Increasing Value in Subspecialty Training: A Comparison of Variation in Surgical Complications for Pediatric Versus Other Fellowship-trained American Board of Orthopaedic Surgery Candidates in the Treatment of Supracondylar Fractures.

INTRODUCTION: The effect of orthopaedic fellowship subspecialization on surgical complications for patients with supracondylar fracture is unknown. This study seeks to compare the effect of subspecialty training on supracondylar fracture complications. METHODS: The American Board of Orthopaedic Surgery Part II Examination Case List database was reviewed for all supracondylar fractures from 1999 to 2016. Procedures were divided by fellowship subspecialty (trauma, pediatric, or other) and case volume and assessed by surgeon-reported surgical complications. Predictive factors of complications were analyzed using a binary multivariate logistic regression. RESULTS: Of 10,961 supracondylar fractures identified, 53.47% were done by pediatric fellowship-trained surgeons. Pediatric-trained surgeons had fewer surgical complications compared with their trauma or other trained peers (4.54%, 5.67%, and 6.24%; P = 0.001). Treatment by pediatric-trained surgeons reduced surgical complications (OR = 0.79, 95% CI: 0.66 to 0.94; P = 0.010), whereas increased case volume (31+ cases) showed no significant effect (OR = 0.79, 95% CI: 0.62 to 1.02; P = 0.068). Patient sex, age, and year of procedure did not affect complication rates, while those treated in the Southeast region of the United States and those with a complex fracture type were at increased odds. DISCUSSION: Treatment of supracondylar fractures by pediatric-trained surgeons demonstrates reduced surgeon-reported complications compared with their other fellowship-trained counterparts, whereas case volume does not. This suggests the value of fellowship training beyond pertinent surgical caseload among pediatric-trained surgeons and may lie in targeted education efforts.

Differential Utilization Patterns of Total Ankle Arthroplasty vs Arthrodesis: A United States National Ambulatory Database Analysis.

Background: End-stage ankle osteoarthritis is a condition that can be treated with ankle arthrodesis (AA) or total ankle arthroplasty (TAA). The goal of this study is to estimate the 2016-2017 United States' utilization of TAA and AA in specific ambulatory settings and delineate patient and hospital factors associated with the selection of TAA vs AA for treatment of ankle osteoarthritis. Methods: TAA and AA procedures performed for ankle osteoarthritis were identified in the 2016-2017 Nationwide Ambulatory Surgery Sample (NASS) Database. Notably, the NASS database only examines instances of ambulatory surgery encounters at hospital-owned facilities. As such, instances of TAA and AA performed at privately owned or freestanding ambulatory surgical centers or those performed inpatient are excluded from this analysis. Cases were weighted using nationally representative discharge weights. Univariate analyses and a combined multiple logistic regression model were used to compare demographic, hospital-related, and socioeconomic factors associated with TAA vs AA. Results: In total, 6577 cases were identified, which represents 9072 cases after weighting. Of these, TAA was performed for 2233 (24.6%). Based on the logistic regression model, several factors were associated with increased utilization of TAA vs AA. With regard to patient factors, older patients were more likely to undergo TAA, as well as females. Conversely, patients with a higher comorbidity burden were less likely to receive TAA over AA.With regard to socioeconomic factors, urban teaching and urban nonteaching hospitals were significantly more likely to use TAA compared to rural hospitals. Similarly, privately insured patients and those with a median household income of $71 000 or more were also more likely to receive TAA over AA. Private hospitals ("not-for-profit" and "investor-owned") were significantly more likely to offer TAA over AA. Conclusion: Using a large nationally representative cohort, the current data revealed that during 2016-2017, 24.6% of operatively treated cases of end-stage ankle osteoarthritis in the ambulatory setting are treated with TAA. Associations between socioeconomic and hospital-level factors with TAA utilization suggest that nonclinical factors may influence surgical treatment choice for ankle osteoarthritis. Level of Evidence: Level III, retrospective cohort study.

Optimizing spine surgery instrument trays to immediately increase efficiency and reduce costs in the operating room.

