Publications by authors named "Regan W Bergmark"

57 Publications

Disparities in the Geographic Distribution of Neurosurgeons in the US: A Geospatial Analysis.

World Neurosurg 2021 Apr 5. Epub 2021 Apr 5.

Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA; Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, MA; Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital-Dana Farber Cancer Institute. Electronic address:

Objective: Large disparities in access to neurosurgical care are known, but there is limited data on whether geographical distribution of the neurosurgery workforce potentially play a role in these disparities. The goal of this study was to identify the geographic distribution of neurosurgeons in the United States and to study the association of the per-capita workforce distribution with socioeconomic characteristics of the population.

Methods: The number of practicing neurosurgeons in the United States in 2016 was obtained from the 2017-2018 American Medical Association (AMA) Masterfile contained within the Area Health Resource File. The association of the number of neurosurgeons per 100,000 population with socioeconomic characteristics was assessed through linear regression analysis at Hospital Referral Region (HRR) level.

Results: The median number of neurosurgeons per capita across all HRRs was 1.47 neurosurgeons per 100,000 population (IQR 1.02-2.27). Bivariable analysis revealed that greater supply of neurosurgeons was positively associated with regional levels of college education, median income, and median age. The number of neurosurgeons per capita at the HRR level was negatively associated with unemployment, poverty, and percent uninsured.

Conclusions: Regions characterized by low socioeconomic status have fewer neurosurgeons per capita in the United States. Low income, low number of college graduates, and high unemployment rate are associated with fewer numbers of neurosurgeons per capita. Further research is needed to determine if these geographical workforce disparities contribute to poor access to quality neurosurgical care.
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http://dx.doi.org/10.1016/j.wneu.2021.03.152DOI Listing
April 2021

The ACA at 10 Years: Evaluating the Evidence and Navigating an Uncertain Future.

J Surg Res 2021 Feb 25;263:102-109. Epub 2021 Feb 25.

Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan. Electronic address:

The year 2020 marks the 10th anniversary of the signing of the Affordable Care Act (ACA). Perhaps the greatest overhaul of the US health care system in the past 50 y, the ACA sought to expand access to care, improve quality, and reduce health care costs. Over the past decade, there have been a number of challenges and changes to the law, which remains in evolution. While the ACA's policies were not intended to specifically target surgical care, surgical patients, surgeons, and the health systems within which they function have all been greatly affected. This article aims to provide a brief overview of the impact of the ACA on surgical patients in reference to its tripartite aim of improving access, improving quality, and reducing costs.
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http://dx.doi.org/10.1016/j.jss.2020.12.056DOI Listing
February 2021

Association of perioperative ibuprofen exposure with post-tonsillectomy bleeding requiring operative management.

Int J Pediatr Otorhinolaryngol 2021 Mar 13;142:110627. Epub 2021 Jan 13.

Department of Otolaryngology, Massachusetts Eye and Ear, Boston, MA, USA.

Introduction: Pediatric tonsillectomy is one of the most common surgical procedures performed in the United States. The safety of ibuprofen use after surgery is debated given concern for increased bleeding. The primary objective of this study was to compare the rate of post-tonsillectomy hemorrhage requiring operative management in patients who received ibuprofen perioperatively vs. patients who did not.

Methods: Retrospective cohort study of patients 0-18 years old who underwent tonsillectomy with or without adenoidectomy (T&A) with recorded inpatient medication administration data at a single tertiary care institution from 1/2005-1/2019. The association between perioperative medication administration and return to operating room (OR) for control was evaluated using multivariable logistic regression adjusted for patient demographics and operative indication. Secondary outcomes evaluated included the time to operative bleed when it occurred.

Results: A total of 4098 patients with a median age of 6 years old (IQR 4-10) underwent T&A over the study period. The overall rate of post-tonsillectomy hemorrhage requiring OR was 3.37% (n = 138/4098). After adjustment for confounders, the odds of bleeding requiring OR did not differ significantly between the ibuprofen (OR 1.16, 95% CI (0.76, 1.74), 3.55%, n = 41/1,156, p = 0.47) and non-ibuprofen groups (3.30%, n = 97/2942). The median time to bleeding requiring OR was postoperative day 6.5 (IQR6-8) in the ibuprofen group and day 6 (IQR 3-8) in the non-ibuprofen group.

Conclusions: No difference in post-tonsillectomy hemorrhage requiring OR was observed between patients receiving perioperative ibuprofen versus those patients not receiving this medication. Additional research is required to definitively determine a safe dose and interval for ibuprofen administration following tonsillectomy.
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http://dx.doi.org/10.1016/j.ijporl.2021.110627DOI Listing
March 2021

The Expanding Digital Divide: Digital Health Access Inequities during the COVID-19 Pandemic in New York City.

J Urban Health 2021 Jan 20. Epub 2021 Jan 20.

Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1007/s11524-020-00508-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7816740PMC
January 2021

Aspirin-Exacerbated Respiratory Disease: Association Between Patient-Reported Sinus and Asthma Morbidity.

J Allergy Clin Immunol Pract 2021 Apr 8;9(4):1604-1611. Epub 2020 Dec 8.

Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.

Background: The association between sinonasal and pulmonary symptoms in aspirin-exacerbated respiratory disease is not fully established.

Objective: To characterize sinonasal and asthma symptomatology, and to determine whether reported sinonasal symptoms predict asthma severity.

