UT Southwestern Medical School

Permanent URI for this collectionhttps://hdl.handle.net/2152.5/6690

Welcome to the UT Southwestern Medical School’s electronic theses and dissertations (ETD) collection.

Most UT Southwestern ETDs are subject to a default embargo period of two (2) years from the date of degree conferral. These embargoed ETDs are unavailable until the embargo expires.

It might be possible to contact the author for more information before the end of the embargo. For assistance or more information, please contact the UT Southwestern Medical School Dean’s Office by email.

To verify whether an ETD is available or if you have other questions, please contact etd-utsw@utsouthwestern.edu.

Print theses and dissertations from 1943 to 2004 are located in the Library's Special Collections and Archives (Room E3.314) and are available by appointment. (Note: Former students may request a digitized copy of their work by email, but other users may submit an Interlibrary Loan request.) For more information, contact archives@utsouthwestern.edu.

Browse

Now showing 1 - 20 of 241

Improving Intra-Operative Parathyroid Hormone Result Times at the University Hospitals
(2022-05) Wang, Virginia Y.; Reed, W. Gary; Nwariaku, Fiemu; Holt, Shelby A.
Intra-operative parathyroid hormone (ioPTH) levels are the current gold standard for assessing completeness of resection in parathyroidectomy surgery. Due to the time-sensitive nature of these results, delays in processing ioPTH samples lead to non-value-added time (NVAT) in the operating room, which generates unnecessary financial burdens and potential safety hazards for both patients and the hospital system. Baseline analysis of data from 191 parathyroidectomy cases performed by the UT Southwestern Endocrine Surgery Group at Clements University Hospital (CUH) and the Outpatient Surgery Center (OSC) between September 2020 and April 2021 identified a statistically significant delay in the sample-to-lab interval time in cases at the OSC (mean of 27 minutes) compared to cases at CUH (mean of 8 minutes). The need for a lab courier at the OSC is likely a major contributor to this NVAT, as the OSC does not have an in-house lab. Though altering the lab infrastructure to make in-house ioPTH processing at the OSC would be the most effective way to equalize the delay, it was also infeasible within the time constraints of this project given the depth of high-level decision-making this would necessitate. I chose to focus instead on optimizing parathyroidectomy case preparation. I worked with CUH OR nursing clinical leads to modify the Epic template text of surgeon preference cards, which OR nursing staff use to prepare for cases. Analysis of pre- and post-change data from 43 parathyroidectomy cases performed in February and March of 2022 at CUH revealed post-change special cause variation in both the sample-to-lab and lab-to-result interval times. Moving forward, many other interventions are available to continue to improve team communication and knowledge sharing and protocolize contingency plans; further work also remains to be done to address logistical constraints at the OSC on an institutional level.
The UT Southwestern Perioperative Optimization of Senior Health Program: Impact on Postoperative Delirium After Spine Surgery
(2022-05) Pernik, Mark Nicholas; Bagley, Carlos; Aoun, Salah; Adogwa, Owoicho
BACKGROUND: Delirium is a common complication in geriatric patients who often have multiple underlying risk factors after surgery or hospitalizations. Delirium is most effectively prevented prophylactically, as treatment of delirium may not shorten the duration or severity of delirium. Several investigations of pharmacological prophylaxis have shown minimal effect, whereas many non-pharmacological interventions have been shown to reduce the incidence of delirium. Multicomponent nonpharmacologic interventions can be effective in preventing delirium; however, implementation of preventative measures and programs are variable in perioperative care. OBJECTIVE: The aim of our study was to assess whether the Perioperative Optimization of Senior Health Program (POSH) reduced the incidence of postoperative delirium in geriatric patients undergoing elective spine surgery. METHODS: The POSH program is an interdisciplinary perioperative program involving geriatrics, surgery, and anesthesia. Preoperatively, patients enrolled in POSH (n=147) were referred for a geriatric assessment and optimization for surgery. Intraoperatively, patients underwent an individualized geriatric anesthesia protocol. Patients were co-managed postoperatively by the primary surgical team and the geriatrics consult service. POSH patients were retrospectively compared to a matched historical control group (n=177) treated with standard care. Outcomes included post-operative delirium, provider recognition of delirium, ICU and hospital LOS, initiation of walking postoperatively, and readmission. RESULTS: Patients enrolled in the POSH program were significantly older (75.5 vs. 71.5 years; p<0.001), had more comorbidities (8.0 vs. 6.6; p<0.001), and were more likely to undergo pelvic fixation (36.1% vs. 17.5%; p<0.001). The incidence of postoperative delirium was lower in POSH group compared to historical controls, although not statistically significant (11.6% vs. 19.2%; p=0.065). Delirium was significantly lower in patients who underwent complex spine surgery (≥4 levels of vertebral fusion; N=106) in the POSH group (11.7% vs. 28.9%, p=0.03). There was a 3-fold increase in the recognition of postoperative delirium by providers after program implementation, (76.5% vs. 23.5%; p=0.001). CONCLUSION: Interdisciplinary care for high-risk geriatric patients undergoing elective spine surgery may reduce the incidence of postoperative delirium and increase provider recognition of delirium. The benefit may be greater for those undergoing larger procedures.
Decreased Emergency Department Utilization by Lower Socioeconomic Status Population as a Result of the COVID-19 Pandemic
(2022-05) Plumber, Arifa; Chang, Mary; Marshall, Amanda L.; Idris, Ahamed H.
