Clinical Care Redesign to Improve Value for Trigger Finger Release: A Before-and-After Quality Improvement Study.

Background: Trigger finger release (TFR) is a commonly performed procedure. However, there is great variation in the setting, care pathway, anesthetic, and cost. We compared the institutional cost for isolated TFR before and after redesigning our clinical care pathway. Methods: Total direct cost to the health system (excluding the surgeon and anesthesiology costs) and time spent by the patient at the surgery center were collected for 1 hand surgeon's procedures at an ambulatory surgery center over a 3-year period. We implemented a redesigned pathway that altered phases of care and anesthetic use by transitioning from intravenous (IV) sedation to wide awake local anesthesia with no tourniquet. Cost data were reported as percentage change in the median and compared both pre- to post-implementation and with 2 control surgeons using the traditional pathway within the same center. Power analysis was based on prior work on a carpal tunnel pathway. Significance was defined by a P-value < .05. Results: Ten TFRs (90% local with IV sedation) and 44 TFRs (89% local alone) were performed pre- and post-implementation, respectively. From pre- to post-implementation, the study surgeon's total direct cost decreased by 18%, while the control surgeons decreased by 2%. Median time spent at the surgery center decreased by 41 minutes post-implementation with significantly shorter setup time in the operating room (OR), total time in the OR, and time spent in recovery prior to discharge. Conclusions: Redesigning the care pathway for TFR led to a decrease in institutional cost and patient time spent at the surgery center.

Case Volume and Outcomes of Congenital Diaphragmatic Hernia Surgery in Academic Medical Centers.

OBJECTIVE: The outcome of patients with congenital diaphragmatic hernia (CDH) has not improved in the last decade and surgical repair remains the mainstay of treatment. The purpose of the present study was to assess whether a volume-outcome relationship exists in the U.S. academic medical centers performing surgical repair of neonatal CDH. STUDY DESIGN: A retrospective cross-sectional analysis of discharge data for neonates undergoing CDH repair in academic medical center members of the University Health-System Consortium was employed. Unadjusted mortality was compared between lower and higher surgical volume centers. A binary logistic regression model was fit to test the relationship of surgical volume with mortality. RESULTS: A total of 3,738 patients underwent surgical repair in 122 unique academic medical centers in the United States. The overall rate of survival was 75.2%. There was no difference in unadjusted mortality between lower and higher volume centers. After controlling for patient and hospital variables, there was no difference in the odds of mortality between lower and higher volume centers (odds ratio 1.03 [95% confidence interval, 0.86-1.23, p = 0.730]). CONCLUSIONS: Neonates born with congenital diaphragmatic hernia can undergo surgical repair in the U.S. academic medical centers independent of center procedure volume and expect good surgical outcomes.