Demographic Disparities amongst Patients Receiving Carpal Tunnel Release: A Retrospective Review of 92,921 Patients

Area Deprivation Index Is Not Associated With the Severity of Carpal Tunnel Syndrome

BACKGROUND

While living in a socially disadvantaged neighborhood is linked with numerous health outcomes, its effect on patient-reported outcome scores and diagnostic measures in carpal tunnel syndrome (CTS) is not fully understood. This study examines the effect of neighborhood socioeconomic deprivation on CTS severity as measured by the Boston Carpal Tunnel Questionnaire (BCTQ), 6-item Carpal Tunnel Symptoms Scale (CTS-6), and diagnostic testing modalities.

METHODS

This was a retrospective analysis of patients who presented to the hand clinic at a single hospital system with symptoms consistent with CTS. Ultrasound cross-sectional area (CSA) of the median nerve, CTS-6, Symptom Severity Scale (SSS) and Functional Status Scale (FSS) of the BCTQ, and the Area Deprivation Index (ADI) national rank percentile were collected. Patients were grouped into 4 quartiles based on their ADI national percentile. Analyses of variance (ANOVAs) were conducted to test for statistical differences between the 4 quartiles based on the average values of median nerve CSA, CTS-6, SSS, and FSS score. The bottom quartile was compared with the upper 75% of the sample (26th-100th percentile) and to the upper quartile via Student t test. Statistical significance was set at P < .05.

RESULTS

Analyses of variance revealed no statistically significant differences between the 4 quartiles for either median nerve CSA, CTS-6, SSS, or FSS. When comparing the bottom quartile with the upper 75% of the sample and the upper quartile, no significant statistical differences were identified.

CONCLUSIONS

No relationships were found between social deprivation (ADI) and patient-reported outcomes, CTS-6 scores, or median nerve CSA.

Risks of carpal tunnel syndrome and carpal tunnel release surgery in users of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists: A target trial emulation study

AIM

Preclinical studies have shown that sodium-glucose cotransporter 2 inhibitors (SGLT2is) have a neuroprotective effect. This study compared the risks of carpal tunnel syndrome and carpal tunnel release surgery between new users of SGLT2is and new users of glucagon-like peptide-1 receptor agonists (GLP-1RAs).

METHODS

A retrospective new-user active comparator cohort study with a target trial design was conducted by using the TriNetX platform. Patients with type 2 diabetes mellitus prescribed SGLT2is or GLP-1RAs were identified. Covariates were balanced using propensity score matching to form 2 homogenous treatment groups. Outcomes were the risk of carpal tunnel syndrome and the risk of carpal tunnel release surgery. Hazard ratios (HRs) with 95 % confidence intervals (CIs) were calculated using the TriNetX platform.

RESULTS

The crude cohort included 86,188 and 100,244 patients in the SGLT2is group and GLP-1RAs group, respectively. After matching, each group included 65,464 patients. The SGLT2is group had an average age of 59.6 years, and 46 % were women. The GLP-1RAs group had an average age of 59.5 years, and 45.9 % were women. The incidences of carpal tunnel syndrome (HR: 0.928; 95 % CI: 0.869 to 0.991) and carpal tunnel release surgery (HR: 0.840; 95 % CI: 0.726 to 0.971) were significantly lower in the SGLT2is group than in the GLP-1RAs group.

CONCLUSION

In patients with type 2 diabetes mellitus, SGLT2is seem to decrease the risk of carpal tunnel syndrome and the need for carpal tunnel release surgery. Prospective studies are required to confirm our results.

Understanding Changing Demographic and Treatment Trends of Distal Radius Fractures: A TriNetX Database Contemporary Analysis of 32,912 Patients

Purpose

Distal radius fractures (DRF) are among the most commonly encountered fractures. The population of the United States is rapidly growing, aging, and diversifying. This study was undertaken to better understand current incidences and treatment trends across all ages, gender, and races to inform resource allocation and to potentially address treatment inequities.

Methods

The TriNetX US Collaborative Network was queried for all patients diagnosed with DRFs from 2017 to 2022. Cohorts were defined by inclusion and exclusion of Current Procedural Terminology procedure codes and categorized into operative and nonsurgical groups. Statistical analysis was performed to determine differences in management among demographic groups across the 6-year time period.

