Risk score for one-year mortality following emergent infra-inguinal bypass.

OBJECTIVE: The purpose of this study is to identify variables that place patients at higher risk for mortality following emergent infra-inguinal bypass. Further, this study will create a risk score for mortality following emergent infra-inguinal bypass to help tailor postoperative and long-term patient management. METHODS: In the Vascular Quality Initiative, we identified 2126 patients who underwent emergent infra-inguinal artery bypass. Two primary outcomes were investigated: 30 day mortality following emergent infra-inguinal bypass; and 1-year mortality following emergent infra-inguinal bypass. The first step in analysis was univariable analysis for each outcome with χ2 analysis for categorical variables and Student t-test for comparison of means of ordinal variables. Next, binary logistic regression analysis was performed for each outcome utilizing variables that achieved a univariable P value ≤ .10. Factors with a multivariable P value ≤ .05 were included in the risk score, and points were weighted and assigned based on the respective regression beta-coefficient in the multivariable regression. RESULTS: Variables with a significant multivariable association (P < .05) with 1-year mortality were: increasing age; body mass index less than 20 kg/m2; coronary artery disease; active hemodialysis at time of presentation; anemia at admission; prosthetic conduit for emergent bypass; postoperative myocardial infarction; postoperative acute renal insufficiency; perioperative stroke; baseline non-ambulatory status; new onset hemodialysis requirement perioperatively; need for bypass revision or thrombectomy during index admission; lack of statin prescription at discharge; lack of antiplatelet medication at discharge; and, lack of anticoagulation at time of hospital discharge. Pertinent negatives included all sociodemographic variables including rural living status, insurance status, and Area Deprivation Index home area. The risk score achieved an area under the curve of 0.820, and regression analysis of the risk score achieved an overall accuracy of 87.9% with 97.7% accuracy in predicting survival, indicating the model performs better in determining which patients will survive rather than precisely determining who will experience 1-year mortality. CONCLUSIONS: Discharge medications are the primary modifiable variable impacting survival after emergent infra-inguinal bypass surgery. In the absence of contraindication, all these patients should be discharged on antiplatelet, statin, and anticoagulant medications after emergent infra-inguinal bypass as they significantly enhance survival. Social determinants of health do not impact survival among patients treated with emergent infra-inguinal bypass at Vascular Quality Initiative centers. A risk score for mortality at 1 year after emergent infra-inguinal bypass has been created that has excellent accuracy.

Socioeconomic disadvantage is a leading variable in risk score for major amputation following emergent infrainguinal arterial bypass surgery.

OBJECTIVE: The purpose of this study was to identify patients at particularly high risk for major amputation after emergent infrainguinal bypass to help tailor postoperative and long-term patient management. METHODS: In the Vascular Quality Initiative, we identified 2126 patients who underwent emergent infrainguinal artery bypass. Two primary outcomes were investigated: major ipsilateral amputation above the ankle level during the index hospitalization and major amputation above the ankle at any time after emergent infrainguinal bypass surgery (perioperative and postdischarge combined). Binary logistic regression analysis was performed for each outcome using variables that achieved a univariable P value of ≤.10. We then determined which variables have a multivariable association for the outcomes as defined by a regression P value of ≤.05. A risk score was then created for the outcome of amputation after emergent infrainguinal bypass using weighted beta-coefficient. Variables with a multivariable P value of ≤.05 were included in the risk score and weighted based on their respective regression beta-coefficient in a point scale. RESULTS: Overall, 17.1% of patients (368/2126) underwent major amputation at some point in follow-up after emergent infrainguinal artery bypass. The mean follow-up duration on the amputation variable was 261 days with the end point being time of amputation or time of last follow-up data on the amputation variable. Variables with a significant multivariable association (P < .05) with major amputation at any point after emergent infrainguinal arterial bypass were home status in top 10% (most deprived) of Area Deprivation Index, prior infrainguinal ipsilateral arterial bypass, prior ipsilateral endovascular arterial intervention, prosthetic bypass conduit, postoperative skin/soft tissue infection, and postoperative need to revise or thrombectomize bypass. Pertinent negatives on multivariable analysis included all baseline comorbidities, insurance status, race, and gender. There is steep progression in amputation rate ranging from 5% at scores of 0 and 1 to >60% for scores in of >10. Area under the curve analysis revealed a value of 0.706. CONCLUSIONS: Patients living in the most disadvantaged socioeconomic neighborhoods have an increased risk of amputation after emergent infrainguinal arterial bypass independent of baseline comorbidities and perioperative events. Baseline comorbidities are not impactful regarding amputation rates after emergent infrainguinal bypass surgery. The need for bypass revision or thrombectomy during the index hospitalization is the most impactful factor toward amputation after emergency bypass. A risk score with quality accuracy has been developed to help identify patients at particularly high likelihood of limb loss, which may aid in counseling regarding heightened vigilance in postoperative and long-term follow-up care.

