The Application of Medicare Data for Musculoskeletal Research in the United States: A Systematic Review.

INTRODUCTION: Musculoskeletal conditions disproportionately affect the lives of aging adults. We aimed to examine the literature using Medicare claims data in the United States for musculoskeletal surgical procedures. METHODS: Following the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, we searched the PubMed and Medline databases for peer-reviewed articles published between 1990 and 2015. We included the studies that (1) reported primary Medicare claims data use, (2) involved musculoskeletal surgery, and (3) were original peer-reviewed studies. We abstracted the types of surgical procedure and aims, and evaluated outcomes, and strengths and weaknesses of each included article. We assessed the quality of included articles with Newcastle Ottawa Assessment Scale. RESULTS: The literature search returned 3,233 articles, of which 119 met our inclusion criteria. These studies focused on different outcomes: epidemiology and treatment variation (26), cost of care (15), hospital-level analyses (30), health outcomes (31), the validity and accuracy of Medicare claims data (4), disparities in health care (10), and policy evaluation (3). DISCUSSION: Medicare claims data provide a unique way for researchers to study a nationally representative patient population longitudinally. A significant limitation of using claims data has been a lack of granularity on defining severity of a condition. LEVEL OF EVIDENCE: Therapeutic level III.

The Stener Lesion: Historical Perspective and Evolution of Diagnostic Criteria.

BACKGROUND: In 1962, Bertil Stener first described the anatomy and treatment of the displaced ulnar collateral ligament of the metacarpophalangeal joint, later called the Stener lesion. Since Stener's publication, treatment algorithms for ulnar collateral ligament rupture have aided in preoperative diagnosis, yet the best diagnostic method to assess ligament displacement remains largely undefined. METHODS: An extensive literature search was performed to explore the treatment evolution of the Stener lesion and explore how technical development has influenced Stener lesion diagnosis. We also sought to illuminate the life and work of Bertil Stener. RESULTS: Studies evaluating the use of magnetic resonance imaging (MRI) and ultrasound (US) technology have suggested that these modalities have improved Stener lesion diagnosis. CONCLUSION: Despite the utility of developing MRI and US technology, consensus for one superior diagnostic tool for Stener lesions does not currently exist.

A Systematic Review of Economic Analysis of Surgical Mission Trips Using the World Health Organization Criteria.

BACKGROUND: Although the World Health Organization (WHO) has developed tools to standardize economic evaluations of global health interventions, little is known about the cost-effectiveness of surgical mission trips and their economic values. Our objective was to systematically evaluate the current literature on surgical volunteering trips to measure their adherence to WHO CHOosing Interventions that are cost-effective (WHO-CHOICE). We hypothesized that the majority of studies use some type of cost-effectiveness analysis that do not adhere to these standards. METHODS: A systematic review of Pubmed, Medline, and Embase databases was performed in accordance with PRISMA guidelines, with inclusion criteria set a priori. Of the 908 publications screened, 72 were selected for full text review; 17 met inclusion criteria. RESULTS: Only 17 out of 72 studies reported some type of economic analysis. We categorized the studies into service, educational, and combination (service and educational) surgical trips. Although seven of the service studies calculated the cost per disability-adjusted life year averted, the results were not based on WHO-CHOICE standards to facilitate comparisons among alternative options. Furthermore, none of the three educational trips calculated the value of the education provided, but only published cost estimates of the resources used during the trip. CONCLUSIONS: Although a few studies performed some type of economic analysis, owing to their non-adherence to WHO-CHOICE standards, the results were not comparable to other studies. International surgical trips are expensive. To improve the efficacy and optimal use of limited resources, studies on surgical trips should follow the guidelines set by the WHO-CHOICE.

Cross-cultural variation in preference for replantation or revision amputation: Societal and surgeon views.

Treatment decisions after an injury like finger amputation are made based on injury and patient factors. However, decisions can also be influenced by provider and patient preferences. We compared hand surgeon and societal preferences and attitudes regarding finger amputation treatment in Japan and the US. We performed a cross-sectional survey with subjects derived from large tertiary care academic institutions in the US and Japan. We secured 100% participation of American hand surgeon members of the Finger Replantation and Amputation Multicenter Study and presenting hand surgeons at the 32nd Annual meeting of the Central Japanese Society for Surgery of the Hand. Societal preferences were gathered from volunteers at the 2 universities in the US and Japan. There were no significant differences in estimations of function, sensation, or appearance after replantation; American and Japanese societal participants preferred replantation compared to surgeons, although this was more pronounced in Japan. The Japanese society displayed more negative attitudes toward finger amputees than did Japanese surgeons. American respondents anticipated more public stigmatisation of amputees than did American surgeons. Societal preference for replantation was not caused by inflated expectations of outcomes after replantation. Japanese societal preference was likely driven by negative views of finger amputees. American society noted no decrease in physical health after amputation, but did note a quality of life decrease attributed to public stigmatisation. Japanese society and surgeons had a stronger preference for replantation than American society and surgeons, possibly attributed to cultural differences.

