The Cost of Ambulatory Breast Reduction: Hospital Reimbursement Versus Surgeon Payments.

Introduction: Reduction mammoplasty (RM) is one of the most common operations performed in plastic surgery. While US national surgical expenditures have risen in recent years, studies have reported decreasing reimbursement rates for plastic surgeons. The purpose of this study is to characterize the trends in charges and payments for a common plastic surgery operation, ambulatory RM, for facilities and physicians. Methods: A Medicare patient records database was used to capture hospital, surgeon, and anesthesiologist charges and payments for ambulatory RM from 2005 to 2014. Values were adjusted for inflation. A ratio of hospital to surgeon charges and payments were calculated: charge multiplier (CM) and payment multiplier (PM), respectively. Charges, payments, Charlson comorbidity index, CM, and PM values were analyzed for trends. Results: This study included 1001 patients. During the study period, the facility charge for RM per patient increased from $8477 to $11,102 (31% increase; p < .0005), and the surgeon charge increased from $7088 to $7199 (2% increase; p = .0009). Facility payments increased from $3661 to $3930 (7% increase; p < .0005), and surgeon payments decreased from $1178 to $1002 (15% decrease; p < .0005). CM increased from 1.2 to 1.54, and PM increased from 3.11 to 3.92. Conclusions: Charges and payments to facilities for ambulatory RM increased disproportionately to that of surgeons, likely due in part to rising administrative costs in health care delivery. This may disincentivize plastic surgeons from offering RM at hospital-based surgical centers, limiting patient access to this operation.

Introduction: La mammoplastie de réduction (MR) est l'une des interventions les plus courantes pratiquées en chirurgie plastique. Alors que les dépenses chirurgicales aux États-Unis ont augmenté au niveau national au cours des dernières années, les études ont signalé une diminution des taux de remboursement pour les chirurgiens plasticiens. L'objectif de cette étude est de définir les tendances dans les frais et paiements pour une intervention courante de chirurgie plastique, une MR ambulatoire, pour les établissements et pour les médecins. Méthodes: Une base de données des dossiers de patients Medicare a été utilisée pour collecter les frais pour les hôpitaux, les chirurgiens et les anesthésiologistes ainsi que les paiements pour MR ambulatoires de 2005 à 2014. Les valeurs ont été ajustées pour tenir compte de l'inflation. Des ratios des frais hôpital/chirurgien et des paiements ont été calculés : respectivement, un facteur de multiplication des frais (MF) et des paiements (MP). Les tendances de la valeur des frais, des paiements, de l'indice de comorbidité de Charlson, du MF et du MP ont été analysées. Résultats: Cette étude a inclus 1001 patients. Au cours de la période de l'étude, les frais pour MR par patient à la charge de l'établissement ont augmenté de 8 477 $ à 11 102 $, soit une augmentation de 31 % (P < 0,0005) et les frais du chirurgien sont passés de 7 088 $ à 7 199 $, soit une augmentation de 2 % (P = 0,0009). Les paiements de l'établissement ont augmenté de 3 661 $ à 3 930 $, soit une augmentation de 7 % (P < 0,0005) et les paiements du chirurgien ont diminué de 1 178 $ à 1 002 $, soit une diminution de 15 % (P < 0,0005). Le facteur MF est passé de 1,2 à 1,54 et le facteur MP est passé de 3,11 à 3,92. Conclusions: Les frais et paiements aux établissements pour MR ambulatoire ont augmenté de manière disproportionnée par rapport à ceux des chirurgiens, probablement en partie à cause de l'augmentation des coûts administratifs croissants de l'administration des soins. Cela pourrait inciter les chirurgiens plasticiens à ne plus offrir de MR dans les centres chirurgicaux hospitaliers et pourrait donc limiter l'accès des patients à cette opération.

Determinants of pressure injury development in patients with COVID-19.