Methods: Prospectively collected data from an aspirin-exacerbated respiratory disease registry cohort were included from 2013 to 2018. Sinonasal symptomatology measured by Sino-Nasal Outcomes Test (SNOT) 22-item total scores was used as the predictor variable, with Asthma Control Test (ACT) scores and percent predicted FEV (FEV% predicted) as primary outcomes. All instances of paired data on the same date were used. ACT score was also evaluated with FEV% predicted as the outcome. Mixed effects regression was completed.

Results: From 1065 aspirin-exacerbated respiratory disease registry subjects (mean age, 48.1 ± 12.8 years; 68.0% females, 29.8% males), mean SNOT-22 score was 42.3 ± 24.12 (n = 1307 observations from 869 subjects), mean ACT score was 19.4 ± 5.2 (n = 1511 observations from 931 subjects), and mean FEV% predicted was 82.8 ± 19.6 (n = 777 observations from 307 subjects). SNOT-22 score significantly predicted ACT scores (P < .0001, 1185 paired observations from 845 subjects) and FEV% predicted (P = .018, 485 observations from 246 subjects). Any 10-point increase in SNOT-22 score was associated with a 0.87-point decrease in ACT score and a 0.75% decrease in FEV% predicted. Any 1-point increase in ACT score was associated with a 1.0% increase in FEV% predicted (P < .0001, 616 observations from 269 subjects). The most severe SNOT-22 symptoms were sense of smell/taste and blockage/congestion of nose.

Conclusions: SNOT-22 scores significantly predict ACT scores and FEV% predicted, and ACT scores significantly predict FEV% predicted. This study demonstrates an association between patient-reported rhinosinusitis and asthma symptom severity and subjective and objective measures of asthma severity.
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http://dx.doi.org/10.1016/j.jaip.2020.11.051DOI Listing
April 2021

Problematic Reporting of Gender Differences in Clinical Productivity Among Otolaryngologists-Reply.

JAMA Otolaryngol Head Neck Surg 2021 Feb;147(2):222

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamaoto.2020.4631DOI Listing
February 2021

Role of physician density in predicting stage and survival for head and neck squamous cell carcinoma.

Head Neck 2021 Feb 4;43(2):438-448. Epub 2020 Oct 4.

Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, Massachusetts, USA.

Background: Identifying and linking barriers to access to head and neck cancer care, specifically provider density, to stage of diagnosis and survival outcomes is important to serve as a foundation for policy interventions.

Methods: Retrospective cohort study using patients with head and neck squamous cell (HNSCC) in the Surveillance, Epidemiology, and End Results (SEER) database from 2007 to 2016 and Area Resource File. Primary outcomes included stage of presentation and cancer-specific 5-year survival and relation to provider density.

Results: The initial cohort consisted of 18 342 patients with oral cavity, 21 809 oropharyngeal, 15 860 laryngeal, and 2887 patients with hypopharyngeal malignancy. Non-Hispanic Black race and being uninsured increased the odds of presenting with advanced stage HNSCC and increased hazard of death. There was no significant and consistent association identified between Health Service Areas provider density and advanced stage at diagnosis or cancer-specific 5-year mortality.

Conclusions: Provider density of otolaryngologists and primary care physicians and dentists was not significantly associated with stage of presentation or cancer-specific survival for HNSCC while race and insurance status remained independent predictors for worse outcomes.
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http://dx.doi.org/10.1002/hed.26495DOI Listing
February 2021

COVID-19, Disparities, and Opportunities for Equity in Otolaryngology-Unequal America.

JAMA Otolaryngol Head Neck Surg 2020 Sep 10. Epub 2020 Sep 10.

Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamaoto.2020.2874DOI Listing
September 2020

Transmastoid Labyrinthectomy for Menière's Disease: Experience and Outcomes.

Otol Neurotol 2020 12;41(10):1413-1418

Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School.

Objective: To characterize presurgical symptoms and treatment history and postoperative course in patients with medically recalcitrant Menière's disease undergoing transmastoid labyrinthectomy in the post-intratympanic gentamicin era.

Study Design: Retrospective case series.

Setting: Tertiary academic medical center.

Patients: All patients who underwent transmastoid labyrinthectomy for medically recalcitrant Menière's disease in 2003 to 2019 by the senior author.

Interventions: Review of patients' medical records for: preoperative history of drop attacks, gentamicin injections, endolymphatic sac decompression or vestibular neurectomy, preoperative audiograms, length of hospital stay, postoperative complications, and persistent symptoms or challenging recovery.

Main Outcome Measures: Presurgical clinical history and proximal postoperative outcomes.

Results: Seventy-two patients with a mean age of 56.7 (standard deviation [SD] 10.7) were included. All cases were unilateral. Forty-three patients (59.7%) suffered from drop attacks. Sixty-two (86.1%) had failed sufficient symptom control with gentamicin injections. The mean preoperative word recognition score was 36.4% (SD 23.7) versus 95.1% (SD 8.5) in the contralateral ear. The mean pure-tone average (PTA) of the ipsilateral ear before surgery was 65.5 dB (SD 18.0) versus 16.2 (SD 13.5) for the contralateral ear. Mean hospital stay was 2.0 days (SD 0.87 days, range of 1-5 d). Three patients (4.2%) had prolonged postoperative vertigo.

