Utilization Trends of Nerve Autograft Alternatives for the Reconstruction of Peripheral Nerve Defects.

BACKGROUND: Autologous nerve grafting is the time-honored reconstruction method for peripheral nerve gaps. However, it is associated with donor-site morbidities. A growing number of studies have demonstrated the effective use of decellularized nerve allograft and synthetic conduits, which are convenient options with no donor deficit. The specific aim of this study was to characterize changes in practice trends for peripheral nerve defect reconstruction. METHODS: The authors queried the 2015 to 2020 Merative MarketScan Databases for patients who underwent nerve autograft, allograft, synthetic conduit, and/or vein graft reconstruction. Patient demographic data (ie, location, indication) and hospital characteristics (ie, facility, provider type) were recorded. Regression analysis identified changes in trends over the study period. RESULTS: A total of 4331 patients underwent one or more nerve gap reconstructive procedures over the study period. Since the introduction of allograft CPT code in 2018, segmented mixed effect longitudinal modeling revealed that allograft utilization significantly increased from 21.5% to 29.6% after 2018 ( P < 0.001), whereas nerve autograft use decreased from 18.6% to 15.8% and conduit use decreased from 60% to 54.7% ( P = 0.09 and P = 0.03, respectively). When stratifying autograft by size, use of autograft less than or equal to 4 cm significantly decreased from 10.6% to 7.7% after 2018 ( P = 0.03), and autograft greater than 4 cm did not. When stratifying by state, there is heterogeneity in utilization rates of each product. CONCLUSION: After creation of a designated allograft CPT code in 2018, there was an increase in allograft use with concomitant decrease in conduit and short length autograft use, suggesting that allograft replaced a portion of procedures used in short nerve gap reconstruction.

Predictors and Variation in Steroid Injection Use for Carpal Tunnel Syndrome from a Multicenter Quality Collaborative.

BACKGROUND: Steroid injections are commonly used as first-line treatment for carpal tunnel syndrome (CTS); however, research has shown that their benefit is generally short-term and many patients go on to receive carpal tunnel release. The study purpose was to determine the variation in steroid injection use by hand surgeons. METHODS: We analyzed data from a 9-center hand surgery quality collaborative. Data from 1,586 patients (2,381 hands) were included if they underwent elective CTR at one of the sites. Mixed effects logistic regression models were used to examine the association of receipt of steroid injection and association of receipt of more than one steroid injection among patient-level covariates. RESULTS: Steroid injection use significantly varied by practice, ranging from 12-53% of patients. The odds of receiving a steroid injection were 1.4 times higher for females (p<0.01), 1.6 times higher for patients with chronic pain syndrome (p<0.01), 0.5 times lower for patients with moderate electromyography (EMG) and 0.4 times lower for patients with severe EMG classification (both p<0.01). Patients with high CTS-6 scores (p=0.02) and patients with moderate (p=0.04) or severe EMG (p=0.05) had lower odds of receiving multiple steroid injections. Complete symptomatic improvement after steroid injection was significantly reported by patients with high CTS-6 score (p=0.03) or patients with severe EMG classification (p=0.02). CONCLUSIONS: We found wide patient-level and practice-level variation in the use of steroid injections prior to undergoing CTR. These findings underscore the need for improved data and standard practice guidelines regarding which patients benefit from steroid injection.

A Quality Collaborative Study of the Concordance of Electrodiagnostic Scores and Clinical Severity in Carpal Tunnel Syndrome.

BACKGROUND: Electrodiagnostic studies are commonly used to diagnose carpal tunnel syndrome. However, these examinations are prone to false-positive and false-negative values. The authors evaluated the agreement of electrodiagnostic study severity, clinical assessment scores, and probability of carpal tunnel syndrome [Six-Item Carpal Tunnel Syndrome Evaluation Tool (CTS-6) scores. METHODS: This was a retrospective cohort study of 609 patients with carpal tunnel syndrome (941 hands). Data were collected from nine hand surgery practices in the Michigan Collaborative Hand Initiative for Quality in Surgery. Goodman and Kruskal gamma statistics (γ) measured the agreement between electrodiagnostic studies and clinical assessment scores and between electrodiagnostic studies and CTS-6 scores. The authors performed cumulative logistic regression with mixed effects to evaluate the association among electrodiagnostic study severity, clinical assessments, and patient characteristics. RESULTS: The concordance between electrodiagnostic study severity and CTS-6 scores was γ = 0.31 (95 percent CI, 0.21 to 0.40), with an accuracy of 43 percent. The concordance between electrodiagnostic study severity and clinical assessment scores was γ = 0.66 (95 percent CI, 0.58 to 0.74), with an accuracy of 58 percent. Wide site-level variation in the γ coefficient between electrodiagnostic studies and clinical assessment scores and between electrodiagnostic studies and CTS-6 was seen. Male sex, increasing age, and increasing body mass index were significantly associated with increased odds of electrodiagnostic study severity. CONCLUSIONS: Wide practice-level variation underscores the variability in diagnostic testing accuracy. Physicians should consider patient characteristics (e.g., sex, age, body mass index) when assessing carpal tunnel syndrome severity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Task-Specific Patient Preferences for Shared Decision-Making in Hand Surgery.

