United States

Background 
Street Medicine Phoenix, a medical outreach program advocating for unhoused individuals, is the first United States based program utilizing the USee global vision refraction kit (USee) to enhance vision care. Costing $5 per use, the USee can refract patients and provide eyewear within 15 minutes, avoiding delays associated with shipment times and patients lost to follow-up. Other more widely used forms of refraction, such as the portable PlenOptika autorefractor (PlenOptika), are more expensive and can only provide a prescription, which is usually paired with another modality of creating and distributing glasses. This two-step process leads to the delivery of glasses weeks after initial refraction, which is not optimal for a population in constant flux. We report on the USee’s effectiveness in improving visual acuity compared to the PlenOptika.

Methods
This participation-based study first assessed patients&#39; uncorrected refraction. Patients were then refracted using PlenOptika and USee devices. Applying the manual refraction prescription, USee corrective lenses were inserted into frames, and corrected visual acuity was rerecorded. 2x2 Factorial ANOVA, spilt plot design was used to compare before and after refraction visual acuity. Bland Altman assessed the difference in spheres obtained from both devices. In addition, patients whose visual acuity improved to at least 20/40 monocularly were recorded (the legal minimum for driving in Arizona).

Results
180 eyes in 90 patients with mean age of 51.50 ± 12.66 years underwent refraction utilizing each device. Primary outcome was change in visual acuity with use of the USee device. Visual acuity in LogMar before refraction was 0.713 (0.624 - 0.801) and visual acuity in LogMar after refraction was 0.322 (0.269 - 0.374), p&lt; 0.001. Bland Altman showed minimal outliers. 76% of patients were refracted to within 20/40. Median VA improved from 20/80 to 20/30, a 4 Snellen line improvement. Before and after percentage of patients with the ability to drive was 35.9% and 79.2%, respectively.

Conclusion
The USee provides refractive measurements similar to that from the PlenOptika and provides measurable improvement in visual acuity among patients, making it a viable, more expedient option for use in under-resourced populations. By increasing this population&#39;s ability to drive, the intervention enables more individual freedom and job opportunities. Refraction with instantaneous eyewear distribution significantly improves outcomes for transient populations in need of refractive improvement.


AMA Research Challenge 2024 

Novel Refractive Technology to Improve Vision in an Urban Homeless Population

Background 
Street Medicine Phoenix, a medical outreach program advocating for unhoused individuals, is the first United States based program utilizing the USee global vision refraction kit (USee) to enhance vision care. Costing $5 per use, the USee can refract patients and provide eyewear within 15 minutes, avoiding delays associated with shipment times and patients lost to follow-up. Other more widely used forms of refraction, such as the portable PlenOptika autorefractor (PlenOptika), are more expensive and can only provide a prescription, which is usually paired with another modality of creating and distributing glasses. This two-step process leads to the delivery of glasses weeks after initial refraction, which is not optimal for a population in constant flux. We report on the USee’s effectiveness in improving visual acuity compared to the PlenOptika.

Methods
This participation-based study first assessed patients' uncorrected refraction. Patients were then refracted using PlenOptika and USee devices. Applying the manual refraction prescription, USee corrective lenses were inserted into frames, and corrected visual acuity was rerecorded. 2x2 Factorial ANOVA, spilt plot design was used to compare before and after refraction visual acuity. Bland Altman assessed the difference in spheres obtained from both devices. In addition, patients whose visual acuity improved to at least 20/40 monocularly were recorded (the legal minimum for driving in Arizona).

Results
180 eyes in 90 patients with mean age of 51.50 ± 12.66 years underwent refraction utilizing each device. Primary outcome was change in visual acuity with use of the USee device. Visual acuity in LogMar before refraction was 0.713 (0.624 - 0.801) and visual acuity in LogMar after refraction was 0.322 (0.269 - 0.374), p< 0.001. Bland Altman showed minimal outliers. 76% of patients were refracted to within 20/40. Median VA improved from 20/80 to 20/30, a 4 Snellen line improvement. Before and after percentage of patients with the ability to drive was 35.9% and 79.2%, respectively.

