Faculty Bibliography

LEARNING OBJECTIVES:After studying this article, the participant should be able to: 1. Understand the autologous graft options available to the rhinoplasty surgeon, including septal cartilage, auricular cartilage, costal cartilage, and bone. 2. Understand the autograft and allograft options available to the rhinoplasty surgeon, including cadaveric costal cartilage, silicone, Medpor, and Gore-Tex. 3. Identify the ideal situations to use each of these implant materials. 4. Understand the advantages and disadvantages of the different autografts, allografts, and implants in rhinoplasty. SUMMARY:This review focuses on the graft options available to the modern rhinoplasty surgeon. Autologous options are varied in the quality of cartilage harvested and the morbidity of the donor site. In addition, surgeons should understand the allograft options should autologous grafting be unfeasible or undesirable. New technological advances in processing of allograft cartilage makes this an attractive secondary option.

BACKGROUND:Hospitalist physicians' workload-the total number of patients they care for daily-is rising in the U.S. Hospitalists report that increased workload negatively affects patients care. OBJECTIVE:Measure the associations between hospitalist physicians' workload and clinical outcomes. DESIGN, SETTINGS, AND PARTICIPANTS/METHODS:Observational study, using electronic health record (EHR) data, of adults hospitalized on the hospitalist service at Yale-New Haven Hospital from 2015-2018. MAIN OUTCOME AND MEASURES/METHODS:We defined hospitalists' workload as the number of patients they cared for on the first full hospital day of a given patient's encounter. We used multilevel Poisson and logistic regression to examine associations between workload and length of stay (LOS), return to the Emergency Department (ED), and readmission. We adjusted for sociodemographic factors, patient complexity and severity of illness, and weekend admission (for LOS) or discharge (for ED visits or readmission). RESULTS:We analyzed 38,141 hospitalizations. Median patient age was 64 years (IQR 51-78 years), 53% were female, and 34% were nonwhite. Mean workload was 15 patients (SD 3 patients; range 10-34 patients). LOS was prolonged by 0.05 days (95% CI 0.02, 0.08; p(0.001) when comparing the 75th workload percentile (16 patients) to the 25th workload percentile (13 patients). There were no associations between workload and ED visits or readmission within 7 and 30 days. CONCLUSIONS:There was a statistically significant but modest relationship between workload and LOS; workload was not associated with ED visits or readmissions.Given clinical reports of the deleterious effects of increased hospitalist workload, there is a need for prospective research assessing a range of outcomes, beyond those measurable in contemporary EHR data.

Although the Affordable Care Act requires nonprofit hospital organizations to report how they identify and invest in community health needs, the utility of mandated reporting documents for tracking investments in the social determinants of health has been questioned. Using public reporting documents and focusing on housing as a social determinant of health, we describe how nonprofit hospital organizations in 5 communities with the highest rates of homelessness document needs and investments related to housing on their Community Health Needs Assessments, Implementation Strategies, and Schedule H (990H) tax forms. Of 47 organizations, 55% identified housing as a health need, 36% described housing-related implementation strategies, and 26% reported relevant 990H spending. Overall concordance among identified needs, strategies, and spending was low, with only 15% of organizations addressing housing across all 3 documents. Regulatory reform could help promote accountability and transparency in organizations' efforts to address housing and other health-related social needs.

Telehealth services may improve access to care, but there are concerns around whether availability of telehealth may increase care utilization. We assessed whether usage of telehealth was associated with differential primary care utilization at a large, urban public healthcare system. Using electronic health record data from 23 primary care clinics, we categorized patients as telehealth users and non-users. Then, we compared the number of visits per patient between groups using Welch's t-tests while stratifying by comorbidity count. We used multivariable Poisson regression to test for associations between telehealth usage and visit count while controlling for other demographic factors. Compared with telehealth non-users, telehealth users had approximately 1 more primary care visit per patient over the year regardless of comorbidity count or other patient characteristics. Availability of telehealth services may be associated with increased primary care utilization in a safety-net setting, though further research on outcomes, costs of care, and patient and clinician experiences is needed to better inform decisions regarding provision and reimbursement of telehealth services.