BACKGROUND: Shared decision-making for surgery can increase patient engagement, satisfaction, and clinical outcomes. However, the level of involvement that patients desire at each step of the decision-making process is unknown. METHODS: The authors surveyed patients at an academic hand surgery clinic to examine the preferred role in decision-making using validated questionnaires (i.e., Control Preference Scale, Problem-Solving Decision-Making Scale, and General Self-Efficacy Scale). The Control Preference Scale assesses general treatment preferences, whereas the Problem-Solving Decision-Making Scale distinguishes between problem-solving tasks (e.g., making diagnoses, calculating risks/benefits) and decision-making tasks. Patients' self-beliefs and perceived ability to handle difficult situations were assessed with the General Self-Efficacy Scale. The authors used linear regression models and ordinal logistic regression to examine the relationship between self-efficacy and patients' preferred role in treatment decision-making. RESULTS: Patients overall preferred an equal share of decision-making responsibility with the surgeon (mean Control Preference Scale score, 3.3 ± 0.7). Specifically, for problem-solving tasks, however, 81 percent of patients wanted to "hand over" the responsibility and 19 percent preferred shared decision-making. In contrast, for decision-making tasks, 54 percent of patients preferred shared decision-making. Each point increase in General Self-Efficacy Scale score correlated with 12 percent greater odds of preferring to retain the responsibility (OR, 1.12; 95 percent CI, 1.05 to 1.21; p = 0.001). However, self-efficacy did not show a significant effect for problem-solving tasks. CONCLUSIONS: The authors found that patients prefer surgeons to provide expert knowledge for problem-solving tasks but desire equal share of responsibility in decision-making tasks. The authors' findings support the current shift away from the paternalistic model of surgical decision-making, and provide an effective strategy to tailor shared decision-making to align care delivery with patient preferences.

Preventable Hospitalization Trends Before and After the Affordable Care Act.

Introduction: The Patient Protection and Affordable Care Act aimed to increase the number of individuals with health insurance, which may lead to adequate primary care management and reduced rates of preventable hospitalizations. To investigate the rates of preventable hospitalization after the passing of the Affordable Care Act in 2010 and Medicaid expansion in 2014 across 26 states, a population-based study was conducted using the Healthcare Cost and Utilization Project National Inpatient Sample database from 2005-2017. Methods: A logistic regression and trend analysis was performed to assess the changes in preventable hospitalization rates over time and the impact of policy changes on the rate of preventable hospitalization. Individuals were included if they were aged between 18 and 64 years and had a preventable quality indicator International Classification of Diseases, Ninth or Tenth Revision code as determined by the Agency for Healthcare Research and Quality. Results: More than 45 million preventable-hospitalization admissions were reported between 2005 and 2017. There was a significant decrease in preventable hospitalization rates after the passing of the Affordable Care Act from 12.0% to 10.8% (p<0.01) and from 11.5% to 10.6% (p<0.01) after Medicaid expansion. Bacterial pneumonia declined from 1.5% to 0.6% (p<0.01), along with chronic obstructive pulmonary disease and asthma in older adults from 1.9% to 1.7% (p=0.01) after the expansion. Conclusions: States that have not implemented Medicaid expansion should make it a priority because it may lead to a reduction in preventable hospitalization rates. Furthermore, preventable hospitalization rates may be considered a quality measure to examine the accessibility and effectiveness of primary care intervention.

Evaluation of Factors Relevant to Pain Control Among Patients After Surgical Treatment.

