The Hand Surgeon's Practice and the Evolving Merit-Based Incentive Payment System.

The Merit-Based Incentive Payment System began scoring physicians in 2017, with implementation of payment adjustments started in 2019. The program continues to evolve, with adjustments to measures, score weighting and consideration of patient complexity. However, there remain concerns about unintended consequences of this latest value-based payment program. This review summarizes the roll-out of the program in the first performance year (2017) and changes that will have an impact on payment adjustments in the 2022 performance year. Further, it explains the need for policy informed by clinical experience to protect access for vulnerable patients.

Plastic Surgeons and Equity: Are Merit-Based Incentive Payment System Scores Impacted by Minority Patient Caseload?

BACKGROUND: The Centers for Medicare and Medicaid Services introduced the Merit-based Incentive Payment System (MIPS) in 2017 to extend value-based payment to outpatient physicians. The authors hypothesized that the MIPS scores for plastic surgeons are impacted by the existing measures of patient disadvantage, minority patient caseload, and dual eligibility. METHODS: The authors conducted a retrospective cohort study of plastic surgeons participating in Medicare and MIPS using the Physician Compare national downloadable file and MIPS scores. Minority patient caseload was defined as nonwhite patient caseload. The authors evaluated the characteristics of participating plastic surgeons, their patient caseloads, and their scores. RESULTS: Of 4539 plastic surgeons participating in Medicare, 1257 participated in MIPS in the first year of scoring. The average patient caseload is 85% white, with racial/ethnicity data available for 73% of participating surgeons. In multivariable regression, higher minority patient caseload is associated with a lower MIPS score. CONCLUSIONS: As minority patient caseload increases, MIPS scores decrease for otherwise similar caseloads. The Centers for Medicare and Medicaid Services must consider existing and additional measures of patient disadvantage to ensure equitable surgeon scoring.

Improving Perioperative Preparation for Patients Undergoing Surgical Treatment for Distal Radius Fractures.

We aimed to review common patient concerns after surgical repair of distal radius fracture (DRF) to identify potential interventions to improve the gap between expectation and education for DRF patients. Methods: We conducted a retrospective cohort study of 100 consecutive patients who underwent surgical repair of DRF at a level I trauma center. Patient-initiated communication notes were reviewed with thematic analysis to identify the common reasons patients required additional information. We used the Patient Education Materials Assessment Tool to score the available educational resources for DRF patients for the understandability and actionability of the educational materials provided to the patients. Results: Of 165 patient communication episodes, 88.5% occurred postoperatively. The most common concerns were pain (30, 15.4%) and surgical site changes (24, 12.3%). Most communications (171, 83.4%) were resolved with patient education through instruction or reassurance. The reviewed materials did not address pain or surgical site changes. No reviewed materials provided actionable steps patients could take to facilitate recovery. Conclusions: Pain management and normal wound healing were the most common surgical concerns of DRF patients. We identify opportunities to improve expectation-setting in online materials and during face-to-face education to create a more patient-centered perioperative experience.

Predicting persistent opioid use after hand surgery: a machine learning approach.

BACKGROUND: The aim of this study was to evaluate the use of machine learning to predict persistent opioid use after hand surgery. METHODS: We trained two algorithms to predict persistent opioid use, first using a general surgery dataset and then using a hand surgery dataset, resulting in four trained models. Next, we tested each model's performance using hand surgery data. Participants included adult surgery patients enrolled in a cohort study at an academic center from 2015-2018. The first algorithm (Michigan Genomics Initiative model) was designed to accommodate patient-reported data and patients with or without prior opioid use. The second algorithm (claims model) was designed for insurance claims data from patients who were opioid-naïve only. The main outcome was model discrimination, measured by area under the receiver operating curve (AUC). RESULTS: Of 889 hand surgery patients, 49% were opioid-naïve and 21% developed persistent opioid use. Most patients underwent soft tissue procedures (55%) or fracture repair (20%). The MGI model had AUCs of 0.84 when trained only on hand surgery data, and 0.85 when trained on the full cohort of surgery patients. The claims model had AUCs of 0.69 when trained only on hand surgery data, and 0.52 when trained on the opioid-naïve cohort of surgery patients. CONCLUSION: Opioid use is common after hand surgery. Machine learning has the potential to facilitate identification of patients who are at risk for prolonged opioid use, which can promote early interventions to prevent addiction.