BACKGROUND: The SARS-CoV-2 (virus which causes COVID-19) pandemic has resulted in lower emergency department (ED) volumes. It precipitated business and school closures along with the implementation of physical distancing measures, which culminated in a Shelter-in-Place Order (SIPO) issued for a major urban area county in March 2020. OBJECTIVE: The objective of this study was to determine the effect of the COVID-19 pandemic on access to health care by patients of different socioeconomic status by examining differences in ED volume by zip code stratified by the SocioNeeds Index, a measure of socioeconomic need correlated with poor health outcomes. Our hypothesis was that decrease in patient visits due to the SIPO was not uniform across Dallas County but was based on socioeconomic need and proximity to Parkland's ED. METHODS: This retrospective chart review examines whether there was a quantitative change in patient visits to an urban, tertiary county hospital (Parkland or PMH) ED from 2019-2020 by zip code. The inclusion criterion was any ED visit from a patient with a zip code within Dallas County, and the exclusion criterion was any blank, alphanumeric, or PO box zip codes including zip codes located outside of Dallas County. The SocioNeeds Index, which rates each zip code by demographic factors relative to others in the county, was used as a proxy for the socioeconomic status of residents of each zip code. We mapped daily patient visits by zip code for four phases: Phase 1 was the three months preceding the first COVID-19 case's announcement in Dallas, Phase 2 began with the first COVID case, Phase 3 encompassed when the SIPO was in effect for Dallas County, and Phase 4 comprised the three months following the expiration of the SIPO. We compared this data to records over the same time period from the previous year to control for seasonal variation in the absence of a pandemic. RESULTS: There were 275,756 ED patient visits included in this study. We identified a statistically significant decrease in ED visits among patients from all zip codes during the pandemic: 24% between Phase 1 and 4 (p<0.0001) in 2020. Additionally, there was a decrease in visits after the first case in Dallas: Phase 2 (-14%, p<0.0001), Phase 3 (-41%, p<0.0001) and Phase 4 (-25%, p<0.0001) when compared to 2019 but an increase in visits (36%, p< 0.0001) in 2020 once the SIPO expired. Zip codes with highest SNI ranks (highest needs communities) were found to have greater reductions in visits during the SIPO and more sluggish recoveries after the expiration of the SIPO in comparison to those zip codes with the lowest needs. An examination of the geographic distribution of self-reported zip codes indicated that most communities in Dallas County saw a reduction in patient visits over Phases 2 and 3 (especially zip codes further from the ED) and an increase in visits during Phase 4 although not to pre-pandemic values. These changes, however, were not uniform across the county and were tied to socioeconomic factors and proximity of residence to PMH. CONCLUSION: Our hypothesis was supported by the results obtained: a significant decrease in ED visits was observed during the pandemic relative to a non-pandemic year among patients in most zip codes except those with the highest socioeconomic status, suggesting that the threat of the virus and SIPO deterred patients disproportionately from the higher socioeconomic needs communities from accessing healthcare. These results could have implications for future pandemic public health messaging and targeted outreach to communities with barriers to healthcare access.
HPV-Positive and HPV-Negative Vulvar Squamous Cell Carcinoma Are Biologically, but Not Clinically, Distinct
(2022-05) Kolitz, Elysha Megan; Wang, Richard; Mauskar, Melissa M.; Hosler, Gregory A.
BACKGROUND: Vulvar squamous cell carcinoma (VSCC) pathogenesis is traditionally defined by the presence or absence of human papillomavirus (HPV), but the definition of these groups and their molecular characteristics remains ambiguous across studies. OBJECTIVE: The hypothesis of this project was that HPV-positive and HPV-negative VSCC are distinct diagnoses with unique biomarkers and clinically distinct behaviors. The objective was to determine the clinical and biologic relevance of these two groups in VSCC. METHODS: A retrospective cohort analysis of 36 patients with invasive VSCC was performed where HPV status was determined using RNA in situ hybridization (ISH) and polymerase chain reaction (PCR). Clinical annotation, p16 immunohistochemistry (IHC), programmed death ligand-1 (PD-L1) IHC, HPV16 circular E7 RNA (circE7) detection, and RNA-sequencing (RNA-seq) of the cases was performed. RESULTS: A combination of ISH and PCR identified 20 cases (55.6%) as HPV-positive. HPV-status did not impact overall survival (HR: 1.36, 95% CI: 0.307 to 6.037, p=0.6857) or progression-free survival (HR: 1.12, 95% CI: 0.388 to 3.22, p=0.8367), and no significant clinical differences were found between the groups. PD-L1 expression did not correlate with HPV status, but increased expression of PD-L1 correlated with worse overall survival. Transcriptomic analyses (n=23) revealed distinct groups, defined by HPV status, with multiple differentially expressed genes previously implicated in HPV-induced cancers. HPV-positive tumors showed higher global expression of endogenous circular RNAs (circRNAs), including several circRNAs that have previously been implicated in the pathogenesis of other cancers. CONCLUSIONS: In summary, this retrospective cohort analysis did not detect clinical differences between HPV-positive and HPV-negative cases or an association with biomarkers, PD-L1 and circE7. The transcriptomic analysis of VSCC confirmed the biological distinction between these two groups in VSCC and suggested specific diagnostic and therapeutic targets for future studies, including several circRNAs.
Decisional Regret: Investigating the Patient Experience with Shared Decision Making as a Public Health Concern
(2022-05) Deme, Palvasha Reddy; Reed, W. Gary; Stutzman, Sonja; Adogwa, Owoicho
BACKGROUND: Among older adults (> 65 years old), adult spinal deformity (ASD) is a leading cause of disability, with a population prevalence of 60%-70%. Surgical referral for deformity correction is common despite the high rates of postoperative complications. Because surgery involves trade-offs between clear benefits and risks, the patient's perspective is essential in deciding whether or not to undergo surgery. LOCAL PROBLEM: The UT Southwestern Spine Center takes a multidisciplinary approach to the care of older patients through the implementation of the POSH (Perioperative Optimization of Senior Health) Program. This study will determine the prevalence of decisional regret in patients who have undergone spine surgery for symptomatic degenerative scoliosis and identify the root causes that may contribute to high decisional regret in these patients. METHODS: Older adults with a diagnosis of ASD who underwent spinal surgery at a quaternary medical center from January 2016 to March 2019, were enrolled in this study. Patients were categorized into medium/high or low-decisional regret cohorts based on their responses to the Ottawa decision regret questionnaire. Decisional regret assessments were completed 24 months after surgery. Using purposeful sampling we identified older adult patients who underwent deformity correction surgery between the aforementioned time period. We conducted semi-structured, in-depth interviews with six patients (average age 73 years old, 83% women, all white) and five spine surgeons (years in practice 3 - 11). Two investigators independently coded the transcripts using constant comparative method, as well as an integrative, team-based approach to identify themes. RESULTS: Four themes emerged from interviews with patients: (1) patients felt surgery was their only choice because they were running out of time to undergo invasive procedures; (2) patients mentally committed to surgery prior to the initial encounter with their surgeon and contextualized the desired benefits while minimizing the potential risks; (3) patients felt that the current decision support tools were ineffective in preparing them for surgery; and (4) patients felt that pain management was the most difficult part of recovery from surgery which wasn't discussed comprehensively by their surgeon/care team prior to surgery. Four themes emerged from interviews with surgeons: (1) although spine surgeons intuitively understood the concept of shared decision making, they varied substantially in their interpretations; (2) spine surgeons did not consider patients' chronological age as a major contraindication to undergoing surgery; (3) there is a goal mismatch between patients and surgeons in the desired outcomes from surgery, where patients prioritize complete pain relief whereas surgeons prioritize concrete functional improvement; and (4) spine surgeons felt that patient expectations from surgery were often established prior to their initial surgery visit, and frequently required recalibration. CONCLUSION: While the majority of older adults were appropriately counselled and satisfied with their decision, one-in-five older adults regret their decision to undergo surgery. Older adult patients viewed the decision to have surgery as time-sensitive, whereas spine surgeons expressed the need for recalibrating patient expectations and balancing the risks and benefits when considering surgery for older adults with symptomatic spinal deformity. These findings highlight the need for improved understanding of both sides of shared decision making which should involve the needs and priorities of older adults to help convey patient-specific risks and choice awareness.
