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Choi YH, Kwon TH, Chung CY, Jeong N, Lee KM. Comparison of current relative value unit-based prices and utility between common surgical procedures, including orthopedic surgeries, in South Korea. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2024; 22:27. [PMID: 38605377 PMCID: PMC11007986 DOI: 10.1186/s12962-024-00538-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 03/28/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND The medical pricing system strongly influences physicians' job satisfaction and patient health outcomes. This study aimed to investigate the current relative value unit (RVU)-based pricing and utility of patients in commonly performed surgical procedures in South Korea. METHODS Fifteen common surgical procedures were selected from OECD statistics, and three additional orthopedic procedures were examined. The current pricing of each surgical procedure was retrieved from the Korea National Health Insurance Service, and the corresponding utilities were obtained as quality-adjusted life year (QALY) gains from previous studies. The relationship between the current prices (RVUs) and the patients' utility (incremental QALY gains/year) was analyzed. Subgroup analysis was performed between fatal and non-fatal procedures and between orthopedic and non-orthopedic procedures. RESULTS A significant negative correlation (r = - 0.558, p < 0.001) was observed between RVU and incremental QALY among all 18 procedures. The fatal subgroup had a significantly higher RVU than the non-fatal subgroup (p < 0.05), while the former had a significantly lower incremental QALY than the latter (p < 0.001). Orthopedic procedures showed higher incremental QALY values than non-orthopedic procedures, but they did not show higher prices (RVU). CONCLUSIONS This paradoxical relationship between current prices and patient utility is attributed to the higher pricing of surgical procedures for fatal and urgent conditions. Orthopedic surgery has been found to be a cost-effective treatment strategy. These findings could contribute to a better understanding of the potential role of incremental QALY in pursuing value-based purchasing or reasonable modification of the current medical fee schedule.
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Affiliation(s)
- Yoon Hyo Choi
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, 300 Gumi-Dong, Bundang-Gu, Seongnam-Si, Gyeonggi, South Korea
| | - Tae Hun Kwon
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, 300 Gumi-Dong, Bundang-Gu, Seongnam-Si, Gyeonggi, South Korea
| | - Chin Youb Chung
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, 300 Gumi-Dong, Bundang-Gu, Seongnam-Si, Gyeonggi, South Korea
| | - Naun Jeong
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, 300 Gumi-Dong, Bundang-Gu, Seongnam-Si, Gyeonggi, South Korea
| | - Kyoung Min Lee
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, 300 Gumi-Dong, Bundang-Gu, Seongnam-Si, Gyeonggi, South Korea.
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Mehraban N, Lew AR, Foran IM, Lee S, Bohl DD, Hamid KS. Lateral Locking Plate Fixation of Simple Weber B Fibula Fractures Without a Lag Screw Yields Excellent Radiographic Results. Foot Ankle Spec 2024; 17:131-136. [PMID: 34747245 DOI: 10.1177/19386400211055280] [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: 11/15/2022]
Abstract
BACKGROUND The most common first-line fixation technique for simple Weber B fibula fractures is a lag screw with lateral neutralization plate. The most common surgical technique for unstable Weber B fibula fracture is one-third semi-tubular plate and cortical screws, implemented with lag screw when appropriate. However, the lag technique can be technically challenging in osteoporotic bone or within fibulas of smaller diameter, and in some cases can result in fragmentation at the fracture site, malreduction, or peroneal irritation. The purpose of this study is to examine an alternative first-line method for routine treatment of simple Weber B fibula fractures. METHODS Fifty-two consecutive patients undergoing open reduction internal fixation (ORIF) of a Weber B fibula fracture by a single surgeon were included in this retrospective study. After reduction, a lateral locking plate was applied with cortical screws proximally and locking screws distally. No screw crossed the fracture in any case. Per published precedent, nonunion was defined as either a gap of >3 mm between fracture surfaces >6 months postoperatively or a fracture line >2 to 3 mm wide and sclerosing of the fracture surfaces. Similarly, malunion was defined as one or more of the following: talar tilt >2º, talar subluxation >2 mm, or tibiofibular clear space ≥5 mm. RESULTS The mean (± standard deviation) age of the 52 included patients was 44.2 ± 16.2 years, the mean body mass index was 27.7 ± 6.6 kg/m2, and 63.5% of patients identified themselves as female sex. The mean follow-up was 6.2 (range: 1.5-15) months. In addition to undergoing fixation of the lateral malleolus, 21 patients also underwent fixation of the posterior malleolus, 27 underwent fixation of the medial malleolus, 29 underwent fixation across the syndesmosis, and 7 underwent repair of the deltoid. In all patients, bony anatomic union of the fibula and congruence of the mortise were achieved with no cases of malunion or nonunion. CONCLUSIONS The Arbeitsgemeinschaft für Osteosynthesefragen (AO) fixation technique for simple Weber B fractures with a lag screw and lateral neutralization plating has provided good outcomes for decades. We present an alternative technique for ORIF of these fractures with a lateral locking plate and no lag screw. In our series, we evaluated radiographic union and alignment as our primary outcome measures and found no cases of nonunion or malunion. Prospective cohort testing of lateral locking plates versus traditional fixation in the context of patient-centered value is warranted.Level of Evidence: Level III.
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Affiliation(s)
- Nasima Mehraban
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois (NM, ARL, IMF, SL, DDB, KSH)
| | - Alexandra R Lew
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois (NM, ARL, IMF, SL, DDB, KSH)
| | - Ian M Foran
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois (NM, ARL, IMF, SL, DDB, KSH)
| | - Simon Lee
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois (NM, ARL, IMF, SL, DDB, KSH)
| | - Daniel D Bohl
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois (NM, ARL, IMF, SL, DDB, KSH)
| | - Kamran S Hamid
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois (NM, ARL, IMF, SL, DDB, KSH)
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Chawla S. CORR Insights®: How Have Patient Out-of-pocket Costs for Common Outpatient Orthopaedic Foot and Ankle Surgical Procedures Changed Over Time? A Retrospective Study From 2010 to 2020. Clin Orthop Relat Res 2024; 482:323-324. [PMID: 37713265 PMCID: PMC10776160 DOI: 10.1097/corr.0000000000002859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/16/2023] [Indexed: 09/16/2023]
Affiliation(s)
- Sagar Chawla
- Associate Staff, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
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Arciero E, Desai S, Coury J, Gupta P, Trofa DP, Sardar Z, Lombardi J. Comparison of Psychometric Properties of Patient-Reported Outcomes Measurement Information System With Traditional Outcome Metrics in Spine Surgery. JBJS Rev 2023; 11:01874474-202303000-00006. [PMID: 36947636 DOI: 10.2106/jbjs.rvw.22.00193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
OBJECTIVE Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to address certain shortcomings of traditional, or legacy patient-reported outcome measures (PROMs). Because the use of PROMIS across orthopedic populations continues to increase, the purpose of this study was to provide a comprehensive overview of the use and validation of PROMIS in spine surgery. METHODS PubMed and Google Scholar were searched for relevant articles reporting on the use and validation of PROMIS in spine surgery. The PROMIS formats and individual domains used by investigators were noted. Additionally, psychometric properties reported in validation studies were evaluated. RESULTS Both individual studies and systematic reviews have demonstrated the convergent validity of PROMIS domains, reporting moderate-to-strong correlations with legacy measures in a variety of spine patient populations. Across spine surgery patient populations, PROMIS instruments are consistently efficient, demonstrating decreased question burden compared with legacy PROMs. PROMIS domains overall exhibit responsiveness comparable with legacy measures, and the normalization of PROMIS scores to a general population allows for broad coverage, resulting in acceptable floor and ceiling effects. Despite the many strengths of PROMIS, there remain some populations where PROMIS is not suited to be used in isolation. CONCLUSIONS PROMIS is widely used as an outcome measure in spine surgery and has been validated in a range of patient populations. Although PROMIS domains cannot fully replace legacy measures in spine patients, they can be used in certain settings to provide an efficient and psychometrically sound PROM.
