Cost, profile, and postoperative resource use for surgically managed acute hand and wrist injuries with emergency department presentation

Effectiveness of a Telerehabilitation Evidence-Based Tablet App for Rehabilitation in Traumatic Bone and Soft Tissue Injuries of the Hand, Wrist, and Fingers

OBJECTIVE

To assess whether feedback-guided exercises performed on a tablet touchscreen improve clinical recovery and reduce health care usage more than the conventional home exercise program prescribed on paper in patients with bone and soft tissue injuries of the wrist, hand, and/or fingers treated by public health services.

DESIGN

A multicenter assessor-blinded, parallel, 2-group controlled trial.

SETTING

Trauma and rehabilitation services of 4 hospitals.

PARTICIPANTS

Six hundred sixty-three patients with limited functional ability due to bone and soft tissue injuries of the wrist, hand, and/or fingers (N=663).

INTERVENTIONS

The experimental group received a home exercise program using a tablet-based application with feedback, monitoring, and progression; the control group received an evidence-based home exercise program on paper.

MAIN OUTCOME MEASURES

The primary outcome was functional ability through Patient Rated Wrist Evaluation for wrist conditions and the short version of Disabilities of the Arm, Shoulder and Hand for all other hand pathologies. Secondary outcomes included dexterity, pain intensity, grip strength, and health care usage (number of patients referred to rehabilitation service and number of clinical appointments).

RESULTS

The experimental group showed a significant improvement on the Patient Rated Wrist Evaluation (P=.001) and the short version of Disabilities of the Arm, Shoulder and Hand (P=.001) with medium effect sizes (η²=0.066-0.067) when compared with the control group. Regarding health care usage, the experimental group presented a reduction of 41% in the rate of referrals to face-to-face rehabilitation service consultations, a reduction of rehabilitation consultations (mean difference=-1.64; 95% confidence interval, -2.64 to -0.65) and physiotherapy sessions (mean difference=-8.52, 95% confidence interval, -16.92 to -0.65) compared to the control group.

CONCLUSIONS

In patients with bone and soft tissue injuries of the wrist, hand, and/or fingers, prescribing feedback-guided exercises performed on a tablet touchscreen was more effective for improving patients' functional ability and reduced the number of patients referred to rehabilitation consultation and number of clinical appointments.

Hand therapy role in return to work for patients with hand and upper limb conditions

STUDY DESIGN

Electronic Web-based survey INTRODUCTION: Evidence supports the use of health-focused interventions combined with service coordination and work modification components to reduce the individual, community, and societal burden associated with acute and chronic musculoskeletal conditions. The levels of engagement, skill, and confidence of Australian hand therapists in assisting their patients to return to work (RTW) are currently unknown.

PURPOSE OF THE STUDY

To identify current practices, skill, and the need for additional training in management of the RTW process from a sample of Australian hand therapists.

METHODS

An electronic survey was sent to current members of the Australian Hand Therapy Association. Data collected included training and/or professional experience, caseload and/or workplace, scope of and barriers to vocational practice, and satisfaction with own contribution to the RTW process for patients.

RESULTS

A total of 99 individual responses (12.4% of total membership) were included, with most indicating a limited role in the RTW process. Only 52.7% said they regularly monitored and adjusted their patients' RTW program. Most plans were informed by formal tests of underlying body structure and function components rather than the patient's ability to perform of a specific work role or task. Median satisfaction with the quality of RTW service they provided was 6 of 10, with 42% scoring ≤ 5 of 10, indicating considerable scope for improvement.

CONCLUSIONS

Practice patterns are described for planning and monitoring RTW, and these did not always align with the evidence-base. Further exploration of clinician barriers to implementing RTW interventions is warranted, as is upskilling for those indicating a lack of confidence in this field.

Patient outcomes and costs after isolated flexor tendon repairs of the hand

BACKGROUND

Acute flexor tendon injuries are challenging injuries for patients, surgeons, and therapists alike. There is ongoing debate about the optimal timing and amount of therapy after these injuries.

PURPOSE

We sought to investigate the relationship between hand therapy utilization and reoperation rates after flexor tendon repair and quantify reoperation rates and costs associated with flexor tendon repair. We hypothesize there will be an inverse relationship between the number of hand therapy visits and later reoperation rates and a positive correlation between reoperation rates and total cost of care.

STUDY DESIGN

A retrospective cohort study of patients undergoing primary flexor tendon repair was pursued.

METHODS

A commercially available database was utilized to access insurance claims data for 20.9 million patients in the US from 2007 to 2015. Patients undergoing primary flexor tendon repair were included and followed for one year. Patients with fractures, vascular injuries, or digit replantation were excluded. We studied post-operative rehabilitation utilization, reoperation rates, and costs. Chi-Square tests and multivariable logistic regressions were used to assess the relationship between therapy utilization and reoperation rates and costs.

RESULTS

The one-year reoperation rate was 11.4 percent at a median time of 100.0 days amongst 1,129 patients undergoing primary tendon repair. In multivariable analysis, age between 30 and 59, male sex, and utilization of over 21 therapy sessions were associated with increased odds of reoperation. Mean insurance reimbursement one year following primary flexor repair was $14,533 per patient but $27,870 if patients went on to reoperation.

CONCLUSION

Continued therapy utilization after primary flexor tendon repair is an independent predictor of reoperation need. These findings may help surgeons counsel patients who require a large number of visits after flexor tendon repair on when to revisit surgical options.

Capturing the costs of acute hand and wrist injuries: Lessons learnt from a prospective longitudinal burden of injury study

Introduction

Given the high incidence of hand and wrist injuries, they are exceptionally costly to the economy. This prospective, longitudinal study aimed to establish methods for capturing the burden of acute hand and wrist injury from an individual and societal perspective.

Methods

A prospective longitudinal design with baseline measures of injury type and severity, and repeated measures of disability, cost, and activity limitations and participation restrictions at six weeks, three months, and six months was selected. Participants were recruited from two large urban Australian public health care services. We sought to establish methods for capturing the burden of acute hand and wrist injury from an individual and societal perspective and compare survey completion by the method of administration.

Results

A total of 206 patients consented to participate in this study, representing 54% of those invited to participate. The survey completion rates were 18% at six weeks, 2.4% at twelve weeks, and 0.004% at six months following injury. From the limited data collected at six weeks, it was noted that nearly half of the patients reported a decrease in usual financial income, 14% reported absenteeism, and 62% reported presenteeism. Participants who elected to have data collected via phone call had the highest survey completion rate ( n = 6/10; 30%) at six-week’s follow-up.

Discussion

The study findings highlight the difficulties of completing longitudinal survey research investigating individual and societal burden with this population. Future research should be carefully designed to encourage participation and retention by considering patient and public involvement in study design, the time burden placed on the participants within and across selected survey time points, providing participants with incentives to participate, and highlighting the relevance and real-world applications of the findings.