Billing I-AIM: a novel framework for ultrasound billing.

BACKGROUND: Point-of-care ultrasound (POCUS) has an ever-growing footprint in medicine. With this growth POCUS billing and reimbursement has become an area gaining quite a bit of attention as a means of funding and sustaining quality and education programs. Standardization across providers is needed to improve the financial viability of POCUS. RESULTS: We created an institutional collaborative which developed a framework to identify critical POCUS billing and reimbursement checkpoints. The framework, Billing I-AIM, provides a feasible structure to enhance provider-based reimbursement and perform quality improvement efforts across variable POCUS environments. CONCLUSIONS: POCUS billing using the Billing I-AIM technique allows administrative oversight, quality assurance, and educational functions as well. A discussion of the framework and respective application is provided.

Robotic distal pancreatectomy and splenectomy: rationale and technical considerations.

Minimally invasive distal pancreatectomy has had significant adoption in the United States over the past decade. Robotic distal pancreatectomy is a type of minimally invasive technique which affords greater dexterity and visualization compared to traditional laparoscopy. In addition to standard distal pancreatectomy procedures with or without splenectomy, the use of robotic surgical systems has been efficacious in performing more complex techniques such as radical antegrade modular pancreatosplenectomy (RAMPS) or spleen-preservation. There are important technical considerations to performing robotic distal pancreatectomy procedures which differ from other minimally invasive approaches. The purpose of this report is to describe the rationale and technical considerations for implementation of robotic distal pancreatectomy procedures in clinical practice.

Outcomes of an Advanced Ultrasound Elective: Preparing Medical Students for Residency and Practice.

OBJECTIVES: Many medical specialties have adopted the use of ultrasound, creating demands for higher-quality ultrasound training at all levels of medical education. Little is known about the long-term benefit of integrating ultrasound training during undergraduate medical education. This study evaluated the effect of a longitudinal fourth-year undergraduate medical education elective in ultrasound and its impact on the future use of ultrasound in clinical practice. METHODS: A cross-sectional survey of medical graduates from The Ohio State University College of Medicine (2006-2011) was done, comparing those who participated and those who did not participate in a rigorous ultrasound program for fourth-year medical students. A 38-item questionnaire queried graduates concerning ultrasound education in residency, their proficiency, and their current use of ultrasound in clinical practice. RESULTS: Surveys were completed by 116 respondents, for a return rate of 40.8% (116 of 284). The participants of the undergraduate medical education ultrasound elective (n = 61) reported more hours of ultrasound training after graduation (hands-on training, bedside scanning, and number of scans performed; P < .001), higher ultrasound proficiency (proficiency in using ultrasound for clinical decision making, use in emergency settings, and use of novel techniques; P< .001), and higher rates of ultrasound use in clinical practice (P < .001). CONCLUSIONS: The longitudinal undergraduate medical education ultrasound elective produced physicians who were more likely to seek additional training in residency, evaluate themselves as more proficient, and use ultrasound in their clinical practice. Early training in bedside ultrasound during undergraduate medical education yields physicians who are better prepared for integration of ultrasound into clinical practice.

Robot-Assisted Versus Laparoscopic Sleeve Gastrectomy: Learning Curve, Perioperative, and Short-Term Outcomes.

BACKGROUND: Currently, sleeve gastrectomy is most commonly performed laparoscopically. However, robot-assisted approach for sleeve gastrectomy is increasing in number among bariatric surgeons. The aim of our study is to compare perioperative outcomes of robot-assisted (RA-LSG) and laparoscopic sleeve gastrectomy (LSG). METHODS: Between June 2008 and December 2014, 647 patients underwent LSG and RA-LSG at our institution. A retrospective review was performed for 379 LSG and 268 R-LSG patients, noting the outcomes and complications of the procedure. RESULTS: The first 100 LSG and RA-LSG cases were separated to reflect the influence of learning curve. Mean length of hospital stay (LOS) was longer in RA-LSG patients at 1.3 ± 0.6 days (range, 1-4), while it was 1.1 ± 0.3 days (range, 1-2) in LSG patients. Thirty-day readmission rate was similar in both groups, 5.0 % in LSG and 6.0 % in RA-LSG group. One mortality (1.0 %) occurred in the RA-LSG group. In patients after 100 cases, mean LOS was still longer in RA-LSG patients at 1.7 ± 1.8 days (range, 1-21), while it was 1.2 ± 0.5 days (range, 1-5) LSG patients. Thirty-day readmission rate and 30-day reoperation rate did not show a significant difference between the two groups. Overall leak rate was 3.2 % (n = 9) in LSG group, and 1.9 % (n = 5) in RA-LSG group, and the difference was not statistically significant. CONCLUSIONS: Our study showed similar 30-day readmission and reoperation rate between LSG and RA-LSG during the learning curve and after the proficiency has been achieved.

Robotic Roux-en-Y Gastric Bypass, is it Safer than Laparoscopic Bypass?

