Are Quality Scores in the Centers for Medicaid and Medicare Services Merit-based Incentive Payment System Associated With Outcomes After Outpatient Orthopaedic Surgery?

BACKGROUND: The Medicare Merit-based Incentive Payment System (MIPS) ties reimbursement incentives to clinician performance to improve healthcare quality. It is unclear whether the MIPS quality score can accurately distinguish between high-performing and low-performing clinicians. QUESTIONS/PURPOSES: (1) What were the rates of unplanned hospital visits (emergency department visits, observation stays, or unplanned admissions) within 7, 30, and 90 days of outpatient orthopaedic surgery among Medicare beneficiaries? (2) Was there any association of MIPS quality scores with the risk of an unplanned hospital visit (emergency department visits, observation stays, or unplanned admissions)? METHODS: Between January 2018 and December 2019, a total of 605,946 outpatient orthopaedic surgeries were performed in New York State according to the New York Statewide Planning and Research Cooperative System database. Of those, 56,772 patients were identified as Medicare beneficiaries and were therefore potentially eligible. A further 34% (19,037) were excluded because of missing surgeon identifier, age younger than 65 years, residency outside New York State, emergency department visit on the same day as outpatient surgery, observation stay on the same claim as outpatient surgery, and concomitant high-risk or eye procedures, leaving 37,735 patients for analysis. The database does not include a list of all state residents and thus does not allow for censoring of patients who move out of state. We chose this dataset because it includes nearly all hospitals and ambulatory surgery centers in a large geographic area (New York State) and hence is not limited by sampling bias. We included 37,735 outpatient orthopaedic surgical encounters among Medicare beneficiaries in New York State from 2018 to 2019. For the 37,735 outpatient orthopaedic surgical procedures included in our study, the mean ± standard deviation age of patients was 73 ± 7 years, 84% (31,550) were White, and 59% (22,071) were women. Our key independent variable was the MIPS quality score percentile (0 to 19th, 20th to 39th, 40th to 59th, or 60th to 100th) for orthopaedic surgeons. Clinicians in the MIPS program may receive a bonus or penalty based on the overall MIPS score, which ranges from 0 to 100 and is a weighted score based on four subscores: quality, promoting interoperability, improvement activities, and cost. The MIPS quality score, which attempts to reward clinicians providing superior quality of care, accounted for 50% and 45% of the overall MIPS score in 2018 and 2019, respectively. Our main outcome measures were 7-day, 30-day, and 90-day unplanned hospital visits after outpatient orthopaedic surgery. To determine the association between MIPS quality scores and unplanned hospital visits, we estimated multivariable hierarchical logistic regression models controlling for MIPS quality scores; patient-level (age, race and ethnicity, gender, and comorbidities), facility-level (such as bed size and teaching status), surgery and surgeon-level (such as surgical procedure and surgeon volume) covariates; and facility-level random effects. We then used these models to estimate the adjusted rates of unplanned hospital visits across MIPS quality score percentiles after adjusting for covariates in the multivariable models. RESULTS: In total, 2% (606 of 37,735), 2% (783 of 37,735), and 3% (1013 of 37,735) of encounters had an unplanned hospital visit within 7, 30, or 90 days of outpatient orthopaedic surgery, respectively. Most hospital visits within 7 days (95% [576 of 606]), 30 days (94% [733 of 783]), or 90 days (91% [924 of 1013]) were because of emergency department visits. We found very small differences in unplanned hospital visits by MIPS quality scores, with the 20th to 39th percentile of MIPS quality scores having 0.71% points (95% CI -1.19% to -0.22%; p = 0.004), 0.68% points (95% CI -1.26% to -0.11%; p = 0.02), and 0.75% points (95% CI -1.42% to -0.08%; p = 0.03) lower than the 0 to 19th percentile at 7, 30, and 90 days, respectively. There was no difference in adjusted rates of unplanned hospital visits between patients undergoing surgery with a surgeon in the 0 to 19th, 40th to 59th, or 60th to 100th percentiles at 7, 30, or 90 days. CONCLUSION: We found that the rates of unplanned hospital visits after outpatient orthopaedic surgery among Medicare beneficiaries were low and primarily driven by emergency department visits. We additionally found only a small association between MIPS quality scores for individual physicians and the risk of an unplanned hospital visit after outpatient orthopaedic surgery. These findings suggest that policies aimed at reducing postoperative emergency department visits may be the best target to reduce overall postoperative unplanned hospital visits and that the MIPS program should be eliminated or modified to more strongly link reimbursement to risk-adjusted patient outcomes, thereby better aligning incentives among patients, surgeons, and the Centers for Medicare ad Medicaid Services. Future work could seek to evaluate the association between MIPS scores and other surgical outcomes and evaluate whether annual changes in MIPS score weighting are independently associated with clinician performance in the MIPS and regarding clinical outcomes. LEVEL OF EVIDENCE: Level III, therapeutic study.

