Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 623
Filtrar
1.
PLoS One ; 15(5): e0232684, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32433648

RESUMO

INTRODUCTION: One out of every 5 elderly patients will suffer a distal radius fracture and these injuries are often related to poor bone health. Several surgical subspecialties have demonstrated that pre-injury activity level can impact patient outcomes. To determine the importance of physical activity, we examined the relationship between pre-injury activity and patient-reported and functional outcomes among fracture patients. METHODS: This is a retrospective analysis of prospectively collected data from participants enrolled in the Wrist and Radius Injury Surgical Trial (WRIST) from April 10, 2012 to December 31, 2016. This study included 304 adults, 60 years or older with isolated unstable distal radius fractures; 187 were randomized to one of three surgical treatments and 117 opted for casting. Participants opting for surgery were randomized to receive volar locking plate, percutaneous pinning, or external fixation. Participants who chose not to have surgery were treated with casting. All participants were stratified prior to analysis into highly and less-active groups based on pre-injury Rapid Assessment of Physical Activity Scores. RESULTS: 280 patients had 12-month assessments of outcomes. Highly active participants scored 8 and 5 points greater on the Michigan Hand Questionnaire at 6 weeks and 3 months respectively, p<0.05. Highly active participants demonstrated greater grip strength at the 3-month (p = 0.017) and 6-month (p = 0.007) time-points. Highly active participants treated with volar locking plate scored 10+ points greater on the Michigan Hand Questionnaire compared to the less-active group at the 6-week (p = 0.032), 3-month (p = 0.009) and 12-month (0.004) time points, with an effect size larger than 0.50, suggesting pre-injury level of activity had a significant clinical impact. CONCLUSIONS: Higher levels of pre-injury activity are predictive of patient-reported and functional outcomes following distal radius fracture. Because of the greater PROs, the early mobility and lower risk of hardware infection reported in the literature, volar plating is preferable to other treatments for highly active patients who request and meet indications for surgery. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT01589692.

2.
Plast Reconstr Surg ; 145(6): 1541-1551, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32459783

RESUMO

BACKGROUND: Health insurance reimbursement structure has evolved, with patients becoming increasingly responsible for their health care costs through rising out-of-pocket expenses. High levels of cost sharing can lead to delays in access to care, influence treatment decisions, and cause financial distress for patients. METHODS: Patients undergoing the most common outpatient reconstructive plastic surgery operations were identified using Truven MarketScan databases from 2009 to 2017. Total cost of the surgery paid to the insurer and out-of-pocket expenses, including deductible, copayment, and coinsurance, were calculated. Multivariable generalized linear modeling with log link and gamma distribution was used to predict adjusted total and out-of-pocket expenses. All costs were inflation-adjusted to 2017 dollars. RESULTS: The authors evaluated 3,165,913 outpatient plastic and reconstructive surgical procedures between 2009 and 2017. From 2009 to 2017, total costs had a significant increase of 25 percent, and out-of-pocket expenses had a significant increase of 54 percent. Using generalized linear modeling, procedures performed in outpatient hospitals conferred an additional $1999 in total costs (95 percent CI, $1978 to $2020) and $259 in out-of-pocket expenses (95 percent CI, $254 to $264) compared with office procedures. Ambulatory surgical center procedures conferred an additional $1698 in total costs (95 percent CI, $1677 to $1718) and $279 in out-of-pocket expenses (95 percent CI, $273 to $285) compared with office procedures. CONCLUSIONS: For outpatient plastic surgery procedures, out-of-pocket expenses are increasing at a faster rate than total costs, which may have implications for access to care and timing of surgery. Providers should realize the increasing burden of out-of-pocket expenses and the effect of surgical location on patients' costs when possible.

3.
Artigo em Inglês | MEDLINE | ID: mdl-32450214

RESUMO

Despite the use of various factors to measure hospital quality, most measures have not resulted in long-term improvements in patient outcomes. This study's purpose is to determine the effect of a previously unassessed measure of quality of care-a hospital's preventable hospitalization rate-on 30-day mortality at both the hospital and individual levels after three major cardiovascular surgery procedures. This is a population-based study using Taiwan's National Health Insurance database. We retrieved data from 2001-2014 for patients who had undergone abdominal aortic aneurysm (AAA) repair, coronary artery bypass graft (CABG), or aortic valve replacement (AVR). Preventable hospitalizations are hospitalizations for 11 chronic conditions that are considered preventable with effective primary care. The outcome was 30-day surgical mortality. Our dataset contained 65,863 patients who had undergone surgery for one of the three cardiovascular procedures. Preventable hospitalization rate was significantly associated with higher hospital mortality rates for all procedures. At the patient level, the adjusted odds of mortality after AAA repair were increased 55% (p<0.01) for every 2% increase in the preventable hospitalization rate. For CABG, preventable hospitalization was not a significant predictor of mortality, but rather patient factors and surgeon factors were significant. For AVR, the adjusted odds of mortality were increased 7% (p<0.01) for every 1% increase in preventable hospitalization rate. High preventable hospitalization rate may serve as a hospital quality measure that could signal an increased odds of mortality for selected cardiovascular procedures, especially for higher risk-lower volume procedures such as AAA repair and AVR.