BACKGROUND: Along with the development of technology, robotic approach is being performed for laparoscopic Roux-en-Y gastric bypass (LRYGB). Some literatures reported same or better peri-operative outcomes with the robotic procedure. The aim of this study is to compare our experience in robot-assisted LRYGB (RA-LRYGB) with LRYGB in terms of peri-operative outcomes. METHODS: From January 1, 2012 to April 30, 2014, a total of 270 patients underwent LRYGB by one surgeon at a single institution. Of these, 64 cases were done robotically. A retrospective review was performed for these patients, noting the outcomes and complications of the procedure. RESULTS: The 64 RA-LRYGB patients had a mean age of 45.9 ± 10.0 years (range, 23-67) and a mean preoperative body mass index (BMI) of 48.4 ± 7.9 kg/m(2) (range, 33.8-76.4). The 207 LRYGB patients had a mean age of 45.0 ± 10.7 years (range, 21-67) and a mean preoperative BMI of 48.4 ± 8.1 kg/m(2) (range, 34.0-80.4). These two groups were clinically comparable. Mean length of hospital stay was 3.0 ± 4.1 days (range, 1-19) in RA-LRYGB patients, significantly longer than 1.6 ± 1.7 days (range, 1-17) in LRYGB patients (p < 0.01). Thirty-day readmission rate was 9.3% (n = 6) in the RA-LRYGB group and 6.8% (n = 14) in the LRYGB group. Higher leak rate was noticed in RA-LRYGB patients at 7.8% (n = 5), compared to 0.5% (n = 1) in LRYGB patients (p < 0.01). All the leaks occurred at the pouch level in the RA-LRYGB group, while one leak from the LRYGB group occurred at the gastrojejunal anastomosis site. CONCLUSIONS: Robot-assisted Roux-en-Y gastric bypass may result in higher leak rate at the pouch level, when compared to that of laparoscopic procedures.

Report of video-capsule endoscopy disruption producing episodic small bowel obstruction after prolonged retention.

INTRODUCTION: Wireless video-capsule endoscopy is a procedure which provides direct visualization of the gastrointestinal tract, particularly the jejunum and ileum. Capsule retention is the main risk associated with capsule endoscopy, occurring at a significantly elevated incidence in patients with known or suspected Crohn's disease. PRESENTATION OF CASE: A case of a prolonged retained capsule with subsequent fragmentation producing a multicentric complete small bowel obstruction in a 39 year old male patient who had undergone wireless video capsule-endoscopy approximately three years prior. Management required surgical resection of the strictured jejunum and removal of retained capsule fragments under fluoroscopic guidance. DISCUSSION: Although capsule endoscopy is capable of diagnosis, evaluation, and monitoring inflammatory bowel disease, understanding the elevated risk for capsule retention is important in this population. Specifically, prolonged capsule retention appears to increase the risk of capsule disruption, and likely the potential for intestinal perforation. CONCLUSION: Patients should therefore be carefully selected for monitoring based upon treatment compliance and offered early endoscopic or surgical intervention in the setting of questionable compliance due to the risk for capsule disruption and subsequent intestinal perforation.

The state of ultrasound education in U.S. medical schools: results of a national survey.

PURPOSE: To determine the state of ultrasound education in U.S. medical schools and assess curricular administrators' opinions on its integration in undergraduate medical education (UME). METHOD: In 2012, curricular administrators at 134 U.S. MD-granting medical schools were surveyed concerning the nature of ultrasound education in medical school. The questionnaire sought ultrasound education program characteristics, structures, and objectives. It also sought respondents' opinions on the role of ultrasound education in UME and barriers to its integration. Frequency and distribution analyses were conducted for survey responses; Rasch analysis was performed for barrier responses. RESULTS: Responses were received from 82 (61.2%) medical schools; these institutions were representative of the U.S. medical school population. Fifty-one respondents (62.2%) reported ultrasound training was integrated into their UME curriculum. Ultrasound was most commonly taught in the third year (38/82; 46.3%), and the purpose of training varied by curricular year. There was agreement that ultrasound should be part of the UME curriculum (56/71; 78.9%), but few respondents reported it was a priority at their institution (13/70; 18.6%). Respondents perceived lack of space in the curriculum (logit = +0.49; standard error [SE] = 0.11) and lack of financial support (logit = +0.42; SE = 0.11) as the most significant barriers to integration. CONCLUSIONS: Despite a general consensus that ultrasound is an important skill to teach in medical school, the integration of ultrasound education in U.S. schools is highly variable. This study indicates a need for national standards to guide the integration of ultrasound education into U.S. medical school curricula.

Minimizing blood loss during hepatectomy: a literature review.

There are numerous techniques surgeons employ to reduce blood loss during partial hepatectomy. In this literature review, prospective studies from the last 20 years are examined to determine the techniques that are best supported by the literature. Some of the techniques include vascular control, multiple parenchymal transection techniques, various hemostatic agents, low central venous pressure, and hemodilution. The strategies supported most convincingly by the literature include low CVP and total hepatic inflow occlusion.

Integrated medical school ultrasound: development of an ultrasound vertical curriculum.