Importance: Opioids are often prescribed after elective surgical treatment despite the potential for misuse. Although various pain control regimens exist, patient preferences for acute postoperative pain management are unknown. Objective: To describe patient-reported key attributes of postoperative pain management. Design, Setting, and Participants: This decision analytical model used responses from a survey based on conjoint analysis to investigate the value patients placed on different aspects of postoperative pain management. Participants were patients aged 18 years or older who underwent elective hand surgical procedures between July 1, 2018, and July 23, 2019, at a single academic center. The survey was completed on a web-based platform and took place between November 2019 and January 2020. Data were analyzed from May through July 2021. Exposures: Participants were presented with a series of discrete-choice tasks and asked to select between 2 postoperative medication options that changed from question to question and had varying characteristics. Main Outcomes and Measures: Attribute importance scores and part-worth utility values for the queried aspects of pain control were calculated. Results: Of 710 individuals invited, 321 (45.2%) completed the survey; there were 212 (66.0%) women and 108 (33.6%) men, and the most common age category was 60 to 69 years (102 participants [31.8%]). Most patients reported previous opioid use (282 individuals [87.9%]). Factors in the decision-making process with the highest attribute importance scores (SDs) were risk of addiction (26.3% [13.0%]) and amount of pain relief (25.6% [14.6%]). Adverse effects 13.9% (7.2%), functional independence 11.8% (7.3%), and level of trust in the prescriber 11.4% (5.8%) had intermediate attribute importance scores (SDs). Cost 7.9% (4.4%) and stigma 3.1% (1.3%) had the lowest attribute importance scores (SDs) in patient decisions. Conclusions and Relevance: These findings suggest that multimodal pain control regimens that are associated with optimized pain relief and minimized risk of addiction are preferable to treat acute postoperative pain. The results suggest that identifying procedures for which patients prioritize minimizing risk of addiction over pain relief and incorporating patient preferences into decision-making may be associated with decreased postoperative opioid prescribing.

Opioid Prescribing after Carpal Tunnel Release: Analysis from the Michigan Collaborative Hand Initiative for Quality in Surgery.

BACKGROUND: Little is known regarding the national practice patterns for postoperative opioid prescribing after carpal tunnel release, which is one of the most common surgical procedures performed. The authors sought to assess the rate of opioid prescribing after carpal tunnel release and patient-, surgeon-, and practice-level predictors of opioid prescriptions after surgery. METHODS: The authors conducted a cohort study from the Michigan Collaborative Hand Initiative for Quality in Surgery, a national consortium of nine practices with 33 surgeons who prospectively collect data for the purpose of quality improvement. Patients were included who underwent carpal tunnel release between July 1, 2019, and December 31, 2019. Multilevel logistic regression was used to determine practice and surgeon variation in postoperative opioid prescribing related to patient characteristics. RESULTS: Of the 648 patients with 792 operative hands, 52.9 percent were prescribed a postoperative opioid. After controlling for patient, surgeon, and practice characteristics, endoscopic carpal tunnel releases were associated with a decreased odds of receiving a postoperative opioid prescription compared to open carpal tunnel releases (OR, 0.19; 95 percent CI, 0.07 to 0.52). However, 57.4 percent of the variation in opioid prescribing was explained at the practice level, and 4.1 percent of the variation was explained at the surgeon level. CONCLUSIONS: Practice-level prescribing patterns play a substantial role in opioid prescribing. National efforts should consider development of evidence-based opioid prescribing recommendations for carpal tunnel release that target all prescribers, including trainees and advanced practice providers. In addition, endoscopic carpal tunnel release may offer an opportunity to minimize opioid prescribing. The authors recommend that providers encourage the use of nonopioid analgesia and limit opioid prescriptions after carpal tunnel release. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Variation in Use of Electrodiagnostic Testing: Analysis From the Michigan Collaborative Hand Initiative for Quality in Surgery.