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Affiliation(s)
- Emily Arciero
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
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Empfehlung für Fragebögen zur Untersuchung der Fuß- und Sprunggelenkfunktion vom Research-Komitee der AGA. ARTHROSKOPIE 2023. [DOI: 10.1007/s00142-023-00594-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
ZusammenfassungDas standardisierte Erheben von Behandlungsergebnissen findet immer mehr Einzug in die moderne Medizin. Hierbei ist vor allem das subjektive Ergebnis aus Patientensicht und die damit häufig einhergehende Zufriedenheit mit der medizinischen Behandlung in den Fokus gerückt. Dies hat in den letzten Jahren nicht nur in der akademischen Landschaft, sondern auch auf gesundheitspolitischer Ebene deutlich an Bedeutung gewonnen. Dies bedeutet, dass das Behandlungsergebnis immer mehr Einfluss auf die Vergütung der Leistungserbringer erhält, auch „value-based healthcare“ genannt. Insbesondere in der Orthopädie und Traumatologie gibt es dabei zahlreiche gelenkspezifische Messinstrumente (Fragebögen, Scores oder „patient-reported outcome measures“ [PROMs]), wobei in der Fuß- und Sprunggelenkchirurgie hierfür eine Vielzahl an Fragebögen verfügbar ist, die sich jedoch häufig sehr heterogen und selten pathologiespezifisch darstellen. In Anbetracht der derzeitigen Mannigfaltigkeit an PROMs in der aktuellen Literatur ist es deshalb von Interesse, die wissenschaftliche Qualität zu prüfen und gleichzeitig die Forschungskommunikation zu vereinheitlichen, indem etablierte und gemäß akademischen Gütekriterien ausgewählte Fragebögen zum Einsatz kommen. Ziel ist es, valide, verlässliche und möglichst repräsentative Daten zu gewinnen, um eine akkurate Darstellung der tatsächlichen Ergebnisse zu erreichen. Dies bedingt neben qualitativen Kriterien auch immer kompakte und leicht verständliche Fragenkataloge, um so eine möglichst hohe Rücklaufquote zu generieren. Schließlich sollte auch immer eine Einschätzung der klinischen Relevanz der erhaltenen Ergebnisse stattfinden. Hierfür hat sich der kleinste vom Patienten als klinische Veränderung wahrgenommene Wert des jeweiligen PROM („minimal clinically important difference“, MCID) durchgesetzt. Für den Fuß- und Sprunggelenkbereich werden dabei vom Research Komitee der AGA unter Berücksichtigung dieser Kriterien folgende Messinstrumente empfohlen: FAOS (Foot and Ankle Outcome Score) zur Beurteilung der allgemeinen Schmerzsymptomatik und Funktion sowie der EQ-5D-Fragebogen zur Beurteilung der Lebensqualität. Zwar kann aufgrund fehlender Datenlage keine pathologiespezifische Empfehlung abgegeben werden, jedoch ist der FAOS für eine Vielzahl von Fuß- und Sprunggelenkpathologien validiert und liegt zudem in deutscher Sprache vor.
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Pelkowski JN, Wilke BK, Glabach MR, Bowman JC, Ortiguera CJ, Blasser KE, Crowe MM, Sherman CE, Ledford CK. The Development and Early Experience of a Destination Center of Excellence Program for Total Joint Arthroplasty. Orthop Nurs 2023; 42:4-11. [PMID: 36702089 DOI: 10.1097/nor.0000000000000911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
High-volume total joint arthroplasty centers are becoming designated as destination centers of excellence to ensure quality of care while containing costs. This study aimed to evaluate the surgical patient journey through a new destination center of excellence program, review acute perioperative course trajectories, and report clinical outcomes. Our institution developed and implemented a destination center of excellence program to integrate into the existing total joint arthroplasty practice. A retrospective record review and analysis were performed for the first 100 destination center of excellence total knee arthroplasties and total hip arthroplasties enrolled in the program to evaluate program efficacy at a minimum 1-year follow-up. The study initially screened 213 patients, of whom 100 (47%) met program criteria and completed surgery (67 total knee arthroplasties and 33 total hip arthroplasties). The complication rate was 2%, and five patients (7.5%) required manipulation under anesthesia for stiffness after total knee arthroplasty. Two reoperations were needed: a neurectomy after total knee arthroplasty and a revision after total hip arthroplasty. The early experience of a destination center of excellence program has been favorable, with low complication rates and excellent outcomes.
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Affiliation(s)
- Jessica N Pelkowski
- Jessica N. Pelkowski, APRN, DNP , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Benjamin K. Wilke, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Michelle R. Glabach, RN , Department of Nursing, Mayo Clinic, Jacksonville, FL
- Jacki C. Bowman, RN , Department of Nursing, Mayo Clinic, Jacksonville, FL
- Cedric J. Ortiguera, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Kurt E. Blasser, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Matthew M. Crowe, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Courtney E. Sherman, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Cameron K. Ledford, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
| | - Benjamin K Wilke
- Jessica N. Pelkowski, APRN, DNP , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Benjamin K. Wilke, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Michelle R. Glabach, RN , Department of Nursing, Mayo Clinic, Jacksonville, FL
- Jacki C. Bowman, RN , Department of Nursing, Mayo Clinic, Jacksonville, FL
- Cedric J. Ortiguera, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Kurt E. Blasser, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Matthew M. Crowe, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Courtney E. Sherman, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Cameron K. Ledford, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
| | - Michelle R Glabach
- Jessica N. Pelkowski, APRN, DNP , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Benjamin K. Wilke, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Michelle R. Glabach, RN , Department of Nursing, Mayo Clinic, Jacksonville, FL
- Jacki C. Bowman, RN , Department of Nursing, Mayo Clinic, Jacksonville, FL
- Cedric J. Ortiguera, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Kurt E. Blasser, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Matthew M. Crowe, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Courtney E. Sherman, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Cameron K. Ledford, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
| | - Jacki C Bowman
- Jessica N. Pelkowski, APRN, DNP , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Benjamin K. Wilke, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Michelle R. Glabach, RN , Department of Nursing, Mayo Clinic, Jacksonville, FL
- Jacki C. Bowman, RN , Department of Nursing, Mayo Clinic, Jacksonville, FL
- Cedric J. Ortiguera, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Kurt E. Blasser, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Matthew M. Crowe, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Courtney E. Sherman, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Cameron K. Ledford, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
| | - Cedric J Ortiguera
- Jessica N. Pelkowski, APRN, DNP , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Benjamin K. Wilke, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Michelle R. Glabach, RN , Department of Nursing, Mayo Clinic, Jacksonville, FL
- Jacki C. Bowman, RN , Department of Nursing, Mayo Clinic, Jacksonville, FL
- Cedric J. Ortiguera, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Kurt E. Blasser, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Matthew M. Crowe, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Courtney E. Sherman, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Cameron K. Ledford, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
| | - Kurt E Blasser
- Jessica N. Pelkowski, APRN, DNP , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Benjamin K. Wilke, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Michelle R. Glabach, RN , Department of Nursing, Mayo Clinic, Jacksonville, FL
- Jacki C. Bowman, RN , Department of Nursing, Mayo Clinic, Jacksonville, FL
- Cedric J. Ortiguera, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Kurt E. Blasser, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Matthew M. Crowe, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Courtney E. Sherman, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Cameron K. Ledford, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
| | - Matthew M Crowe
- Jessica N. Pelkowski, APRN, DNP , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Benjamin K. Wilke, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Michelle R. Glabach, RN , Department of Nursing, Mayo Clinic, Jacksonville, FL
- Jacki C. Bowman, RN , Department of Nursing, Mayo Clinic, Jacksonville, FL
- Cedric J. Ortiguera, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Kurt E. Blasser, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Matthew M. Crowe, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Courtney E. Sherman, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Cameron K. Ledford, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
| | - Courtney E Sherman
- Jessica N. Pelkowski, APRN, DNP , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Benjamin K. Wilke, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Michelle R. Glabach, RN , Department of Nursing, Mayo Clinic, Jacksonville, FL
- Jacki C. Bowman, RN , Department of Nursing, Mayo Clinic, Jacksonville, FL
- Cedric J. Ortiguera, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Kurt E. Blasser, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Matthew M. Crowe, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Courtney E. Sherman, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Cameron K. Ledford, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
| | - Cameron K Ledford
- Jessica N. Pelkowski, APRN, DNP , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Benjamin K. Wilke, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Michelle R. Glabach, RN , Department of Nursing, Mayo Clinic, Jacksonville, FL
- Jacki C. Bowman, RN , Department of Nursing, Mayo Clinic, Jacksonville, FL
- Cedric J. Ortiguera, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Kurt E. Blasser, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Matthew M. Crowe, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Courtney E. Sherman, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
- Cameron K. Ledford, MD , Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
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Shah NS, Umeda Y, Suriel Peguero E, Erwin JT, Laughlin R. Outcome Reporting in Total Ankle Arthroplasty: A Systematic Review. J Foot Ankle Surg 2021; 60:770-776. [PMID: 33766479 DOI: 10.1053/j.jfas.2021.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 02/23/2021] [Accepted: 02/26/2021] [Indexed: 02/03/2023]
Abstract
Total ankle arthroplasty is an increasingly utilized treatment for ankle arthritis due to decreasing failure rates and improved outcomes. However, the literature on this procedure remains heterogeneous with large variability in outcome reporting methods. PRISMA guidelines were used to systematically review outcome reporting measures used in prospective studies and randomized control trials on total ankle arthroplasty published in 15 high-impact journals between Jan 1, 2009-May 1, 2020. A total of 43 studies were included and outcome measures were grouped into seven categories: pain, subjective function, patient satisfaction, complications, objective function, implant survivorship, and imaging. The most common topic of study was implant design followed by differences in outcomes when comparing total ankle arthroplasty and arthrodesis. The most commonly reported outcome measure was post-surgical complications. No study reported on all seven categories, while 22 (51.2%) studies reported on four or more. Subjective measures had significant variability with fifteen different Patient Reported Outcome Measures used across the studies. While the included studies were quite comprehensive, there was little consistency in reporting outcomes after total ankle arthroplasty. With improving outcomes and techniques in total ankle arthroplasty, and thus an expected increase in utilization and number of published studies, efforts should be made to use commonly employed outcome reporting methods to facilitate comparison of results across studies.
