The Permanente journal最新文献

Introduction: Physicians are facing a constant shortage, with market estimates of shortfalls only projected to increase as the population of the United States ages and health care employment needs increase. A lack of physicians has led to a steady increase in the number and scope of advanced practice practitioners (APPs) in the United States. Nurse practitioners and physician assistants have increased, in terms of percentage of the practitioner workforce, with varying degrees of autonomy. The authors describe a model of APPs to determine whether indirect supervision vs direct supervision is fiscally optimum in hospital medicine departments.

Methods: The authors utilized R software in R Studio to simulate, via Monte Carlo methods, APP-independent and supervised models of care. Publicly available salary data were used as the foundation to generate the models. The data were then used to simulate typical care teams of APPs and physicians in hospital medicine, while utilizing typical billing practices.

Discussion: Analysis of the models of care generated demonstrated that APPs, given the current payer reimbursements, are an integral part of the hospital medicine care team. A range of scenarios are accounted for. This research demonstrates that direct supervision has a lower cost per work relative value unit cost to the employer, as opposed to indirect supervision.

Conclusion: APPs will only continue to increase their share of billed visits. In the setting of a hospital medicine workflow, given current payer and salary constraints, direct supervision is recommended to optimize the care team from a fiduciary perspective.

Introduction: Optimal timing of anterior cruciate ligament reconstruction (ACLR) remains controversial. This study evaluated the impact of timing of ACLR on rates of revision, return to the operating room, and pre- and postoperative tibiofemoral laxity.

Methods: A retrospective review was performed from January 1, 2010, to December 31, 2015, and included patients ≥ 16 years of age with no history of prior ipsilateral or contralateral knee surgery who underwent primary arthroscopic ACLR. Patients were categorized as early ACLR (< 6 months postinjury) or delayed ACLR (≥ 6 months). Pre- and postoperative manual-maximum differences (MMDs) based on KT-1000 testing and postoperative pivot shift were examined.

Results: A total of 611 patients met inclusion criteria (n = 198 early ACLR and n = 413 delayed ACLR). Compared to the early ACLR group, patients receiving delayed ACLR had a lower preoperative MMD (mean 6.55 vs 7.27 mm). Postoperative MMD, as measured by a single physical therapist, was not significantly different for early vs delayed reconstruction. Logistic regression controlling for age, graft type, and postoperative laxity revealed that delayed ACLR was associated with lower odds of return to the operating room (odds ratio = 0.523, P = .045).

Conclusion: Delayed ACLR was associated with a lower return to the operating room and no difference in postoperative MMD.

Background: Little is known about how comprehensively the Agency for Healthcare Research and Quality's patient safety indicators (PSIs) capture true complications. Therefore, the authors sought to assess the PSIs' sensitivity using a novel sampling and analytic strategy tailored for unusual events to ensure adequate capture of false negative cases.

Methods: The authors retrospectively reviewed hospitalization records not flagged by 7 selected PSIs, oversampling those with specific diagnosis or procedure codes suggesting an unreported complication, with a special interest in PSI 09 (Postoperative Hemorrhage or Hematoma) and PSI 10 (Postoperative Physiologic and Metabolic Derangement). The authors evaluated data from 27 hospitals in 11 states between 2006 and 2009. For each PSI, the authors determined the negative predictive value (NPV), accounting for sampling weights, and used previous estimates of positive predictive value (PPV) and incidence to estimate sensitivity.

Results: For PSI 09, 32 of 281 abstracted records (including 30 of 116 high-risk records) were falsely negative (NPV 99.73%; 97.5%, confidence interval [CI], 98.96-99.94); the estimated sensitivity was 40% (95% CI, 12-76). For PSI 10, 3 of 230 records (including 3 of 108 high-risk records) were falsely negative (NPV 99.92%; 97.5% CI, 99.28-99.99); the sensitivity was 53% (95% CI, 9-92). The estimated sensitivity of other PSIs varied (19%-100%).

