Postoperative follow-up time and justification in prospective hand surgery research: a systematic review.

We systematically reviewed prospective studies for five hand procedures to analyse postoperative follow-up time, clinical or radiographic plateau, and whether the authors provide justification for times used. Demographic data, outcomes and mean follow-up were analysed. A total of 188 articles met our inclusion criteria. The mean postoperative follow-up time among these studies were carpal tunnel release, 21 months (range 1.5-111); cubital tunnel release, 27 months (2.5-46); open reduction and internal fixation for the distal radius fracture, 24 months (3-120); thumb carpometacarpal joint arthroplasty, 64 months (8.5-228); and flexor tendon repair, 25 months (3-59). Authors provided justification for follow-up intervals in 10% of these reports. We conclude that most prospective clinical studies in hand surgery do not properly justify follow-up length. Clinically unnecessary follow-up is costly without much benefit. In prospective research, we believe justified postoperative follow-up is essential, based on expected time to detect clinical plateau, capture complications and determine the need for secondary surgery.Level of evidence: III.

Variation in the Treatment of Distal Radius Fractures in the United States: 2010 to 2015.

BACKGROUND: It remains unknown whether treatment trends for distal radius fracture have changed in light of value-based care initiatives during recent years. The authors aimed to characterize modern practice patterns for distal radius fracture management. METHODS: Truven MarketScan databases from 2009 to 2015 were used to extract demographic characteristics, geographic location, and comorbidities for patients receiving treatment for a distal radius fracture. Regression modeling and Joinpoint analysis were used to assess treatment trends and the association of patient factors with treatment provided. RESULTS: Among 499,766 eligible encounters, the rate of internal fixation fluctuated around 13 percent. Casting/splinting remained the most frequent treatment across all populations. Treatment trends varied by age; children and adolescents almost exclusively received closed treatment (mean, 97 percent), yet rates of internal fixation increased among adults and elderly patients. Patients aged 55 to 64 years were most likely to undergo internal fixation (OR, 1.89; 95 percent CI, 1.82 to 1.96). Higher median household income also significantly increased odds of receiving internal fixation (p < 0.001). Despite declining rates of external fixation and percutaneous pinning, regional variations among surgical modalities persist. CONCLUSIONS: The increased use of internal fixation for distal radius fractures may be slowing. Treatment type continues to differ widely across demographic groups, underscoring the need for standardization. In accordance with value-based care initiatives, treatment decisions should be made to combine patient needs with financial implications on the health system. Comparative effectiveness data to derive optimal management strategies are still warranted.

Unplanned Emergency Department Visits within 30 Days of Mastectomy and Breast Reconstruction.

BACKGROUND: Unplanned emergency department visits are often overlooked as an indicator of care quality. The authors' objectives were to (1) determine the rate of 30-day emergency department visits following mastectomy with or without immediate reconstruction, (2) perform a risk analysis of potential factors associated with emergency department return, and (3) assess for potentially preventable visits with a focus on returns for pain. METHODS: Using the Healthcare Cost and Utilization Project data, the authors identified adult women who underwent mastectomy with or without reconstruction. Multivariable logistic regression was performed to evaluate risk of unplanned emergency department visits. The authors identified and sorted diagnostic codes to investigate why patients were seeking emergency department care. In addition, the authors performed a subgroup analysis on patients returning with a pain-related diagnosis to evaluate risk. RESULTS: Of 159,275 cases of mastectomy with or without immediate reconstruction, 4917 (3.1 percent) experienced an unplanned return to the emergency department within 30 days of operation. A substantial proportion of those who returned (23 percent) presented with a pain-related diagnosis. Only 0.9 percent of cases with a 30-day emergency department return were readmitted. CONCLUSIONS: Numerous patients return to the emergency department within 30 days of mastectomy with or without immediate reconstruction. There is a need for policy makers and physicians to implement strategies to reduce discretionary emergency department use, specifically among younger or publicly insured patients. Combining unplanned emergency department visits with readmission rates as a care quality indicator warrants consideration. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Improving Effective Magnetic Resonance Imaging (MRI) Application in Soft Tissue Wrist Injury.

