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1.
Cleft Palate Craniofac J ; 60(6): 706-715, 2023 06.
Artículo en Inglés | MEDLINE | ID: mdl-35167397

RESUMEN

OBJECTIVE: Collect data from craniofacial surgeons to analyze mandibular distraction osteogenesis (MDO) protocols, and facial nerve dysfunction (FND) to characterize this common, but poorly documented complication after MDO in infants with Robin Sequence (RS). DESIGN, SETTING, AND PARTICIPANTS: A 16-question anonymous survey designed through REDCap was digitally distributed to members of the American Cleft Palate-Craniofacial Association and International Society of Craniofacial Surgery (ISCFS). MAIN OUTCOME MEASURE(S): Demographic information, MDO perioperative variables, surgeon experience with FND after MDO for patients with RS, and the timing and duration of FND were analyzed. RESULTS: Eighty-four responses were collected, with 80 included for analysis. Almost two-thirds of respondent surgeons reported FND as a complication of MDO in patients with RS (51, 63.8%); 58.8% (n = 47) transient FND and 5% (n = 4) with permanent facial nerve palsy only. Both transient and permanent FND was documented by 13 (16.3%) respondents. Among respondents, FND was observed immediately following initial device placement/osteotomies in 45.1%, during distraction in 45.1%, during consolidation in 19.6%, and following device removal in 43.1%. Twenty-five of these respondent surgeons reported resolution of FND between 1 and 3 months (53.2%, n = 25). CONCLUSIONS: FND after MDO in patients with RS was noted by most respondents in this survey study. While most surgeons noted temporary FND, one-fifth reported long-term dysfunction. FND was documented most commonly following device placement/osteotomies or during active distraction. Further research should seek to establish risk factors associated with FND and identify surgical and perioperative prevention strategies.


Asunto(s)
Obstrucción de las Vías Aéreas , Osteogénesis por Distracción , Síndrome de Pierre Robin , Lactante , Humanos , Estudios Retrospectivos , Síndrome de Pierre Robin/cirugía , Síndrome de Pierre Robin/complicaciones , Osteogénesis por Distracción/métodos , Nervio Facial , Resultado del Tratamiento , Mandíbula/cirugía , Obstrucción de las Vías Aéreas/cirugía
2.
J Hand Surg Am ; 45(6): 553.e1-553.e12, 2020 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-31924436

RESUMEN

PURPOSE: Osteoarthritis (OA) of the hand is commonly treated using implant arthroplasty. Despite the increasing prevalence of hand OA, population-based evidence regarding the complication profile and associated cost for patients undergoing proximal interphalangeal (PIP) joint and metacarpophalangeal (MCP) joint arthroplasty are lacking. Therefore, we aimed to evaluate the complication profiles and variation in cost of care for patients undergoing PIP and MCP joint arthroplasty. METHODS: We analyzed insurance claims from 2009 to 2016 using the Truven MarketScan Databases for adult patients undergoing a PIP and MCP joint arthroplasty following OA or post-traumatic arthritis diagnosis. Multivariable logistic regression was performed to investigate the association of patient-level factors and complications at 2 years after surgery. Cumulative direct cost, defined as the cost of the index surgery and 2-year postoperative episode, and patient-level characteristics were examined. RESULTS: We analyzed a total of 2,859 patients who underwent MCP joint arthroplasty (36%) or PIP joint arthroplasty (64%). On average, these procedures have a 35% complication rate. However, patients undergoing PIP joint arthroplasty were more likely to suffer a prosthetic fracture than patients undergoing MCP joint arthroplasty (3.4% vs 1.5%, respectively). Each complication resulted in an additional cost of $1,076. CONCLUSIONS: This nationwide analysis provides a population estimate of the complication profile and associated costs of MCP and PIP joint arthroplasty for hand OA and post-traumatic arthritis. Minimizing postoperative complications after MCP and PIP joint arthroplasty is one avenue to decrease health care costs. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.


Asunto(s)
Artroplastia para la Sustitución de Dedos , Prótesis Articulares , Osteoartritis , Complicaciones Posoperatorias/epidemiología , Adulto , Artroplastia , Artroplastia para la Sustitución de Dedos/efectos adversos , Articulaciones de los Dedos/cirugía , Humanos , Prótesis Articulares/efectos adversos , Osteoartritis/epidemiología , Osteoartritis/cirugía , Prevalencia , Rango del Movimiento Articular , Estudios Retrospectivos
3.
J Hand Surg Am ; 44(2): 93-103, 2019 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-30579691

