A multiplexed real-time PCR assay for simultaneous quantification of human immunodeficiency virus and Hepatitis B virus for low-and-middle- income countries.

Due to shared routes of transmission, including sexual contact and vertical transmission, HIV-HBV co-infection is common, particularly in sub-Saharan Africa. Measurement of viral load (VL), for both HIV and HBV, plays a critical role for determining their infectious phase and monitoring response to antiviral therapy. Implementation of viral load testing in clinical settings is a significant challenge in resource-limited countries, notably because of cost and availability issues. We designed HIV and HBV primers for conserved regions of the HIV and HBV genomes that were specifically adapted to viral strains circulating in West Africa that are HIV-1 subtype CRF02AG and HBV genotype E. We first validated two monoplex qPCR assays for individual quantification and, then developed a multiplex qPCR for simultaneous quantification of both viruses. HIV RNA and HBV DNA amplification was performed in a single tube using a one-step reverse transcription-PCR reaction with primers and probes targeting both viruses. Performance characteristics such as the quantification range, sensitivity, and specificity of this multiplex qPCR assay were compared to reference qPCR tests for both HIV and HBV viral load quantification. The multiplex assay was validated using clinical samples from co- or mono-infected patients and gave comparable viral load quantification to the HIV and HBV reference test respectively. The multiplex qPCR demonstrated an overall sensitivity of 71.25 % [68.16-74.3] for HBV and 82 % [78.09-85.90] for HIV and an overall specificity of 100 % [94.95-100] for both viruses. Although the overall sensitivities of the HIV and HBV assays were lower than the commercial comparator assays, the sensitivity in the clinical decision range of >1000 copies/mL for HIV was 80 % [71.26-88.73] and >1000 IU/mL for HBV was 100 % [95.51-100] which indicates the test results can be used to guide treatment decisions. This in-house developed multiplex qPCR assay represents a useful diagnostic tool as it can be performed on affordable "open" real-time PCR platforms currently used for HIV or SARS-Cov-2 infection surveillance in Mali.

Fidelity of Enhanced Recovery Protocol Implementation With Assessment of Hospital-Specific Materials.

INTRODUCTION: Variability in implementation of enhanced recovery protocols (ERPs) often reduces the effects of an intervention on clinical outcomes. This study aimed to evaluate hospital-level implementation fidelity to a pediatric gastrointestinal surgery ERP by assessing site-specific implementation materials. METHODS: This document analysis study operationalized implementation fidelity as adherence to the creation of specified materials at each study site. During the 12-mo implementation phase within the stepped-wedge cluster randomized control trial, ENhanced Recovery In CHildren Undergoing Surgery, study sites were provided with materials (e.g., order sets), access to peer-counseling, and given key ERP elements spanning multiple phases of care. Sixteen of the 18 total study sites submitted implementation materials, including 14 anesthesia protocols, 11 order sets, and 16 sets of patient/family education materials. These materials were assessed and graded for fidelity using prespecified criteria. Hospital-level fidelity scores could range from 0 to a maximum score of 18, and were categorized as either high or low, based on whether the score was above or below/equal to the median. Descriptive statistics and Wilcoxon rank sum test were used for analysis. RESULTS: The overall hospital-level median fidelity score for inclusion of ERP elements in the implementation materials was 10.5. The median score was 12.8 at nine high-fidelity sites and was 5.6 at nine low-fidelity sites (P < 0.01). Higher adherence was noted for avoiding prolonged fasting (n = 16/18 hospitals; 89%) and preventing nausea and vomiting (n = 16/18 hospitals; 89%) in anesthesia protocols and/or order sets. Lower adherence was noted for incorporation of minimally invasive surgical techniques (n = 2/18 hospitals, 11%) and of preoperative optimization of medical comorbidities (n = 0/18 hospitals, 0%) in implementation materials. CONCLUSIONS: Despite substantial resources to promote ERP elements, there was wide variation in fidelity for incorporating ERPs into implementation materials among hospital sites. Development of high-fidelity implementation materials for complex ERPs for gastrointestinal surgery in children may require longer than 12 months. Additional implementation strategies, resources, and modification of implementation-focused materials may be needed.