INTRODUCTION: Magnetic resonance imaging (MRI) for soft-tissue wrist injury may be overprescribed, contributing to ineffective health care resource use. We aimed to discern predictive factors that may improve MRI's application in soft-tissue wrist injury. METHODS: We conducted a retrospective chart review of adults who underwent MRIs for possible soft-tissue wrist injury between June 2009 and June 2014. Clinical data and treatment recommendations before and after MRI were analyzed. If the MRI-directed treatment recommendation was different from before MRI, the MRI was noted to have influenced the patient's treatment (Impact MRI). RESULTS: Among 140 MRI scans, 39 (28%) impacted treatment recommendation. Twenty-six Impact MRIs were ordered by hand surgeons, whereas 13 were ordered by referring physicians (P = .001). More Impact MRIs were found when an MRI was ordered for patients younger than 36 years (P = .01), within 6 weeks of symptom onset (P = .03), to question a specific anatomic injury (P = .0001), or by a board-certified hand surgeon (P = .001). Adjusting for other covariates, these 4 clinical factors were identified as independent predictive factors to Impact MRIs. CONCLUSIONS: MRIs for soft-tissue wrist injuries may more likely change management when the patient is younger, ordered within 6 weeks of symptom onset, and prescribed with a specific differential diagnosis. Referral to a hand surgeon should be considered before wrist MRI for the following patients: history of hand surgery/trauma, older than 36 years likely due to confounding chronic wrist changes, symptomatic for more than 6 weeks, and without clear differential diagnoses for the symptoms.

Older Patient Preferences for Internal Fixation after a Distal Radius Fracture: A Qualitative Study from the Wrist and Radius Injury Surgical Trial.

BACKGROUND: Distal radius fracture treatments provide similar functional outcomes. It has been hypothesized that the use of internal fixation is increasing because of physician preferences. The multisite randomized Wrist and Radius Injury Surgical Trial provides a unique opportunity to examine patient preferences in the absence of surgeon influence. The authors' objective was to investigate patient preference for internal fixation even after being informed of the equipoise among treatments. METHODS: The authors performed 30 semistructured interviews with older individuals, all older than 60 years, approached at their institution for the Wrist and Radius Injury Surgical Trial. The authors' sample included three groups: those with a preference for internal fixation (n = 11), those with preference for nonsurgical treatment (n = 6), and those without a preference who consented to surgical randomization (n = 13). We used grounded theory for data collection and analysis. RESULTS: All participants indicated their chief concern was regaining full function. Patients based their preferences for internal fixation on multiple values, including obstacles to recovery, autonomy, aesthetics, and pain relief. Some patients who did not select internal fixation reflected on their experiences, questioning whether they would have had a potentially different outcome with internal fixation treatment. CONCLUSIONS: Without evidence for a superior treatment, patients focus on factors that pertain to recovery rather than outcomes, with most preferring the volar locking plating system. To best align with patient values, physicians should focus their discussion with patients on aspects of the recovery period rather than functional outcomes. Evidence from the Wrist and Radius Injury Surgical Trial will provide high-level information about patient-reported, functional, and radiographic outcomes.

Cost of Surgical Treatment for Distal Radius Fractures and the Implications of Episode-Based Bundled Payments.

PURPOSE: To examine the cost of care of surgical treatment for a distal radius fracture (DRF) and develop episodes that may be used to develop future bundled payment programs. METHODS: Using 2009 to 2015 claims data from the Truven MarketScan Databases, we examined the cost of care for surgical treatment of DRFs among adult patients in the United States. We excluded patients with concurrent fractures, patients who required complex care, and patients in assisted living facilities. We extracted data on cost and type of services provided to eligible patients, tracking patients from 3 days prior to operation to 90 days after operation. From these data, we developed 4 episode-of-care scenarios to develop an estimated bundled payment. We computed the variation in cost between surgery types, time periods, and type of service provided. RESULTS: Our final sample included 23,453 DRF operations, of which 15% were performed on patients 65 years of age or older. The majority (88%) underwent open fixation, the option associated with the highest cost. The average cost of care for a DRF patient ranged from $6,577 to $8,181 depending on the definition of an episode-of-care. Regardless of definition, the variation in cost was high. The cost of surgery itself composed 61% to 91% of the total cost of an episode. Of claims not directly related to the surgery, anesthesia and drugs, imaging, and therapy costs composed the next greatest proportions of the total cost of care. CONCLUSIONS: Many DRF surgical episodes incur substantially higher costs than the average. To maximize cost reduction, bundled payments for DRFs are best designed with a clinically narrow definition that is limited to services related to the fracture and long enough to capture relevant postoperative therapy and imaging costs. CLINICAL RELEVANCE: This study provides insight on spending to lay the foundation for shifting reimbursement strategies.