Background: Over-crowded surgical trays result in perioperative inefficiency and unnecessary costs. While methodologies to reduce the size of surgical trays have been described in the literature, they each have their own drawbacks. In this study, we compared three methods: (1) clinician review (CR), (2) mathematical programming (MP), and (3) a novel hybrid model (HM) based on surveys and cost analysis. While CR and MP are well documented, CR can yield suboptimal reductions and MP can be laborious and technically challenging. We hypothesized our easy-to-implement HM would result in a reduction of surgical instruments in both the laminectomy tray (LT) and basic neurosurgery tray (BNT) that is comparable to CR and MP. Methods: Three approaches were tested: CR, MP, and HM. We interviewed 5 neurosurgeons and 3 orthopedic surgeons, at our institution, who performed a total of 5437 spine cases, requiring the use of the LT and BNT over a 4-year (2017-2021) period. In CR, surgeons suggested which surgical instruments should be removed. MP was performed via the mathematical analysis of 25 observations of the use of a LT and BNT tray. The HM was performed via a structured survey of the surgeons' estimated instrument usage, followed by a cost-based inflection point analysis. Results: The CR, MP, and HM approaches resulted in a total instrument reduction of 41%, 35%, and 38%, respectively, corresponding to total cost savings per annum of $50,211.20, $46,348.80, and $44,417.60, respectively. Conclusions: While hospitals continue to examine perioperative services for potential inefficiencies, surgical inventory will be increasingly scrutinized. Despite MP being the most accurate methodology to do so, our results suggest that savings were similar across all three methods. CR and HM are significantly less laborious and thus are practical alternatives.

Is There Utility to Requiring Spine MRI Pre-authorizations? Pre-authorizations: A Single Institution's Perspective.

STUDY DESIGN: A retrospective cohort study of a patient undergoing treatment at a single institution's Spine Center. OBJECTIVE: The current study assessed the rates and eventual disposition of pre-authorizations required before spine MRIs are ordered from an academic spine center. SUMMARY OF BACKGROUND DATA: Spine magnetic resonance imaging (MRI) often requires preauthorization by insurance carriers. While there are potential advantages to ensuring consistent indicators for imaging modalities, previous studies have found that such processes can add administrative burdens and barriers to care. METHODS: Patients from a single academic institution's spine center who were covered by commercial insurance and had a spine MRI ordered between January 2013 and December 2019 were identified. The requirement for preauthorization and eventual disposition of each of these studies was tracked. Multivariate logistic regression was used to determine if commercial insurance carriers or anatomic region MRIs were associated with requiring a preauthorization. The eventual disposition of studies associated with this process was tracked. RESULTS: In total, 2480 MRI requests were identified, of which preauthorization was needed for 2122 (85.56%). Relative to cervical spine scans, preauthorization had greater odds of being required for thoracic (OR=2.71, P =0.003) and lumbar (OR=2.46, P <0.001) scans. Relative to a reference insurer, 4 of the 5 commercial carriers had statistically significant increased odds of requiring preauthorization (OR=1.54-10.17 P <0.050 for each).Of the imaging studies requiring preauthorization, peer to peer review was required for 204 (9.61%), and 1,747 (82.33% of all requiring preauthorization) were approved. Of 375 (17.67%) initially cancelled or denied by the preauthorization process, 290 (77.33% of those initially cancelled or denied) were completed within 3 months. In total, only 85 were not eventually approved and completed. CONCLUSION: Of 2480 distinct MRI orders, commercial insurers required preauthorization for 85.56%. Nonetheless, 96.57% of all scans went on to be completed within 3 months, raising questions about the costs, benefits, and overall value of this administrative process.

Comparison of Differences in Surgical Complications Between Fellowship-Trained Orthopedic Foot and Ankle Surgeons and All Other Orthopedic Surgeons Using the ABOS Database.