4.
Plast Reconstr Surg ; 145(5): 1315-1322, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32332558

RESUMO

Quality improvement efforts at the federal level have instituted both rewards and penalties as incentives to improve health care quality. However, neither of these methods has shown long-lasting improvements. Furthermore, many programs have focused on decreasing mortality or hospital readmissions, measurements that are not applicable to many surgical fields, including plastic surgery. One model that has been shown to be effective is a collaborative quality initiative that uses a pay-for-participation method whereby participants learn from one another and institute changes to improve patient care. Many of these changes are process measures that are easier to implement and quicker to show improvement than structural or outcome measures. Regional collaborative quality initiatives have been developed in other surgical specialties such as bariatric surgery and urology. Currently, the authors are establishing a new collaborative quality initiative for hand surgery: the Michigan Collaborative Hand Initiative for Quality in Surgery. It is a collaboration of nine sites with the goal of identifying areas that are in need of quality improvement in hand surgery and implementing measures to improve on them. The authors believe that collaborative quality initiatives will promote high-quality care and should be incorporated into the field of plastic surgery.

5.
Artigo em Inglês | MEDLINE | ID: mdl-32345936

RESUMO

Outcomes research has historically been driven by single-center investigations. However, multicenter studies represent an opportunity to overcome challenges associated with single-center studies, including generalizability and adequate power. In hand surgery, most clinical trials are single-center studies, with few having randomized controls and blinding of both participants and assessors. This pervasive issue jeopardizes the integrity of evidence-based practice in the field. Because healthcare payers emphasize applying the best available evidence to justify medical services, multicenter research collaborations are increasingly recognized as an avenue for efficiently generating high-quality evidence. Although no study design is perfect, the potential advantages of multicenter trials include generalizability of the results, larger sample sizes, and a collaboration of experienced investigators poised to optimize protocol development and study conduct. As the era of single-center studies shifts toward investment in multicenter trials and clinical registries, investigators will inevitably be faced with the challenges of conducting or contributing to multicenter research collaborations. We present our experiences in conducting multicenter investigations to provide insight into this demanding and rewarding frontier of research.

6.
J Hand Surg Am ; 2020 Mar 31.
Artigo em Inglês | MEDLINE | ID: mdl-32245714

RESUMO

PURPOSE: Accurate financial disclosure is essential to prevent bias in scientific reporting. We aimed (1) to document the extent of industry financial payments to hand surgery literature authors and (2) to uncover discrepancies in author self-declared conflict of interest (COI). METHODS: We screened all scientific and review articles published in 2017 from the American editions of 4 peer-reviewed journals (Journal of Hand Surgery [JHS], Journal of Bone and Joint Surgery [JBJS], Plastic and Reconstructive Surgery [PRS], and Journal of the American Academy of Orthopaedic Surgeons [JAAOS]) to identify authors of hand, wrist, elbow, and peripheral nerve topics. We compared self-reported disclosures with industry-reported payments on the Centers for Medicare and Medicaid Services' Open Payments Database (OPD) for 3 years prior to publication or per journal policy. We individually examined each for relevance of the corporate payer to the article's subject matter. RESULTS: We found 630 eligible authors from 395 articles. The total amount of industry-reported payments over 3 years prior to publication was $24,396,607.80. The median total payments per author per year was $118.40, with interquartile range from $0 to $1,364; 68% of authors received some industry payment; the most common being food and beverage (66% of authors). Senior authors received significantly more industry payments (median, $2,985.67/y) than first and middle authors ($70.27 and $113.17, respectively). Of all authors examined, 58% had undisclosed payments, but only 14% were relevant to the article subject matter. Authors in JAAOS & JBJS, senior authors, and those receiving more than $500,000 from industry were less likely to accurately report all payments. CONCLUSIONS: Industry payments to hand surgery authors were lower than those reported to other orthopedic specialties and tended to be concentrated in a few authors receiving large amounts. Relevant COI disclosure inaccuracies are infrequent within hand surgery literature. Uniform policies of complete disclosure across journals may remove author judgment regarding payment relevance to published material and help eliminate remaining COI errors. Authors may reference the OPD prior to submitting disclosures to prevent potential discrepancies and identify errors within the database. CLINICAL RELEVANCE: Relationships with industry offer opportunities for innovation, education, and research, but overlooking COI self-reporting may erode confidence in the academic integrity of the hand surgery literature.