Clinical Utility of the AJCC 8th Edition pT1 Subclassification and Impact on Practice Patterns in Stage I Seminoma
(2022-05) Badia, Rohit Reddy; Bagrodia, Aditya; Woldu, Solomon L.; Meng, Xiaosong
BACKGROUND: The American Joint Committee on Cancer 8th edition staging guidelines for testicular cancer established a 3 cm cutoff to subclassify stage T1 seminomas (<3 cm = pT1a and ≥3 cm = pT1b). The efficacy of this cutoff in predicting metastatic disease and impact on treatment patterns have not been studied. METHODS: We retrospectively reviewed patients with pT1 testicular seminoma in the National Cancer Database from 2004-2016. Receiver operating curves (ROC) were used to determine the efficacy of the 3 cm tumor cutoff in identifying metastatic disease, and multivariable regression was used to compute the effect of tumor size on the rate of adjuvant therapy among Stage I patients. RESULTS: 10,134 patients with pT1 seminoma were evaluated. The current size cutoff of 3 cm for subclassification did not exhibit high discrimination in identifying metastatic disease (area under ROC: 0.546). Surveillance has grown as the preferred treatment after orchiectomy - 32.1% in 2004 to 81.2% in 2015. However, the rate of adjuvant therapy for pT1, Stage I seminomas associated positively with tumor size even with adjustment for year of diagnosis. For tumors above 3 cm, the odds ratio stabilized around 1.9. By using the 3cm cutoff to guide adjuvant therapy, up to 85% of T1b patients may be overtreated. CONCLUSION: The 3 cm cutoff for subclassification of Stage I seminoma does not predict metastatic recurrence but is associated with increased receipt of adjuvant therapy. A 3 cm cutoff and the pT1a/b classification may therefore contribute to overtreatment in many young patients with a long life expectancy for whom minimizing adverse effects should be prioritized.
National Practices, Attitudes, and Training Surrounding Long-Acting Reversible Contraception Procedures for Adolescents
(2024-05) Edmondson, Shelby Nicole; Francis, Jenny K. R.; Sendelbach, Dorothy; DeSilva, Nirupama K.
BACKGROUND: Primary care for adolescents in the United States is predominantly provided by pediatricians. For these patients, sexual health and contraception are important parts of primary care. Despite this, pediatricians are often less comfortable providing contraceptive counseling and lack training to administer long-acting reversible contraception (LARC), a highly effective form of contraception. Medically- and socially- complex patients access to contraception is additionally limited, as they often receive much of their medical care in the hospital setting. Training pediatricians and pediatric hospitalists to effectively administer LARC in both outpatient and inpatient settings would increase adolescent access to sexual health care, including LARC. OBJECTIVE: This mixed-methods study aims (1) to quantitatively describe national practices and training for providing sexual health services, including LARC, in the inpatient setting and (2) to qualitatively characterize the attitudes of clinicians about the appropriateness of and training surrounding LARC procedures for adolescents in the inpatient setting to generate strategies to improve training for pediatricians. METHODS: For aim 1, pediatric providers across the nation were invited to complete an online REDCap survey to assess current LARC services at their institution, attitudes about desiring LARC services, and interest in LARC training. Descriptive frequencies were reported. For aim 2, focus group interviews of a subsample of survey participants were facilitated on Zoom to assess barriers and facilitators to sexual health services and training for these sexual health services in pediatric hospitals. Interviews were transcribed and coded using Nvivo. Discordance was resolved by consensus and thematic analysis was performed. RESULTS: Survey data (n = 610) indicated that inpatient LARC services are currently limited (12% and 19% of participants reporting IUDs and implants, respectively, administered inpatient at their hospital site). Among those at hospitals not currently placing LARC, many wished this service was available (43% for IUD and 37% for implant) and over half were willing to learn how to place LARC (49% for IUD and 56% for implant). From the interview data (n = 32), beliefs in the appropriateness of administering LARC to adolescents varied, but many believed it was appropriate in all settings, including inpatient as "every hospitalization is an opportunity to review healthcare maintenance, and contraception- that's healthcare maintenance for a teenager." Regarding training, lack of willingness to learn how to place LARC centered around lack of knowledge, skills, and resources for pediatricians and pediatric hospitalists. Although training opportunities are often available, they are usually elective and at inopportune times. Those who have successfully received training reported it occurring during scheduled training blocks and including instructions on confidentiality and billing. CONCLUSION: Some of the limited availability of LARC for adolescent patients can be attributed to limited contraceptive training for pediatricians and pediatric hospitalists. To expand access, training opportunities for pediatric trainees should be scheduled as part of mandatory didactics and include didactic, simulation, and clinical practice components that touch on logistic aspects including acquiring equipment, confidential counseling, and billing and documentation.
Improving Compliance via Education, Reminders, and Evaluating Physician-Patient Concerns in Glaucoma
(2022-05) Wang, Chuhan Carey; Kooner, Karanjit; Reed, W. Gary; Phelps, Eleanor
PURPOSE: To improve glaucoma treatment compliance via education, medication reminders, and understanding of patient and physician concerns. DESIGN: Prospective Comparative Case Series SUBJECTS: 194 consecutive eligible patients diagnosed with primary open angle glaucoma or ocular hypertension at a single academic center (92 male and 102 female) and 16 glaucoma specialists volunteered their responses. METHODS: All 194 eligible patients were interviewed regarding glaucoma knowledge, medication usage, concerns, and fears. They were counseled, given educational handouts, and reinterviewed after 4 weeks. All 16 glaucoma specialists were also surveyed regarding their concerns for their patients. MAIN OUTCOME MEASURE: Patient's knowledge of the basic premise of glaucoma, compliance to their medications, including concerns and fears of glaucoma in both patients and physicians. RESULTS: In this study, patients aged ≥ 65 years were more compliant than those < 65 years (76% vs 50%, p<0.05). In follow-up interviews of 125 (64%) patients, I found significant increase in glaucoma knowledge from 53% to 67% (p<0.05) and compliance from 77% to 94% (p<0.05). In addition, patients' major fear was becoming dependent on others (p<0.05), while physicians were more concerned about patients' ability to administer eyedrops and understanding of instructions (p<0.05). CONCLUSION: I found that patients aged ≥ 65 were more compliant. Our intervention improved patient compliance by 17 % and represents a potential model for glaucoma management. In addition, the disparity between patient and physician fears suggest that communication barriers must be addressed to improve patient care.