PURPOSE/UNASSIGNED:Hospital at home (HaH) is a means of providing inpatient-level care at home. Selection of admissions potentially suitable for HaH in oncology is not well studied. We sought to create a predictive model for identifying admissions of patients with cancer, specifically solid-tumor malignancies, potentially suitable for HaH. METHODS/UNASSIGNED:In this observational study, we analyzed admissions of patients with solid-tumor malignancies and unplanned admissions (January 1, 2015, to June 12, 2019) at an academic, urban cancer hospital. Potential suitability for HaH was the primary outcome. Admissions were considered potentially suitable if they did not involve escalation of care, rapid response evaluation, in-hospital death, telemetry, surgical procedure, consultation to a procedural service, advanced imaging, transfusion, restraints, and nasogastric tube placement. Admission source, patient demographics, vital signs, laboratory test results, comorbidities, admission and active cancer diagnoses, and recent hospital utilization were included as candidate variables in a multivariable logistic regression model. RESULTS/UNASSIGNED:Of 3,322 admissions, 905 (27.2%) patients were potentially suitable for HaH. After variable selection in the derivation cohort (n = 1,097), thirteen factors predicted potential suitability: admission source; temperature and respiratory rate at presentation; hemoglobin; breast cancer, GI cancer, or malignancy of secondary or ill-defined origin; admission for genitourinary, musculoskeletal, or neurologic symptoms, intestinal obstruction or ileus, or evaluation of secondary malignancy; and emergency department visit in prior 90 days. Model c-statistics were 0.71 (95% CI, 0.68 to 0.75) and 0.63 (0.59 to 0.67) in the derivation and validation (n = 1,095) cohorts. CONCLUSION/UNASSIGNED:Hospital admissions of patients potentially suitable for HaH may be identifiable using data available at admission.

BACKGROUND: To justify nonprofit hospital organizations' tax exemption, the Affordable Care Act (ACA) requires these organizations to report on efforts to identify and invest in local health needs via Community Health Needs Assessments (CHNAs), Implementation Strategies (ISs), and Schedule H (990H) tax forms. However, there is no requirement that 990H spending aligns with topics raised on CHNAs or ISs, and recent reports have questioned whether 990H reporting categories adequately measure investments in social determinants of health. To assess the utility of ACA-mandated reporting for tracking spending on social health needs, this cross-sectional study aimed to describe how often a need identified in CHNAs is reflected in plans noted in ISs and in spending reported in 990Hs. Using housing as an example of a social health need, we focused on communities with the most homelessness to study organizations most likely to address housing.
METHOD(S): We identified nonprofit hospital organizations with facilities in the 5 metropolitan areas with highest per-capita homelessness using Department of Housing & Urban Development data and the Community Benefit Insight (CBI) database. We reviewed organizations' public reporting documents, obtained via internet search and from CBI, to determine whether they ever addressed housing on CHNAs, ISs, and 990Hs from 2015-2017. We excluded 3 organizations for which we could not obtain all 3 documents.
RESULT(S): Of 47 organizations sampled (representing 57 facilities in Washington, DC; Santa Cruz County; Boston; New York City; and San Francisco), housing was noted in 55% (n=26) of CHNAs, 36% (n=17) of ISs, and 26% (n=12) of 990Hs. Among the 26 organizations that recognized housing needs in CHNAs, 10 noted housing-related plans in ISs, and 7 reported spending on housing in 990Hs.
CONCLUSION(S): Although many nonprofit hospital organizations in areas with high homelessness recognize housing as a health need, public reporting documents provide limited evidence that an identified community need for housing was translated into related plans and spending. Further investigation should explore whether discrepancies among documented needs, strategies, and spending reflect inadequacy of the 990H for capturing housing-related spending versus hospitals' uncertainty in whether or how to invest in housing after identifying it as a health need. Regulatory reform to increase guidance for social investments and require greater concordance among CHNAs, ISs, and 990Hs could promote accountability and transparency in organizations' efforts to address housing and other health-related social needs. LEARNING OBJECTIVE #1: Quantify use of public reporting documents by nonprofit hospitals in communities with high rates of homelessness to show how they identify and invest in housing as a community health need (Patient Care) LEARNING OBJECTIVE #2: Appraise policy opportunities to enhance Affordable Care Act-mandated reporting requirements to hold nonprofit hospital organizations accountable to improving community health (SystemsBased Practice)