RESUMEN

PURPOSE: Hand surgery outreach programs to low- and middle-income countries (LMICs) provide much-needed surgical care to the underserved populations and education to local providers for improved care. The cost-effectiveness of these surgical trips has not been studied despite a long history of such efforts. This study aimed to examine the economic impact of hand surgery trips to LMICs using data from the Touching Hands Project and ReSurge International. We hypothesized that hand surgery outreach would be cost-effective in LMICs. METHODS: We analyzed data on the cost of each trip and the surgical procedures performed. Using methods from the World Health Organization (WHO-Choosing Interventions That Are Cost-Effective [WHO-CHOICE]), we determined whether the procedures performed during the outreach trips would be cost-effective. RESULTS: For the 14 hand surgery trips, 378 patients received surgical treatment. Trips varied in the country where interventions were provided, the number of patients served, the severity of the conditions, and the total cost. The cost per disability-adjusted life-year averted ranged from United States (US)$222 to $1,525, all of which were very cost-effective according to WHO-CHOICE thresholds. The cost-effectiveness of global hand surgery was comparable to that of other medical interventions such as multidrug-resistant tuberculosis treatment in similar regions. We also identified a lack of standardized record keeping for these surgical trips. CONCLUSIONS: Hand surgeries performed in LMICs are cost-effective based on WHO-CHOICE criteria. However, a standardized record-keeping method is needed for future research and longitudinal comparison. Understanding the economic impact of hand surgery global outreach is important to the success and sustainability of these efforts, both to allocate resources effectively and to identify areas for improvement. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analysis III.


Asunto(s)
Costo de Enfermedad , Países en Desarrollo , Misiones Médicas/economía , Enfermedades Musculoesqueléticas/terapia , Heridas y Lesiones/terapia , Adolescente , Niño , Preescolar , Análisis Costo-Beneficio , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Enfermedades Musculoesqueléticas/economía , Procedimientos Ortopédicos , Estudios Retrospectivos , Organización Mundial de la Salud , Heridas y Lesiones/economía
4.
J Hand Surg Am ; 43(4): 312-320.e4, 2018 04.
Artículo en Inglés | MEDLINE | ID: mdl-29338893

RESUMEN

PURPOSE: Understanding patient preferences for shared decision making is valuable for surgeons to advance patient-centered care, particularly in cases where there is not a clearly superior treatment option, like distal radius fracture. The existing evidence presents conflicting views on the desired role of the provider among older patients when making medical decisions. We aimed to investigate the perceived versus desired role of the provider in older adult patients with distal radius fracture. METHODS: Thirty patients (≥62 years old) who had sustained a distal radius fracture within the past 5 years were recruited from the screening process of the Wrist and Radius Injury Surgical Trial at the principal investigator's site using purposive sampling. A trained member of the research team conducted interviews in a semistructured format with the help of an interview guide. Findings were derived following the principles of grounded theory. RESULTS: Participants experienced varied levels of shared decision making with the hand surgeon. Subjects' perceived role of the surgeon did not always match their desired role. Most patients placed distinct trust in the recommendations of hand specialists regarding the technical aspects of the treatment. Nonetheless, respondents wanted to provide input when decisions pertained to outcomes or functionality. Many patients sought outside support from family or friends in the health care field, regardless of the outside source's medical specialty. CONCLUSIONS: Despite conflicting evidence, most older adult patients desire a shared approach when making treatment decisions. Exchanging information and preferences on outcomes of each treatment option may be more important to the patient than detailing the specific technical aspects of their care. CLINICAL RELEVANCE: To provide high quality care, surgeons should evaluate the desired role of the patient to make treatment decisions at the start of their interaction. Surgeons must be aware of outside medical influences that guide their patients' decision-making processes.


Asunto(s)
Toma de Decisiones , Prioridad del Paciente , Rol del Médico , Fracturas del Radio/terapia , Cirujanos , Anciano , Anciano de 80 o más Años , Femenino , Teoría Fundamentada , Humanos , Entrevistas como Asunto , Masculino , Persona de Mediana Edad , Paternalismo , Muestreo
5.
J Hand Surg Am ; 42(8): 623-629.e1, 2017 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-28666673