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Affiliation(s)
- Nihar S Shah
- Research Fellow, Department of Orthopaedics and Sports Medicine, University of Cincinnati Medical Center, Cincinnati, OH.
| | - Yuta Umeda
- Medical Student, Department of Orthopaedics and Sports Medicine, University of Cincinnati Medical Center, Cincinnati, OH
| | - Emil Suriel Peguero
- Medical Student, Ohio University Heritage College of Osteopathic Medicine, Athens, OH
| | - Jace T Erwin
- Resident, Department of Orthopaedics and Sports Medicine, University of Cincinnati Medical Center, Cincinnati, OH
| | - Richard Laughlin
- Professor, Department of Orthopaedics and Sports Medicine, University of Cincinnati Medical Center, Cincinnati, OH
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Cregar WM, Beletsky A, Cvetanovich GL, Feeley BT, Nicholson GP, Verma NN. Cost-effectiveness analyses in shoulder arthroplasty: a critical review using the Quality of Health Economic Studies (QHES) instrument. J Shoulder Elbow Surg 2021; 30:1007-1017. [PMID: 32822877 DOI: 10.1016/j.jse.2020.07.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 07/22/2020] [Accepted: 07/26/2020] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS The purpose of this study was to perform a systematic review to identify cost-analysis studies pertaining to shoulder arthroplasty, provide a comprehensive review of published studies, and critically evaluate the quality of the available literature using the Quality of Health Economic Studies (QHES) instrument. METHODS A systematic review of the literature was performed to identify cost analyses examining shoulder arthroplasty. The inclusion criteria included studies pertaining to either shoulder hemiarthroplasty (HA), total shoulder arthroplasty (TSA), or reverse TSA. Articles were excluded based on the following: nonoperative studies, nonclinical studies, studies not based in the United States, and studies in which no cost analysis was performed. The quality of studies was assessed using the QHES instrument. One-sided Fisher exact testing was performed to identify predictors of both low-quality (ie, QHES score < 25th percentile) and high-quality (ie, QHES score > 75th percentile) cost analyses based on items within the QHES checklist. RESULTS Of the 196 studies screened, 9 were included. Seven studies conducted cost analyses comparing reverse TSA vs. arthroscopic rotator cuff repair, HA, or total hip arthroplasty, and 2 studies examined TSA vs. HA for primary glenohumeral arthritis. The average QHES score among all studies was 86.22 ± 13.39 points. Failure to include an annual cost discounting rate was associated with a low-quality QHES score (P = .03). In addition, including a discussion of the magnitude and direction of potential biases was associated with a high-quality score (P = .03). CONCLUSIONS Shoulder arthroplasty is a cost-effective procedure when used to treat a multitude of shoulder pathologies. The overall quality of cost analysis in shoulder arthroplasty is relatively good, with an average QHES score of 86.22 points. Studies failing to include an annual cost discounting rate are more likely to score below the 25th percentile, whereas those including a discussion of the magnitude and direction of potential biases are more likely to achieve a score in excess of the 75th percentile.
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Affiliation(s)
- William M Cregar
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Alexander Beletsky
- San Diego School of Medicine, University of California, La Jolla, CA, USA
| | - Gregory L Cvetanovich
- Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Brian T Feeley
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Gregory P Nicholson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Nikhil N Verma
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
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Akoh CC, Fletcher AN, Chen J, Wang J, Adams SA, DeOrio JK, Nunley JA, Easley ME. Economic Analysis and Clinical Outcomes of Short-Stay Versus Inpatient Total Ankle Replacement Surgery. Foot Ankle Int 2021; 42:96-106. [PMID: 32875812 DOI: 10.1177/1071100720949200] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We aimed to perform an economic analysis and compare the clinical outcomes between inpatient and short-stay designation total ankle replacement (TAR). METHODS We performed a retrospective study on 178 consecutive patients undergoing primary inpatient versus short-stay designation TAR during the 2016 and 2017 fiscal years. Patient demographics, concomitant procedures, perioperative complications, patient-reported outcomes, and perioperative costs were collected. RESULTS The mean age of our cohort was 62.5 ± 9.6 years (range, 30-88 years), with a significant difference in age (64.1 vs 58.5 years) (P = .005) and Charlson Comorbidity Index (3.3 ± 1.9 vs 2.3 ± 1.4; P = .002) for the inpatient and short-stay designation groups, respectively. At a mean follow-up of 29.6 ± 11.8 months (range, 12-52.3 months), there was no difference in complications between groups (P = .97). The inpatient designation TAR group had a worse baseline Short Musculoskeletal Functional Assessment (SMFA) function score (76.1; 95% CI, 70.5-81.6) than the short-stay designation TAR group (63.9; 95% CI, 52.5-75.3) while achieving similar final postoperative SMFA function scores for the inpatient (55.2; 95% CI, 51.1-59.2) and short-stay (56.2; 95% CI, 48.2-64.2) designation TAR groups (P > .05). However, the inpatient designation TAR group showed a significantly greater mean improvement in SMFA function score (20.9; 95% CI, 19.4-22.4) compared with the short-stay designation TAR group (7.7; 95% CI, 3.7-11.1) (P = .0442). The total direct cost was significantly higher for the inpatient designation group ($15 340) than the short-stay designation group ($13 002) (P < .001). CONCLUSION While inpatient designation TARs were more comorbid, short-stay designation TARs were associated with a 15.5% reduction in perioperative costs, comparable complication rates, and similar final postoperative patient-reported outcome scores compared with inpatient TARs. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Craig C Akoh
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Amanda N Fletcher
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jie Chen
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Juanto Wang
- Department of Foot and Ankle Surgery, Shandong University Qilu Hospital, Jinan, China
| | - Samuel A Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - James K DeOrio
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - James A Nunley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mark E Easley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Helkkula A, Buoye AJ, Choi H, Lee MK, Liu SQ, Keiningham TL. Parents' burdens of service for children with ASD – implications for service providers. JOURNAL OF SERVICE MANAGEMENT 2020. [DOI: 10.1108/josm-01-2020-0011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThe purpose of this investigation is to gain insight into parents' perceptions of benefits vs burdens (value) of educational and healthcare service received for their child with ASD. Parents are the main integrators of long-term educational and healthcare service for their child with ASD.Design/methodology/approachDesign/methodology/approach included (1) a sentiment analysis of discussion forum posts from an autism message board using a rule-based sentiment analysis tool that is specifically attuned to sentiments expressed in social media and (2) a qualitative content analysis of one-on-one interviews with parents of children diagnosed with ASD, complemented with interviews with experienced educators and clinicians.FindingsFindings reveal the link between customized service integration and long-term benefits. Both parents and service providers emphasize the need to integrate healthcare and educational service to create holistic long-term care for a child with ASD. Parents highlight the benefits of varied services, but availability or cost are burdens if the service is not publicly provided, or covered by insurance. Service providers' lack of experience with ASD and people's ignorance of the challenges of ASD are burdens.Practical implicationsEnsuring health outcomes for a child with ASD requires an integrated service system and long-term, customer-centric service process because the scope of service covers the child's entire childhood. Customized educational and healthcare service must be allocated and budgeted early in order to reach the goal of a satisfactory service output for each child.Originality/valueThis is the first service research to focus on parents' challenges with obtaining services for their child with ASD. This paper provides service researchers and managers insight into parents' perceptions of educational and healthcare service value (i.e. benefits vs. burdens) received for their child with ASD. These insights into customer-centric perceptions of value may be useful to research and may help service providers to innovate and provide integrated service directly to parents, or indirectly to service providers, who serve children with ASD.
