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Beyond Traditional Metrics: Assessing Value in Carpal Tunnel Surgeries
Get PDFBeyond Traditional Metrics: Assessing Value in Carpal Tunnel Surgeries
Meet Patel1, Emily Mazier2, Megan Carulla1, Trae Hill1, Alex Lindahl2, Charles S. Day3
1Wayne State University, Detroit, MI, 2Oakland University William Beaumont, Auburn Hills, MI, 3Henry Ford Medical System, Detroit, MI
Introduction:
To control healthcare costs, one must consider cost-effectiveness and quality of care metrics. This study compares the value of carpal tunnel release (CTR) performed in the ambulatory surgical center (ASC) to the hospital outpatient department (HOPD).
Methods:
Costs were determined by the Time-Driven Activity-Based Costing (TDABC) methodology. All steps of a patient care pathway for CTR performed in ASC and HOPD were organized into a process map. Costs were categorized into the following: Direct Variable: Staff salaries directly involved in patient care Direct Fixed: Materials, supplies, and building fees Indirect: Maintenance, administration, and marketing
Differences in pre-operative and 3-month post-operative PROMIS UE and PI scores were multiplied by average life-years remaining for each patient to determine quality-adjusted life-years (QALY). Costs were divided by QALYUE and QALYPI to determine incremental cost-effectiveness ratios (ICER), denoted as ICERUE and ICERPI.
Results
16 HOPD patients were compared to 18 ASC patients. Costs were significantly lower in the ASC by 6097/QALY. ICERPI was greater in the HOPD by $3325.69/QALY.
Discussion:
Higher ICER values indicate the HOPD provides less value, despite having better outcomes compared to the ASC. The significant decrease in cost shows the ASC to be more cost-effective.
Significance/Clinical relevance: As healthcare costs continue to rise, value-based care will maintain a pivotal role. Combining TDABC and PROs to determine value can aid clinicians in decision-making
Cidofovir in the Treatment of BK Virus–Associated Hemorrhagic Cystitis Following Hematopoietic Stem Cell Transplantation; A Medication Use and Safety Analysis
Get PDFBK virus hemorrhagic cystitis (BKV-HC) is a complication after allogeneic hematopoietic stem cell transplant (AlloHCT) for which optimal management is uncertain. Intravenous (IV) and intravesicular (IVES) cidofovir have been used with varying degrees of success in small case series of six to 33 patients. While some series have investigated side effects, none have examined medication errors. A retrospective single-center case series of AlloHCT patients with BKV-HC given IV or IVES cidofovir (CDV) from 2018 to 2022 at an urban cancer center in Detroit, MI. Our primary objective was to determine the incidence of CDV related medication errors (ME) and perform a root cause analysis (RCA) to determine factors contributing to such events. Secondary objectives were to describe the effectiveness of CDV for BKV-HC following AlloHCT. Six AlloHCT patients were treated with CDV. Median age was 48 years (range 32-63), with most being high risk for cytomegalovirus (R+) and experiencing acute graft versus host disease. CDV and BKV-HC characteristics are shown in Table 2. BKV-HC occurred a median of 53 days post Allo-HCT (range 27-179). Four patients received IV CDV only and two received both IV and IVES. Median number of doses was 2 (range 1-10). Median BKV-HC severity grade was 2.5, and three of six patients had BK viremia (Table 2). Five of six patients had microscopic resolution of hematuria (median time to resolution 30 days, range 1-116). However, 4 of 6 had died and 1 of 6 had recurrence of BKV-HC within 90 days. The most common CDV side effects were bladder pain/spasms (n=5) and acute kidney injury (n=4). There were 2 MEs; one near miss where CDV was incorrectly ordered IV but changed to IVES by a pharmacist, and one major safety event where an IVES dose was administered IV. RCA analysis revealed multiple contributing factors including similarity in appearance of doses and an overly simplified pump library without an option for IVES administration. In this first case series to describe medication errors in patients treated with CDV for BKV-HC, one in three patients experienced an ME. Clinicians caring for AlloHCT patients should have a high predisposition for error when cidofovir is being prescribed
Addressing Barriers to Black Americans Participation in Clinical Trials: A Faith-based Community Survey
Get PDFBackground: The underrepresentation of high-risk minority groups in clinical trials remains a crisis in American healthcare. Despite pressures from the NIH to increase Black-American participation in trials, recruitment and retention in this group rarely match population demographics. Our company launched an opinion survey polling 260 Blacks regarding their thoughts and awareness about clinical trial participation.
Methods: We created a web-based survey consisting of 38 items and subdivided it into three main sections: (1) cultural affinity, (2) trust, and (3) background information. The survey was conducted using Jotform, a HIPAAcompliant web-based application. Our target population was Black Americans in central Alabama. Response options included numerical, categorical, and ordinal. Respondent demographics polled were age, employment status, health insurance coverage, income, and education level.
Results: 63% of respondents cited recommendations from their PCP as a critical trust indicator, with 67% being willing to go to another physician for a study as long as their PCP recommended it. 44% valued explanations and recruitment by persons of shared ethnicity. Consistently \u3e50% of respondents wanted clear and straightforward explanations before participating in research. 65.4% wanted IRBs that included African Americans.