Predicting Acute Median Neuropathy in Perilunate Injuries.

Purpose: Perilunate fracture dislocation (PLFD) injuries are associated with the development of acute carpal tunnel syndrome (CTS). The purpose of our study was to identify the factors that increase the likelihood of developing CTS in patients with PLFD. Additionally, we attempted to classify patients who did not initially undergo carpal tunnel release (CTR) at the time of injury but eventually underwent CTR within the follow-up period. Methods: Patients presenting to a level-1 trauma center with isolated PLFDs (Mayfield III-IV) were retrospectively identified by using CPT and ICD-10 codes. Polytraumatized patients, those with a history of previous wrist trauma, or those with previous carpal tunnel symptoms or surgery were excluded. Outcomes of interest included the development of acute CTS, pre- and post-reduction changes in CTS symptoms, and associated hand and wrist fractures. Chi-square tests, Kruskal-Wallis tests, and multivariate logistic regression were used to examine the predictors of developing CTS after a PLFD. Results: In total, 43 patients were included in the final cohort, with a mean age of 44 years, of which 77% were men. The most common fracture of the carpus included scaphoid fractures (9/43, 21%). The average time from presentation to reduction was 636 minutes. Acute CTS symptoms before reduction were present in 26% of the patients and increased post-reduction to 28%. No difference exists between the time to sedation and the presence of acute carpal tunnel symptoms (P >.05). During initial surgical intervention, 79% underwent CTR (27/34). Of the seven patients who did not initially undergo a CTR, 57% (4/7) required a CTR within the follow-up period. Conclusion: Reduction of PLFDs did not significantly improve the number of patients with acute CTS. More than 50% of the patients who did not undergo a CTR at the initial surgery required a CTR within the follow-up period. Type of study/level of evidence: Prognostic III.

External Fixation Prior to Fasciectomy Leads to Substantial Improvement of Advanced Dupuytren's PIP Contractures at Mean Follow-up 15 Months.

BACKGROUND: The Digit Widget is an external fixation device that can be used to reverse proximal interphalangeal joint (PIPJ) contractures in the hand. Our hypothesis is that usage of the Digit Widget prior to fasciectomy in patients with severe Dupuytren's proximal interphalangeal (PIP) contractures will result in short-term improvement and maintenance of the PIPJ contracture after fasciectomy. METHODS: Patients who underwent placement of the Digit Widget soft tissue distractor prior to fasciectomy for Dupuytren's disease were identified between January 2015 and December 2018. Multiple fingers were considered separately. Patient Reported Outcome Measurement Information System (PROMIS) Physical Function (PF), Pain Interference, and Depression scores were collected. Patients treated for contractures from etiologies other than Dupuytren's were not included. Multiple linear regression was used to compare initial PIP contractures, PF scores, and final contractures. RESULTS: There were 28 fingers in 24 patients with average age of 56 ± 12 (30.5-69.9) years. Initial mean PIPJ contracture was 81° (50°-120°), which had corrected to 23° at time of removal. Average time between application and fasciectomy was 58 (28-112) days. At final follow-up, average 449 (58-1641) days, the average contracture was 39° (0°-105°). Contracture immediately following fasciectomy was found to be strongly correlated with the contracture at final follow-up. There was no statistical relationship between final PROMIS PF scores and final change in contracture. CONCLUSIONS: Digit Widget external fixation is an effective treatment for the correction of advanced PIPJ contractures related to Dupuytren's disease, with an average of 52% improvement in contracture at 15 months.

