Disparities in Access to Outpatient Surgery Related to Removal of Procedures from Medicare's Inpatient Only List.

OBJECTIVE: We assessed the shift from inpatient to outpatient surgical care related to changes to the Inpatient Only List in 2020 and 2021 compared to 2019. SUMMARY BACKGROUND DATA: The extent to which procedures shift from the inpatient to outpatient setting following removal from Medicare's Inpatient Only List is unknown. Many health systems also encouraged a shift from inpatient to outpatient surgery during the COVID-19 pandemic. Assessing the relative change in outpatient surgical utilization for procedures removed from the Inpatient Only List during COVID-19 would provide empirical data on whether reimbursement policy changes or inpatient capacity needs during the pandemic were more likely to shift care from the inpatient to outpatient setting. METHODS: We used administrative data from the PINC AI Healthcare Database across 723 hospitals to determine the within-facility relative change in outpatient vs inpatient procedural volume in 2020 and 2021 compared to 2019 using a multivariable conditional fixed-effects Poisson regression model. We also assessed whether outpatient surgical utilization varied by race and ethnicity. Using a multivariable linear probability model, we assessed the absolute change in risk-adjusted 30-day complication, readmission, and mortality rates for inpatient and outpatient surgical procedures. RESULTS: In 2020 and 2021 compared to 2019 respectively, there was a 5.3% (95% CI, 1.4% to 9.5%) and 41.3% (95% CI 33.1% to 50.0%) relative increase in outpatient elective procedural volume. Outpatient procedural volume increased most significantly for hip replacement which was removed from the Inpatient Only List in 2020 (increase in outpatient surgical utilization of 589.3% (95% CI, 524.9% to 660.3%)). The shift to outpatient hip replacement procedures was concentrated among White patients; in 2021, hip replacement procedural volume increased by 271.1% (95% CI, 241.2% and 303.7%) for White patients and 29.5% (95% CI, 24.4% and 34.9%) for Black patients compared to 2019 levels. There were no consistent or large changes in 30-day complication, readmission, or mortality risk in 2020 and 2021 compared to 2019. CONCLUSION: There was a modest increase in elective outpatient surgeries and a pronounced increase in outpatient orthopedic surgeries which were removed from the Inpatient Only List during the COVID-19 pandemic. Utilization of outpatient surgical procedures was concentrated among White patients.

The Clinical Management of Cholangiocarcinoma in the United States and Europe: A Comprehensive and Evidence-Based Comparison of Guidelines.

BACKGROUND: The incidence of cholangiocarcinoma has doubled over the last 15 years with a similar rise in mortality, which provides the impetus for standardization of evidence-based care through the establishment of guidelines. METHODS: We compared available guidelines on the clinical management of cholangiocarcinoma in the United States and Europe, which included the National Comprehensive Cancer Network (NCCN), European Society for Medical Oncology (ESMO), British Society of Gastroenterology (BSG) and the International Liver Cancer Association (ILCA) guidelines. RESULTS: There is discordance in the recommendation for biopsy in patients with potentially resectable cholangiocarcinoma and in the recommendation for use of fluorodeoxyglucose positron emission tomography scans. Similarly, the recommendation for preoperative biliary drainage for extrahepatic and perihilar cholangiocarcinoma in the setting of jaundice is inconsistent across all four guidelines. The BILCAP (capecitabine) and ABC-02 trials (gemcitabine with cisplatin) have provided the strongest evidence for systemic therapy in the adjuvant and palliative settings, respectively, but all guidelines have refrained from setting them as standard of care, given heterogeneity in the study cohorts and ABC-02's negative intention-to-treat results. CONCLUSIONS: Future progress in enhancing survivorship of patients with cholangiocarcinoma would likely entail improvements in diagnostic biomarkers and novel systemic therapies. Based on recent results from studies of targeted therapy, future iterations of the guidelines will likely incorporate molecular profiling.

Impact of Post-Hospital Syndrome on Outcomes Following Elective, Ambulatory Surgery.