Care Transfers for Patients With Upper Extremity Trauma: Influence of Health Insurance Type.

PURPOSE: To understand the differences in transfer incidence for patients with upper extremity trauma by hospital trauma center designation. We hypothesized that patients with public or no insurance were more likely to be transferred to another facility compared with privately insured patients. METHODS: Trauma centers are designated by local authorities and verified by the American College of Surgeons. Using the 2012 National Trauma Data Bank, we examined the probability of being transferred from one center to another for patients who sustained isolated upper extremity trauma. We used multivariable logistic regression with a clustered variance method to adjust for intrahospital correlation to compare risk-adjusted transfer incidence for patients with upper extremity injuries by trauma center designation. RESULTS: In 2012, 6,214 patients ages 18-64 with isolated upper extremity trauma presented to 477 hospitals. Overall, transfer incidence was significantly higher among level III trauma centers (26%) compared with level II (11%) or level I (2%) trauma centers. Adjusting for patient and hospital characteristics patients with Medicaid were more likely to be transferred from level III trauma centers to another center compared with privately insured patients. CONCLUSIONS: Current regulations may not prevent unnecessary patient transfers based on insurance status among level III trauma centers. Policy makers should compensate or provide incentives to hospitals that take care of poorly insured patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/decision III.

Hand Trauma Care in the United States: A Literature Review.

BACKGROUND: Hand trauma is one of the most complex injuries treated in the emergency department. Hand trauma injuries are time sensitive and require highly specialized care. Patients may have difficulty accessing appropriate hand trauma care because of a variety of factors. The authors aimed to evaluate the state of the hand trauma system by examining articles that reported on access to hand trauma care. METHODS: The authors conducted a literature review on hand trauma care using the PubMed, Ovid MEDLINE, and Embase databases. The authors included English language articles from the United States that described access to hand trauma care in the emergency health system. RESULTS: Fourteen studies met the authors' inclusion criteria. Ten studies evaluated access to hand trauma care on a patient level. Of these 10 studies, five reported on access to care for transferred patients and five reported on access to care for patients with amputation injuries. The other four studies evaluated access to hand trauma care at a hospital level. CONCLUSIONS: Lack of hand trauma guidelines at emergency departments and a severe shortage of on-call hand specialists at community hospitals and trauma centers have created a suboptimal system of hand emergency care in the United States. The current system of hand trauma care in the United States not only may drive up the cost of care but may also adversely affect patients' health and well-being.

Does Medicare Managed Care reduce racial/ethnic disparities in diabetes preventive care and healthcare expenditures?

OBJECTIVES: Large and persistent racial/ethnic disparities exist in diabetes care. Considering the rapid rate of growth of Medicare Managed Care (MMC) plans among minority populations, our aim was to investigate whether disparities in diabetes management and healthcare expenditures are smaller in MMC versus Medicare fee-for-service (MFFS) plans. We hypothesized that racial/ethnic disparities in diabetes care and in health expenditures would be less pronounced in MMC compared with MFFS plans. STUDY DESIGN: Nationally representative data from the 2006 to 2011 Medical Expenditure Panel Survey on white, African American, and Hispanic seniors with diabetes were analyzed. METHODS: We examined 4 measures of diabetes care-regular foot check, eye exam, cholesterol check, and flu vaccine-and total and out-of-pocket (OOP) healthcare expenditures. We implemented the Institute of Medicine's definition of disparity, applied propensity score weighting to adjust for potential differential selection, and used a difference-in-differences generalized linear framework to estimate outcome measures. RESULTS: For African Americans, MMC was associated with a $1183 (P <.036) reduction and a $547 (P <.001) increase in disparities in total and OOP healthcare expenditures, respectively. For Hispanics, disparities in foot exam, flu shot, and cholesterol check decreased by 5, 10, and 7 percentage points (P <.001); additionally, disparities in total and OOP healthcare expenditures were reduced by $3588 and $276 (P <.001), respectively. MMC plans spend less on everyone, including whites. CONCLUSIONS: Hispanic/white disparities in diabetes management and healthcare expenditures were smaller in MMC than in MFFS plans. African American/white disparities were not consistently larger in 1 setting than the other.

Guyon canal: the evolution of clinical anatomy.

Guyon canal refers to the ulnar tunnel at the wrist named for the French surgeon Jean Casimir Félix Guyon, who described this space in 1861. After Guyon's description, clinicians have focused their interest on symptoms caused by compression of structures occupying this canal (later named ulnar tunnel syndrome or Guyon syndrome). However, disagreement and confusion persisted over the correct anatomical boundaries and terminology used to describe the ulnar tunnel. Through anatomical investigation and evolving clinical case studies, the current understanding of the anatomy of the ulnar tunnel was established. This article examines the evolution of the anatomical description of the ulnar tunnel and its relevant clinical associations and casts light on the life and contributions of Guyon.