1
|
Knopp BW, Esmaeili E. Safety and Efficacy of In-Office Hand Procedures. J Hand Microsurg 2024; 16:100037. [PMID: 38855520 PMCID: PMC11144642 DOI: 10.1055/s-0043-1768484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2024] Open
Abstract
Background The primary concerns with operating on patients in the office setting are insufficient sterility and lack of appropriate resources in case of excessive bleeding or other surgical complications. This study serves to investigate these concerns and determine whether in-office hand surgeries are safe and clinically effective. Methods A retrospective review of patients who underwent minor hand operations in the office setting between December 2020 and December 2021 was performed. The surgical procedures included in this analysis are needle aponeurotomy, trigger finger release, foreign body removal, mass removal, and reduction in a finger fracture with or without percutaneous pinning. All fractures, which primarily included metacarpal and phalangeal fractures, were subsequently splinted. Sterility and hemostatic support were achieved via the Wide-Awake Local Anesthesia No Tourniquet (WALANT) method. Major complications were defined as infection, major bleeding, and neurological deficits. Minor complications were defined as prolonged pain, prolonged inflammation, residual symptoms, and recurrence of symptoms within 1 month. Results Five patients (3.8%) returned to the office for pain, inflammation, or stiffness of the affected finger, with two of the five returning with symptoms associated with osteoarthritis or pseudogout flare-ups. Five additional patients returned due to residual symptoms or recurrence of the primary complaint within 1 month of surgery. No patients experienced exogenous infection. Conclusion The absence of major complications and high success rate for minor hand procedures shows the high degree of safety and efficacy that can be achieved via the in-office setting for select procedures. While proper patient selection is key, our result shows the in-office procedure room setting can offer the necessary elements of sterility and hemostatic support for several common hand surgeries.
Collapse
Affiliation(s)
- Brandon W. Knopp
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida, United States
| | - Ehsan Esmaeili
- Boca Raton Regional Hospital, Boca Raton, Florida, United States
| |
Collapse
|
2
|
Wallace DR, Shiver AL, Whitehead J, Wood M, Snoddy MC. Intraoperative Challenges in Hand Surgery. Orthop Clin North Am 2024; 55:123-128. [PMID: 37980097 DOI: 10.1016/j.ocl.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
A wide array of intraoperative issues can arise during surgery involving the hand and upper extremity. An understanding of the common pitfalls within hand surgery may help practicing hand surgeons circumvent such issues. Within this manuscript, we first identify problems with the increasingly popular technique of wide-awake local anesthesia no tourniquet (WALANT). Achieving appropriate hemostasis and anesthetic can be bothersome, especially for procedures proximal to the distal palmar crease. We discuss our local anesthetic timing and concentrations to help mitigate such issues, as well as other problems that may arise in WALANT procedures. There also lies a barrier in connecting the traumatized patient to care in the outpatient/ambulatory setting. Additionally, the polytraumatized patient increases the complexity of care coordination for not just the hand surgeon, but all surgical providers involved. The order in which multidisciplinary surgical procedures are performed is influenced by both the complexity of the patient's case as well as the institution's current protocol. All academic institutions are faced with challenges in providing optimal intraoperative education to trainees. We acknowledge that there should be a balance between the attending surgeon executing key portions of the procedure and the trainee gaining the appropriate hands-on experience. This manuscript elaborates on the issues of intraoperative education provided to residents and anecdotal methods that may help overcome such challenges. Resources within hand surgery can often be limited and become particularly problematic in the operative setting. Specific examples include but are not limited to the lack of dedicated teams, inability to obtain appropriate intraoperative imaging, access to appropriate hardware, and intraoperative complications in an ambulatory surgery center setting.
