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AMA Research Challenge 2022

A cross-sectional analysis of harms reporting in systematic reviews evaluating laminectomy

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Ricardo Correa, MD, EdD
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Stuart M. Greenstein, MD
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Stephanie Strohbeen, MD
 
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Jessica Li, MD/PhD Candidate
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Charles Lopresto, DO

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Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


poster

Background
In the field of orthopedic surgery, women have been historically underrepresented. In this analysis, we sought to determine the relative proportion of women amongst active orthopedic surgeons by graduation year and explore related trends.
Methods
Utilizing the Centers for Medicare and Medicaid Services, the investigators were able to acquire the Physician Compare National Downloadable File July 2022 dataset for active physicians who indicated “orthopedic surgery” as their primary specialty. Physicians were queried by graduation year, gender, and state of practice, of which duplicates were removed. Physicians who graduated within the past 7 years (from 2016-2022) were excluded from this analysis to retain only the attending physician population. This query yielded 21,320 orthopedic surgeons. Five-year intervals were used to measure the average proportion of female orthopedic surgeons.
Results
There were 1,477 (6.92%) female and 19,843 male (93.1%) practicing orthopedic surgeons in the United States with medical school graduation dates between 1953-2015. Between graduation years 2011-2015, 12.2% (421/3463) were female. From 2006-2010, 10.7% (346/3224) were
female; 2001-2005, 8.40% (160/2656) were female; 1996-2000, 6.02% (160/2656) were female; 1991-1995, 5.05% (135/2674) were female; 1986-1990, 3.52% (87/2475); 1981-1985, 2.47% (48/1945) were female; 1976-1980, 1.39% (15/1080) were female; 1971-1975, 2.14% (11/515) were female; 1966-1970, 0.93% (2/215) were female; 1961-1965 1.39% (1/72) were female; and before 1961, 0% (0/12) graduates were female. Additionally, geographic trends were recognized by state, with the highest proportions of active female orthopedic surgeons in Hawaii (14.1%, 12/85) and the District of Columbia (13.6%), and the lowest proportions in Nebraska (2.7%, 4/148) and Alaska (0%, 0/72) .
Conclusion
These basic results indicate the proportion of female orthopedic surgery graduates is increasing, yet longstanding gender inequities in orthopedic surgery training remain.

Increasing rates of active female orthopedic surgeons in the United States

In the field of orthopedic surgery, women have been historically underrepresented. In this analysis, we sought to determine the relative proportion of women amongst active orthopedic surgeons by graduation year and explore related trends.
Methods
Utilizing the Centers for Medicare and Medicaid Services, the investigators were able to acquire the Physician Compare National Downloadable File July 2022 dataset for active physicians who indicated “orthopedic surgery” as their primary specialty. Physicians were queried by graduation year, gender, and state of practice, of which duplicates were removed. Physicians who graduated within the past 7 years (from 2016-2022) were excluded from this analysis to retain only the attending physician population. This query yielded 21,320 orthopedic surgeons. Five-year intervals were used to measure the average proportion of female orthopedic surgeons.
Results
There were 1,477 (6.92%) female and 19,843 male (93.1%) practicing orthopedic surgeons in the United States with medical school graduation dates between 1953-2015. Between graduation years 2011-2015, 12.2% (421/3463) were female. From 2006-2010, 10.7% (346/3224) were
© 2022 American Medical Association. All rights reserved.
female; 2001-2005, 8.40% (160/2656) were female; 1996-2000, 6.02% (160/2656) were female; 1991-1995, 5.05% (135/2674) were female; 1986-1990, 3.52% (87/2475); 1981-1985, 2.47% (48/1945) were female; 1976-1980, 1.39% (15/1080) were female; 1971-1975, 2.14% (11/515) were female; 1966-1970, 0.93% (2/215) were female; 1961-1965 1.39% (1/72) were female; and before 1961, 0% (0/12) graduates were female. Additionally, geographic trends were recognized by state, with the highest proportions of active female orthopedic surgeons in Hawaii (14.1%, 12/85) and the District of Columbia (13.6%), and the lowest proportions in Nebraska (2.7%, 4/148) and Alaska (0%, 0/72) .
Conclusion
These basic results indicate the proportion of female orthopedic surgery graduates is increasing, yet longstanding gender inequities in orthopedic surgery training remain.

