Improving Perioperative Preparation for Patients Undergoing Surgical Treatment for Distal Radius Fractures.

We aimed to review common patient concerns after surgical repair of distal radius fracture (DRF) to identify potential interventions to improve the gap between expectation and education for DRF patients. Methods: We conducted a retrospective cohort study of 100 consecutive patients who underwent surgical repair of DRF at a level I trauma center. Patient-initiated communication notes were reviewed with thematic analysis to identify the common reasons patients required additional information. We used the Patient Education Materials Assessment Tool to score the available educational resources for DRF patients for the understandability and actionability of the educational materials provided to the patients. Results: Of 165 patient communication episodes, 88.5% occurred postoperatively. The most common concerns were pain (30, 15.4%) and surgical site changes (24, 12.3%). Most communications (171, 83.4%) were resolved with patient education through instruction or reassurance. The reviewed materials did not address pain or surgical site changes. No reviewed materials provided actionable steps patients could take to facilitate recovery. Conclusions: Pain management and normal wound healing were the most common surgical concerns of DRF patients. We identify opportunities to improve expectation-setting in online materials and during face-to-face education to create a more patient-centered perioperative experience.

Task-Specific Patient Preferences for Shared Decision-Making in Hand Surgery.

BACKGROUND: Shared decision-making for surgery can increase patient engagement, satisfaction, and clinical outcomes. However, the level of involvement that patients desire at each step of the decision-making process is unknown. METHODS: The authors surveyed patients at an academic hand surgery clinic to examine the preferred role in decision-making using validated questionnaires (i.e., Control Preference Scale, Problem-Solving Decision-Making Scale, and General Self-Efficacy Scale). The Control Preference Scale assesses general treatment preferences, whereas the Problem-Solving Decision-Making Scale distinguishes between problem-solving tasks (e.g., making diagnoses, calculating risks/benefits) and decision-making tasks. Patients' self-beliefs and perceived ability to handle difficult situations were assessed with the General Self-Efficacy Scale. The authors used linear regression models and ordinal logistic regression to examine the relationship between self-efficacy and patients' preferred role in treatment decision-making. RESULTS: Patients overall preferred an equal share of decision-making responsibility with the surgeon (mean Control Preference Scale score, 3.3 ± 0.7). Specifically, for problem-solving tasks, however, 81 percent of patients wanted to "hand over" the responsibility and 19 percent preferred shared decision-making. In contrast, for decision-making tasks, 54 percent of patients preferred shared decision-making. Each point increase in General Self-Efficacy Scale score correlated with 12 percent greater odds of preferring to retain the responsibility (OR, 1.12; 95 percent CI, 1.05 to 1.21; p = 0.001). However, self-efficacy did not show a significant effect for problem-solving tasks. CONCLUSIONS: The authors found that patients prefer surgeons to provide expert knowledge for problem-solving tasks but desire equal share of responsibility in decision-making tasks. The authors' findings support the current shift away from the paternalistic model of surgical decision-making, and provide an effective strategy to tailor shared decision-making to align care delivery with patient preferences.

Trust and Distrust in Opioid Decision-Making: A Qualitative Assessment of Patient-Doctor Relationship.

PURPOSE: Surgeons often prescribe opioid analgesics for pain management after surgery. However, we understand little about how patients perceive opioid prescribing and make decisions to use opioids for postoperative pain management. In this study, we aimed to gain an understanding of patients' decision-making process on postoperative opioid use. METHODS: We conducted semi-structured interviews with 30 adult patients undergoing elective surgery at our institution. The interviews were content-coded for thematic analysis. We used trust in the medical setting as a conceptual framework to interpret and find the inherent theory in the data. RESULTS: We found that participants based their opioid decisions on their trust or distrust toward various elements of their postoperative pain management. Participants believed that the surgeons "know," thereby, reinforcing their trust in surgeons' postoperative opioid prescribing to be in the participants' best interest. Moreover, the positive reputation of the institution strengthened the participants' trust. However, participants conveyed nuanced trust because of their distrust toward the opioid medications themselves, which were viewed as "suspicious," and the pharmaceutical companies, that were "despised." Despite this distrust, participants had confidence in their inherent ability to protect themselves from opioid use disorders. CONCLUSIONS: Understanding how patients perceive and form decisions on postoperative opioid use based on their trust and distrust toward various factors involved in their care highlights the importance of the patient-doctor relationship and building trust to effectively address postoperative pain and reduce opioid-related harms. CLINICAL RELEVANCE: Through a strengthened therapeutic alliance between patients and surgeons, we can improve our strategies to overcome the ongoing opioid epidemic through patient-centered approaches.