BACKGROUND: Physician-performed focused ultrasonography is a rapidly growing field with numerous clinical applications. Focused ultrasound is a clinically useful tool with relevant applications across most specialties. Ultrasound technology has outpaced the education, necessitating an early introduction to the technology within the medical education system. There are many challenges to integrating ultrasound into medical education including identifying appropriately trained faculty, access to adequate resources, and appropriate integration into existing medical education curricula. As focused ultrasonography increasingly penetrates academic and community practices, access to ultrasound equipment and trained faculty is improving. However, there has remained the major challenge of determining at which level is integrating ultrasound training within the medical training paradigm most appropriate. METHODS: The Ohio State University College of Medicine has developed a novel vertical curriculum for focused ultrasonography which is concordant with the 4-year medical school curriculum. Given current evidenced-based practices, a curriculum was developed which provides medical students an exposure in focused ultrasonography. The curriculum utilizes focused ultrasonography as a teaching aid for students to gain a more thorough understanding of basic and clinical science within the medical school curriculum. The objectives of the course are to develop student understanding in indications for use, acquisition of images, interpretation of an ultrasound examination, and appropriate decision-making of ultrasound findings. RESULTS: Preliminary data indicate that a vertical ultrasound curriculum is a feasible and effective means of teaching focused ultrasonography. The foreseeable limitations include faculty skill level and training, initial cost of equipment, and incorporating additional information into an already saturated medical school curriculum. CONCLUSIONS: Focused ultrasonography is an evolving concept in medicine. It has been shown to improve education and patient care. The indications for and implementation of focused ultrasound is rapidly expanding in all levels of medicine. The ideal method for teaching ultrasound has yet to be established. The vertical curriculum in ultrasound at The Ohio State University College of Medicine is a novel evidenced-based training regimen at the medical school level which integrates ultrasound training into medical education and serves as a model for future integrated ultrasound curricula.

Advanced ultrasound training for fourth-year medical students: a novel training program at The Ohio State University College of Medicine.

Ultrasound training and education in medical schools is rare, and the foci of current ultrasound curricula are limited. There is a significant need for advanced ultrasound training models in medical school curricula to reduce educational burdens for physician residency programs and improve overall physician competency.The authors describe and evaluate the advanced ultrasound training program developed at The Ohio State University College of Medicine (OSU COM). The OSU COM program is a longitudinal advanced ultrasound curriculum for fourth-year medical students pursuing specialties that require frequent use of focused ultrasound. One hundred fifty student participants have completed the yearlong program to date. Participants engage in didactic lectures, journal club sessions, hands-on training, teaching and patient-modeling activities, and complete a final project. Experienced Ohio State University Medical Center faculty are recruited from specialties that frequently use ultrasound (e.g., emergency medicine, internal medicine, obstetrics-gynecology). A multimodal instructional assessment approach ensures that ultrasound training yields experience with cognitive, behavioral, and constructive learning components. The authors discuss the benefits of the program as well as its challenges and future directions.The advanced ultrasound training program at OSU COM demonstrates a novel approach to providing ultrasound training for medical students, offering a feasible model for meeting training guidelines without increasing the educational requirements for residency programs.

I-AIM: a novel model for teaching and performing focused sonography.

This project was designed to use existing evidence in education and clinical quality improvement to design an educational and clinical model specific for physician-performed focused sonography. The I-AIM model (indication, acquisition, interpretation, and medical decision making) was created to serve as both a mnemonic and checklist. The model follows a stepwise logic for performing focused sonographic examinations and contains detailed subcomponent listings that cover specific areas to improve use and performance. Although validation and reliability studies will be required before implementation, the I-AIM model represents the first effort to standardize and improve clinical and educational focused-sonography.

Brightness mode quality ultrasound imaging examination technique (B-QUIET): quantifying quality in ultrasound imaging.

OBJECTIVES: Ultrasound image interpretation and education relies on obtaining a high-quality ultrasound image; however, no literature exists to date attempting to define a high-quality ultrasound image. The purpose of this study was to design and perform a pilot reliability study of the Brightness Mode Quality Ultrasound Imaging Examination Technique (B-QUIET) method for ultrasound quality image assessment. METHODS: A single sonologist performed a Trinity hypotensive ultrasound protocol on 3 participants of varying body types. Each participant's ultrasound examination was repeated in 4 locations; static clinic location, mobile ambulance, airplane, and helicopter. Images were reviewed by a sonographer, radiologist, and emergency medicine physician using the B-QUIET method and underwent statistical analysis using generalizability theory for reliability of the assessments using the tool. RESULTS: The B-QUIET method showed high reliability of most subscale items. Approximately two-thirds of the reviewed images had complete inter-rater reliability on 90% of the items. There was relatively low inter-rater reliability for the Identification/ Orientation subscale items. The inter-rater reliability κ value was calculated as 0.676 overall for the method. CONCLUSIONS: The need for a standardized method to evaluate the quality of an ultrasound image is well documented. The B-QUIET method represents the first attempt to quantify the sonographer component of ultrasound images. Further reliability and validation studies of this method will be needed; however, it represents a tool for standardized ultrasound interpretation, ultrasound training, and institutional quality assessment.

Ultrasound-assisted musculoskeletal procedures: A practical overview of current literature.

Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.