Change in Patient Enrollment After Site Principal Investigator Turnover in Surgical Clinical Trials.

This cohort study examines the association of principal investigator (PI) turnover with patient enrollment in surgical clinical trials.

Recommendations to Improve Neonatal Circumcision Training.

BACKGROUND: Although multiple specialties perform neonatal circumcision (NC), overall NC proceduralist availability is limited. The approach to training new practitioners varies. This study aims to describe NC training experiences, current practices, and make suggestions for future improvements. METHODS: Perinatal physicians across 11 hospitals in a large Midwestern United States city who perform NC or who conduct newborn examinations and provide circumcision counseling were recruited for semistructured interviews about NC care. Interviews were transcribed; training-related comments underwent inductive and deductive qualitative coding. Themes related to circumcision training and recommendations for improving the experience of future circumcision learners were summarized. RESULTS: Twenty-three physicians (10 family medicine, 8 pediatrics, and 5 obstetrics; 78% currently perform circumcision) participated. All participants conducted newborn examinations and provided circumcision counseling, but only 21/23 were trained to perform circumcision. Several themes related to training emerged: (1) personal training experience, (2) training others to perform circumcision, and (3) current training needs and barriers. Most reported learning in residency by a "see one, do one, teach one" approach with minimal formal didactic or structured training. Compared with their personal experience, participants noted a shift toward more direct supervision and preprocedure preparation for current trainees. However, most reported that circumcision learning continues to be "hands-on." Participants desired a more structured approach for future trainees. CONCLUSIONS: Perinatal physicians noted a shift in the current NC training to a more hands-on approach than they experienced personally. Development of a structured NC curriculum was recommended to improve training.

Development and acceptability of a culturally competent skills and knowledge assessment tool for patients with diabetes mellitus.

Background: Patients newly diagnosed with type 2 diabetes mellitus (DM) and newly prescribed insulin need to learn essential self-care and management skills quickly. To optimize teaching, clinicians need to assess a patient's basic understanding of DM and their skills. While DM patient assessments exist, this study reports the development of an assessment of patient DM management skills and knowledge, using feedback from DM clinicians, patients, and caregivers. Research Design and Methods: A systematic search of Pubmed/Medline and Scopus (1980-2017) of DM knowledge assessments was performed. Twenty-four studies were identified. Content from the existing assessments was adapted to create a 12 item DM-Skills Knowledge Assessment (SKA) to assess a patient's DM management skills and knowledge. To assess cultural humility, modified cognitive interviews were conducted in individual user sessions and semi-structured focus groups. Audio-transcripts of the interviews/focus groups were independently coded, and codes were grouped into key themes. Participant demographic characteristics were assessed. Results: Five focus groups and eleven key informant interviews were conducted, including 10 DM clinicians, 12 patients/caregivers, and 15 laypersons. All 10 clinicians reported that the DM-SKA addresses the key domains of DM education deemed to be of highest importance during the transition from hospital to home and that their patients would be willing to complete the assessment. More than half of the patient/caregiver/layperson participants self-reported race/ethnicity other than non-Hispanic white and performed similarly to non-Hispanic white participants in understanding each item, willingness to complete the DM-SKA, and perception that family or community members would be willing to complete the DM-SKA. The DM-SKA has a baseline Flesch reading score of 81.3, indicating low complexity language. Conclusion: DM clinicians agreed that the DM-SKA assesses all essential DM management skills. For patients/caregivers, it has acceptable literacy, cognitive validity, and culturally acceptable for racial/ethnic minority populations in the study, including elderly persons.

Mapping the process of ICU care delivery to improve treatment decisions in acute respiratory failure.

