Understanding Health Economics in Hand Surgery.

Rising health care costs in the United States, besides evolving payment models that place emphasis on value instead of volume, have led to an increasing number of studies evaluating hand surgery from an economic perspective. To better understand such economics-based studies, this review provides a foundational understanding of what value entails by defining its features of quality and cost. Principles of evaluating value through cost-benefit, cost-effectiveness, and cost-utility analyses are discussed. Models of discounting and clinical decision analyses are also discussed. Understanding such concepts and their evaluation in economic analyses will provide greater insight into the economic landscape of hand surgery and improving patient care.

Understanding Health Economics in Joint Replacement Surgery.

The number of arthroplasty procedures has been rising at a significant rate, contributing to a notable portion of the nation's health care spending. This growth has contributed to an increase in the number of health care economic studies in the field of adult reconstruction surgery. Although these articles are filled with important information, they can be difficult to understand without a background in business or economics. The goal of this review is to define the common terminology used in health care economic studies, assess their value and benefit in the context of total joint arthroplasty, and highlight shortcomings in the current literature. [Orthopedics. 2022;45(4):e174-e182.].

Temporal and Geographic Trends in Medicare Reimbursement of Primary and Revision Shoulder Arthroplasty: 2000 to 2020.

INTRODUCTION: A comprehensive understanding of the trends for financial reimbursement of shoulder arthroplasty is important as progress is made toward achieving sustainable payment models in orthopaedics. This study analyzes Medicare reimbursement trends for shoulder arthroplasty. We hypothesize that Medicare reimbursement has decreased for shoulder arthroplasty procedures from 2000 to 2020 and that revision procedures have experienced greater decreases in reimbursement. METHODS: The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for each Current Procedural Terminology code used in shoulder arthroplasty, and physician reimbursement data were extracted. All monetary data were adjusted for inflation to 2020 US dollars. Both the average annual and the total percentage change in surgeon reimbursement were calculated based on these adjusted trends for all included procedures. Mean percentage change in adjusted reimbursement among primary procedures in comparison to revision procedures was calculated. The mean reimbursement was assessed and visually represented by geographic state. RESULTS: The average reimbursement for all shoulder arthroplasty procedures decreased by 35.5% from 2000 to 2020. Revision total shoulder arthroplasty (TSA) experienced the greatest mean decrease (-44.6%), whereas primary TSA (-23.9%) experienced the smallest mean decrease. The adjusted reimbursement rate for all included procedures decreased by an average of 1.8% each year. The mean reimbursement for revision procedures decreased more than the mean reimbursement for primary procedures (-41.1% for revision, -29.9% for primary; P < 0.001). The mean reimbursement for TSA in 2020, and the percent change in reimbursement from 2000 to 2020, varied by state. DISCUSSION: Medicare reimbursement for shoulder arthroplasty procedures has decreased from 2000 to 2020, with revision procedures experiencing the greatest decrease. Increased awareness and consideration of these trends will be important as healthcare reform evolves, and reimbursements for large joint arthroplasty are routinely adjusted.

Understanding Health Economics in Spine Surgery.

¼: The United States has faced substantial increases in health-care expenditure, with specifically large increases in spine surgery costs. ¼: Many different formulas are utilized to determine value in spine surgery, including cost- benefit analyses, cost-effectiveness analyses, and cost-utility analyses, with the overall determination of value being quality/cost. ¼: Quality often is calculated indirectly using either process measures or outcome measures and represents the potential benefit of a given intervention, usually over a specific time period to yield quality-adjusted life years. ¼: Costs are particularly difficult to calculate given the interhospital, regional, national, and global variability, as well as indirect costs of an intervention, and many different methods are utilized to estimate costs. ¼: Spine surgeons should be familiar with the elements that compose cost-effectiveness and their potential shortcomings in order for providers and health-care policy makers to identify the highest-quality studies and interventions that provide the greatest benefit to patients.

Pediatric Digit Replantation Following Traumatic Amputation: Nationwide Analysis of Patient Selection, Outcomes, and Cost.