Collapse
Affiliation(s)
- Doyle R Wallace
- Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, USA.
| | - Austin Luke Shiver
- Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, USA
| | - Jonathon Whitehead
- Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, USA
| | - Matthew Wood
- Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, USA
| | - Mark C Snoddy
- Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, USA
| |
Collapse
|
3
|
Eckhoff MD, Schwartz BT, Parikh SB, Wells ME, Brugman SC. Admission of Upper Extremity Injuries Presenting to the Emergency Department: An NEISS Study. Hand (N Y) 2023:15589447231219711. [PMID: 38159239 DOI: 10.1177/15589447231219711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Upper extremity injuries account for 36.5% of presentations to the emergency department in the United States. This study seeks to determine current rates of upper extremity injuries that present to the emergency department and the injury characteristics of patients requiring admission. METHODS National Electronic Injury Surveillance System was queried for a 10-year period for upper extremity injuries. Further analysis was done to evaluate specific patient demographics, injury characteristics, and mechanisms of injury of those patients who were admitted to the hospital. RESULTS Between 2012 and 2021, 39 160 365 persons are estimated to have presented to 100 United States emergency departments for managing upper extremity injuries, accounting for 28.8% of total presentations. A total of 12 662 041 upper extremity patients were pediatric (32.3%). Admissions occurred in 4.6% of presentations. The most common presenting diagnosis was laceration (24.9%), while the most common admission diagnosis was fracture (49.7%). The majority had injuries involving their forearms (19.9%). The most common injury-associated consumer product group was stairs, ramps, landings, and floors at 28.5%. Of the 445 644 patients, those estimated to have been injured by stairs, ramps, landings, and floors adults were 429 435 or 96.4%. The most common injury-associated product in pediatric populations was playground equipment (23.6%), of which 53.7% was from monkey bars and other climbing apparatuses. CONCLUSION This study demonstrates an overall increase in admissions for upper extremity injuries in the setting of similar rates of overall upper extremity injuries with fractures and forearm being the most common diagnosis and body part involved, respectively. LEVEL OF EVIDENCE IV; Database.
Collapse
Affiliation(s)
- Michael D Eckhoff
- Brian D. Allgood Army Community Hospital, Camp Humphreys, Republic of Korea
| | - Brandon T Schwartz
- Brian D. Allgood Army Community Hospital, Camp Humphreys, Republic of Korea
| | - Soham B Parikh
- Brian D. Allgood Army Community Hospital, Camp Humphreys, Republic of Korea
| | | | - Sean C Brugman
- Brian D. Allgood Army Community Hospital, Camp Humphreys, Republic of Korea
| |
Collapse
|
4
|
Graf AR, Ahmed AS, Thompson D, Wagner E, Gottschalk M, Suh N, Seiler JG. Intramedullary Metacarpal Fracture Fixation: A Biomechanical Study of Screw Diameter and Comparison With Intramedullary Wire Stabilization. J Hand Surg Am 2023:S0363-5023(23)00067-9. [PMID: 36914453 DOI: 10.1016/j.jhsa.2023.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 01/02/2023] [Accepted: 01/25/2023] [Indexed: 03/16/2023]
Abstract
PURPOSE Interest in intramedullary metacarpal fracture fixation (IMFF) with screws is increasing. However, the optimal screw diameter for fracture fixation is not yet established. In theory, larger screws should be more stable, but there is concern about long-term sequelae of larger metacarpal head defects and extensor mechanism injury created during insertion as well as implant cost. Therefore, the purpose of this study was to compare different diameter screws for IMFF to a popular and more cost-effective alternative of intramedullary wiring. METHODS Thirty-two cadaveric metacarpals were used in a transverse metacarpal shaft fracture model. Treatment groups consisted of IMFF with 3.0 × 60 mm, 3.5 x 60 mm, and 4.5 x 60 mm screws as well as 4 1.1-mm intramedullary wires. Cyclic cantilever bending was performed with the metacarpals mounted at 45° to simulate physiologic loading. Cyclical loading at 10, 20, and 30 N was performed to determine fracture displacement, stiffness, and ultimate force. RESULTS At 10, 20, and 30 N of cyclical loading, all screw diameters tested provided similar stability as measured by fracture displacement and were superior to the wire group. However, ultimate force under load to failure testing was similar between the 3.5- and 4.5-mm screws and superior to 3.0-mm screws and wires. CONCLUSIONS For IMFF, 3.0, 3.5, and 4.5-mm diameter screws provide adequate stability for early active motion and are superior to wires. When comparing the different screw diameters, 3.5- and 4.5-mm diameter screws offer similar construct stability and strength superior to the 3.0-mm diameter screw. Therefore, to minimize metacarpal head morbidity, smaller screw diameters may be preferable. CLINICAL RELEVANCE This study suggests that IMFF with screws is biomechanically superior to wires in cantilever bending strength in the transverse fracture model. However, smaller screws may be sufficient to permit early active motion while minimizing metacarpal head morbidity.
