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Nulty S, Fore J, Madison J, Day CS. Revenue Generation and Follow-up for a Hand Trauma Program for Emergency Department Patients in an Inner-City Metropolitan Area. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202311000-00014. [PMID: 37976438 PMCID: PMC10659688 DOI: 10.5435/jaaosglobal-d-23-00173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 09/03/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Although hand trauma care has proved to be profitable, loss of trauma patients from a system may lead to revenue loss. Our study aimed to (1) elucidate the economic effect of hand trauma programs, (2) quantify the potential fiscal effect of loss of follow-up, and (3) determine factors contributing to leakage of patients from the healthcare system. METHODS Revenue data were retrospectively extracted for all adult hand trauma patients within a multicenter healthcare system from 2014 to 2018. Demographic and encounter factors were analyzed using Wilcoxon rank-sum test for differences in continuous variables, Pearson chi square test for categorical variables, and odds ratios. A follow-up model was created using logistic regression. RESULTS A total of 56,995 (31% new, 69% established) hand trauma encounters were recorded. Follow-up was markedly affected by many factors, including new vs. established patients. Of the 17,748 new patients, 8638 (48.6%) returned for subsequent care, generating $34M. The patients who did not return may have lost $176M for the system. CONCLUSIONS Many factors lead to loss of follow-up. Understanding these factors can help target efforts to minimize leakage of hand trauma patients. Hand trauma introduces new patients to hospitals, generating notable revenue. Leakage of hand trauma patients has substantial revenue losses.
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Kohan J, Mangan J, Patel A. Access to Reconstructive Hand Surgery in the United States-Investigating the Obstacles: A Scoping Review. Hand (N Y) 2023; 18:721-731. [PMID: 36317809 PMCID: PMC10336803 DOI: 10.1177/15589447221131853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND Mechanisms that affect access to surgical hand care appear to be complex and multifaceted. This scoping review aims to investigate the available literature describing such mechanisms and provide direction for future investigation. METHODS The methodological framework outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews was used to guide this review. In November 2021, MEDLINE and EMBASE databases were searched. A narrative summary of the characteristics and key findings of each paper is used to present the data to facilitate the integration of diverse evidence. RESULTS Of 471 initial studies, 49 were included in our final analysis. Of these, 33% were cohort studies; 27% reported that underinsured patients are less likely to get an appointment with a hand specialist or to receive treatment. Overburdened emergency departments accounted for the second-most reported reason (16%) for diminished access to surgical hand care. Elective procedure financial incentives, poor emergency surgical hand coverage, distance to treatment, race, and policy were also notably reported across the literature. CONCLUSIONS This study describes the vast mechanisms that hinder access to surgical hand care and highlights their complexity. Possible solutions and policy changes that may help improve access have been described.
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Affiliation(s)
- Joshua Kohan
- The University of Vermont Robert Larner College of Medicine, Burlington, USA
| | - Jack Mangan
- The University of Vermont Robert Larner College of Medicine, Burlington, USA
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Tuaño KR, Fisher MH, Woodall J, Iorio ML. Plastic Surgery Training: Trends in Hand Surgery Fellowship in the Setting of a Pandemic. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5066. [PMID: 37342304 PMCID: PMC10278718 DOI: 10.1097/gox.0000000000005066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 04/26/2023] [Indexed: 06/22/2023]
Abstract
Given the diminishing presence of hand surgeons trained in plastic surgery, we evaluated the associated trends in annual hand meeting educational content and postgraduate job offerings, and analyzed the effect of the coronavirus disease 2019 (COVID-19) pandemic on trainees in hand surgery. Methods Hand meeting registration and educational content were analyzed over the past 10 years. Current hand surgery job offerings were evaluated for training requirements, and the annual rates of subspecialty certificate in surgery of the hand board certifications were compared across training backgrounds. Results Top categories of annual meeting educational content were "bone/joint," "other," and "professional development." A majority of American Society for Surgery of the Hand presidents had training backgrounds in orthopedics (55%), followed by plastics (23%) and general surgery (22%). The job offerings on the American Society for Surgery of the Hand and Association for Surgery of the Hand websites specified more training requirements in orthopedics than in plastics. Additionally, there were two to three times as many examinees taking the surgery of the hand examination from orthopedic surgery compared with plastics, with an overall higher pass rate. Hand fellowship programs were also predominantly offered for orthopedic surgery (80.8%). Conclusions Optimization of training, society membership, and clinical practice profiles may increase the presence of plastic surgery-trained hand surgeons. The extent of the economic impact of the COVID-19 pandemic is yet to be fully determined, but our analysis suggests that a lucrative market for reconstructive/hand surgery may exist in the face of economic downturn.