PURPOSE: To evaluate factors that predict the use of electrodiagnostic testing (EDS) for patients undergoing carpal tunnel release (CTR). METHODS: In this cohort study, we analyzed 553 patients who underwent primary CTR from 8 practices between July 1, 2019 and December 1, 2019 by 32 surgeons in the Michigan Collaborative Hand Initiative for Quality in Surgery (M-CHIQS). The M-CHIQS is a collaborative initiative aimed at improving quality in hand surgery. Demographic and clinical characteristics were collected, including the 6-item carpal tunnel symptoms scale (CTS-6) scores and EDS timing. Multilevel logistic regression was used to assess practice and surgeon variation in EDS use related to clinical diagnostic criteria. RESULTS: Of the 553 patients who underwent CTR during the study period, 461 (83.3%) received preoperative EDS. After controlling for patient clinical and demographic characteristics, CTS-6 scores were not associated with receiving any preoperative EDS (lower probability of CTS: odds ratio [OR], 0.94; 95% confidence interval [95% CI], 0.59-1.51), preconsultation EDS (low probability of CTS: OR, 1.00; 95% CI, 0.73-1.38), or postconsultation EDS (low probability of CTS, OR, 1.10; 95% CI, 0.77-1.60). For use of any EDS, 9.3% of the variation in testing was explained at the practice level and 31.1% of the variation in testing was explained at the surgeon level. CONCLUSIONS: Variation in EDS use is explained primarily at the practice and surgeon levels and is not related to patient clinical criteria. We recommend that providers and practices assess their use of preoperative EDS and limit its use to patients with an unclear clinical CTS diagnosis, as stated in current clinical practice guidelines. Likewise, providers should be encouraged to use the CTS-6 before prescribing EDS. CLINICAL RELEVANCE: Limiting the use of EDS to patients with an unclear clinical diagnosis of CTS will reduce costs and improve patient care by eliminating the discomfort and time associated with this test.

A Nationwide Study Assessing Preventable Hospitalization Rate on Mortality After Major Cardiovascular Surgery.

Despite the use of various factors to measure hospital quality, most measures have not resulted in long-term improvements in patient outcomes. This study's purpose is to determine the effect of a previously unassessed measure of quality of care-a hospital's preventable hospitalization rate-on 30-day mortality at both the hospital and individual levels after three major cardiovascular surgery procedures. This is a population-based study using Taiwan's National Health Insurance database. We retrieved data from 2001 to 2014 for patients who had undergone abdominal aortic aneurysm (AAA) repair, coronary artery bypass graft, or aortic valve replacement (AVR). Preventable hospitalizations are hospitalizations for 11 chronic conditions that are considered preventable with effective primary care. The outcome was 30-day surgical mortality. Our dataset contained 65,863 patients who had undergone surgery for one of the three cardiovascular procedures. Preventable hospitalization rate was significantly associated with higher hospital mortality rates for all procedures. At the patient level, the adjusted odds of mortality after AAA repair were increased 55% (P < 0.01) for every 2% increase in the preventable hospitalization rate. For coronary artery bypass graft, preventable hospitalization was not a significant predictor of mortality, but rather patient factors and surgeon factors were significant. For AVR, the adjusted odds of mortality were increased 7% (P < 0.01) for every 1% increase in preventable hospitalization rate. High preventable hospitalization rate may serve as a hospital quality measure that could signal increased odds of mortality for selected cardiovascular procedures, especially for higher risk-lower volume procedures such as AAA repair and AVR.

A Nationwide Population-based Study From Taiwan Assessing the Influence of Preventable Hospitalization Rate on Mortality After Oncologic Surgery.

OBJECTIVE: To determine the effect of a previously unassessed measure of quality-preventable hospitalization rate-on mortality after oncologic surgery for 4 procedures with established volume-outcome relationships. We hypothesize that hospitals with higher preventable hospitalization rates (indicating poor quality of primary care) have increased hospital mortality. Additionally, patients having surgery at hospitals with higher preventable hospitalization rates have increased mortality. SUMMARY BACKGROUND DATA: Although different factors have been used to measure healthcare quality, most have not resulted in long-term hospital-based improvements in patient outcomes. METHODS: We retrieved data from Taiwan's National Health Insurance database for patients who underwent surgery during 2001 to 2014 for esophagectomy, pancreatectomy, lung resection, or cystectomy. Preventable hospitalization rates assess hospitalizations for 11 chronic conditions that are deemed to be preventable with effective primary care. The outcome was 30-day surgical mortality. Identifiable factors potentially related to surgical mortality, including surgeon and hospital volume, were controlled for in the models. RESULTS: Our dataset contained 35,081 patients who had surgery for one of the procedures. For all procedures, hospitals with high preventable hospitalization rates were associated with higher mortality rates (all P < 0.01). For esophagectomy, lung resection, and cystectomy, the adjusted odds of individual mortality increased by 8% to 10% (P < 0.01) for every 1% increase in the preventable hospitalization rate. For pancreatectomy, the adjusted odds of individual mortality increased by 21% for every 1% increase in preventable hospitalization rate when the rate was ≥8% (P < 0.01). CONCLUSIONS: Preventable hospitalization rates could serve as warning signs of low quality of care and be a publically-reported quality measure.

Quality Measures in Postmastectomy Breast Reconstruction: Identifying Metrics to Improve Care.