Collapse
Affiliation(s)
- Alexander R Graf
- Emory University, Department of Orthopedic Surgery, Atlanta, GA.
| | - Adil S Ahmed
- Emory University, Department of Orthopedic Surgery, Atlanta, GA
| | - Dan Thompson
- Emory University, Department of Orthopedic Surgery, Atlanta, GA
| | - Eric Wagner
- Emory University, Department of Orthopedic Surgery, Atlanta, GA
| | | | - Nina Suh
- Emory University, Department of Orthopedic Surgery, Atlanta, GA
| | | |
Collapse
|
5
|
Bernstein DN, Calfee RP, Hammert WC, Rozental TD, Witkowski ML, Porter ME. Value-Based Health Care in Hand Surgery: Where Are We & Where Do We Go From Here? J Hand Surg Am 2022; 47:999-1004. [PMID: 35941002 DOI: 10.1016/j.jhsa.2022.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/17/2022] [Accepted: 06/21/2022] [Indexed: 02/02/2023]
Abstract
Health care delivery is broken. The cost of care continues to skyrocket and the outcomes most important to patients are often a mystery. Further, care is often delivered via a fee-for-service model where surgeons are rewarded for the quantity, not the quality, of services provided. Such a health care delivery system is not sustainable and does not incentivize stakeholders to focus on the most important element of the health care delivery "puzzle": the patient. Fortunately, we are in the midst of transforming our health care delivery system, with a focus on optimizing the value of care delivery (ie, health outcomes achieved per dollar spent across a full care cycle). In hand surgery, progress has been made as part of this health system evolution. However, there remains much to accomplish. In this article, the authors review the 6 components of a strategic agenda for moving to a high-value health care delivery system for hand surgery, focusing on where we are today and where we need to go from here.
Collapse
Affiliation(s)
- David N Bernstein
- Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, Boston, MA; Institute for Strategy & Competitiveness, Harvard Business School, Boston, MA.
| | - Ryan P Calfee
- Department of Orthopedic Surgery, Washington University School of Medicine, St Louis, MO
| | - Warren C Hammert
- Department of Orthopaedics & Physical Performance, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Tamara D Rozental
- Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mary L Witkowski
- Institute for Strategy & Competitiveness, Harvard Business School, Boston, MA
| | - Michael E Porter
- Institute for Strategy & Competitiveness, Harvard Business School, Boston, MA
| |
Collapse
|
6
|
Welch JM, Zhuang T, Shapiro LM, Harris AHS, Baker LC, Kamal RN. Is Low-value Testing Before Low-risk Hand Surgery Associated With Increased Downstream Healthcare Use and Reimbursements? A National Claims Database Analysis. Clin Orthop Relat Res 2022; 480:1851-1862. [PMID: 35608508 PMCID: PMC9473771 DOI: 10.1097/corr.0000000000002255] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 05/05/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Minor hand procedures can often be completed in the office without any laboratory testing. Preoperative screening tests before minor hand procedures are unnecessary and considered low value because they can lead to preventable invasive confirmatory tests and/or procedures. Prior studies have shown that low-value testing before low-risk hand surgery is still common, yet little is known about their downstream effects and associated costs. Assessing these downstream events can elucidate the consequences of obtaining a low-value test and inform context-specific interventions to reduce their use. QUESTIONS/PURPOSES (1) Among healthy adults undergoing low-risk hand surgery, are patients who receive a preoperative low-value test more likely to have subsequent diagnostic tests and procedures than those who do not receive a low-value test? (2) What is the increased 90-day reimbursement associated with subsequent diagnostic tests and procedures in patients who received a low-value test compared with those who did not? METHODS In this retrospective, comparative study using a large national database, we queried a large health insurance provider's administrative claims data to identify adult patients undergoing low-risk hand surgery (carpal tunnel release, trigger finger release, Dupuytren fasciectomy, de Quervain release, thumb carpometacarpal arthroplasty, wrist ganglion cyst, or mass excision) between 