Abstract
ACA: Healthcare Economics for Academic and Private Practice
Jerome W. Thompson, MD, MBA (presenter)
The Affordable Care Act and economic stresses have forced an evolution in the way we practice medicine. Many academic physicians have had to move their practices into partnerships with hospitals that have made them little more than relative value unit generators. Many private practitioners have faced the same fate, because of decreased reimbursement, rising overhead, and federal requirements. Most are unaware of the economic motives of the universities, hospitals, and government. Nor are they aware of the mechanisms at work to achieve their goal of a single payer. I will discuss the current structure of the practice of medicine, as it was, as it is, its problems, and the attempted solutions. The future of our specialty rests in otolaryngologists’ and other physicians’ understanding these forces and then learning how to adapt—not just to survive but to thrive in the coming world.
Affordable Care Act Expanded Coverage Provision in Otolaryngology
Stephen R. Chorney, MD (presenter); Richard T. Kelley, MD
Objectives: In 2009, the expanded coverage provision within the Affordable Care Act allowed millions of young adults to remain beneficiaries under their parents’ insurance until the age of 26. However, the clinical impact of this extension is unknown, particularly as it relates to otolaryngology-specific outcomes. To begin assessing this expansion, we analyzed emergency department (ED) visits for tonsillitis, sinusitis, and otitis media as a proxy for health care access.
Methods: Retrospective review at a tertiary care ED from 2007 to 2014 of young adults 19 to 25 years old and adults 26 to 34 years old. Primary outcomes were incidences of these diagnoses with secondary outcomes of insurance status and complication rates.
Results: Diagnoses of tonsillitis decreased significantly in the 19- to 25-year-old group (2.60% vs 2.27%, P = .024), whereas those of sinusitis (0.587% vs 0.445%, P = .04) and otitis media (0.576% vs 0.428%, P = .031) decreased significantly in the 26- to 34-year-old group. Public insurance coverage increased significantly in both groups as did decreases in ED visits for the uninsured. After 2009, 19- to 25-year-olds continued to have higher uninsurance rates compared with 26- to 34-year-olds (19.8% vs 15.6%).
Conclusions: The expanded coverage reduced utilization among 19- to 25-year-olds for tonsillitis but not for sinusitis or otitis media compared with adults 26 to 34 years of age. With approximately 20% of young adults presenting to the ED without insurance for these common otolaryngologic problems, further efforts are needed to insure these individuals under the Affordable Care Act.
Clinical Evidence Supporting FDA Approval of Novel Drugs and Devices
Vinay K. Rathi (presenter); Bo Wang, PharmD; Joseph S.Ross, MD, MHS; Nicholas S. Downing, MD; Aaron S. Kesselheim, MD, JD, MPH; Stacey T. Gray, MD
Objectives: (1) Describe the pivotal clinical evidence required for Food and Drug Administration (FDA) approval of pharmaceuticals and high-risk devices, which are subject to different statutory standards of review. (2) Characterize variations in the strength of clinical evidence supporting FDA approval of novel otolaryngic therapeutics.
Methods: The FDA approves novel prescription pharmaceuticals and high-risk devices on the basis of premarket pivotal clinical studies designed to demonstrate safety and efficacy. We conducted a cross-sectional analysis using publicly available FDA documents to characterize the strength of clinical evidence supporting recently approved (2005-2014) drugs and devices indicated for conditions treated by otolaryngologists or their multidisciplinary teams. Pivotal studies were categorized by the following design features: enrollment, randomization, blinding, comparator, and primary endpoint.
Results: Between 2005 and 2014, the FDA approved 19 otolaryngic drugs (31 pivotal studies; median per approval = 1, interquartile range [IQR] = 1-2) and 14 devices (16 pivotal studies; median per approval = 1, IQR = 1-1). Median enrollment was 233 patients (IQR = 108-330) in pivotal drug studies, nearly all of which were randomized (97%), blinded (81%), and designed to compare against active/placebo treatment (94%). Median enrollment was 122 patients (IQR = 100-216) in pivotal device studies, at least half of which were randomized (63%), blinded (63%), and designed to compare against active/placebo treatment (50%). Most pivotal studies used clinical outcomes/scales as primary endpoints to assess drug (74%) and device (88%) therapeutic benefit.
Conclusions: The strength of clinical evidence supporting FDA approval of otolaryngic drugs and devices differed widely. Otolaryngologists should consider variations in premarket evidence while helping patients make informed treatment decisions about newly approved therapeutics.
ENT vs. General Surgery Tracheotomy Experience in Residency
David Lesko (presenter); Ceisha Ukatu, MD; Jason Showmaker, MD; C.W. David Chang, MD
Objectives: (1) Analyze recent trends in otolaryngology and general surgery tracheotomy training. (2) Recognize significant decline in tracheotomy case numbers among otolaryngology residents.