OBJECTIVE: The aim of this study was to investigate whether post-hospital syndrome (PHS) places patients undergoing elective hernia repair at increased risk for adverse postoperative events. SUMMARY OF BACKGROUND DATA: PHS is a transient period of health vulnerability following inpatient hospitalization for acute illness. PHS has been well studied in nonsurgical populations, but its effect on surgical outcomes is unclear. METHODS: State-specific datasets for California in 2011 available through the Healthcare Cost and Utilization Project (HCUP) were linked. Patients older than 18 years who underwent elective hernia repair were included. The primary exposure variable was PHS, defined as any inpatient admission within 90 days of an elective hernia repair performed in an ambulatory surgery center. The primary outcome was an adverse event, defined as any unplanned emergency department visit or inpatient admission within 30 days postoperatively. Mixed-effects logistic models were used for multivariable analyses. RESULTS: A total of 57,988 patients met inclusion criteria. The 30-day risk-adjusted adverse event rate was significantly higher for PHS patients versus non-PHS patients (11.8% vs 5.8%, P < 0.001). PHS patients were more likely than non-PHS patients to experience postoperative complications (odds ratio 2.2, 95% confidence interval 1.6-3.0). Adverse events attributable to PHS cost an additional $63,533.46 per 100 cases in California. The risk of adverse events due to PHS remained elevated throughout the 90-day window between hospitalization and surgery. CONCLUSIONS: Patients hospitalized within 90 days of an elective surgery are at increased risk of adverse events postoperatively. The impact of PHS on outcomes is independent of baseline patient characteristics, medical comorbidities, quality of center performing the surgery, and reason for hospitalization before elective surgery. Adverse events owing to PHS are costly and represent a quality improvement target.

Development and validation of a Spanish translation of the Yale activity questionnaire.

BACKGROUND: Valid measures of physical activity are critical research tools. The objective of this study was to develop a Spanish translation of the Yale Physical Activity Survey, and to provide preliminary evidence of its validity in a population of Dominican patients with lower extremity arthritis. METHODS: A Dominican bilingual health care professional translated the Yale Physical Activity Survey (YPAS) from English to Spanish. Several Dominican adults reviewed the translation to ensure it was linguistically and culturally appropriate. The questionnaire was back-translated to English by a North American researcher who is fluent in Spanish. Discrepancies between the original and back-translated versions were resolved by the translator and back-translator. The Spanish translation was administered to 108 Dominican subjects with advanced hip or knee arthritis prior to (N = 44) or one to four years following (N = 64) total joint replacement. We assessed construct validity by examining the association of YPAS scores and measures of functional status and pain (WOMAC), quality of life (EQ-5D) and the number of painful lower extremity joints. RESULTS: A higher YPAS Part II Activity Dimensions Summary Index score had weak to modest correlations with worse function and quality of life as measured with the WOMAC function scale (r = 0.21, p = 0.03), SF-36 Physical Activity Scale (r = 0.29, p = 0.004) and EQ-5D (r = 0.34, p = 0.0007). Total minutes of vigorous activity and walking had weak to modest correlation with these measures (WOMAC Function Scale (r = 0.15, p = 0.15), SF-36 Physical Activity Scale (r = 0.21, p = 0.04) and EQ-5D utility (r = 0.24, p = 0.02)). Correlations between the YPAS Part I energy expenditure score and these measures were lower (WOMAC Function Scale (r = 0.07, p = 0.49), SF-36 Physical Activity Scale (r = 0.03, p = 0.74) and EQ-5D utility (r = 0.18, p = 0.07)). CONCLUSIONS: We have developed a new Spanish translation of the Yale Physical Activity Survey and provided evidence of convergent validity in a sample of Dominican patients prior to or 1-4 years following total joint replacement.

Hematocrit and Renal Failure in Aortic Arch Surgery: A Society of Thoracic Surgeons Database Study.

