Cost Savings and Patient Experiences of a Clinic-Based, Wide-Awake Hand Surgery Program at a Military Medical Center: A Critical Analysis of the First 100 Procedures.

PURPOSE: Wide-awake, local anesthesia, no tourniquet (WALANT) hand surgery was developed to improve access to hand surgery care while optimizing medical resources. Hand surgery in the clinic setting may result in substantial cost savings for the United States Military Health Care System (MHS) and provide a safe alternative to performing similar procedures in the operating room. METHODS: A prospective cohort study was performed on the first 100 consecutive clinic-based WALANT hand surgery procedures performed at a military medical center from January 2014 to September 2015 by a single hand surgeon. Cost savings analysis was performed by using the Medical Expense and Performance Reporting System, the standard cost accounting system for the MHS, to compare procedures performed in the clinic versus the operating room during the study period. A study specific questionnaire was obtained for 66 procedures to evaluate the patient's experience. RESULTS: For carpal tunnel release (n = 34) and A1 pulley release (n = 33), there were 85% and 70% cost savings by having the procedures performed in clinic under WALANT compared with the main operating room, respectively. During the study period, carpal tunnel release, A1 pulley release, and de Quervain release performed in the clinic instead of the operating room amounted to $393,100 in cost savings for the MHS. There were no adverse events during the WALANT procedure. CONCLUSIONS: A clinic-based WALANT hand surgery program at a military medical center results in considerable cost savings for the MHS. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analysis IV.

Time to Death and Reenrollment After Live Discharge From Hospice: A Retrospective Look.

BACKGROUND: The purpose of our study was to identify time to death and/or reenrolled patients alive at the time of hospice discharge. METHODS: Medical records of all adults alive at hospice discharge during a 5-year period were retrospectively reviewed. RESULTS: In all, 83 patients were alive at discharge, with 3 lost to follow-up. Average time from discharge to death was 199.9 days for all patients and 50 days for the 17 patients who reenrolled. Average time from discharge to reenrollment was 245 days. CONCLUSION: Our research supports past findings that over a third of patients disenrolled from hospice die within 6 months, indicating ongoing hospice eligibility up to the time of death. Interestingly, if enrollment was revoked by patient or family, as often was done to allow the patient to pursue more aggressive treatments, the mortality risk was higher in the 6 months after discharge. This should prompt careful reevaluation of disenrolled hospice patients in the months after disenrollment, and hospice reenrollment should be continually available and offered during this time.