Conclusion
The USee provides refractive measurements similar to that from the PlenOptika and provides measurable improvement in visual acuity among patients, making it a viable, more expedient option for use in under-resourced populations. By increasing this population's ability to drive, the intervention enables more individual freedom and job opportunities. Refraction with instantaneous eyewear distribution significantly improves outcomes for transient populations in need of refractive improvement.

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The growing popularity of social media platforms like TikTok has facilitated increased discourse on refractive eye surgeries (RESs), such as Laser-Assisted In-Situ Keratomileusis (LASIK), among healthcare providers and patients. This study aims to evaluate the quality, reliability, and user engagement of RES-related content on TikTok, with a focus on comparing content created by ophthalmology-related providers (ORPs) and non-ORPs (patients). A total of 124 videos were analyzed based on understandability, reliability, and accountability, using the PEMAT-A/V, CRAAP, and JAMA Benchmark criteria, respectively. Videos were selected through predefined search terms and hashtags, and statistical analysis was performed using independent two-tailed t-tests. Results showed that ORP videos garnered significantly more views than non-ORP videos (p = 0.027), although user engagement metrics did not differ substantially between the two groups. ORP videos scored higher in both actionability (PEMAT, p = 0.024) and overall quality (CRAAP and JAMA, p = 0.001). Despite these strengths, ORP content frequently omitted explanations of technical jargon and potential negative outcomes such as chronic dry eye or financial conflicts of interest. In contrast, non-ORP content was more transparent about costs and negative experiences but scored lower in reliability and accuracy. This study underscores the need for enhanced regulation and standardized criteria to ensure the dissemination of accurate and transparent RES-related information on social media. Future research should focus on addressing existing gaps in accountability, reliability, and educational quality in TikTok's medical content.

Ophthalmology and TikTok: A Study on the Portrayal of Refractive Eye Surgery Procedures on Social Media

Abstract
Aims: To examine if healthcare access modifies the association between age at diagnosis of diabetes and the prevalence of retinopathy. 
Methods: BRFSS 2020 survey data was obtained from 12,198 adults. Participants with missing information in the variables “retinopathy” (N = 569) and "insurance-cost barrier” (N = 75) were excluded. The final sample included 11,556 participants. Age at diagnosis of diabetes was the main exposure and retinopathy was the main outcome. We tested if the main association was different among the insurance-cost barrier variable. Binary logistic regression models were used to calculate odds ratios (OR) and 95% confidence intervals (CI). 
Results: The odds of retinopathy decreased by 26% in patients 46-64 years-of-age (OR 0.74; 95 CI 0.58-0.95) and 57% in those 65+ (OR 0.43; 95 CI 0.28-0.64). The odds decreased by 39% if female (OR 0.61; 95 CI 0.49- 0.76). An increase in odds by 83% (OR 1.83; 95 CI 1.07-3.14) occurred in other non-Hispanics, 50% (OR 1.50; 95 CI 1.14-1.98) in black non-Hispanics and 60% (OR 1.60; 95 CI 1.10-2.31) in Hispanics. There was no evidence that age at diagnosis of diabetes and presence of retinopathy varied by insurance cost (p>0.05).
Conclusion: Health professionals may utilize these results to advocate for early disease intervention.



The Association Between Age at Diagnosis of Diabetes and Development of Diabetic Retinopathy and Assessment of Healthcare Access as an Effect Modifier

Introduction: Socioeconomic status (SES) has been associated with differences in patient-reported outcome scores and complication rates across orthopedics. Area Deprivation Index (ADI) is a validated measure of an area’s socioeconomic status based on 17 different census variables. ADI has been associated with complications following total knee arthroplasty and may be associated with clinical outcomes and complications following rotator cuff repair.  The purpose of this study is to investigate the impact socioeconomic factors have on outcomes following primary arthroscopic rotator cuff repair.   
  
Methods: Patients who underwent primary rotator cuff repair at a single institution from 3/11/2014-9/29/2022 were identified. Patient demographics, pre- and post-operative Visual Analog Scale (VAS) scores, Patient-Reported Outcomes Measurement Information System (PROMIS) scores—specifically PROMIS Upper Extremity (UE) function, PROMIS Pain Interference (PI), and PROMIS Depression (D)—range of motion, complications, and subsequent ipsilateral shoulder surgeries were collected. ADI was collected from an online mapping database using each patient’s home address. Patients were split into ADI terciles, with ADI 1 representing the least disadvantaged group and ADI 3 representing the most disadvantaged group. ANOVA, T-test and chi-square analyses were conducted for continuous variables and categorical variables, respectively.   
  