Conclusions: Transmastoid labyrinthectomy at our center is performed for unilateral Menière's disease, generally when intratympanic gentamicin has failed. A majority of surgical patients suffer from drop attacks preoperatively. Hospital stay is typically brief.
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http://dx.doi.org/10.1097/MAO.0000000000002805DOI Listing
December 2020

Travel Time to Access Obstetric and Neonatal Care in the United States.

Obstet Gynecol 2020 09;136(3):610-612

Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; the Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada; the Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; the Department of Epidemiology, Technical University Munich, Munich, Germany; and the Departments of Obstetrics and Gynecology, Brigham and Women's Hospital, Massachusetts General Hospital, and Beth Israel Deaconess Medical Center, Boston, Massachusetts.

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http://dx.doi.org/10.1097/AOG.0000000000004053DOI Listing
September 2020

Assessment of Gender Differences in Clinical Productivity and Medicare Payments Among Otolaryngologists in 2017.

JAMA Otolaryngol Head Neck Surg 2020 09;146(9):1-10

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston.

Importance: Women comprise an increasing proportion of the otolaryngology workforce. Prior studies have demonstrated gender-based disparity in physician practice and income in other clinical specialties; however, research has not comprehensively examined whether gender-based income disparities exist within the field of otolaryngology.

Objective: To determine whether diversity of practice, clinical productivity, and Medicare payment differ between male and female otolaryngologists and whether any identified variation is associated with practice setting.

Design, Setting, And Participants: Retrospective cross-sectional analysis of publicly available Medicare data summarizing payments to otolaryngologists from January 1 through December 31, 2017. Male and female otolaryngologists participating in Medicare in facility-based (FB; hospital-based) and non-facility-based settings (NFB; eg, physician office) for outpatient otolaryngologic care were included.

Main Outcomes And Measures: Number of unique billing codes (diversity of practice) per physician, number of services provided per physician (physician productivity), and Medicare payment per physician. Outcomes were stratified by practice setting (FB vs NFB).

Results: A total of 8456 otolaryngologists (1289 [15.2%] women; 7167 [84.8%] men) received Medicare payments in 2017. Per physician, women billed fewer unique codes (mean difference, -2.10; 95% CI, -2.46 to -1.75; P < .001), provided fewer services (mean difference, -640; 95% CI, -784 to -496; P < .001), and received less Medicare payment than men (mean difference, -$30 246 (95% CI, -$35 738 to -$24 756; P < .001). When stratified by practice setting, women in NFB settings billed 1.65 fewer unique codes (95% CI, -2.01 to -1.29; P < .001) and provided 633 fewer services (95% CI, -791 to -475; P < .001). In contrast, there was no significant gender-based difference in number of unique codes billed (mean difference, 0.04; 95% CI, -0.217 to 0.347; P = .81) or number of services provided (mean difference, 5.1; 95% CI, -55.8 to 45.6; P = .85) in the FB setting. Women received less Medicare payment in both settings compared with men (NFB: mean difference, -$27 746; 95% CI, -$33 502 to -$21 989; P < .001; vs FB: mean difference, -$4002; 95% CI, -$7393 to -$612; P = .02), although the absolute difference was lower in the FB setting.

Conclusions And Relevance: Female sex is associated with decreased diversity of practice, lower clinical productivity, and decreased Medicare payment among otolaryngologists. Gender-based inequity is more pronounced in NFB settings compared with FB settings. Further efforts are necessary to better evaluate and address gender disparities within otolaryngology.
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http://dx.doi.org/10.1001/jamaoto.2020.1928DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7393586PMC
September 2020

The Surgeon's Perceived Value of Patient-reported Outcome Measures (PROMs): An Exploratory Qualitative Study of 5 Different Surgical Subspecialties.

Ann Surg 2020 Jul 9. Epub 2020 Jul 9.

Massachusetts General Hospital Physician Organization, Boston, Massachusetts.

Objective: To understand the surgeon's perceived value of PROMs in 5 different surgical subspecialties.

Summary Of Background Data: PROMs are validated questionnaires that assess the symptoms, function, and quality of life from the patient's perspective. Despite the increasing support for use of PROMs in the literature, there is limited uptake amongst surgeons. Furthermore, there is insufficient understanding of the surgeons' perceived value of PROMs. The aim of this study is to understand how surgeons perceive value in PROMs.

Methods: We conducted an exploratory qualitative study to understand the perceived value of PROMs from the perspective of surgeons in various subspecialties. Per convenience sampling, we conducted semi-structured interviews with 30 surgeons from 5 subspecialties across 3 academic medical centers. The surgical subspecialties included bariatric surgery, breast oncologic surgery, orthopedic surgery, plastic and reconstructive surgery, and rhinology. Interviews were transcribed, coded, and evaluated with thematic analysis.

Results: Surgeons endorsed that PROMs can be used to enhance clinical management, counsel patients in the preoperative and postoperative settings, and elicit sensitive information from patients that otherwise may go undetected. Obstacles to PROMs use include failure to generate actionable data, implementation obstacles, and inappropriate use of PROMs as a performance metric, with concerns regarding inadequate risk adjustment.

Conclusions: Establishing an effective PROMs program requires an understanding of the surgeon's perspective of PROMs. Despite obstacles, different subspecialty surgeons find PROMs to be valuable in different settings, depending on the specialty and clinical context.
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http://dx.doi.org/10.1097/SLA.0000000000004253DOI Listing
July 2020

Impact of insurance on hospital course and readmission after resection of benign meningioma.