OBJECTIVE: Pressure injuries (PIs) often develop in critically ill patients due to immobility, and underlying comorbidities that decrease tissue perfusion and wound healing capacity. This study sought to provide epidemiological data on determinants and current managements practices of PI in patients with COVID-19. METHOD: A US national insurance-based database consisting of patients with coronavirus or COVID-19 diagnoses was used for data collection. Patients were filtered by International Classification of Diseases (ICD) codes corresponding to coronavirus or COVID-19 diagnosis between 2019-2020. Diagnosis of PI following COVID-19 diagnosis was queried. Demographic data and comorbidity information was compared. Logistic regression analysis was used to determine predictors for both PI development and likelihood of operative debridement. RESULTS: A total of 1,477,851 patients with COVID-19 were identified. Of these, 15,613 (1.06%) subsequently developed a PI, and 8074 (51.7%) of these patients had an intensive care unit (ICU) admission. The average and median time between diagnosis of COVID-19 and PI was 39.4 and 26 days, respectively. PI was more likely to occur in patients with COVID-19 with: diabetes (odds ratio (OR): 1.39, 95% confidence interval (CI): 1.29-1.49; p<0.001); coronary artery disease (OR: 1.11, 95% CI: 1.04-1.18, p=0.002), hypertension (OR: 1.43, 95% CI: 1.26-1.64; p<0.001); chronic kidney disease (OR: 1.18, 95% CI: 1.10-1.26; p<0.001); depression (OR: 1.45, 95% CI 1.36-1.54; p<0.001); and long-term non-steroidal anti-inflammatory drug use (OR: 1.21, 95% CI: 1.05-1.40; p=0.007). They were also more likely in critically ill patients admitted to the ICU (OR: 1.40, 95% CI: 1.31-1.48; p<0.001); and patients requiring vasopressors (OR:1.25, 95% CI: 1.13-1.38; p<0.001), intubation (OR: 1.21, 95% CI 1.07-1.39; p=0.004), or with a diagnosis of sepsis (OR: 2.38, 95% CI 2.22-2.55; p<0.001). ICU admission, sepsis, buttock and lower back PI along with increasing Charlson Comorbidity Index (CCI) (OR: 1.04, 95% CI 1.00-1.08; p=0.043) was associated with surgical debridement. The vast majority of patients with COVID-19 did not undergo operative debridement or wound coverage. CONCLUSION: PIs are widely prevalent in patients with COVID-19, especially in those who are critically ill, yet the vast majority do not undergo operative procedures. DECLARATION OF INTEREST: The authors have no conflicts of interest to declare.

Trends in Physician Payments for Hand Surgery Consultations and Clinic Visits.

PURPOSE: The primary objective of this study was to identify the trends in reimbursement for hand surgeons for new patient visits, outpatient consultations, and inpatient consultations from the years 2010-2018. In addition, we sought to investigate the influence of payer mix and coding level of service on physician reimbursement in these settings. METHODS: The PearlDiver Patients Records Database was used to identify clinical encounters and their respective physician reimbursements for analysis within this study. This database was queried using Current Procedural Terminology codes to identify relevant clinical encounters for inclusion, filtered for the presence of valid demographic information and by physician specialty for the presence of a hand surgeon, and tracked by primary diagnoses. Cost data were then calculated and analyzed regarding the payer type and level of care. RESULTS: In total, 156,863 patients were included in this study. The mean reimbursement for inpatient consultations, outpatient consultations, and new patient encounters increased by 92.75% ($134.85 to $259.93), 17.80% ($161.33 to $190.04), and 26.78% ($102.58 to $130.05), respectively. When normalized to 2018 dollars to adjust for inflation, the percent increases were 67.38%, 2.24%, and 10.09%, respectively. Commercial insurance reimbursed hand surgeons to a greater degree than any other payer type. Mean physician reimbursement differed depending on the level of service billed, with the level of service V reimbursing 4.41 times more than the level of service I visits for new outpatient visits, 3.66 times more for new outpatient consultations, and 3.04 times more for new inpatient consultations. CONCLUSIONS: This study helps to provide physicians, hospitals, and policymakers with objective information regarding the trends in reimbursement to hand surgeons. Although this study indicates increasing reimbursements for consultations and new patient visits to hand surgeons, the margins shrink when adjusted for inflation. LEVEL OF EVIDENCE: Economic Analysis IV.

Arthroscopic Versus Open Treatment of Septic Wrist Arthritis: National Trends in Usage and Impact on Length of Stay, Reoperation, Postoperative Readmissions, and Complications.