Results: In total 467 patients underwent rotator cuff repair and had complete demographic data and postoperative follow-up through one year. There was a significant difference in race, with 78.2% of patients identifying as black in ADI 3 versus 18.1% in ADI 1 (P<0.001). Pre-operative PROMIS-PI, VAS, forward flexion (FF), and abduction (ABD) were significantly worse in ADI 3 compared to ADI 1 (P=0.001, P<0.001, P=0.012, P=0.023). Patients in ADI 3 had significantly worse PROMIS-UE score, PROMIS-PI, VAS, FF and ABD at 1-year postoperatively compared to ADI 1 (P=0.016, P<0.001, P<0.001, P<0.001, P=0.034). 9.8% of patients in ADI 1, 32.6% in ADI 2 and 57.6% in ADI 3 experienced a postoperative complication (P=0.54). Retears were more common in ADI 3 (62%) compared to ADI 2 (28%) and ADI 1 (10%) (P=0.47). There was a greater but not significant number of reoperations performed for patients in ADI 3 (63.4%) compared to ADI 2 (31.7%) and ADI 1 (4.9%) (P=0.22).   
  
Conclusion: Lower socioeconomic status measured by ADI is associated with worse preoperative and 1-year postoperative pain, shoulder function and range of motion following rotator cuff repair, but no difference in reoperation or complications.

Lower Socioeconomic Status is Correlated with Worse Outcomes After Arthroscopic Rotator Cuff Repair

Background: Downward trends in inflation-adjusted Medicare reimbursement to hand surgeons have been reported, likely to offset increasing costs associated with the aging population. Less is known regarding Medicaid reimbursement to physicians, but generally Medicaid reimbursement rates are thought to be lower than Medicare. Given the ability for each state to set rates for a given procedure, discrepancies exist in Medicaid reimbursements between states. This study compared Medicaid and Medicare rates for common hand surgery procedures to determine national and state differences in reimbursement.

Methods: Medicare rates for 26 commonly billed hand procedures, based on prior reimbursement studies, were obtained from the Center for Medicare & Medicaid fee schedule database. Corresponding work RVUs for each procedure were also collected here. Medicaid rates were found at states’ Medicaid online fee schedule website. State rates were compared to corresponding Medicare rates using mean values and dollar differences. These dollar differences were also divided by work RVUs. Each states’ reimbursement values were also adjusted using the Medicare Wage Index to account for regional wage differences. Variability between states and between procedures was analyzed using percentages as a function of Medicare reimbursement and by coefficient of variation values. Coefficient of variation values were calculated by dividing the standard deviation by the mean for each procedure, and values further from zero indicate higher variability within a dataset.

Results: Medicaid reimbursement was lower than Medicare for 22 of the 26 procedures included in the analysis. On average, Medicaid rates were 18% lower than Medicare, a difference that increased to 29% when accounting for wage differences. Average dollar differences by procedure ranged from $205 less to $110 more for Medicaid. Dollar differences per RVU ranged from $38 less to $48 more for Medicaid. State Medicaid rates ranged from 30% to 158% of Medicare. Variability was low among Medicare procedures, with a coefficient of variation of 0.06. Medicaid variability between states ranged from 0.26-0.57 for unadjusted data and 0.36-0.67 for wage-adjusted data.

Conclusion: On average, Medicaid reimbursement is substantially lower than Medicare for common hand surgery procedures. There was wide variability in Medicaid rates, both between states and procedures. Adjustment for wage differences increased the percent difference and variability, suggesting a lack of objective metrics used to set Medicaid prices. Hand surgeons should be aware of variable prices between states and advocate for policy that fairly reimburses them while promoting better access to care for this vulnerable population.