The 18-Month Curriculum: The Impact of Mixed Learning Clerkships
(2022-05) Kwon, Adelaide Jiwon; Sendelbach, Dorothy; Faulkner, Christopher; Tessnow, Alex
BACKGROUND: UT Southwestern implemented a new, 18-month, shortened pre-clerkship curriculum in the Fall of 2015 in order to increase the clerkship phase from 1 year to 18 months, beginning mid-second year. In keeping with this new curriculum schedule, it was necessary to combine MS2 and MS3 students on clerkships from January to June; during that time, both MS2 and MS3 students are on the same clerkship simultaneously, creating opportunities for informal near-peer learning. Each clerkship handles this mixing differently: some create mixed-year teams, others group students together with their peers, while still others do not create teams at all. OBJECTIVE: We are interested in determining the impact of mixing students on team dynamics, narrative assessments, and grades. HYPOTHESIS: Upperclassmen and underclassmen participating on the same clerkships in a mixed learning environment will report predominantly positive experiences but will have significant differences in their grades and narrative assessments compared to each other. METHODS: A tri-pronged approach was taken, looking at qualitative student perspectives, qualitative attending perspectives, and quantitative scores on de-identified student evaluations. In the first arm of the study, students in the classes of 2020 and 2021 were sent a voluntary survey seeking comments regarding their experiences on mixed clerkships and to indicate their interest in participating in a follow-up 30-minute focus group interview. Four purposeful focus groups of 4-5 students, two groups from each class, were interviewed to learn more about perceived advantages and disadvantages of mixed clerkships. Interviews were audio-recorded, transcribed, and coded for themes. Transcripts were validated by the interviewees and de-identified prior to analysis. In the second and third arms of the study, student evaluations from 2019 in the Internal Medicine, Pediatrics, and Psychiatry clerkships were gathered and de-identified. From these, 120 narrative assessments were randomly selected for qualitative analysis. Final grades and four scored skills were selected for quantitative analysis. Finally, de-identified quantitative data from 2015-2016, prior to the implementation of the 18-month curriculum, were analyzed for additional insights. RESULTS: In the first arm of the study, interviewees reported overall positive experiences with mixed clerkships. Common perceived advantages as an MS2 paired with MS3s included being able to ask "dumb" questions without being judged; being taught "practical" skills such as how to use the electronic medical record (EMR) and how to write a note; having fears allayed through candid discussions; and having a sense of camaraderie. Common advantages as an MS3 paired with MS2s included satisfaction in teaching MS2s and being motivated by MS2 enthusiasm. Perceived disadvantages were less commonly mentioned but still present, and mostly centered around fears of being compared by evaluators. In the second and third arms of the study, the mixed clerkships of Pediatrics and Psychiatry tended to show more significant differences in MS2 and MS3 evaluations than the non-mixed clerkship of Internal Medicine. However, this was highly nuanced, and there was some, but not consistent, division between differences observed in "learned" skills such as history-taking or note-writing and "inherent" skills such as professionalism or confidence. Comparison with students on the old curriculum also revealed significant differences with different MS2 and MS3 cohorts suggesting both positive and negative effects of the mixed learning environment on student evaluations. CONCLUSION: Overall, students reported more positive experiences and perceived advantages on mixed clerkships than negative experiences and disadvantages. However, attendings reported a higher proportion of significant differences between less and more experienced students on mixed clerkships. Despite this, the impact of cross-class comparison versus other factors, such as natural student improvement, contributing to these differences is unclear, and therefore mixed clerkships resulting from the 18-month curriculum have had a generally positive impact despite some negative effects. Further research, including research into other assessments of educational outcomes such as shelf exam scores as well as research into cross-clerkship comparisons, is needed to provide a fuller picture of the impact of these mixed clerkships.
Reducing Patient No-Show Rates in Diabetes Clinic
(2022-05) Jafri, Farzan Haider; Reed, W. Gary; Phelps, Eleanor; Gunasekaran, Uma
BACKGROUND: Patients missing scheduled appointments, or no-shows, is a pervasive issue across outpatient clinics. The estimated no-show rate among primary care clinics is estimated to be between 14% and 50% (Daggy, Lawley et al. 2010). In addition, no-shows are estimated to cost the US healthcare system $150 billion a year (Toland 2013). At many clinics no-shows have necessitated overbooking clinic slots to maintain efficiency (Muthuraman and Lawley 2008). However, patient no-shows themselves and the overbooking that no-shows necessitate causes problems for both the patient and provider. LOCAL PROBLEM: No-show rates have a number of adverse effects on the clinic, including at the Parkland Diabetes Clinic in Dallas, TX. This leads to longer wait times when all patients show, patient/provider/staff stress and frustration, and reduced clinical efficiency. No-shows and late cancellations can also lead to reduced patient access to care and potential increase in disease progression risk for those patients who fail to receive follow-up care. METHODS: This project used the PDSA cycle from quality improvement methodology. We started by analyzing the current situation at the diabetes clinic to determine the baseline no-show rate and the reasons for patient no-shows. Baseline data on no-shows were provided by Dr. Gunasekaran and Miriam Gomez-Wakeling; data was analyzed by Farzan Jafri. The scheduling process was mapped in an effort to identify inefficiencies in the scheduling process. Phone calls were then conducted with patients who no-showed in which a survey helped pinpoint reasons for no-shows. Using the process map and survey data, we brainstormed interventions to target root causes of no-shows at the clinic. PLANNED OR ACTUAL INTERVENTIONS: Our first intervention is ensuring that every patient receives a phone call reminder for their appointment. Our second intervention is limiting the degree to which the Patient Access Center, a call center, handles scheduling for the Diabetes clinic. RESULTS: Interventions were implemented in August 2020, and subsequent data collected from November 2020 to October 2021 was analyzed to determine changes in the no-show rate. The average no-show rate during this post-intervention period was ~22.2% ± 2.50 (t-test, p <0.05), a significant decrease from the baseline rate of ~31.9% ± 2.19. We predict this reduction will result in more consistent follow-up care, less risk of disease progression, and increased clinical efficiency. Our next step will be to transition our interventions into long-term sustainable solutions to maintain the lower no-show rate. CONCLUSIONS: Our project demonstrates that by following quality improvement methodology and the PDSA cycle, root causes for system inefficiencies can be targeted with site specific interventions. With support from leadership and buy-in from staff, these interventions can go on to positively impact the main problem being studied, or in our case the high no-show rate at the Parkland Diabetes clinic. While our specific interventions may not apply to every clinical context, the methods employed in this study can certainly be reproduced to target high no-show rates at other outpatient centers.