Purpose: The purpose of this study was to use a national claims database to analyze trends in the usage of arthroscopic versus open irrigation and debridement of septic wrist arthritis and compare complication rates, readmission rates, and reoperation rates between the 2 treatment modalities. Methods: The PearlDiver database was used to identify patients in the United States who underwent open or arthroscopic debridement for suspected septic wrist arthritis from 2010 to 2017. Data on patient demographics and comorbidities were obtained. Pearson's chi-square tests were performed to compare the treatment modality to demographic data and the year of diagnosis. Univariate logistic regressions were used to measure differences in 90-day hospital readmission rates, 90-day complication rates, and 1-year reoperation rates. Results: The database captured 1,145 patients who received treatment for septic arthritis of the wrist during this period. Among these, 212 (18.5%) patients underwent arthroscopic debridement and 933 (81.5%) patients underwent open debridement. Open management was more common in all ages; however, arthroscopic debridement was used more frequently in younger age groups. The proportion of open cases per year seemed to increase over the study period. In limited comparisons, no significant differences were observed in 90-day hospital readmission rates, 90-day complication rates, and 1-year reoperation rates. Conclusions: Open irrigation and debridement was the preferred method for treatment of septic wrist arthritis in all age groups and time points in this study. No univariate differences were found between rates of readmission, complications, and reoperations between arthroscopic and open treatment modalities; however, more robust data and analyses are needed to better understand the differences between these approaches, especially across different patient groups. Level of evidence: Prognostic IV.

Revision of Flexor Tendon Repair: Factors Associated With Flexor Tenolysis.

BACKGROUND: Tenolysis restores mobility to the flexor tendon through the lysis of adhesions that inhibit and negatively impact functional outcomes following flexor tendon repair. Despite extensive literature on operative techniques and therapy protocols used to minimize adhesion formation, there are limited data examining the association of patient, injury, and postoperative factors with tenolysis. This study aims to: (1) quantify tenolysis rates following flexor tendon repair or reconstruction; and (2) identify patient demographic factors, medical comorbidities, injury characteristics, postoperative diagnoses, and complications associated with tenolysis. METHODS: PearlDiver was used to identify patients who underwent a flexor tendon repair or reconstruction from 2010 to 2020. Patients were stratified by whether or not flexor tenolysis was performed. Patient demographics, comorbidities, injury characteristics, postoperative diagnoses, and complications were recorded. Logistic regression analysis was used to identify independent risk factors associated with tenolysis. RESULTS: Database review identified 10 264 patients who underwent either flexor tendon repair or reconstruction, with 612 patients (6.0%) subsequently undergoing tenolysis. Logistic regression analysis determined that vascular injury preceding flexor tendon repair, surgical wound disruption, nerve injury diagnosed postoperatively, postoperative tendon rupture, and need for repeat flexor tendon repair were associated with an increased odds of tenolysis. Patient age, sex, and comorbidities were not associated with performance of tenolysis. CONCLUSIONS: Although tenolysis rates may differ according to physician and patient preferences, identification of factors associated with tenolysis following flexor tendon repair allows surgeons to risk-stratify patients prior to surgery and help guide postoperative expectations if complications arise.

Peripherally Inserted Central Line Catheters following Hand and Wrist Infections.

Hand and wrist infections may cause varying degrees of morbidity requiring antibiotic therapy of variable duration and often operative intervention. Peripherally inserted central line catheters (PICCs) are placed when an extended course of intravenous antibiotics is anticipated. The present study aims to analyze utilization and impact of PICC placement on the management of hand, wrist, and forearm infections. Methods: The PearlDiver Patients Records Database was queried to identify patients who underwent treatment for infection of the hand, wrist, and forearm between 2010 and 2018. Logistic regression analysis was utilized to evaluate the association of patient-related risk factors with PICC utilization, complications, readmissions, and length of stay (LOS). Results: A total of 24,665 patients with an upper extremity infection were included in the study. Ultimately, 416 patients required a PICC placement (1.69%). Patients with older age, male gender, certain medical comorbidities, and infection involving deeper structures were more likely to require a PICC. Ninety-day all-cause medical complication rates were significantly higher for the PICC group (19.7% versus 6.7%) compared to those without. Any hospital readmission rates were significantly higher for PICC group at 90 days (28.4% versus 6.3%) and 1 year (35.8% versus 10.9%). Readmission rates remained slightly higher at 1 year for both groups. The PICC group demonstrated significantly longer LOS by 2 days (7.72 days versus 5.14 days). Conclusion: While not required for the majority of hand, wrist, and forearm infections, PICC placement is associated with increased medical complications, more frequent hospital readmissions, and longer LOS.

