Background: About half of Minneapolis VA patients reside in rural areas, receiving their primary care at a Community Based Outpatient Clinic (CBOC). Although some CBOC’s are over 200 miles away, patients must travel to the Twin Cities for surgical services. 

Methods: The 167 consecutive patients who opted for telehealth postoperative visits were surveyed. Data collected included travel time and distance to the Minneapolis VA and their local CBOC, need for transportation assistance to the clinic/VA, complications as a result of telehealth and a 1-10 overall satisfaction score. 

Results: Respondents reported a mean + SD satisfaction score of 9.60 ± 1.20, with a mean cost savings of $51.94 ± $40.92, decrease in travel time of 99.4 ± 76.58 minutes and no post-surgical complications missed. 

Conclusions: The telehealth program appears to be safe, saves time and money for veterans and results in extremely high patient satisfaction.


Efficacy of Telehealth for Postoperative Visits at the Minneapolis VA

Background: While most births in the U.S occur in a hospital, out-of-hospital births have been increasing in popularity with one in every 61 births occuring at home or in a community birthing center. The fear of disrespect and loss of autonomy have been cited as primary drivers for planned home births with data showing higher rates of mistreatment occurring in hospital settings than at home. This was especially apparent for individuals who transferred from a community setting to the hospital after the onset of labor. Approximately 10% of home births will experience transfer to a hospital due to urgent and non-urgent reasons. Despite this, there are still no standardized guidelines for managing home birth transfers to hospital care which can lead to delays in receiving care. Additionally, there have been reports of significant opposition to home births among hospital-based clinicians (HBCs) which negatively impacts the birthing person’s experience with hospital births. 

Washington’s Smooth Transitions™ Quality Improvement Program aims to better understand the perceptions of birthing persons on transfers from planned community births to hospitals in order to identify barriers and areas of improvement. 

Methods: Smooth Transitions distributed an online mixed-methods survey to birthing persons upon discharge to capture lived experiences of home to hospital birth transfers in 17 Washington-based hospitals. Free response questions inquired about quality of care, overall birthing experience, and collaboration between the birthing care team. The data was coded for thematic content to identify best practices and potential areas of improvement.

Results: A total of 190 birthing persons completed the survey. 18% of these respondents felt that their personal preferences were not respected by the HBCs and 21% felt pushed into agreeing with care options. Birthing persons valued the HBCs respecting their autonomy, birth plan, and support team. Areas of improvement included shorter check-in times, allowing the community midwife to be present and more involved in care plans, and better patient education provided by the HBCs.

Conclusion: Birthing persons’ perceptions of transfers help us better understand opportunities for improving their experience with hospital births. Respondents self-reported various levels of disrespect, lack of autonomy, and inadequate informed consent by HBCs which were exacerbated by patient-provider disagreements around care plans. Further efforts need to be made to understand and reconcile the goals of care for HBCs, patients, and their support team. This will help to create a best practices guideline for these transfers and improve maternal and fetal health outcomes.

Patient Perceptions on Transfers from Planned Community Births to Hospital care in Washington State

Background: Breast cancer is the second most common cancer amongst women in the United States. From 2013 to 2018, the breast cancer death rate fell by 1%; this decline was attributed to earlier screening and awareness. Early diagnosis of breast cancer can reduce morbidity and the intensity of treatment plans (ex: chemotherapies). There are many different screening tests to predict 5 year and lifetime risk of breast cancer. These screening tests and software programs have large variabilities in their risk prediction. Recent publications show a 5% to 19% overdiagnosis of breast cancer in women. In this study we predicted the 5-year risk, 10-year risk, and lifetime risk of breast cancer for mammogram patients using four different breast cancer screening tools: Mammorisk, Tyer Cuzick 2013 (TC 2013), Tyer Cuzick 2017 (TC 2017), and Gail. We compared their variability using t test statistical analysis. The purpose of our study is to determine the precision of these screening tests and begin streamlining the screening process for breast cancer. 

Methods: We collected Mammorisk data from 242 participants at Southwood Imaging (Youngstown, OH) who came in for their annual mammogram. Most women were between 40 to 70 years old. While participants waited to be screened, we asked them to fill out a questionnaire. The questionnaire contained 19 questions about the patient’s personal health, prior breast biopsies, and family history of breast cancer. We put this additional patient information into the additional screening tests Tyer Cuzick 2013, Tyer Cuzick 2017, and Gail. We calculated the 5-year risk and lifetime risk for each patient. We then measured the 5-year risk, 10-year risk, and lifetime risk assessment using t-test statistical analysis (two tailed). 