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Beck EC, Nwachukwu BU, Lee EK, Chapman R, Stubbs AJ, Gitelis M, Rasio J, Nho SJ. Travel Distance Does Not Affect Outcomes in Hip Preservation Surgery: A Case for Centers of Excellence. Orthop J Sports Med 2020; 8:2325967120908821. [PMID: 32232069 PMCID: PMC7092385 DOI: 10.1177/2325967120908821] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 10/18/2019] [Indexed: 12/17/2022] Open
Abstract
Background: Previous studies have evaluated the effect of distance to high-volume centers on outcomes after joint replacement. However, there is limited evidence on whether this distance has an effect on outcomes after undergoing hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS). Purpose: To determine whether increased distance from a patient’s home to his or her primary orthopaedic clinic has an influence on the ability to achieve the minimal clinically important difference (MCID) on outcome measures after surgery for FAIS. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective cohort analysis was performed on patients undergoing surgery for FAIS by a single surgeon from January 2012 through January 2017. A total of 692 patients were identified and split into 2 groups: driving distance of <50 miles from our institution (referral group) and driving distance of <50 miles from our institution (local group). Preoperative and 2-year postoperative scores on patient-reported outcome measures (PROMs), including the Hip Outcome Score Activities of Daily Living and Sport-Specific subscales, International Hip Outcome Tool–12, and modified Harris Hip Score, were assessed. Patients achieving the MCID on any included PROM were analyzed using a chi-square analysis. Logistic regression was performed to determine whether driving distance and other demographic variables of interest had an effect on achieving the MCID. Study data were analyzed using PatientIQ, a cloud-based research and analytics platform for health care. Results: There were 647 patients who completed 2-year follow-up and were included in the analysis. Of these patients, 116 (17.9%) were identified as being ≥50 miles from their orthopaedic provider, and 531 (82.1%) were identified as having a driving distance of <50 miles. A total of 100 patients (86.2%) in the referral group reached the MCID, and 476 patients (89.6%) in the local group reached the MCID. There was no statistically significant difference in reaching the MCID on any of the included PROMs between the 2 groups (P = .364). The same result held when controlling for a number of factors including age, body mass index, and adjusted gross income with logistic regression. Conclusion: When controlling for a number of factors including age, body mass index, and adjusted gross income, distance to a high-volume hip arthroscopic surgery center did not have an effect on postoperative outcome scores or achieving the MCID 2 years after undergoing surgery for FAIS.
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Affiliation(s)
- Edward C. Beck
- Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
- Edward C. Beck, MD, MPH, Department of Orthopaedic Surgery, Wake Forest Baptist Health, 1 Medical Center Boulevard, Winston-Salem, NC 27157, USA ()
| | - Benedict U. Nwachukwu
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | | | - Reagan Chapman
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Allston J. Stubbs
- Investigation performed at Rush University Medical Center, Chicago, Illinois, USA
| | | | - Jonathan Rasio
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Shane J. Nho
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Beletsky A, Lu Y, Manderle BJ, Patel BH, Chahla J, Nwachukwu BU, Forsythe B, Verma NN. Quantifying the Opportunity Cost of Resident Involvement in Academic Orthopaedic Sports Medicine: A Matched-Pair Analysis. Arthroscopy 2020; 36:834-841. [PMID: 31919030 DOI: 10.1016/j.arthro.2019.09.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 09/09/2019] [Accepted: 09/12/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To quantify the cost of resident involvement in academic sports medicine by examining differences in operative time, relative value units (RVUs) per case, and RVUs per hour between attending-only cases and cases with resident involvement. METHODS A retrospective analysis of common sports medicine procedures identified by Current Procedural Terminology code was performed using data from the American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2015. Matched cohorts were generated based on demographic variables, comorbidities, preoperative laboratory values, and surgical procedures. Bivariate analysis examined mean differences in operative time, RVUs per case, and RVUs per hour between attending-only cases and cases with resident involvement. A cost analysis was performed to quantify differences in RVUs generated per hour in terms of dollars per case. RESULTS A total of 14,840 attending-only cases and 2,230 resident-involved cases were used to generate 2 matched cohorts (N = 4,460). Resident cases had greater mean operative times than attending-only cases, with operative time increasing as residents became more senior (P < .01). Residents participated in cases with larger mean RVUs per case (P < .01). Cases with lone attendings showed greater RVUs per hour (P < .01). The cost of resident involvement increased nearly 8-fold from postgraduate year 1 to postgraduate year 6 residents ($25.70 vs $200.07). CONCLUSIONS In academic sports medicine, the involvement of resident physicians increases operative time. The associated decrease in attending physician efficiency in RVUs per hour equates to an average cost per case of $159.18, with costs increasing as residents become more senior. LEVEL OF EVIDENCE Level III, retrospective comparative trial.
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Affiliation(s)
- Alexander Beletsky
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Yining Lu
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Brandon J Manderle
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Bhavik H Patel
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jorge Chahla
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Benedict U Nwachukwu
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Brian Forsythe
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Nikhil N Verma
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A..
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Five-Year Follow-Up of Distal Tibia Bone and Foot and Ankle Trauma Treated with a 3D-Printed Titanium Cage. Case Rep Orthop 2019; 2019:7571013. [PMID: 31885986 PMCID: PMC6899301 DOI: 10.1155/2019/7571013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 09/14/2019] [Indexed: 12/26/2022] Open
Abstract
Large bone defects from trauma or cancer are difficult to treat. Current treatment options include the use of external fixation with bone transport, bone grafting, or amputation. These modes of therapy continue to pose challenges as they are associated with high cost, failure, and complication rates. In this study, we report a successful case of bone defect treatment using personalized 3D-printed implant. This is the longest known follow-up using a 3D-printed custom implant for this specific application. Ultimately, this report adds to existing literature as it demonstrates successful and maintained incorporation of bone into the titanium implant. The use of patient-specific 3D-printed implants adds to the available arsenal to treat complex pathologies of the foot and ankle. Moreover, the technology's flexibility and ease of customization makes it conducive to tailor to specific patient needs.
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Abstract
OBJECTIVES With value-based payment models on the horizon, this study was designed to examine the perceptions of value-based care among orthopaedic traumatologists and how they influence their practice. DESIGN Systems-based survey study. SETTING Orthopaedic Trauma Association (OTA) research surveys. PARTICIPANTS OTA members. MAIN OUTCOME MEASURE Thirty-eight-question surveys focusing on 5 areas related to value-based care: understanding value, assessing interest, barriers, perceptions around implementing value-based strategies, and policy. RESULTS Of 1106 OTA members, 252 members responded for a response rate of 22.7%. Consideration around cost was not different between hospital, academic, and private practice settings (P = 0.47). Previous reported experience in finance increased the amount surgical decision-making was influenced by cost (P < 0.01), along with reported understanding of implant costs (P < 0.01). Over half of the respondents (59.4%) believed value-based payments are coming to orthopaedic trauma. The vast majority (88.5%) believed bundled payments would be unsuccessful or only partially successful. With respect to barriers, a third of respondents (34.7%) indicated accurate cost data prevented the implementation of programs that track and maximize value, another third (31.5%) attributed it to a limited ability to collect patient-reported outcomes, and the rest (33.8%) were split between lack of institutional interest and access to funding. CONCLUSION Our study indicated the understanding of value in orthopaedic trauma is limited and practice integration is rare. Reported experience in finance was the only factor associated with increased consideration of value-based care in practice. Our results highlight the need for increased exposure and resources to changing health care policy, specifically for orthopaedic traumatologists. LEVEL OF EVIDENCE Level V. See Instructions for Authors for a complete description of levels of evidence.