Conclusions: The sensitivity of several Agency for Healthcare Research and Quality PSIs, estimated from a sample of hospitalizations enriched with records suggesting an unreported complication, varied widely. Although the 2-stage complex stratified sampling design (using weights based on sampling probabilities) allows estimation of the sensitivity of hospital outcome measures, large sample sizes are still required for unusual events.

Background: The volume and complexity of administrative regulations, standards, and associated tasks contribute to administrative burden in health care. Misinterpretation and misapplication of regulations impede efficiency and contribute to professional dissatisfaction.

Objectives: The authors aimed to 1) understand the compliance professional role, training, and background; 2) uncover their perspectives toward documentation and administrative burden; and 3) identify common regulatory misconceptions by compliance professionals.

Methods: In June 2023, the authors surveyed a sample of professionals serving in compliance roles listed within the directory of a national network of federally qualified health centers. Data were collected through REDCap. Follow-up interviews were completed with 4 participants between September and November of 2023. Descriptive statistics were calculated for all quantitative variables; interview transcripts were analyzed using rapid qualitative analysis. Methodological triangulation was employed to identify themes across survey and interview responses.

Results: About one-third (5/16, 31%) of compliance professionals had formal training. The majority (15/16, 94%) agreed or strongly agreed that "If a clinician's action is not documented it is not 'done.'" Compliance professionals' perceptions of regulatory adherence in clinical scenarios showed high variability, with some participants noting noncompliance in situations where there were no regulatory infractions. Participants perceived administrative burden and waste in health care but diverged in their views of whether they have a role in protecting clinicians from administrative burden.

Conclusions: This study reveals inaccuracies in compliance professionals' interpretations of regulations and standards and suggests a gap between written regulations and interpretation at the organizational level. This overinterpretation may create unnecessary work for physicians and their teams.

Introduction: Trigger finger is one of the most common conditions treated by hand surgeons. Although corticosteroid injection is a common first-line treatment, there is no consensus regarding the most effective type of steroid.

Methods: The authors performed a retrospective cohort study of patients with a diagnosis of trigger finger within Kaiser Permanente Northern California, a large, community-based, integrated health system with a comprehensive electronic medical record. Patients were potentially exposed to 4 different steroid regimens: betamethasone, dexamethasone, methylprednisolone, and triamcinolone. The primary outcome was the possibility of subsequent trigger finger surgery following initial corticosteroid treatment.

Results: Among 20,141 patients with an injection for trigger finger diagnosis, 1668 (8.3%) had a trigger finger release procedure following injection. Compared with patients injected with triamcinolone, dexamethasone patients had a hazard ratio of 4.12 for surgery (95% confidence interval [CI], 3.06-5.54), betamethasone patients had a hazard ratio of 2.40 (95% CI, 1.86-3.10), and methylprednisolone had a hazard ratio of 1.77 (95% CI, 1.32-2.37).

Discussion: This large, retrospective observational study suggests that the type of corticosteroid used for trigger finger may influence the possibility of subsequent surgery.

Conclusions: This information may inform corticosteroid choice for treating trigger finger, but findings should be confirmed in a prospective study.

This case report and technical note details the successful surgical repair of a latissimus dorsi (LD) tendon rupture in a high-demand athlete using a single-incision axillary approach with an all-suture anchor tension slide technique. The patient, a 38-year-old competitive athlete, sustained the injury during a Spartan Race, presenting with substantial functional limitations, including shoulder weakness and impaired performance in athletic and professional activities. Clinical and imaging findings confirmed a complete LD tendon rupture with 6 cm of retraction and associated teres major partial tearing. Surgical repair involved tendon mobilization, preparation of the humeral footprint, and fixation with all-suture anchors in a tension slide configuration. Postoperatively, the patient underwent a tailored rehabilitation protocol, achieving near-complete return to preinjury function by 7 months. This innovative technique offered advantages, including cosmetic incision, minimized surgical morbidity, and familiarity with sports surgeons' techniques. The all-suture anchors avoid metal implants, reduce bone loss, and simplify the procedure compared to cortical buttons. Although effective, the approach requires technical expertise, particularly in mitigating neurovascular risks. This report underscores the efficacy and reproducibility of this method in treating LD tendon ruptures in high-demand athletes. Further biomechanical and clinical comparisons are warranted to refine surgical indications and optimize outcomes.