Evidence suggests system-level norms and care processes influence individual patients' medical decisions, including end-of-life decisions for patients with critical illnesses like acute respiratory failure. Yet, little is known about how these processes unfold over the course of a patient's critical illness in the intensive care unit (ICU). Our objective was to map current-state ICU care delivery processes for patients with acute respiratory failure and to identify opportunities to improve the process. We conducted a process mapping study at two academic medical centers, using focus groups and semi-structured interviews. The 70 participants represented 17 distinct roles in ICU care, including interprofessional medical ICU and palliative care clinicians, surrogate decision makers, and patient survivors. Participants refined and endorsed a process map of current-state care delivery for all patients admitted to the ICU with acute respiratory failure requiring mechanical ventilation. The process contains four critical periods for active deliberation about the use of life-sustaining treatments. However, active deliberation steps are inconsistently performed and frequently disrupted, leading to prolongation of life-sustaining treatment by default, without consideration of patients' individual goals and priorities. Interventions to standardize active deliberation in the ICU may improve treatment decisions for ICU patients with acute respiratory failure.

Barriers and facilitators to smartwatch-based prehabilitation participation among frail surgery patients: a qualitative study.

BACKGROUND: For older, frail adults, exercise before surgery through prehabilitation (prehab) may hasten return recovery and reduce postoperative complications. We developed a smartwatch-based prehab program (BeFitMe) for older adults that encourages and tracks at-home exercise. The objective of this study was to assess patient perceptions about facilitators and barriers to prehab generally and to using a smartwatch prehab program among older adult thoracic surgery patients to optimize future program implementation. METHODS: We recruited patients, aged ≥50 years who had or were having surgery and were screened for frailty (Fried's Frailty Phenotype) at a thoracic surgery clinic at a single academic institution. Semi-structured interviews were conducted by telephone after obtaining informed consent. Participants were given a description of the BeFitMe program. The interview questions were informed by The Five "Rights" of Clinical Decision-Making framework (Information, Person, Time, Channel, and Format) and sought to identify the factors perceived to influence smartwatch prehab program participation. Interview transcripts were transcribed and independently coded to identify themes in for each of the Five "Rights" domains. RESULTS: A total of 29 interviews were conducted. Participants were 52% men (n = 15), 48% Black (n = 14), and 59% pre-frail (n = 11) or frail (n = 6) with a mean age of 68 ± 9 years. Eleven total themes emerged. Facilitator themes included the importance of providers (right person) clearly explaining the significance of prehab (right information) during the preoperative visit (right time); providing written instructions and exercise prescriptions; and providing a preprogrammed and set-up (right format) Apple Watch (right channel). Barrier themes included pre-existing conditions and disinterest in exercise and/or technology. Participants provided suggestions to overcome the technology barrier, which included individualized training and support on usage and responsibilities. CONCLUSIONS: This study reports the perceived facilitators and barriers to a smartwatch-based prehab program for pre-frail and frail thoracic surgery patients. The future BeFitMe implementation protocol must ensure surgical providers emphasize the beneficial impact of participating in prehab before surgery and provide a written prehab prescription; must include a thorough guide on smartwatch use along with the preprogrammed device to be successful. The findings are relevant to other smartwatch-based interventions for older adults.

External Validation of a Tool to Identify Low-Risk Patients With Isolated Subdural Hematoma and Preserved Consciousness.

STUDY OBJECTIVE: The SafeSDH Tool was derived to identify patients with isolated (no other type of intracranial hemorrhage) subdural hematoma who are at very low risk of neurologic deterioration, neurosurgical intervention, or death. Patients are low risk by the tool if they have none of the following: use of anticoagulant or nonaspirin antiplatelet agent, Glasgow Coma Score (GCS) <14, more than 1 discrete hematoma, hematoma thickness >5 mm, or midline shift. We attempted to externally validate the SafeSDH Tool. METHODS: We performed a retrospective chart review of patients aged ≥16 with a GCS ≥13 and isolated subdural hematoma who presented to 1 of 6 academic and community hospitals from 2005 to 2018. The primary outcome, a composite of neurologic deterioration (seizure, altered mental status, or symptoms requiring repeat imaging), neurosurgical intervention, discharge on hospice, and death, was abstracted from discharge summaries. Hematoma thickness, number of hematomas, and midline shift were abstracted from head imaging reports. Anticoagulant use, antiplatelet use, and GCS were gathered from the admission record. RESULTS: The validation data set included 753 patients with isolated subdural hematoma. Mortality during the index admission was 2.1%; 26% of patients underwent neurosurgical intervention. For the composite outcome, sensitivity was 99% (95% confidence interval [CI] 97 to 100), and specificity was 31% (95% CI 27 to 35). The tool identified 162 (21.5%) patients as low risk. Negative likelihood ratio was 0.03 (95% CI 0.01 to 0.11). CONCLUSION: The SafeSDH Tool identified patients with isolated subdural hematoma who are at low risk for poor outcomes with high sensitivity. With prospective validation, these low-risk patients could be safe for management in less intensive settings.