BACKGROUND: This study examined the association between cardiopulmonary bypass (CPB) hematocrit and postoperative acute renal failure (ARF) in patients undergoing aortic arch surgery with hypothermic circulatory arrest. METHODS: The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried from 2011 to 2019 for patients undergoing aortic arch surgery with hypothermic circulatory arrest. A multivariable logistic regression model estimated the adjusted odds of postoperative ARF on the basis of CPB hematocrit. Effects were stratified by preoperative kidney function and the duration of hypothermic circulatory arrest by using interaction terms. The study also investigated the association between postoperative ARF and major postoperative outcomes by using multivariable regression models. RESULTS: On adjusted analysis, higher CPB hematocrit (>20%-25%, >25%-30%, >30%) was associated with lower odds of ARF as compared with lower CPB hematocrit (≤20%) (>20-25%, aOR, 0.78; 95% CI, 0.65-0.93; P = .006; >25%-30%, aOR, 0.65; 95% CI, 0.50-0.84; P = .0007; >30%, aOR, 0.45; 95% CI, 0.28-0.72; P = .0008). The predicted probability of postoperative ARF by CPB hematocrit was higher in patients with lower preoperative renal function (estimated glomerular filtration rate, <60 mL/min/1.73 m2) (interaction P = .03). The association between hematocrit and postoperative ARF was not significantly modified by hypothermic circulatory arrest time (interaction P = .74). All postoperative outcomes were significantly worse in patients with postoperative ARF (all P < .0001). CONCLUSIONS: Among patients undergoing aortic arch surgery, a higher CPB hematocrit level is associated with reduced likelihood of postoperative ARF. Preoperative renal function, but not hypothermic circulatory arrest duration, significantly modified this association. The maintenance of higher CPB hematocrit may reduce the incidence of postoperative ARF, especially for patients with poor preoperative renal function.

Medical Students and Patients Benefit from Virtual Non-Medical Interactions Due to COVID-19.

BACKGROUND: Patient care restrictions created by the COVID-19 pandemic constrained medical students' ability to interact directly with patients. Additionally, organ transplant recipients faced increasing isolation due to the rise of telemedicine, the importance of social distancing and their immunosuppressed state. We created a pilot program to pair students with transplant patients for structured, virtual encounters and studied its impact on medical students and patients. METHODS: In May 2020, medical students conducted virtual visits with patients via telephone or video conferencing. Patients and students were surveyed regarding their experiences and independent focus groups were conducted. The survey responses and focus group discussions were deidentified, transcribed, and analyzed for themes. RESULTS: Ten participating students were in their first, second, or final year of medical school. The 14 patients were liver or kidney transplant recipients or kidney donors. All interactions lasted longer than 30 minutes, with 56% greater than 1 hour. Three themes emerged related to the student experience: improvement of their clinical communication skills, development of knowledge and attitudes related to organ transplantation and donation, and independent management of a patient encounter. Three themes related to the patient experience: appreciation of the opportunity to share their personal patient experience to help educate future physicians, a cathartic and personally illuminating experience and an opportunity to share the message of donation. CONCLUSIONS: This pilot program provided a novel opportunity for virtual student-patient interactions that was feasible, well-received, and mutually beneficial. The use of virtual non-medical patient experiences allowed for experiential learning during which students learned about both clinical medicine and enhanced their communication skills directly from patients. Additionally, patients were able to engage with medical students in a new way, as teachers of clinical interactions, and reported a high level of satisfaction in addition to deriving personal benefit.

Virtual student-transplant patient interactions empower patients and enhance student transplantation knowledge.

INTRODUCTION: There is variation in exposure to transplantation in undergraduate medical education. We created a program pairing medical students with transplant patients for semi-structured, virtual encounters and studied the impact on both students and patients using qualitative content analysis. METHODS: Fifty medical students were paired with transplant recipients and donors for non-medical virtual encounters. Separate focus groups were conducted, deidentified, and analyzed using a constant comparative method. RESULTS: Three themes related to the student experience emerged: transplant-related relationships, a deeper understanding of the patient's journey to transplant, and alterations of their personal view of organ donation and transplantation. Three themes emerged from the patient's experiences: the benefits of conversations, the patient as a teacher, and spreading the message of organ donation and transplantation. CONCLUSIONS: This novel program demonstrates that virtual student-patient interactions are a useful approach to engage patients and a unique way to teach medical students about transplantation and donation.

Measuring and Improving the Design Quality of Operating Rooms.

BACKGROUND: Existing research regarding design improvements to the operating room (OR) is scarce and emphasizes the compelling need to measure and test new design strategies and interventions. METHODS: We propose a conceptual framework for measuring and improving OR physical space design by outlining how two existing measurement schemes can be adapted for ORs. The structure, process, outcomes model described by Donabedian in 1966 is used to show how each of these three measurement approaches can be used to evaluate OR design. In addition, we describe a common design framework that focuses on the end-user experience to highlight the impact different OR stakeholders can have on the prioritization of improvements. RESULTS: The structure, process, outcomes model has both benefits and drawbacks for measuring OR design quality. For example, these components are easy to measure, highly actionable when deficient, and have high validity as the bottom line. However, they may not necessarily reflect better quality or correlate to better care, and some need risk adjustment to make comparisons fair. The end-user experience model should account for the needs of patients, OR nurses, anesthesiologists, surgeons, facilities managers, hospital administrators, infection control officers, and regulators, among others. CONCLUSION: The design quality of ORs influences outcomes and determines the quality of experience for multiple stakeholders. Patients, providers, and hospital staff would benefit directly from efforts to improve OR physical space design. By adapting previously established frameworks, it is possible to measure, evaluate, and improve OR design.

