Feasibility, effectiveness and patient satisfaction of telerehabilitation after thumb carpometacarpal arthroplasty and reverse total shoulder arthroplasty: A pilot study.

INTRODUCTION: Telemedicine is an effective, emerging interface to connect practitioners with patients. It facilitates access to healthcare expertise, reduces costs, time demands and health disparities while improving satisfaction. This pilot study evaluated the feasibility, effectiveness and patient satisfaction of telerehabilitation for thumb carpometacarpal (CMC) arthroplasty and reverse shoulder arthroplasty (rTSA). METHODS: This prospective investigation was performed at a single academic institution with two hand and upper extremity fellowship-trained orthopaedic surgeons. All patients undergoing CMC arthroplasty or rTSA were eligible for inclusion. Telerehabilitation was delivered by a hybrid model including an in-person post-operative visit, followed by alternating in-clinic and virtual videoconference visits. All patients were offered participation in the study arm; those that preferred in-person therapy were included as a control group. Therapy was initiated two weeks post-operative with an in-clinic evaluation. Patients then participated in alternating in-clinic and virtual visits weekly for eight weeks, followed by one virtual visit at 14-weeks post-operative and one clinical visit at 16-weeks post-operative. Patient reported and functional outcomes were collected at each visit. RESULTS: In the CMC group, 19 study and 11 control patients were enrolled. In the rTSA group, five study and 14 control patients were enrolled. No statistically significant differences between telerehabilitation and control for range-of-motion, pain and patient-reported functional outcomes was noted. All patients in the telerehabilitation arms reported high satisfaction. DISCUSSION: Utilizing telehealth in rehabilitation may be a viable option in upper extremity recovery. We hope this pilot programme can be a model for development of future telerehabilitation programmes.

Predictors of Insurance Claim Rejection in Hand and Upper Extremity Surgery.

INTRODUCTION: Insurance claim rejections represent a challenge for healthcare providers because of the potential for lost revenue and administrative costs of reworking claims. METHODS: The billing records of five hand and upper extremity surgeons at a tertiary academic center were queried for all patient billing activity over a 1-year period yielding a total of 14,421 unique patient encounters. RESULTS: A total of 11,839 unique patient encounters were included, and the overall claim rejection rate was 19.3%. Claim rejection rate varied significantly by payer (P < 0.0001) and was lowest in private insurance (14.0%) and highest in Medicare (31.2%). The use of multiple Current Procedure Terminology codes for an encounter was independently associated with an increased risk of claim rejection for both office (25.6%, relative risk [RR] 1.27, 95% confidence interval [CI] 1.03 to 1.49, P = 0.0032) and surgical (25.6%, RR 1.67, 95% CI 1.28 to 2.18, P = 0.0002) settings. After multivariate regression adjustment, modifier 25 was associated with a decreased risk of claim rejection (23.3%, RR 0.72, 95% CI 0.61 to 0.85, P < 0.0001). DISCUSSION: Insurance claim rejection occurs frequently (19.3%) in hand/upper extremity surgery and varies by insurance type, with the highest rejection rate occurring in Medicare (31.2%). For a given encounter, the use of multiple Current Procedure Terminology codes and specific modifiers are predictive of rejection risk. LEVEL OF EVIDENCE: Level III, prognostic.

Cost of Immediate Surgery Versus Non-operative Treatment for Trigger Finger in Diabetic Patients.

PURPOSE: As health care costs continue to rise, providers must increasingly identify and implement cost-effective practice measures without sacrificing quality of care. Corticosteroid injections are an established treatment for trigger finger; however, numerous clinical trials have documented the limited efficacy of these injections in the diabetic population. Furthermore, the most cost-effective treatment strategy for diabetic trigger finger has not been determined. The purpose of this study was to perform a decision analysis to identify the least costly strategy for effective treatment of diabetic trigger finger using existing evidence in the literature. METHODS: Four treatment strategies for diabetic trigger finger were identified: (1) 1 steroid injection followed by surgical release, (2) 2 steroid injections followed by surgical release, (3) immediate surgical release in the operating room, and (4) immediate surgical release in the clinic. A literature review was conducted to determine success rates of the different treatment strategies. Costing analysis was performed using our institutional reimbursement from Medicare. One-way sensitivity and threshold analysis was utilized to determine the least costly treatment strategy. RESULTS: The least costly treatment strategy was immediate surgical release in the clinic. In patients with insulin-dependent diabetes mellitus, this strategy results in a 32% and a 39% cost reduction when compared with treatment with 1 or 2 corticosteroid injections, respectively. For 1 or 2 corticosteroid injections to be the most cost-effective strategy, injection failure rates would need to be less than 36% and 34%, respectively. The overall cost of care for immediate surgical release in the clinic was $642. CONCLUSIONS: Diabetic trigger finger is a common problem faced by hand surgeons, with a variety of acceptable treatment algorithms. Management of diabetic trigger finger with immediate surgical release in the clinic is the most cost-effective treatment strategy, assuming a corticosteroid injection failure rate of at least 34%. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/decision III.