Cannabinoids and Pain for the Plastic Surgeon: What Is the Evidence?

BACKGROUND: Since the passage of the 2018 Farm Bill, practitioners have encountered more patients self-treating pain with over-the-counter topical cannabidiol (CBD) derived from hemp-Cannabis sativa with less than 0.3% delta-9-tetrahydrocannabinol-with reported improvements in pain control and activities of daily living. Cannabidiol has been touted for its capacity to improve inflammatory, arthritic, and neuropathic pain conditions, and increasing numbers of patients are exploring its use as potential replacement for opioids. However, limited rigorous clinical trials have been performed evaluating the safety and efficacy of cannabinoids for the treatment of pain. METHODS: A systematic search of PubMed was performed using the Medical Subject Headings (MeSH) terms "cannabinoid" or "CBD" or "cannabidiol" or "cannabis" or "medical marijuana" and "pain." It yielded 340 article titles. Twelve full-text primary studies of oral or topical CBD for chronic pain were selected for review, including 6 animal (2 randomized clinical trial and 4 prospective trials) and 6 human (4 randomized clinical trial and 2 prospective trials) studies. RESULTS: With respect to the safety and efficacy of oral and topical CBD for treating pain, animal and human studies have shown early positive results with limited minor side effects. However, all human studies may be underpowered with small sample sizes. CONCLUSIONS: With respect to the safety and efficacy of oral and topical CBD for treating pain, the evidence remains inconclusive in that we have a paucity of data to share with our patients who are considering the use of these products, which may be associated with significant costs.

Scleroderma and Raynaud Phenomenon: The Cold Truth Regarding the Use of Operative Management.

BACKGROUND: Raynaud phenomenon, with and without scleroderma, is a common vasospastic condition that manifests with extremity pain and skin discoloration. When conservative management fails, complications such as ischemia, ulceration, and gangrene may warrant surgical intervention. The purpose of this study was to determine the risk factors and use of surgical intervention in this population. METHODS: A national insurance claims-based database with patient records from the Centers for Medicare and Medicaid Services was used for data collection. Patients with first diagnoses of Raynaud phenomenon, scleroderma, or both between 2005 and 2014 were identified. Primary outcomes included the presence of upper extremity amputation or vascular procedure, and history of amputation within 5 years of a vascular procedure. Secondary outcomes included hospital admissions, upper extremity wounds, and amputation within 1 year of diagnosis. RESULTS: The Raynaud phenomenon, scleroderma, and Raynaud phenomenon with scleroderma cohorts consisted of 161,300, 117,564, and 25,096 patients, respectively. A diagnosis of both Raynaud phenomenon and scleroderma increased the odds of upper extremity amputation by 5.4-fold, vascular procedure by 4.8-fold, and amputation within 5 years of a vascular procedure by 1.5-fold. Patients with Raynaud phenomenon or scleroderma alone were 3.1 and 5.6 times less likely to undergo amputation within 5 years of a vascular procedure, respectively. CONCLUSIONS: Patients with both Raynaud phenomenon and scleroderma have higher likelihoods of having upper extremity amputations, vascular procedures, and amputations following vascular procedures compared to each diagnosis alone. Vascular procedures are rarely being performed. Further research is necessary to establish a standard of care and determine whether early and more frequent intervention with vascular procedures can decrease amputation rates in this patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

A Randomized Controlled Trial of Topical Cannabidiol for the Treatment of Thumb Basal Joint Arthritis.