The Migraine Disability Assessment (MIDAS) as an Indicator of Resilience in Patients with Headaches
(2022-05) Hans, Avneet; Friedman, Deborah I.; Wakhlu, Sidarth; Dave, Hina
BACKGROUND: The Migraine Disability Assessment is a clinical tool to measure disability in migraine patients. However, Migraine Disability Assessment predicted disability does not always correlate with actual functional disability, with some high-scoring patients remaining high functioning, and some low-scoring patients having poor functional outcomes. Based on these observed discrepancies, we investigated whether the Migraine Disability Assessment was also an indicator of resilience. Our objectives were to correlate the degree of headache disability with measures of resilience, as quantified by the Conner Davidson Resilience Scale; determine whether the level of resilience modified the association between headache severity/frequency and disability; and assess the association between anxiety and depression with resilience in headache patients. METHODS: We prospectively recruited patients with primary headache disorders seen in an academic, tertiary Headache Medicine program between 02/20/2018 and 08/02/2019 to participate in this study. Each participant completed 5 validated measures in the clinic: Migraine Disability Assessment, Conner Davidson Resilience Scale, Patient Health Questionnaire-9, General Anxiety Disorder-7 and WHO Well-Being Index. RESULTS: Complete data were obtained and analyzed for 160 participants. Consistent with our hypothesis, the Conner Davidson Resilience Scale score was negatively correlated with total Migraine Disability Assessment score (r= -.0.21, p=0.0091), total General Anxiety Disorder-7 score (r= -0.56, p<.0001) and total Patient Health Questionnaire-9 score (r=-0.34, p<.0001). In participants with severe headache-related disability (Migraine Disability Assessment > 21), logistical regression models showed negative associations between resilience and headache-related disability, anxiety and depression. A one point increase in the Conner Davidson Resilience Scale score decreased the odds of being severely disabled by 4% (OR = 0.96, p=0.001). After adjusting for resilience score and age, only the total General Anxiety Disorder-7 score was associated with severe disability, with a one-point increase in total General Anxiety Disorder-7 score increasing the odds of severe disability by 16% (OR=1.16, p<.001). Similarly, a one point increase in total Patient Health Questionnaire-9 score, increased the odds of being severely disabled by 24% (OR=1.24, p<.001). CONCLUSION: A higher resilience score inversely correlated with headache-related disability in this cohort. In participants with severe disability as measured by Migraine Disability Assessment, higher levels of anxiety and depression were associated with increased levels of headache-related disability.
Impact of Quality Improvement Curriculum on Intensive Care Unit Upgrades by Resident Physicians
(2022-05) Bohman, Seth Reid; Reed, W. Gary; Kedia, Raashee S.; Danko, Colin
BACKGROUND: Patients admitted to the hospital ward from the emergency department (ED) can decompensate rapidly and require transfer to the intensive care unit (ICU). These patients may benefit from identification of critical illness in the ED and earlier admission to the ICU. This could reduce delays in care, improve patient outcomes, and reduce healthcare expenses. The 66 emergency medicine (EM) residents at a single academic medical center are part of a quality improvement curriculum known as Residents Enhancing Safety and Quality (RES-Q). The "ICU upgrades" group in the curriculum evaluates patients who require transfer from the inpatient floor to the ICU within 12 hours of admission from the ED. For a period of 6 months, residents participate in structured case review of qualifying patient encounters and attempt to determine the root causes for ICU upgrades. LOCAL PROBLEM: The Parkland Hospital ED has one of the largest patient volumes in the country.1 Given the busy nature of the department, learning and following-up on patient visits by the EM residents can take the backburner. A dedicated quality analysis curriculum, called RES-Q, was enacted in 2014 to help improve the residents' education. RES-Q consists of four major groups for review: ICU upgrades, 72-hour patient return visits, intubations, ED mortalities. Two additional groups are added on a year-to-year basis depending on resident interest. Residents evaluate patient cases in these groups each month and determine if there were any issues or learning points. These analyses are then presented during the monthly EM resident conference. Participation in each group is rotated every six months over three-year span of the residents' training to allow involvement in all groups. The ICU upgrades group evaluates patients that are dispositioned to the floor but decompensate within 12 hours and subsequently get "upgraded" to an ICU bed. METHODS: A retrospective analysis was performed to determine the effectiveness of this quality improvement program in reducing the number of clinical ICU upgrades. This took place at a large, urban, county hospital with over 200,000 ED visits per year. The initial analysis compared second-year EM residents who participated in the ICU upgrades curriculum during their first year to second-year EM residents who did not participate in the curriculum during their first year. The method of maximum likelihood was estimated by fitting a generalized Poisson linear regression model to the data. INTERVENTIONS: The primary intervention consisted of a quality improvement curriculum that involved structured case review of qualifying patient encounters, focusing on resident education and exposure to common causes of intensive care unit upgrades. This was complemented by a survey of the resident physicians that participated in the program, providing insight into their perceived value of the program and the general time commitment required to complete the program. RESULTS: Analysis of the 242 qualifying ICU upgrade cases from July 2019 - December 2021 showed 19 second-year EM residents who completed the curriculum were responsible for 19 ICU upgrades, and 26 second-year EM residents who had not yet completed the curriculum were responsible for 40 ICU upgrades. The incidence rate ratio of ICU upgrade cases for second-year residents who didn't complete the curriculum was 1.54 (95% CI: 0.89-2.66; p=0.122) compared to second-year residents who completed the curriculum. CONCLUSION: Initial analysis suggests that completion of the RES-Q ICU upgrades curriculum may improve resident proficiency in recognizing and appropriately dispositioning critical patients from the ED. This is associated with reduced number of patients requiring transfer from the inpatient floor to the ICU within 12 hours of admission. A limitation to this study is that all residents participated in the monthly RES-Q conference which presents data and learning points of all groups. Additional time periods and residency classes are currently under review to better determine the effect of the RES-Q ICU upgrades curriculum.
Pathologic Fracture Secondary to Acute Hematogenous Osteomyelitis in Children in New Zealand
(2022-05) Atadja, Louise Aseye; Chang, Mary; Boyle, Matthew; Copley, Lawson A. B.