Physician Perspectives on Performing Newborn Circumcisions: Barriers and Opportunities.

OBJECTIVE: Over half of infant boys born in the United States undergo newborn circumcision. However, available data indicate that boys who are publicly insured, or Black/African American, have less access to desired newborn circumcision, thus concentrating riskier, more costly operative circumcision among these populations. This study ascertains perinatal physician perspectives about barriers and facilitators to providing newborn circumcisions, with a goal of informing future strategies to ensure more equitable access. METHODS: Qualitative interviews about newborn circumcision care were conducted from April-June 2020 at eleven Chicago-Area hospitals. Physicians that provide perinatal care (pediatricians, family medicine physicians, and obstetricians) participated in qualitative interviews about newborn circumcision. Inductive and deductive qualitative coding was performed to identify themes related to barriers and facilitators of newborn circumcision care. RESULTS: The 23 participating physicians (78% female, 74% white, median 16 years since medical school graduation [range 5-38 years], 52% hospital leadership role, 78% currently perform circumcisions) reported multiple barriers including difficulty with procedural logistics and inconsistent clinician availability and training; corresponding suggestions for operational improvements were also provided. Regarding newborn circumcision insurance coverage and reimbursement, physicians reported limited knowledge, but noted that some insurance reimbursement policies financially disincentivize clinicians and hospitals from offering inpatient newborn circumcision. CONCLUSIONS: Physicians identified logistical/operational, and reimbursement-related barriers to providing newborn circumcision for desirous families. Future studies and advocacy work should focus on developing clinical strategies and healthcare policies to ensure equitable access, and incentivize clinicians/hospitals to perform newborn circumcisions.

Growth in Newborn Circumcisions Performed by Pediatric Urologists and Advanced Practice Providers Between 2010 and 2021 in the United States.

OBJECTIVE: To characterize changes in the proportion of newborn circumcisions performed by pediatric urologists and advanced practiced providers (APPs) in the United States over the last decade. METHODS: The Merative MarketScan Commercial Database was queried for newborn circumcision private health insurance claims (Common Procedural Terminology 54150) between 2010 and 2021. Setting (inpatient/outpatient), US Census Bureau region, clinician specialty, and patient age (days) were determined for the full study time period, and by study year. Simple linear regression assessed growth in proportion of newborn circumcisions performed by pediatric urologists and APPs (nurse practitioner/physician assistant/midwife), over time. RESULTS: In total, 1,006,748 newborn circumcisions (59% inpatient) were identified; while most were performed by obstetricians (45%) or pediatricians (33%); APPs performed 0.9%, and pediatric urologists performed 0.7%. From 2010-2021, the proportion of newborn circumcisions performed by pediatric urologists increased from 0.3% to 2.0% and by APPs in from 0.5% to 2.9% (P < .001 for both). Growth for both pediatric urologists and APPs occurred APPs predominantly from 2016 to 2021. Trends in proportion of newborn circumcision performed by pediatricians was stable [31.5% (2010) and 32.5% (2021)], but decreased for obstetricians [48.8% (2014) and 38.1% (2021)]. CONCLUSION: The proportion of newborn circumcisions performed by pediatric urologists and APPs increased more than 6-fold between 2010 and 2021, though both specialties still perform a minority of newborn circumcisions. These data provide important baseline information for newborn circumcision workforce planning, including evaluating collaborative care models where pediatric urologists train APPs to perform circumcision.