Proportion of Female Orthopedic Surgeons by Year in the United States 

Background
Acoustic neuromas, also known as vestibular schwannomas, are benign tumors of the vestibulocochlear nerve typically presenting with hearing loss. More common in adults, these are also associated with neurofibromatosis type 2 in children. Once diagnosed via audiogram and MRI, options include conservative management, radiotherapy, or surgical resection. Prior studies have demonstrated disparities such as Black patients tending to be managed conservatively despite larger tumor size at diagnosis and having increased mortality when managed surgically. Given such disparities, this study aims to investigate further socioeconomic factors potentially impacting acoustic neuroma management to facilitate systemic healthcare changes for equitable outcomes.

Methods
Acoustic Neuroma patient data were obtained from the Surveillance, Epidemiology, and End Results (SEER) database and analyzed using binary logistic regression in SPSS 27.0. Demographic variables including sex, age, race, income, and county attributes were analyzed with respect to the dependent variable of initial management with surgery. Demographic groupings were determined using preset SEER coding and United States demographic data.

Results
This was a retrospective analysis of 19,624 patients diagnosed with acoustic neuroma from 2000 to 2019, which consisted of 9,426 males (48.1%) and 10,198 females (51.9%). Factors that predicted whether a patient’s initial treatment was surgery included age between 18 and 64 (p<0.001), race other than Black (p<0.001), income between $60,000 and $75,000 (p<0.001), and living in a county with a population less than one million (p<0.001).

Conclusion
This study indicates that multiple demographic factors predict the course of care for patients with acoustic neuromas. Noticeably, Black patients were treated more conservatively, as they were less likely to be treated with surgery. Other demographic variables in this study indicate that there are likely other factors that play a role in determining a patient’s clinical course, which may include clinical judgment, coexisting comorbidities, and access to non-surgical modalities of care. These findings can inform health system policy on potential shortcomings of care provided to at-risk populations.

Manuscript - Sounds Like Surgery: Socioeconomic and Demographic Predictors of Acoustic Neuroma Treatment

Objective: Biologic medications are novel therapeutics in the treatment of Autoimmune Inner Ear Disease (AIED), an etiology of Sensorineural Hearing Loss (SNHL). The goal of this study is to review the currently available literature on the efficacy of biologic medications on autoimmune-mediated hearing loss and associated symptomology among patients with AIED. 

Methods: A systematic review of Pubmed, Scopus, Cochrane, and Web of Science databases was conducted to identify studies investigating the impact of biologic medications on hearing outcomes. Bias assessment was independently conducted by three authors and studies were stratified based on risk of bias. 

Results: Of 174 unique abstracts screened, 13 articles met inclusion criteria for formal review. One randomized control trial, eight prospective cohort studies, and four retrospective cohort studies were included. Seven biologic medications, Etanercept, Infliximab, Adalimumab, Golimumab, Rituximab, Anakinra, and Canakinumab, were identified targeting three unique molecular targets, TNF-a, CD20, and IL-1. 

Conclusion: The effects of biologic medications in treating SNHL was highly variable without clear efficacy of a drug or drug category, likely due to rarity of disease, multifactorial etiologies of AIED, and cohort heterogeneity. However, several medications alleviate symptoms associated with AIED, such as vertigo and tinnitus. While biologic medications may be promising therapeutics in AIED patients, the evidence is currently inconclusive. Large-scale randomized control trials and prospective cohort reviews are required to establish the efficacy of biologic medications in treating hearing loss. 