"The dead shall be raised": Multidisciplinary analysis of human skeletons reveals complexity in 19th century immigrant socioeconomic history and identity in New Haven, Connecticut.

In July 2011, renovations to Yale-New Haven Hospital inadvertently exposed the cemetery of Christ Church, New Haven, Connecticut's first Catholic cemetery. While this cemetery was active between 1833 and 1851, both the church and its cemetery disappeared from public records, making the discovery serendipitous. Four relatively well-preserved adult skeletons were recovered with few artifacts. All four individuals show indicators of manual labor, health and disease stressors, and dental health issues. Two show indicators of trauma, with the possibility of judicial hanging in one individual. Musculoskeletal markings are consistent with physical stress, and two individuals have arthritic indicators of repetitive movement/specialized activities. Radiographic analyses show osteopenia, healed trauma, and other pathologies in several individuals. Dental calculus analysis did not identify any tuberculosis indicators, despite osteological markers. Isotopic analyses of teeth indicate that all four were likely recent immigrants to the Northeastern United States. Nuclear and mitochondrial DNA were recovered from three individuals, and these analyses identified ancestry, hair/eye color, and relatedness. Genetic and isotopic results upended our initial ancestry assessment based on burial context alone. These individuals provide biocultural evidence of New Haven's Industrial Revolution and the plasticity of ethnic and religious identity in the immigrant experience. Their recovery and the multifaceted analyses described here illuminate a previously undescribed part of the city's rich history. The collective expertise of biological, geochemical, archaeological, and historical researchers interprets socioeconomic and cultural identity better than any one could alone. Our combined efforts changed our initial assumptions of a poor urban Catholic cemetery's membership, and provide a template for future discoveries and analyses.

Superusers: Drivers of health care resource utilization in the national trauma population.

BACKGROUND: Health care spending is driven by a very small percentage of Americans, many of whom are patients with prolonged durations of stay. The objective of this study was to characterize superusers in the trauma population. METHODS: The National Trauma Data Bank for 2008-2012 was queried. Superusers were defined as those with a duration of stay in the top 0.06% of the population and were compared with the remainder of the population to determine differences in demographic characteristics, comorbidities, prehospital factors, and outcomes. Multivariate analysis was used to determine independent predictors of being classified as a superuser. RESULTS: A total of 3,617,261 patients met inclusion criteria, with 34,728 qualifying as superusers. Mean duration of stay for superusers was 58.7 days compared with the average 4.6 days (P < .001). Superusers were more likely to be male, black, Medicaid insured, and have a higher Injury Severity Score and lower Glasgow Coma Scale score. The hospital course of superusers was likely to be complicated by pneumonia, acute respiratory distress syndrome, decubitus ulcer, and acute kidney injury. CONCLUSION: Age, sex, race, and insurance were associated with prolonged use of inpatient care in the trauma patient population. Specific comorbidities and complications are associated with being a superuser. This subset of the trauma population confers a disproportionate burden on the health care system and can serve as a potential target for intervention.

Seeing the forest beyond the trees: Predicting survival in burn patients with machine learning.

BACKGROUND: This study aims to identify predictors of survival for burn patients at the patient and hospital level using machine learning techniques. METHODS: The HCUP SID for California, Florida and New York were used to identify patients admitted with a burn diagnosis and merged with hospital data from the AHA Annual Survey. Random forest and stochastic gradient boosting (SGB) were used to identify predictors of survival at the patient and hospital level from the top performing model. RESULTS: We analyzed 31,350 patients from 670 hospitals. SGB (AUC 0.93) and random forest (AUC 0.82) best identified patient factors such as age and absence of renal failure (p < 0.001) and hospital factors such as full time residents (p < 0.001) and nurses (p = 0.004) to be associated with increased survival. CONCLUSIONS: Patient and hospital factors are predictive of survival in burn patients. It is difficult to control patient factors, but hospital factors can inform decisions about where burn patients should be treated.