During the past decade, US orthopedic residency graduates have become increasingly subspecialized presumably for decreased patient complications; however, no study has examined this clinical utility for foot and ankle (F&A) surgeries among different fellowship subspecialties. Data from American Board of Orthopaedic Surgery 1999 to 2016 Part II Board Certification Examinations were used to assess patients treated by F&A fellowship-trained, trauma fellowship-trained, and all other fellowship-trained orthopedic surgeons performing ankle fracture repair. Adverse events were compared by surgical complexity and fellowship status. Factors independently associated with surgical complications were identified using a binary multivariate logistic regression. A total of 45,031 F&A cases met inclusion criteria. From 1999 to 2016, the percentage of F&A procedures performed by F&A fellowship surgeons steadily increased. Surgical complications were significantly different between fellowship trainings (F&A, 7.23%; trauma, 6.65%; and other, 7.84%). This difference became more pronounced with more complicated fracture pattern. On multivariate regression, F&A fellowship training was associated with significantly decreased likelihood of surgeon-reported complications (odds ratio, 0.83; 95% CI, 0.76-0.92; P<.001), as was trauma fellowship training (odds ratio, 0.90; 95% CI, 0.81-0.99; P=.035). Despite presumed increased complexity of cases treated by F&A fellowship-trained surgeons, these patients had significantly decreased risk of surgeon-reported surgical complications, thus highlighting the value of F&A fellowship training. In the absence of vital patient comorbidity data in the American Board of Orthopaedic Surgery database, further research must examine specific patient comorbidities and case acuity and their influence on treatments and surgical complications between fellowship-trained and other orthopedic surgeons to further illuminate the value of subspecialty training. [Orthopedics. 2023;46(4):e237-e243.].

Preoperative Deficiency Anemia in Digital Replantation: A Marker of Disparities, Increased Length of Stay, and Hospital Cost.

Introduction The effects of preoperative anemia have been shown to be an independent risk factor associated with poor outcomes in both cardiac and noncardiac surgery. Socioeconomic status and race have also been linked to poor outcomes in a variety of conditions. This study was designed to study iron deficiency anemia as a marker of health disparities, length of stay and hospital cost in digital replantation. Materials and Methods Digit replantations performed between 2008 and 2014 were reviewed from the National Inpatient Sample (NIS) database using the ICD-9-CM procedure codes 84.21 and 84.22. Patients with more than one code or with an upper arm (83.24) or hand replantation (84.23) code were excluded. Extracted variables included age, race, comorbidities, hospital type, hospital region, insurance payer type, and median household income quartile. Digit replantations were separated into patients with and without deficiency anemia. Demographics, comorbidities, and access to care were compared between cohorts by chi-squared and t -tests. Multivariate regressions were utilized to assess the effects of anemia on total cost and length of stay. The regression controlled for demographics, region, income, insurance, hospital type, and comorbidities. Beta coefficient was calculated for length of stay and hospital cost. The regression controlled for significant age, race, region, and comorbidities in addition to the above variables. Results In the studied patient population of those without anemia, 59.5% were Caucasian, and in patients with anemia, 46.7% were Caucasian ( p < 0.001). Whereas in the in the studied patient population of those without anemia, 6.7% were Black, and in patients with anemia, 15.7% were Black ( p < 0.001). Median household income, payer information, length of stay and total cost of hospitalization had statistically significant differences. Using regression and ß-coefficient, the effect of anemia on length of stay and cost was also significant ( p < 0.001). Regression controlled for age, race, region and comorbidities, with the ß-coefficient for effect on cost 37327.18 and on length of stay 3.96. Conclusion These data show that deficiency anemias are associated with a significant increase in length and total cost of stay in patients undergoing digital replantation. Additionally, a larger percentage of patients undergoing digital replantations and who have deficiency anemia belong to the lowest income quartile. Our findings present an important finding for public health prevention and resource allocation. Future studies could focus on clinical intervention with iron supplementation at the time of digital replantation.

Patient Demographic and Socioeconomic Factors Associated With Physical Therapy Utilization After Uncomplicated Meniscectomy.

INTRODUCTION: The extent to which physical therapy (PT) is used after meniscectomy is unknown. The objective of this study was to estimate the extent to which PT is implemented after meniscectomy and to identify factors associated with its utilization. METHODS: The Mariner PearlDiver database was queried to identify patients who underwent uncomplicated meniscectomy. The number of PT visits for each patient was tabulated. Logistic regressions were used to compare demographic factors associated with no use of PT and use of nine or more PT visits. RESULTS: In total, 92,291 patients met inclusion criteria. Of these patients, 72.21% did not use PT and 27.8% used 1 or more PT visits. Of the patients who used PT, 19.76% had 1 to 8 PT visits and 8.03% had 9 or more PT visits. Older age and noncommercial insurance types were associated with no PT use. Male sex, Medicaid, and Medicare were associated with markedly lower odds of increased PT utilization. CONCLUSION: PT is used in the minority of the time after meniscectomy. Among patients who do use PT, however, notable variation exists in the amount of PT visits used. Patient age, sex, insurance status, and geographic variables were independently associated with PT utilization.