Is state trauma funding associated with mortality among injured hospitalized patients?

BACKGROUND: We sought to quantify the association between state trauma funding and (1) in-hospital mortality and (2) transfers of injured patients. METHODS: We conducted an observational cross-sectional study of states with publicly available trauma funding data. We analyzed in-hospital mortality using linked data from the Nationwide Inpatient Sample (NIS), American Hospital Association (AHA) Annual Survey, and these State Department of Public Health trauma funding data. RESULTS: A total of 594,797 injured adult patients were admitted to acute care hospitals in 17 states. Patients in states with >$1.00 per capita state trauma funding had 0.82 (95 â€‹% CI: 0.78-0.85, p â€‹< â€‹0.001) decreased adjusted odds of in-hospital mortality compared to patients in states with less than $1.00 per capita state trauma funding. CONCLUSIONS: Increased state trauma funding is associated with decreased adjusted in-hospital mortality.

Identifying Patterns of Medical Intervention in Acute Respiratory Failure: A Retrospective Observational Study.

IMPORTANCE: Characterizing medical interventions delivered to ICU patients over time and their relationship to outcomes can help set expectations and inform decisions made by patients, clinicians, and health systems. OBJECTIVES: To determine whether distinct and clinically relevant pathways of medical intervention can be identified among adult ICU patients with acute respiratory failure. DESIGN SETTING AND PARTICIPANTS: Retrospective observational study using all-payer administrative claims data from 2012 to 2014. Patients were identified from the Healthcare Cost and Utilization Project State Inpatient Databases from Maryland, Massachusetts, Nevada, and Washington. MAIN OUTCOMES AND MEASURES: Patterns of cumulative medical intervention delivery, over time, using temporal k-means clustering of interventions delivered up to hospital days 0, 5, 10, 20, and up to discharge. RESULTS: A total of 12,175 admissions were identified and divided into training (75%; n = 9,130) and validation sets (25%; n = 3,045). Without applying a priori classification and using only medical interventions to cluster, we identified three distinct pathways of intervention accounting for 93.5% of training set admissions. We found 45.9% of admissions followed a "cardiac" intervention pathway (e.g., cardiac catheterization, cardioversion); 36.7% followed a "general" pathway (e.g., diagnostic interventions); and 17.4% followed a "prolonged" pathway (e.g., tracheostomy, gastrostomy). Prolonged pathway admissions had longer median hospital length of stay (13 d; interquartile range [IQR], 7.5-18.5 d) compared with cardiac (5; IQR, 2.5-7.5) and general (5; IQR, 3-7). In-hospital death occurred in 24.6% of prolonged pathway admissions compared with 17.9% of cardiac and 6.9% of general. Findings were confirmed in the validation set. CONCLUSIONS AND RELEVANCE: Most ICU admissions for acute respiratory failure follow one of three clinically relevant pathways of medical intervention which are associated with hospitalization outcomes. This study helps define the longitudinal nature of critical care delivery, which can inform efforts to predict patient outcomes, communicate with patients and their families, and organize critical care resources.

Applying machine learning to consumer wearable data for the early detection of complications after pediatric appendectomy.

When children are discharged from the hospital after surgery, their caregivers often rely on subjective assessments (e.g., appetite, fatigue) to monitor postoperative recovery as objective assessment tools are scarce at home. Such imprecise and one-dimensional evaluations can result in unwarranted emergency department visits or delayed care. To address this gap in postoperative monitoring, we evaluated the ability of a consumer-grade wearable device, Fitbit, which records multimodal data about daily physical activity, heart rate, and sleep, in detecting abnormal recovery early in children recovering after appendectomy. One hundred and sixty-two children, ages 3-17 years old, who underwent an appendectomy (86 complicated and 76 simple cases of appendicitis) wore a Fitbit device on their wrist for 21 days postoperatively. Abnormal recovery events (i.e., abnormal symptoms or confirmed postoperative complications) that arose during this period were gathered from medical records and patient reports. Fitbit-derived measures, as well as demographic and clinical characteristics, were used to train machine learning models to retrospectively detect abnormal recovery in the two days leading up to the event for patients with complicated and simple appendicitis. A balanced random forest classifier accurately detected 83% of these abnormal recovery days in complicated appendicitis and 70% of abnormal recovery days in simple appendicitis prior to the true report of a symptom/complication. These results support the development of machine learning algorithms to predict onset of abnormal symptoms and complications in children undergoing surgery, and the use of consumer wearables as monitoring tools for early detection of postoperative events.