Commercial quality "awards" are not a strong indicator of quality surgical care.

BACKGROUND: This study aimed to determine whether publicized hospital rankings can be used to predict surgical outcomes. METHODS: Patients undergoing one of nine surgical procedures were identified, using the Healthcare Cost and Utilization Project State Inpatient Database for Florida and New York 2011-2013 and merged with hospital data from the American Hospital Association Annual Survey. Nine quality designations were analyzed as possible predictors of inpatient mortality and postoperative complications, using logistic regression, decision trees, and support vector machines. RESULTS: We identified 229,657 patients within 177 hospitals. Decision trees were the highest performing machine learning algorithm for predicting inpatient mortality and postoperative complications (accuracy 0.83, P<.001). The top 3 variables associated with low surgical mortality (relative impact) were Hospital Compare (42), total procedure volume (16) and, Joint Commission (12). When analyzed separately for each individual procedure, hospital quality awards were not predictors of postoperative complications for 7 of the 9 studied procedures. However, when grouping together procedures with a volume-outcome relationship, hospital ranking becomes a significant predictor of postoperative complications. CONCLUSION: Hospital quality rankings are not a reliable indicator of quality for all surgical procedures. Hospital and provider quality must be evaluated with an emphasis on creating consistent, reliable, and accurate measures of quality that translate to improved patient outcomes.

Adverse Effect of Post-Discharge Care Fragmentation on Outcomes after Readmissions after Liver Transplantation.

BACKGROUND: Post-discharge surgical care fragmentation is defined as readmission to any hospital other than the hospital at which surgery was performed. The objective of this study was to assess the impact of fragmented readmissions within the first year after orthotopic liver transplantation (OLT). STUDY DESIGN: The Healthcare Cost and Utilization Project State Inpatient Databases for Florida and California from 2006 to 2011 were used to identify OLT patients. Post-discharge fragmentation was defined as any readmission to a non-index hospital, including readmitted patients transferred to the index hospital after 24 hours. Outcomes included adverse events, defined as 30-day mortality and 30-day readmission after a fragmented readmission. All statistical analyses considered a hierarchical data structure and were performed with multilevel, mixed-effects models. RESULTS: We analyzed 2,996 patients with 7,485 readmission encounters at 299 hospitals; 1,236 (16.5%) readmissions were fragmented. After adjustment for age, sex, readmission reason, index liver transplantation cost, readmission length of stay, number of previous readmissions, and time from transplantation, post-discharge fragmentation increased the odds of both 30-day mortality (odds ratio [OR] = 1.75; 95% CI 1.16 to 2.65) and 30-day readmission (OR = 2.14; 95% CI 1.83 to 2.49). Predictors of adverse events after a fragmented readmission included increased number of previous readmissions (OR = 1.07; 95% CI 1.01 to 1.14) and readmission within 90 days of OLT (OR = 2.19; 95% CI 1.61 to 2.98). CONCLUSIONS: Post-discharge fragmentation significantly increases the risk of both 30-day mortality and subsequent readmission after a readmission in the first year after OLT. More inpatient visits before a readmission and less time elapsed from index surgery increase the odds of an adverse event after discharge from a fragmented readmission. These parameters could guide transfer decisions for patients with post-discharge fragmentation.

"Take the Volume Pledge" may result in disparity in access to care.

BACKGROUND: "Take the Volume Pledge" proposes restricting pancreatectomies to hospitals that perform ≥20 per year. Our purpose was to identify those factors that characterize patients at risk for loss of access to pancreatic cancer care with enforcement of volume standards. METHODS: Using the Healthcare Cost and Utilization Project State Inpatient Database from Florida, we identified patients who underwent pancreatectomy for pancreatic malignancy from 2007-2011. American Hospital Association and United States Census Bureau data were linked to patient-level data. High-volume hospitals were defined as performing ≥20 pancreatic resections per year. Univariable and multivariable statistics compared patient characteristics and utilization of high-volume hospitals. Classification and Regression Tree modeling was used to predict patients at risk for losing access to care. RESULTS: Our study included 1,663 patients. Five high-volume hospitals were identified, and they treated 1,056 (63.5%) patients. Patients residing far from high-volume hospitals, in areas with the highest population density, non-Caucasian ethnicity, and greater income had decreased odds of obtaining care at high-volume hospitals. Using these factors, we developed a Classification and Regression Tree-based predictive tool to identify these patients. CONCLUSION: Implementation of "Take the Volume Pledge" is an important step toward improving pancreatectomy outcomes; however, policymakers must consider the potential impact on limiting access and possible health disparities that may arise.