The use of biologics in the treatment of autoimmune inner ear disease

Introduction: Endoscopic surveillance guidelines for patients with repaired esophageal atresia (EA) rely primarily on expert opinion. Prior to embarking on a prospective EA surveillance registry, we sought to understand EA surveillance practices within the Eastern Pediatric Surgery Network (EPSN). 
Methods: An anonymous, 23-question Qualtrics survey was emailed to 181 physicians (surgeons and gastroenterologists) at 19 member institutions. Likert scale questions gauged agreement with international EA surveillance guideline-derived statements. Multiple-choice questions assessed individual and institutional practices.
Results: The response rate was 77%. Most respondents (80%) strongly agree or agree that EA surveillance endoscopy should follow a set schedule, while only 36% claimed to perform routine upper GI endoscopy regardless of symptoms. Many institutions (77%) have an aerodigestive clinic, even if some lack a multi-disciplinary EA team. Most physicians (72%) expressed strong interest in helping develop evidence-based guidelines. 
Conclusions: Our survey reveals physician agreement with current guidelines but weak adherence. Surveillance methods vary greatly, underscoring the lack of evidence-based data to guide EA care. Aerodigestive clinics may help implement surveillance schedules. Respondents support evidence-based protocols, which bodes well for care standardization. Results will inform the first multi-institutional EA databases in the United States (US), which will be essential for evidence-based care.
Key Words: Esophageal atresia, surveillance, esophageal disease


Assessing Current Esophageal Atresia Surveillance Practices in the Eastern Pediatric Surgery Network

Background
Preoperative marking is an essential safety practice to prevent ‘never’ events, including wrong site surgery. Moreover, the Joint Commission regulations of Universal Protocol require that patients be marked to indicate the operative site. Marking typically occurs with a pen or marker that may be disposable or reusable. Previous studies have demonstrated that methicillin-resistant staphylococcus aureus (MRSA) can survive in the dark, moist, capped environment of the marking pen and thus, could plausibly be a nidus for transmission from patient to patient. The Joint Commission has established no increased risk of postoperative infection with these markings. With this study, we aimed to determine the colonization of surgical marking pens in the plastic surgery population.

Methods
Two marking pens from five different attending plastic surgeons at a single institution were cultured in standard fashion for aerobic and anaerobic growth. All pens were used repeatedly in office settings for performing patient markings. Those same ten marking pens were then used to mark incision sites on mock patients. Standard povidone-iodine prepping was then performed in a paint only fashion over the skin markings and cultures were again taken. A control group consisted of cultures from five sterile pens from the operating room. Each sterile pen was opened, uncapped, and then swabbed. All twenty-five cultures were analyzed in the hospital laboratory in a blinded fashion.

Results
The five control pens revealed no bacterial growth. Of the ten direct pen cultures, two samples grew coagulase-negative staphylococci and one culture contained pseudomonas aeruginosa. The ten-patient marked and prepped specimens showed 8 negative cultures and two with coagulase-negative staphylococci. Although pseudomonas was detected on standard pen culture, no pseudomonal growth was present in any of the samples after patient marking and prepping with povidone-iodine.

Conclusion
Our findings reaffirm that marking pens may be vehicles for bacterial transmission and expands upon previous studies by describing the presence of bacterial colonization on marking pens even after surgical site preparation with povidone-iodine.

Surgical Marking Pen Contamination: Writing a postoperative infection into your preoperative plan

Background:
Acellular dermal matrix (ADM) has become commonplace in reconstructive surgery despite incomplete FDA safety and efficacy clearance and high cost. Further, it has been the focus of approximately 500 plastic surgery publications since its wide adaptation. An aim of this investigation was to describe external factors associated with the rise of ADM usage over the past two decades. Attention was paid to report individual ADM-related academic output and correlation with industry funding or public interest in the costs of plastic surgery. 

Methods:
All PubMed indexed studies focusing on ADM, in eleven plastic surgery journals, were included (n=534). Data on industry funding to the 17 authors with five or more first and last author publications were extracted from the Open Payments Database. To measure public interest, Google Trends in “plastic surgery cost” and “breast surgery cost”-related searches were queried. Relationships between publication quantity, author industry funding, and public interest were analyzed by Pearson’s Correlation and linear regression.

Results:
ADM-focused studies were published at an approximate rate of 4/year from 2000-09 with a precipitous peak to 71 publications in 2012 and subsequent normalization to approximately 36/year. The 17 most-published authors produced eight qualifying publications on average [5-17]. These individuals grossed a total of $19million industry dollars overall with $17M (89%) in non-consulting compensation from ADM-producing companies (NC-ADM). 