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Affiliation(s)
- Krystle R. Tuaño
- From the Division of Plastic and Reconstructive Surgery, University of Colorado, Department of Surgery, Anschutz Medical Center, Aurora, Col
| | - Marlie H. Fisher
- From the Division of Plastic and Reconstructive Surgery, University of Colorado, Department of Surgery, Anschutz Medical Center, Aurora, Col
| | - Jhade Woodall
- From the Division of Plastic and Reconstructive Surgery, University of Colorado, Department of Surgery, Anschutz Medical Center, Aurora, Col
| | - Matthew L. Iorio
- From the Division of Plastic and Reconstructive Surgery, University of Colorado, Department of Surgery, Anschutz Medical Center, Aurora, Col
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Chen H, Sui S, Yang L, Sha X, Wang C, Tao W, Yu X. Study on the influence and countermeasures of high-quality nursing in controlling wound infection in emergency treatment of hand trauma. Minerva Surg 2022; 77:612-614. [PMID: 34889554 DOI: 10.23736/s2724-5691.21.09178-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Hongmei Chen
- Department of Emergency, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Sheng Sui
- Department of Nursing, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Liping Yang
- Department of Emergency, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Xiaomei Sha
- Department of Emergency, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Chao Wang
- Department of Emergency, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Wei Tao
- Department of Emergency, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Xianqiu Yu
- Department of Hematology, Affiliated Hospital of Jiangsu University, Zhenjiang, China -
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Stankowski TJ, Schumacher JR, Hanlon BM, Tucholka JL, Venkatesh M, Yang DY, Poore SO, Neuman HB. Barriers to breast reconstruction for socioeconomically disadvantaged women. Breast Cancer Res Treat 2022; 195:413-419. [PMID: 35969284 PMCID: PMC9639139 DOI: 10.1007/s10549-022-06697-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 07/27/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Socioeconomic disparities in post-mastectomy breast reconstruction exist. Key informants have suggested that finding providers who accept Medicaid insurance and longer travel time to a plastic surgeon are important barriers. Our objective was to assess the relationship between these factors and reconstruction for socioeconomically disadvantaged women in Wisconsin. METHODS We identified women < 75 years of age with stage 0-III breast cancer who underwent mastectomy using the Wisconsin Cancer Reporting System. Women in the most disadvantaged state-based tertile of the Area Deprivation Index were included (n = 1809). Geocoding determined turn-by-turn drive time from women's address to the nearest accredited Commission on Cancer or National Accreditation Program for Breast Centers. Multivariable logistic regression determined the relationship between reconstruction, Medicaid, and travel time, controlling for patient factors known to impact reconstruction. Average adjusted predicted probabilities of receiving reconstruction were calculated. RESULTS Most patients had early-stage breast cancer (51% stage 0/I) and 15.2% had Medicaid. 37% of women underwent reconstruction. Socioeconomically disadvantaged women with Medicaid (OR = 0.62, 95% CI 0.46-0.84) and longer travel times (OR = 0.99, 95% CI 0.99-1.0) were less likely to receive reconstruction. Patients with the lowest predicted probability of reconstruction were those with Medicaid who lived furthest from a plastic surgeon. CONCLUSION Among socioeconomically disadvantaged women, Medicaid and travel remained associated with lower rates of reconstruction. Further work will explore opportunities to improve access to reconstruction for women with Medicaid. This is particularly challenging as it may require socioeconomically disadvantaged women to travel further to receive care.
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Affiliation(s)
- Trista J Stankowski
- School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, W 53792, USA
| | - Jessica R Schumacher
- School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, W 53792, USA
- University of Wisconsin Carbone Cancer Center, Madison, USA
| | - Bret M Hanlon
- School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, W 53792, USA
| | - Jennifer L Tucholka
- School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, W 53792, USA
| | - Manasa Venkatesh
- School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, W 53792, USA
| | - Dou-Yan Yang
- School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, W 53792, USA
| | - Samuel O Poore
- School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, W 53792, USA
| | - Heather B Neuman
- School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, W 53792, USA.
- University of Wisconsin Carbone Cancer Center, Madison, USA.
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Providing Gender Confirmation Surgery at an Academic Medical Center: Analysis of Use, Insurance Payer, and Fiscal Impact. J Am Coll Surg 2019; 229:479-486. [PMID: 31326537 DOI: 10.1016/j.jamcollsurg.2019.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 06/25/2019] [Accepted: 07/01/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Expansion of insurance coverage for gender confirmation surgery (GCS) has led to a large demand for GCS in the US. We sought to determine the financial impact of providing comprehensive GCS services at an academic medical center. METHODS This was a cross-sectional study of patients older than 18 years who presented for GCS between January 1, 2015 and July 31, 2018 at a single academic medical center. The use of GCS services and associated work relative value units is reported. Departmental and hospital-level operating (profit) margins are reported relative to other hospital services, as well as the payer mix. RESULTS A total of 818 patients underwent 970 GCS procedures between January 2015 and July 2018. Mean (SD) age was 35.32 (12.84) years. Four hundred and ninety-three (60.3%) patients underwent a masculinizing procedure, and 325 (39.7%) had a feminizing procedure. The most commonly performed procedure was chest masculinization (n = 403). The GCS case volume grew to generate 23.8% (plastic surgery) and 17.8% (urology) of total annual departmental work relative value units, and was associated with positive operating margins after recouping new faculty hiring costs. There were positive operating margins for GCS procedures for the hospital system that compare favorably with other common procedures and admissions. Medicare and Medicaid remained the most common payer throughout the study period, but dropped from 70% in 2015 to 48% in 2018. CONCLUSIONS We found that providing GCS at our academic medical center is profitable for both the surgical department and the hospital system. This suggests such a program can be a favorable addition to academic medical centers in the US.