Medicaid Reimbursement to Hand Surgeons is 18% Less than Medicare and Highly Variable, Ranging from 30-158% of Average Medicare Rates by State

Objective: This study aims to compare HPV vaccination rates, knowledge, and treatment decision-making between a predominantly white and Asian population. 

Study Design: Cross-sectional survey-based study

Setting: Otolaryngology clinics at a tertiary academic center. 

Methods: Descriptive statistics were utilized to assess rates of vaccination, HPV knowledge, and HPV vaccine treatment decision-making, with significance testing utilized to compare between the Asian American and non-Asians of the sample. Multivariable logistic regression was utilized to understand factors associated with vaccination. 

Results: In this cohort (n=237), vaccination among adults (n=69, 29.4%) and their children (n=62, 51.2%) was low. Knowledge that the HPV vaccine is not recommended only for women was lower among the Asian cohort (66.7% vs. 79.9%; p=0.023), while knowledge that full protection requires more than one dose was higher among Asians (76.3% vs. 54.2%; p=0.001). Asians were more likely to report that when they did not receive HPV vaccination it was due to not being knowledgeable about the vaccine (52.6% vs. 17.4%; p<0.001). Among those with non-vaccinated children, Asians were more likely to report that their children were not vaccinated because they were not knowledgeable about the vaccine (40.0% vs. 32.4%; p=0.045), friends and family discouraged vaccination (12.0% vs. 0.0% p=0.038). In a multivariable regression of factors associated with HPV vaccination, only increased age showed significant association with likelihood (OR: 0.92 [95%CI: 0.89-0.94]).

Conclusion: This study generates hypotheses regarding reasons why Asian-Americans may be less likely to receive HPV vaccination, and it demonstrates a potential opportunity to improve HPV vaccination in this cohort.

HPV Vaccination and Treatment Decision-Making Among Asian-Americans

Introduction:
Sickle cell disease (SCD) is an inherited hematological disorder characterized by the presence of sickle-shaped red blood cells, leading to various systemic complications due to vaso-occlusion and hemolysis. ENT manifestations, particularly hearing loss, are less frequently highlighted but can significantly impact patients' quality of life and overall health outcomes.

Methods:
A retrospective study was conducted within the TriNetX database. Queries targeted patients aged 18 or older with or without a diagnosis of sickle cell disease (SCD) who had a documented outpatient visit between May 1, 2022, and December 31, 2022. Cohorts were propensity score-matched by age, sex, ethnicity, and race. Selected ENT outcomes were extracted using relevant ICD-10 codes to compare the occurrence between the SCD and non-SCD cohorts.

Results:
Among 8,934,438 adults identified, 13,870 were diagnosed with SCD. After propensity score matching, 13,870 patients were retained in each cohort, with a mean age of 40.9 years. The majority in each cohort were Black or African American (N=9,966, 71.9%) and a small proportion were Hispanic or Latino (N=613, 4.4%). Hearing loss was more likely in the SCD cohort (6.0% vs. 2.6%; OR=2.4, 95% CI=2.1-2.7, p<.001). When stratified by hearing loss type, only sensorineural hearing loss was found to be higher (3.2% vs. 1.3%; OR=2.5, 95% CI=2.1-3.0, p<.001), while conductive hearing loss incidence did not differ from the non-SCD cohort (p=.238). Other conditions found to be more likely in the SCD cohort were obstructive sleep apnea (11.9% vs. 6.8%; OR=1.8, 95% CI=1.7-2.0, p<.001), allergic rhinitis (5.9% vs. 3.6%; OR=1.7, 95% CI=1.5-1.9, p<.001), and acute or chronic sinusitis (5.2% vs. 4.5%; OR=1.2, 95% CI=1.1-1.3, p=.004).

Conclusions:
SCD patients included in the TriNetX database have a higher risk of sensorineural hearing loss compared to those without SCD. This finding underscores the need for routine hearing assessments in SCD patients to mitigate this risk and improve overall patient care.