RESUMEN

PURPOSE: We sought to evaluate how often physicians who perform carpal tunnel release in the state of Michigan routinely request electrodiagnostic studies (EDS) or other diagnostic tests prior to an initial consultation and whether provider or practice characteristics had an influence on requirements for preconsultation diagnostic tests. METHODS: Through online data sources, we identified 356 providers in 261 practices throughout the state of Michigan with profiles confirming hand surgery practice or surgical treatment of carpal tunnel syndrome (CTS). We recorded American Society for Surgery of the Hand (ASSH) membership, teaching facility status, practice size, and primary specialty for each provider. Using a standardized telephone script, 219 providers were contacted by telephone to determine whether any diagnostic tests were needed before an appointment. Using multivariable logistic regression, we evaluated the relationship between the requirement for preconsultation testing and surgeon and practice characteristics. RESULTS: Among the 134 providers who were confirmed to perform carpal tunnel release, 57% (n = 76) required and 9% (n = 12) recommended a diagnostic test prior to the initial consultation. Of the 88 physicians who required/recommended testing, 85% (n = 75) requested EDS, 22% (n = 19) requested magnetic resonance imaging, 13% (n = 11) requested a computed tomography scan, and 9% (n = 8) requested an x-ray. Patients were asked to have multiple studies by 19 (22%) of the 88 surgeons who requested/recommended testing. In the multivariable analysis, ASSH membership, size of practice, and teaching facility status did not have a significant relationship with the requirement for preconsultation testing. CONCLUSIONS: Most surgeons who treat CTS in the state of Michigan routinely request EDS before evaluation, rather than reserving the test for cases in which the diagnosis is unclear. CLINICAL RELEVANCE: In the quest for high-value care, providers must consider whether the benefit of diagnostic tests for CTS likely outweighs the costs, inconvenience, and potential for treatment delay.


Asunto(s)
Síndrome del Túnel Carpiano/diagnóstico , Electrodiagnóstico , Pautas de la Práctica en Medicina , Síndrome del Túnel Carpiano/cirugía , Toma de Decisiones Clínicas , Humanos , Imagen por Resonancia Magnética , Michigan , Selección de Paciente , Tomografía Computarizada por Rayos X
6.
Plast Reconstr Surg ; 2024 Jul 30.
Artículo en Inglés | MEDLINE | ID: mdl-39085102

RESUMEN

BACKGROUND: Breast reconstruction following mastectomy is underused in the United States. Evidence suggests that more competitive hospital markets offer increased access to procedural care across specialties. This study aims to determine the impact of regional plastic surgeon competition on use, outcomes, and cost of breast reconstruction following mastectomy for breast cancer. METHODS: We conducted a retrospective cross-sectional analysis using Marketscan claims data from 2009 to 2020. The Herfindahl-Hirschman Index (HHI), a measure of market concentration, was calculated using the sum-of-squares of the proportion of breast reconstruction cases performed by each surgeon in a metropolitan statistical area (MSA). Multivariable logistic regression was used to identify differences in rates, outcomes, and costs of reconstruction by HHI. RESULTS: Odds of receiving breast reconstruction within two years of mastectomy were higher for those in moderately competitive (OR: 1.51 [95% CI: 1.37 to 1.66]; p<0.001) or competitive (OR: 1.71 [95% CI: 1.58 to 1.86]; p<0.001) = regions compared to noncompetitive regions. Patient out-of-pocket costs decreased when comparing moderately competitive regions to noncompetitive regions (-$67.38, [95% CI: -$88.65 to -$46.11]; p=0.007), and further decreased when comparing competitive to non-competitive regions (-$113.06, [95% CI: -$137.00 to -$89.12]; p=0.02). No linear association between total, surgeon, or facility cost and market competition strata was identified. CONCLUSION: Greater competition among surgeons is associated with improved access to reconstructive surgery, but no difference in cost. Application of this evidence may include system-level strategies to bolster care coordination, while targeting drivers of cost, such as hospitals and hospital systems, through policy.

7.
Plast Reconstr Surg ; 2023 Oct 17.
Artículo en Inglés | MEDLINE | ID: mdl-37847588

RESUMEN

BACKGROUND: Effective information transfer relies on the proper use of educational tools. Evaluating the quality of presentations permits us to improve educational materials in plastic surgery. Our specific aims were to assess the quality of presentations at a national hand surgery meeting using a checklist of presentation standards from the literature and to identify areas of improvement. METHODS: Our sample included presentations from the Clinical Papers Sessions at the 2020 American Society for Surgery of the Hand (ASSH) Annual Meeting. A modified checklist based on the literature was used to assess the presentations. Two members of the research team extracted data from the included presentations and disagreements were reviewed collaboratively. RESULTS: A total of 96 presentations were included in this sample. The mean number of deficiencies per slide set was approximately nine. Misused graphics, ambiguous content (undefined abbreviations, undefined symbols, etc.), and overdetermined slides were the most common deficiencies identified in our sample. One-way ANOVA analysis of presenter role found a significant difference in the mean number of deficiencies (F (2, 93) = 7.36, p = 0.001) among different types of presenters with surgeon presenters exhibiting more deficiencies than students and other healthcare professionals. CONCLUSION: The use of a checklist to evaluate a presentation helps in cultivating more effective presentations in national meetings. A collaborative peer-review process incorporating feedback from multiple trainees, audience members, and colleagues facilitates effective information transfer through presentations.