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Abstract
BACKGROUND Economic conditions affect surgical volumes, particularly for elective procedures. In this study, the authors aimed to identify the effects of the 2008 U.S. economic downturn on hand surgery volumes to guide surgeons and managers when facing future economic crises. METHODS The authors used the California State Ambulatory Surgery and Services Database from January of 2005 to December of 2011, which includes the entire period of the Great Recession (December of 2007 to June of 2009). The authors abstracted the monthly volume of five common hand procedures using International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes. Pearson statistics were used to identify the correlation between unemployment rate and surgical volume for each procedure. RESULTS The total number of operative cases was 345,583 during the 7-year study period. Most common elective hand procedures, such as carpal tunnel release and trigger finger release, had a negative correlation with unemployment rate, but the volume of distal radius fracture surgery did not show any correlation. Compared with carpal tunnel release (r = -0.88) or trigger finger release volumes (r = -0.85), thumb arthroplasty/arthrodesis volumes (r = -0.45) showed only a moderate correlation. CONCLUSIONS The economic downturn decreased elective hand procedure surgical volumes. This may be detrimental to small surgical practices that rely on revenue from elective procedures. Taking advantage of the principle that increased volume reduces unit cost may mitigate the lost revenue from these elective procedures. In addition, consolidating hand surgery services at larger, regional centers may reduce the effect of the economic environment on individual hand surgeons.
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Siotos C, Ibrahim Z, Bai J, Payne R, Seal S, Lifchez S, Hyder A. Hand injuries in low- and middle-income countries: systematic review of existing literature and call for greater attention. Public Health 2018; 162:135-146. [DOI: 10.1016/j.puhe.2018.05.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 04/21/2018] [Accepted: 05/15/2018] [Indexed: 11/16/2022]
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Effects of the Affordable Care Act on Payer Mix and Physician Reimbursement in Hand Surgery. J Hand Surg Am 2018; 43:511-515. [PMID: 29602658 DOI: 10.1016/j.jhsa.2018.02.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 01/22/2018] [Accepted: 02/21/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the effect of the Affordable Care Act (ACA) on the payer distribution and reimbursement rate for hand surgery at our institution. METHODS We reviewed records of 4,257 patients who underwent hand surgery at our institution between January 2008 and June 2016; 2,601 patients underwent surgery before the implementation of the ACA, and 1,656 patients after. Type of procedure, insurance status, amount of money billed, and amount collected were recorded. RESULTS After the implementation of the ACA, we performed fewer metacarpal fracture repairs, distal radius fracture repairs, and abscess incision and drainage procedures. We performed more endoscopic carpal tunnel releases. The proportion of uninsured patients decreased significantly (15% to 6.4%), and the proportion of patients on Medicare (15.4% to 20.3%) and Medicaid (9.5% to 17.8%) increased significantly. The overall reimbursement rate did not change significantly (32.3% to 30.3%) between the 2 time periods. CONCLUSIONS After the implementation of the ACA, we observed a significant reduction in the number of uninsured patients and an increase in Medicaid and Medicare patients. However, this led to no significant change in reimbursement rates. TYPE OF STUDY/LEVEL OF EVIDENCE Economic and design analysis II.
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Epstein S, Tran BN, Cohen JB, Lin SJ, Singhal D, Lee BT. Racial disparities in postmastectomy breast reconstruction: National trends in utilization from 2005 to 2014. Cancer 2018; 124:2774-2784. [DOI: 10.1002/cncr.31395] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 02/19/2018] [Accepted: 03/09/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Sherise Epstein
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
- Harvard T. H. Chan School of Public Health; Harvard Medical School; Boston Massachusetts
| | - Bao N. Tran
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Justin B. Cohen
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Samuel J. Lin
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Dhruv Singhal
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Bernard T. Lee
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
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Abstract
BACKGROUND Hand conditions commonly present to the emergency department (ED), yet data are lacking regarding the magnitude of hand-related conditions in the emergency setting. The purpose of this study is to describe the burden and quantify the health care resource utilization of hand conditions seen in EDs across the United States. METHODS Using the National Emergency Department Sample, we identified all ED encounters by patients at least 18 years of age that were associated with a hand condition in 2009 to 2012. The primary outcomes were prevalence, etiology, and associated health care charges for specific categories of hand conditions. RESULTS The final sample included 34.4 million ED encounters associated with a common hand condition generating $180.4 billion in health care charges. The volume of hand-related presentations varied in a predictable and cyclical manner, peaking in July and waning in December of each year. Trauma was the most common etiology (77.5%) predominantly due to falls (26.2%) and lacerations (19.7%). Over 4 years, the volume of ED encounters rose (5% increase, P < .001) and as did the resulting health care charges (24.6% increase, P < .001). CONCLUSIONS Our study confirms that hand-related conditions contribute significantly to ED volume and consume a growing quantity of health care resources in the United States. The volume of patients presenting to EDs with hand-related conditions fluctuates cyclically throughout the year. Open wounds are the most common cause of presentation and mostly occur in young adults, followed by joint pain, contusions, and fractures.