Prevalence of Hearing Loss in Adult Patients with Sickle Cell Disease: A Retrospective Cohort Study

Background
Since the early 2000’s, there have been local, state, and federal efforts to provide a framework for developing school health programs that meet a minimum recommendation for emergency preparedness. New York State has instituted multiple educational and public health laws offering guidance to school health officials on program infrastructure, school health communicable disease, emergency medical care, and school safety plans. These laws allow for, but do not require, schools to stock and maintain epinephrine auto-injectors, narcotic overdose kits, tourniquet kits, and allow for the development of school safety plans in response to a school crisis. However, compliance with these recommendations and statutes in schools has not been investigated. The objective of this study is to systematically identify the policies and procedures that schools have implemented to address community and individual emergencies.

Methods
Cross-sectional study conducted between March 2024 and May 2024. An electronic survey based on a priori policies, federal regulations and NYS laws was sent to 6,600 eligible schools from a publicly available registry of NYS schools. Each respondent reported the school's demographics, as well as questions pertaining to various elements of emergency preparedness policies. There was no incentive provided by the research team for respondents to complete the survey. Descriptive analysis of the survey results was performed.

Results
185 total survey responses were received. The policies with the greatest implementation included presence of an emergency crisis plan (68.11%), emergency communication plan (67.57%), onsite CPR equipment (67.57%), onsite AED (63.78%), emergency contact information for all students and staff (63.24%), and staff trained in CPR onsite (61.62%). The presence of Narcan (28.65%), tourniquets (25.41%), glucagon (21.08%), and stress dose steroids (7.03%) onsite was notably low. Overall implementation of the recommended policies was found to be approximately the same (44-46%) among all school types, except for religious nonpublic schools, which noted substantially less (29.2%) overall adherence to the policy recommendations.

Conclusion
We found that many of the policies recommended by state and federal authorities were not implemented by the majority of schools that responded. This creates a potential gap in care that is especially relevant given the recent increase in school violence. Further studies should focus on identifying trends in noncompliance and barriers to implementation of these policies, with the ultimate goal of providing students with the proper resources when school emergencies do occur.

Are New York State Schools Adequately Prepared For School Health Emergencies?
A Descriptive Analysis

Purpose 
Food insecurity (FI), the lack of access to sufficient food to meet nutritional needs, is strongly associated with poor quality of life, child development, and mental health. The stress and financial strain of their child’s hospital admission may incite caregivers to go hungry during the hospitalization, a term known as inpatient FI. Caregiver hunger may hinder processing and comprehension of information which poses safety concerns during and after a hospital stay. 

Methods
Caregivers of pediatric hospitalized patients were surveyed at a large, urban academic institution in July 2024. Respondents were queried on their sociodemographic characteristics (e.g., income, race/ ethnicity), and caregiver household and inpatient FI. The Hunger Vital sign, a 2-question validated screener tool, was used to assess household FI and a modified tool based on the US Department of Agriculture’s Food Security Survey Module was used to assess inpatient FI. Caregivers who noted an interest in sharing additional information were called to share qualitative feedback. Statistical analysis included descriptive statistics, Fischer, and chi-squared tests analyzed via R Statistical Software (v4.1.2; R Core Team, 2021).

Results
Over one in every four caregivers (27%, N=51) reported experiencing FI during their child’s hospitalization. Among those experiencing inpatient FI, the majority (86%) of families reported annual incomes below the poverty threshold (measured as less than $30k) and most (86%) self-identified as non-white in race/ethnicity. Moreover, over a quarter (29%) of caregivers queried noted that they had not been told how to get food in the hospital. Patients who experienced household food insecurity were 2.54 times more likely to experience inpatient food insecurity compared to those without household food insecurity CI (1.08, 5.99). No statistically significant associations were found between inpatient FI and families being informed about food options available in the hospital (p = 0.7), annual household income (p = 0.4), or race/ethnicity (p = 0.7).

Conclusion
Inpatient FI is a present and significant challenge affecting pediatric hospitalization. Comprehensive, evidence-based policy interventions such as providing clear information about available food resources, integrating food assistance programs into hospital services, and collaborating with community organizations to support caregivers must be considered. Addressing inpatient FI among caregivers may build their capacity to provide care for their child during their hospitalization, have therapeutic effects on health care delivery, and is essential for promoting positive health outcomes for family units.

Evaluating Inpatient Food Insecurity among Caregivers in a Pediatric Hospital Setting

Objective: Quantify the value and cost-effectiveness of institution-subsidized childhood immunizations in a community health clinic setting.