Objective: This study aimed to evaluate associations among pretreatment hearing deficit, corticosteroid intervention, and audiologic recovery among patients presenting with sudden sensorineural hearing loss within an integrated health system.

Methods: Electronic health records within a multicenter integrated health system were queried for clinical encounters with a diagnosis of sudden sensorineural hearing loss in 2021. Patient demographics, audiometric data, and therapeutic steroid intervention were recorded. Audiologic response was defined as a decrease of 15 dB in 4-frequency (500, 1000, 2000, 4000 Hz) pure tone average (PTA). Audiologic recovery, or complete response, was defined as a follow-up PTA (PTA2) of ≤ 25 dB or within 10 dB of 1) baseline or 2) contralateral ear. Logistic regressions were performed to evaluate for predictive factors.

Results: A total of 403 patients (mean age 59.27 ± 15.80 years, 57.32% male) met inclusion criteria, of which 355 underwent corticosteroid intervention. The nonsteroid group had a less severe hearing deficit (median PTA1 49.38 dB vs 58.75 dB with steroid group; P < .05). Median PTA improvement was 6.25 dB with steroid therapy and 3.63 dB without (P < .05), but median PTA2 between steroid and nonsteroid users was not significantly different (42.5 dB and 38.13 dB, respectively; P = .821). Steroid intervention within 14 days was predictive of an audiologic response (odds ratio [OR] = 2.33) and recovery (OR = 2.46; both P < .05) compared with patients who did not undergo steroid therapy, whereas delayed steroid intervention was not, regardless of steroid regimen. Severe hearing loss had worse odds of audiologic response (OR = 0.40) or recovery (OR = 0.10; both P < .05) compared with mild hearing loss.

Conclusion: Pretreatment hearing deficit and initiation of empiric steroid therapy within 14 days were associated with audiologic prognosis, independent of the corticosteroid regimen. These findings reinforce the benefit of prompt steroid intervention, while further highlighting a need for standardized measures of audiometric outcomes.

Introduction: Restricted in-person interaction throughout the pandemic coincided with increased reliance on telehealth for patient evaluation and treatment. However, few studies have investigated telehealth efficacy and accuracy compared with in-person musculoskeletal physical examination. Importantly, this virtual platform can be challenging for practitioners whose care relies on physical examination measurements. This study evaluated the validity and accuracy of measuring hip and shoulder strength and range of motion (ROM) via telehealth examination.

Methods: In this cross-sectional study, 45 participants without hip or shoulder pain underwent an in-person physical examination and a telehealth examination. Hip and shoulder ROM were measured from in-person and telehealth examinations, using Halo goniometers (Halo Medical Devices) and virtual goniometers, respectively. Hip and shoulder strength were also assessed. Measures obtained from in-person and telehealth examinations were compared, and percent agreements were calculated.

Results: The mean age of participants was 32.0 ± 7.2 years; 67% (n = 30) were female. Hip flexion strength, right hip abduction, and right shoulder strength had the strongest percent agreement (91.1%-100.0%) across in-person and telehealth modalities. Left hip abduction, left shoulder active abduction, shoulder internal ROM, and shoulder external ROM showed moderate-to-high agreement (26.7%-77.8%). Left (2.2%) and right hip (8.9%) external ROM showed poor agreement.

Discussion: Measurements with the greatest agreement between telehealth and in-person examinations included hip flexion, shoulder strength, hip abduction, and shoulder active abduction.

Conclusion: Certain strength and ROM tests can be accurately assessed via telehealth examination. Future research is needed to expand upon these findings and to develop a reliable, standardized protocol for the telehealth musculoskeletal physical examination.