The Duality of "Goals of Care" Language: A Qualitative Focus Group Study With Frontline Clinicians.

CONTEXT: The phrase "goals of care" (GOC) is common in serious illness care, yet it lacks clarity and consistency. Understanding how GOC is used across healthcare contexts is an opportunity to identify and mitigate root causes of serious illness miscommunication. OBJECTIVES: We sought to characterize frontline palliative and critical care clinicians' understanding and use of the phrase GOC in clinical practice. METHODS: We conducted a secondary qualitative thematic analysis of focus group transcripts (n = 10), gathered as part of a parent study of care delivery for patients with respiratory failure. Participants (n = 59) were members of the palliative and critical care interprofessional teams at two academic medical centers. RESULTS: Clinicians primarily use GOC as a shorthand signal among team members to indicate a patient is nearing the end of life. This signal can also indicate conflict with patients and families when clinicians' expectations-typically an expected "transition" toward a different type of care-are not met. Clinicians distinguish their clinical use of GOC from an "ideal" meaning of the phrase, which is broader than end of life and focused on patients' values. Palliative care specialists encourage other clinicians to shift toward the "ideal" GOC concept in clinical practice. CONCLUSION: Frontline palliative and critical care clinicians understand a duality in GOC, as an idealized concept and as an expeditious signal for clinical care. Our findings suggest ambiguous phrases like GOC persist because of unmet needs for better ways to discuss and address diverse and complex priorities for patients with serious illness.

Relationship between patient sex and anatomical sites of extrapulmonary tuberculosis in Mali.

Background: Contribution of host factors in mediating susceptibility to extrapulmonary tuberculosis is not well understood. Objective: To examine the influence of patient sex on anatomical localization of extrapulmonary tuberculosis. Methods: We conducted a retrospective cross-sectional study in Mali, West Africa. Hospital records of 1,304 suspected cases of extrapulmonary tuberculosis, available in TB Registry of a tertiary tuberculosis referral center from 2019 to 2021, were examined. Results: A total of 1,012 (77.6%) were confirmed to have extrapulmonary tuberculosis with a male to female ratio of 1.59:1. Four clinical forms of EPTB predominated, namely pleural (40.4%), osteoarticular (29.8%), lymph node (12.5%), and abdominal TB (10.3%). We found sex-based differences in anatomical localization of extrapulmonary tuberculosis, with males more likely than females to have pleural TB (OR: 1.51; 95% CI [1.16 to 1.98]). Conversely, being male was associated with 43% and 41% lower odds of having lymph node and abdominal TB, respectively (OR: 0.57 and 0.59). Conclusion: Anatomical sites of extrapulmonary tuberculosis differ by sex with pleural TB being associated with male sex while lymph node and abdominal TB are predominately associated with female sex. Future studies are warranted to understand the role of sex in mediating anatomical site preference of tuberculosis.

For-Profit Businesses as Public Health Partners to Promote COVID-19 Vaccination: A Multiple Case Study.

OBJECTIVE: This study aimed to describe the actions used by health professionals employed by large, for-profit businesses to promote uptake of COVID-19 vaccines, and factors that facilitated and hindered coordination with local public health leaders. METHODS: In this qualitative multiple case study, we conducted telephone interviews with health professionals from businesses, health department leaders, and others who could provide information about local vaccination efforts (e.g., emergency managers, reporters). RESULTS: Businesses' self-interest (i.e., need to keep employees working), vaccine mandates, and characteristics of the businesses (e.g., ownership, expertise) facilitated leadership in COVID-19 vaccination efforts. Coordination with local health departments was influenced by the resources of the local health department and history of collaboration. CONCLUSIONS: Health professionals employed by large businesses can serve as key public health partners, but their role is shaped by characteristics of the businesses and communities.