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Affiliation(s)
- David L. Colen
- Hospital of the University of Pennsylvania, Division of Plastic and Reconstructive Surgery, Philadelphia, USA,David L. Colen, Hospital of the University of Pennsylvania, Division of Plastic and Reconstructive Surgery, Perelman Center for Advanced Medicine, South Pavilion-14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Justin P. Fox
- Hospital of the University of Pennsylvania, Division of Plastic and Reconstructive Surgery, Philadelphia, USA
| | - Benjamin Chang
- Hospital of the University of Pennsylvania, Division of Plastic and Reconstructive Surgery, Philadelphia, USA
| | - Ines C. Lin
- Hospital of the University of Pennsylvania, Division of Plastic and Reconstructive Surgery, Philadelphia, USA
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Sundet A, Ipaktchi K, Kunrath C, Banegas RN. Management of the Pediatric Patient Following Upper Extremity Replantation or Revascularization: A Suggested Protocol. J Hand Surg Asian Pac Vol 2017; 22:479-483. [PMID: 29117833 DOI: 10.1142/s0218810417500538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Traumatic pediatric amputations of the hand and upper extremity can have long-term financial, psychological, developmental, and functional consequences that readily extend beyond the realm of that which is normally encountered in comparatively injured adults. These factors, along with a paucity of medical comorbidities, have guided a more liberal and aggressive approach to treating pediatric amputations in hopes of optimizing psychosocial, aesthetic, and developmental outcomes. Furthermore, advances in pharmacology and microsurgical replantation techniques have allowed what were otherwise exceedingly rare surgeries to become commonplace in hospitals all over the world. Despite these gains, vascular thrombosis remains the leading cause of failure in microvascular surgeries. A recent survey showed that 96% of reconstructive surgeons use some form of anticoagulation therapy in their treatment, but no consensus regarding pharmacologic agents, dosing, or efficacy exists. The risk of thrombosis is further complicated by the dynamic nature of vasculature in response to stressors such as sympathetic tone, decreased intravascular volume, and response to external temperature. Given the lack of a higher-level evidence to guide the replantation surgeon in postoperative orders, we created an inclusive protocol, outlining complete and proper management of the pediatric patient following revascularization or replantation surgery. METHODS We reviewed the methods employed by our microvascular surgeons and consulted with board-certified pediatricians to produce a final document that was adopted ubiquitously among our providers. RESULTS We do not have head-to-head data demonstrating improved outcomes with use of the protocol. Nonetheless, the original document has been modified and reproduced here for your consideration and use. CONCLUSIONS Since initiating the protocol, we feel it has helped standardize our practice, avoid instances of incomplete or missed order sets, and facilitate interdisciplinary management through decreased gaps in communication, especially in those surgeries terminating in the middle of the night.
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Affiliation(s)
- Alec Sundet
- * Department of Orthopedics, University of Colorado School of Medicine, Denver Health Medical Center, USA
| | - Kyros Ipaktchi
- * Department of Orthopedics, University of Colorado School of Medicine, Denver Health Medical Center, USA.,† Division of Hand and Microvascular Surgery, Denver Health Medical Center, USA
| | - Claudia Kunrath
- ‡ Department of Pediatrics, University of Colorado School of Medicine, Denver Health Medical Center, USA
| | - Rodrigo N Banegas
- * Department of Orthopedics, University of Colorado School of Medicine, Denver Health Medical Center, USA.,† Division of Hand and Microvascular Surgery, Denver Health Medical Center, USA
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Procedural Portfolio Planning in Plastic Surgery, Part 1: Strategic Changes in Clinical Practice to Increase Physician Revenue, Improve Operative Throughput, and Maintain Patient Satisfaction. Ann Plast Surg 2017; 76 Suppl 4:S344-6. [PMID: 27187253 DOI: 10.1097/sap.0000000000000772] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Portfolio planning in health care represents the strategic prioritization of services that permits an organization to better achieve its goals of margin and mission. Because of recent volatility in the economy, declining reimbursement, and rising costs of providing care, such strategic planning has become increasingly important if physicians want to remain leaders in health care. This project assesses the financial impact of procedural portfolio planning on an academic plastic surgery practice from the physician's perspective. METHODS We tracked the top 50 procedures, defined as total charges per CPT code, that were performed in our baseline year, for 6 providers in a stable plastic surgery practice. At the end of the first year, we implemented 3 types of strategic changes: growth of areas with high contribution margin (laser resurfacing of burn scars), curtailment of high-risk procedures with negative contribution margin (panniculectomy in smokers), and improved efficiency of mission-critical services with high resource consumption (free-flap breast reconstruction). During the 2-year study period, we had no turnover in faculty, did not pursue any formal marketing, did not change our surgical fees or billing system, provided care independent of payer mix, and maintained our commitment to indigent care. Outcome measures included procedural charges and revenue, collection rates, work relative value units, operating room times, idle times (room time less case time), receipts/minute in operating room, uncompensated charity care, and patient satisfaction (Press-Gainey scores). Before the study period, annual incremental growth in our practice was 1% to 2%, in terms of charges and receipts. RESULTS After implementation of the portfolio planning project, the financial position of our division improved significantly, with patient satisfaction rates increasing from 85.5% to 94.1% and charity care remaining constant at US $400,000 per year. Encounters, work relative value units, charges, and receipts all increased by 16% to 27%, with receipts/minute increasing from US $5.60 per minute to US $7.28 per minute. Interestingly, but not surprisingly, highest margin cases did not correspond with highest volume or highest revenue cases; portfolio analysis helped us to align these parameters, without sacrificing patient satisfaction or commitment to indigent care. The highest receipt/minute procedure was laser ablation of vascular lesions (US $23.87), whereas one of the lowest receipt/minute cases was muscle free flap (US $3.07). CONCLUSIONS Procedural portfolio analysis is a powerful tool that can guide strategy and positively impact the financial position and clinical value of the services provided by an academic plastic surgery practice. Identifying high margin procedures allows the surgeon to focus marketing efforts, target areas of future growth, and optimize the blend of margin and mission.