Results: The 5-year risk did not significantly differ between breast cancer risk models. The 10-year risk did not significantly differ between breast cancer risk models. The results showed statistically significant differences between lifetime risk for breast cancer risk models. Mammorisk and TC2017 lifetime risks differed by 0.544. The difference in percent lifetime risk between the Mammorisk and TC2013 models was -2.666. Mammorisk and Gail lifetime risks varied by 0.104. Even though our lifetime risk data was significant, the effect size was low . So some of our data may be inconclusive.

Conclusion: Our study indicated a lack of significant difference in 5-year and 10-year risk between models, but lifetime risk did significantly differ between breast cancer risk models. This creates variability that is difficult for physicians to interpret. This can affect physicians’ decision making and future patients’ health outcomes. Additional studies with a larger and more diverse population are needed for definitive evidence in variability between breast cancer risk models. Our study is a first step in finding a streamlined way to approach breast cancer risk in patients. In creating a streamlined approach radiologists will be able to care for cancer patients in a more organized manner.

Variability Between Different Breast Cancer risk Models and Effects on Various Parameters

Background: Many medical schools have begun including health systems science (HSS) in their curricula to address emerging healthcare needs. With this principle in mind, a clinical reasoning exercise was developed by the Johns Hopkins neurology clerkship team in 2017. Students are given a standardized case of a patient presenting with falls and asked to develop an assessment & plan. During the COVID-19 pandemic, Johns Hopkins replaced tiered grading (honors/high pass/pass/fail) with pass/fail grading for core clerkships. This study seeks to determine if clerkship grading (tiered versus pass/fail) influences the quality of the differential diagnoses, localization of the disease process, clinical reasoning, and diagnostic/management options.

Methods: Data was extracted from the case reports submitted by students in the Neurology clerkship between 2017 and 2022. Report elements in tiered versus pass/fail curricula were compared using chi-squared tests.

Results: Of the 592 students, 306 (51.7%) were in the tiered curriculum, and 286 (48.3%) were in the pass/fail curriculum. With respect to differential diagnoses, students were more likely to include drug-induced parkinsonism (p<0.05) in the tiered system, and Lewy body dementia (p<0.05) in the pass/fail system. The inclusion of other diagnoses was not significantly different between the two systems. For localization, students were more likely to localize to the substantia nigra specifically (p<0.05) in the pass/fail compared to tiered system. Clinical reasoning elements like dysautonomia and timing (p<0.05) were cited more in the tiered system, while discussion of REM sleep behavior was not significantly different between the two systems. Students were more likely to order labs but less likely to order imaging (p<0.05) in the tiered versus pass/fail system. Lastly, for management, students were more likely to request outside consultations/referrals, initiate physical therapy, stop metoclopramide, and treat urinary symptoms and hypotension (p<0.05) in the tiered versus pass/fail system. Treatment with carbidopa-levodopa did not significantly differ between the two systems.

Conclusion: Although clerkship grading does not appear to influence differential formation or clinical reasoning strongly, it does influence diagnostic testing and management choices. Tiered grading correlates with aspects of HSS, including value-based care (deferring imaging, stopping metoclopramide) and interprofessional collaboration (consults, physical therapy).

Looking Backwards to Look Forward: An Analysis of Clinical Reasoning Reports in the Neurology Core Clerkship before and after the transition to Pass/Fail Grading

**Scoring is only possible in the semifinals hall**

**Abstract:**



Evaluating Demographic Reporting in Publicly Available Prostate MRI Data Sets

Robotic assisted surgery (RAS) is a form of minimally invasive surgery. During RAS, surgical instruments are connected to a robotic system that is controlled by a surgeon located at an isolated console. Although RAS has advantages such as faster recovery times and less post-operative pain for patients, there are challenges that the technology brings to the operating room such as changes in workflow and space constraints. Therefore, we sought to understand expert perspectives on current and future challenges of surgical team members during the use of RAS. This study aims to identify expert perceptions of RAS for potential future opportunities and improvements for RAS workflow. In-person observations were conducted to learn more about the overall process and workflow of RAS. Focus groups were conducted with eleven surgical techs, eight circulating nurses, and two medical administrations. The focus group questions were used for insights on staff demographics, RAS experience between different hospitals, built environments, training, and interactions. These results were then used to perform a thematic analysis, and the following themes emerged: training, usability, communication, environment, management, and scheduling. These themes were further broken down into subthemes. Definitions and quotes were used to help define each subtheme. Further thematic analysis needs to be conducted to gain additional perspectives from other RAS operating room team members.