Results

Incidence rates of operative intervention for DRF increased from 19.6% in 2017 to 23.6% in 2022. Incidence rates of operative intervention increased from 21.7% to 25.2% for females and from 15.3% to 19.7% for males. A bimodal distribution was observed in females with more fractures occurring in the pediatric and geriatric ages, but this distribution was not observed in males. All demographic groups had an overall higher incidence of nonsurgical intervention. Patients aged 40-64 years were more likely to undergo operative intervention than patients 18-39 years. Females were more likely to undergo operative intervention than males. White patients were more likely to undergo operative intervention than Black patients and Asian patients.

Conclusions

The incidence of DRFs continues to climb, as does their rate of operative management. The classic bimodal distribution was observed in females, but not males. However, differences in management of DRFs were also observed across different demographic groups with ongoing racial disparities. Future consideration should be taken into optimizing treatment disparities relative to demographic status.

Type of Study/Level of Evidence

Prognosis IV.

Predictors and Variation in Steroid Injection Use for Carpal Tunnel Syndrome from a Multicenter Quality Collaborative

BACKGROUND

Steroid injections are commonly used as first-line treatment for carpal tunnel syndrome (CTS); however, research has shown that their benefit is generally short term, and many patients go on to receive carpal tunnel release (CTR). The purpose of this study was to determine the variation in steroid injection use by hand surgeons.

METHODS

The authors analyzed data from a nine-center hand surgery quality collaborative. Data from 1586 patients (2381 hands) were included if they underwent elective CTR at one of the sites. Mixed effects logistic regression models were used to examine the association of receipt of steroid injection and association of receipt of more than one steroid injection among patient-level covariates.

RESULTS

Steroid injection use significantly varied by practice, ranging from 12% to 53% of patients. The odds of receiving a steroid injection were 1.4 times higher for women ( P < 0.01), 1.6 times higher for patients with chronic pain syndrome ( P < 0.01), 0.5 times lower for patients with moderate electromyography (EMG) classification, and 0.4 times lower for patients with severe EMG classification (both P < 0.01). Patients with high scores on the Six-Item CTS Scale ( P = 0.02) and patients with moderate ( P = 0.04) or severe EMG ( P = 0.05) classification had lower odds of receiving multiple steroid injections. Complete symptomatic improvement after steroid injection was significantly reported by patients with a high Six-Item CTS Scale score ( P = 0.03) and patients with severe EMG classification ( P = 0.02).

CONCLUSIONS

The authors found wide patient-level and practice-level variation in the use of steroid injections before CTR. These findings underscore the need for improved data and standard practice guidelines regarding which patients benefit from steroid injection.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

The effect of Medicaid expansion on rates of carpal tunnel release: an interrupted time series analysis

BACKGROUND

Medicaid expansion through the Affordable Care Act (ACA) has been associated with greater access and utilization of surgical services in underserved populations. However, its impact on use of hand surgical care is less understood. The purpose of this study was to evaluate the association between New York State adoption of the ACA and carpal tunnel release (CTR) procedural volume in Medicaid beneficiaries.

METHODS

We conducted a pooled cross-sectional analysis of patients who underwent CTR using the Healthcare Cost and Utilization Project New York State all-payer database (2010-2018). An interrupted time series (ITS) analysis using an autoregressive integrated moving average model estimated the immediate and long-term impact of Medicaid expansion in January 2014 on CTR procedural volume in Medicaid beneficiaries and uninsured individuals.

RESULTS

A total of 112,569 patients were included in the sample. After expansion, we observed an absolute increase of 6% in the share of CTR procedures provided to Medicaid beneficiaries. Policy implementation was associated with an immediate 1.81% increase (95% CI=0.0085, 0.0277; p<0.001) in the probability of Medicaid as the primary payer and an annual increase of 1.68% (95% CI=0.0134, 0.0202; p<0.001) after reform. ITS analysis found this resulted in 4,190 additional CTR procedures in Medicaid beneficiaries than predicted without expansion.

CONCLUSIONS

Study results suggest New York's adoption of the ACA was associated with an immediate and steady increase in use of outpatient CTR in Medicaid beneficiaries. Most of this increase represented newly treated patients rather than those who were previously uninsured.