Eponyms Describing Soft Tissue Pathologies in Orthopedic Hand Surgery.

Orthopedic surgery literature utilizes numerous eponyms, and they have become commonplace among orthopedic surgeons and the general public alike. These eponyms can have important historical implications and their history is often overlooked by the physicians using such terms. This paper seeks to specifically explore the origins of eponyms in orthopedic soft tissue diseases involving the upper extremity. Shedding light onto the origin of these eponyms can provide greater respect and understanding of their use in orthopedic surgery today.

Development of de Quervain Tenosynovitis After Distal Radius Fracture.

BACKGROUND: We sought to determine the risk factors for the development of de Quervain tenosynovitis after distal radius fractures. Our hypothesis is that longer periods of immobilization and higher-energy fracture patterns will correlate with the development of de Quervain tenosynovitis. METHODS: This is a 10-year retrospective study of 1451 consecutive patients with distal radius fractures presenting to a large academic institution. The incidence and relative risk of de Quervain tenosynovitis within 1 year of sustaining a distal radius fracture were analyzed. RESULTS: In total, 41 patients developed posttraumatic de Quervain tenosynovitis at an average time of 6.5 months. In the operative cohort, the incidence was 2.2%, and that of the nonoperative group was 3.8%. Among all affected patients, 78% admitted to strenuous, overuse activities or careers. Compared with the unaffected cohort, the de Quervain tenosynovitis group was more likely to be female and black with similar age and body mass index. The traumatic cohort was less likely to respond to corticosteroid injections. A separate extensor pollicis brevis (EPB) sheath was noted in all patients requiring surgical release. CONCLUSIONS: Patients with a nonoperative distal radius fracture were 4.2 times more likely to develop de Quervain's than the general population, and those treated operatively were 2.4 times more likely. These patients were more likely to be female, black, and engage in strenuous overuse activities or careers. They demonstrated higher-energy fracture patterns and worse response to corticosteroid injections, more frequently requiring surgical decompression. Among those requiring surgery, patients were 2.5 times more likely to have a separate EPB sheath than those with atraumatic Quervain's.

Prospective Analysis of Hand Infection Rates in Elective Soft Tissue Procedures of the Hand: The Role of Preoperative Antibiotics.

Background: The purpose of this study was to evaluate the efficacy of prophylactic antimicrobial prophylaxis in elective hand surgery in preventing postoperative infection. Methods: Between 2009 and 2012, we performed a multicenter trial in which patients undergoing elective hand surgeries were categorized into an antibiotic or control group depending on the center they were enrolled in. Surgical site infections were defined according to the Centers for Diseases Control and Prevention. Results: In total, 434 patients were included: 257 did not receive antibiotics (control) and 177 received antibiotics at a mean age of 61.0 years. In the control group, comorbidities were more common with 23.7% (61/257) in comparison to the antibiotics group with 14.1% (25/177). Only one surgical site infection in each group was identified. One wound was opened surgically, and an antimicrobial treatment was indicated in both cases. In addition, we observed four complications in the control group and three complications in the antibiotics group which required conservative management. No significant differences in the two cohorts in infection rate (0.006% vs 0.003%, χ2 = 0.07, P > .05) and complication rate (2.8% vs 1.6%, χ2 = 0.01, P > .05) were found. Conclusions: Our prospective multicenter trial showed no significant difference in infection rate in elective hand surgery whether antibiotics were administered preoperatively or not.

Operative Treatment is Not Associated with More Relief of Depression Symptoms than Nonoperative Treatment in Patients with Common Hand Illness.