A mixed-method approach to generate and deliver rapid-cycle evaluation feedback: lessons learned from a multicenter implementation trial in pediatric surgery.

BACKGROUND: Rapid-cycle feedback loops provide timely information and actionable feedback to healthcare organizations to accelerate implementation of interventions. We aimed to (1) describe a mixed-method approach for generating and delivering rapid-cycle feedback and (2) explore key lessons learned while implementing an enhanced recovery protocol (ERP) across 18 pediatric surgery centers. METHODS: All centers are members of the Pediatric Surgery Research Collaborative (PedSRC, www.pedsrc.org ), participating in the ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US) trial. To assess implementation efforts, we conducted a mixed-method sequential explanatory study, administering surveys and follow-up interviews with each center's implementation team 6 and 12 months following implementation. Along with detailed notetaking and iterative discussion within our team, we used these data to generate and deliver a center-specific implementation report card to each center. Report cards used a traffic light approach to quickly visualize implementation status (green = excellent; yellow = needs improvement; red = needs significant improvement) and summarized strengths and opportunities at each timepoint. RESULTS: We identified several benefits, challenges, and practical considerations for assessing implementation and using rapid-cycle feedback among pediatric surgery centers. Regarding potential benefits, this approach enabled us to quickly understand variation in implementation and corresponding needs across centers. It allowed us to efficiently provide actionable feedback to centers about implementation. Engaging consistently with center-specific implementation teams also helped facilitate partnerships between centers and the research team. Regarding potential challenges, research teams must still allocate substantial resources to provide feedback rapidly. Additionally, discussions and consensus are needed across team members about the content of center-specific feedback. Practical considerations include carefully balancing timeliness and comprehensiveness when delivering rapid-cycle feedback. In pediatric surgery, moreover, it is essential to actively engage all key stakeholders (including physicians, nurses, patients, caregivers, etc.) and adopt an iterative, reflexive approach in providing feedback. CONCLUSION: From a methodological perspective, we identified three key lessons: (1) using a rapid, mixed method evaluation approach is feasible in pediatric surgery and (2) can be beneficial, particularly in quickly understanding variation in implementation across centers; however, (3) there is a need to address several methodological challenges and considerations, particularly in balancing the timeliness and comprehensiveness of feedback. TRIAL REGISTRATION: NIH National Library of Medicine Clinical Trials. CLINICALTRIALS: gov Identifier: NCT04060303. Registered August 7, 2019, https://clinicaltrials.gov/ct2/show/NCT04060303.

Re-triage moderates association between state trauma funding and lower mortality of trauma patients.

BACKGROUND: Severely injured patients who are re-triaged (emergently transferred from an emergency department to a high-level trauma center) experience lower in-hospital mortality. Patients in states with trauma funding also experience lower in-hospital mortality. This study examines the interaction of re-triage, state trauma funding, and in-hospital mortality. STUDY DESIGN: Severely injured patients (Injury Severity Score (ISS) >15) were identified from 2016 to 2017 Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases in five states (FL, MA, MD, NY, WI). Data were merged with the American Hospital Association Annual Survey and state trauma funding data. Patients were linked across hospital encounters to determine if they were appropriately field triaged, field under-triaged, optimally re-triaged, or sub-optimally re-triaged. A hierarchical logistic regression modeling in-hospital mortality was used to quantify the effect of re-triage on the association between state trauma funding and in-hospital mortality, while adjusting for patient and hospital characteristics. RESULTS: A total of 241,756 severely injured patients were identified. Median age was 52 years (IQR: 28, 73) and median ISS was 17 (IQR: 16, 25). Two states (MA, NY) allocated no funding, while three states (WI, FL, MD) allocated $0.09-$1.80 per capita. Patients in states with trauma funding were more broadly distributed across trauma center levels, with a higher proportion of patients brought to Level III, IV, or non-trauma centers, compared to patients in states without trauma funding (54.0% vs. 41.1%, p < 0.001). Patients in states with trauma funding were more often re-triaged, compared to patients in states without trauma funding (3.7% vs. 1.8%, p < 0.001). Patients who were optimally re-triaged in states with trauma funding experienced 0.67 lower adjusted odds of in-hospital mortality (95% CI: 0.50-0.89), compared to patients in states without trauma funding. We found that re-triage significantly moderated the association between state trauma funding and lower in-hospital mortality (p = 0.018). CONCLUSION: Severely injured patients in states with trauma funding are more often re-triaged and experience lower odds of mortality. Re-triage of severely injured patients may potentiate the mortality benefit of increased state trauma funding.