Conclusion: Black Americans are open to clinical research. However, certain trust and safety measures should be in place. A history of abuse, dishonesty, and lack of black leadership still haunts people of color’s ability to trust medical research as safe spaces. Plain language explanations, people of color in decision-making roles, and active PCP engagement are vital steps toward increased research participation
Anterior Cruciate Ligament Hybrid Remnant Preservation Reconstruction Demonstrates Similar Outcomes as Traditional Reconstruction after 6 Months: A Randomized Control Trial
Get PDFBackground
The anterior cruciate ligament (ACL) is often debrided during reconstruction (ACLR) to improve visualization. However, remnant ACL tissue contains nerve fibers and including remnant tissue in ACLR could provide benefit. Therefore, a technique was developed that preserves the tibial remnant and incorporates it into ACLR: Hybrid Remnant Preservation Reconstruction (HRPR) ACLR. This study compares HRPR-ACLR to traditional reconstruction by comparing patient reported outcomes and complications.
Methods
Patients presenting to one surgeon\u27s clinic with an ACL injury are screened. Exclusion criteria are patient age\u3c14 years, multi-ligament injury, chronic tears, and revision ACLR. Patients are consented and randomized to HRPR or traditional ACLR. Demographics, patient-reported outcomes, range of motion (ROM) and complications were collected.
Results
Thirty-three patients were included, 20 HRPR and 13 controls. No demographic differences were noted. PROMIS-PF, PROMIS-PI, IKDC and PASS scores were equivalent. HRPR reported higher PROMIS-D scores at 6 months (41.90 ± 8.52 vs 34.92 ± 3.33, p=0.009). HRPR demonstrated significantly increased ROM in the affected (137.81 ± 9.69 vs. 127.33 ± 14.82, p=0.05) and unaffected (144.06 ± 9.26 vs 135.25 ± 7.34, p=0.01) legs after 3 months. No ROM difference existed after 6 months in the affected leg (139.0 ± 8.46 vs 131.0 ± 13.42, p=0.07) although a difference existed in the unaffected leg (142.32 ± 8.27 vs 135.62 ± 7.69, p=0.03). Two control group patients suffered complications compared to zero HRPR (p=0.07).
Conclusion
HRPR-ACLR demonstrates similar patient-reported outcomes and significantly increased range of motion without increased complications compared to traditional ACLR after 6 months
A Review of Anthropological Adaptations of Humans Living in Extreme Conditions and Health Implications
Get PDFUnderstanding gene variations in people living under extreme conditions has the potential of curing diseases caused by exposure to heat, cold, fatty diets, hypoxia, and pathogens. One candidate gene associated with heat resistance is ACE1, encoding angiotensin-converting enzyme 1. Associations have also been made between cold resistance or fatty diets and polymorphisms of several genes including ACTN3, encoding alpha-actinin-3, and CPTIA, encoding carnitine palmitoyltransferase 1A. A prominent role in resistance to hypoxia has been given for polymorphisms of EPAS1, encoding endothelial PAS domain protein 1, and EGLN1, encoding Egl-9 family hypoxia inducible factor 1. Variants conferring human resistance to pathogens include HBB, encoding hemoglobin subunit beta, and ACE2, encoding angiotensin-converting enzyme 2. Genetic knowledge concerning malaria and hypoxia should continue to promote advances in gene therapy
Stephen Dwoskin: The Feminist Gaze and Postwar Jewish Masculinity
No full textIt is perhaps well known that Stephen Dwoskin was a survivor of polio and made work that was in many ways defined by the lifelong legacy of that childhood event. The focus on the body and its subjectivities has other resonances that demonstrate deep roots of preoccupation to do with Dwoskin’s cultural background that I aim to discuss in this article. Not explicitly explored in the film work, critically this aspect of his work has been ignored. Jonathan Boyarin, in his text, “Unheroic Conduct: The Rise of Heterosexuality and the Jewish Man” (1997) sets out a framework for the rethinking of Jewish masculinity as an embodied and proudly feminized entity. He sets this against the stereotypes of a Christian normative macho male identity and the overtly antisemitic trope of the feminized male Jew. In popular culture, postwar American Jewish writers such as Philip Roth and Norman Mailer often embraced the macho male (and its misogynist tendencies), symptomatic of the assimilationist impulse and opportunity of the US at that time. For Stephen Dwoskin, the tension between the Jewish masculinity of his upbringing and the postwar macho masculinity can be seen in the ambivalence of his films towards women. This tension is heightened by Dwoskin’s own disability, which left him in calipers and subsequently, a wheelchair. Boyarin’s claim that the outsiderness of the Jew affords empathy with the feminist critiques of manhood resonates with Dwoskin’s own claim that his works such as Dyn Amo (1972) were empathetic to the plight of women’s oppression. Through a close reading of passages from this early film, and comparisons with Dwoskin’s later autobiographical films such as Trying to Kiss the Moon (1994) and Grandpere’s Pear (2003), I will interrogate the tensions in Dwoskin’s masculinity, disability, and representation of women through Boyarin’s framework of Jewishness
Landscapes of Memory: Visualizing Holocaust Testimony in But I Live: Three Stories of Child Survivors of the Holocaust
No full textWe are now at a time that will see the end of direct survivor testimony, and thus the transmission of Holocaust memory is increasingly complicated by its mediation through the voices and narratives of subsequent generations of Holocaust writers and scholars. The rendition of Holocaust testimony has expanded to include not only visual and textual forms of representation, but the hybrid genre of Holocaust graphic narratives. But I Live: Three Stories of Child Survivors of the Holocaust, a polyphonic dialogue among scholars, survivors, and graphic artists, is an innovative approach to Holocaust representation that depends upon not only a conversation among text and image but also past and present. At the center of this book are the testimonies of child survivors, whose accounts of resilience and resistance are illustrated by comics artists. This article discusses the ways in which comics artists, in reinscribing survivors’ narratives, create a visual testimony to memory by recreating a material landscape of trauma