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Raouf T, Rogero R, McDonald E, Fuchs D, Shakked RJ, Winters BS, Daniel JN, Pedowitz DI, Raikin SM. Value of Preoperative Imaging and Intraoperative Histopathology in Morton's Neuroma. Foot Ankle Int 2019; 40:1032-1036. [PMID: 31142153 DOI: 10.1177/1071100719851121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recent studies have demonstrated that clinical diagnosis of Morton's neuroma is highly correlated with operative and histopathologic diagnosis, whereas others have questioned the cost-effectiveness of intraoperative histopathology of excised specimens. The purpose of this study was to determine the utility of both preoperative imaging and intraoperative histology in the treatment of Morton's neuroma in making an accurate diagnosis, guiding treatment decisions, and altering clinical outcomes. METHODS A retrospective review was performed on all patients who underwent operative resection suspected Morton's neuroma with 4 fellowship-trained foot and ankle surgeons between 2007 and 2017. Procedures were excluded from the study if the pathology report was not available for review. Diagnoses were made either by clinical examination and/or by the results of preoperative imaging. All pathology reports were reviewed to determine the final diagnosis, considered the "gold standard." Postoperative chart notes were reviewed to determine if any treatment regimen was altered based on the pathology report revealing an alternate diagnosis other than Morton's neuroma. Two hundred eighty-seven procedures in 269 patients with 313 clinically suspected neuromas met inclusion criteria. RESULTS Of the 313 suspected neuromas, 309 (98.7%) were confirmed Morton's neuromas on histopathologic examination. For no patient did the results of the pathology report alter the postoperative treatment course. Preoperative imaging results were available for 179 (57.2%) suspected neuromas, with magnetic resonance imaging (MRI) and ultrasonography used to preoperatively image 121 and 71 suspected neuromas, respectively, including 13 using both. The total estimated cost of histopathologic analysis for the cohort was $143 667, and the estimated combined cost of preoperative imaging and intraoperative histopathology in our cohort totaled $278 567. CONCLUSION Our study found that the diagnosis of Morton's neuroma could be made clinically with extreme accuracy and positive predictive value, calling into question the utility and costs of other imaging modalities and intraoperative sampling for histopathologic diagnosis. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Tammer Raouf
- 1 Rothman Orthopaedic Institute, Philadelphia, PA, USA.,2 Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - Ryan Rogero
- 1 Rothman Orthopaedic Institute, Philadelphia, PA, USA.,3 Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Elizabeth McDonald
- 1 Rothman Orthopaedic Institute, Philadelphia, PA, USA.,3 Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Daniel Fuchs
- 1 Rothman Orthopaedic Institute, Philadelphia, PA, USA
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Matthews M, Klein E, Acciani A, Sorensen M, Weil L, Weil LS, Fleischer A. Correlation of Preoperative Radiographic Severity With Disability and Symptom Severity in Hallux Valgus. Foot Ankle Int 2019; 40:923-928. [PMID: 31006267 DOI: 10.1177/1071100719845002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Some US insurance companies have recently started to require minimum angular measurements, for coverage decisions, in patients seeking operative correction for symptomatic hallux valgus. This logic naturally assumes that the magnitude of radiographic bunion deformity is related to the magnitude of patient's presenting symptoms and/or disability. METHODS We conducted an analysis of existing data in our practice to determine whether patient-reported symptoms and disability prior to bunion surgery correlated with preoperative radiographic measurements commonly used to quantify hallux valgus severity. Symptoms and disability level were determined using patient-reported preoperative Foot and Ankle Outcome Score (FAOS), a validated instrument commonly used in hallux valgus assessment. Spearman correlation coefficient was then used to quantify the strength of any correlations. Preoperative data from 107 patients (107 feet) with mean age of 49.3 ± 13.8 years who underwent isolated osseous hallux valgus surgery within our practice between June 1, 2016, and July 30, 2018, were available. RESULTS No radiographic variable achieved even a moderate correlation with any of the FAOS subscales with the exception of tibial sesamoid position with FAOS Pain (rho=0.402, P = .01) in patients aged 56 years and older. The direction of this correlation was positive, indicating that greater preoperative sesamoid abnormalities were paradoxically associated with less presenting pain (ie, higher FAOS Pain scores). CONCLUSION It would appear that radiographic severity of bunion deformity is not well correlated with symptom level and/or disability and, we would argue, should not play a role in coverage decisions for patients presenting for hallux valgus surgery. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
| | - Erin Klein
- 1 Weil Foot and Ankle Institute, Des Plaines, IL, USA
| | - Alyse Acciani
- 2 Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | | | - Lowell Weil
- 1 Weil Foot and Ankle Institute, Des Plaines, IL, USA
| | - Lowell S Weil
- 1 Weil Foot and Ankle Institute, Des Plaines, IL, USA
| | - Adam Fleischer
- 1 Weil Foot and Ankle Institute, Des Plaines, IL, USA.,2 Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
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Matthews M, Klein E, Youssef A, Weil L, Sorensen M, Weil LS, Fleischer A. Correlation of Radiographic Measurements With Patient-Centered Outcomes in Hallux Valgus Surgery. Foot Ankle Int 2018; 39:1416-1422. [PMID: 30136598 DOI: 10.1177/1071100718790255] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND: Evaluation of patients undergoing hallux valgus surgery has historically emphasized radiographic angles and relationships. However, patient-reported outcomes are increasingly important as health care systems trend towards a "value-based" delivery approach. METHODS: We conducted a retrospective analysis of pre-existing data in our practice to examine whether patient-reported outcomes after bunion surgery, determined via Foot and Ankle Outcome Scores (FAOS), correlated with radiographic parameters commonly measured in hallux valgus deformity. Pearson correlation statistics and simple and multiple linear regression models were used to identify important radiographic predictors. There were 80 patients (80 feet) with mean follow-up of 59.3 ± 11.6 weeks (median 55, range 45.7-96.3 weeks) with complete data. RESULTS: No radiographic measurement/variable achieved anything more than a weak correlation with any of the FAOS subscale scores at final follow-up; the study's best was postoperative first-second intermetatarsal (IM) angle with sports and recreation scores ( r = -0.328, P = .005). There was no correlation found between change in hallux valgus angle, change in first-second IM angle, magnitude of preoperative hallux valgus angle or magnitude of preoperative first-second IM angle ( P > .05 for all). Furthermore, none of the study's final multivariable models achieved an R2 > 0.24, and nearly all fell between 0.10 and 0.17. CONCLUSION: We conclude that radiographic angles were not well correlated with patient-centered outcomes in hallux valgus surgery. This study calls into question the current emphasis that is placed on x-ray values both pre- and postoperatively. LEVEL OF CLINICAL EVIDENCE: Level III, comparative study.
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Affiliation(s)
| | - Erin Klein
- 1 Weil Foot and Ankle Institute, Des Plaines, IL, USA
| | - Angie Youssef
- 1 Weil Foot and Ankle Institute, Des Plaines, IL, USA
| | - Lowell Weil
- 1 Weil Foot and Ankle Institute, Des Plaines, IL, USA
| | | | - Lowell S Weil
- 1 Weil Foot and Ankle Institute, Des Plaines, IL, USA
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Ramkumar PN, Haeberle HS, Iannotti JP, Ricchetti ET. The Volume-Value Relationship in Shoulder Arthroplasty. Orthop Clin North Am 2018; 49:519-525. [PMID: 30224013 DOI: 10.1016/j.ocl.2018.05.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Improving value in shoulder arthroplasty has gained increasing importance as procedure volume increases. To enhance the value of shoulder arthroplasty, an improvement of outcomes or a decrease in associated costs must occur. With the recent shift to a value-based care delivery model, analysis of the effects of surgical volume presents an opportunity to improve outcomes and reduce costs in shoulder arthroplasty. There are multiple reports in the literature expanding on the relationship between increased surgeon and hospital procedure volume and increased value for shoulder arthroplasty, by way of improved outcomes or decreased cost. This article highlights these studies.