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The Effect of Medicaid Expansion on Delivery of Finger and Thumb Replantation Care to Medicaid Beneficiaries and the Uninsured. Plast Reconstr Surg 2016; 136:640e-647e. [PMID: 26505721 DOI: 10.1097/prs.0000000000001697] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Despite advances in replantation, over 80 percent of finger and thumb amputation injuries in the United States result in revision amputation. Although numerous factors contribute to this, disparities in access and delivery of replantation care play a substantial role. With ongoing Medicaid expansion under the Affordable Care Act, it is prudent to understand whether expansion of coverage changes use of replantation care. METHODS The authors used the 2001 Medicaid expansion in New York State to evaluate changes in replantation for Medicaid beneficiaries and the uninsured. Data for patients having undergone replantation between 1998 and 2006 were obtained from the New York State Inpatient Database. The authors used an interrupted time series to evaluate the effect of Medicaid expansion on the probability that Medicaid beneficiaries or uninsured patients underwent replantation. Census data were used for population-adjusted case volume analysis. RESULTS After expansion, the likelihood of Medicaid as the primary payer for replantation increased 0.0059 percent per quarter, reaching a 1.7 percent increase 5 years after expansion. With population-based analysis, this indicates that Medicaid covered 12 additional replantation cases in New York State annually. After expansion, 11 fewer of the replantation cases in New York State each year were provided to patients without health care coverage. CONCLUSIONS Medicaid expansion resulted in a modest but significant increase in replantation for Medicaid beneficiaries. In addition, fewer patients that underwent replantation remained uninsured. Considering the substantial cost and effort burden of replantation, these findings support the benefits of Medicaid expansion on delivery and payer coverage of replantation.
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Sears ED, Chung KC. Future education and practice initiatives in hand surgery: improving fulfillment of patient needs. Hand Clin 2014; 30:377-86, vii-viii. [PMID: 25066857 DOI: 10.1016/j.hcl.2014.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In the current health care environment, there are several areas in the delivery of health care to patients having hand surgery that need improvement to adequately fulfill patient needs, including difficulty in maintaining adequate emergency call coverage for patients having hand surgery, decreasing trends in hand surgeons willing to perform microsurgery and replantation, and deficiencies in musculoskeletal education of non-hand surgery providers. Both educational reforms and reforms in the practice environment are needed to improve the ability of hand surgeons to fulfill patient needs in the future.
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Affiliation(s)
- Erika D Sears
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System, 2130 Taubman Center, SPC 5340, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5340, USA.
| | - Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System, 2130 Taubman Center, SPC 5340, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5340, USA
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Sebastin SJ, Chung KC. Challenges in measuring outcomes following digital replantation. Semin Plast Surg 2014; 27:174-81. [PMID: 24872766 DOI: 10.1055/s-0033-1360584] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In the early period of replantation surgery, the emphasis was on digit survival. Subsequently, with better microsurgical techniques and instrumentation, the focus has shifted to function and in recent years to consideration of cost-effectiveness. Despite over 40 years of effort in refining digital replantation surgery, a rigorous evaluation of the outcomes of digital replantation has not been performed. This is because of the many confounding variables that influence outcome comparisons. These variables include the mechanism of injury (guillotine, crush, avulsion), the injury itself (total, near total, subtotal, partial amputation), and the surgical procedure (replantation, revascularization). In addition, the traditional outcome measures (two-point discrimination, range of motion, grip strength, or the ability to return to work) are reported inconsistently and vary widely among publications. All these factors make meaningful comparison of outcomes difficult. The recent emphasis on outcome research and cost-effectiveness necessitates a rethinking in the way we report outcomes of digital replantation. In this article, the authors summarize the challenges in assessing outcomes of digital replantation and explain the need to measure outcomes using rigorous clinical research designs that incorporate cost-effectiveness studies in the research protocol.