8.
JAMA Netw Open ; 6(7): e2325487, 2023 07 03.
Artículo en Inglés | MEDLINE | ID: mdl-37494042

RESUMEN

Importance: Racial disparities influencing breast reconstruction have been well-researched; however, the role of implicit racial bias remains unknown. An analysis of the disparities in care for patients with breast cancer may serve as a policy target to increase the access and quality of care for underserved populations. Objective: To identify whether variations in implicit racial bias by region are associated with the differences in rates of immediate breast reconstruction, complications, and cost for White patients and patients from minoritized racial and ethnic groups. Design, Setting, and Participants: This cohort study used data from the National Inpatient Sample (NIS) from 2009 to 2019. Adult female patients with a diagnosis of or genetic predisposition for breast cancer receiving immediate breast reconstruction at the time of mastectomy were included. Patients receiving both autologous free flap and implant-based reconstruction were included in this analysis. US Census Bureau data were extracted to compare rates of reconstruction proportionately. The Implicit Association Test (IAT) was used to classify whether implicit bias was associated with the primary outcome variables. Data were analyzed from April to November 2022. Exposure: IAT score by US Census Bureau geographic region. Main Outcomes and Measures: Variables of interest included demographic data, rate of reconstruction, complications (reconstruction-specific and systemic), inpatient cost, and IAT score by region. Spearman correlation was used to determine associations between implicit racial bias and the reconstruction utilization rate for White patients and patients from minoritized racial and ethnic groups. Two-sample t tests were used to analyze differences in utilization, complications, and cost between the 2 groups. Results: A total of 52 115 patients were included in our sample: 38 487 were identified as White (mean [SD] age, 52.0 [0.7] years) and 13 628 were identified as minoritized race and ethnicity (American Indian, Asian, Black, and Hispanic patients and patients with another race or ethnicity; mean [SD] age, 49.7 [10.5] years). Implicit bias was not associated with disparities in breast reconstruction rates, complications, or cost. Nonetheless, the White-to-minoritized race and ethnicity utilization ratio differed among the regions studied. Specifically, the reconstruction ratio for White patients to patients with minoritized race and ethnicity was highest for the East South Central Division, which includes Alabama, Kentucky, Mississippi, and Tennessee (2.17), and lowest for the West South Central Division, which includes Arkansas, Louisiana, Oklahoma, and Texas (0.75). Conclusions and Relevance: In this cohort study of patients with breast cancer, regional variation of implicit bias was not associated with differences in breast reconstruction utilization, complications, or cost. Regional disparities in utilization among racial and ethnic groups suggest that collaboration from individual institutions and national organizations is needed to develop robust data collection systems. Such systems could provide surgeons with a comparative view of their care. Additionally, collaboration with high-volume breast centers may help patients in low-resource settings receive the desired reconstruction for their breast cancer care, helping improve the utilization rate and quality of care.


Asunto(s)
Neoplasias de la Mama , Mamoplastia , Racismo , Adulto , Humanos , Femenino , Persona de Mediana Edad , Neoplasias de la Mama/cirugía , Mastectomía , Estudios de Cohortes
9.
Plast Reconstr Surg ; 152(2): 281-290, 2023 08 01.
Artículo en Inglés | MEDLINE | ID: mdl-36728197

RESUMEN

BACKGROUND: Given the national attention to disparities in health care, understanding variation provided to minorities becomes increasingly important. This study will examine the effect of race on the rate and cost of unplanned hospitalizations after breast reconstruction procedures. METHODS: The authors performed an analysis comparing patients undergoing implant-based and autologous breast reconstruction in the Healthcare Cost and Utilization Project. The authors evaluated the rate of unplanned hospitalizations and associated expenditures among patients of different races. Multivariable analyses were performed to determine the association among race and readmissions and health care expenditures. RESULTS: The cohort included 17,042 patients. The rate of an unplanned visit was 5%. The rates of readmissions among black patients (6%) and Hispanic patients (7%) in this study are higher compared with white patients (5%). However, after controlling for patient-level characteristics, race was not an independent predictor of an unplanned visit. In our expenditure model, black patients [adjusted cost ratio, 1.35 (95% CI, 1.11 to 1.66)] and Hispanic patients [adjusted cost ratio, 1.34 (95% CI, 1.08 to 1.65)] experienced greater cost for their readmission compared with white patients. CONCLUSIONS: Although race is not an independent predictor of an unplanned hospital visit after surgery, racial minorities bear a higher cost burden after controlling for insurance status, further stimulating health care disparities. Adjusted payment models may be a strategy to reduce disparities in surgical care. In addition, direct and indirect measures of disparities should be used when examining health care disparities to identify consequences of inequities more robustly.


