Daniel J. Rocke

A Cost-Utility Analysis of Recurrent Laryngeal Nerve Monitoring in the Setting of Total Thyroidectomy

Importance Intraoperative nerve monitoring (IONM) of the recurrent laryngeal nerve (RLN) is used as a tool to decrease the rate of nerve injury, although study findings are divergent on IONM efficacy. The cost-effectiveness of this approach to total thyroidectomy has not been well studied. Objective To determine whether IONM is a cost-effective intervention in the setting of total thyroidectomy. Design and Setting This study creates a decision-tree model of total thyroidectomy to analyze, from a societal perspective, the cost-effectiveness of universal IONM (ie, use in every case) vs selective IONM (ie, high-risk cases including reoperative cases, substernal or toxic goiters, and cases with known cancer) vs no IONM (visual identification only). Parameters for the model were derived from review of the literature, and deterministic and probabilistic analyses were performed to test the models robustness. All analyses were performed from the model; there were no human participants. Interventions Modeled total thyroidectomy with and without IONM of the RLN. Main Outcomes and Measures Cost-effectiveness of universal IONM vs selective IONM vs visual identification only of the RLN. Results Visual identification of the RLN led to a cost savings of

Physician knowledge of and attitudes toward the Patient Protection and Affordable Care Act.

179.40 and

Complications of Bilateral Neck Dissection in Thyroid Cancer From a Single High-Volume Center

683.20 per patient, and an improvement of 0.001 and 0.004 quality-adjusted life-years, over selective IONM and universal IONM, respectively. Visual identification was the most cost-effective approach, despite variations in costs and utilities in both deterministic and probabilistic sensitivity analyses. In a 1-way sensitivity analysis, decreasing the probability of RLN injury with IONM made selective IONM more cost-effective. When the rate of RLN injury for visual identification was kept constant (at 3.86%), selective IONM became the most cost-effective approach when its RLN injury rate dropped below 1.9%. As the rate of RLN injury with IONM dropped below 50.4% of the visual identification RLN injury rate, selective IONM became the most cost-effective approach. Conclusions and Relevance Visual identification of the RLN is more cost-effective than any use of IONM. If a clinician can, with use of IONM, decrease the rate of RLN injury by 50.4% or more compared with visual identification, selective use of IONM in high-risk cases is most cost-effective.

Effect of Physician Perspective on Allocation of Medicare Resources for Patients with Advanced Cancer

Objective To assess otolaryngology physician knowledge of and attitudes toward the Patient Protection and Affordable Care Act (PPACA) and compare the association of bias toward the PPACA with knowledge of the provisions of the PPACA. Study Design Cross-sectional survey. Setting Nationwide assessment. Subjects Members of the American Academy of Otolaryngology—Head and Neck Surgery. Methods Otolaryngology physicians answered 10 true/false questions about major provisions of the PPACA. They also indicated their level of agreement with 9 statements about health care and the PPACA. Basic demographic information was collected. Results Email solicitation was sent to 9972 otolaryngologists and 647 responses were obtained (6.5% response rate). Overall correct response rate was 74%. Fewer than 60% of physicians correctly answered questions on whether small businesses receive tax credits for providing health insurance, the effect of the PPACA on Medicare benefits, and whether a government-run health insurance plan was created. Academic center practice setting, bias toward the PPACA, and Democratic Party affiliation were associated with significantly more correct responses. Conclusion Overall physician knowledge of the PPACA is assessed as fair, although better than the general public in 2010. There are several areas where knowledge of physicians regarding the PPACA is poor, and this knowledge deficit is more pronounced within certain subgroups. These knowledge issues should be addressed by individual physicians and medical societies.

Physician Allocation of Medicare Resources for Patients with Advanced Cancer

Importance The morbidity of bilateral lateral neck dissection (BLND) for thyroid cancers has not been described in detail. This study delineates the specific complications arising from BLND for thyroid cancers at a single high-volume center. Objective To determine the morbidity associated with BLNDs for differentiated thyroid cancers at our institution. Design, Setting, and Participants This was a retrospective review of medical records performed to identify patients having undergone BLNDs for thyroid cancers by a single surgeon at an academic, tertiary medical center in Toronto, Ontario, Canada, from 1988 to 2015. Patients who underwent BLND for papillary, follicular, or medullary thyroid cancers were identified through operative procedure codes and review of operative and pathology reports. The indication for this procedure was suspicious bilateral lateral compartment on imaging and clinical examination. Sixty-two patients who underwent BLND for thyroid cancers, with or without total thyroidectomy and central compartment dissection, were identified. Main Outcomes and Measures The main outcome measures for this study were unanticipated medical or surgical complications during the operation or in the postoperative period. Secondary measures were oncologic outcomes, including regional structural or biochemical recurrence. Results Of the 62 patients, 24 were male (39%), and 38 (61%) were female. Their mean age was 46 years (range, 17-80 years). The overall risk of permanent hypoparathyroidism was 37%. There was 1 case of unanticipated permanent recurrent nerve paralysis and 1 case of temporary nerve paresis. Postoperative chyle fistula occurred in 6 cases (10%). There were 3 readmissions within 30 days of surgery, 1 pulmonary embolism, and 1 perioperative mortality. Fifty percent of patients had pN0 contralateral necks despite preoperative clinical suspicion. Four patients were found to have anaplastic thyroid cancers intraoperatively. Five patients (8%) developed nodal recurrence in the neck. Four patients died of their disease within available follow-up (mean, 3.2 years). Conclusions and Relevance Bilateral lateral neck dissection for thyroid cancers confers a significant amount of morbidity, including a significant rate of hypoparathyroidism. Knowledge of the complications of this procedure, especially in the setting of questionable survival benefit, may assist in preoperative decision-making and patient counseling.