BACKGROUND: Acute hematogenous osteomyelitis is a common pediatric musculoskeletal infection that has been well studied in the literature. Moderate to severe cases of osteomyelitis may weaken and destabilize the bone architecture leading to complications like pathologic fracture. The purpose of this study was to investigate the risk factors for the development of pathologic fracture following acute hematogenous osteomyelitis for children in New Zealand. METHODS: Nine patients who were treated for a pathologic long-bone fracture secondary to Staphylococcus aureus osteomyelitis between January 2009 to December 2019 at the Starship Children's Hospital in Auckland, New Zealand were identified. These patients were compared with a age and sex matched control group of twenty-seven children with Staphylococcus aureus osteomyelitis without a pathologic fracture. A retrospective review of patient's clinical records, lab and microbiological findings was performed. RESULTS: Patients who developed a fracture presented with osteomyelitis at a mean age of 5.3 years (range, 0.1 to 8.6 years). The mean time from initial osteomyelitis onset to pathologic fracture was 49 days (range, nine to 116 days). Patients with an increased NZ deprivation score and those of Pacific-Islander ethnicity differed significantly between the two groups. For initial clinical presentation, it was found that swelling, reduced range of motion and erythema, and higher CRP levels showed significant differences between the two groups. Length of stay, PICU admission and increased readmissions also showed significant differences between the two groups. The management strategy of the pathologic fracture group was also presented. CONCLUSIONS: Patients presenting with more severe acute infections are at significant risk of pathologic fracture following osteomyelitis. Prophylactic treatment plans such as early immobilization and casting may be necessary in patients presenting with these risk factors to prevent the long and difficult treatment of pathologic fracture.
Improving Teamwork Competencies and Patient Handovers of Students in the Emergency Medicine Clinical Learning Environment
(2024-05) Lokesh, Nidhish; Reed, W. Gary; Greilich, Philip; Pierce, Ava E.
BACKGROUND: Communication failures contribute to significant teamwork failures causing adverse events for patients and providers, especially during patient handovers when providers transition care of patients to each other. Teamwork education has been shown to improve knowledge, skills, and communication in prelicensure learners. Despite knowledge of the problem and potential solutions, as well as requirements and recommendations by national medical accreditation and oversight agencies, there exists a gap in standardized teamwork education and assessment. The Emergency Department is a setting rife with inherent barriers to teamwork with a high frequency of patient handovers. LOCAL PROBLEM: At UT Southwestern, students used to have limited opportunities to improve teamwork in structured ways during their time on the clinical wards. In response, the institution developed and is implementing an educational quality enhancement plan - TeamFIRST - with the goal of developing a competency-based teamwork education (CBTE) strategy for students that is progressive, interprofessional, and continuous through the pre-clerkship, clerkship, and post-clerkship phases of medical school. Module 4 out of the 5 modules TeamFIRST developed focuses on improving teamwork competencies specifically in the clinical learning environment, i.e. during clinical rotations in most students' second years and beyond. This includes the Emergency Medicine clinical rotation, which most students undergo at Parkland Memorial Hospital, the busiest emergency department in the nation, as well as at other local Emergency Departments like Clements University Hospital and Presbyterian Dallas. Until now, the Emergency Medicine clinical rotation at UT Southwestern did not have any formal handover or teamwork education, despite being the clinical setting in which teamwork and handovers arguably provide the most value. METHODS: Continuous Quality Improvement (QI) and Implementation Science tools and methodologies were used in the study of the current state of handovers in the ED and in the design of interventions to implement effective handovers. Define-Measure-Analyze-Design-Verify methodology was used to iterate our interventions. Interviews with stakeholders were conducted to determine critical needs, learn about the main drivers for intervention, and map the current state of the ED clerkship rotation so that a suitable educational module could be developed. These stakeholders mainly included faculty, course directors, residents, and students in the Emergency Medicine rotation as well as members of TeamFIRST. Shared requirements from stakeholders included focusing on improving handovers, limiting time commitment due to already busy schedules, and mixing virtual with in-person education. Information was also gathered on the state of different handover types in the ED to design assessment tools that captured the critical components. TeamFIRST identified nine of the twelve Teamwork Competencies - Structured Communication, Closed Loop Communication, Asking Clarifying Questions, Sharing Unique Information, Mutual Trust, Team Mental Models, Mutual Performance Monitoring, Obstacles to Teamwork, and Psychological Safety - for the Module 4 interventions to address. Working in concert with TeamFIRST and the Emergency Medicine stakeholders, we developed a teamwork education curriculum that integrated into the existing Emergency Medicine clerkship rotation and focused specifically on improving patient handovers. Each teamwork competency was explored to differing degrees among the spectrum of inform, demonstrate, practice, and feedback. We selected various process, outcome, and balancing measures such as impact (effectiveness), fidelity of activities, acceptability and appropriateness, and feasibility. Impact of the curriculum was measured by assessing students' knowledge, confidence in skills, and attitudes on the teamwork competencies. Both quantitative and qualitative data was collected. Statistical methods such as Z test of proportion and Mann-Whitney U test were used to analyze pre- and post- data to determine any significant changes. INTERVENTIONS: The teamwork curriculum initially designed for the Emergency Medicine clerkship rotation (the "test" phase, designated "Curriculum 1.0") had three main aspects: a pre-orientation, asynchronous, virtual educational module on teamwork and handovers, integrated handover practice and assessment throughout the rotation, integrated teamwork participation/observation, reflection, and debriefing during the rotation. The pre-orientation module was designed with a pre-assessment to determine students' capacities before being exposed to the material and a post-assessment to measure changes in knowledge and receive feedback after going through the didactic curriculum that covered the teamwork competencies and dedicated a full section to patient handovers. The handover practice was scattered throughout teaching shifts, simulation center cases and a dedicated handover station, and while working on regular emergency department shifts with accompanying assessment tools made to allow residents and faculty to evaluate student handovers and provide learners feedback. Lastly, students participated in and observed teamwork instances throughout their rotation and were encouraged to note these experiences down in a Teamwork Competency Journal so they could reflect and debrief on them in a group session late in the rotation. Finally, an end-of-rotation assessment was administered to capture changes in knowledge, skills, and attitudes, as well as feedback on acceptability, appropriateness, and feasibility. Whereas feasibility data were derived from the qualitative feedback, fidelity to the learning activities were assessed quantitatively. These interventions were first tested with a non-representative student sample outside of the EM rotation at the end of the summer 2020 and during field tests in Spring 2021 to improve the process and optimize the interventions. The official, representative test within the clerkship, "Curriculum 1.0", began in June 2021 and ran through March 2023 (22 months total). "Curriculum 2.0", the more streamlined version, is our pilot phase, and has been running from April 2023 through the present. RESULTS: We had 124 students participate in the Curriculum 1.0 test over 13 rotation blocks and collected qualitative and quantitative data on acceptability, appropriateness, fidelity, feasibility, and impact. So far, the curriculum has shown to be effective in improving knowledge (significant in 5/8 categories, p<0.05) and confidence in teamwork skills (significant in 11/11 categories, p<0.05). Also, students have deemed the curriculum acceptable and appropriate (all average ratings >4/5). However, some learning activities were deemed less feasible, and the fidelity (completion as intended) of different activities was low (48% completion or less). Feedback was generally positive, with common themes being that the handover education and practice were useful and relevant, the teamwork debrief was excellent, and the course was unique. Negative feedback commonly addressed a lack of clarity in communication about the curriculum requirements and the need for more active student roles. CONCLUSION: Overall, the impact and acceptability/appropriateness of Curriculum 1.0 were high, feasibility of the curriculum was moderate, and fidelity was low. Some of the key takeaways include that our stakeholders found the education to be effective and valuable, a combination of asynchronous and synchronous learning seemed the most feasible and acceptable, and that the time pressures on our EM residents and faculty are high. Going forward, we will continue to pilot the streamlined "Curriculum 2.0", which has already shown to be more feasible and sustainable, to improve the experience for learners and instructors, improve data collection, and focus on getting students more practice on patient handovers.