Low-Income, Poor Physical Health, Poor Mental Health, and Other Social Risk Factors Are Associated With Decreased Access to Care in Patients With Carpal Tunnel Syndrome

BACKGROUND

Carpal Tunnel Syndrome (CTS) is associated with a significant personal and societal burden. Evaluating access to care can identify barriers, limitations, and disparities in the delivery of healthcare services in this population. The purpose of this study was to evaluate access to overall healthcare and healthcare utilization among patients with CTS.

METHODS

This is a retrospective cohort study conducted with the All of Us database. Patients diagnosed with CTS that completed the access to care survey were included and matched to a control group. The primary outcomes were access to care across 4 domains: (1) delayed care, (2) could not afford care, (3) skipped medications, and (4) over 1 year since seeing provider. Secondary analysis was then performed to identify patient-specific factors associated with reduced access to care.

RESULTS

In total, 7649 patients with CTS were included and control matched to 7649 patients without CTS. In the CTS group, 33.7% (n = 2577) had delayed care, 30.4% (n = 2323) could not afford care, 15.4% (n = 1180) skipped medications, and 1.6% (n = 123) had not seen a provider in more than 1 year. Within the CTS cohort, low-income, worse physical health, and worse mental health were associated with poor access to care.

CONCLUSION

Patients experience notable challenges with delayed care, affordability of care, and medication adherence regardless of having a diagnosis of CTS. Targeted interventions on modifiable risk factors such as low income, poor mental health, and poor physical health are important opportunities to improve access to care in this population.

Evaluation of Racial, Ethnic, and Socioeconomic Disparities in Indication for Carpal Tunnel Release

BACKGROUND

Disparities in the utilization of orthopaedic surgery based on race and ethnicity continue to be reported. We examined the impact of sociodemographic factors on treatment recommendation by hand surgeons for carpal tunnel syndrome (CTS) of similar disease severity.

METHODS

Patients with electrodiagnostic study (EDS)-confirmed CTS were evaluated at a single institution between 2016 and 2020. Data including patient age, sex, race/ethnicity, ZIP Code, and EDS severity were collected. The primary outcome was the recommended treatment by the hand surgeon at the first clinic visit according to patient race/ethnicity and the Social Deprivation Index (SDI). Secondary outcomes included the treatment selected by patients (nonsurgical or surgical) and the time to surgery.

RESULTS

The 949 patients had a mean age of 58 years (range, 18 to 80 years); 60.5% (n = 574) were women. The race/ethnicity of the patient cohort was 9.8% (n = 93) Black non-Hispanic, 11.2% (n = 106) Hispanic/Latino, 70.3% (n = 667) White non-Hispanic, and 8.7% (n = 83) "other." Overall, Black non-Hispanic patients (38.7%; odds ratio, [OR] 0.62; 95% confidence interval [CI], 0.40 to 0.96) and Hispanic/Latino patients (35.8%; OR, 0.55; 95% CI, 0.36 to 0.84) were less likely to have surgery recommended at their first visit compared with White non-Hispanic patients (50.5%). This was no longer apparent after adjusting for demographic and clinical variables including EDS severity and SDI (Black non-Hispanic patients: adjusted odds ratio [aOR], 0.67; 95% CI, 0.4 to 1.11; Hispanic/Latino patients: aOR, 0.69: 95% CI, 0.41 to 1.14). Across all categories of EDS severity, surgeons were less likely to recommend surgery to patients with a higher SDI (aOR: 0.66, 0.64, and 0.54 for quintiles 2, 3 and 4, respectively). When surgery was recommended, patients in the highest SDI quintile were less likely to proceed with surgery (p = 0.032). There was no association between patient race/ethnicity and the treatment selected by the patient or time to surgery (p = 0.303 and p = 0.725, respectively).