J Neurooncol 2020 Aug 11;149(1):131-140. Epub 2020 Jul 11.

Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA.

Introduction: Surgical outcomes and healthcare utilization have been shown to vary based on patient insurance status. We analyzed whether patients' insurance affects case urgency for and readmission after craniotomy for meningioma resection, using benign meningioma as a model system to minimize confounding from the disease-related characteristics of other neurosurgical pathologies.

Methods: We analyzed 90-day readmission for patients who underwent resection of a benign meningioma in the Nationwide Readmission Database from 2014-2015.

Results: A total of 9783 meningioma patients with private insurance (46%), Medicare (39%), Medicaid (10%), self-pay (2%), or another scheme (3%) were analyzed. 72% of all cases were elective; with 78% of cases in privately insured patients being elective compared to 71% of Medicare (p > 0.05), 59% of Medicaid patients (OR 2.3, p < 0.001), and 49% of self-pay patients (OR 3.4, p < 0.001). Medicare (OR 1.5, p = 0.002) and Medicaid (OR 1.4, p = 0.035) were both associated with higher likelihood of 90-day readmission compared to private insurance. In comparison, 30-day analyses did not unveil this discrepancy between Medicaid and privately insured, highlighting the merit for longer-term outcomes analyses in value-based care. Patients readmitted within 30 days versus those with later readmissions possessed different characteristics.

Conclusions: Compared to patients with private insurance coverage, Medicaid and self-pay patients were significantly more likely to undergo non-elective resection of benign meningioma. Medicaid and Medicare insurance were associated with a higher likelihood of 90-day readmission; only Medicare was significant at 30 days. Both 30 and 90-day outcomes merit consideration given differences in readmitted populations.
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http://dx.doi.org/10.1007/s11060-020-03581-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7484429PMC
August 2020

Endoscopic management of lateral sphenoid cerebrospinal fluid leaks: Identifying a radiographic parameter for surgical planning.

Laryngoscope Investig Otolaryngol 2020 Jun 8;5(3):375-380. Epub 2020 Jun 8.

Department of Otolaryngology-Head and Neck Surgery Harvard Medical School Boston Massachusetts USA.

Objective: Repair of cerebrospinal fluid (CSF) leaks of the lateral recess of the sphenoid (LRS) sinus can be challenging to accomplish via an endoscopic transphenoidal approach. The endoscopic transpterygoid approach can improve surgical access to the lateral recess but requires more extensive surgical dissection. We review our experience with LRS CSF leak repair via both techniques to determine whether preoperative radiologic data can help predict the most appropriate surgical approach.

Methods: Electronic medical records of patients with LRS CSF leaks were retrospectively reviewed at a single tertiary referral center. Radiographic measurements from preoperative computed tomography images were reviewed.

Results: Twenty-two LRS CSF leaks were identified. The transphenoidal and transpterygoid approach were used in 6 (27.3%) and 16 (72.7%) cases, respectively.The mean vidian canal to foramen rotundum angle of the repairs accessed transphenoidally as compared to the transptyergoid approach were not significantly different (41.93° ±10.91, 40.72° ±19.49, respectively; .63). However, the mean volume of the LRS accessed by the transpterygoid approach was significantly greater compared to those accessed through the transphenoidal approach (0.97 cm ± 0.48, 0.39 cm ± 0.40, respectively; .04). A LRS volume of 0.400 cm or greater predicted the use of the transpterygoid approach with 93.3% sensitivity and 60.0% specificity.

Conclusion: This study demonstrated that LRS CSF leaks that necessitated repair by the transpterygoid approach, rather than transphenoidal approach, were in the context of significantly larger lateral recess. Assessment of the LRS volume is a quantifiable parameter to aid in preoperative surgical planning.

Level Of Evidence: Level 4.
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http://dx.doi.org/10.1002/lio2.412DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7314466PMC
June 2020

Aspirin-exacerbated respiratory disease: A review.

Laryngoscope Investig Otolaryngol 2020 Jun 1;5(3):360-367. Epub 2020 May 1.

Division of Otolaryngology-Head and Neck Surgery Brigham and Women's Hospital Boston Massachusetts USA.

Objectives: Aspirin-exacerbated respiratory disease (AERD) is a chronic respiratory condition characterized by a triad of symptoms: asthma, chronic rhinosinusitis with nasal polyposis, and a respiratory reaction to aspirin and other cyclooxygenase-1 inhibitors, also known as nonsteroidal anti-inflammatory drugs. The objective of this review is to provide otolaryngologists with an overview of the pathophysiology, diagnosis, and treatment of this under-recognized condition.

Data Sources And Methods: Foundational papers on AERD were reviewed, focusing on the clinical otolaryngology and allergy/immunology literature and other high impact journals or trials.

Results: AERD results from increased production of pro-inflammatory leukotrienes and a decrease in production of anti-inflammatory prostaglandins associated with the dysregulation of multiple enzymes influencing eicosanoid metabolism. Diagnosis hinges on a high index of suspicion, careful history, and confirmatory testing for all three elements. Treatments include endoscopic sinus surgery; topical, inhaled, or oral corticosteroids; aspirin desensitization; leukotriene modifying drugs; and the new class of biologics such as dupilumab.

Conclusion: AERD is an under-recognized disease associated with substantial patient-reported morbidity. We expect rapid progress in the pathophysiological understanding of this disease and available treatments in the coming decades.