Does Surgical Intensity Correlate With Opioid Prescribing?: Classifying Common Surgical Procedures.

OBJECTIVE: To examine the relationship between aspects of surgical intensity and postoperative opioid prescribing. SUMMARY OF BACKGROUND DATA: Despite the emergence of postoperative prescribing guidelines, recommendations are lacking for many procedures. identifying a framework based on surgical intensity to guide prescribing for those procedures in which guidelines may not exist could inform postoperative prescribing. METHODS: We used clustering analysis with 4 factors of surgical intensity (intrinsic cardiac risk, pain score, median operative time, and work relative value units) to devise a classification system for common surgical procedures. We used IBM MarketScan Research Database (2010-2017) to examine the correlation between this framework with initial opioid prescribing and rates of refill for each cluster of procedures. RESULTS: We examined 2,407,210 patients who underwent 128 commonly performed surgeries. Cluster analysis revealed 5 ordinal clusters by intensity: low, mid-low, mid, mid-high, and high. We found that as the cluster-order increased, the median amount of opioid prescribed increased: 150 oral morphine equivalents (OME) for low-intensity, 225 OME for mid-intensity, and 300 OME for high-intensity surgeries. Rates of refill increased as surgical intensity also increased, from 17.4% for low, 26.4% for mid, and 48.9% for high-intensity procedures. The odds of refill also increased as cluster-order increased; relative to low-intensity procedures, high-intensity procedures were associated with 4.37 times greater odds of refill. CONCLUSION: Surgical intensity is correlated with initial opioid prescribing and rates of refill. Aspects of surgical intensity could serve as a guide for procedures in which guidelines based on patient-reported outcomes are not available.

Evaluation of Factors Relevant to Pain Control Among Patients After Surgical Treatment.

Importance: Opioids are often prescribed after elective surgical treatment despite the potential for misuse. Although various pain control regimens exist, patient preferences for acute postoperative pain management are unknown. Objective: To describe patient-reported key attributes of postoperative pain management. Design, Setting, and Participants: This decision analytical model used responses from a survey based on conjoint analysis to investigate the value patients placed on different aspects of postoperative pain management. Participants were patients aged 18 years or older who underwent elective hand surgical procedures between July 1, 2018, and July 23, 2019, at a single academic center. The survey was completed on a web-based platform and took place between November 2019 and January 2020. Data were analyzed from May through July 2021. Exposures: Participants were presented with a series of discrete-choice tasks and asked to select between 2 postoperative medication options that changed from question to question and had varying characteristics. Main Outcomes and Measures: Attribute importance scores and part-worth utility values for the queried aspects of pain control were calculated. Results: Of 710 individuals invited, 321 (45.2%) completed the survey; there were 212 (66.0%) women and 108 (33.6%) men, and the most common age category was 60 to 69 years (102 participants [31.8%]). Most patients reported previous opioid use (282 individuals [87.9%]). Factors in the decision-making process with the highest attribute importance scores (SDs) were risk of addiction (26.3% [13.0%]) and amount of pain relief (25.6% [14.6%]). Adverse effects 13.9% (7.2%), functional independence 11.8% (7.3%), and level of trust in the prescriber 11.4% (5.8%) had intermediate attribute importance scores (SDs). Cost 7.9% (4.4%) and stigma 3.1% (1.3%) had the lowest attribute importance scores (SDs) in patient decisions. Conclusions and Relevance: These findings suggest that multimodal pain control regimens that are associated with optimized pain relief and minimized risk of addiction are preferable to treat acute postoperative pain. The results suggest that identifying procedures for which patients prioritize minimizing risk of addiction over pain relief and incorporating patient preferences into decision-making may be associated with decreased postoperative opioid prescribing.