Optimizing Opioid Prescription for Outpatient Surgery
(2022-05) Day, Lauren Nicole; Reed, W. Gary; Kandil, Enas; Hamilton, Elizabeth
INTRODUCTION: Opioid overprescribing by surgeons has contributed to the current opioid epidemic. This has occurred both from the transition of patients to chronic opioid use after initial use for acute pain only and from diversion of unused opioids from prescriptions intended for acute surgical pain. Factors leading to overprescribing by surgeons include historical misinformation about the addictive nature of opioids, societal and governmental expectations, and lack of standard prescribing guidelines. Multiple academic medical centers have developed opioid stewardship programs to study, optimize, and standardize opioid prescribing after surgery through consensus of all relevant stakeholders without changes to patient satisfaction or pain control. OBJECTIVE: No similar guidelines existed at the University of Texas Southwestern Medical Center's Clements University Hospital for acute surgical pain prescription oversight. Our project centered around developing an opioid stewardship program at our own institution using existing resources to align opioid prescribing after common day surgery procedures with established guidelines published by other major institutions. METHODS: We developed a multitiered approach for our opioid stewardship program. This included developing a database, providing educational opportunities to prescribers, and implementing process change in EPIC workflow. Our multidisciplinary team analyzed surgery billing information and EPIC pharmacy data for prescriber type, strength, and average number of pills/dosage of each opioid prescription. Procedures initially targeted included laparoscopic cholecystectomies, laparoscopic appendectomies, inguinal hernia repairs (both open and laparoscopic), and umbilical hernia repairs. To standardize measurements, prescriptions were converted to morphine milligram equivalent (MME), where one opioid tablet= Oxycodone 5mg= MME of 7.5 per tablet. Data was compared to current Outpatient Procedure Guidelines as set forth by the University of Michigan and Johns Hopkins University. A dashboard was created for physicians using collected data to enable review of prescribing habits. Small and large group education sessions on prescribing guidelines were implemented targeting attendings and residents. We identified areas of potential improvement in existing process and changed EPIC order-sets and quantity defaults for prescriptions after routine outpatient procedures. RESULTS: A prescription database was created and formatted for easy analysis in Tableau. Preliminary analysis suggests residents write more than 80% of prescriptions following routine outpatient surgical procedures. Tylenol #3 and Tramadol are the most commonly prescribed. Large variation exists regarding the type and quantity of the opioid medication prescribed. There appears to be a clear downward trend each year in the average MME prescribed, particularly following initial interventions in the summer of 2018, however no robust statistical analysis has yet been performed. There also appears to be less variation in MME and type of medication prescribed beginning in 2017. Educational opportunities in the form of small group and Grand Rounds were offered to faculty, residents and students. EPIC order-sets were implemented within our system for the prescribing of opioids following outpatient procedures and defaults within EPIC were changed. CONCLUSIONS: It is possible to set up a multidisciplinary multi-tiered opioid stewardship program using existing resources. Residents are the primary prescribers of opioids at our institution and targeting this group remains a high priority of the authors of this study. Smaller quantities of opioids are being prescribed after targeted surgical procedures over time post-intervention, and it appears that opioid quantities being prescribed are aligning more closely with published guidelines.
Optimizing Glucose Meter Downloads at Parkland Diabetes Clinic
(2022-05) Wees, Isabel Rose; Reed, W. Gary; Meneghini, Luigi; Gunasekaran, Uma; Phelps, Eleanor
BACKGROUND: Diabetes is a common chronic condition that has vast health and economic consequences. Diabetes requires constant monitoring and attention to various metabolic variables. Self-monitoring of blood glucose (SMBG) levels has been shown to reduce microvascular and macrovascular disease complications. LOCAL PROBLEM: The Parkland Diabetes Clinic (PDC) encourages patients to take an active role in their health through SMBG, which requires them to check their blood sugar at home and then share this data with their provider to create personalized treatment plans. Currently, only about 50% of patients at this clinic bring their meter to their appointments. Thus, the provider struggles to provide personalized, effective care due to lack of blood sugar history. METHODS: This project began by obtaining a benchmark for the current percentage of patients at the PDC that bring their glucose meters to their appointments. Provider and patient surveys were created to better understand beliefs and habits regarding SMBG and utility of bringing glucometers to clinic appointments. The survey results were obtained and analyzed. PLANNED OR ACTUAL INTERVENTIONS: The intervention implemented for this project was determined based on analysis of the survey results as well as discussion with clinic staff and providers. A staff education session was conducted every 3 months during the intervention period and small glucometer messaging reminder posters were hung to improve communication between staff/providers and patients. The percentage of patients that brought their glucometers improved from 50.71% to 57.76%. This showed a statistically significantly increase following the intervention period, indicating a successful and reproducible intervention.
Formative Feedback Passport: A Tool to Engage Students in Reflecting on and Incorporating Mid-Point Feedback
(2022-05) Postma, Heather Elizabeth; Abraham, Reeni; Collins, Sarah; Brinker, Stephanie
BACKGROUND: The importance of formative feedback in undergraduate medical education is widely appreciated; however, it is historically inadequate. The formative feedback passport (FF tool) was developed and implemented in the Internal Medicine (IM) clerkship at UT Southwestern to address these concerns. OBJECTIVE: This dissertation examines the FF tool's role in facilitating an optimal formative feedback process. METHODS: Initially, a pre-intervention study was conducted, in which randomly selected, de-identified FF tools from the 2018-2019 IM clerkship were analyzed for content and quality of student reflection. Results revealed that student reflection on feedback was insufficient, with transformative, thoughtful reflection seldom occurring. In response to these findings, the FF tool's instructions were augmented with a module to encourage critical reflection. Subsequently, a post-intervention study was conducted, in which randomly selected, de-identified FF tools from the 2020-2021 IM clerkship were analyzed in the same manner as the pre-intervention study. RESULTS: 149 feedback tips from 50 FF tools were included in the pre-intervention study, and 162 feedback tips from 54 FF tools were included in the post-intervention study for a total of 311 feedback tips from 104 FF tools analyzed. In both studies, most of the feedback tips aligned with established standards for resident and faculty evaluators. In addition, the mean scores for each REFLECT Rubric criterion were significantly higher in the post-intervention group than the pre-intervention group. CONCLUSION: The FF tool is an invaluable electronic feedback tool in the IM clerkship at UT Southwestern. It enables documentation of formative feedback and promotes critical student engagement, reflection upon feedback, and the development of plans to implement feedback for improvement. Study results demonstrate that students receive formative feedback from an attending, resident, or patient that is appropriate in content. Additionally, study results demonstrate that the intervention improved student engagement and quality of reflection on feedback using the FF tool.