Level Of Evidence: 5.
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http://dx.doi.org/10.1002/lio2.387DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7314471PMC
June 2020

The Surgical Health Services Research Agenda for the COVID-19 Pandemic.

Ann Surg 2020 09;272(3):e226-e229

Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1097/SLA.0000000000004126DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7467032PMC
September 2020

Patient-Reported Morbidity Instruments: A Systematic Review.

Value Health 2020 06 27;23(6):791-811. Epub 2020 May 27.

Department of Otolaryngology - Head and Neck Surgery, Harvard Medical School, Boston, MA, USA; Center for Surgery and Public Health, Patient Reported Outcomes, Value and Experience Center, Brigham and Women's Hospital, Boston, MA, USA.

Objectives: Although comorbidities play an essential role in risk adjustment and outcomes measurement, there is little consensus regarding the best source of this data. The aim of this study was to identify general patient-reported morbidity instruments and their measurement properties.

Methods: A systematic review was conducted using multiple electronic databases (Embase, Medline, Cochrane Central, and Web of Science) from inception to March 2018. Articles focusing primarily on the development or subsequent validation of a patient-reported morbidity instrument were included. After including relevant articles, the measurement properties of each morbidity instrument were extracted by 2 investigators for narrative synthesis.

Results: A total of 1005 articles were screened, of which 34 eligible articles were ultimately included. The most widely assessed instruments were the Self-Reported Charlson Comorbidity Index (n = 7), the Self-Administered Comorbidity Questionnaire (n = 3), and the Disease Burden Morbidity Assessment (n = 3). The most commonly included conditions were diabetes, hypertension, and myocardial infarction. Studies demonstrated substantial variability in item-level reliability versus the gold standard medical record review (κ range 0.66-0.86), meaning that the accuracy of the self-reported comorbidity data is dependent on the selected morbidity.

Conclusions: The Self-Reported Charlson Comorbidity Index and the Self-Administered Comorbidity Questionnaire were the most frequently cited instruments. Significant variability was observed in reliability per comorbid condition of patient-reported morbidity questionnaires. Further research is needed to determine whether patient-reported morbidity data should be used to bolster medical records data or serve as a stand-alone entity when risk adjusting observational outcomes data.
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http://dx.doi.org/10.1016/j.jval.2020.02.006DOI Listing
June 2020

Indications for and Outcomes of Endoscopic Sinus Surgery and Other Rhinologic Surgery After Facial Transplant.

JAMA Otolaryngol Head Neck Surg 2020 07;146(7):669-671

Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamaoto.2020.0774DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7290693PMC
July 2020

Revaluation of Otolaryngologic Procedures With 10- and 90-Day Global Periods in the Medicare Physician Fee Schedule.

Otolaryngol Head Neck Surg 2020 Oct 9;163(4):755-758. Epub 2020 Jun 9.

Massachusetts Eye and Ear, Boston, Massachusetts, USA.

A recent investigation by the Centers for Medicare and Medicaid Services (CMS) suggests that physicians provide fewer postoperative visits (POVs) than expected for procedures with 10- and 90-day global periods. CMS is now contemplating revaluation of these procedures, which could result in lower Medicare payments to otolaryngologists. To estimate the impact of such reform on otolaryngologic procedures, we conducted a secondary subgroup analysis of CMS-contracted research, which used claims-based estimates of POVs to revalue procedures with 10- and 90-day global periods. Among the top 10 highest volume procedures performed in 2018, the proportion of median physician-reported to CMS-expected POVs ranged between 0.0% (myringotomy ± ventilation tube insertion, mouth biopsy, and complex wound repair) and 40.0% (total thyroidectomy). The top 5 procedures accounted for nearly three-quarters ($6.2 million and $8.6 million; 72.6%) of the estimated Medicare payment reduction. Further study is necessary to guide the development of equitable and effective payment reform.
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http://dx.doi.org/10.1177/0194599820932126DOI Listing
October 2020

Otolaryngologist Performance in the Merit-Based Incentive Payment System in 2017.

JAMA Otolaryngol Head Neck Surg 2020 07;146(7):639-646

Department of Otolaryngology, Massachusetts Eye and Ear, Boston.

Importance: The Merit-Based Incentive Payment System (MIPS) for Medicare is the largest pay-for-performance program in the history of health care. Although the Centers for Medicare & Medicaid Services (CMS) launched the MIPS in 2017, the participation and performance of otolaryngologists in this program remain unclear.

Objective: To characterize otolaryngologist participation and performance in the MIPS in 2017.

Design, Setting, And Participants: Retrospective cross-sectional analysis of otolaryngologist participation and performance in the MIPS from January 1 through December 31, 2017, using the publicly available CMS Physician Compare 2017 eligible clinician public reporting database.

Main Outcomes And Measures: The number and proportion of active otolaryngologists who participated in the MIPS in 2017 were determined. Overall 2017 MIPS payment adjustments received by participants were determined and stratified by reporting affiliation (individual, group, or alternative payment model [APM]). Payment adjustments were categorized based on overall MIPS performance scores in accordance with CMS methodology: penalty (<3 points), no payment adjustment (3 points), positive adjustment (between 3 and 70 points), or bonus for exceptional performance (≥70 points).