Complications of Proximal Interphalangeal Joint Injuries: Prevention and Treatment.

Proximal interphalangeal joint injuries are one of the most common injuries of the hand. The severity of injury can vary from a minor sprain to a complex intra-articular fracture. Because of the complex anatomy of the joint, complications may occur even after an appropriate treatment. This article provides a comprehensive review on existing techniques to manage complications and imparts practical points to help prevent further complications after proximal interphalangeal joint injury.

Learning from an Unsuccessful Study Idea: Reflection and Application of Innovative Techniques to Prevent Future Failures.

A well-organized, thoughtful study design is essential for creating an impactful study. However, pressures promoting high output from researchers can lead to rushed study proposals that overlook critical weaknesses in the study design that can affect the validity of the conclusions. Researchers can benefit from thorough review of past failed proposals when crafting new research ideas. Conceptual frameworks and root cause analysis are two innovative techniques that can be used during study development to identify flaws and prevent study failures. In addition, conceptual frameworks and root cause analysis can be combined to complement each other to provide both a big picture and detailed view of a study proposal. This article describes these two common analytical methods and provides an example of how they can be used to evaluate and improve a study design by critically examining a previous failed research idea.

The Desired Role of Health Care Providers in Guiding Older Patients With Distal Radius Fractures: A Qualitative Analysis.

PURPOSE: Understanding patient preferences for shared decision making is valuable for surgeons to advance patient-centered care, particularly in cases where there is not a clearly superior treatment option, like distal radius fracture. The existing evidence presents conflicting views on the desired role of the provider among older patients when making medical decisions. We aimed to investigate the perceived versus desired role of the provider in older adult patients with distal radius fracture. METHODS: Thirty patients (≥62 years old) who had sustained a distal radius fracture within the past 5 years were recruited from the screening process of the Wrist and Radius Injury Surgical Trial at the principal investigator's site using purposive sampling. A trained member of the research team conducted interviews in a semistructured format with the help of an interview guide. Findings were derived following the principles of grounded theory. RESULTS: Participants experienced varied levels of shared decision making with the hand surgeon. Subjects' perceived role of the surgeon did not always match their desired role. Most patients placed distinct trust in the recommendations of hand specialists regarding the technical aspects of the treatment. Nonetheless, respondents wanted to provide input when decisions pertained to outcomes or functionality. Many patients sought outside support from family or friends in the health care field, regardless of the outside source's medical specialty. CONCLUSIONS: Despite conflicting evidence, most older adult patients desire a shared approach when making treatment decisions. Exchanging information and preferences on outcomes of each treatment option may be more important to the patient than detailing the specific technical aspects of their care. CLINICAL RELEVANCE: To provide high quality care, surgeons should evaluate the desired role of the patient to make treatment decisions at the start of their interaction. Surgeons must be aware of outside medical influences that guide their patients' decision-making processes.

The Effect of Impactful Articles on Clinical Practice in the United States: Corticosteroid Injection for Patients with Lateral Epicondylitis.

BACKGROUND: Following publication of high-level evidence demonstrating that it is not an effective treatment for lateral epicondylitis, a reduction in the corticosteroid injection rate would be expected. The authors aimed to clarify current clinical practice pattern for lateral epicondylitis and identify factors that influence the introduction of evidence into clinical practice. METHODS: In this administrative claims analysis, the authors used 2009 to 2015 Truven MarketScan data to extract claims for corticosteroid injection, physical therapy, platelet-rich plasma injection, and surgery for lateral epicondylitis. The authors performed multivariable analysis using a generalized estimating equation model to identify the variables that potentially affect the odds of receiving a given treatment. RESULTS: Among 711,726 claims, the authors found that the odds of receiving a corticosteroid injection increased slightly after publication of contradictory evidence (OR, 1.7; 95 percent CI, 1.04 to 1.11 in 2015). Being male (OR, 1.21; 95 percent CI, 1.19 to 1.23), older (OR, 1.16; 95 percent CI, 1.13 to 1.19), and having managed care insurance (OR, 1.15; 95 percent CI, 1.13 to 1.18) significantly contributed to increased odds of receiving corticosteroid injections. Patients seen at facilities in the South (OR, 1.33; 95 percent CI, 1.30 to 1.36 compared with the Northeast) and by plastic/orthopedic surgeons (OR, 2.48; 95 percent CI, 2.43 to 2.52) also had increased odds of receiving corticosteroid injection. CONCLUSIONS: Corticosteroid injection use did not decrease after publication of impactful articles, regardless of provider specialty or other patient-related factors. This finding emphasizes that there are various barriers for even high-level evidence to overcome the inertia of current practice.