Using Ethnography to Capture Learner Experience in Handover Simulation Modules
(2022-05) Jacob, Benjamin Richard; Reed, W. Gary; Greilich, Philip; Phelps, Eleanor
BACKGROUND: Patient handovers, frequent, diverse, and integral parts of modern medical practice, involve the transfer of patient responsibility from one team of providers to another.1 This transition of care is often fragmented and has been shown to cause various adverse events, including patient injury, medication errors, and lengthened hospital stays.2-4 LOCAL PROBLEM: As simulation-based activities have increased in medical schools across the nation, an accompanying need to understand the learner experience has developed.5,6 UTSW has incorporated simulation-based learning with the Quality Enhancement Plan (QEP) to teach medical and health professions students team based communication. The aim of this study was to characterize learner attitudes toward simulation education during two simulation-based modules and to determine critical-to-quality elements of these courses through focused ethnography. METHODS: We describe a focused ethnographic study of two simulation-based modules of handover education using direct participant observation. The observers, medical students, and physician assistant student participant of these modules were asked to provide reflective summaries of their experiences during the simulation, including a description of what happened, attitudes about the experience, and reflections on potential improvement. Using qualitative analysis software, these ethnographic summaries were coded, and major themes were identified These themes were subsequently used to develop critical elements of the simulation activity in a Critical to Quality (CTQ) tree. RESULTS: Our analysis showed that the handover-simulation modules were regarded as generally both acceptable and appropriate. Coding of the ethnographic summaries clarified the major proponents of and deterrents to acceptability (Figure 2). Our analysis determined five components for a quality experience: organization, safety/security, engagement, reinforcement, and standardization. Out of the five critical to quality elements we identified, all five needs were described and confirmed in two concomitant focus group analyses of handover-simulation module participants, further validating an ethnographic approach in this context. CONCLUSION: Ethnographic research methods are an efficient and effective way to characterize learner attitudes and experiences in simulation education. Focused ethnography has identified several significant targets for improving the Safe Patient Handover simulation.
The Effect of Antibiotic Prophylaxis on Infection Rates in Mohs Micrographic Surgery: A Single-institution Retrospective Study
(2021-05-01T05:00:00.000Z) Li, Jeffrey Niu; Srivastava, Divya; Nijhawan, Rajiv I.; Nguyen, Khang
BACKGROUND: Data and recommendations regarding antibiotic prophylaxis in dermatologic surgery vary in terms of effectiveness in preventing surgical site infection, prosthetic joint infection, infective endocarditis, and specifics regarding administration. OBJECTIVE: The objective of this study is to describe the effect of antibiotic prophylaxis (AP) in Mohs micrographic surgery (MMS) on infective endocarditis, prosthetic joint infection, and surgical site infection. METHODS: A single-institution retrospective cohort study of antibiotic use (pre-/intra-operative, post-operative or none) among 2,364 patient encounters treated with MMS was performed. Information regarding patient demographics, surgical site infection, prophylactic antibiotic administration (e.g. none, pre-/intraoperative loading dose, postoperative), type of repair, tumor type, surgery site, duration of patient stay, and other relevant covariates were collected. Inclusion criteria also included those who had at last one follow-up appointment or phone call with any provider after surgery. Bivariate logistic regression evaluated for associations between patient and operative characteristics, antibiotic use, and infectious complications. RESULTS: 85.8% of patients received no AP, 10.0% received post-operative AP, and 4.1% received pre-/intra-operative AP. The overall surgical site infection (SSI) rate was 1.3%. SSI did not differ between patients who received pre-/intra-operative prophylaxis, post-operative prophylaxis or no antibiotics. One patient receiving pre-/intra-operative prophylaxis developed SSI. Repairs involving porcine xenografts and interpolation/pedicle flaps were associated with increased SSI. In addition, there were no patients who post-operatively experienced an infected joint or infective endocarditis. CONCLUSION: There was no difference in rates of SSI when comparing MMS patients who received pre-/intra-operative, post-operative or no AP. There were no cases of infective endocarditis or infected prosthetic joints.
Cervical Cancer Treatment Pathway in Botswana
(2021-05-01T05:00:00.000Z) Mehta, Priyanka Chetan; Grover, Surbhi; Nwachukwu, Chika; Kumar, Kiran
BACKGROUND: The incidence and mortality of cervical cancer in Botswana are among the highest in the world. Despite availability of chemoradiation and government funding for cancer treatment, many patients referred for chemoradiation in Botswana do not receive treatment. OBJECTIVES: This study sought to determine the proportion of cervical cancer patients referred for chemoradiation who do not receive cancer treatment and identify factors associated with receipt or non-receipt of treatment. Time between key steps in the care cascade was quantified to identify points that contribute to delays in care. This study also examined the impact of Princess Marina Hospital's multidisciplinary gynecologic oncology (PMH MDT) clinic on treatment receipt. METHODS: 230 patients with biopsy-proven cervical cancer were enrolled from January 2015 to July 2018 at Princess Marina Hospital in Gaborone, Botswana and followed until November 2019. Patient demographics, clinical characteristics, treatment characteristics, and time between steps in the care cascade were compared between treated and untreated patients using Wilcoxon rank sum tests, chi-squared tests, student's t tests, and univariate binomial logistic regression. RESULTS: 43 (18.7%) patients did not receive cancer treatment. Higher FIGO stage at initial presentation (OR: 0.50, 95% CI: 0.31-0.83, p < 0.01) and presentation during MDT clinic's first year (OR: 0.30, 95% CI: 0.15-0.59, p < 0.001) were associated with significantly lower odds of receiving treatment. Age, residential distance from treatment site, and HIV status were not predictive of treatment receipt. The largest discrepancy in time between treated and untreated patients was median time between pathology report and first MDT clinic visit: 22 days for treated patients (IQR: 9-63; n = 162) vs. 44 days for untreated patients (IQR: 9-146; n = 33) (p > 0.05). CONCLUSION: The MDT model is an evidence-based strategy to improve care coordination and reduce treatment disparities, thus improving outcomes for cancer patients. While there are still gaps in Botswana's cervical cancer care cascade, the PMH MDT clinic has led to significant improvements in cancer care among this population. The PMH MDT clinic provides strong evidence that MDT clinics can and should be established in under-resourced settings.

Browse

Recent Submissions