Adherence to Non-operative Clinical Quality Measures in Carpal Tunnel Syndrome.

Background: Clinical quality measures exist for non-operative management of carpal tunnel syndrome (CTS). Factors predicting adherence are unclear. Methods: A retrospective cohort study of patients with chronic CTS using MarketScan Research Database (2015-2020) was conducted. Six logistic regression models were designed to study adherence to quality measures within 1 year after diagnosis. Results: Of 782,717 patients identified, 514,073 (65.7%) were female with an average (SD) age of 51.4 (13.4) years. Only 88 patients (0.01%) met all quality measures. Greatest compliance observed with receipt of nerve conduction study (NCS; 283,959 [36.3%]), no prescription of medications (336,297 [43.0%]) and no laser therapy (772,979 [98.8%]); 294,305 patients (37.6%) received hand surgeon referral. Hand surgeon referral predicted higher likelihood of NCS and splinting (OR, 1.83; 95% CI: 1.81-1.84; OR, 2.53; 95% CI: 2.50-2.56) and medication over-prescription (OR, 1.05; 95% CI: 1.00-1.10). Females were more likely to be referred to a hand surgeon and be referred for splinting (OR 1.02; 95% CI: 1.01-1.03; OR 1.19; 95% CI: 1.18-1.21) but less likely to have no prescriptions or avoid laser therapy (OR 0.85, 95% CI: 0.84-0.85; OR 0.82, 95% CI: 0.79-0.86). Medicare recipients adhered less to quality measures compared to patients with fee-for-service insurance. As comorbidities increased, patients were less likely to receive hand surgeon referral and carpal tunnel release. Conclusions: Findings suggest that hand surgery referrals increased adherence to quality measures. Females, Medicare recipients and multimorbid patients should be targeted for improved care. Future quality care efforts should incentivise adherence for Medicare beneficiaries and improve guideline recognition amongst physicians. Level of Evidence: Level III (Therapeutic).

Interfacility Competition and its Impact on Cost of Carpal Tunnel Release.

BACKGROUND: Carpal tunnel release (CTR) is the most common hand surgery procedure, but little is known about how healthcare market characteristics influence cost. The objective of this study was to understand the association of healthcare market competition and facility availability on out-of-pocket and total insurer payments for patients undergoing CTR. METHODS: This retrospective cross-sectional study used a national sample of private insurance claims from 2015-2020. Adults who had CTR were included, while acute or inpatient CTRs, or lacking geographical information were excluded. Linear regression was applied to investigate the impact of the healthcare market competition and facility availability (ambulatory surgery center (ASC), hospital outpatient departments (HOPD), outpatient clinics) on the out-of-pocket expenses and total insurer payment. Market competition was measured using the Herfindahl-Hirschman Index. RESULTS: Of 119,828 patients, 76% underwent open CTR. The most competitive hospital markets were HOPDs and ASCs, respectively. As HOPD competition decreased, out-of-pocket expenses and total insurer payment decreased significantly. As ASC competition decreased, only total insurer payments decreased significantly. CTRs performed in outpatient clinics increased slightly over time. However, HOPDs remained the most common location until 2020 when their popularity was similar to ASCs. Finally, out-of-pocket expenses increased significantly whereas total insurer payments did not change significantly throughout the study period. CONCLUSIONS: This study found decreased healthcare market competition was not associated with increased CTR costs, suggesting that costs are complex and multifactorial. To reduce healthcare costs, this study supports the movement of CTRs to clinic and ASCs.

Factors in Hand Surgery Access for Rheumatoid Arthritis Before vs After the Patient Protection and Affordable Care Act.