Asunto(s)
Disparidades en Atención de Salud , Hospitalización , Mamoplastia , Grupos Minoritarios , Readmisión del Paciente , Humanos , Disparidades en Atención de Salud/economía , Disparidades en Atención de Salud/etnología , Disparidades en Atención de Salud/estadística & datos numéricos , Hispánicos o Latinos/estadística & datos numéricos , Hospitalización/economía , Hospitalización/estadística & datos numéricos , Mamoplastia/efectos adversos , Mamoplastia/economía , Mamoplastia/métodos , Mamoplastia/estadística & datos numéricos , Grupos Minoritarios/estadística & datos numéricos , Estudios Retrospectivos , Factores Raciales/economía , Factores Raciales/estadística & datos numéricos , Readmisión del Paciente/economía , Readmisión del Paciente/estadística & datos numéricos , Blanco/estadística & datos numéricos , Negro o Afroamericano/estadística & datos numéricos , Gastos en Salud/estadística & datos numéricos
10.
Med Educ Online ; 28(1): 2189558, 2023 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-36966504

RESUMEN

Evidence-informed data may help students matching into competitive residency programs guide curricular activities, extracurricular activities, and residency career choices. We aimed to examine the characteristics of students applying to competitive surgical residencies and identify predictors of matching success. We identified the five lowest match rates for the surgical subspecialities listed in the 2020 National Resident Matching Program report to define a surgical residency as competitive. We analyzed a database from 115 United States medical schools regarding application data from 2017 to 2020. Multilevel logistic regression was used to determine predictors of matching. Statistical significance was set at p < 0.05.A total of 1,448 medical students submitted 25,549 applications. The five most competitive specialties included were plastic surgery (N = 172), otolaryngology (N = 342), neurological surgery (N = 163), vascular surgery (N = 52), orthopedic surgery (N = 679), and thoracic surgery (N = 40). We found that medical students with a geographical connection (adjusted OR, 1.65 [95% CI, 1.41 to 1.93]), and students who did an away rotation at the applied program (adjusted OR, 3.22 [95% CI, 2.75 to 3.78]) had statistically significantly increased odds of matching into a competitive surgical specialty. Furthermore, we found that students with a United States Medical Licensing Examination (USMLE) Step 1 score below 230 and Step 2 Clinical Knowledge (CK) score below 240 had increased odds of matching if they completed an away rotation at the applied program. Completing an away rotation and geographical connection to the institution may contribute more than academic criteria for selection into a competitive surgical residency after an interview. This finding may be due to less variation in academic criteria among this pool of high-performing medical students. Students with limited resources who apply to a competitive surgical specialty may be at a disadvantage given the financial burden of an away rotation.


Asunto(s)
Internado y Residencia , Medicina , Ortopedia , Estudiantes de Medicina , Humanos , Estados Unidos , Ortopedia/educación , Selección de Profesión
11.
Plast Reconstr Surg Glob Open ; 11(3): e4837, 2023 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-36910723

RESUMEN

Calcinosis cutis is the term used to describe the deposition of calcium compounds within the skin and subcutaneous tissue, which can occur after the administration of intravenous calcium compounds. Its etiology is broad, and the clinical presentation is variable, creating a diagnostic challenge. Although iatrogenic calcinosis cutis is extremely uncommon, awareness and early diagnosis of this entity can reduce the risks of severe complications, including soft tissue damage, restricted joint mobility, and even nerve compression. Clinical suspicion should prompt a thorough review of the medical history and appropriate radiographic studies. Evidence of extensive soft tissue calcification must be present on radiographic imaging to confirm the diagnosis. Iatrogenic calcinosis cutis is managed conservatively, and resolution of symptoms is expected within 2 months of symptom onset. Herein we report the case of an infant with DiGeorge syndrome who developed iatrogenic calcinosis cutis after receiving an intraoperative infusion of calcium gluconate. Our patient presented with right lower extremity swelling, erythema, and warmth over a broad area of the leg centered on the entry point of the venipuncture. This was initially mistaken and managed as cellulitis, but once an accurate diagnosis was made, the symptoms gradually resolved with conservative care and no functional sequelae. We also present the literature on iatrogenic and idiopathic calcinosis cutis in the pediatric population.