Background: Indications for replantation following traumatic digit amputations are more liberal in the pediatric population than in adults, but delineation of patient selection within pediatrics and their outcomes have yet to be elucidated. This study uses a national pediatric database to evaluate patient characteristics and injury patterns involved in replantation and their outcomes. Methods: The Healthcare Cost and Utilization Project Kid's Inpatient Database was queried for traumatic amputations of the thumb and finger from 2000 to 2012. Participants were separated into those who underwent replantation and those who underwent amputation. Patients undergoing replantation were further divided into those requiring revision amputation and/or microvascular revision. Patient age, sex, insurance, digit(s) affected, charges, length of stay, and complications were extracted for each patient. Results: Traumatic digit amputations occurred in 3090 patients, with 1950 (63.1%) undergoing revision amputation and 1140 (36.9%) undergoing replantation. Younger patients, those with thumb injuries, females, and those covered under private insurance were significantly more likely to undergo replantation. Cost, length of stay, and in-hospital complications were significantly greater in replantation patients than in those who had undergone amputation. Following replantation, 237 patients (20.8%) underwent revision amputation and 209 (18.3%) underwent vascular revision, after which 58 required revision amputation. Risk of revision following replantation involved older patients, males, and procedures done recently. Conclusions: Pediatric patients who underwent replantation were significantly younger, female, had thumb injuries, and were covered by private insurance. Our findings demonstrate that in addition to injury factors, demographics play a significant role in the decision for finger replantation and its outcomes.

Cost-Effectiveness of Initial Revision Digit Amputation Performed in the Emergency Department Versus the Operating Room.

Background: The objective of this study was to determine the comparative cost-effectiveness of performing initial revision finger amputation in the emergency department (ED) versus in the operating room (OR) accounting for need for unplanned secondary revision in the OR. Methods: We retrospectively examined patients presenting to the ED with traumatic finger and thumb amputations from January 2010 to December 2015. Only those treated with primarily revision amputation were included. Following initial management, the need for unplanned reoperation was assessed and associated with setting of initial management. A sensitivity analysis was used to determine the cost-effectiveness threshold for initial management in the ED versus the OR. Results: Five hundred thirty-seven patients had 677 fingertip amputations, of whom 91 digits were initially primarily revised in the OR, and 586 digits were primarily revised in the ED. Following initial revision, 91 digits required unplanned secondary revision. The unplanned secondary revision rates were similar between settings: 13.7% digits from the ED and 12.1% of digits from the OR (P = .57). When accounting for direct costs, an incidence of unplanned revision above 77.0% after initial revision fingertip amputation in the ED would make initial revision fingertip amputation in the OR cost-effective. Therefore, based on the unplanned secondary revision rate, initial management in the ED is more cost-effective than in the OR. Conclusions: There is no significant difference in the incidence of unplanned/secondary revision of fingertip amputation rate after the initial procedure was performed in the ED versus the OR.

Critical Assessment of the Contemporary Orthopaedic Surgery Residency Application Process.

BACKGROUND: Matching into orthopaedic surgery residency in the United States has become an increasingly competitive process because of the large number of well-qualified applicants. Over the past several years, applicants have sought to maximize their chances of matching by submitting an increasing number of applications. The purpose of this study was to assess trends in application numbers, applicant qualifications, and application reviews, with the goal of obtaining data to help inform future improvements in the orthopaedic surgery residency application process. METHODS: Applicant data were obtained from the Electronic Residency Application Service (ERAS, www.aamc.org/services/eras/stats) and the National Resident Matching Program (NRMP, www.nrmp.org/report-archives). These included residency application data from 2000 to 2017. In addition, we analyzed available NRMP Applicant Survey Reports between 2008 and 2017, Program Director Survey Reports between 2008 and 2016, and NRMP's Charting Outcomes in the Match between 2006 and 2016. RESULTS: The number of U.S. senior medical student applicants per orthopaedic surgery residency position was stable from 2000 to 2017 (1.13 vs. 1.16 for 2000 and 2017, respectively). A significant increase in the United States Medical Licensing Examination (USMLE) Step-1 and Step-2 scores and self-reported research activity was present over the same time period. The number of applications submitted per applicant significantly increased, by 71.7%, from 48.4 in 2006 to 83.1 in 2017. Additionally, applications per program increased 46.4% from 457 in 2010 to 669 in 2016. In 2010, programs performed in-depth reviews for 54% of applications; however, in 2016, in-depth reviews had decreased to 45% of applications. CONCLUSIONS: Orthopaedic residency applicant USMLE scores and research productivity have increased over time. Concurrently, the average number of applications submitted per applicant has increased, with the average applicant applying to nearly half of all orthopaedic residency programs. Consequently, programs have seen more than double the number of applications over this study period. The accompanying decline in the proportion of applications undergoing in-depth review, along with the applicant and program resources associated with these changes, warrants the development of strategies to enhance the efficiency of the application process for orthopaedic residency.