Patterns of Upper Extremity Reconstruction for Patients With Tetraplegia Across the United States: A Retrospective Study.

PURPOSE: The rates of upper extremity reconstruction for patients with tetraplegia remain low. We performed a retrospective study to assess recent reconstruction rates and delineate factors associated with the occurrence of reconstruction. METHODS: We examined the National Inpatient Sample database (2012-2017) for the rate of reconstruction for patients with tetraplegia. The details of provider distribution characteristics and neighborhood attributes were obtained from the American Medical Association Physician Masterfile and based on the area deprivation index, respectively. We calculated the mean reconstruction rate per year and generated multivariable logistic regression models to examine the influence of patient factors, hospital characteristics, and provider distribution on the odds of undergoing functional reconstruction for tetraplegia patients. RESULTS: Among 404,660 encounters with patients with tetraplegia, only 1,430 (0.4%) patients underwent upper extremity reconstruction from 2012 to 2017, with a mean rate of 238 procedures per year. We identified 5,450 hand surgeons, 12,751 physiatrists, and 444 spinal cord injury specialists, with variation in their national distribution. A greater number of surgeons near SCIS was associated with increased probability of reconstruction (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.03-1.12). The odds of surgery were greater for patients receiving care at urban teaching (OR 5.00, 95% CI 3.35-7.47) or urban nonteaching (OR 1.71, 95% CI 1.11-2.63) hospitals, whereas those at private nonprofit (OR 0.67, 95% CI 0.58-0.78) or investor-owned (OR 0.65, 95% CI 0.52-0.82) hospitals had lower odds. Although most patients had insurance coverage, patients with a higher income or those who received subsidized care had greater odds of undergoing reconstruction. CONCLUSIONS: Reconstruction rates remain low and are correlated with the environment of care, financial factors, and provider availability. Policies that focus on reducing these factors in addition to increasing interspecialty collaboration could improve access to surgery for patients with tetraplegia. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic I.

A Qualitative Study of Patient Protection against Postoperative Opioid Addiction: A Thematic Analysis of Self-Agency.

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.

Association of Interfacility Transfer and Patient and Hospital Characteristics With Thumb Replantation After Traumatic Amputation.

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.

Developing Strategies for Targeted Improvement of Perioperative Education for Postbariatric Surgery Body-Contouring Patients.

BACKGROUND: The quality of perioperative patient education impacts surgical outcomes, patient experiences, and resources needed to address patient concerns and unplanned visits. We examined patient inquiries and education materials to assess the quality of perioperative education and identify areas of targeted improvement for postbariatric surgery body-contouring procedures. METHODS: We examined 100 consecutive postbariatric procedures at an academic center. Themes of patient-generated calls, e-mails, and electronic medical record portal messages during the perioperative period were identified via qualitative analysis. Understandability and actionability of perioperative educational resources were assessed using the Patient Education Materials Assessment Tool (PEMAT). RESULTS: Among 212 communications identified, 167 (79%) were postoperative. Common themes were concerns regarding the surgical site (38%), medications (10%), and activity restrictions (10%). One hundred thirty inquiries were resolved through patient re-education (57%), but 36 (16%) required in-person evaluation including 4 unplanned emergency department visits and 3 readmissions for surgical-site concerns. The PEMAT scores for institutional materials were fair for understandability (69%) and actionability (60%). American Society of Plastic Surgeons materials were more understandable (84%) but less actionable (40%). CONCLUSIONS: Patient queries can be leveraged as a source of qualitative data to identify gaps in perioperative education. High-yield topics, such as education regarding the surgical site and medications, can be targeted for quality improvement through better communication and potentially reduce the number of unnecessary visits. Using the PEMAT, we also identified how directly the education materials can be revised. Improving perioperative education can promote mutual understanding between patients and surgeons, better outcomes, and efficient resource utilization.