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Affiliation(s)
- Sandeep J Sebastin
- Department of Hand and Reconstructive Microsurgery, National University Health System, Singapore
| | - Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System; Ann Arbor, Michigan
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Factors Associated with Transfer of Hand Injuries to a Level 1 Trauma Center. Plast Reconstr Surg 2014; 133:842-848. [DOI: 10.1097/prs.0000000000000017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Therapists in the United Kingdom and worldwide have for many years ventured into extended scope roles taking on increasing degrees of responsibility for the development and continuation of new clinical services. With a solid background of training and education in anatomy, diagnosis and assessment, therapists are well placed to effectively perform such roles. This paper looks at the development of a new therapy-led clinic at an acute hospital trust in Manchester, UK, which successfully achieved its aim of establishing an improved pathway for closed hand trauma patient care.
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Affiliation(s)
- Fiona H Peck
- Wythenshawe Hospital, University Hospital of South Manchester, Manchester, UK
| | - Sarah Turner
- Wythenshawe Hospital, University Hospital of South Manchester, Manchester, UK
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Costs and outcome for serious hand and arm injuries during the first year after trauma - a prospective study. BMC Public Health 2013; 13:501. [PMID: 23706070 PMCID: PMC3681586 DOI: 10.1186/1471-2458-13-501] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 05/17/2013] [Indexed: 01/14/2023] Open
Abstract
Background To study costs and outcome for serious hand and arm injuries during the first year after the trauma. Methods In patients with a Hand Injury Severity Score (HISS) > 50, DASH and EQ-5D scores as well as factors related to costs within the health care sector, costs due to lost production and total costs were evaluated. Cox-regression analysis stratifying for mechanism of injury was used to analyse return to work. Results The majority of the 45 included patients (median 42 years 16–64) were men with severe (n = 9) or major (n = 36) injuries with different type of injuries (amputations n = 13; complex injuries n = 18; major nerve injuries/full house n = 13; burn injury n = 1). DASH and EQ-5D decreased and increased, respectively, significantly over time during one year. Total costs (+34%) and costs of lost production were highest for persons injured at work. Factors associated with higher health care costs were age >50 years (+52%), injury at work (+40%) and partial labour market activity (+66%). Costs of lost production had a significant role in total costs of injury. Patients with major injuries had longer duration of sick leave. Patients with severe injuries were more likely to return to work [(RR 3.76 (95% CI 1.38-10.22) from Cox regression, controlling for age, gender and presence of nerve injury]. Conclusions Despite the fact that work environments have constantly improved over the last decades, we found that hand injuries at work were most costly both in terms of health care and costs of lost production, although the severity, i.e. HISS, did not differ from injuries occurring at home or during leisure.
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Hartzell TL, Kuo P, Eberlin KR, Winograd JM, Day CS. The overutilization of resources in patients with acute upper extremity trauma and infection. J Hand Surg Am 2013; 38:766-73. [PMID: 23395105 DOI: 10.1016/j.jhsa.2012.12.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 12/12/2012] [Accepted: 12/12/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare patients with acute upper extremity injuries and infections presenting initially to the emergency department with patients transferred from outside institutions, and to evaluate triage guidelines for the appropriate transfer of these patients. METHODS We reviewed the records of 1,172 consecutive patients with acute upper extremity injuries or infections presenting to 2 level 1 trauma centers over 3-month periods. We analyzed demographics, transfer details, injury characteristics, intervention received, follow-up, and complications. Triage guidelines were established by a board of academic upper extremity and emergency physicians and retrospectively applied to patient data. RESULTS Of 1,172 patients, 155 (13%) arrived via transfer from outside facilities. Transferred patients had more complex injuries by our guidelines, but many did not require level 1 emergent care. The receiving emergency department discharged 26% of the transferred patients without upper extremity specialist evaluation, and 24% of the transferred patients received no procedural intervention at any point. Only 10% went to the operating room emergently. Implementing our guidelines for appropriate triage, we found that 53% of transfers did not require emergent transfer to a level 1 facility. These nonemergent transfers spent an average of 15.2 hours from the time of initial evaluation at the outside facility to discharge from the level 1 emergency department, compared with 3.1 hours in patients who arrived primarily. Retrospectively, our triage guidelines had a 2% undertriage rate and a 3% overtriage rate. CONCLUSIONS Over half of the patients transferred with upper extremity injuries and infections for specialized evaluation may be transferred unnecessarily. Guidelines for the care and transfer of patients with acute upper extremity injuries or infections may lead to better use of resources. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic III.
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Hand education for emergency medicine residents: results of a pilot program. J Hand Surg Am 2012; 37:1245-8.e12. [PMID: 22554611 DOI: 10.1016/j.jhsa.2012.03.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 03/10/2012] [Accepted: 03/13/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE Multiple studies have demonstrated the lack of knowledge of hand anatomy and pathology among those who first see patients with hand disorders. The goal of this study was to determine whether a hand surgery rotation for emergency medicine residents would improve this group's knowledge of the hand and its disorders as assessed at the end of their residency training. METHODS Seven postgraduate year (PGY) 2 emergency medicine residents completed a 4-week hand surgery rotation. Hand knowledge was assessed at the start, at the end, and 1 year after this rotation (end of PGY 3). Knowledge of a control group of 7 PGY 3 emergency medicine residents who did not have this rotation was also assessed. RESULTS Hand knowledge in the residents who completed the rotation was significantly improved. This was true for overall test performance (88% vs 70% correct responses), as well as for each of the anatomy and function (89% vs 57%), diagnosis (96% vs 86%), and treatment (79% vs 51%) categories. Overall test performance (78% vs 66%) and anatomy and function category performance (75% vs 43%) were significantly better at the end of PGY 3 for the residents who completed the rotation as compared to the control residents. CONCLUSIONS A hand surgery rotation during an emergency medicine residency program improved the knowledge of hand anatomy and disorders. This knowledge was retained 1 year later and was greater than the knowledge of matched emergency medicine residents who did not have this rotation. Better knowledge of hand anatomy and disorders among emergency physicians might improve their ability to initially evaluate and treat patients with these conditions. Such knowledge might allow emergency department physicians to play a more important role in the management of hand emergencies. A hand surgery rotation has been incorporated into the PGY 2 curriculum for all emergency medicine residents at my institution.