Results: In 2017, CMS required 6512 of 9526 (68.4%) of active otolaryngologists to participate in the MIPS. Among these otolaryngologists, 5840 (89.7%) participated; 672 (10.3%) abstained and thus incurred penalties (-4% payment adjustment). The 6512 participating otolaryngologists reported MIPS data as individuals (1990 [30.6%]), as groups (3033 [46.6%]), and through CMS-designated APMs (964 [14.8%]). The majority (4470 of 5840 [76.5%]) received bonuses (maximum payment adjustment, +1.9%) for exceptional performance, while a minority received only a positive payment adjustment (1006 of 5840 [17.2%]) or did not receive an adjustment (364 of 5840 [6.2%]). Whereas nearly all otolaryngologists reporting data via APMs (936 of 964 [97.1%]) earned bonuses for exceptional performance, fewer than 70% of otolaryngologists reporting data as individuals (1124 of 1990 [56.5%]) or groups (2050 of 3033 [67.6%]) earned such bonuses. Of note, nearly all otolaryngologists incurring penalties (658 of 672 [97.9%]) were affiliated with groups.

Conclusions And Relevance: Most otolaryngologists participating in the 2017 MIPS received performance bonuses, although variation exists within the field. As CMS continues to reform the MIPS and raise performance thresholds, otolaryngologists should consider adopting measures to succeed in the era of value-based care.
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http://dx.doi.org/10.1001/jamaoto.2020.0847DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7243162PMC
July 2020

Trends in Ambulatory Surgery Center Utilization for Otolaryngologic Procedures among Medicare Beneficiaries, 2010-2017.

Otolaryngol Head Neck Surg 2020 Jun 14;162(6):873-880. Epub 2020 Apr 14.

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.

Objective: Surgical care is increasingly shifting to freestanding ambulatory surgical centers (ASCs). The extent to which otolaryngologists use ASCs has implications for patient safety and health care spending. This study characterizes trends in utilization and resultant financial implications for common otolaryngologic procedures performed at ASC and hospital outpatient departments (HOPDs).

Study Design: Retrospective cross-sectional analysis.

Setting: ASCs, HOPDs.

Subjects And Methods: Subjects included Medicare beneficiaries undergoing outpatient otolaryngologic procedures between 2010 and 2017. Procedures included the 20 highest-volume procedures performed by otolaryngologists at ASCs in 2017. Main outcomes included absolute and relative percentage difference in the proportion of procedures furnished at ASCs and HOPDs and estimated Medicare cost savings resulting from increased ASC utilization between 2011 and 2017.

Results: The proportion of outpatient otolaryngologic procedures performed at ASCs increased by 1.8% (relative difference: 10.0%; mean annual relative increase: 1.60%), and the proportion located at HOPDs decreased by 6.0% (relative difference: -11.8%; mean annual relative decrease: -1.6%) between 2010 and 2017. Rhinoplasty accounted for the largest absolute increase in ASC utilization over the study period (absolute [relative] 8.9% [33.5%]). Increased ASC utilization resulted in an estimated $7.1 million in cost savings to Medicare between 2011 and 2017.

Conclusion: Otolaryngologists shifted outpatient surgical care from HOPDs to ASCs between 2010 and 2017, with resultant reductions in Medicare expenditures. Further research is necessary to examine the impact of this shift on patient safety.
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http://dx.doi.org/10.1177/0194599820914298DOI Listing
June 2020

National Geographical Variation in Sinus Balloon Dilation.

Otolaryngol Head Neck Surg 2020 May 3;162(5):761-766. Epub 2020 Mar 3.

Department of Otolaryngology, Harvard Medical School, Massachusetts Eye and Ear, Boston, Massachusetts, USA.

Objective: The primary aim of this study was to describe national variations in sinus balloon dilation (SBD), examine the relationship between endoscopic sinus surgery (ESS) and SBD prevalence patterns, and evaluate associations between reimbursement rates and regional variations in sinus surgery.

Study Design: Retrospective observational study.

Setting: Medicare Provider Utilization and Payment (PUP) Part B Data from January 1, 2016, to December 31, 2016.

Subjects And Methods: Physicians in the PUP Part B Database Performing ESS or SBD in 2016. States were stratified into average- or high-volume utilizers based on the number of ESS procedures and SBD procedures per population and compared.

Results: Eight states were classified as high-volume utilizers of SBD-Florida, Kansas, Louisiana, Mississippi, Nevada, New Mexico, South Dakota, and Texas. Only 3 of these states-Kansas, Mississippi, and Nevada-were classified as high-volume utilizers of ESS. Reimbursement rates were significantly higher for SBD as compared to ESS ($1538 [interquartile range (IQR), 1473-1664] vs $335 [IQR, 261-412] per procedure, < .001). High-volume utilizer SBD states had a higher number of otolaryngologists (13.0 [IQR, 7-16] vs 6.0 [IQR, 2-3]) otolaryngologists per state ( < .001) and a trend toward an increased rate of performing ESS procedures (19 [IQR, 19-41] vs 6.0 [IQR, 2-32], = .034) procedures per million residents) than average-volume utilizer SBD states.

Conclusions: The southern United States has a significantly higher rate of SBD procedures performed compared to the rest of the country, but these rates do not appear to be directly related to statewide variations in SBD reimbursement.
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http://dx.doi.org/10.1177/0194599820908217DOI Listing
May 2020

Female Authorship of Opinion Pieces in Leading Otolaryngology Journals between 2013 and 2018.

Otolaryngol Head Neck Surg 2020 01 29;162(1):35-37. Epub 2019 Oct 29.

Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.

