United States

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&lt;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&lt;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&lt;0.001, P&lt;0.001, P&lt;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.  


AMA Research Challenge 2024 

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

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.

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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.


The Perception of the COVID-19 Vaccine Amongst Parents of Pediatric Postural Orthostatic Tachycardia Syndrome (POTS) Patients

ABSTRACT
Soldiers on the battlefield are affected by heavy body armor and excessive march load. It is well known, but the long-term effects of this extra weight on the musculoskeletal system of military veterans, specifically the lumbar spine, are unclear. In Iraq and Afghanistan, most body armors weighed over 33 pounds (15 kg). These armors were 3 times heavier than those used in Vietnam. Chiropractors at the Fargo VA Hospital are seeing more young veterans with non-traumatic lower back pain. This article presents a perspective on the impact of body armor weight and excessive carry load on lumbosacral disc herniation with radicular pain in military veterans.
This study is a retrospective case series. We used a convenient sampling method. We selected the first 10 military veterans who came to a Fargo VA chiropractor in late fall 2023. Each veteran filled out a VA Form 10-5345 to give us permission
to access their electronic health records. All 10 veterans also completed a survey. The survey asked about their active combat status, the type and weight of their body armor, how long they wore the armor each day, how much weight they
carried, and their opinion on the cause of their lower back pain (service related or not). The Fargo VA does not require an institutional review board for a case series.
This study found that military veterans experience lower back pain at an average age of 35 years. This is at least 5 years earlier than non-service men. Lower back pain with disc herniation typically occurs at the L4-L5 and L5-S1 disc levels. All 10 veterans in the study believe that their lower back pain is related to their service. Sixty percent of the participants in the study have a service-connected disability because of back pain.
For military veterans, onset of lower back pain from a disc herniation at a young age may be linked to carrying heavy
body armor and loads. However, the small sample size of this case series limits causal relationship inferences.

Body Armor and Lumbar Disc Herniation in Young Military Veterans:
A Case Series

Background
Physical and occupational therapy has grown significantly from 1965 to 2023. Despite this growth, challenges related to Medicare and accessibility remain for both professions, impacting their ability to serve all populations effectively. This research aims to investigate the distribution of physical and occupational therapists at the county, state, and national levels. The project seeks to identify factors contributing to disparities in therapist distribution and explore the consequences of underserved areas lacking sufficient resources in these fields.
Methods
The data utilized in this research study were sourced from the Centers for Medicare & Medicaid Services (CMS) for 2023. The number of physical and occupational therapists enrolled in Medicare was analyzed nationally and statewide via proportion tests. Pearson regression models compared the relationship between physical and occupational therapists in the United States and Ohio. The trend in practicing rehabilitation therapists was explored by graduation year.
Results
Approximately 229,740/364,720 (63.0%) of rehabilitation therapists were physical therapists nationally. However, 74,836/86,373 (86.6%) of rehabilitation therapists enrolled in Medicare were physical therapists (P<0.001). Additionally, on a state level, there were significantly fewer counties in Ohio that had at least one occupational therapist (P<0.05). There was a significant relationship between physical therapists and occupational therapists nationally (P<0.001, R=0.95) and in Ohio (P<0.001, R=0.89). The number of graduating physical therapists who practice in Ohio has increased significantly faster than occupational therapists (P<0.01).
Conclusion
When comparing physical and occupational therapists, there is a significant disparity in the number of these healthcare professionals registered with Medicare. The lower enrollment rate of occupational therapists in Medicare contributes to reduced accessibility to their services within the healthcare system. This limitation hinders certain populations from receiving assistance with their daily tasks. In contrast, the availability of physical therapists is increasing, potentially improving accessibility to their services with Medicare.

Trends and Impacts of Medicare Enrollment Among Physical and Occupational Therapists

Background: Conflicts of interest pose a significant risk to the integrity of clinical research. As a part of the Sunshine Act, the Open Payments Program was established to provide transparency in financial relationships between industry partners and physicians. Previous research indicates considerable disparities between industry payments self-reported by plastic surgeon authors and those disclosed by their industry partners. The goal of this study was to determine if the Sunshine Act enhances transparency regarding authors’ conflicts of interest for readers of peer-reviewed plastic surgery journals.

Methods: Articles from the Aesthetic Surgery Journal and Plastic and Reconstructive Surgery published between 2017 and 2022 were reviewed. Self-reported disclosures for plastic surgeon authors were aggregated and compared against the Open Payments database using Python scripts. 

Results: 8,040 articles were reviewed. After filtering, 1,469 unique plastic surgeons and 5,987 authorships were identified. A total of 11,593 discrepancies were found, with 82% of authors having at least one discrepancy. Average total payments for authors with discrepancies were greater than for authors without discrepancies ($106,928 vs. $6,501; p<0.001). A discrepancy in self-reporting was more likely to be identified for a senior author (p<0.001). 

Conclusions: Plastic surgeon authors continue to underreport their financial relationships, and the lack of oversight continues to be problematic. Plastic surgery journals may consider automated systems to assess self-reporting accuracy.

Next from AMA Research Challenge 2024

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

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