CONCLUSIONS

Patients experiencing higher levels of social deprivation were less likely to be recommended for CTS surgery and were less likely to proceed with surgery, regardless of patient race/ethnicity. Additional investigation into the social factors influencing both surgeon and patient selection of treatment for CTS, including the impact of patient socioeconomic background, is warranted.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Disparities in Hand Surgery Exist in Unexpected Populations

Background The purpose of our study is to investigate disparities in the patient populations and outcomes of carpal tunnel release (CTR) and trigger finger release (TFR).  Methods A retrospective review of 777 CTR and 395 TFR patients from May 2021 to August 2022 was completed. The shortened form of the Disabilities of the Arm, Shoulder, and Hand (DASH) scores (QuickDASH) was recorded to evaluate physical function preoperatively and at one and three months postoperatively. This study was deemed institutional review board-exempt by the institutional clinical research committee. Results Compared to CTR, TFR patients resided in zip codes with higher levels of social vulnerability across dimensions of 'household composition and disability' (p=0.018) and 'minority status and language' (p=0.043). When analyzing QuickDASH scores by demographics and procedure, preoperative scores were statistically significantly higher for non-married (p=0.002), White (p=0.003), and female sex (p=0.001) CTR patients. Further, one-month postoperative scores were statistically higher for White and non-married CTR patients (0.016 and 0.015, respectively). At three months postoperatively, female and non-married patients had statistically significant higher scores (0.010 and 0.037, respectively). In TFR patients, one-month postoperative QuickDASH scores for White and female patients were statistically significantly higher (0.018 and 0.007, respectively). There were no significant differences in QuickDASH scores between rural and non-rural patients, household income (HHI) above or below the median, or the Social Vulnerability Index (SVI) dimensions.  Conclusion Our study found marital status, sex, and race were associated with disparities in pre-and postoperative physical function in patients undergoing carpal tunnel or trigger finger release. However, future studies are warranted to confirm and develop solutions to disparities within this population.

Sex differences in neuromuscular disorders

The prevalence, onset, pathophysiology, and clinical course of many neuromuscular disorders (NMDs) may significantly differ between males and females. Some NMDs are more frequently observed in females, and characterized to show a higher grade of severity during or after the pregnancy. Meanwhile, others tend to have an earlier onset in males and exhibit a more variable progression. Prevalently, sex differences in NMDs have a familiar character given from genetic inheritance. However, they may also influence clinical presentation and disease severity of acquired NMD forms, and are represented by both hormonal and genetic factors. Consequently, to shed light on the distinctive role of biological factors in the different clinical phenotypes, we summarize in this review the sex related differences and their distinctive biological roles emerging from the current literature in both acquired and inherited NMDs.

The Value of Diversity, Equity, and Inclusion: Race and Ethnicity Affecting Patients

Patient race and ethnicity are important factors in health-care inequity, including care for the patient with hand and upper extremity pathologic condition. Physician diversity has been shown to promote better access, improve health-care quality, and improve satisfaction for underserved populations. Concordance, most often defined as a similarity or shared identity between physician and patient, has been shown to have a positive influence on health-care disparities. Although diversity among Hand surgeons is increasing, it is not matching the diversity of the population as a whole. It is imperative that we work to increase and maintain diversity in order to provide the best care for our patients.

Recruitment of the Next Generation of Diverse Hand Surgeons

Hand surgery encompasses a diaspora of pathology and patients, but the surgeons treating this population are not commensurately diverse. A physician population that reflects the population it treats consistently leads to improved patient outcomes. Despite increasing diversity amongst surgeons entering into pipeline specialties such as General Surgery, Plastic Surgery, and Orthopaedic Surgery, the overall makeup of practicing hand surgeons remains largely homogenous. This article outlines organizations, such as the Perry Initiative, which have increased recruitment of women and underrepresented minorities into pipeline programs. Techniques of minimizing bias and increasing opportunities for underrepresented groups are also discussed.

Patient Disparities and Provider Diversity in Orthopaedic Surgery: A Complex Relationship

Disparities in the access to, utilization of, and outcomes after orthopaedic surgery are a notable problem in the field that limits patients' ability to access the highest level of care and achieve optimal outcomes. Disparities exist based on numerous sociodemographic factors, with sex and race/ethnicity being two of the most well-studied factors linked to disparities in orthopaedic care. These disparities cross all subspecialties and tend to negatively affect women and racial/ethnic minorities. The increased recognition of the disparities in orthopaedic care has been paralleled by an increased recognition of the lack of diversity among orthopaedic surgeons. Although efforts are being made to improve the representation of women and underrepresented minorities among orthopaedic surgeons, the numbers, particularly of racial and ethnic minorities, show little improvement. The lack of gender and racial diversity among orthopaedic surgeons may be one of many factors related to the gender and racial disparities seen in orthopaedic care. Patients may prefer a provider that they can better identify with and that may affect care. Orthopaedic surgery as a specialty must continue to work to foster an inclusive environment and make concerted efforts to improve diversity through the recruitment of women and underrepresented minorities, among others, for the benefit of patients, surgeons, and the continued growth of the field as a whole.