PURPOSE: Since the passage of the Agricultural Improvement Act of 2018, hand surgeons have increasingly encountered patients seeking counseling on over-the-counter, topical cannabidiol (CBD) for the treatment of pain. To this end, we designed a human clinical trial to investigate the therapeutic potential of CBD for the treatment of pain associated with thumb basal joint arthritis. METHODS: Following Food and Drug Administration and institutional approval, a phase 1 skin test was completed with 10 healthy participants monitored for 1 week after twice-daily application of 1 mL of topical CBD (6.2 mg/mL) with shea butter. After no adverse events were identified, we proceeded with a phase 2, double-blinded, randomized controlled trial. Eighteen participants with symptomatic thumb basal joint arthritis were randomized to 2 weeks of twice-daily treatment with CBD (6.2 mg/mL CBD with shea butter) or shea butter alone, followed by a 1-week washout period and then crossover for 2 weeks with the other treatment. Safety data and physical examination measurements were obtained at baseline and after completion of each treatment arm. RESULTS: Cannabidiol treatment resulted in improvements from baseline among patient-reported outcome measures, including Visual Analog Scale pain; Disabilities of the Arm, Shoulder, and Hand; and Single Assessment Numeric Evaluation scores, compared to the control arm during the study period. There were similar physical parameters identified with range of motion, grip, and pinch strength. CONCLUSIONS: In this single-center, randomized controlled trial, topical CBD treatment demonstrated significant improvements in thumb basal joint arthritis-related pain and disability without adverse events. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Estimating the Impact of Postamputation Pain.

BACKGROUND: Neuromas, neuralgia, and phantom limb pain commonly occur after lower-extremity amputations; however, incidence of these issues is poorly reported and understood. Present literature is limited to small cohort studies of amputees, and the reported incidence of chronic pain after amputation ranges as widely as 0% to 80%. We sought to objectively investigate the incidence of postamputation pain and nerve-related complications after lower-extremity amputation. METHODS: Patients who underwent lower-extremity amputation between 2007 and 2017 were identified using a national insurance-based claims database. Incidence of reporting of postoperative neuroma, neuralgia, and phantom limb pain were identified. Patient demographics and comorbidities were assessed. Average costs of treatment were determined in the year after lower-extremity amputation. Logistic regression analyses and resulting odds ratios were calculated to determine statistically significant increases in incidence of postamputation nerve-related pain complications in the setting of demographic factors and comorbidities. RESULTS: There were 29,507 lower amputations identified. Postoperative neuralgia occurred in 4.4% of all amputations, neuromas in 0.4%, and phantom limb pain in 10.9%. Nerve-related pain complications were most common in through knee amputations (20.3%) and below knee amputations (16.7%). Male sex, Charlson Comorbidity Index > 3, diabetes mellitus, diabetic neuropathy, diabetic angiopathy, diabetic retinopathy, obesity, peripheral vascular disease, and tobacco abuse were associated with statistically significant increases in incidence of 1-year nerve-related pain or phantom limb pain. CONCLUSIONS: Given the incidence of these complications after operative extremity amputations and associated increased treatment costs, future research regarding their pathophysiology, treatment, and prevention would be beneficial to both patients and providers.

Magnetic Resonance Arthrography of the Wrist: The Impact on Operative Management of Wrist Injuries.

Background There is no consensus on the utility of arthrography in the evaluation of wrist injuries. This study evaluates ordering trends of different types of magnetic resonance imaging (MRI) of the wrist and compares rates of surgery following these imaging modalities. Methods A national claims-based database was used to identify patients who underwent MRI within 90 days of a first-instance diagnosis of wrist injury from 2010 to 2018. The utilization of MRI without intravenous (IV) contrast, MRI with IV contrast, and MRI with arthrogram was investigated. The instances of operative procedures of the wrist within 1 year of MRI study were recorded. Patient demographics, comorbidities, type of operative procedure, and ordering physician specialty were obtained. Logistic regression analysis was used to evaluate the utilization of MRI and subsequent 1-year operative intervention rates as well as association of patient-related factors. Results Magnetic resonance arthrography use was associated with higher rates of subsequent operative treatment. Surgeons were more likely to order an arthrogram at the time of MRI. Younger patients were more likely to undergo MRI-based advanced imaging. Conclusion Surgeons may perceive MRA of the wrist to play an important role in operative decision-making following wrist injury. Level of Evidence This is a Level III, retrospective cohort study.