Effectiveness of a postoperative disposition protocol for sleep apnea surgery

Objectives To assess how physician perspective (perspective of patient vs perspective of physician) affects Medicare resource allocation for patients with advanced cancer and compare physician allocations with actual cancer patient and caregiver allocations. Study Design Cross-sectional assessment. Setting National assessment. Subjects Otolaryngologists. Methods Physicians used a validated tool to create a Medicare plan for patients with advanced cancer. Participants took the perspective of an advanced cancer patient and made resource allocations between 15 benefit categories (assessment 2, November/December 2012). Results were compared with data from a prior assessment made from a physician’s perspective (assessment 1, February/March 2012) and with data from a separate study with patients with cancer and caregivers. Results In total, 767 physicians completed assessment 1 and 237 completed assessment 2. Results were compared with 146 cancer patient and 114 caregiver assessments. Assessment 1 physician responses differed significantly from patients/caregivers in 14 categories (P < .05), while assessment 2 differed in 11. When comparing physician data, assessment 2 allocations differed significantly from assessment 1 in 7 categories. When these 7 categories were compared with patient/caregiver data, assessment 2 allocations in emotional care, drug coverage, and nursing facility categories were not significantly different. Assessment 1 allocations in cosmetic care, dental, home care, and primary care categories were more similar to patient/caregiver preferences, although all but home care were still significantly different. Conclusions Otolaryngology–head and neck surgery physician perspectives on end-of-life care differ significantly from cancer patient/caregiver perspectives, even when physicians take a patient’s perspective when allocating resources. This demonstrates the challenges inherent in end-of-life discussions.

Tongue Entrapment in Metal Drinking Bottle

BACKGROUND Little is known about what patients and physicians value in end-of-life care, or how these groups would craft a health plan for those with advanced cancer. OBJECTIVE The study objective was to assess how otolaryngology, head and neck surgery (OHNS) physicians would structure a Medicare benefit plan for patients with advanced cancer, and to compare this with cancer patient and cancer patient caregiver preferences. DESIGN OHNS physicians used an online version of a validated tool for assessing preferences for health plans in the setting of limited resources. These data were compared to cancer patient and caregiver preferences. SETTING AND PARTICIPANTS OHNS physicians nationwide were assessed with comparison to similar data obtained in a separate study of cancer patients and their caregivers treated at Duke University Medical Center. RESULTS Otolaryngology physicians (n=767) completed the online assessment and this was compared with data from 146 patients and 114 caregivers. OHNS physician allocations differed significantly in 14 of the 15 benefit categories when compared with patients and caregivers. Physicians elected more coverage in the Advice, Emotional Care, Palliative Care, and Treatment for Cancer benefit categories. Patients and their caregivers elected more coverage in the Cash, Complementary Care, Cosmetic Care, Dental and Vision, Drug Coverage, Home Improvement, House Calls, Nursing Facility, Other Medical Care, and Primary Care benefit categories. CONCLUSIONS Otolaryngology physicians have significantly different values in end-of-life care than cancer patients and their caregivers. This information is important for efficient allocation of scarce Medicare resources and for effective end-of-life discussions, both of which are key for developing appropriate health policy.

Ultrasound Characteristics of Non-endocrine Cervical Pathology

PURPOSE 1) Evaluate the effectiveness of a postoperative disposition protocol for upper airway surgery in patients with sleep apnea. 2) Compare the cost-effectiveness of outpatient and overnight observational sleep apnea surgery versus surgical intensive care admission determined by preoperative screening criteria. MATERIALS AND METHODS A new preoperative protocol for sleep apnea surgery was instituted at the Durham Veterans Affairs Medical Center in 2008 to triage patients undergoing sleep apnea surgery to one of three postoperative dispositions: intensive care, routine ward bed, or discharge home. An Institutional Review Board approved retrospective chart review of patients undergoing sleep apnea surgery between May 2008 and January 2012 was performed. Postoperative complications and cost comparisons were assessed between each of the three postoperative disposition groups. RESULTS 115 patients underwent sleep apnea surgery between July 2008 and January 2012. 11 patients were excluded leaving 104 patients in the final analysis. Median follow-up was 1.25months. Overall complication rate was 12.5%. Eight complications occurred in the group triaged to intensive care, and 5 occurred in those triaged to lesser levels of postoperative care. All serious complications occurred during the immediate postoperative period. Based on only room charges,

Variation in tonsillectomy rates by health care system type

125,275 was saved over the 3.6years of this study. CONCLUSION A post operative disposition protocol can be effectively used to triage patients to less than intensive postoperative care. In institutions like the Durham VA, where sleep apnea patients were routinely triaged to intensive care, postoperative resources will be more efficiently utilized.

Medical Errors: Teachable Moments in Doing the Right Thing

Oral foreign bodies are involved in a wide range of pediatric cases, from benign occurrences to those that threaten the airway. Included are cases of tongue entrapment leading to pain, edema, and ischemia. Cases in the literature report tongue entrapment in glass bottles, 1-3 aluminum cans, 4,5 and pieces of balloon. 6 Because such cases are sufficiently sparse, treatment often requires a creative and novel approach to ensure safe removal of the constricting object without exacerbating or causing injury to the patient. The otolaryngologist also must be prepared to provide airway management after foreign-body removal. We report, to our knowledge, the first case of a tongue trapped in a metal water bottle, subsequent removal of the bottle and management of the tongue, and a review of the literature for airway edema associated with tongue entrapment. The Duke University Medical Center Institutional Review Board reviewed this study and granted it exempt status.