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Squitieri L, Reichert H, Kim HM, Steggerda J, Chung KC. Patterns of surgical care and health disparities of treating pediatric finger amputation injuries in the United States. J Am Coll Surg 2011; 213:475-85. [PMID: 21856185 DOI: 10.1016/j.jamcollsurg.2011.07.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Revised: 07/15/2011] [Accepted: 07/15/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND Digital amputation in children is a very strong indication for replantation, but little is known about the epidemiology and distribution of care for pediatric finger amputation injuries in the United States. The specific aims of this study were to examine trends in the surgical management of pediatric finger amputation injuries in the United States from 2000 to 2006, and to identify potential treatment disparities among various demographic groups. STUDY DESIGN Data from the 2000, 2003, and 2006 Healthcare Cost and Utilization Project Kids' Inpatient Database were used to identify discharge records containing at least one ICD-9-CM procedure code corresponding to digit amputation or replantation. National estimates were generated using weighted frequency calculations, and a weighted logistic regression model was used to examine the influence of various demographic factors on treatment. RESULTS There were 1,321 weighted discharge records that satisfied our inclusion criteria. From 2000 to 2006, the rate of attempted digit replantation for pediatric finger amputation injuries has remained stable at approximately 40%. The majority of injuries were treated at nonchildren's (86%) and teaching (76%) hospitals; 52% of digit replantations were performed at hospitals with a volume of 1 to 2 digit replantations per year. We found that blacks (odds ratio [OR] 0.47), Hispanics (OR 0.37), and children without insurance (OR 0.38) were less likely to receive attempted replantation (all p < 0.05), even after controlling for potential confounding factors. CONCLUSIONS The proportion of pediatric digit amputation injuries managed by replantation remained stable between 2000 and 2006. Whites and children with private health insurance were more likely to receive replantation than blacks, Hispanics, and children without health insurance, even after controlling for confounding factors.
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Affiliation(s)
- Lee Squitieri
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Keck School of Medicine at The University of Southern California, Los Angeles, CA, USA
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Babu MA, Nahed BV, DeMoya MA, Curry WT. Is Trauma Transfer Influenced by Factors Other Than Medical Need? An Examination of Insurance Status and Transfer in Patients With Mild Head Injury. Neurosurgery 2011; 69:659-67; discussion 667. [DOI: 10.1227/neu.0b013e31821bc667] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Abstract
BACKGROUND To the best of our knowledge, there have been no previous studies evaluating the correlation of the US economy and hand surgery volume. Therefore, in light of the current recession, our objective was to study our institution's hand surgery volume over the last 17 years in relation to the nation's economy. METHODS A retrospective analysis of our institution's hand surgery volume, as represented by our most common procedure (ie, carpal tunnel release), was performed between January 1992 and October 2008. Liposuction and breast augmentation volumes were chosen to serve as cosmetic plastic surgery comparison groups. Pearson correlation statistics were used to estimate the relationship between the surgical volume and the US economy, as represented by the 3 market indices (Dow Jones, NASDAQ, and S&P500). RESULTS A combined total of 7884 hand surgery carpal tunnel release (open or endoscopic) patients were identified. There were 1927 (24%) and 5957 (76%) patients within the departments of plastic and orthopedic surgery, respectively. In the plastic surgery department, there was a strong negative (ie, inverse relationship) correlation between hand surgery volume and the economy (P < 0.001). In converse, the orthopedic department's hand surgery volume demonstrated a positive (ie, parallel) correlation (P < 0.001). The volumes of liposuction and breast augmentation also showed a positive correlation (P < 0.001). CONCLUSION To our knowledge, we have demonstrated for the first time an inverse (ie, negative) correlation between hand surgery volumes performed by plastic surgeons in relation to the US economy, as represented by the 3 major market indices. In contrast, orthopedic hand surgery volume and cosmetic surgery show a parallel (ie, positive) correlation. This data suggests that plastic surgeons are increasing their cosmetic surgery-to-reconstructive/hand surgery ratio during strong economic times and vice versa during times of economic slowdown.