12.
Plast Reconstr Surg Glob Open ; 10(3): e3808, 2022 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-35291334

RESUMEN

Plastic and Reconstructive Surgery (PRS) recently developed an open access counterpart, PRS Global Open (PRS-GO), to increase dissemination of research in an efficient and widespread manner. We aimed to (1) examine the differences in the dissemination of research published in PRS and PRS-GO, and (2) identify differences in the authorship between the journals. Methods: We extracted data on Altmetric Attention Scores, article mentions, citations, and author characteristics using the Altmetric Explorer Database from January 1, 2018, to January 1, 2020. We stratified research outputs into traditional dissemination and social media dissemination. Additionally, multivariable linear regression models were used to examine differences in dissemination between the journals. Results: A total of 1798 articles were included in the analysis (PRS = 1031, PRS-GO = 767). The average Altmetric Attention Score was higher for PRS compared with PRS-GO (PRS = 15.2, PRS-GO = 8.1). Articles in PRS had a greater Altmetric Attention Score (ß-coefficient: 7.50, P < 0.001), higher measures of traditional dissemination (ß-coefficient: 3.11, P < 0.001), and higher measures of social media dissemination than articles in PRS-GO (ß-coefficient: 4.38, P = 0.73). Conclusions: Despite being an open access journal, PRS-GO had significantly fewer measures of social media and traditional dissemination compared with PRS. Given that numerous factors may influence the dissemination of scientific literature, it is imperative that publications identify specific ways to provide a fair advantage for both researchers and readers. Additional initiatives to engage readership for open access may include creative campaigns targeting an appropriate audience.

13.
JAMA Netw Open ; 4(2): e2036297, 2021 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-33533928

RESUMEN

Importance: Given that 40% of hand function is achieved with the thumb, replantation of traumatic thumb injuries is associated with substantial quality-of-life benefits. However, fewer replantations are being performed annually in the US, which has been associated with less surgical expertise and increased risk of future replantation failures. Thus, understanding how interfacility transfers and hospital characteristics are associated with outcomes warrants further investigation. Objective: To assess the association of interfacility transfer, patient characteristics, and hospital factors with thumb replantation attempts and success. Design, Setting, and Participants: This cross-sectional study used data from the US National Trauma Data Bank from 2009 to 2016 for adult patients with isolated traumatic thumb amputation injury who underwent revision amputation or replantation. Data analysis was performed from May 4, 2020, to July 20, 2020. Exposures: Interfacility transfer, defined as transfer of a patient from 1 hospital to another to obtain care for traumatic thumb amputation. Main Outcomes and Measures: Replantation attempt and replantation success, defined as having undergone a replantation without a subsequent revision amputation during the same hospitalization. Multilevel logistic regression models were used to assess the associations of interfacility transfer, patient characteristics, and hospital factors with replantation outcomes. Results: Of 3670 patients included in this analysis, 3307 (90.1%) were male and 2713 (73.9%) were White; the mean (SD) age was 45.8 (16.5) years. A total of 1881 patients (51.2%) were transferred to another hospital; most of these patients were male (1720 [91.4%]) and White (1420 [75.5%]). After controlling for patient and hospital characteristics, uninsured patients were less likely to have thumb replantation attempted (odds ratio [OR], 0.61; 95% CI, 0.47-0.78) or a successful replantation (OR, 0.64; 95% CI, 0.49-0.84). Interfacility transfer was associated with increased odds of replantation attempt (OR, 1.34; 95% CI, 1.13-1.59), with 13% of the variation at the hospital level. Interfacility transfer was also associated with increased replantation success (OR, 1.23; 95% CI, 1.03-1.47), with 14% of variation at the hospital level. Conclusions and Relevance: In this cross-sectional study, interfacility transfer and particularly hospital-level variation were associated with increased thumb replantation attempts and successes. These findings suggest a need for creating policies that incentivize hospitals with replantation expertise to provide treatment for traumatic thumb amputations, including promotion of centralization of replantation care.


Asunto(s)
Amputación Traumática/cirugía , Hospitales/estadística & datos numéricos , Pacientes no Asegurados/estadística & datos numéricos , Transferencia de Pacientes/estadística & datos numéricos , Reimplantación , Pulgar/lesiones , Adulto , Factores de Edad , Certificación , Estudios Transversales , Femenino , Traumatismos de los Dedos/cirugía , Capacidad de Camas en Hospitales/estadística & datos numéricos , Hospitales Comunitarios/estadística & datos numéricos , Hospitales de Enseñanza/estadística & datos numéricos , Hospitales Universitarios/estadística & datos numéricos , Humanos , Seguro de Salud , Modelos Logísticos , Masculino , Cuerpo Médico de Hospitales/estadística & datos numéricos , Medicare , Persona de Mediana Edad , Análisis Multinivel , Oportunidad Relativa , Cirujanos Ortopédicos/provisión & distribución , Centros Traumatológicos/estadística & datos numéricos , Resultado del Tratamiento , Estados Unidos
14.
Plast Reconstr Surg Glob Open ; 9(3): e3484, 2021 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-33747694

RESUMEN

Tibial nerve entrapment is uncommon in the pediatric population, and presents diagnostic and treatment challenges. We present the unusual case of a 3-year-old male child with progressive lower leg atrophy of an unknown etiology. Preoperative electrodiagnostic testing and magnetic resonance imaging suggested proximal tibial neuropathy. Surgical exploration showed compression of the tibial nerve at the inferior fascial edge of the long head of the biceps femoris and at the soleal sling. Release and external neurolysis led to improvement of distal leg motor function.