Median/quartile individual total compensation and NC-ADM compensation were $194K/$320K/$1.25M and $17K/$210K/$1.1M respectively. These variables showed strong correlation with individual publication rate [r=0.662 & r=0.647, (p<0.01*)] with a linear regression coefficient of $110K per NC-ADM publication (p< 0.01*). Authors disclosed funding in a mean of 65+/-26% of their work with strong correlation between disclosure and NC-ADM (r=0.576, p=0.02*). Google trends in searches for “breast surgery cost” have risen precipitously in strong correlation with ADM-related publications (r=0.671, p<0.01*). 

Conclusions:
This study demonstrates significant correlations between ADM-related publication, industry funding, funding disclosure, and public interest. Education in the potential for such relationships and the importance of objectivity in operative protocol design is necessary. Continued analysis for potential biases in evidence and transparency in publication are critical when adopting new techniques and technology.

The Rise of Acellular Dermal Matrix: Cost Consciousness, Industry Payments, and Publication Productivity

Background: Renal colic represents a leading cause of emergency department (ED) presentation nationally, yet most require neither hospital admission nor surgical intervention. While not historically considered an ambulatory care-sensitive condition—a condition for which effective outpatient management may prevent admission—we hypothesize that urinary stone disease may share many features, such as high prevalence in socioeconomically disadvantaged populations. No research currently exists on the frequency and characteristics of preventable ED visits for renal colic. We investigated factors associated with potentially avoidable ED visits and their economic burden.

Methods: Patients presenting to the ED for index renal colic events were selected using Florida and New York all-payer data from the 2016 Healthcare Cost and Utilization Project State Databases. Avoidable visits were defined as those that did not result in intervention, admission, or referral to an acute care facility. Utilizing multivariable logistic and linear regression, researchers discerned patient and facility factors predictive of avoidable ED presentations and associated costs.



Results: Of 167,102 renal colic-related ED encounters, 68.2% met pre-determined criteria as potentially avoidable, with cumulative costs totaling $229,269,273.77 over one year. Associated factors included Hispanic ethnicity (Hispanic vs. white: OR 1.12, 95%CI 1.02-1.24: p=0.02) and rural care settings (rural vs. large metropolitan OR, 1.41 95%CI 1.26-1.59: p=0.001). Conversely, increased comorbidities (Elixhauser score ≥3 vs. 0: OR 0.02, 95%CI 0.02-0.02: p<0.001), lower education (≥13% less than high school level education vs. <9.7%: OR 0.73, 95%CI 0.63-0.86: p<0.001), female gender (female vs. male: OR 0.76, 95%CI 0.73-0.79: p<0.001), and Medicare/Medicaid beneficiary status (Medicare vs. private: OR 0.64, 95%CI 0.60-0.67: p<0.001)/(Medicaid vs. private: OR 0.70, 95%CI 0.66-0.75: p<0.001) were protective against avoidable visits. Experiencing an avoidable visit was associated with more renal colic-related ED encounters (OR 4.01, 95%CI 3.69-4.36; p<0.001).

Conclusion: Several non-clinical factors are associated with potentially avoidable ED encounters for renal colic. Given the frequency of presentations that we posit may have been safely managed in outpatient or urgent care settings, our findings support investment into outpatient diagnostic and procedural alternatives to inpatient care, instead diverting patients to lower-acuity care settings. If appropriately targeted, standardization of care may reduce spending without compromising care.

Predictors of Potentially Avoidable Emergency Department Presentations for Renal Colic and Their Associated Costs

Background:
Clinical trials often struggle to enroll participants. Unnecessarily varied eligibility criteria create barriers to clinicians offering trials, particularly if the variation has limited clinical significance (e.g., eGFR 45 vs. 60; ECOG 1 vs. 2). However, the degree of variation in trial eligibility criteria remains poorly characterized. For these reasons, we analyzed the variability in eligibility criteria of genitourinary cancer trials at our institution.

Methods:
We extracted eligibility criteria from protocol documents for active genitourinary cancer trials at our institution. We grouped and compared eligibility criteria within prostate cancer and bladder cancer trials. 

Results:
We identified 35 active genitourinary cancer trials at our institution. Eligibility criteria were highly varied. For example, in prostate cancer trials (n=25), there were 6 different kidney function criteria (4 eGFR and 2 creatinine cutoffs). For all trials, there were 7 different eGFR cutoffs (25, 30, 40, 45, 50, 51, 60) with marginal practical implications. Other criteria were similarly varied. 