General surgery residency and action toward surgical equity: A scoping review of program websites.

BACKGROUND: Surgical residents are increasingly concerned about inequities in patient access and outcomes. This study reviews general surgery residency programs websites for educational and community-focused efforts to recognize and intervene on the root causes of structural inequities. METHODS: We reviewed the websites of the 332 ACGME-accredited general surgery residency programs for mission statement, curriculum and research details in addition to diversity, equity and inclusion statements. Through deductive coding, we pursued a thematic analysis of visible and intentional steps to incorporate and emphasize surgical equity in surgical training. RESULTS: The majority (76%) of training program websites do not mention healthcare inequity. Of the programs that do, 24 (7% of all residencies reviewed) describe initiatives, including an endowed lectureship in anti-racism and community engagement work. CONCLUSIONS: We identified efforts to prioritize surgical equity at general surgery residency programs across a range of resources and settings. This review of public efforts toward equity highlights opportunities for programs to engage with their trainees and communities.

Evaluation of the Merit-Based Incentive Payment System and Surgeons Caring for Patients at High Social Risk.

Importance: The latest step in the Centers for Medicaid & Medicare transformation to pay-for-value is the Medicare Merit-Based Incentive Payment System (MIPS). Value-based payment designs often do not account for uncaptured clinical status and social determinants of health in patients at high social risk, and the consequences for clinicians and patients associated with their use have not been explored. Objective: To evaluate MIPS scoring of surgeons caring for patients at high social risk to determine whether this implementation threatens disadvantaged patients' access to surgical care. Design, Setting, and Participants: A retrospective cohort study of US general surgeons participating in MIPS during its first year in outpatient surgical practices across the US and territories. The study was conducted from September 1, 2020, to May 1, 2021. Data were analyzed from November 1, 2020, to March 30, 2021 (although data were collected during the 2017 calendar year and reported ahead of 2019 payment adjustments). Main Outcomes and Measures: Characteristics of surgeons participating in MIPS, overall MIPS score assigned to clinician. and practice-level disadvantage measures. The MIPS scores can range from 0 to 100. For the first year, a score of less than 3 led to negative payment adjustment; a score of greater than 3 but less than 70 to a positive adjustment; and a score of 70 or higher to the exceptional performance bonus. Results: Of 20 593 general surgeons, 10 252 participated in the first year of MIPS. Surgeons with complete patient data (n = 9867) were evaluated and a wide range of dual-eligible patient caseloads from 0% to 96% (mean [SD], 27.1% [14.5%]) was identified. Surgeons in the highest quintile of dual eligibility cared for a Medicare patient caseload ranging from 37% to 96% dual eligible for Medicare and Medicaid. Surgeons caring for the patients at highest social risk had the lowest final mean (SD) MIPS score compared with the surgeons caring for the patients at least social risk (66.8 [37.3] vs 71.2 [35.9]; P < .001). Conclusions and Relevance: Results of this cohort study suggest that implementation of MIPS value-based care reimbursement without adjustment for caseload of patients at high social risk may penalize surgeons who care for patients at highest social risk.

Extensor Carpi Ulnaris Subluxation.

Extensor carpi ulnaris tendon subluxation can be a challenging diagnosis as a cause of wrist pain. The tendon is stabilized by a tough subsheath. This subsheath is vulnerable to tears in acute wrist movements, especially those combining supination, flexion, and ulnar deviation. The patient presenting acutely may experience swelling, tenderness, and pain. In a chronic setting, the complaint is often an unstable wrist. The diagnosis can be made with a thorough examination, and ultrasonography can be used to evaluate the dynamics of the tendon. Surgical repair with a flap of extensor retinaculum to re-create the tendon's stabilizing subsheath is recommended.

Oxygen exposure promotes fuel diversity for Shewanella oneidensis microbial fuel cells.

Miniature microbial fuel cells (mini-MFCs) were used to monitor the current generated by Shewanella oneidensis DSP10 under both anaerobic and aerobic conditions when exposed to glucose as a potential electron donor. In addition to glucose, other carbon fuels including fructose, sucrose, acetate, and ascorbic acid were also tested. When the anolyte containing S. oneidensis was grown in the presence of oxygen, power densities of 270+/-10, 350+/-20, and 120+/-10 W/m(3) were recorded from the mini-MFC for glucose, fructose, and ascorbic acid electron donors, respectively, while sucrose and acetate produced no response. The power produced from glucose decreased considerably (