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Affiliation(s)
- Prem N Ramkumar
- Cleveland Clinic, Department of Orthopaedic Surgery, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Heather S Haeberle
- Baylor College of Medicine, Department of Orthopaedic Surgery, 7200 Cambridge Street, Houston, TX 77030, USA
| | - Joseph P Iannotti
- Cleveland Clinic, Department of Orthopaedic Surgery, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Eric T Ricchetti
- Cleveland Clinic, Department of Orthopaedic Surgery, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Dekker TJ, Hamid KS, Federer AE, Steele JR, Easley ME, Nunley JA, Adams SB. The Value of Motion: Patient-Reported Outcome Measures Are Correlated With Range of Motion in Total Ankle Replacement. Foot Ankle Spec 2018; 11:451-456. [PMID: 29277111 DOI: 10.1177/1938640017750258] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The proposed benefit of total ankle replacement (TAR) over ankle fusion is preserved ankle motion, thus we hypothesized that an increase in range of motion (ROM) is positively correlated with validated patient-reported outcome measures (PROMs) in individuals receiving TAR. METHODS Patients undergoing TAR at a single academic medical center between 2007 and 2013 were evaluated in this study. In addition to a minimum of 2-year follow-up, complete preoperative and postoperative outcome measures for the Foot and Ankle Disability Index (FADI), Short Musculoskeletal Function Assessment (SMFA) Bother and Function Indices, Visual Analog Scale (VAS), and 36-Item Short Form Health Survey (SF-36) were requisite for inclusion. Standardized weightbearing maximum dorsiflexion and plantarflexion sagittal radiographs were obtained and previously described ankle and foot measurements were performed to determine ankle ROM. RESULTS Eighty-eight patients met inclusion criteria (33 INBONE, 18 Salto-Talaris, 37 STAR). Mean time to final ROM radiographs was 43.8 months (range 24-89 months). All aforementioned PROMs improved between preoperative evaluation and most recent follow-up ( P < .01). Final ankle ROM was significantly correlated with postoperative FADI, SF-36 Mental Component Summary (MCS), SMFA Bother and Function Indices, and VAS. Additionally, dorsiflexion was positively associated with FADI, SF-36 MCS, and SMFA Function ( P < .05) but plantarflexion had no such influence on outcomes. No differences were identified with subset stratification by prosthesis type, fixed versus mobile-bearing design or etiology. CONCLUSION In this TAR cohort with prospectively collected outcomes data, radiographic sagittal plane ankle motion was positively correlated with multiple PROMs. Disease-specific and generic health-related quality of life PROMs demonstrated improvement postoperatively in all domains when evaluating final total range of motion. Patients who undergo TAR for end-stage osteoarthritis with improvement in ROM demonstrate a direct correlation with improved patient-centric metrics and outcome scores. LEVELS OF EVIDENCE Level III: Retrospective comparative study.
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Affiliation(s)
- Travis J Dekker
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Kamran S Hamid
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Andrew E Federer
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - John R Steele
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mark E Easley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - James A Nunley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Samuel B Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
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Karhade AV, Kwon JY. Cost-Utility Analyses in US Orthopaedic Foot and Ankle Surgery: A Systematic Review. Foot Ankle Spec 2018; 11:1938640018782588. [PMID: 29923750 DOI: 10.1177/1938640018782588] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND While investigations have been performed examining the quality of US-based cost-utility analyses for other orthopaedic subspecialties and have provided important insights, a similar analysis has not been performed examining the foot and ankle literature. METHODS A systematic review of foot and ankle studies was conducted to identify cost-utility analyses published between 2000 and 2017. Of 687 studies screened by abstract, 4 cost-utility studies were identified and scored by the Quality of Health Economic Studies instrument. RESULTS Of these 4 studies, 3 examined end-stage arthritis and 1 examined unstable ankle fractures. Cost-effective interventions identified by these studies included the performance of total ankle arthroplasty over ankle arthrodesis or nonoperative treatment for end-stage arthritis and suture button fixation over syndesmotic screws for unstable supination-external rotation ankle fractures. The mean Quality of Health Economic Studies scores for these studies was 87.5. CONCLUSION Despite the increasing focus on value-based care delivery in the United States, there are few foot and ankle cost-utility analyses. Nonetheless, the quality of existing analyses is high. Certain interventions have been identified as cost-effective as highlighted above and the findings of this review can be used to help design future analyses in order to best demonstrate the cost-effectiveness of foot and ankle interventions. LEVELS OF EVIDENCE Level III: Systematic Review of level III studies.
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Affiliation(s)
- Aditya V Karhade
- Orthopaedic Foot & Ankle Service, Department of Orthopaedic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - John Y Kwon
- Orthopaedic Foot & Ankle Service, Department of Orthopaedic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Gagné OJ, Veljkovic A, Glazebrook M, Daniels TR, Penner MJ, Wing KJ, Younger ASE. Prospective Cohort Study on the Employment Status of Working Age Patients After Recovery From Ankle Arthritis Surgery. Foot Ankle Int 2018; 39:657-663. [PMID: 29506397 DOI: 10.1177/1071100718757722] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND People who are affected by end-stage ankle arthritis are as disabled as those suffering from arthritis in other main articulations of the lower extremity. Once these patients become unable to perform their job duties, they leave the workforce and require financial aid from government agencies, which represents a considerable economic burden. Regardless of whether arthrodesis or arthroplasty is performed, we hypothesized that patients younger than 55 years at the time of surgery should be able to return to work within 2 years and require less social assistance. METHODS Patients from 2002 to 2014 included in the nationwide prospective Ankle Reconstruction Database treated for end-stage ankle arthritis with a total ankle replacement or an ankle arthrodesis and younger than 55 years at the time of surgery were included. This study used a standard preoperative survey (AAOS, SF-36) along with the same survey filled by patients in intervals up to 2 years postoperatively. Their employment status was determined at each time point. Participation in third-party wage assistance programs was recorded. This cohort had 194 patients with an average age of 47.0 ± 7.2 years and was balanced in terms of sex (104 female) and side (94 left). RESULTS The employment rate prior to surgery was 56%, which increased to 62% at the 2-year postoperative mark. With regards to worker's compensation, disability, and social security, 20% of patients left all subsidized programs whereas 4% entered at least 1 which is significant (P < .05). CONCLUSION The 2-year follow-up after tibiotalar arthrodesis/arthroplasty in patients younger than 55 years showed that significantly more people were able to leave subsidized work assistance programs than enroll in them. LEVEL OF EVIDENCE Level II, prospective comparative study.