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Abstract
The anatomy of the hand is complex, which allows for the dexterity, strength, and adaptability of the most functional aspect of the musculoskeletal system. The evaluation and management of injuries to this area can be time consuming and pose a significant medicolegal risk to the emergency physician. Improperly diagnosed and managed injuries can lead to chronic pain, inability to perform activities of daily living, and even seemingly minor injuries can lead to missed work causing a significant cost to the individual and society. The purpose of this article is to review injuries to the hand and wrist and discuss diagnostic studies and treatment plans that the emergency physician can use to treat patients effectively and minimize their exposure to risk.
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Melkun ET, Ford C, Brundage SI, Spain DA, Chang J. Demographic and Financial Analysis of EMTALA Hand Patient Transfers. Hand (N Y) 2010; 5:72-6. [PMID: 19603237 PMCID: PMC2820622 DOI: 10.1007/s11552-009-9214-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Accepted: 06/26/2009] [Indexed: 01/28/2023]
Abstract
In the United States, the Emergency Medical Treatment and Active Labor Act (EMTALA) effectively requires Level I trauma centers to accept hand trauma transfers for higher level of care if capacity exists. However, patient transfer for non-medical reasons, such as ability to pay, is still perceived as a common practice. We hypothesized that EMTALA would cause selective transfer of hand patients who were underinsured or uninsured, thus, effectively burdening a Level I trauma center. A dedicated transfer center documented the demographics and outcomes of all calls for hand trauma transfers from December 2003 to September 2005. This data registry was reviewed for age, gender, race, insurance status, and length of hospital stay. This data was compared with direct admissions to the emergency room for hand emergencies during that same time period. During the 2-year time period, a total of 151 calls for EMTALA transfer were received for hand emergencies. Our institution accepted 92 of these patients for transfer. Reasons for not accepting transfer included lack of bed availability and unavailability of the on-call surgeon due to other emergency operative cases. Compared with hand emergency patients brought directly to our emergency department during the same time period, transferred patients were younger and had a shorter length of stay. Interestingly, they were very similar in terms of sex, race, and insurance status. These data suggest that the primary motivations for EMTALA hand trauma transfers are truly complexity of patient care and specialist availability. Given the often urgent nature of hand trauma surgery and the limited resources available, expansion and development of hand and microsurgery regional centers will be vital to adequately meet demand without overburdening existing centers.
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Affiliation(s)
- Edward T. Melkun
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, 770 Welch Rd., Suite 400, Palo Alto, CA 94304 USA
| | - Christian Ford
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, 770 Welch Rd., Suite 400, Palo Alto, CA 94304 USA
| | - Susan I. Brundage
- Section of Trauma/Critical Care Surgery, Department of Surgery, Stanford University Medical Center, 300 Pasteur Dr., Stanford, CA 94305 USA
| | - David A. Spain
- Section of Trauma/Critical Care Surgery, Department of Surgery, Stanford University Medical Center, 300 Pasteur Dr., Stanford, CA 94305 USA
| | - James Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, 770 Welch Rd., Suite 400, Palo Alto, CA 94304 USA
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Abstract
Clinical research designed to enhance the quality of health care has always received a great deal of national attention. Outcomes studies, clinical trials, and evidence-based research are key components of clinical research that have advanced the field of hand surgery. The purpose of the Weiland Award is to encourage innovations and progress in clinical research in hand surgery for the betterment of patients and to promote hand surgery's visibility in American medicine. This article will highlight my efforts in clinical research through 3 specific research themes: (1) outcomes research, (2) economic analysis, and (3) evidence-based research and quality assessment in health care.
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Affiliation(s)
- Kevin C Chung
- Section of Plastic Surgery, The University of Michigan Medical School, Ann Arbor, MI, USA.
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Hand Anatomy and Examination. Plast Reconstr Surg 2010. [DOI: 10.1007/978-1-84882-513-0_34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Pushman AG, Chung KC. Future of the US healthcare system and the effects on the practice of hand surgery. Hand (N Y) 2009; 4:99-107. [PMID: 19156466 PMCID: PMC2686797 DOI: 10.1007/s11552-008-9161-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Accepted: 12/22/2008] [Indexed: 11/28/2022]
Abstract
The multitier healthcare system of the USA has several major flaws. High costs and uncertain quality of care indicate that this system is no longer practical. Several improvement initiatives, such as the Oregon Health Plan, Leapfrog, Lean Manufacturing, and Pay-for-Performance have been implemented into the current system. All of these quality improvement models are being experimented in a limited fashion and do not address the biggest problem in the US healthcare, inequality of care. There is now increasing support for a universal health coverage model as an ethically sound and just way to decrease health disparities in the USA. The current quality initiatives as well as an adoption of universal coverage appear to be the best way to improve quality of care, reduce cost, and increase equality in healthcare. These initiatives may have considerable effects on the practice of hand surgery in the near future, and thus, it is important for the field of hand surgery to become more engaged in advocacy and public policy arena. The purpose of this paper is to examine the current problems in the US healthcare system and to evaluate potential solutions that will enhance quality while simultaneously curbing the unchecked increase in healthcare expenditure.
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Affiliation(s)
- Allison G. Pushman
- Section of Plastic Surgery, University of Michigan Health System, 2130 Taubman Center 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0340 USA
| | - Kevin C. Chung
- Section of Plastic Surgery, University of Michigan Health System, 2130 Taubman Center 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0340 USA
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