15.
Plast Reconstr Surg ; 147(5): 1124-1131, 2021 May 01.
Artículo en Inglés | MEDLINE | ID: mdl-33890894

RESUMEN

BACKGROUND: Opioids are commonly used following outpatient surgery. However, we understand little about patients' perspectives and how patients decide on postoperative opioid use. This study seeks to investigate aspects of patients' thought processes that most impact their decisions. METHODS: The authors conducted semistructured interviews with 30 adults undergoing minor elective hand surgery at one tertiary hospital. Narratives were content-coded to arrive at the authors' thematic analysis. The authors incorporated Bandura's concept of self-agency to interpret the data and develop a conceptual framework that best explained the implicit theory within participants' responses. RESULTS: The authors found six themes under two domains of self-agency. Participants actively sought out protective mechanisms supporting their decision on opioid use, but sometimes did so unconsciously. They would avoid opioids postoperatively because they were "tough" and wanted to evade the risk of addiction as "good citizens." They conveyed a nuanced safety against addiction because they were "not the kind" to become addicted and because they trusted the surgeons' prescribing. However, participants felt discouraged by the stigma associated with opioids. Both intentionally and unintentionally, participants integrated a strong sense of self in their decision-making processes. CONCLUSIONS: A robust understanding of how patients choose to take opioids for postoperative pain control is imperative to develop patient-centered strategies to treat the opioid epidemic. Effective opioid-reduction policies should consider patients as active agents who negotiate various internal and external influences in their decision-making processes. Surgeons must incorporate patients' individual goals and perspectives regarding postoperative opioid use to minimize opioid-related harm after surgery.


Asunto(s)
Trastornos Relacionados con Opioides/prevención & control , Complicaciones Posoperatorias/prevención & control , Autocuidado , Analgésicos Opioides/uso terapéutico , Humanos , Dolor Postoperatorio/tratamiento farmacológico , Investigación Cualitativa
16.
Plast Reconstr Surg ; 145(4): 855e-864e, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-32221241

RESUMEN

Countless efforts have been made by global surgery outreach organizations to provide care to individuals in low- and middle-income countries; however, there is a paucity of data on these interventions. The authors created the Data Instrument for Surgical Global Outreach to collect basic program, cost, and clinical data on surgical outreach efforts using the literature and the experience of our team. The authors performed a two-round modified Delphi technique to build content validity on the instrument and establish consensus. Experts engaged in global health or global surgery as a health care provider, researcher, or policymaker participated in the validation. In addition, the authors calculated Cronbach's alpha to determine the degree of agreement among experts. A total of 22 experts in global health participated in the validation of the data tool. Changes were made to reword, combine, remove, add, clarify, and simplify data points. There was a unanimous decision to accept the revised data collection instrument among the experts after the second Delphi round. Cronbach's alpha was 0.86 for the first round and 0.95 for the second round, indicating a high degree of internal consistency. The global surgery outreach community must define a set of strategies to collect more robust data on surgical outreach efforts to low- and middle-income countries. Such data will permit policymakers to identify shortfalls in programs and researchers to pursue sustainable treatment modalities and processes of care. Quality collaboratives for surgical outreach organizations may serve as a tool to overcome variation, reduce cost, and improve the quality of care for patients.


Asunto(s)
Recolección de Datos/métodos , Salud Global/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Formulación de Políticas , Especialidades Quirúrgicas/estadística & datos numéricos , Consenso , Recolección de Datos/normas , Técnica Delphi , Salud Global/economía , Accesibilidad a los Servicios de Salud/economía , Accesibilidad a los Servicios de Salud/organización & administración , Humanos , Mejoramiento de la Calidad , Especialidades Quirúrgicas/economía , Especialidades Quirúrgicas/organización & administración , Desarrollo Sostenible
17.
Hand Clin ; 36(2): 145-153, 2020 05.
Artículo en Inglés | MEDLINE | ID: mdl-32307044

RESUMEN

Hand surgery researchers should focus on developing high-quality evidence to support the development of health policies affecting surgical care. Policy-makers and leaders of national hand societies can help reduce the variation of care for patients receiving hand surgery by incorporating evidence into guidelines and policies. Comprehensive guidelines for perioperative care help encourage the translation of evidence into practice. Moreover, the identification of institutional-level barriers and facilitators of integration ensures the successful implementation of hand surgery-specific programs. The development of robust metrics to evaluate the effect of policy on practice helps examine the feasibility of clinical guidelines.


