Investigating the Amoxicillin Shortage in Pennsylvania in the Era of Supply Chain Challenges: A Cross-Sectional Study

References

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The Board of Governors for the American Academy of Otolaryngology Head and Neck Surgery held its Spring meeting on April 29th 2023 as a live virtual event promoting legislative advocacy, candidate’s forum, and practice management session. Registration was free to all members of the Academy. Participants could earn 2.50 AMA PPRA Category 1 credits. The program did focus on legislative advocacy with updates on health care bills and the 118th Congress, the academy's legislative priorities for 2023, and the AMA advocacy plan. The AMA recovery plan focuses on fixing prior authorization, reforming Medicare payment, fighting scope creep, supporting telehealth, and strategies for reducing physician burnout. Dr. Bobby Mukkamala, otolaryngologist and immediate past chair of the AMA Board of Trustees gave an informative presentation on those topics.

The meeting also included a candidates forum including a question and answer session involving the two presidentelect candidates in this year's upcoming elections, Dr. Troy Woodard (Rhinologist at Cleveland Clinic) and Dr. Mark Wax (Head and Neck Surgeon at Oregon University). This gave grassroot members the opportunity to learn more about both candidates and hear their vision for the future of the specialty. The third component of the program involved practice management pearls. Learning about successful payer contract negotiation strategies that a practice could immediately implement and understanding how insurance companies approach practices in all regions of the country were addressed. Providers must learn to navigate future reimbursement models, contract language, payer policies, and their relationship with payers. Providers must continually oversee billing and collections to optimize reimbursement. Participants did learn from experts in healthcare management from the Lighthouse Healthcare Advisors Company based in Maryland on how to evaluate your current reimbursement, understand potential pain points within contract language, and best practices for A/R and Denial management.

In addition, an update on coding was provided by Dr. Peter Manes and a discussion on the importance of quality metrics by Dr. Willard Harrill.

The Board of Governors will also be sponsoring on June 21 a webinar on the otolaryngology workforce as it currently stands in our country. Dr Andrew Tompkins will be the lead presenter on this topic and has worked extensively on accumulating this data and analyzing it for the Academy. The discussion will take a comprehensive look at where the workforce currently stands, where it may be headed, patient access needs, market forces affecting the workforce, and evaluation of the 2022 otolaryngology workforce survey. The BOG will be highlighting this presentation in the next few months.

Efforts to continue to improve communication between the Board of Governors and state specialty societies and grassroot members of the Academy continue to grow. The importance of sharing information and enhancing communication amongst all members of the Academy continues to be of vital importance. Please continue to participate in the many webinars and podcasts that are being promoted by the BOG and AAO and stay involved. Don’t forget to vote in the upcoming election for Academy leaders as well!

Karen A. Rizzo, MD FACS Chair BOG PA Governor/BOG

Sana Siddiqui MD

Joseph Spiegel, MD

Thomas Jefferson University

Dr. Spiegel, would you consider doing something that I found about on Reddit?” With this question, I was introduced to the on-line “no burp” community and became one of the physicians on their “list.” Our first patient with retrograde cricopharyngeal dysfunction (RCPD) came to us for what she described as a “swallowing problem.” She didn’t realize that her lifelong inability to burp was a related symptom until she started searching the internet. There, on Reddit, she found a community of people that all had a similar array of symptoms. Those that had sought medical evaluation were frustrated that they had undergone many tests yet received no answers or effective treatment.

Our colleague, Dr. Robert Bastian, in the Chicago area, was the first to identify the syndrome and establish a protocol for treatment. His patients also were self-diagnosed from internet blogs. His paper detailing treatment of 51 patients was published in early 2019, just as our first patient presented to our clinic. Based on Dr. Bastian’s report, we proceeded to treat our patient with a Botox injection to the UES which resulted in complete resolution of her symptoms and she proceeded to let the blog know that there was now another doctor that could care for them. We have now treated more that 150 patients with RCPD at Jefferson.

RCPD is a syndrome with four symptoms:

1) the lifelong inability to burp, 2) abdominal bloating, 3) throat and chest noises (“squeaks” or “croaks”), and, 4) excessive flatulence, and the absence of dysphagia as a fifth “negative symptom.” Some patients’ families report occasional burps in early childhood and some patients can produce a burp with great effort. Many patients also report difficulty vomiting or a severe fear of vomiting. Those patients that present for medical evaluation are often treated for gastroesophageal reflux and worked up for GERD and inflammatory bowel disease. These patients routinely come in with files full of normal test results.

Two things stand out that make RCPD unique. First, the condition was defined via “crowd sourcing” on internet blogs where multiple patients with similar symptoms came together. These bloggers brought the definition of the syndrome to the healthcare system and that process continues currently. In our published study of the first 85 patients treated at Jefferson, only one was seen as a result of physician referral and all of the others were self-referred after internet research. This pattern has mostly continued. But, we are starting to see some awareness of the condition in our local GI and Pediatric communities so we are slowly, beginning to see more direct medical referrals. The second unique issue with RCPD is that we have chosen to treat this cohort of patients based exclusively on their symptom complex without further testing or workup. While choosing a subgroup to study with videofluoroscopy and high-resolution esophageal manometry may help define the pathophysiology of RCPD, it has not been necessary to perform these tests to proceed to safe and effective treatment. As a result, this additional testing, outside of a study, may well represent a waste of healthcare resources when the symptombased syndrome is so consistent.

When patients present with the RCPD symptom complex, they are offered treatment with Botox injection to the UES. Most initial injections are performed in the OR, under general anesthesia and esophagoscopy is done at that time as well. The injections can also be performed in the office under local anesthesia with EMG guidance, using either a lateral or trans-tracheal approach and are well tolerated. We are currently looking across multiple institutions to assess if there is a difference in response depending on approach.

In our initial cohort at Jefferson, 88.2% of patients had a successful response to their initial UES Botox treatment. Many in the group that failed to have a good response went on to have a response to a second injection. Most of the responders have maintained good symptom control well beyond the expected three month lifespan of the Botox effect. 30% of patients complain of transient dysphagia for 3-4 weeks after injection and a few patients have had heartburn, regurgitation or mild dyspnea during this interval. Otherwise, there have been no significant side effects or complications of treatment.

There are patients out there with RCPD that have been suffering a restricted quality of life but could not find a solution in the healthcare community. They first found each other, defined their own problem and have now broken through the barriers to be recognized and treated. Listen to your patients, especially when they can’t burp!

Bastian RW, Smithson ML, Inability to Belch and Associated Symptoms Due to Retrograde Cricopharyngeus Dysfunction: Diagnosis and Treatment, Diagn Treat OTO Open, 2019; 3:2473974X19834553.

Siddiqui SH, Sagalow ES, Fiorella MA, Jain N, Spiegel JR, Retrograde Cricopharyngeal Dysfunction: The Jefferson Experience, Laryngoscope, 00:1-5:2022