The threat of longitudinal cracking after distal radius fracture treatment with volar locking plate.

The purpose of this study was to examine the occurrence rate of longitudinal cracks and associated characteristics following volar locking plate fixation of the distal radius. Using case records from Shizuoka Saiseikai General Hospital dated between March 2008 and March 2015, a total of 419 eligible adult patients were identified. Standard anteroposterior postoperative radiographs were evaluated to classify longitudinal crack occurrence. Documented variables were compared between patients with longitudinal cracking and those without. Univariate analyses were conducted among each plate group. There were 38 confirmed cases of cracking (Acu-Loc: n = 25, Acu- Loc 2: n = 11, VA-TCP: n = 2). All cracks healed within 4 to 6 weeks after the operation. Plate type, along with patient age and sex were significantly associated with the occurrence of a longitudinal crack (p < 0.05). Although no severe complications related to longitudinal cracking were observed, associated risks for specific patient groups should be considered.

Use and Associated Spending for Anesthesiologist-Administered Services in Minor Hand Surgery.

BACKGROUND: Evidence is lacking to support the use of specialized anesthesia providers in minor surgical operations for patients without medical necessity. The authors sought to estimate the extent of potentially discretionary service use (anesthesiologist-administered anesthesia services among low-risk patients). METHODS: The authors performed a retrospective claims analysis using the Truven MarketScan Database to estimate the prevalence and cost of anesthesiologist-administered anesthesia services provided to patients undergoing minor hand surgery (i.e., carpal tunnel release, trigger finger release, or de Quervain release) from 2010 to 2015. A predictive probability model was created to estimate patient risk status. The authors examined the relationship between patient risk status and anesthesia use using multivariable regression models. RESULTS: Of 441,579 eligible procedures, 352,779 (80 percent) involved anesthesiologist-administered anesthesia services. The total proportion of estimated anesthesiologist-administered anesthesia use in low-risk patients who did not need anesthesiologist support declined over the study period (from 69.7 percent in 2010 to 65.8 percent in 2015). Although total payments for these services remained steady between 2010 and 2014, the average payment per procedure increased regardless of procedure type (from $376.8 in 2010 to $427.9 in 2015 for a carpal tunnel release operation). Approximately 83.7 percent of payments ($133 million) to anesthesia providers is credited to services in low-risk patients. CONCLUSIONS: Anesthesiologist-administered anesthesia services are commonly rendered to low-risk surgical patients. Existing health care reform efforts do not adequately address discretionary services that can be a targeted area for cost saving. It is important to consider the implications of potentially discretionary use of specialized anesthesia providers, particularly with the advancement of bundled payment models.

A Population-Based Study of Replantation After Traumatic Thumb Amputation, 2007-2012.

PURPOSE: The recommended surgical treatment after thumb amputation is replantation. In the United States, fewer than 40% of thumb amputation injuries are replanted, and little is known about factors associated with the probability of replantation. We aimed to investigate recent trends and examine patient and hospital characteristics that are associated with increased probability of attempted thumb replantation. We hypothesized that higher-volume teaching hospitals and level-I trauma centers attempted more replantations. METHODS: We used 2007-2012 data from the National Trauma Data Bank. Our final sample included 2,206 traumatic thumb amputation patients treated in 1 of 365 centers during the study period. First, we used a 2-level hierarchical logistic model to estimate the odds of replantation. In addition, we used a treatment effect estimation method, with the inverse propensity score weighting to examine the difference in thumb replantation if the only variation among patients was their presumptive payer. RESULTS: There was a higher probability of attempted replantation at teaching hospitals than nonteaching hospitals (odds ratio [OR], 1.40). Patients were less likely to undergo replantation at a level II (OR, 0.53) or a level III (OR, 0.33) trauma center. The uninsured were less likely to undergo replantation (OR, 0.61) than those with private insurance. CONCLUSIONS: Having insurance coverage and being treated in a high-volume, teaching, level-I trauma hospital increased the odds of replantation after traumatic thumb amputation. Regionalization may lead to a higher number of indicated cases of replantation actually being attempted. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.