Revision Total Hip and Knee Arthroplasty are Associated With Lower Hospital Consumer Assessment of Healthcare Providers and Systems Patient Satisfaction Scores Compared With Primary Arthroplasty.

INTRODUCTION: As rates of primary total joint arthroplasty continue to rise, so do rates of revision. Revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) are more frequently done at larger centers, are associated with higher morbidity, and may have different patient satisfaction outcomes. This study compares the survey results of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) between patients who underwent primary versus revision THA or TKA. METHODS: All adult patients who underwent inpatient, elective, primary, and revision THA or TKA at a single institution were selected for retrospective analysis. Patient demographics, comorbidities, functional status, surgical variables, 30-day outcomes, and HCAHPS scores were assessed. Univariate and multivariate analyses were done to determine correlations between the aforementioned variables and top-box HCAHPS survey scores for primary versus revision THA and TKA. RESULTS: Of 2,707 patients who met the inclusion criteria and had returned the HCAHPS survey, primary THA was documented in 1,075 patients (39.71%), revision THA in 75 (2.77%), primary TKA in 1,497 (55.30%), and revision TKA in 60 (2.22%). Revision THA patients were more functionally dependent, and TKA patients had higher American Society of Anesthesiologists score than their primary comparators. Revisions had longer hospital length of stay for both procedures. For THA, revision THA patients demonstrated lower total top-box rates compared withprimary THA patients (71.64% versus 75.67% top-box, P < 0.001) and lower scores on the care from doctors subsection (76.26% versus 85.34%, P < 0.001) of the HCAHPS survey. Similarly, for TKA, revision TKA patients demonstrated lower total top-box rates (76.13% versus 79.22%, P < 0.013) and lower scores on the care from doctors subsection (66.28% versus 83.65%, P < 0.001) of the HCAHPS survey. DISCUSSION: For both THA and TKA, revision procedures were associated with lower total HCAHPS scores and rated care from doctors. This suggests that HCAHPS scores may be biased by factors outside the surgeon's control, such as the complexity associated with revision procedures. LEVEL OF EVIDENCE: Level III.

Hospital Consumer Assessment of Healthcare Providers and Systems survey response rates are significantly affected by patient characteristics and postoperative outcomes for patients undergoing primary total knee arthroplasty.

INTRODUCTION: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey measures patients' satisfaction of their hospital experience. A minority of discharged patients return the survey. Underlying bias among who ultimately returns the survey (non-response bias) after total knee arthroplasty (TKA) may affect results of the survey. Thus, the objective of the current study is to assess the relationship between patient characteristics and postoperative outcomes on HCAHPS survey nonresponse. METHODS: All adult patients at a single institution undergoing inpatient, elective, primary TKA between February 2013 and May 2020 were selected for analysis. Following discharge, all patients had been mailed the HCAHPS survey. The primary outcome analyzed in the current study is survey return. Patient characteristics, surgical variables, and 30-day postoperative outcomes were analyzed. Univariate and multivariate analyses were performed to identify factors independently associated with return of the HCAHPS survey. RESULTS: Of 4,804 TKA patients identified, 1,498 (31.22%) returned HCAHPS surveys. On multivariate regression analyses controlling for patient factors, patients who did not return the survey were more likely to have a higher American Society of Anesthesia score (ASA score of 4 or higher, OR = 2.37; P<0.001), and be partially or totally dependent (OR = 2.37; P = 0.037). Similarly, patients who did not return the survey were more likely to have had a readmission (OR = 1.94; P<0.001), be discharged to a place other than home (OR = 1.52; P<0.001), or stay in the hospital for longer than 3 days (OR = 1.43; P = 0.004). DISCUSSION: Following TKA, HCAHPS survey response rate was only 31.22% and completion of the survey was associated with several demographic and postoperative variables. These findings suggest that HCAHPS survey results capture a non-representative fraction of the true TKA patient population. This bias is necessary to consider when using HCAHPS survey results as a metric for quality of healthcare and federal reimbursement rates.

Spine Surgery HCAHPS Patient Satisfaction Survey Results Inversely Correlate with Survey Response Time.

