An Evaluation of Emergency Hand Coverage in Tennessee After Implementation of the Affordable Care Act.

Although the upper extremity is the most commonly injured part of the body, many studies have indicated that there is a lack of emergency hand coverage in the United States. In 2010, our laboratory evaluated on-call hand coverage in Tennessee (TN) and found that only 7% of hospitals had a hand surgeon on call for emergency cases at all times. In 2014, the Affordable Care Act (ACA) was implemented with the goal of increasing overall access to care and decreasing health care costs. Hand surgeons were surveyed on their attitudes toward the ACA, and the majority of surgeons surveyed disagreed or strongly disagree that the ACA would improve access to emergent hand surgery. This study aimed to determine if there has been an increase in emergency hand coverage in TN since the implementation of the ACA. A survey was administered to all hospitals in TN with both an emergency department and operating room to determine the percentage of TN hospitals offering elective hand surgery and on-call emergency hand coverage. With 94% of TN hospitals responding to the emergency department survey, we determined that there has been a 138% significant increase in the percentage of hospitals reporting 24/7 emergency hand coverage by a hand specialist since our last study in 2010. There has also been a significant increase in elective hand coverage in TN, although much smaller at 13% since 2010. This study suggests that there has been an overall increase in access to hand care in TN since the implementation of the ACA, most profoundly seen in the increase in hand specialists available for emergent cases.

Transfers for Hand Surgery Correlate with Increased Reoperations for Complications.

Wrist, hand, and finger trauma are the most common nonlethal injuries presenting to emergency departments. In Tennessee, lack of available hand care, particularly the need for emergency hand surgery, could be detrimental to patient outcomes. This is a retrospective outcomes study of patients requiring revisional hand surgeries. Patients were identified and stratified by distance to Vanderbilt University Medical Center (VUMC) to determine if patient complications increase with distance from VUMC. As distance of patient county of residence from VUMC increased, per cent of patients without a complication decreased (P < 0.0001). Counties without 24/7 comprehensive hand call also showed a distance difference in complication rates. Per capita income and mean household income showed no effect on complications. Distance from treating facility is correlated with patient outcomes and need for revisional surgery. Limitations in care availability in Tennessee are not specific to hand surgery. If the trend toward poorer outcomes as a result of limited local care availability extends to other specialties, this could have implications regarding health-care realignment. Specifically for patients with complex injuries or conditions that will be referred to centralized flagship hospitals, increases in patient travel may limit positive outcomes.

Tennessee emergency hand care distributions and disparities: Emergent hand care disparities.

BACKGROUND: Hand trauma is the most frequently treated injury in emergency departments, but presently there is a crisis of insufficient emergency coverage. This study evaluates the discrepancy of emergent and elective hand care trends based on socioeconomic factors in the state of Tennessee. METHODS: We identified 119 hospitals in Tennessee that contained operating and emergency room facilities. Of these, 111 hospitals participated in a survey to determine the availability of elective and emergency hand surgery. Wilcoxon rank-sum test or permutation chi-square test and logistic regression were used to analyze reported measures. RESULTS: Our results revealed that hospitals in counties with the lowest per capita income and median household income are less likely to have hand specialists or offer hand call. There are also significantly fewer hospitals that have hand specialists and offer hand call that are located in medically underserved areas. In the state of TN, level 1 trauma facilities are required by the Tennessee Department of Health to have staffed hand specialists and 24/7 hand call. Our study revealed that while 7/8 (87.5 %) level 1 trauma facilities have hand specialists, only 2/8 (25 %) provide 24/7 hand specialist call. CONCLUSION: Our results strongly suggest the presence of a health care disparity for hand trauma in counties with a low income and in medically underserved areas.