Integrating Expert Perspectives On Current and Future Challenges for Robotic Assisted Surgery (RAS) Workflow

Introduction-
The internet has become a prominent tool for patients, with an estimated 80% of Americans having turned to the internet for health information. The Literacy Project proports that over half of Americans would struggle to read a book written beyond an 8th grade reading level. Studies have found association between poor patient understanding and worse outcomes and decreased patient satisfaction.

To combat these issues related to the readability of patient education materials, The American Medical Association (AMA) recommends patient health information be written at a 6th grade reading level. Previous studies into the readability of online patient information on a wide variety of topics have revealed much online patient education materials surpass this recommendation. With one recent study of the readability of online patient information on the topic of appendectomies was 12th-14th grade, well beyond the abilities of the average American reader and AMA recommendations. 

Because caring for a surgical wound is a prolonged process and often involves at home care, online resources on this topic may particularly useful to patients. Despite this, investigations into the readability of these sources are lacking. This study provides formal assessment of the current state of the readability of online patient education materials on the topic of surgical wound care.

Methods-
A google search for “surgical wound care” was done with a cleared browser. The first 30 results to meet criteria were analyzed. Advertisements, audiovisual resources, and scientific/professional articles were excluded.

The analysis tool readable.com was used to obtain Flesch Kincaid Grade Level Scores and Gunning Fog Index Scores (measures of grade level required to read) as well as Flesch Reading Ease Scores (measure of general ease of read). Average scores with 95% confidence intervals were calculated to compare to recommended reading levels. Associations between readaility and source were also explored.

Results-
Average Flesch Kincaid Grade Level Score was 6.8 95% CI [6.1, 7.5] and average Gunning Fog Index Score was 8.9 95% CI [8.1, 9.7]. The average Flesch Reading Ease Score was 65.3 95% CI [60.9, 69.7], with scores over 60 indicating overall easy readability. Only 10% (3/30) Flesch Reading Ease Score were above 80. (12/30) met AMA recommendations by Flesch Kincaid grade scores, but none met AMA recommendations by Gunning Fog Index Score. 

Information sources could be categorized as; health information websites, government affiliated organizations, hospitals/health systems, private clinics, and others (ie- insurance company). These categorizations aren’t completely mutually exclusive.

There was no statistical difference in scores between organizations with/without government affiliation. 

Conclusions-
Flesch Kincaid Grade Level Scores indicated nearly half (12/30) met AMA criteria, but Flesch Reading Ease Scores and Gunning Fox Grade Level Scores indicated 3/30 and 0/30 met AMA guidelines, respectively. While this is considerable variance, it resulted from a difference of only 2.1 grade levels between average scores of the different grade level calculation methods. Additionally, half of all materials were still within 2.3 grade levels of AMA recommendations based on Gunning Fox Grade Level Scores. Taken together, this likely indicates that there is a proportion of patient information materials that meet AMA guidelines, but the majority still do not meet AMA recommendations and a significant number of people would likely have some trouble with them. 

While there is inherent complexity to medical topics, there are many simple ways to improve the readability of any writing. These include things like removing unnecessary words and breaking up longer sentences. Given the large number of patient education materials within a couple grade levels of the AMA guideline, simple modifications to writing techniques like these may bring a significant proportion into compliance.


Readability Assessment of Online Patient Education Materials on Surgical Wound Care

Depression and Anxiety - Diagnosis and Management in Primary Care:
Alternate Therapy Modalities: A Review

Background 
Due to the harmful effects of unmet social needs on patient health outcomes, professional societies currently recommend providers in all healthcare settings screen patients for social risk factors. Unfortunately, current literature shows that patients with social risk factors have difficulty accessing primary care and have increased preventable emergency care utilization. Limited research is available to determine if ambulatory clinics adequately capture vulnerable populations. This study compares the prevalence of social risk factors among patients screened in primary care clinics to the prevalence of those factors in Connecticut in general to determine if vulnerable populations are receiving ambulatory care.

Methods 
Researchers reviewed data from screenings performed from 9/13/2021 to 5/6/2022 at 3 primary care clinics in Connecticut. Volunteers screened patients for social risk factors using the Protocol for Responding to and Assessing Patients’ Assets, Risk, and Experiences assessment tool. To determine the screening’s effectiveness; the measured prevalence of unemployment, food insecurity, low educational attainment (no GED equivalent), utilities stress, homelessness, and decreased English fluency was compared to state-wide prevalence of those factors. Investigators determined the state-wide prevalence of utilities stress and homelessness through finding the proportion of the population that received CT Energy Assistance Program benefits or contacted the CT Coordinated Access Network in need of housing assistance. Government data published between 2019 and 2021 provided the prevalence of all other factors. Researchers compared the prevalences using Chi-Square Tests of Independence with a p-values of <0.05.