Although women represent an increasing proportion of the physician workforce, barriers to the professional advancement of women persist, particularly within surgical fields such as otolaryngology. Authorship of scientific opinion articles serves as an important opportunity for professional development. We conducted a retrospective cross-sectional study to characterize the authorship patterns of scientific opinion articles by gender in leading otolaryngology journals between 2013 and 2018. Outcome measures were the number and proportion of female physician first authors and female last authors as compared with the proportion of the otolaryngology workforce. Between 2013 and 2018, female authors accounted for 24.1% of first of multiple authors, 30.4% of sole authors, and 25.3% of last authors. Women were equitably represented in comparison with the proportion of practicing female otolaryngologists (17.1% in 2017). The proportion of female first authorship increased from 20.0% in 2013 to 32.0% in 2018. Additional efforts are necessary to support the equitable advancement of women in otolaryngology.
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http://dx.doi.org/10.1177/0194599819886119DOI Listing
January 2020

Associations between national financial trends and facial plastic surgery procedural volume.

Laryngoscope 2020 03 11;130(3):632-636. Epub 2019 Oct 11.

Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts.

Objective(s): To characterize procedural trends in facial plastic and reconstructive surgery procedures in relation to the United States economy.

Methods: Retrospective cohort study examining annual procedure rates were determined from the American Society of Plastic Surgeons (ASPS) National Clearinghouse of Plastic Surgery Procedural Statistics from January 1 2007 to December 30, 2017. Procedures were compared to economic activity of the United States as measured by gross domestic product (GDP) were compared using Kolmogorov-Smirnov goodness of fit testing and piecewise multivariate regression modeling.

Results: Annual trends in procedural rates showed an overall decrease in the rates of rhinoplasty (284,960 to 218,924), blepharoplasty (240,660 to 209,571), and otoplasty (28,571 to 23,433) from 2007 to 2017. Total cosmetic surgery remained fairly stable, while minimally invasive cosmetic surgery increased in frequency over the study period. On piecewise regression analysis, rhinoplasty (P = .02), rhytidectomy (P = .007), invasive cosmetic surgery (P < .001) were significantly associated with GDP, whereas otoplasty (P = .98) and reconstructive surgery (P = .11) were not associated with GDP.

Conclusion: Cosmetic plastic surgery procedures show a greater correlation to GDP than reconstructive procedures. Trends in plastic surgery cases over the last decade show a decreasing number of rhinoplasty, otoplasty, and blepharoplasty, with stabilization in the last few years. An increasing number of reconstructive cases are found.

Level Of Evidence: 4 Laryngoscope, 130:632-636, 2020.
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http://dx.doi.org/10.1002/lary.28311DOI Listing
March 2020

Association of Vessel-Sealant Devices vs Conventional Hemostasis With Postoperative Neck Hematoma After Thyroid Operations.

JAMA Surg 2019 11 20;154(11):e193146. Epub 2019 Nov 20.

Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.

Importance: Vessel-sealant devices (VSDs) have been popularized for use in thyroid operations; however, the association of their use with postoperative neck hematoma, a rare but potentially fatal complication, has not been well studied.

Objective: To examine the association of VSDs vs conventional hemostasis (CH) in thyroid operations with the development of neck hematoma.

Design, Setting, And Participants: This retrospective cohort study evaluated 10 903 patients in the Thyroid Procedure-Targeted Database of the National Surgical Quality Improvement Program from January 1, 2016, to December 31, 2017. One-to-one nearest-neighbor propensity score matching was conducted to adjust for differences in baseline covariates, including demographics, comorbidities, indications for thyroid procedure (goiter, Graves disease, malignant and benign thyroid nodule), and several other thyroid-specific characteristics, between the VSD and CH groups.

Main Outcomes And Measures: The primary outcome was postoperative hematoma requiring intervention with open evacuation, return to the operating room, tracheostomy, additional observation, or extended length of stay. Secondary outcomes include recurrent laryngeal nerve injury, operative duration, and hospital length of stay.

Results: One-to-one propensity score matching yielded 6522 patients (mean [SD] age, 52 [15] years; 8544 [78.4%] female) with 3261 in each exposure group such that distribution of observed baseline covariates was not different between groups of the same propensity score. Within the matched cohort, CH was associated with higher odds of neck hematoma compared with VSD (odds ratio, 2.33; 95% CI, 1.55-3.49; P < .001), with 34 (1.0%) hematomas in the VSD group and 78 (2.4%) in the CH group. On the basis of this analysis, the number needed to treat with a VSD to prevent 1 postoperative hematoma was 74. Secondary outcomes included longer length of hospital stay (incidence rate ratio, 1.29; 95% CI, 1.23-1.36; P < .001]) in the CH group compared with the VSD group but no difference in the odds of recurrent laryngeal nerve injury (odds ratio, 0.90; 95% CI, 0.73-1.11; P = .32) or operative duration (incidence rate ratio, 0.99; 95% CI, 0.96-1.01; P = .24).

Conclusions And Relevance: Use of VSDs during thyroid operations was associated with reduced odds of neck hematoma compared with CH techniques without increasing odds of nerve injury. The results suggest that postoperative neck hematoma rates after thyroid surgery may differ based on the hemostasis technique and that these differences should be considered when developing strategies for quality improvement of postoperative outcomes.
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http://dx.doi.org/10.1001/jamasurg.2019.3146DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6751786PMC
November 2019

Disparities in Oral Cancer Screening Among Dental Professionals: NHANES 2011-2016.