Methods: Aggregate Accreditation Council for Graduate Medical Education data from 2004 to 2014 for graduating residents in otolaryngology and general surgery were obtained and analyzed with Excel. Average graduating otolaryngology resident tracheotomy case numbers were derived from summing “resident surgeon,” “assistant surgeon,” and “resident supervisor” average resident numbers. Average graduating general surgery resident tracheotomy case numbers were derived from summing “surgeon chief” and “surgeon junior” average resident numbers.
Results: (1) From 2004 to 2014, the average number of tracheotomies performed by otolaryngology residents declined at 2.59% per year, from 81.3 to 64.2 cases, with residents functioning in a leading role (resident surgeon or resident supervisor) in 88.8% of cases. (2) Average number of tracheostomies performed by general surgery residents increased at 1.82% per year, from 12.5 to 14.7 cases. (3) Total tracheotomies performed by graduating otolaryngology residents significantly decreased, whereas total tracheotomies performed by graduating general surgery residents significantly increased.
Conclusions: Current graduating otolaryngology residents have a robust experience in tracheotomy. However, over the past 10 years, tracheotomy case volume in otolaryngology residency has decreased steadily in comparison with general surgery residency on a national scale. Care must be taken to ensure that future otolaryngology residents have sufficient volume to obtain proficiency at performing tracheotomy prior to graduation.
Modifiable Applicant Characteristics in the Otolaryngology Match
Vivian Nguyen; Leah Hauser, MD; Grant Gebhard, MD; Cristina Cabrera-Muffly, MD (presenter)
Objectives: (1) Determine whether modifiable applicant characteristics such as type of research publications and letter of recommendation attributes correlate with match rates among otolaryngology residency applicants. (2) Determine whether clerkship grades, class rank, languages spoken, and hobbies correlate with match rates among applicants.
Methods: Applications to an allopathic otolaryngology residency program between 2011 and 2013 were analyzed. Of the 1018 applicants, 952 first-time applicants were included. Modifiable applicant characteristics were compared with match rates to determine correlation. Characteristics included types of research publications, recommendation letter attributes, clerkship grades, and hobbies.
Results: Match rates did not correlate with increased numbers of peer-reviewed publications, first author publications, or poster presentations. Applicants with more letters of recommendation from otolaryngology chairs (P < .001) and other otolaryngologists (P = .006) were more likely to match, whereas those with more letters from other surgical specialties (P < .001) and nonsurgical specialties (P < .001) were less likely to match. Applicants with lower grades in surgical clerkship, medicine clerkship, and lower class rank were less likely to match (P < .001, P = .002, and P < .001, respectively). Applicants who spoke more languages had a decreased match rate (P = .003). When evaluating hobbies, the only activity that increased match rate was sports and exercise (P = .03).
Conclusions: Modifiable applicant characteristics, including recommendation letter attributes, clerkship grades, and certain types of hobbies, correlate with match rates to otolaryngology residency. Knowledge of which characteristics are correlated with matching allows for more effective advising of medical student applicants.
Time-Related Outcomes of Dedicated Otolaryngology Consult Service
Ronald J. Schroeder II, MD (presenter); Brian D. Nicholas, MD
Objectives: (1) Compare time-related outcomes of a dedicated otolaryngology consult service to a hospital-based service. (2) Compare time-related outcomes of different otolaryngology consults.
Methods: A retrospective review of time-related outcomes of otolaryngology consults at SUNY Upstate University Hospital were reviewed from March 1, 2014, to January 9, 2016. Time-related measures were extracted from our electronic medical record, which included time consult order placed, time note started, and time note signed. As of July 1, 2015, our department changed to a dedicated consult service during weekdays from 7
Results: A total of 699 otolaryngology consult encounters (574 emergency department [ED], 125 floor) were included. A total of 489 consults (399 ED and 90 floor) were seen prior to July 1, 2015, with a hospital-based service, and 210 consults (175 ED and 35 floor) were seen after with a dedicated consult service. For all consults, the consult service was quicker to start and sign consult notes (1.77 hours vs 2.56 hours, P < .001; 3.34 hours vs 4.68 hours, P < .001, respectively). When separated into ED and floor consults, the consult service was quicker to start and sign both ED consult notes (1.83 hours vs 2.34 hours, P = .001; 3.45 hours vs 4.44 hours, P = .001, respectively) and floor consult notes (1.49 hours vs 3.55 hours, P = .002; 2.76 hours vs 5.80 hours, P = .001, respectively).
Conclusions: This is the first study looking at time-related outcomes of a dedicated otolaryngology consult service. This new approach was more efficient in seeing and documenting consults than a hospital-based service. This may translate into better communication between hospital services improving patient care and satisfaction.