Results
Volunteers screened 2,150 patients. Analysis found no significant difference between the state-wide prevalence of educational attainment (8.9% vs. 8.7%, p=0.79), utility stress (5.8% vs. 5.7%, p=0.87), food insecurity (4.2% vs. 4.7%, p=0.21), and decreased English fluency (10.0% vs. 10.3%, p=0.61) and the prevalence of those factors among patients screened. Patients screened had a significantly higher prevalence of unemployment (9.2% vs. 6.3%, p<0.05) and homelessness (3.0% vs. 1.3%, p<0.05) compared to the state overall.

Conclusion 
Although current literature shows that vulnerable populations experience barriers to receiving primary care and have increased utilization of emergency care, our study found that the prevalence of social risk factors among patients seen in ambulatory clinics was similar to, if not higher than, the prevalence of those factors in the state overall. This indicates that ambulatory clinics adequately capture vulnerable populations. Results argue that the screening performed was effective in identifying social risk factors and that ambulatory clinics could be an adequate site for targeted interventions. Generalizability of these results to other states, pediatric populations, and specialty clinics may be limited as the screenings reviewed were performed with adults at primary care clinics in Connecticut.

Social Determinants of Health Screening Demonstrates that Vulnerable Populations Do Receive Ambulatory Care

**Objective** The Agency for Healthcare Research and Quality
(AHRQ) Evidence-based Practice Center (EPC) Program
produces rigorous and comprehensive systematic reviews that
are posted on the Effective Health Care (EHC) website. To
improve presentation, user experience, and accessibility of
reports and their findings, a redesign of the EHC website was
implemented to display important systematic review
elements through interactive tools presented on a clean and
easy-to-use webpage. 
 **Design** The interactive site was initially designed by the
Scientific Resource Center (SRC) before being piloted by the
American Institutes for Research among clinical and other
stakeholders within 6 large learning health systems. The SRC
incorporated findings from pilot activities to update the site
design, and the EPC Program is now implementing this new
web-based design that prioritizes interactive data
presentation and end-user inquiry-based exploration of
findings. 
 **Results** To date, 7 EPC systematic reviews had been
transformed into interactive formats and were live on the
EHC website, with additional reports being added as
available. Three elements improved accessibility of report
findings and are key features in implementation of the site
redesign: Main Findings (summary bullet points), the Visual
Dashboard (interactive graphs and tables designed in
Tableau), and the Report Snapshot. The Main Findings allow
end users to get the bottom line with minimal time
investment. The Visual Dashboard offers customizable data
visualizations, allowing end users to explore data relevant to
their clinical decision-making or research questions. For
users who prefer a more text-based presentation, the Report
Snapshot displays data and summary statements within a
table. Both the Visual Dashboard and the Report Snapshot
hyperlink specific data points to the underlying studies on
PubMed. These design elements address end users’ need to
quickly identify key messages and evaluate the data according
to their own needs and questions, whether these users are
health system leaders, practicing clinicians, guideline
developers, or researchers. 
 **Conclusions** The EHC website redesign offers users
multiple methods to explore the findings from AHRQ EPC
reports in an accessible and dynamic format. The
implementation of the redesign will incorporate the peer
review process to improve the quality of reporting. Evidence
producers of all types should begin to better meet the
informational needs of evidence consumers by moving away
from flat-file presentation of findings toward more interactive
and web-based displays. 
 **Conflict of Interest Disclosures** None reported. 
 **Funding/Support** This work was funded by the AHRQ EHC
Program through a contract to the SRC (HHSA 2902017003C).
The authors of this manuscript are responsible for its content.
Statements in the manuscript do not necessarily represent the
official views of or imply endorsement by the AHRQ. 
 ![](https://assets.underline.io/uploads/markdown_image/1/image/4eafff7f27e425b6236f700d6be6f72d.png)

Redesigning Web-based Presentation of Agency for Healthcare Research and Quality Evidence-based Practice Center Program Systematic Reviews