Importance: Rheumatoid arthritis (RA) has severe functional and economic consequences. The implications of the Patient Protection and Affordable Care Act (ACA) and demographic factors for access to surgical treatment are unclear. Objective: To investigate factors associated with time to RA hand surgery, surgical incidence, and cost after implementation of the ACA. Design, Setting, and Participants: This cross-sectional study used insurance data from the IBM MarketScan Research Databases from 2009 through 2020 to compare time to surgery, surgical incidence, and treatment cost for RA of the hand before and after ACA implementations. Included patients were 18 years or older with a new diagnosis for RA of the hand and at least 1 procedural code for arthroplasty, arthrodesis, tenolysis, tendon repair, or tendon transfer. Patients with coexisting inflammatory arthritis diagnoses were excluded. Demographic variables analyzed included patient sex, age at index date, residence within or outside a metropolitan statistical area (MSA; hereafter urban or nonurban), insurance and health plan type, Social Deprivation Index, Elixhauser Comorbidity Index score, and Rheumatic Disease Comorbidity Index. Data analysis occurred from October 2022 to April 2023. Exposures: Surgery for RA of the hand during the pre-ACA (before 2014) vs post-ACA (2014 or later) periods. Main Outcomes and Measures: Time to surgery, surgical incidence, and cost of treating RA in patients undergoing hand surgery for RA. Results: Among 3643 patients (mean [SD] age, 57.6 [12.3] years) who underwent hand surgery for RA, 3046 (83.6%) were women. Post-ACA passage, 595 (86.2%) patients who resided in urban areas had a significantly lower time to surgery than those who did not (-70.5 [95% CI, -112.6 to -28.3] days; P < .001). Among urban patients, the least socially disadvantaged patients experienced the greatest decrease in time to surgery after ACA but the change was not statistically significant. For all patients, greater social disadvantage (ie, a higher SDI score) was associated with a longer time to surgery in the post-ACA period; for example, compared with the least socially disadvantaged group (SDI decile, 0-10), patients in SDI decile 10 to 20 waited an additional 254.0 days (95% CI, 65.2 to 442.9 days; P = .009) before undergoing surgery. Compared with the pre-ACA period, the mean surgical incidence in the post-ACA period was 83.4% lower (162.3 vs 26.9 surgeries per 1000 person-years; P < .001), and surgical incidence was 86.3% lower in nonurban populations (27.2 vs 3.7 surgeries per 1000 person-years; P < .001) but only 82.8% lower in urban populations (135.1 vs 23.2 surgeries per 1000 person-years; P < .001). Per capita total costs of all treatment related to RA of the hand decreased in the post-ACA period but the change was not statistically significant. Insurer-paid costs were lower in the post-ACA period but the change was not statistically significant. Out-of-pocket expenses did not change. Conclusions and Relevance: Findings of this cross-sectional study suggest that after ACA passage, disparities exist in access to timely, cost-effective hand surgery for RA. Increased access to surgical hand specialists is needed for nonurban residents and those with greater social deprivation, along with insurance policy reforms to further decrease out-of-pocket spending for RA hand surgery.

Inappropriate wrist MRI: did guidelines have an impact?

OBJECTIVES: To assess the national prevalence and cost of inappropriate MRI in patients with wrist pain prior to and following American College of Radiology (ACR) guideline publication. STUDY DESIGN: We used administrative claims from the IBM MarketScan Research Databases to evaluate the appropriateness of wrist MRI in a national cohort of patients with commercial insurance or Medicare Advantage. METHODS: Adult patients with a diagnosis of wrist pain between 2016 and 2019 were included and followed for 1 year. We made assessments of appropriateness based on ACR guidelines for specific wrist pain etiologies. We tabulated the total costs and out-of-pocket expenses associated with inappropriate MRI studies using weighted mean payments for facility and professional fees. We performed segmented logistic regression on interrupted time series data to identify predictors of receiving inappropriate imaging and the impact of guideline publication on MRI use. RESULTS: The study cohort consisted of 867,119 individuals. Of these, 40,164 individuals (4.6%) had MRI, of whom 52.6% received an inappropriate study. Inappropriate studies accounted for $44,493,234 in total payments and $8,307,540 in out-of-pocket expenses. The interrupted time series found an approximately 1% monthly decrease in the odds of receiving an inappropriate study after guideline dissemination. CONCLUSIONS: MRI as a diagnostic tool for wrist pain is often inappropriate and expensive. Our findings support interventions to increase guideline adherence, such as integrated clinical decision support tools.