Asunto(s)
Mano/cirugía , Ortopedia/normas , Guías de Práctica Clínica como Asunto , Corticoesteroides/administración & dosificación , Medicina Basada en la Evidencia , Humanos , Dolor Postoperatorio/terapia , Trastorno del Dedo en Gatillo/tratamiento farmacológico , Trastorno del Dedo en Gatillo/cirugía
18.
Health Policy Open ; 1: 100018, 2020 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-37383317

RESUMEN

Phenomenon: Numerous political, demographic, and policy changes have influenced the evolving structure of healthcare in China. As China continues to experience healthcare reform, the medical educational system should strive for parallel advancement. Approach: We conducted a review of the literature to describe the nature of healthcare reform in China and establish recommendations for the reform of medical education. Specifically, we aim to summarize the current challenges faced by medical education in China and identify the strengths, weaknesses, opportunities, and threats for the development of new medical schools. Findings: The Chinese medical education system is currently experiencing problems in organization, training, standardization, and evaluation. New medical schools in China have an immense opportunity to be a disruptive force in healthcare by introducing business and engineering concepts into the curriculum, research enterprise, and clinical delivery. Insights: The need for physicians capable of meeting the healthcare needs of the Chinese population only becomes more imperative as the population continues to grow and change. Given the numerous challenges experienced by healthcare professionals, new medical schools have the ability to adopt strategies used by the United States, United Kingdom, among other countries, to establish a robust, effective medical education system.

19.
Hand Clin ; 36(2): 221-229, 2020 05.
Artículo en Inglés | MEDLINE | ID: mdl-32307053

RESUMEN

Considerable variation exists in the practice of hand surgery that may lead to wasteful spending and less than optimal quality of care. Hand surgeons can benefit from a centralized system that tracks process and outcome measures, delivers national benchmarking, and encourages the sharing of knowledge. A national registry can fulfill these needs for hand surgeons and incorporate quality improvement into their daily routine. Leaders in hand surgery should convene to appraise the organization of a national registry for their field and reach consensus on how the registry can be designed and funded.


Asunto(s)
Mano/cirugía , Ortopedia , Mejoramiento de la Calidad , Sistema de Registros , Humanos , Ortopedia/normas , Satisfacción del Paciente , Estados Unidos
20.
Plast Reconstr Surg ; 145(2): 471-481, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31985644

RESUMEN

BACKGROUND: Hand surgeons can alleviate the burden associated with various congenital anomalies, burn sequelae, and trauma that debilitate individuals in low- and middle-income countries. Because few surgeons in these areas have the necessary resources to perform complex hand surgery, surgical trips provide essential surgical care. The authors aimed to determine the economic benefit of hand surgical trips to low- and middle-income countries to comprehensively determine the economic implications of hand surgery trips in low-resource settings. METHODS: The authors collected data from two major global hand surgery organizations to analyze the economic benefit of hand surgery trips in low- and middle-income countries. The authors used both the human capital approach and the value of a statistical life-year approach to conduct this cost-benefit analysis. To demonstrate the economic gain, the authors subtracted the budgeted cost of each trip from the economic benefit. RESULTS: The authors analyzed a total of 15 trips to low- and middle-income countries. The costs of the trips ranged from $3453 to $87,434 (average, $24,869). The total cost for all the surgical trips was $373,040. The authors calculated a net economic benefit of $3,576,845 using the human capital approach and $8,650,745 using the value of a statistical life-year approach. CONCLUSIONS: The authors found a substantial return on investment using both the human capital approach and the value of a statistical life-year approach. In addition, the authors found that trips emphasizing education had a net economic benefit. Cost-benefit analyses have substantial financial implications and will aid policy makers in developing cost-reduction strategies to promote surgery in low- and middle-income countries.


Asunto(s)
Países en Desarrollo/economía , Deformidades Congénitas de la Mano/economía , Traumatismos de la Mano/economía , Mano/cirugía , Adolescente , Adulto , Anciano , Niño , Preescolar , Análisis Costo-Beneficio , Atención a la Salud/economía , Femenino , Deformidades Congénitas de la Mano/cirugía , Traumatismos de la Mano/cirugía , Humanos , Masculino , Turismo Médico/economía , Área sin Atención Médica , Persona de Mediana Edad , Embarazo , Años de Vida Ajustados por Calidad de Vida , Estudios Retrospectivos , Viaje/economía , Viaje/estadística & datos numéricos , Adulto Joven
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