STUDY DESIGN: Retrospective review. OBJECTIVE: The aim of this study was to understand the potential correlation of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey response time on reported satisfaction following spine surgery hospitalization. SUMMARY OF BACKGROUND DATA: With increasing emphasis on patient satisfaction metrics, such as HCAHPS, hospital reputations, and reimbursements are being affected by the results of such surveys. HCAHPS is a 32-question survey about patient experience in the hospital and after discharge. METHODS: HCAHPS surveys were routinely sent to all patients admitted after spine surgery at an academic medical center between January 2013 and August 2017. Survey data, survey return time, patient demographics, and 30-day postoperative outcomes were gathered for all spine surgery patients who returned the survey. Multivariate regression analysis controlling for age, sex, BMI, functional status, American Society of Anesthesiologists class, education, and race was used to determine whether there were differences in rates of "Top Box" response between different time ranges of survey return. RESULTS: In total, 1495 consecutive spinal surgery patients who returned their HCAHPS survey were identified. Of these, 31.51% returned their surveys within 21 days, 48.09% returned them between 22 to 42 days, 13.58% returned them between 43 to 64 days, and 6.82% returned them ≥65 days after distribution. Multivariate regression demonstrated no statistical differences in reported satisfaction between surveys returned between days 0 to 21 and days 22 to 42. However, there were significantly lower scores reported by surveys returned on days 43 to 64 and 65 plus days. CONCLUSION: Centers for Medicare and Medicaid Services only considers HCAHPS surveys returned within the first 42 days. It appears that the survey responses are similar over this time period. Beyond this time, lower scores are reported. Further attention to this less satisfied, later HCAHPS survey returning group seems warranted.Level of Evidence: 2.

Patient Factors and Perioperative Outcomes Affect Hospital Consumer Assessment of Healthcare Providers and Systems Survey Response Rates After Primary Total Hip Replacement.

INTRODUCTION: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a federally mandated survey that assesses patient satisfaction after hospitalization. It has been noted that a minority of patients actually return the survey. Potential bias in who does and does not respond to the survey (nonresponse bias) after total hip arthroplasty (THA) may affect the survey results. METHODS: All adult patients undergoing inpatient elective primary THA between February 2013 and May 2020 at a single institution were selected for retrospective analysis. After discharge, all had been mailed the HCAHPS survey, and the primary outcome for the current study was survey return. Patient characteristics and 30-day perioperative outcomes were assessed. Univariate and multivariate analyses were performed to determine correlations between the above variables and HCAHPS survey return status. RESULTS: Of 3,310 THA patients analyzed, 1,049 (31.69%) returned the HCAHPS surveys. On multivariate regression analyses, patients who did not return the survey were more likely to have a higher American Society of Anesthesia score (score of three or higher, odds ratio [OR] = 2.27; P < 0.001), be more functionally dependent (OR = 2.69; P = 0.005), or be Black/African American (OR = 3.40; P < 0.001). Similarly, patients who did not return the survey were more likely to have had any adverse event (OR = 1.80; P = 0.012), major adverse event (OR = 2.88; P = 0.007), readmission (OR = 2.13; P < 0.001), be discharged to a place other than home (OR = 1.71; P < 0.001), or stay in the hospital for longer than 3 days (OR = 1.89; P < 0.001). DISCUSSION: After THA, the HCAHPS survey response rate was only 31.69% and completion of the survey correlated with demographic and perioperative variables. These findings suggest that the HCAHPS survey results should be interpreted as a skewed sample of the true surgical patient population. Nonresponse bias is an important factor to consider when evaluating healthcare quality, patient satisfaction survey results, and their effects on federal hospital reimbursement rates.

Orthopaedic Foot and Ankle Surgeon Industry Compensation Reported by the Open Payments Database.