Am J Prev Med 2019 10 20;57(4):447-457. Epub 2019 Aug 20.

Division of Oral Medicine, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, Massachusetts.

Introduction: As early detection of oral cancers is associated with better survival, oral cancer screening should be included in dental visits for adults. This study examines the rate and predictors of oral cancer screening exams among U.S. adults with a recent dental visit.

Methods: Individuals aged ≥30 years who received a dental visit in the last 2 years, in the 2011-2016 National Health and Nutrition Examination Survey were analyzed in December 2018. Weighted multivariable logistic regression models examined the likelihood of intraoral and extraoral oral cancer screening exams, adjusting for age, sex, race/ethnicity, education, marital status, poverty income ratio, health insurance, tobacco smoking, and alcohol consumption. Subgroup analyses were conducted among races/ethnicities, smokers, and alcohol consumers. Statistical significance was set at p<0.01.

Results: A total of 37.6% and 31.3% reported receiving an intraoral and extraoral oral cancer screening exam, respectively. Minority racial/ethnic groups versus white, non-Hispanics, less-educated versus more-educated, uninsured and Medicaid-insured versus privately insured, and low-income versus high-income participants were less likely to have received intraoral or extraoral oral cancer screening exams. There was no difference in the likelihood of being screened based on smoking status. Alcohol consumers were more likely to be screened. Among subgroups, less-educated and low-income individuals were less likely to be screened.

Conclusions: A significantly higher proportion of minority race/ethnicity and low SES individuals report not receiving an oral cancer screening exam, despite a recent dental visit. This selective screening by dental professionals is incompliant with guidelines and concerning because these groups are more likely to present with an advanced stage of oral cancer at diagnosis. An understanding of the reasons for discriminatory oral cancer screening practices could help develop effective interventions.
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http://dx.doi.org/10.1016/j.amepre.2019.04.026DOI Listing
October 2019

Differential perception and tolerance of chronic rhinosinusitis symptoms as a confounder of gender-disparate disease burden.

Int Forum Allergy Rhinol 2019 10 17;9(10):1119-1124. Epub 2019 Jul 17.

Department of Otolaryngology-Head & Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.

Background: Previous studies have consistently shown that females with chronic rhinosinusitis (CRS) have a greater CRS symptom burden than males with CRS. Our objective was to determine whether differential disease perception could explain this phenomenon.

Methods: A total of 500 participants (239 males, 261 females) with CRS were recruited. CRS symptom burden was assessed with the 22-item Sino-Nasal Outcome Test (SNOT-22). General health-related quality of life was assessed with the visual analog scale of the 5-dimensional EuroQol questionnaire (EQ-5D VAS). Participants were asked to rate their CRS symptom control as "Not at all," "A little," "Somewhat," "Very," and "Completely." "Not at all," "A little," and "Somewhat" controlled symptoms were considered to reflect poorly controlled symptoms.

Results: SNOT-22 score was significantly more severe (p < 0.001) among females (mean, 44.0; standard deviation [SD], 22.5) than males (mean, 36.3; SD, 20.2). However, there was no significant difference in male- vs female-reported CRS symptom control (p = 0.154). In addition, there was no significant difference (p = 0.109) in EQ-5D VAS score between males (mean, 70.9; SD, 19.0) and females (mean, 68.4; SD, 19.5). Although a SNOT-22 score of ≥25 was predictive of poorly controlled symptoms in males (sensitivity, 82.6%; specificity, 62.5%), a SNOT-22 score of ≥30 was predictive of poorly controlled symptoms in women (sensitivity, 82.4%; specificity, 64.5%).

Conclusion: Females with CRS reported more severe SNOT-22 scores, despite reporting a similar level of symptom control and general health-related quality of life as men. Women had a higher SNOT-22 threshold for poorly controlled symptoms. Female CRS patients may have greater perception and tolerance of CRS symptoms without a corresponding significant, disparate downstream impairment.
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http://dx.doi.org/10.1002/alr.22390DOI Listing
October 2019

Periostin and Inflammatory Disease: Implications for Chronic Rhinosinusitis.

Otolaryngol Head Neck Surg 2019 06 2;160(6):965-973. Epub 2019 Apr 2.

1 Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.

Objective: To provide a comprehensive overview of the emerging role of periostin, an extracellular matrix protein, as a key component in the development, diagnosis, and treatment of patients with chronic rhinosinusitis.

Data Sources: Medline database.

Review Methods: A state of the art review was performed targeting English-language studies investigating the role of periostin in cardiopulmonary, neoplastic, and inflammatory diseases, with emphasis on recent advances in the study of periostin in chronic rhinosinusitis.

Conclusions: Periostin has emerged as a novel biomarker and therapeutic target for numerous human pathologies, including cardiac, pulmonary, and neoplastic disease. The upregulation of periostin in chronic rhinosinusitis suggests the potential for similar roles among patients with sinonasal disease.

Implications For Practice: Chronic rhinosinusitis is a widespread disease with major clinical and societal impact. A critical limitation in the current treatment of patients with chronic rhinosinusitis is the absence of clinically relevant biomarkers to guide diagnosis and treatment selection. A review of the literature supports a likely role of periostin as a biomarker of chronic rhinosinusitis, as well as a novel therapeutic target in the future treatment of patients with sinonasal disease.
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http://dx.doi.org/10.1177/0194599819838782DOI Listing
June 2019