive pupils had poor outcomes, 9/14 (64%) of patients with sluggish pupils had poor outcomes, and 9/20 (45%) with normal pupil reactivity had poor outcomes. Pupil size did not predict outcome, but NPi (AUC = 0.72 [0.59-0.86], p < 0.001), %PLR (AUC = 0.75 [0.62-0.88], p < 0.001) and CV (AUC = 0.78 [0.66-0.91], p < 0.001) at 6 h predicted poor outcome. When nonreactive pupils were first detected, 75% were < 5 mm. CONCLUSIONS: Very early after resuscitation from cardiac arrest, abnormal Neurological Pupil index and pupillary light reflex measurements by pupillometer are predictive of poor outcome, and are not usually associated with dilated pupils.

Evaluating Interventions to Increase Influenza Vaccination Rates among Pediatric Inpatients.

INTRODUCTION: Hospitalization provides an ideal opportunity for influenza vaccination, and strategies can enhance existing tools within the electronic medical record (EMR). The objectives of the study were to introduce and evaluate the effectiveness of provider and family-directed interventions to increase influenza vaccination ordering among inpatients. METHODS: We conducted a quality improvement initiative for children aged older than 6 months on medical inpatient teams at a large pediatric tertiary care hospital from September 2014 to March 2015, comprising 2 intervention groups (provider reminders and family education) and 1 control group for comparison, using EMR prompts alone. The provider reminder interventions comprised weekly e-mails indicating inpatient immunization status; vaccination reports; and visual reminders. The family education group intervention consisted of handouts regarding the benefits and safety of influenza vaccination. We measured vaccine ordering rates for each group among eligible children and overall vaccination rates. Data were analyzed using Statistical Process Control Charts and Chi-square tests. RESULTS: Among 2,552 patients aged older than 6 months hospitalized during the study period, 1,657 were unimmunized. During the intervention period, the provider group ordered 213/409 (52%) influenza vaccines, the family education group ordered 138/460 (30%) and the control group ordered 71/279 (25%) (P < 0.0001). The provider group had higher influenza immunization status than the control group (61% versus 53%; P = 0.0017). Exposure to the intervention did not impact the length of stay/discharge time. CONCLUSIONS: Provider reminders including e-mails, visual reminders, and vaccination reports are effective ways of increasing inpatient influenza vaccination rates and are more effective than family education, or EMR prompts alone.

Exploring provider and parental perceptions to influenza vaccination in the inpatient setting.

BACKGROUND: Hospitalization provides an ideal opportunity for immunization, but few studies have explored provider and parental attitudes toward pediatric inpatient vaccination against influenza. OBJECTIVES: The objectives were to determine provider and caregiver attitudes and explore potential barriers to inpatient influenza vaccination. METHODS: We developed and distributed two surveys to parents/caregivers as well as providers of general pediatric inpatients at Children's Hospital Colorado between October 2014 and March 2015 assessing attitudes toward influenza and inpatient influenza vaccination. We analyzed the Likert scale responses using univariate analyses and multiple logistic regression to assess associations between responses and vaccination status. RESULTS: The overall response rate was 95% and 58% for parents and providers, respectively. Parents of hospitalized children who agreed that flu vaccines are safe (adjusted OR 2.50 [95%CI 1.76-3.58]), and that the influenza vaccine is needed every year had higher odds of having a vaccinated child (adjusted OR 3.30 [95%CI 2.30-4.81]). Most providers (91%) agree that influenza vaccination is an important priority among inpatients, but believe that parental misconceptions and their reluctance for inpatient vaccination are the most important barriers to influenza vaccination. Providers forgetting to ask about vaccination status and order the vaccine are the next most commonly identified barriers. In contrast, most parents surveyed had favorable attitudes toward inpatient influenza vaccination and disagreed that their child was too sick to receive the vaccine during hospitalization.