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Affiliation(s)
- Oliver J Gagné
- 1 University of British Columbia Orthopedics, Vancouver, BC, Canada
| | - Andrea Veljkovic
- 2 Saint-Paul's Hospital Department of Orthopedics, Vancouver, BC, Canada
| | - Mark Glazebrook
- 3 Queen Elizabeth Health Science Center, Halifax, NS, Canada
| | | | | | - Kevin J Wing
- 2 Saint-Paul's Hospital Department of Orthopedics, Vancouver, BC, Canada
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Hamid KS, Nwachukwu BU, Bozic KJ. Decisions and Incisions: A Value-Driven Practice Framework for Academic Surgeons. J Bone Joint Surg Am 2017; 99:e50. [PMID: 28509834 DOI: 10.2106/jbjs.16.00818] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Kamran S Hamid
- 1Rush University Medical Center, Chicago, Illinois 2Hospital for Special Surgery, New York, NY 3Dell Medical School, The University of Texas at Austin, Austin, Texas
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Gonzalez T, Fisk E, Chiodo C, Smith J, Bluman EM. Economic Analysis and Patient Satisfaction Associated With Outpatient Total Ankle Arthroplasty. Foot Ankle Int 2017; 38:507-513. [PMID: 28061741 DOI: 10.1177/1071100716685551] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total ankle arthroplasty (TAA) is a rapidly growing treatment for end-stage ankle arthritis that is generally performed as an inpatient procedure. The feasibility of outpatient total ankle arthroplasty (OTAA) has not been reported in the literature. We sought to establish proof of concept for OTAA by comparing outpatient vs inpatient perioperative complications, postoperative emergency department (ED) visits, readmissions, patient satisfaction, and cost analysis. METHODS From July 2010 to September 2015, a total of 36 patients underwent TAA. Patients with prior ankle replacement, prior ankle infections, neuroarthropathy, or osteonecrosis of the talus were excluded from the study. All patient demographics, tourniquet times, estimated blood loss, comorbidities, concomitant procedures, complications, return ED visits, and readmissions were recorded. Patient satisfaction questionnaires were collected. Twenty-one patients had outpatient surgery and 15 had inpatient surgery. The cohorts were matched demographically. RESULTS The average length of stay for the inpatient group was 2.5 days. The overall cost differential between the groups was 13.4%, with the outpatient group being less costly. This correlates to a cost savings of nearly $2500 per case. One patient in the outpatient group had a return ED visit on postoperative day 1 for urinary retention. There were no 30-day readmissions in either group. Seventy-one percent of the outpatient group and 93% of the inpatient group would not change to a different postoperative admission status if they were to have the procedure again. CONCLUSION Our results show that OTAA was a cost-effective and safe alternative with low complication rates and high patient satisfaction. With proper patient selection, OTAA was beneficial to both the patient and the health care system by driving down total cost. It has the capacity to generate substantial savings while providing equal or better value to the patient. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Tyler Gonzalez
- 1 Harvard Combined Orthopaedic Residency Program, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Erica Fisk
- 2 Harvard Medical School, Brigham Foot & Ankle Center, Faulkner Hospital, Boston, MA, USA
| | - Christopher Chiodo
- 3 Orthopaedic Surgery, Harvard Medical School, Chief, Division of Foot and Ankle Surgery, Brigham and Women's Hospital, Brigham Foot and Ankle Center, Faulkner Hospital, Jamaica Plain, MA, USA
| | - Jeremy Smith
- 2 Harvard Medical School, Brigham Foot & Ankle Center, Faulkner Hospital, Boston, MA, USA
| | - Eric M Bluman
- 2 Harvard Medical School, Brigham Foot & Ankle Center, Faulkner Hospital, Boston, MA, USA
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Gross CE, Hamid KS, Green C, Easley ME, DeOrio JK, Nunley JA. Operative Wound Complications Following Total Ankle Arthroplasty. Foot Ankle Int 2017; 38:360-366. [PMID: 28367692 DOI: 10.1177/1071100716683341] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Wound complications following total ankle replacement (TAR) potentially lead to devastating consequences. The aim of this study was to compare the operative and demographic differences in patients with and without major wound problems which required operative management. We hypothesized that increased tourniquet and operative time would negatively influence wound healing. METHODS We identified a consecutive series of 762 primary TARs performed between December 1999 and April 2014 whose data were prospectively collected. We then identified the subset of patients who required a secondary surgery to treat major wound complications (ie, operative debridement, split-thickness skin grafting, and soft tissue reconstruction). All patients requiring a second surgery had operative wound debridement. We then compared the demographics, operative characteristics, and functional scores to see if any differences existed between patients with and without major wound complications. Clinical outcomes including secondary procedures and implant failure rates were recorded. RESULTS Twenty-six patients (3.4%) had a total of 49 operative procedures to treat major wound issues. Eighteen patients had flaps and 14 had split-thickness skin grafts. The median time to operatively treating the wound was 1.9 (range: 0.5-12.5) months after the index TAR. The median follow-up time from the wound procedure was 12.7 (range: 1.2-170.8) months. Compared to the control group, patients with major wounds had a significantly longer mean surgery (214.8 vs 189.3 minutes, P = .041) time and trended toward a longer median tourniquet time (151 vs 141 minutes, P = .060). Patients without wound complications were more likely to have posttraumatic arthritis, whereas those with wound complications were more likely to have primary osteoarthritis ( P = .006). The control group trended toward having a higher mean BMI (29.5 vs 27.2, P = .056). There were 6 failures in the major wound complication cohort (23.1%), including 2 below the knee amputations. CONCLUSION Ankle wounds that required operative management had high failure rates and some resulted in devastating outcomes. We did not find any increase in major wound complications in those with various risk factors as identified by other studies. Given our data, we recommend limiting operative time. While correcting hindfoot and midfoot alignment is important for improving patient functionality and survivorship of the implant, thought should be given to staging the TAR if multiple pathologies are to be addressed at the time of surgery to limit operative time. LEVEL OF EVIDENCE Level III, retrospective comparative series.
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Affiliation(s)
- Christopher E Gross
- 1 Department of Orthopaedics, Medical University of South Carolina, Charleston, SC, USA
| | - Kamran S Hamid
- 2 Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Cynthia Green
- 3 Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Mark E Easley
- 4 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - James K DeOrio
- 4 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - James A Nunley
- 4 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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25
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Hamid KS, Dekker TJ, White PW, Adams SB. Radiolucent Triangle as a Positioning Tool to Simplify Prone Ankle Fracture Surgery. Foot Ankle Spec 2017; 10:51-54. [PMID: 27798067 DOI: 10.1177/1938640016675411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
UNLABELLED Prone positioning affords significant benefits for the fixation of trimalleolar ankle fractures and has been the long-time standard for treatment of these injuries. However, 2 primary disadvantages hamper its utility. First, access to the medial ankle is impeded by the contralateral limb and inability to rotate the operative leg to the extent that is possible in other positions. Second, lateral fluoroscopic imaging of the ankle can be cumbersome and often necessitates physically elevating the ankle for a radiograph then placing it back on the operative table. We describe a simple and cost-conscious technique for overcoming these obstacles of prone positioning in ankle fracture surgery. Judicious placement of a radiolucent triangle under the nonoperative leg in the prone position allows for unobstructed access to the medial ankle in conjunction with simplified lateral fluoroscopic imaging. An alternative technique is to place the radiolucent triangle under the operative leg with the bed in reverse Trendelenberg. Surgeons should consider adding these positioning techniques to their operative armamentarium for usage in appropriate cases. LEVELS OF EVIDENCE Level V.
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Affiliation(s)
- Kamran S Hamid
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Travis J Dekker
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Peter W White
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Samuel B Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
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26
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Hamid KS, Matson AP, Nwachukwu BU, Scott DJ, Mather RC, DeOrio JK. Determining the Cost-Savings Threshold and Alignment Accuracy of Patient-Specific Instrumentation in Total Ankle Replacements. Foot Ankle Int 2017; 38:49-57. [PMID: 27649973 DOI: 10.1177/1071100716667505] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Traditional intraoperative referencing for total ankle replacements (TARs) involves multiple steps and fluoroscopic guidance to determine mechanical alignment. Recent adoption of patient-specific instrumentation (PSI) allows for referencing to be determined preoperatively, resulting in less steps and potentially decreased operative time. We hypothesized that usage of PSI would result in decreased operating room time that would offset the additional cost of PSI compared with standard referencing (SR). In addition, we aimed to compare postoperative radiographic alignment between PSI and SR. METHODS Between August 2014 and September 2015, 87 patients undergoing TAR were enrolled in a prospectively collected TAR database. Patients were divided into cohorts based on PSI vs SR, and operative times were reviewed. Radiographic alignment parameters were retrospectively measured at 6 weeks postoperatively. Time-driven activity-based costing (TDABC) was used to derive direct costs. Cost vs operative time-savings were examined via 2-way sensitivity analysis to determine cost-saving thresholds for PSI applicable to a range of institution types. Cost-saving thresholds defined the price of PSI below which PSI would be cost-saving. A total of 35 PSI and 52 SR cases were evaluated with no significant differences identified in patient characteristics. RESULTS Operative time from incision to completion of casting in cases without adjunct procedures was 127 minutes with PSI and 161 minutes with SR ( P < .05). PSI demonstrated similar postoperative accuracy to SR in coronal tibial-plafond alignment (1.1 vs 0.3 degrees varus, P = .06), tibial-plafond alignment (0.3 ± 2.1 vs 1.1 ± 2.1 degrees varus, P = .06), and tibial component sagittal alignment (0.7 vs 0.9 degrees plantarflexion, P = .14). The TDABC method estimated a PSI cost-savings threshold range at our institution of $863 below which PSI pricing would provide net cost-savings. Two-way sensitivity analysis generated a globally applicable cost-savings threshold model based on institution-specific costs and surgeon-specific time-savings. CONCLUSIONS This study demonstrated equivalent postoperative TAR alignment with PSI and SR referencing systems but with a significant decrease in operative time with PSI. Based on TDABC and associated sensitivity analysis, a cost-savings threshold of $863 was identified for PSI pricing at our institution below which PSI was less costly than SR. Similar internal cost accounting may benefit health care systems for identifying cost drivers and obtaining leverage during price negotiations. LEVEL OF EVIDENCE Level III, therapeutic study.