Background:
Child and adolescent immunizations are critical life-saving and cost-saving interventions, as the cost of treating vaccine-preventable diseases is greater than the cost of providing vaccination. Thus, the value of avoiding preventable disease in an integrated health system can offset the cost of implementing immunization programs. Additionally, vaccines have been shown to increase patient quality of life as measured by Quality-Adjusted Life-Years (QALYs), an economic estimate of the value of specific medical interventions. Vaccinations can generate QALYs at a lower cost than other interventions. We aimed to determine the cost-effectiveness of providing immunizations in a community health clinic to help clinicians, administrators, and policymakers advocate for institutional funding.

Methods:
This retrospective study quantifies the value created—measured in QALYs—by providing reduced-cost immunization series for an underserved patient population in a community clinic and provides an estimate of institutional funds expended per QALY generated.
A university-based community clinic provides primary care and immunizations to a marginalized and minoritized population. This clinic accepts private (15%) and public (75%) insurance and has an income-adaptive charge system for those who are uninsured (10%).
Vaccinations provided by the clinic from 2019-2022 were quantified using Current Procedural Technology codes. Series completed during this period were measured in person-lifetimes by combining the lowest total fulfilled immunization schedules among all vaccinations collectively. Established Clinically Preventable Burden scores were utilized to determine the number of QALYs generated per vaccination series. These values were compared to the clinic's operational expenditures and cost per vaccine to estimate expenditures in US Dollars per QALY generated.

Results:
From 2019-2022, the clinic had operational costs of $7,204,100. The clinic administered 26,419 vaccines falling under CDC recommendations for immunizations at a total cost of $161,308 (Table 1). Extrapolated over 18 years, these vaccinations represent 753 total completed lifetime vaccination series (excluding influenza vaccinations) for children and adolescents aged 0-18 years, estimated to have generated a minimum of 132 QALYs. The clinic generated these QALYs through a maximum estimated expenditure of approximately $11,600 per QALY.

Conclusions:
Access to vaccinations decreases population disease burden and future associated costs. Medical institutions with large service areas and associated payers are uniquely positioned to improve their financial outcomes and the health of the populations they serve. Using clinic-based actual costs, the $11,600 per QALY generated is notably lower than previously published estimates for the total economic cost of providing vaccinations; current estimates suggest vaccination in adults involves costs of up to $39,000 per QALY for influenza vaccinations. These findings highlight a crucial opportunity for healthcare systems and payers to responsibly and sustainably expand critical services to underserved populations.

Quality of Life and Financial Outcomes of Childhood Immunization in a Community Clinic Setting

Background: Postural Orthostatic Tachycardia Syndrome (POTS) is associated with orthostatic intolerance manifested by an excessive heart rate rise with position change associated with multi-systemic symptoms of autonomic dysfunction. Patients can experience sudden clinical deterioration with any infectious stress. Evidence has shown COVID-19 to be an aggressive infection with serious consequences that can be ameliorated by the COVID-19 vaccination. The goal of this survey is to understand and identify the parental gaps in knowledge regarding the safety and efficacy of the COVID-19 vaccine, allowing healthcare professionals to better advocate, educate, and manage the needs of this vulnerable population. 
Methods: Parents of 203 pediatric POTS patients from a local group practice completed an online survey with a response rate of 37%. The survey focused on demographics, previous COVID-19 infection, vaccination, reason for vaccination, and knowledge of COVID-19. Results were analyzed using Chi-square test of independence to interpret the perception of COVID-19 illness and vaccine. 
Results: The results show 59% of patients are vaccinated, independent of sex, income, or education levels. Fear of side effects (37%) was the most common reason for not vaccinating. Almost no patients experienced side effects from the vaccine. More than half of surveys reported not receiving information from medical professionals on COVID-19. 
Conclusion: Lower vaccination rates highlight a fearful and negative perception of the COVID-19 vaccine despite no reported side effects in those vaccinated. Overall results demonstrate knowledge gaps regarding COVID-19 virus and vaccine. Education and advocacy are required from qualified sources to prevent significant morbidity in this already susceptible patient population.


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