Background. The current study aims to characterize and explore trends in Open Payments Database (OPD) payments reported to orthopaedic foot and ankle (F&A) surgeons. OPD payments are classified as General, Ownership, or Research. Methods. General, Ownership, and Research payments to orthopaedic F&A surgeons were characterized by total payment sum and number of transactions. The total payment was compared by category. Payments per surgeon were also assessed. Median payments for all orthopaedic F&A surgeons and the top 5% compensated were calculated and compared across the years. Medians were compared through Mann-Whitney U tests. Results. Over the period, industry paid over $39 million through 29,442 transactions to 802 orthopaedic F&A surgeons. The majority of this payment was General (64%), followed by Ownership (34%) and Research (2%). The median annual payments per orthopaedic F&A surgeon were compared to the 2014 median ($616): 2015 ($505; P = .191), 2016 ($868; P = .088), and 2017 ($336; P = .084). Over these years, the annual number of compensated orthopaedic F&A surgeons increased from 490 to 556. Averaged over 4 years, 91% of the total orthopaedic F&A payment was made to the top 5% of orthopaedic F&A surgeons. The median payment for this group increased from $177 000 (2014) to $192 000 (2017; P = .012). Conclusion. Though median payments to the top 5% of orthopaedic F&A surgeons increased, there was no overall change in median payment over four years for all compensated orthopaedic F&A surgeons. These findings shed insight into the orthopaedic F&A surgeon-industry relationship.Levels of Evidence: III, Retrospective Study.

Patient-related Factors and Perioperative Outcomes Are Associated with Self-Reported Hospital Rating after Spine Surgery.

BACKGROUND: Since 2013, the Centers for Medicare & Medicaid Services has tied a portion of hospitals' annual reimbursement to patients' responses to the Hospital Consumer Assessment and Healthcare Providers and Systems (HCAHPS) survey, which is given to a random sample of inpatients after discharge. The most general question in the HCAHPS survey asks patients to rate their overall hospital experience on a scale of 0 to 10, with a score of 9 or 10 considered high, or "top-box." Previous work has suggested that HCAHPS responses, which are meant to be an objective measure of the quality of care delivered, may vary based on numerous patient factors. However, few studies to date have identified factors associated with HCAHPS scores among patients undergoing spine surgery, and those that have are largely restricted to surgery of the lumbar spine. Consequently, patient and perioperative factors associated with HCAHPS scores among patients receiving surgery across the spine have not been well elucidated. QUESTIONS/PURPOSES: Among patients undergoing spine surgery, we asked if a "top-box" rating on the overall hospital experience question on the HCAHPS survey was associated with (1) patient-related factors present before admission; (2) surgical variables related to the procedure; and/or (3) 30-day perioperative outcomes. METHODS: Among 5517 patients undergoing spine surgery at a single academic institution from 2013 to 2017 and who were sent an HCAHPS survey, 27% (1480) returned the survey and answered the question related to overall hospital experience. A retrospective, comparative analysis was performed comparing patients who rated their overall hospital experience as "top-box" with those who did not. Patient demographics, comorbidities, surgical variables, and perioperative outcomes were compared between the groups. A multivariate logistic regression analysis was performed to determine patient demographics, comorbidities, and surgical variables associated with a top-box hospital rating. Additional multivariate logistic regression analyses controlling for these variables were performed to determine the association of any adverse event, major adverse events (such as myocardial infarction, pulmonary embolism), and minor adverse events (such as urinary tract infection, pneumonia); reoperation; readmission; and prolonged hospitalization with a top-box hospital rating. RESULTS: After controlling for potential confounding variables (including patient demographics), comorbidities that differed in incidence between patients who rated the hospital top-box and those who did not, and variables related to surgery, the patient factors associated with a top-box hospital rating were older age (compared with age ≤ 40 years; odds ratio 2.2, [95% confidence interval 1.4 to 3.4]; p = 0.001 for 41 to 60 years; OR 2.5 [95% CI 1.6 to 3.9]; p < 0.001 for 61 to 80 years; OR 2.1 [95% CI 1.1 to 4.1]; p = 0.036 for > 80 years), and being a man (OR 1.3 [95% CI 1.0 to 1.7]; p = 0.028). Further, a non-top-box hospital rating was associated with American Society of Anesthesiologists Class II (OR 0.5 [95% CI 0.3 to 0.9]; p = 0.024), Class III (OR 0.5 [95% CI 0.3 to 0.9]; p = 0.020), or Class IV (OR 0.2 [95% CI 0.1 to 0.5]; p = 0.003). The only surgical factor positively associated with a top-box hospital rating was cervical surgery (compared with lumbar surgery; OR 1.4 [95% CI 1.1 to 1.9]; p = 0.016), while nonelective surgery (OR 0.5 [95% CI 0.3 to 0.8]; p = 0.004) was associated with a non-top-box hospital rating. Controlling for the same set of variables, a non-top-box rating was associated with the occurrence of any adverse event (OR 0.5 [95% CI 0.3 to 0.7]; p < 0.001), readmission (OR 0.5 [95% CI 0.3 to 0.9]; p = 0.023), and prolonged hospital stay (OR, 0.6 [95% CI 0.4 to 0.8]; p = 0.004). CONCLUSIONS: Identifying patient factors present before surgery that are independently associated with HCAHPS scores underscores the survey's limited utility in accurately measuring the quality of care delivered to patients undergoing spine surgery. HCAHPS responses in the spine surgery population should be interpreted with caution and should consider the factors identified here. Given differing findings in the literature regarding the effect of adverse events on HCAHPS scores, future work should aim to further characterize this relationship. LEVEL OF EVIDENCE: Level III, therapeutic study.