Differential Insurance Plan Coverage and Surgeon Reimbursement of Pediatric Circumcision at an Urban, Midwestern Hospital.

OBJECTIVE: To explore private vs public pediatric circumcision insurance coverage and surgeon reimbursement. METHODS: A telephone survey about circumcision coverage (Current Procedural Terminology codes: 54150, 54161) was conducted in October 2021 with insurance plan representatives from the 12 plans that comprised ≥1% of institutional pediatric urology visits to compare plan characteristics and coverage details. Circumcision billing data were collected at one pediatric hospital to assess surgeon reimbursement (insurance+patient payment) by plan type using bivariate statistics. RESULTS: Ten plans (5 private and 5 public) responded (83.3% response rate). All except one public plan covered newborn circumcision. For non-newborn circumcisions, most public plans (80%) had unrestricted coverage, whereas all private plans required medical necessity. Median reimbursement for newborn circumcision (CPT: 54150) was $484 for private and $78 for public plans, P < .001 while median reimbursement for non-newborn circumcision (CPT: 54161) was $314 for private and $147 for public plans, P < .001. CONCLUSION: Private insurance plans reimburse significantly more than public plans for newborn circumcision. For non-newborn circumcision, private plans reimburse more than public but the coverage is more restricted, with a smaller differential between newborn and non-newborn circumcision. This coverage and reimbursement structure may indirectly encourage newborn circumcision for privately insured boys and non-newborn circumcision for publicly insured boys.

Evaluation of emergency department treat-and-release encounters after major gastrointestinal surgery.

BACKGROUND AND OBJECTIVES: Emergency department (ED) utilization after gastrointestinal cancer operations is poorly characterized. Our study objectives were to determine the incidence of, reasons for, and predictors of ED treat-and-release encounters after gastrointestinal cancer operations. METHODS: Patients who underwent elective esophageal, hepatobiliary, gastric, pancreatic, small intestinal, or colorectal operations for cancer were identified in the 2015-2017 Healthcare Cost and Utilization Project State Inpatient and State Emergency Department Databases for New York, Maryland, and Florida. The primary outcomes were the incidence of ED treat-and-release encounters and readmissions within 30 days of discharge. RESULTS: Among 51 527 patients at 406 hospitals, 4047 (7.9%) had an ED treat-and-release encounter, and 5573 (10.8%) had an ED encounter with readmission. In total, 40.7% of ED encounters were treat-and-release encounters. ED treat-and-release encounters were most frequently for pain (12.0%), device/ostomy complaints (11.7%), or wound complaints (11.4%). ED treat-and-release encounters predictors included non-Hispanic Black race/ethnicity (odds ratio [OR] 1.24, 95% confidence interval [CI] 1.12-1.37) and Medicare (OR 1.27, 95% CI 1.16-1.40) or Medicaid (OR 1.82, 95% CI 1.62-2.40) coverage. CONCLUSIONS: ED treat-and-release encounters are common after major gastrointestinal operations, making up nearly half of postdischarge ED encounters. The reasons for ED treat-and-release encounters differ from those for ED encounters with readmissions.