7.
Hand Clin ; 36(2): 123-129, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32307041

RESUMO

Collaboration with organizations beyond the clinical setting is necessary to identify safety hazards that contribute to the high incidence and severity of hand conditions. Hand surgeons are acutely aware of obstacles patients face while navigating the health care system. Advocacy efforts encourage the development of equitable insurance policies and improve health resource allocation so that hand surgeons can treat a larger patient population. Participation in quality initiatives supports the development of evidence-based clinical guidelines. Further evidence must be generated to ensure that surgeons remain proficient in the latest techniques and uphold high standards of care as hand surgery procedures evolve.

8.
Hand Clin ; 36(2): 131-136, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32307042

RESUMO

Despite the significant investment in scientific investigation to enhance clinical care, the uptake of new interventions and innovations into clinical care and policy remains slow. Understanding and examining the factors that influence the dissemination and implementation of best practices are critical to promote high-quality health care. This review provides an overview of the evidence base in hand surgery, the science that underlies dissemination and innovation, and the emergence of learning health systems in health care.

9.
Hand Clin ; 36(2): 137-144, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32307043

RESUMO

Each step of the evidence-based practice process is critical and requires clear understanding for accurate application. To practice evidence-based care, providers must acquire a specific skillset that facilitates translation of a patient problem into an answerable research question. Additional requirements are understanding of electronic databases, critical appraisal of the available evidence, and integration of the findings to generate a specific, individualized treatment plan. Although this process is demanding, evidence-based practice is essential in the delivery of optimal patient care.

10.
Hand Clin ; 36(2): 145-153, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32307044

RESUMO

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

11.
Hand Clin ; 36(2): 205-213, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32307051

RESUMO

Hand therapy is a time-sensitive and essential postoperative service for patients undergoing reparative or corrective procedures in the hand and plays an important role in achieving best functional outcomes. In the United States, therapy is an independent service from a payer's standpoint. Access is affected by global and distinct factors in health care. This article presents views on certain aspects of health care that aide in and those that impede access to hand therapy for patients in the United States, and concludes with a brief glimpse into some ongoing efforts to improve access for patients.

12.
Hand Clin ; 36(2): 221-229, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32307053

RESUMO

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

13.
Hand Clin ; 36(2): 231-243, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32307054

RESUMO

Health services research using secondary data is a powerful tool for guiding quality/performance measure development, payment reform, and health policy. Patient preferences, physical examination findings, use of postoperative care, and other factors specific to hand surgery research are critical pieces of information required to study quality of care and improve patient outcomes. These data often are missing from data sets, causing limitations and challenges when performing secondary data analyses in hand surgery. As the role of secondary data in surgical research expands, hand surgeons must apply novel strategies and become involved in collaborative initiatives to overcome the limitations of existing resources.

14.
Hand Clin ; 36(2): xi, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32307059
16.
Plast Reconstr Surg ; 145(4): 855e-864e, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32221241

RESUMO

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

17.
Plast Reconstr Surg ; 145(6): 1054e-1066e, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32195857

RESUMO

BACKGROUND: Optimal treatment for distal radius fractures in older adults remains uncertain. No randomized trials comparing the most frequently used treatments in this population have been conducted. Surgical treatment rates vary widely, and the sustained benefits of surgery are uncertain. METHODS: The Wrist and Radius Injury Surgical Trial, a randomized, multicenter trial, enrolled 304 adults aged 60 years and older with isolated, unstable distal radius fractures at 24 institutions. Patients who wanted surgery (n = 187) were randomized to internal fixation, external fixation, or percutaneous pinning; patients who preferred conservative management (n = 117) received casting. The primary outcome was the 12-month Michigan Hand Outcomes Questionnaire (MHQ) summary score. RESULTS: At 12 months, there were no differences by treatment in primary outcome. Twelve-month MHQ summary scores differed between internal fixation and external fixation by 3 points (97.5 percent CI, 6.0 to 11.5) and between internal fixation and pinning by -0.14 (97.5 percent CI, -9.2 to 8.9). However, at 6 weeks, the mean MHQ summary score for internal fixation was greater than for external fixation by 19 (p < 0.001), pinning by 11 (p < 0.001), and casting by 7 (p = 0.03). Internal fixation participants demonstrated significantly better radiologic alignment throughout the follow-up period. Malunion was experienced by 48 percent of casting participants. CONCLUSIONS: Recovery was fastest for internal fixation and slowest for external fixation according to most measures, but by 12 months there were no meaningful differences in outcomes. Casting participants experienced satisfactory results despite loss of radiologic alignment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