Perioperative support, not volume, is necessary to optimize outcomes in surgical management of necrotizing enterocolitis.

BACKGROUND: This study examines the relationship between hospital volume of surgical cases for necrotizing enterocolitis (NEC) and patient outcomes. METHODS: A retrospective cross-sectional review was performed using the HCUP SID for California from 2007 to 2011. Patients with NEC who underwent surgery were identified using ICD-9CM codes. Risk-adjusted models were constructed with mixed-effects logistic regression using patient and demographic covariates. RESULTS: 23 hospitals with 618 patients undergoing NEC-related surgical intervention were included. Overall mortality rate was 22.5%. There were no significant differences in the number of NICU beds (p = 0.135) or NICU intensivists (p = 0.469) between high and low volume hospitals. Following risk adjustment, no difference in mortality rate was observed between high and low volume hospitals respectively (24.0% vs. 20.3%, p = 0.555). CONCLUSIONS: Our observation that neonates with NEC treated at low-volume centers have no increased risk of mortality may be explained by similar availability of NICU and intensivists resources across hospitals.

Characterizing the role of a high-volume cancer resection ecosystem on low-volume, high-quality surgical care.

BACKGROUND: Our objective was to determine the hospital resources required for low-volume, high-quality care at high-volume cancer resection centers. METHODS: Patients who underwent esophageal, pancreatic, and rectal resection for malignancy were identified using Healthcare Cost and Utilization Project State Inpatient Database (Florida and California) between 2007 and 2011. Annual case volume by procedure was used to identify high- and low-volume centers. Hospital data were obtained from the American Hospital Association Annual Survey Database. Procedure risk-adjusted mortality was calculated for each hospital using multilevel, mixed-effects models. RESULTS: A total of 24,784 patients from 302 hospitals met the inclusion criteria. Of these, 13 hospitals were classified as having a high-volume, oncologic resection ecosystem by being a high-volume hospital for ≥2 studied procedures. A total of 11 of 31 studied hospital factors were strongly associated with hospitals that performed a high volume of cancer resections and were used to develop the High Volume Ecosystem for Oncologic Resections (HIVE-OR) score. At low-volume centers, increasing HIVE-OR score resulted in decreased mortality for rectal cancer resection (P = .038). HIVE-OR was not related to risk-adjusted mortality for esophagectomy (P = .421) or pancreatectomy (P = .413) at low-volume centers. CONCLUSION: Our study found that in some settings, low-volume, high-quality cancer surgical care can be explained by having a high-volume ecosystem.

Physical activity and experience of total knee replacement in patients one to four years postsurgery in the dominican republic: a qualitative study.

OBJECTIVE: Musculoskeletal disorders are the second leading cause of years lived with disability globally. Total knee replacement (TKR) offers patients with advanced arthritis relief from pain and the opportunity to return to physical activity. We investigated the impact of TKR on physical activity for patients in a developing nation. METHODS: As part of the Operation Walk Boston surgical mission program, we interviewed 18 Dominican patients (78% women) who received TKR about their level of physical activity after surgery. Qualitative interviews were conducted in Spanish, and English transcripts were analyzed using content analysis. RESULTS: Most patients found that TKR increased their participation in physical activities in several life domains, such as occupational or social pursuits. Some patients limited their own physical activities due to uncertainty about medically appropriate levels of joint use and postoperative physical activity. Many patients noted positive effects of TKR on mood and mental health. For most patients in the study, religion offered a framework for understanding their receipt of and experience with TKR. CONCLUSION: Our findings underscore the potential of TKR to permit patients in the developing world to return to physical activities. This research also demonstrates the influence of patients' education, culture, and religion on patients' return to physical activity. As the global burden of musculoskeletal disease increases, it is important to characterize the impact of activity limitation on patients' lives in diverse settings and the potential for surgical intervention to ease the burden of chronic arthritis.