BACKGROUND: Depression symptoms are prevalent in the general population, and as many as one in eight patients seeing a hand surgeon may have undiagnosed major depression. It is not clear to what degree lower mood is the consequence or cause of greater symptoms and limitations. If depressive symptoms are a consequence of functional limitations, they might be expected to improve when pathophysiology and impairment are ameliorated. Because surgical treatment is often disease-modifying or salvage, surgery might have a greater impact than nonoperative treatment, which is more often palliative (symptom relieving) than disease-modifying. QUESTIONS/PURPOSES: (1) For which hand or wrist conditions are depression symptoms lower after operative compared with nonoperative treatment? (2) Among the subset of patients with the highest depression scores, are depression symptoms lower after operative treatment compared with nonoperative treatment? (3) Among the subset of patients who had nonoperative treatment, are depression symptoms lower after a corticosteroid injection compared with no specific biomedical intervention? METHODS: At an academic orthopaedic department, 4452 patients had a new office visit for carpal tunnel syndrome, benign neoplasm, primary hand osteoarthritis, de Quervain's tendinopathy, or trigger digit. We analyzed the 1652 patients (37%) who had a return visit at least 3 months later for the same diagnosis. Patients completed the Patient-reported Outcomes Measurement Information System (PROMIS) Depression computerized adaptive test at every office visit (higher scores indicate more depression symptoms) and PROMIS Pain Interference (higher scores indicates greater hindrance in daily life owing to pain). Patients with a return visit were more likely to have surgical treatment and had greater Pain Interference scores at the first visit. Thirteen percent of patients (221 of 1652) had incomplete or missing scores at the initial visit and 33% (550 of 1652) had incomplete or missing scores at the final return visit. We used multiple imputations to account for missing or incomplete data (imputations = 50). In a multivariable linear regression analysis, we compared the mean change in Depression scores between patients treated operatively and those treated nonoperatively, accounting for PROMIS Pain Interference scores at the first visit, age, gender diagnosis, provider, and treatment duration. A post-hoc power analysis demonstrated that the smallest patient cohort (benign lump, n = 176) provided 99% power (α = 0.05) with eight predictor variables to detect a change of 2 points in the PROMIS Depression score (minimally important difference = 3.5). RESULTS: After controlling for potentially confounding variables such as pain interference and age, only carpal tunnel release was associated with a slightly greater decrease in depression symptoms compared with nonoperative treatment (regression coefficient [RC] = -3 [95% confidence interval -6 to -1]; p = 0.006). In patients with the highest PROMIS Depression scores for each diagnosis, operative treatment was not associated with an improvement in depression symptoms (carpal tunnel release: RC = 5 [95% CI -7 to 16]; p = 0.44). Moreover, a corticosteroid injection was not associated with fewer depression symptoms than no biomedical treatment (carpal tunnel release: RC = -3 [95% CI -8 to 3]; p = 0.36). CONCLUSIONS: Given that operative treatment of hand pathology is not generally associated with a decrease in depression symptoms, our results support treating comorbid depression as a separate illness rather than as a secondary effect of pain or physical limitations. LEVEL OF EVIDENCE: Level II, therapeutic study.

The Association Between Symptoms of Depression and Office Visits in Patients With Nontraumatic Upper-Extremity Illness.

PURPOSE: Because psychological and social factors increase symptoms and limitations, it is possible that they are also related to higher use of care. METHODS: We used a database of an academic outpatient orthopedic department in which patient-reported outcome measures were routinely collected and identified 3,620 patients with de Quervain tendinopathy, ganglion, trapeziometacarpal arthritis, trigger digit, or carpal tunnel syndrome who remained in care at least 3 months. At every office visit, patients completed the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Computerized Adaptive Test (CAT), PROMIS Pain Interference CAT, and PROMIS Depression CAT. We conducted multivariable Poisson regression analysis of factors associated with the total number of office visits, accounting for PROMIS scores at the first office visit, age, surgical treatment, sex, diagnosis, and clinician team. RESULTS: Operative treatment had the greatest influence on the number of office visits. Other variables associated with the number of visits were female sex, younger age, higher PROMIS Depression scores, and higher Pain Interference scores. CONCLUSIONS: Treatment choice had the greatest influence on the number of subsequent visits for atraumatic conditions. The fact that the total number of office visits is associated with greater symptoms of depression and greater pain interference, independent of treatment choice, suggests a relation between mental health and resource use. CLINICAL RELEVANCE: Quality improvement efforts and future research might address whether adding strategies to decrease symptoms of depression and optimize coping strategies (to reduce pain interference) might improve upper-extremity health more efficiently than standard treatment alone.