A Geospatial Analysis of Hand Trauma Care: A Statewide Cross-Sectional Study.

BACKGROUND: Traumatic hand injuries often present with high acuity, but little is known about the influence of geospatial and socioeconomic factors on the timely delivery of care. METHODS: This cross-sectional study used the Michigan Trauma Quality Improvement Program database, a state-wide registry with 35 level I or II trauma centers. Adult patients sustained hand trauma requiring urgent operative treatment between 2016 and 2021. Zip codes of injury location were linked with the corresponding percentile score on the Area Deprivation Index (ADI), a comprehensive measure of neighborhood disadvantage. Multiple regression analyses were used to determine associations of patient, injury and geospatial characteristics with the odds of sustaining acute hand trauma and time to operative treatment. RESULTS: Among 1,826 patients, the odds of sustaining acute hand trauma based on the ADI followed a bimodal distribution. Female sex, smoking, obesity, work-related injury and residence in a minor city were associated with increased odds, while younger age, comorbidities, and rural residence were associated with decreased odds. For 388 patients who underwent surgery within 48 hours, time to treatment was significantly increased in the highest ADI quintile, for patients who underwent fracture fixation, and for those with severe global injury severity. Multi-system injuries, moderate global injury severity and direct admission to an orthopaedic service were associated with shorter times to treatment. CONCLUSIONS: Patients in areas with greater neighborhood disadvantage may experience delayed operative care after acute hand trauma. This study highlights the importance of considering underserved populations and geospatial factors when determining the allocation of hand surgery resources. LEVEL OF EVIDENCE: Prognostic Level III.

Plastic Surgeons and Equity: Are Merit-Based Incentive Payment System Scores Impacted by Minority Patient Caseload?

BACKGROUND: The Centers for Medicare and Medicaid Services introduced the Merit-based Incentive Payment System (MIPS) in 2017 to extend value-based payment to outpatient physicians. The authors hypothesized that the MIPS scores for plastic surgeons are impacted by the existing measures of patient disadvantage, minority patient caseload, and dual eligibility. METHODS: The authors conducted a retrospective cohort study of plastic surgeons participating in Medicare and MIPS using the Physician Compare national downloadable file and MIPS scores. Minority patient caseload was defined as nonwhite patient caseload. The authors evaluated the characteristics of participating plastic surgeons, their patient caseloads, and their scores. RESULTS: Of 4539 plastic surgeons participating in Medicare, 1257 participated in MIPS in the first year of scoring. The average patient caseload is 85% white, with racial/ethnicity data available for 73% of participating surgeons. In multivariable regression, higher minority patient caseload is associated with a lower MIPS score. CONCLUSIONS: As minority patient caseload increases, MIPS scores decrease for otherwise similar caseloads. The Centers for Medicare and Medicaid Services must consider existing and additional measures of patient disadvantage to ensure equitable surgeon scoring.

Quasi-Experimental Design for Health Policy Research: A Methodology Overview.

SUMMARY: Health policy impacts all aspects of the authors' field. Research on this topic informs future policy direction and serves as an impactful means to advocate for their patients. The present work aims to promote policy research in plastic surgery. To accomplish this goal, the authors discuss quasi-experimental research design. The authors include in-depth discussion regarding study techniques that are well suited to health policy, including interrupted time series, difference-in-differences analysis, regression discontinuity design, and instrumental variable design. For each study design, the authors discuss examples and potential limitations.

Dupuytren contracture: using qualitative data to inform a conceptual framework for shared decision-making.

Multiple treatment options are available to patients with Dupuytren contracture, making shared decision-making complex. Our rigorous qualitative analysis sought to understand patient perceptions of shared decision-making in Dupuytren contracture treatment and create a conceptual framework to optimize patient-physician communication. We interviewed 30 patients with Dupuytren contracture to learn about their experience with treatment selection. The following themes were integral to shared decision-making for Dupuytren contracture treatment: discussing disease progression and treatment initiation, presenting all available treatment options, assessing patients' pre-existing biases towards treatment, patient values and preferences for treatment trade-offs, treatment risks and benefits, physician recommendation and active patient participation. This model can optimize communication about treatment options and expectations for relevant outcomes including, recovery time, contracture recurrence, complications, and treatment-related expenses.Level of evidence: V.