Conclusion: 
Trial eligibility criteria have unnecessary variation. These variations are of dubious clinical significance but increase the complexity of trials and may decrease trial acceptability, adoption, and patient enrollment. Simplifying trials, perhaps by creating standards for trial eligibility criteria, may address these barriers. Such standards could make trials more acceptable, less expensive, and more feasible through diminished administrative burden. 


Unnecessary Variation in Clinical Trial Eligibility Criteria: a Call for Standardization

Background: Electronic health records (EHR) were implemented to improve patient care, reduce healthcare disparities, engage patients and families, improve care coordination, and maintain privacy and security. Unfortunately, the mandated use of EHR has also resulted in significantly increased clerical and administrative burden, with physicians spending an estimated three-fourths of their daily time interacting with the EHR, which negatively affects within-clinic processes and contributes to burnout. In-room scribes are associated with improvement in all aspects of physician satisfaction and increased productivity, though less is known about the use of other technologies such as GG, Natural Language Processing (NLP) and Machine-Based Learning (MBL) systems. Given the need to decrease administrative burden on clinicians, particularly in the utilization of the EHR, there is a need to explore the intersection between varying degrees of technology in the clinical encounter and their ability to meet the aforementioned goals of the EHR.

Aims: The primary aim is to determine predictors of overall perception of care dependent on varying mechanisms used for documentation and medical decision-making in a routine clinical encounter. Secondary aims include comparing the perception of individual vignettes based on demographics of the participants and investigating any differences in perception questions by demographics of the participants.

Methods: Video vignettes were shown to 498 OhioHealth Physician Group patients and to ResearchMatch volunteers during a 15-month period following IRB approval. Data included a baseline survey to gather demographic and background characteristics and then a perceptual survey where patients rated the physician in the video on 5 facets using a 1 to 5 Likert scale. The analysis included summarizing data of all continuous and categorical variables as well as overall perceptions analyzed using multivariate linear regression with perception score as the outcome variable.

Results: Univariate modeling identified sex, education, and type of technology as three factors that were statistically significantly related to the overall perception score. Males had higher scores than females (p=0.03) and those with lower education had higher scores (p<0.001). In addition, the physician documenting outside of the room encounter had statistically significantly higher overall perception scores (mean=22.2, p<0.001) and the physician documenting in the room encounter had statistically significantly lower overall perception scores (mean=15.3, p<0.001) when compared to the other vignettes. Multivariable modeling identified all three of the univariably significant factors as independent factors related to overall perception score. Adjusted least squares means (LSM) were calculated and males had higher scores than females (LSM=20.7 vs. 19.9, p=0.03). Those with lower education had higher scores (p<0.001). Specifically, high school education had higher scores than associate/bachelor education (LSM=21.6 vs. 19.9, p=0.0002) and high school education had higher scores than master/higher education (LSM=21.6 vs. 19.5, p<0.0001). Differences in technology were found with the physician documenting outside of the room encounter having significantly higher overall perception scores (LSM =22.6) and physician documenting in the room encounter having significantly lower overall perception scores (LSM =15.7) compared to the other vignettes. No differences between age groups were found on the individual perception scores. Males had higher scores than females on ‘The doctor clearly explained the diagnosis and treatment to the patient’ and ‘The doctor was sincere and trustworthy’. High school education had higher scores than associate/bachelor and master/higher on all five individual perception scores.

Conclusion: The study found sex, education, and type of technology were significant indicators for overall perception of varying technologies used for documentation and medical decision-making in a routine clinical encounter. Importantly, the vignette depicting the least interaction with the EHR received the most positive overall perception score, while the vignette depicting the physician utilizing the EHR during the interaction received the least positive overall perception score. This suggests patients most value having the full attention of the physician and feel less strongly about differentiating the logistics of data transcription and medical decision-making, provided they feel engaged during the interaction. Therefore, the authors suggest maximizing face-to-face time in the integration of technology into the clinical encounter, allowing for increased perceptions of personal attention in the patient-physician interaction.

Next from AMA Research Challenge 2022

Increasing rates of active female orthopedic surgeons in the United States

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The use of biologics in the treatment of autoimmune inner ear disease