Out-of-Pocket and Total Costs for Common Hand Procedures From 2008 to 2016: A Nationwide Claims Database Analysis

PURPOSE

Rising patient out-of-pocket (OOP) costs and financial distress have been associated with reduced access to and delays in care. We evaluated whether OOP and total costs for common hand procedures have increased from 2008 to 2016 and identified key drivers of these costs.

METHODS

Using the IBM MarketScan Research Databases, we identified patients who underwent trigger finger release, open carpal tunnel release, thumb carpometacarpal joint arthroplasty, cubital tunnel release, or open treatment of distal radius fracture in the outpatient setting between 2008 and 2016. Patient OOP costs included copayment, coinsurance, and deductible payments. Costs not directly related to medical care, such as transportation and childcare costs, were not included. The overall cost was defined as the sum of the patient OOP cost and insurer reimbursements. We calculated changes in OOP and total overall costs over the study period. We also performed multivariable linear regressions to evaluate the associations between costs and procedure type, insurance type, region, and site of service.

RESULTS

The mean patient OOP cost increased by 55% to 71% and the total overall cost increased by 20% to 45%, depending on the procedure, between 2008 and 2016. Facility overall costs increased by 38%, whereas professional overall costs increased by 9%. Procedures performed in an office-based setting were associated with the lowest patient OOP and total overall costs, whereas high-deductible health plans were associated with the highest OOP costs.

CONCLUSIONS

Patient OOP and total overall costs increased for the most common hand procedures between 2008 and 2016, driven by a substantial increase in facility costs. Office-based procedures were associated with the lowest costs.

CLINICAL RELEVANCE

To alleviate the rising patient cost burden, hand surgeons could incorporate OOP cost considerations into shared decision-making tools, identify patients who may benefit from financial counseling, and shift procedures to an office-based setting.

Social and Demographic Factors Impact Shoulder Stabilization Surgery in Anterior Glenohumeral Instability

Purpose

To assess independent predictors of surgery after an emergency department visit for shoulder instability, including patient-related and socioeconomic factors.

Methods

Patients presenting to the emergency department were identified in the New York Statewide Planning and Research Cooperative System database from 2015 to 2018 by International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for anterior shoulder dislocation or subluxation. All shoulder stabilization procedures in the outpatient setting were identified using Current Procedural Terminology codes (23455, 23460, 23462, 23466, and 29806). A multivariable logistic regression was performed to assess the impact of patient factors on the likelihood of receiving surgery. The variables included in the analysis were age, sex, race, social deprivation, Charlson Comorbidity Index, recurrent dislocation, and primary insurance type.

Results

In total, 16,721 patients with a shoulder instability diagnosis were included in the analysis and 1,028 (6.1%) went on to have surgery. Patients <18 years old (odds ratio [OR] 8.607, P < .0001), those with recurrent dislocations (OR 2.606, P < .0001), or worker’s compensation relative to private insurance (OR 1.318, P = .0492) had increased odds of receiving surgery. Hispanic (OR 0.711, P = .003) and African American (OR 0.63, P < .0001) patients had decreased odds of surgery compared with White patients. Patients with Medicaid (OR 0.582, P < .0001) or self-pay (OR 0.352, P < .0001) insurance had decreased odds of undergoing surgery relative to privately insured patients. Patients with greater levels of social deprivation (OR 0.993, P < .0001) also were associated with decreased odds of surgery.

Conclusions

Anterior glenohumeral instability and subsequent stabilization surgery is associated with disparities among patient race, primary insurance, and social deprivation.

Clinical Relevance

Considering the relationship between differential care and health disparities, it is critical to define and increase physician awareness of these disparities to help ensure equitable care.

Surgeon and Facility Volumes Are Associated With Social Disparities and Post-Operative Complications After Total Hip Arthroplasty

BACKGROUND

The purpose of this study is to further characterize the volume dependence of facilities and surgeons on morbidity and mortality after total hip arthroplasty (THA).