Evaluating Shared Decision-Making in Treatment Selection for Dupuytren Contracture: A Mixed Methods Approach.

BACKGROUND: Patients with Dupuytren contracture can receive a variety of surgical and nonsurgical treatments. The extent to which patients participate in the shared decision-making process is unclear. METHODS: An explanatory-sequential mixed-methods study was conducted. Participants completed the Nine-Item Shared Decision-Making Questionnaire and the brief Michigan Hand Outcomes Questionnaire before completing semi-structured interviews in which they described their experience with selecting treatment. RESULTS: Thirty participants [25 men (83%) and five women (17%); mean age, 69 years (range, 51 to 84 years)] received treatment for Dupuytren contracture (11 collagenase injection, six needle aponeurotomy, and 13 limited fasciectomy). Adjusted mean scores for the Shared Decision-Making Questionnaire and brief Michigan Hand Outcomes Questionnaire were 71 (SD 20) and 77 (SD 16), respectively, indicating a high degree of shared decision-making and satisfaction. Patients who received limited fasciectomy accepted invasiveness and prolonged recovery time because they believed it provided a long-term solution. Patients chose needle aponeurotomy and collagenase injection because the treatments were perceived as safer and more convenient and permitted rapid return to daily activities, which was particularly valued by patients who were employed or had bilateral contractures. CONCLUSIONS: Physicians should help patients choose a treatment that aligns with the patient's preferences for long-term versus short-term results, recovery period and postoperative rehabilitation, and risk of complications, because patients used this information to assist in their treatment selection. Areas of improvement for shared decision-making include equal presentation of all treatments and ensuring realistic patient expectations regarding the chronic and recurrent nature of Dupuytren contracture regardless of treatment received.

Factors Associated With Quality Care Among Adults With Rheumatoid Arthritis.

Importance: Although quality care markers exist for patients with rheumatoid arthritis (RA), the predictors of meeting these markers are unclear. Objective: To explore factors associated with quality care among patients with RA. Design, Setting, and Participants: A retrospective cohort study using insurance claims from 2009 to 2017 was conducted, and 6 sequential logistic regression models were built to evaluate quality care markers. Quality care markers were measured at 1 year post-RA diagnosis for each patient. The MarketScan Research Database, which contains commercial and Medicare Advantage administrative claims data from more than 100 million individuals in the US, was used to identify patients aged 18 to 64 years with a diagnosis claim for RA. Patients with conditions presenting similar to RA and missing demographic characteristics were excluded. Data analysis occurred between February 18 and May 5, 2022. Exposures: Success or failure to meet selected RA quality care markers within 1 year after RA diagnosis. Main Outcomes and Measures: Prevalence of meeting successive quality care markers for RA. Results: Among 581 770 patients, 430 843 (74.1%) were women and the mean (SD) age was 48.9 (11.3) years. Most patients (236 285 [40.6%]) resided in the South and had an income less than or equal to $45 200 (490 366 [84.3%]). Of the total study population, 399 862 individuals (68.7%) met at least 1 quality care marker and 181 908 (31.3%) met 0 markers. Most commonly, patients met annual laboratory testing (299 323 [51.5%]) and referral to a rheumatologist (256 765 [44.1%]) markers. The least met marker was receiving hepatitis B screening prior to initiation of disease-modifying antirheumatic drug (DMARD) therapy (18 548 [3.2%]). Women were most likely to meet all quality care markers except receiving DMARDs with hepatitis B screening (odds ratio, 1.14; 95% CI, 1.12-1.16). Individuals with lower median household income had lower odds of receiving a rheumatologist referral, an annual physical examination, or annual laboratory testing, but greater odds of receiving the other quality care markers. Patients with Medicare and those with comorbidities were generally less likely to meet quality care markers. Conclusions and Relevance: In this cohort study of patients with RA, findings indicated downstream associations with rheumatologist referral and receiving DMARDs and varied associations between meeting quality care markers and patient characteristics. These findings suggest that prioritizing early care, especially for vulnerable patients, will ensure that quality care continues.