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27
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Hamid KS, Nunley JA. Quo Vadis? Perspectives on the Future of Foot & Ankle Fellowship Training. Foot Ankle Int 2016; 37:1146-1148. [PMID: 27030232 DOI: 10.1177/1071100716642245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Kamran S Hamid
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - James A Nunley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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28
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Affiliation(s)
- Kamran S Hamid
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Selene G Parekh
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Samuel B Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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What Are the Strength of Recommendations and Methodologic Reporting in Health Economic Studies in Orthopaedic Surgery? Clin Orthop Relat Res 2015; 473:3289-96. [PMID: 26024580 PMCID: PMC4562945 DOI: 10.1007/s11999-015-4369-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 05/19/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cost-effectiveness research is an increasingly used tool in evaluating treatments in orthopaedic surgery. Without high-quality primary-source data, the results of a cost-effectiveness study are either unreliable or heavily dependent on sensitivity analyses of the findings from the source studies. However, to our knowledge, the strength of recommendations provided by these studies in orthopaedics has not been studied. QUESTIONS/PURPOSES We asked: (1) What are the strengths of recommendations in recent orthopaedic cost-effectiveness studies? (2) What are the reasons authors cite for weak recommendations? (3) What are the methodologic reporting practices used by these studies? METHODS The titles of all articles published in six different orthopaedic journals from January 1, 2004, through April 1, 2014, were scanned for original health economics studies comparing two different types of treatment or intervention. The full texts of included studies were reviewed to determine the strength of recommendations determined subjectively by our study team, with studies providing equivocal conclusions stemming from a lack or uncertainty surrounding key primary data classified as weak and those with definitive conclusions not lacking in high-quality primary data classified as strong. The reasons underlying a weak designation were noted, and methodologic practices reported in each of the studies were examined using a validated instrument. A total of 79 articles met our prespecified inclusion criteria and were evaluated in depth. RESULTS Of the articles included, 50 (63%) provided strong recommendations, whereas 29 (37%) provided weak recommendations. Of the 29 studies, clinical outcomes data were cited in 26 references as being insufficient to provide definitive conclusions, whereas cost and utility data were cited in 13 and seven articles, respectively. Methodologic reporting practices varied greatly, with mixed adherence to framing, costs, and results reporting. The framing variables included clearly defined intervention, adequate description of a comparator, study perspective clearly stated, and reported discount rate for future costs and quality-adjusted life years. Reporting costs variables included economic data collected alongside a clinical trial or another primary source and clear statement of the year of monetary units. Finally, results reporting included whether a sensitivity analysis was performed. CONCLUSIONS Given that a considerable portion of orthopaedic cost-effectiveness studies provide weak recommendations and that methodologic reporting practices varied greatly among strong and weak studies, we believe that clinicians should exercise great caution when considering the conclusions of cost-effectiveness studies. Future research could assess the effect of such cost-effectiveness studies in clinical practice, and whether the strength of recommendations of a study's conclusions has any effect on practice patterns. CLINICAL RELEVANCE Given the increasing use of cost-effectiveness studies in orthopaedic surgery, understanding the quality of these studies and the reasons that limit the ability of studies to provide more definitive recommendations is critical. Highlighting the heterogeneity of methodologic reporting practices will aid clinicians in interpreting the conclusions of cost-effectiveness studies and improve future research efforts.
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Nwachukwu BU, Schairer WW, O'Dea E, McCormick F, Lane JM. The Quality of Cost-Utility Analyses in Orthopedic Trauma. Orthopedics 2015; 38:e673-80. [PMID: 26270752 DOI: 10.3928/01477447-20150804-53] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 10/23/2014] [Indexed: 02/03/2023]
Abstract
As health care in the United States transitions toward a value-based model, there is increasing interest in applying cost-effectiveness analysis within orthopedic surgery. Orthopedic trauma care has traditionally underemphasized economic analysis. The goals of this review were to identify US-based cost-utility analysis in orthopedic trauma, to assess the quality of the available evidence, and to identify cost-effective strategies within orthopedic trauma. Based on a review of 971 abstracts, 8 US-based cost-utility analyses evaluating operative strategies in orthopedic trauma were identified. Study findings were recorded, and the Quality of Health Economic Studies (QHES) instrument was used to grade the overall quality. Of the 8 studies included in this review, 4 studies evaluated hip and femur fractures, 3 studies analyzed upper extremity fractures, and 1 study assessed open tibial fracture management. Cost-effective interventions identified in this review include total hip arthroplasty (over hemiarthroplasty) for femoral neck fractures in the active elderly, open reduction and internal fixation (over nonoperative management) for distal radius and scaphoid fractures, limb salvage (over amputation) for complex open tibial fractures, and systems-based interventions to prevent delay in hip fracture surgery. The mean QHES score of the studies was 79.25 (range, 67-89). Overall, there is a paucity of cost-utility analyses in orthopedic trauma; however, the available evidence suggests that certain operative interventions can be cost-effective. The quality of these studies, however, is fair, based on QHES grading. More attention should be paid to evaluating the cost-effectiveness of operative intervention in orthopedic trauma.
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31
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Soukup DS, O'Malley MJ, Ellis SJ. Costs Versus Benefits of Routine Histopathological Examination in Total Ankle Replacement. Foot Ankle Int 2015; 36:801-5. [PMID: 25761849 DOI: 10.1177/1071100715576371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Routine histopathological examination has previously been scrutinized as a source of extraneous cost in orthopedic foot and ankle care. As an increasingly prevalent joint replacement operation, total ankle replacement poses a notable cost to the health care market in an era of cost containment. The purpose of this study was to compare the costs and benefits of routine histopathological examination of specimens removed during total ankle replacement. We hypothesized that a new diagnosis would rarely be found and such examination would seldom alter patient care. METHODS A retrospective review was conducted of all total ankle replacement operations between 2006 and July 2014 at the investigators' institution. Medical records for 90 patients, undergoing a total of 95 total ankle replacement operations, were reviewed to determine the clinical and pathological diagnoses for each operation and, subsequently, the rates of discrepancy and discordance. Professional charges were determined using estimated reimbursement rates for the Current Procedural Terminology (CPT) codes billed: 88304 (level III microscopic examination), 88305 (level IV microscopic examination), and 88311 (decalcification). RESULTS Degenerative joint disease was diagnosed by the pathologist in 93.7% of cases (89/95), pseudogout in 4.2% (4/95), and rheumatoid arthritis in 2.1% (2/95). The 4 diagnoses of pseudogout were the only cases of new diagnoses based on pathological review. A total of $16,536.81 was spent for examination of all specimens, for an estimated $4,134.20 spent per discrepant diagnosis. Patient care was unaffected by pathological examination. CONCLUSION A new diagnosis was rarely found by histopathological examination, and patient care remained unaltered in all cases. The costs of routine histopathological examination of tissue specimens removed during total ankle replacement, therefore, outweigh clinical benefits, and such examination should be left to the discretion of the operating surgeon. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Dylan S Soukup
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Martin J O'Malley
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Scott J Ellis
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
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Nwachukwu BU, Dy CJ, Burket JC, Padgett DE, Lyman S. Risk for Complication after Total Joint Arthroplasty at a Center of Excellence: The Impact of Patient Travel Distance. J Arthroplasty 2015; 30:1058-61. [PMID: 25639857 DOI: 10.1016/j.arth.2015.01.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 01/02/2015] [Accepted: 01/11/2015] [Indexed: 02/01/2023] Open
Abstract
Healthcare reorganization and bundled payment schemes have resulted in increased patient travel distances in orthopedics. Travel distance has been previously associated with increased complication risk but has yet to be studied in orthopedics. We analyzed the impact of patient travel distance on short-term complications. We reviewed 38,887 TJAs performed between 2008 and 2011 and identified 1606 complications in 1110 procedures. There was no significant association between complication risk and patient travel distance. Complication risk was associated with age, ASA class, Medicare and Medicaid status (P<0.0001 for all). Regional centers of excellence appear to be a viable model in healthcare reorganization however continued attention should be paid to attenuating the individual patient factors associated with complication at these institutions.
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