Preoperative PROMIS Scores Predict Postoperative PROMIS Score Improvement for Patients Undergoing Hand Surgery.

Background: Patient-Reported Outcomes Measurement Information System (PROMIS) can be used alongside preoperative patient characteristics to set postsurgery expectations. This study aimed to analyze whether preoperative scores can predict significant postoperative PROMIS score improvement. Methods: Patients undergoing hand and wrist surgery with initial and greater than 6-month follow-up PROMIS scores were assigned to derivation or validation cohorts, separating trauma and nontrauma conditions. Receiver operating characteristic curves were calculated for the derivation cohort to determine whether preoperative PROMIS scores could predict postoperative PROMIS score improvement utilizing minimal clinically important difference principles. Results: In the nontrauma sample, patients with baseline Physical Function (PF) scores below 31.0 and Pain Interference (PI) and Depression scores above 68.2 and 62.2, respectively, improved their postoperative PROMIS scores with 95%, 96%, and 94% specificity. Patients with baseline PF scores above 52.1 and PI and Depression scores below 49.5 and 39.5, respectively, did not substantially improve their postoperative PROMIS scores with 94%, 93%, and 96% sensitivity. In the trauma sample, patients with baseline PF scores below 34.8 and PI and Depression scores above 69.2 and 62.2, respectively, each improved their postoperative PROMIS scores with 95% specificity. Patients with baseline PF scores above 52.1 and PI and Depression scores below 46.6 and 44.0, respectively, did not substantially improve their postoperative scores with 95%, 94%, and 95% sensitivity. Conclusions: Preoperative PROMIS PF, PI, and Depression scores can predict postoperative PROMIS score improvement for a select group of patients, which may help in setting expectations. Future work can help determine the level of true clinical improvement these findings represent.

Factors Associated With a Discretionary Upper-Extremity Surgery.

PURPOSE: Surgery for nontraumatic upper-extremity problems is largely discretionary and preference-sensitive. Psychological and social determinants of health correlate with greater symptoms and limitations and might be associated with discretionary operative treatment. METHODS: We used routinely collected patient-reported outcome measures from patients with de Quervain tendinopathy, ganglion cyst, trapeziometacarpal arthritis, trigger digit, and carpal tunnel syndrome to study factors associated with discretionary surgery using multiple logistic regression. Patients completed a measure of the magnitude of physical limitations (Patient-Reported Outcomes Measurement Information System [PROMIS] Physical Function Computerized Adaptive Test [CAT]), a measure of the degree to which a person limits activities owing to pain (PROMIS Pain Interference CAT), and a measure of symptoms of depression (PROMIS Depression CAT) at every office visit. RESULTS: Higher PROMIS Pain Interference score, diagnoses of carpal tunnel syndrome, and treatment by teams 3, 4, or 5 were independently associated with discretionary operative treatment. CONCLUSIONS: People with a greater tendency to limit activity owing to pain are more likely to choose discretionary surgery. CLINICAL RELEVANCE: Interventions that help people remain active despite pain by addressing the psychological and social determinants of health might affect the rate of discretionary surgery.

Depression and Pain Interference Correlate With Physical Function in Patients Recovering From Hand Surgery.

Background: Patient-reported outcome measures vary more than expected based on underlying pathology, in part due to the substantial influence of mood and coping strategies. Methods: This study addressed the primary null hypothesis that the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function score 1 month (range, 3-8 weeks) after hand surgery is not associated with PROMIS Depression and PROMIS Pain Interference scores prior to surgery, accounting for other factors. Using an institution-wide database of routinely collected patient-reported outcomes, we identified adult patients who underwent wrist ganglion excision, trapeziometacarpal arthroplasty, hand ganglion excision, trigger digit, De Quervain, and carpal tunnel release. Measures collected included the PROMIS Physical Function Computerized Adaptive Test (CAT), PROMIS Pain Interference CAT, and PROMIS Depression CAT. We sought factors associated with postsurgical PROMIS Physical Function scores and change between preoperative and postoperative score using multivariable linear regression, accounting for age, sex, surgery type, provider, and time from surgery to postsurgical measurement. Results: Higher postoperative PROMIS Physical Function score was independently associated with lower PROMIS Pain Interference scores, lower PROMIS Depression scores, younger age, and treatment by provider team 3. Greater change in PROMIS Physical Function score was independently associated with greater PROMIS Pain Interference scores, greater time from surgery, and treatment by provider team 3. Conclusions: Mood and effective coping strategies affect the level of symptoms and limitations during recovery from hand surgery and represent important treatment opportunities for enhancing recovery.

