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.

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.

Representation of Ethics in COVID-19 Research: A Systematic Review.

BACKGROUND: Ethical discourse in the scientific community facilitates the humane conduct of research. The urgent response to COVID-19 has rapidly generated a large body of literature to help policymakers and physicians address novel pandemic challenges. Plastic surgeons, in particular, have to manage the postponement of elective procedures and safely provide care for non-COVID-19 patients. Although COVID-19 research may provide guidance on these challenges, the extent to which ethical discussions are present in these publications remains unknown. METHODS: Articles were identified systematically by searching the PubMed, Embase, Central, and Scopus databases using search terms related to ethics and COVID-19. The search included articles published during the first 9 months of the COVID-19 pandemic. The following data were extracted: presence of an ethical discussion, date of publication, topic of ethical discussion, and scientific discipline of the article. RESULTS: One thousand seven hundred fifty-three articles were included, of which seven were related to plastic surgery. The ethical principle with the greatest representation was nonmaleficence, whereas autonomy had the least representation. Equity and access to care was the most common topic of ethical discussion; the mental health effects of COVID-19 were the least common. The principle of justice had the greatest variation in representation. CONCLUSIONS: In a systematic review of COVID-19-related articles that were published during the first 9 months of the pandemic, the ethical principles of autonomy and justice are neglected in ethical discussions. As ethical dilemmas related to COVID-19 remain prevalent in plastic surgery, attention to ethical discourse should remain a top priority for leaders in the field.

Preventable Hospitalization Trends Before and After the Affordable Care Act.

Introduction: The Patient Protection and Affordable Care Act aimed to increase the number of individuals with health insurance, which may lead to adequate primary care management and reduced rates of preventable hospitalizations. To investigate the rates of preventable hospitalization after the passing of the Affordable Care Act in 2010 and Medicaid expansion in 2014 across 26 states, a population-based study was conducted using the Healthcare Cost and Utilization Project National Inpatient Sample database from 2005-2017. Methods: A logistic regression and trend analysis was performed to assess the changes in preventable hospitalization rates over time and the impact of policy changes on the rate of preventable hospitalization. Individuals were included if they were aged between 18 and 64 years and had a preventable quality indicator International Classification of Diseases, Ninth or Tenth Revision code as determined by the Agency for Healthcare Research and Quality. Results: More than 45 million preventable-hospitalization admissions were reported between 2005 and 2017. There was a significant decrease in preventable hospitalization rates after the passing of the Affordable Care Act from 12.0% to 10.8% (p<0.01) and from 11.5% to 10.6% (p<0.01) after Medicaid expansion. Bacterial pneumonia declined from 1.5% to 0.6% (p<0.01), along with chronic obstructive pulmonary disease and asthma in older adults from 1.9% to 1.7% (p=0.01) after the expansion. Conclusions: States that have not implemented Medicaid expansion should make it a priority because it may lead to a reduction in preventable hospitalization rates. Furthermore, preventable hospitalization rates may be considered a quality measure to examine the accessibility and effectiveness of primary care intervention.

Quality Metrics in Hand Surgery: A Systematic Review.

PURPOSE: The enactment of the Patient Protection and Affordable Care Act in 2010 placed an emphasis on measuring the quality of care. However, the issue of how best to measure quality remains in question. Although some surgical specialties frequently rely on quality measures such as the mortality rate, measuring quality in hand surgery necessitates the use of metrics beyond this traditional scope. A review was performed of the potential quality metrics used in the hand surgery literature published after the Affordable Care Act was enacted, to identify current trends in quality measurement and guide efforts to improve the quality of care in hand surgery. METHODS: We searched the PubMed and EMBASE databases to identify original research articles within hand surgery to assess how care is being measured. Data extracted from the articles included study characteristics, quality metrics, and the domain(s) of quality. RESULTS: A total of 7,308 articles were identified, and 63 prospective and retrospective articles were included in the analysis. The most common quality measure reported in the hand surgery literature was an outcome measure (100%) and the least common was a structure measure (30.2%). The most common metrics were pain (44.4%) and patient-reported measures (41.3%). Effectiveness (42.9%) was the most frequently assessed domain of quality, whereas efficiency (3.2%) was the least studied. CONCLUSIONS: We identified quality measures used in contemporary hand surgery literature and found a substantial variation in the representation of quality metrics. Structure and process measures can be leveraged to provide a more holistic assessment of the quality of care in hand surgery. CLINICAL RELEVANCE: Although outcome measurements are critical to understanding effectiveness, structure and process measures should be considered and reported as necessary, because these metrics may influence treatment outcomes and the development of quality measures.

Cost-Benefit Analysis of Ultrasonography in the Hand Clinic.

BACKGROUND: Despite previous studies demonstrating the benefit of office-based ultrasonography for musculoskeletal evaluation, many hand surgery clinics have yet to adopt this practice. The authors conducted a cost-benefit analysis of establishing an ultrasound machine in a hand clinic. METHODS: The authors used the Medicare Physician Fee Schedule, Physician/Supplier Procedure Summary, and Physician Compare National Downloadable File databases to estimate provider reimbursement and annual frequency of office-based upper extremity-related ultrasound procedures. Ultrasound machine cost, maintenance fees, and consumable supply prices were gleaned from the literature. The primary outcomes were net cost-benefit difference and benefit-cost ratio at 1 year, 5 years, and 10 years after implementation. Sensitivity analyses were performed by varying factors that influence the net cost-benefit difference. RESULTS: The estimated total initial expense to establish ultrasonography in the clinic was $53,985. The overall cost-benefit difference was -$49,530 per practice at the end of the first year (benefit-cost ratio, 0.3), -$1049 after 5 years (benefit-cost ratio, 1.0), and $52,022 after 10 years (benefit-cost ratio, 1.4). Benefits primarily accrued because of physician reimbursements. One-way sensitivity analysis revealed machine price, annual procedure volume, and reimbursement rate as the most influential parameters in determining the benefit-cost ratio. Ultrasonography was cost beneficial when the machine price was less than $46,000 or if the billing frequency exceeded six times per week. A societal perspective analysis demonstrated a large net benefit of $218,162 after 5 years. CONCLUSIONS: Implementation of office-based ultrasound imaging can result in a positive financial return on investment. Ultrasound machine cost and procedural volume were the most critical factors influencing benefit-cost ratio.