**Objective** Conflicts of interest in systematic reviews (SRs)
have gained recognition,1,2 but overall knowledge is limited,
in particular from a clinical perspective. This study addresses
financial conflict of interest (fCOI) statements in SRs relevant
to primary care. 
 **Design** A cross-sectional study of SRs published in 2010 and
2019 that evaluated interventions for 6 common diagnoses
was designed. The diagnoses covered a substantial range of
primary care specialties: chronic obstructive pulmonary
disease, type 2 diabetes, hypertension, dementia, major
depressive disorder, and osteoarthritis. PubMed was searched
by a librarian in June 2021. Two independent researchers
selected relevant SRs; any disagreements were resolved in
consensus. Basic characteristics and data on fCOI and
funding were extracted from full-text versions of SRs. The
SRs of authors disclosing fCOI or reporting funding from the
industry were categorized as “yes.” The SRs of authors
declaring no fCOI and reporting no funding from the industry
were categorized as “no.” Missing information either on
authors ́ disclosure of conflicting interests or information on
funding of the SRs was categorized as “information missing.”
A random sample of 50 SRs per fCOI category (“yes,” “no,” or
“information missing”) was drawn, and data on fCOI and
funding of the primary studies reported in these 150 SRs were
extracted. 
 **Results** Of 2234 initially retrieved records, 746 (33%)
relevant SRs were included. Diabetes and pharmacological
interventions were the most common topics: 186 of 746 SRs
(25%) for diabetes and 247 of 746 (33%) SRs for
pharmacological interventions. Most often the first author
was affiliated with an institution in China (130 [17%]). The
number of relevant SRs increased 4-fold, from 156 in 2010 to
590 in 2019. In 2010, 38 (24%) SRs fulfilled the criteria for
the fCOI “yes” category vs 109 (18%) in 2019 (**Table 29**). For
osteoarthritis, the pattern was the opposite, with 3 (13%)
categorized as “yes” in 2010 and 28 (23%) in 2019. The
largest proportion of the fCOI “yes” category was noticed for
depression, with 12 (34%) SRs in 2010 and 27 (32%) in 2019.
In 2010, 57 (37%) SRs were categorized as “information
missing” vs 120 (20%) in 2019. The only exception was for
hypertension, with 7 (24%) SRs in 2010 vs 28 (36%) in 2019.
Of the random subsample of 150 SRs, 30 (20%) reported data
on fCOI or funding for the included primary studies. 
 ![](https://assets.underline.io/uploads/markdown_image/1/image/1aef13c06e6a4f10ee52c89c524a4d87.png) 
 **Conclusions** The proportion of SRs disclosing fCOI or
funding from industry was lower in 2019 compared with 2010
but was still missing in every fifth SR, with a direct clinical
association with primary care. Risk factors for these
shortcomings need to be identified, and given this, policies of
journals are notable. Only a few SRs reported data on fCOI
among the included primary studies. 
 **References**
1. Hakoum MB, Anouti S, Al-Gibbawi M, et al. Reporting of
financial and non-financial conflicts of interest by authors of
systematic reviews: a methodological survey. BMJ Open.
2016;6:e011997. doi:10.1136/bmjopen-2016-011997 
 2. Hansen C, Lundh A, Rasmussen K, Hróbjartsson A.
Financial conflicts of interest in systematic reviews:
associations with results, conclusions, and methodological
quality. Cochrane Database Syst Rev. 2019;8(8):MR000047.
doi:10.1002/14651858.MR000047.pub2 
 **Conflict of Interest Disclosures** None reported. 
 **Funding/Support** The project was supported financially by the
Center for Clinical Research Dalarna, Falun, Sweden. 
 **Role of the Funder/Sponsor** The funder did not have any role
in the design and conduct of the study; collection, management,
analysis, and interpretation of the data; preparation, review, or
approval of the abstract; and decision to submit the abstract for
presentation.

![](https://assets.underline.io/uploads/markdown_image/1/image/a211c2f7797199ab257e2fe7efe76e27.png)

Underline digital video library

Efficacy of Telehealth for Postoperative Visits at the Minneapolis VA

Patient Perceptions on Transfers from Planned Community Births to Hospital care in Washington State

Variability Between Different Breast Cancer risk Models and Effects on Various Parameters

Looking Backwards to Look Forward: An Analysis of Clinical Reasoning Reports in the Neurology Core Clerkship before and after the transition to Pass/Fail Grading

Evaluating Demographic Reporting in Publicly Available Prostate MRI Data Sets

Integrating Expert Perspectives On Current and Future Challenges for Robotic Assisted Surgery (RAS) Workflow

Readability Assessment of Online Patient Education Materials on Surgical Wound Care

Depression and Anxiety - Diagnosis and Management in Primary Care: Alternate Therapy Modalities: A Review

Social Determinants of Health Screening Demonstrates that Vulnerable Populations Do Receive Ambulatory Care

Redesigning Web-based Presentation of Agency for Healthcare Research and Quality Evidence-based Practice Center Program Systematic Reviews

Conflict of Interest in Published Systematic Reviews on Interventions for 6 Common Clinical Diagnoses, 2010-2019

See you never: Predicting patient readmissionas a preventative and cost-effective measure

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