Assessment of Anatomic Restoration of Distal Radius Fractures Among Older Adults: A Secondary Analysis of a Randomized Clinical Trial.

Importance: The value of precise anatomic restoration for distal radius fractures (DRFs) in older adults has been debated for many decades, with conflicting results in the literature. In light of the growing population of adults aged 60 years and older, both fracture incidence and associated treatment costs are expected to increase. Objective: To determine the association between radiographic measures of reduction and patient outcomes after DRF in older patients. Design, Setting, and Participants: Data were collected from the Wrist and Radius Injury Surgical Trial (WRIST), a multicenter randomized clinical trial of DRF treatments for adults aged 60 years and older (enrollment from April 10, 2012, to December 31, 2016, with a 2-year follow-up). Data analysis was performed from January 3, 2019, to August 19, 2019. WRIST participants who completed 12-month assessments were included in the study. According to the biomechanical principle of alignment, 2-phase multivariable regression models were adopted to assess the association between radiographic measures of reduction and functional and patient-reported outcomes 12 months following treatment. Interventions: Participants were randomized to receive volar locking plate, percutaneous pinning, or external fixation. Those who opted for nonoperative treatment received casts. Main Outcomes and Measures: Hand grip strength, wrist arc of motion, radial deviation, ulnar deviation, the Michigan Hand Outcomes Questionnaire (MHQ) total score, MHQ function score, and MHQ activities of daily living score were measured at 12 months following treatment. Results: Data from 166 WRIST participants (144 [86.7%] women; mean [SD] age, 70.9 [8.9] years) found that only 2 of the 84 correlation coefficients calculated were statistically significant. For patients aged 70 years or older, every degree increase in radial inclination away from normal (22°) grip strength in the injured hand was 1.1 kg weaker than the uninjured hand (95% CI, 0.38-1.76; P = .004) and each millimeter increase toward normal (0 mm) in ulnar variance was associated with a 10.4-point improvement in MHQ ADL score (95% CI, -16.84 to -3.86; P = .003). However, neither of these radiographic parameters appeared to be associated with MHQ total or function scores. Conclusions and Relevance: The study results suggest that precise restoration of wrist anatomy is not associated with better patient outcomes for older adults with DRF 12 months following treatment. Surgeons can consider this evidence to improve quality of care by prioritizing patient preferences and efficient use of resources over achieving exact realignment. Trial Registration: ClinicalTrials.gov identifier: NCT01589692.

Investigating the causal effect of socioeconomic status on quality of care under a universal health insurance system - a marginal structural model approach.

BACKGROUND: Social disparities in healthcare persist in the US despite the expansion of Medicaid under the Affordable Care Act. We investigated the causal impact of socioeconomic status on the quality of care in a setting with minimal confounding bias from race, insurance type, and access to care. METHODS: We designed a retrospective population-based study with a random 25% sample of adult Taiwan population enrolled in Taiwan's National Health Insurance system from 2000 to 2016. Patient's income levels were categorized into low-income group (<25th percentile) and high-income group (≥25th percentile). We used marginal structural modeling analysis to calculate the odds of hospital admissions for 11 ambulatory care sensitive conditions identified by the Agency for Healthcare Research and Quality and the odds of having an Elixhauser comorbidity index greater than zero for low-income patients. RESULTS: Among 2,844,334 patients, those in lower-income group had 1.28 greater odds (95% CI 1.24-1.33) of experiencing preventable hospitalizations, and 1.04 greater odds (95% CI 1.03-1.05) of having a comorbid condition in comparison to high-income group. CONCLUSIONS: Income was shown to be a causal factor in a patient's health and a determinant of the quality of care received even with equitable access to care under a universal health insurance system. Policies focusing on addressing income as an important upstream causal determinant of health to provide support to patients in lower socioeconomic status will be effective in improving health outcomes for this vulnerable social stratum.