METHODS

Adults who underwent THA from 2009 to 2014 were identified using International Classification of Diseases, Ninth Revision, Clinical Modification and Procedural codes in the New York Statewide Planning and Research Cooperative System database. Complication rates were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression controlling for factors such as the Social Deprivation Index. Surgeon and facility volumes were compared between the low and high volume using cutoffs established by prior research.

RESULTS

In total, 99,832 patients were included. Low volume facilities had higher rates of readmission, urinary tract infection (UTI), acute renal failure, pneumonia, surgical site infection (SSI), cellulitis, wound complications, deep vein thrombosis (DVT), in-hospital mortality, and revision. Low volume surgeons had higher rates of readmission, UTI, acute renal failure, pneumonia, SSI, acute respiratory failure, pulmonary embolism, cellulitis, wound complications, in-hospital mortality, cardiorespiratory arrest, DVT, and revision. African Americans, Hispanics, and those with federal insurance had increased rates of readmission. Those with ≥1 Charlson comorbidities or from areas of higher social deprivation had increased incidence of treatment by low volume surgeons and facilities.

CONCLUSION

Both low volume facilities and surgeons performing primary THA have higher rates of readmission, UTI, acute renal failure, pneumonia, SSI, cellulitis, wound complications, DVT, in-hospital mortality, and revision. Demographic disparities exist between who is treated at low vs high volume surgeons and facilities placing those groups at higher risks for complications.

Carpal Tunnel Syndrome and Ulnar Nerve Entrapment Are Associated with Impaired Psychological Health in Adults as Appraised by Their Increased Use of Psychotropic Medication

We aimed to study psychological health, as approximated by the use of psychotropic drugs, in a population diagnosed and surgically treated for carpal tunnel syndrome (CTS) or ulnar nerve entrapment (UNE), or both, also considering the demographic and socioeconomic factors of the individuals. Linking data from five large national registers, use of psychotropics (at least one dispensation during the first year after the surgery or the baseline date) was examined in around 5.8 million people 25–80 years old residing in Sweden 2010. Among these individuals, 9728 (0.17%), 890 (0.02%) and 149 (0.00%) were identified as diagnosed and surgically treated for CTS, UNE, or both, respectively. As much as 28%, 34% and 36% in each group, respectively, used psychotropic drugs, compared with 19% in the general population. Regression analyses showed a general higher risk for use of psychotropics related to these nerve compression disorders, to higher age, being a woman, and having low income or low occupational qualification level. Individuals born outside of Sweden had a lower risk. We conclude that surgically treated individuals with a nerve compression disorder have an increased risk of impaired psychological health. Caregivers should be aware of the risk and provide necessary attention.

Surgeon and Facility Volume are Associated With Postoperative Complications After Total Knee Arthroplasty

Background

Surgeon and hospital volumes may affect outcomes of various orthopedic procedures. The purpose of this study is to characterize the volume dependence of both facilities and surgeons on morbidity and mortality after total knee arthroplasty.

Methods

Adults who underwent total knee arthroplasty for osteoarthritis from 2011 to 2015 were identified using International Classification of Diseases-9 Clinical Modification diagnostic and procedural codes in the New York Statewide Planning and Research Cooperative System database. Readmission, in-hospital mortality, and other adverse events were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression, while controlling for patient demographic and clinical factors. Surgeon and facility volumes were compared between the lowest and highest 20%.

Results

Of 113,784 identified patients, 71,827 were treated at a high- or low-volume facility or by low- or high-volume surgeon. Low-volume facilities had higher 1-month, 3-month, and 12-month rates of readmission, urinary tract infection, cardiorespiratory arrest, surgical site infection, and wound complications; higher 3- and 12-month rates of pneumonia, cellulitis, and in-facility mortality; and higher 12-month rates of acute renal failure and revision. Low-volume surgeons had higher 1-, 3-, and 12-month rates of readmission, urinary tract infection, acute renal failure, pneumonia, surgical site infection, deep vein thrombosis, pulmonary embolism, cellulitis, and wound complications; higher 3- and 12-month rates of cardiorespiratory arrest; and higher 12-month rate of in-facility mortality.

Conclusions

These results suggest volume shifting toward higher volume facilities and/or surgeons could improve patient outcomes and have potential cost savings. Furthermore, these results can inform healthcare policy, for example, designating institutions as centers of excellence.