18.
Hand (N Y) ; : 1558944720906503, 2020 Feb 23.
Artigo em Inglês | MEDLINE | ID: mdl-32088982

RESUMO

Background: Patients are increasingly responsible for direct medical expenditures with a growth in out-of-pocket (OOP) expenses, which can impede access to care and affect treatment. This study aims to investigate the impact of capitation on OOP expenses for surgical and presurgical treatment for thumb carpometacarpal (CMC) joint arthritis. Methods: Patients with a diagnosis of thumb CMC arthritis who underwent surgery (2009-2016) comprised our study cohort. Sociodemographic data, total cost, and OOP expenses were collected at the time of surgery and 2 years prior. Patients were stratified by insurance type: fee-for-service (FFS), managed care (MC), Medicare-MC, and Medicare-FFS. Capitated plans were included in the MC and Medicare-MC groups. A generalized linear regression was performed to investigate the association between OOP expenses and insurance type. Results: Our cohort consisted of 7780 patients with FFS insurance, 953 with MC insurance, 2136 with Medicare-FFS, and 265 with Medicare-MC. There was no difference in total costs for FFS and MC (FFS $7281 vs. MC $7306, P = .73; Medicare-FFS $6663 vs. Medicare-MC $6183, P = .19). However, patients with FFS incurred significantly greater OOP costs (FFS $952 vs. MC $434, P < .01; Medicare-FFS $343 vs. Medicare-MC $232, P < .01). In the adjusted regression, MC, Medicare-FFS, and Medicare-MC had approximately 21% to 46% of the predicted OOP expenses of patients with FFS plans (P < .01). Conclusion: Despite similar total costs, OOP expenses were significantly greater for patients with FFS or Medicare-FFS insurance. With healthcare costs transitioning to patients, providers should consider cost sharing when conferring care to help alleviate the financial burden placed on patients.

19.
Plast Reconstr Surg ; 145(3): 746-754, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32097319

RESUMO

Research bias, or the systematic errors of a study, can arise before, during, or after a trial ends. These biases hinder the internal validity of the study, which is the accuracy of a study's conclusions regarding the effects of an intervention on a given group of subjects. With the growing use of evidence-based medicine, there is a demand for high-quality evidence from the research community. Systematic reviews and meta-analyses of randomized controlled trials are considered the highest level of evidence, followed by individual randomized controlled trials. However, most surgical trials cannot be conducted as randomized controlled trials because of factors such as patient preferences and lack of equipoise among surgeons. Therefore, surgical trials may lack features that are held as important standards for high-quality evidence, such as randomization and blinding. To demonstrate the biases that surgical trials may encounter, the authors examined a prospective cohort study, the Silicone Arthroplasty in Rheumatoid Arthritis study. The authors focus on the challenges that arise during a surgical trial, including the design, implementation, and methods used to report the clinical evidence. By recognizing and addressing obstacles that exist in research, investigators will provide health care providers with high-quality evidence needed to make well-informed, evidence-based clinical decisions.

20.
JAMA Netw Open ; 3(2): e1921626, 2020 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-32083690

RESUMO

Importance: Optimal treatment for traumatic finger amputation is unknown to date. Objective: To use statistical learning methods to estimate evidence-based treatment assignment rules to enhance long-term functional and patient-reported outcomes in patients after traumatic amputation of fingers distal to the metacarpophalangeal joint. Design, Setting, and Participants: This decision analytical model used data from a retrospective cohort study of 338 consenting adult patients who underwent revision amputation or replantation at 19 centers in the United States and Asia from August 1, 2016, to April 12, 2018. Of those, data on 185 patients were included in the primary analysis. Exposures: Treatment with revision amputation or replantation. Main Outcomes and Measures: Outcome measures were hand strength, dexterity, hand-related quality of life, and pain. A tree-based statistical learning method was used to derive clinical decision rules for treatment of traumatic finger amputation. Results: Among 185 study participants (mean [SD] age, 45 [16] years; 156 [84%] male), the median number of fingers amputated per patient was 1 (range, 1-5); 115 amputations (62%) were distal to the proximal interphalangeal joint, and 110 (60%) affected the nondominant hand. On the basis of the tree-based statistical learning estimates, to maximize hand dexterity or to minimize patient-reported pain, replantation was found to be the best strategy. To maximize hand strength, revision amputation was the best strategy for patients with a single-finger amputation but replantation was preferred for all other injury patterns. To maximize patient-reported quality of life, revision amputation was the best approach for patients with dominant hand injuries, and replantation was the best strategy for patients with nondominant hand injuries. Conclusions and Relevance: The findings suggest that the approach to treating traumatic finger amputations varies based on the patient's injury characteristics and functional needs.

SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA