Lisa E. Ishii’s research while affiliated with Johns Hopkins University and other places

Objective To estimate and adjust for rater effects in operating room surgical skills assessment performed using a structured rating scale for nasal septoplasty. Methods We analyzed survey responses from attending surgeons (raters) who supervised residents and fellows (trainees) performing nasal septoplasty in a prospective cohort study. We fit a structural equation model with the rubric item scores regressed on a latent component of skill and then fit a second model including the rating surgeon as a random effect to model a rater‐effects‐adjusted latent surgical skill. We validated this model against conventional measures including the level of expertise and post‐graduation year (PGY) commensurate with the trainee's performance, the actual PGY of the trainee, and whether the surgical goals were achieved. Results Our dataset included 188 assessments by 7 raters and 41 trainees. The model with one latent construct for surgical skill and the rater as a random effect was the best. Rubric scores depended on how severe or lenient the rater was, sometimes almost as much as they depended on trainee skill. Rater‐adjusted latent skill scores increased with attending‐estimated skill levels and PGY of trainees, increased with the actual PGY, and appeared constant over different levels of achievement of surgical goals. Conclusion Our work provides a method to obtain rater effect adjusted surgical skill assessments in the operating room using structured rating scales. Our method allows for the creation of standardized (i.e., rater‐effects‐adjusted) quantitative surgical skill benchmarks using national‐level databases on trainee assessments. Level of Evidence N/A Laryngoscope , 2024

Objective: To develop an expert consensus statement (ECS) on the management of dysphagia in head and neck cancer (HNC) patients to address controversies and offer opportunities for quality improvement. Dysphagia in HNC was defined as swallowing impairment in patients with cancers of the nasal cavity, paranasal sinuses, nasopharynx, oral cavity, oropharynx, larynx, or hypopharynx. Methods: Development group members with expertise in dysphagia followed established guidelines for developing ECS. A professional search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements targeted at providers managing dysphagia in adult HNC populations. The development group prioritized topics where there was significant practice variation and topics that would improve the quality of HNC patient care if consensus were possible. Results: The development group identified 60 candidate consensus statements, based on 75 initial proposed topics and questions, that focused on addressing the following high yield topics: (1) risk factors, (2) screening, (3) evaluation, (4) prevention, (5) interventions, and (6) surveillance. After 2 iterations of the Delphi survey and the removal of duplicative statements, 48 statements met the standardized definition for consensus; 12 statements were designated as no consensus. Conclusion: Expert consensus was achieved for 48 statements pertaining to risk factors, screening, evaluation, prevention, intervention, and surveillance for dysphagia in HNC patients. Clinicians can use these statements to improve quality of care, inform policy and protocols, and appreciate areas where there is no consensus. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to dysphagia in HNC patients.

Background: The relationship between the value of reconstructive surgery and the visual attention drawn by facial deformity has not been studied. Objectives: We hypothesized that willingness to pay (WTP) for reconstructive surgery would increase as visual attention to deformity increased in a Mohs defect eye-tracking model. Methods: We conducted a randomized observational study. Eighty casual observers participated in timed eye-tracking trials utilizing preoperative and postoperative photographs from 32 patients with facial Mohs defects. Fixation on each defect was quantified in milliseconds. For each photograph, casual observers reported how much they would be willing to pay for a perfect reconstruction and rated defect severity and patient attractiveness. The associations between defect fixation time and WTP, attractiveness, and severity were modeled using a multivariate mixed-effects model. Results: Increased defect fixation time was associated with increased WTP (regression coefficient = 0.332651, p < 0.001), decreased attractiveness (regression coefficient = -0.221779, p < 0.001), and increased severity (regression coefficient = 0.363111, p < 0.001). As defect fixation time increased, WTP increased exponentially. Conclusions: Observer WTP for facial reconstruction increases exponentially as defects become more distracting. These findings justify the dedication of health care resources to reconstructive procedures that decrease attentional distraction to the greatest extent possible.

Background: Surgeons must select cases whose complexity aligns with their skill set. Objectives: To determine how accurately trainees report involvement in procedures, judge case complexity, and assess their own skills. Methods: We recruited attendings and trainees from two otolaryngology departments. After performing septoplasty, they completed identical surveys regarding case complexity, achievement of goals, who performed which steps, and trainee skill using the septoplasty global assessment tool (SGAT) and visual analog scale (VAS). Agreement regarding which steps were performed by the trainee was assessed with Cohen's kappa coefficients (κ). Correlations between trainee and attending responses were measured with Spearman's correlation coefficients (rho). Results: Seven attendings and 42 trainees completed 181 paired surveys. Trainees and attendings sometimes disagreed about which steps were performed by trainees (range of κ = 0.743-0.846). Correlation between attending and trainee responses was low for VAS skill ratings (range of rho = 0.12-0.34), SGAT questions (range of rho = 0.03-0.53), and evaluation of case complexity (range of rho = 0.24-0.48). Conclusion: Trainees sometimes disagree with attendings about which septoplasty steps they perform and are limited in their ability to judge complexity, goals, and their skill.

Purpose: Surgery involves modifying anatomy to achieve a goal. Reconstructing anatomy can facilitate surgical care through surgical planning, real-time decision support, or anticipating outcomes. Tool motion is a rich source of data that can be used to quantify anatomy. Our work develops and validates a method for reconstructing the nasal septum from unstructured motion of the Cottle elevator during the elevation phase of septoplasty surgery, without need to explicitly delineate the surface of the septum. Approach: The proposed method uses iterative closest point registration to initially register a template septum to the tool motion. Subsequently, statistical shape modeling with iterative most likely oriented point registration is used to fit the reconstructed septum to Cottle tip position and orientation during flap elevation. Regularization of the shape model and transformation is incorporated. The proposed methods were validated on 10 septoplasty surgeries performed on cadavers by operators of varying experience level. Preoperative CT images of the cadaver septums were segmented as ground truth. Results: We estimated reconstruction error as the difference between the projections of the Cottle tip onto the surface of the reconstructed septum and the ground-truth septum segmented from the CT image. We found translational differences of 2.74 ( 2.06 - 2.81 ) mm and a rotational differences of 8.95 ( 7.11 - 10.55 ) deg between the reconstructed septum and the ground-truth septum [median (interquartile range)], given the optimal regularization parameters. Conclusions: Accurate reconstruction of the nasal septum can be achieved from tool tracking data during septoplasty surgery on cadavers. This enables understanding of the septal anatomy without need for traditional medical imaging. This result may be used to facilitate surgical planning, intraoperative care, or skills assessment.