Industry Payments to Pediatric Orthopaedic Surgeons Reported by the Open Payments Database: 2014 to 2017.

BACKGROUND: The Open Payments Database (OPD), mandated by the Sunshine Act, is a national registry of physician-industry transactions. Payments are reported as either General, Research, or Ownership payments. The current study aims to investigate trends in OPD General payments reported to pediatric orthopaedic surgeons from 2014 to 2017. METHODS: General industry payments made to pediatric orthopaedic surgeons (as identified by OPD) were characterized by median payment, payment subtype, and census region. As fewer Research and Ownership payments were made, only payment totals for these categories were determined. General payment data were analyzed for trends using the nonparametric Mann-Whitney U test. RESULTS: For General payments, there was an increase in the number of compensated pediatric orthopaedists from 2014 to 2017 (324 vs. 429). Of those compensated, there was no significant change in median payment per compensated surgeon ($201 vs. $197; P=0.82). However, a large percentage of total General payment dollars in pediatric orthopaedics were made to the top 5% of compensated pediatric orthopaedists each year (average 71% of total General industry compensation). For this top 5% group, median General payment per compensated surgeon increased from 2014 ($14,624) to 2017 ($32,752) (P=0.006). A significant increase in median subtype aggregate payment per surgeon was observed in the education (P<0.001) and royalty/license (P=0.031) subtypes; a significant decrease was observed for travel/lodging payments (P=0.01). Midwest pediatric orthopaedists received the highest median payment across all years studied. Few payments for research and ownership were made to pediatric orthopaedists. Four-year aggregate payment totals were $18,151 and $3,223,554 for Research and Ownership payments, respectively. CONCLUSIONS: Many expected payments to surgeons to decrease when put under the public scrutiny of the OPD. Not only was this decrease not observed for General payments to pediatric orthopaedic surgeons during the 2014 to 2017 period, but also the median General payment to the top 5% increased. These findings are important to note in the current era of increased transparency. LEVEL OF EVIDENCE: Level III.

Scoliosis in myelomeningocele: epidemiology, management, and functional outcome.

OBJECTIVE The authors aimed to provide an updated and consolidated report on the epidemiology, management, and functional outcome of cases of myelomeningocele (MMC) in patients with scoliosis. METHODS A comprehensive literature search was performed using MEDLINE, Embase, Google Scholar, and the Cochrane Database of Systematic Reviews on cases of MMC in patients with scoliosis between 1980 and 2016. The initial search yielded 670 reports. After removing duplicates and applying inclusion criteria, we included 32 full-text original articles in this study. RESULTS Pooled statistical analysis of the included articles revealed the prevalence of scoliosis in MMC patients to be 53% (95% CI 0.42-0.64). Slightly more females (56%) are affected with both MMC and scoliosis than males. Motor level appears to be a significant predictor of prevalence, but not severity, of scoliosis in MMC patients. Treatment options for these patients include tethered cord release (TCR) and fusion surgeries. Curvature improvement and stabilization after TCR may be limited to patients with milder (< 50°) curves. Meanwhile, more aggressive fusion procedures such as a combined anterior-posterior approach may result in more favorable long-term scoliosis correction, albeit with greater complication rates. Quality of life metrics including ambulatory status and sitting stability are influenced by motor level of the lesion as well as the degree of the scoliosis curvature. CONCLUSIONS Scoliosis is among the most common and challenging comorbidities from which patients with MMC suffer. Although important epidemiological and management trends are evident, larger, prospective studies are needed to discover ways to more accurately counsel and more optimally treat these patients.