Modified Long Toe Extensor Tendon Harvest for Use as Intercalary Graft in Upper Extremity Reconstruction.

Autograft tendon harvested from the long toe extensors are of great utility as intercalary grafts in upper extremity reconstruction. However, standard full-length harvest is complicated by the presence of extensor retinacula and multiple juncturae between adjacent extensors, which often necessitate extensive dissection, increasing the potential for morbidity. We describe a modified technique for partial harvest of the long toe extensors, which is performed entirely proximal to the superior extensor retinaculum. This technique requires a single incision and provides adequate length of graft for the majority of forearm to fingertip reconstructions. The technique is described in the context of our preliminary cadaver findings, with a case example provided to further illustrate the utility of this technique.

Principles of Tendon Transfer.

Tendon transfers provide a substitute, either temporary or permanent, when function is lost due to neurologic injury in stroke, cerebral palsy or central nervous system lesions, peripheral nerve injuries, or injuries to the musculotendinous unit itself. This article reviews the basic principles of tendon transfer, which are important when planning surgery and essential for an optimal outcome. In addition, concepts for coapting the tendons during surgery and general principles to be followed during the rehabilitation process are discussed.

Results of laboratory evaluation of acute knee effusion after anterior cruciate ligament reconstruction: what is found in patients with a noninfected, painful postoperative knee?

BACKGROUND: Infection after anterior cruciate ligament reconstruction is a rare and potentially devastating complication. No normative data have been reported for knee aspiration after anterior cruciate ligament reconstruction in the early postoperative period. HYPOTHESIS: Determining normative laboratory data from a retrospective review of noninfected early postoperative anterior cruciate ligament reconstruction knee effusions will allow for the calculation of an aspirate white blood cell (WBC) threshold value indicative of infection. STUDY DESIGN: Case series (diagnosis); Level of evidence, 4. METHODS: A 2-year retrospective chart review of 151 anterior cruciate ligament reconstruction patients was performed. Thirty-one noninfected patients meeting the inclusion and exclusion criteria and 1 infected patient had laboratory data collected, including peripheral blood and knee effusion aspirate analyses. Laboratory data from pertinent published studies of infected knees after anterior cruciate ligament reconstruction were combined with the data of our 1 infected patient, establishing a historical control group. Data were analyzed and results were then compared. Infected aspirate WBC threshold value statistics were then calculated. RESULTS: Analysis of noninfected knee effusion aspirates revealed a mean WBC count of 9600/uL (standard deviation [SD], 15 200), and a mean of 66% polymorphonuclear (PMN) cells (SD, 34). Aspirate WBC 98% confidence interval (CI) was 2800/uL to 16 200/uL, and the 98% CI for PMN cells was 58% to 84%. Aspirate WBC count >16 200/uL is 86% sensitive, 92% specific, and has a positive likelihood ratio of 10.4 as an indicator of infection. CONCLUSION: Benign effusion after anterior cruciate ligament reconstruction is common and is associated with elevated inflammatory markers. When concerned, knee aspiration after anterior cruciate ligament surgery gives the highest yield to differentiate between a painful effusion and a septic knee in the early postoperative period while awaiting definitive culture results. The authors report confidence intervals defining the range of cell count variables for noninfected patients requiring aspiration, specifically WBC and PMN, and suggest a WBC threshold value of >16 200/uL be used as an indicator of infection. On the basis of comparison with historical control data, the authors believe these data are significant and will be reliable for clinical use.