Regional Anesthesia for Hip Arthroscopy.

Pain after hip arthroscopy can be severe, yet we lack a consensus method for non-narcotic analgesia. Here we describe anatomic elements of hip arthroscopy and our current understanding of the relevant sensory innervation as a prelude to the evaluation of locoregional analgesic techniques. Many regional nerve blocks and local anesthetic infiltration techniques are reviewed, including 2 newer ultrasound fascial plane blocks. Further study of targeted, motor-sparing approaches, either ultrasound-guided or under direct surgical visualization is needed.

Opioid Prescribing for Proximal Row Carpectomy versus Four-Corner Arthrodesis.

Background Proximal row carpectomy (PRC) and four-corner arthrodesis (4-CA) represent motion-sparing procedures for addressing degenerative wrist pathologies. While both procedures demonstrate comparable functional outcomes, postoperative pain presents a surgical challenge that often necessitates the use of opioids. Objectives The aim of this study was to (1) compare opioid prescribing patterns surrounding PRC and 4-CA, (2) identify risk factors predisposing patients to increased perioperative and prolonged postoperative opioids, and (3) examine the association between opioids and perioperative health care utilization. Patients and Methods PearlDiver Patients Records Database was used to retrospectively identify patients undergoing primary PRC and 4-CA between 2010 and 2018. Patient demographics, comorbidities, prescription drug usage, and perioperative health care utilization were evaluated. Perioperative opioid prescriptions and post-operative opioid prescriptions were recorded. Logistic regression analysis evaluated the association of patient risk factors. Results There was no significant difference in perioperative (PRC [odds ratio {OR}: 0.84, p = 0.788]; 4-CA [OR: 0.75, p = 0.658]) or prolonged postoperative opioid prescriptions (PRC [OR: 0.95, p = 0.927]; 4-CA [OR: 0.99, p = 0.990]) between PRC and 4-CA. Chronic back pain and use of benzodiazepines or anticonvulsants were associated with increased risks of prolonged postoperative opioids. Prolonged postoperative opioids presented increased risks of emergency department visits (OR: 2.09, p = 0.019) and hospital readmissions (OR: 10.2, p = 0.003). Conclusion No significant differences exist in the prescription of opioids for PRC versus 4-CA. Both procedures have high amounts of prolonged postoperative opioid use, which is associated with increased risks of emergency department visits and hospital readmissions. Level of Evidence This is a level III, retrospective comparative study.

Risk Factors for Prolonged Opioid Consumption in Lower Extremity Amputees.

Extremity amputation is a common procedure performed to treat a variety of different problems and affects quality of life in a number of ways. In addition to acute postoperative pain, amputations have been shown to cause chronic pain that is often neuropathic in many amputees. This study sought to better characterize the role of opioids in postoperative pain control in lower extremity amputees. METHODS: Patients who underwent lower extremity amputation between 2010 and 2018 were identified in a national insurance-claims database using ICD-9, ICD-10, and CPT codes. Patient demographics, comorbidities, perioperative opioid use, and prolonged postoperative opioid use were then determined for both groups. Descriptive statistics and logistic regression analysis were utilized to evaluate the association of patient-related risk factors and neuropathic pain conditions with perioperative and prolonged postoperative opioid use. RESULTS: In total, 2247 opioid-naive lower extremity amputees were identified. An estimated 54.7% of patients utilized opioids in the perioperative period, and 44.6% were found to have prolonged opioid use. Younger age (ages 40-50 versus older), history of chronic pain, migraines, lower back pain, Charlson Comorbidity Index greater than 1, preoperative benzodiazepine, muscle relaxant, anticonvulsant, and antidepressant use were all significantly related to prolonged postoperative opioid use. CONCLUSIONS: Prolonged postoperative opioid use is a problem that affects nearly half of lower extremity amputees and seems to be significantly related to the preoperative use of benzodiazepines, muscle relaxants, anticonvulsants, and antidepressants. Further research into the diagnosis and treatment of postamputation neuropathic pain is needed to prevent reliance on opioids in this patient population.