BACKGROUND: Specific measures tailored to the properties of individual procedures will ensure the appropriate evaluation of quality. Because postmastectomy breast reconstruction (PMBR) is becoming increasingly common, a review of the literature is timely to identify potential breast reconstruction-specific measures that can be applied by institutions and national healthcare organizations to improve quality. METHODS: We searched PubMed and Embase for studies examining the quality of care for patients undergoing PMBR. Data extracted from the articles include basic study characteristics, the number of quality metrics, type of quality metric (defined by Donabedian model), and the domain of quality (defined by the National Academy of Medicine). RESULTS: A total of 2,158 articles were identified in the initial search, and 440 studies were included for data extraction. The most common type of quality measure was outcome measures (91%), and the least common measure was structure measures (1%). The most common metrics were operative time (41%), hospital type (28%), and aspects of the patient-provider interactions (20%). Additionally, we found that timeliness and equity were least common among the 6 National Academy of Medicine domains. CONCLUSIONS: We identified metrics utilized in the PMBR, some of which can be further investigated through high-level evidence studies and incorporated into policy. Because many factors influence surgical outcomes and breast reconstruction is driven by patient preferences, an inclusion of structure, process, and outcome metrics will help improve care for this patient population. Moreover, nonpunitive initiatives, specifically quality collaboratives, may provide an avenue to improve care quality without compromising patient safety.

The Next Frontier of Outcomes Research: Collaborative Quality Initiatives.

Quality improvement efforts at the federal level have instituted both rewards and penalties as incentives to improve health care quality. However, neither of these methods has shown long-lasting improvements. Furthermore, many programs have focused on decreasing mortality or hospital readmissions, measurements that are not applicable to many surgical fields, including plastic surgery. One model that has been shown to be effective is a collaborative quality initiative that uses a pay-for-participation method whereby participants learn from one another and institute changes to improve patient care. Many of these changes are process measures that are easier to implement and quicker to show improvement than structural or outcome measures. Regional collaborative quality initiatives have been developed in other surgical specialties such as bariatric surgery and urology. Currently, the authors are establishing a new collaborative quality initiative for hand surgery: the Michigan Collaborative Hand Initiative for Quality in Surgery. It is a collaboration of nine sites with the goal of identifying areas that are in need of quality improvement in hand surgery and implementing measures to improve on them. The authors believe that collaborative quality initiatives will promote high-quality care and should be incorporated into the field of plastic surgery.

Outcomes Following Replantation/Revascularization in the Hand.

The variability in reported outcomes and outcome measures used in digit replantation makes it difficult to compare results among studies. This article reviews the principles of measuring functional and patient-reported outcomes after replantation, and describes the recommended instruments to use and ways to report results.

Finger Replantation Optimization Study (FRONT): Update on National Trends.

PURPOSE: Traumatic digit amputations have an adverse impact on patients' daily living. Despite experts advocating for digit replantation, studies have shown a continued decrease in rate of replantation. We performed a national-level investigation to examine the recent trend of practice for digital replantation. METHODS: We used the National Inpatient Sample database under the Healthcare Cost and Utilization Project to select adult patients with traumatic digit amputation from 2001 to 2014. We calculated the rate of attempted and rate of successful digit replantation per year, subcategorizing for digit type (thumb or finger) and for hospital type (rural, urban nonteaching, or urban teaching). We also analyzed the pattern of distribution of case volume to each hospital type per year. We used 2 multivariable logistic regression models to investigate patient demographic and hospital characteristics associated with the odds of replantation attempt and success. RESULTS: Among the 14,872 adult patients with a single digit amputation from 2001 to 2014, only 1,670 (11.2%) underwent replantation. The rate of replantation attempt trended down over the years for both thumb and finger injuries at all hospital types, despite increasing proportions of cases being sent to urban teaching hospitals where they were more than twice as likely to undergo replantation. The rate of successful replantation stayed stable for the thumb at 82.9% and increased for fingers from 76.1% to 82.4% over the years. Patients were more likely to undergo replantation if they had private insurance or a higher level of income. Neither hospital case volume nor hospital type was predictive of successful replantation. CONCLUSIONS: Although more single-digit amputations were treated by urban teaching hospitals with higher likelihood to replant, the downward trend in rate of attempt regardless of hospital type demonstrates that concentration of case volume is not the solution to reverse the declining trend. CLINICAL RELEVANCE: Financial aspects of digit replantation need to be considered from both the patients' and the surgeons' perspectives to improve delivery of care for digit replantation.