Outcomes Following Replantation/Revascularization in the Hand.

The variability in reported outcomes and outcome measures used in digit replantation makes it difficult to compare results among studies. This article reviews the principles of measuring functional and patient-reported outcomes after replantation, and describes the recommended instruments to use and ways to report results.

Finger Replantation Optimization Study (FRONT): Update on National Trends.

PURPOSE: Traumatic digit amputations have an adverse impact on patients' daily living. Despite experts advocating for digit replantation, studies have shown a continued decrease in rate of replantation. We performed a national-level investigation to examine the recent trend of practice for digital replantation. METHODS: We used the National Inpatient Sample database under the Healthcare Cost and Utilization Project to select adult patients with traumatic digit amputation from 2001 to 2014. We calculated the rate of attempted and rate of successful digit replantation per year, subcategorizing for digit type (thumb or finger) and for hospital type (rural, urban nonteaching, or urban teaching). We also analyzed the pattern of distribution of case volume to each hospital type per year. We used 2 multivariable logistic regression models to investigate patient demographic and hospital characteristics associated with the odds of replantation attempt and success. RESULTS: Among the 14,872 adult patients with a single digit amputation from 2001 to 2014, only 1,670 (11.2%) underwent replantation. The rate of replantation attempt trended down over the years for both thumb and finger injuries at all hospital types, despite increasing proportions of cases being sent to urban teaching hospitals where they were more than twice as likely to undergo replantation. The rate of successful replantation stayed stable for the thumb at 82.9% and increased for fingers from 76.1% to 82.4% over the years. Patients were more likely to undergo replantation if they had private insurance or a higher level of income. Neither hospital case volume nor hospital type was predictive of successful replantation. CONCLUSIONS: Although more single-digit amputations were treated by urban teaching hospitals with higher likelihood to replant, the downward trend in rate of attempt regardless of hospital type demonstrates that concentration of case volume is not the solution to reverse the declining trend. CLINICAL RELEVANCE: Financial aspects of digit replantation need to be considered from both the patients' and the surgeons' perspectives to improve delivery of care for digit replantation.

Use of Routine Pathologic Evaluation of Nonmalignant Lesions in Hand Surgery: A National Study.

BACKGROUND: Most lesions of the upper extremity are common and benign, and many have questioned the need for routine pathologic evaluation of these specimens. The authors aim to examine the national use of routine pathologic examination of nonmalignant hand lesions to help guide health care policy and practice patterns. METHODS: The authors used a national level MarketScan database to form a cohort of adult patients who underwent excision of nonmalignant upper extremity lesions. The authors calculated the rate of submission for each surgical procedure and separately for each diagnosis. The authors also investigated demographic and clinical characteristics associated with the submission of surgical specimens using a multivariable logistic regression model. The authors calculated the total cost of routine pathologic evaluation. RESULTS: The final study cohort included 222,947 patients and 182,962 specimens from 153,518 cases. The mean rate of submission was 69 percent. Older age, Northeast region, and high comorbidity scores showed significant correlation with the odds of having a specimen submitted for pathologic evaluation. Excision of primary wrist ganglion was the most performed procedure, and benign lesions larger than 4.0 cm were most frequently submitted for pathologic evaluation. The mean cost of routine pathologic examination was $133 per specimen, and the annual expenditure was $5 million. CONCLUSIONS: The routine pathologic examination of benign hand lesions is used frequently but provides limited clinical benefit at a cost. To increase efficiency and improve quality of care, surgeons should be aware of the low value of routine pathologic evaluation and be more selective for cases for which diagnostic testing will change management.