2011 and 2017. This database was selected for its ability to track patient claims longitudinally with direct provision of reimbursement data in a large, geographically diverse patient population. Patients who received at least one preoperative low-value test, including complete blood count, basic metabolic panel, electrocardiogram, chest radiography, pulmonary function test, and urinalysis within the 30-day preoperative period, were matched with propensity scores to those who did not. Among the 73,112 patients who met our inclusion criteria (mean age 57 ± 14 years; 68% [49,847] were women), 27% (19,453) received at least one preoperative low-value test and were propensity score-matched to those who did not. Multivariable regression analyses were performed to assess the frequency and reimbursements of subsequent diagnostic tests and procedures in the 90 days after surgery while controlling for potentially confounding variables such as age, sex, comorbidities, and baseline healthcare use. RESULTS When controlling for covariates such as age, sex, comorbidities, and baseline healthcare use, patients in the low-value test cohort had an adjusted odds ratio of 1.57 (95% confidence interval [CI] 1.50 to 1.64; p < 0.001) for a postoperative use event (a downstream diagnostic test or procedure) compared with those who did not have a low-value test. The median (IQR) per-patient reimbursements associated with downstream utilization events in patients who received a low-value test was USD 231.97 (64.37 to 1138.84), and those who did not receive a low-value test had a median of USD 191.52 (57.1 to 899.42) (adjusted difference when controlling for covariates: USD 217.27 per patient [95% CI 59.51 to 375.03]; p = 0.007). After adjusting for inflation, total additional reimbursements for patients in the low-value test cohort increased annually. CONCLUSION Low-value tests generate downstream tests and procedures that are known to provide minimal benefit to healthy patients and may expose patients to potential harms associated with subsequent, unnecessary invasive tests and procedures in response to false positives. Nevertheless, low-value testing remains common and the rising trend in low-value test-associated spending demonstrates the need for multicomponent interventions that target change at both the payer and health system level. Such interventions should disincentivize the initial low-value test and the cascade that may follow. Future work to identify the barriers and facilitators to reduce low-value testing in hand surgery can inform the development and revision of deimplementation strategies. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
Affiliation(s)
- Jessica M. Welch
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| | - Thompson Zhuang
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| | | | - Alex H. S. Harris
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Laurence C. Baker
- Department of Health Research Policy, Stanford University, Stanford, CA, USA
| | - Robin N. Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| |
Collapse
|
7
|
Site of service of irrigation and debridement of open finger and hand fractures: a retrospective review of trends and outcomes. CURRENT ORTHOPAEDIC PRACTICE 2022; 33:358-362. [DOI: 10.1097/bco.0000000000001123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
8
|
Benage TC, Del Core MA, Bass AJ, Ahn J, Pientka WF, Golden AS. Risk Factors and Reasons for Emergency Department Visits Within 30 Days of Elective Hand Surgery: An Analysis of 3,261 Patients. J Hand Surg Asian Pac Vol 2022; 27:76-82. [PMID: 35037576 DOI: 10.1142/s2424835522500047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: The frequency of hand and elbow surgeries occurring in outpatient and elective settings is on the rise. Emergency department (ED) visits in the postoperative period are increasingly used as quality measures for surgical care. The aim of this study is to determine the number of postoperative ED visits, the primary reason for these visits, and to identify risk factors associated with these visits. Methods: We examined all elective hand and elbow procedures performed at two hospitals within a single healthcare network between 2008 and 2017. A total of 3,261 patients met the study criteria. Descriptive statistics were calculated for our population, followed by univariate and multivariate analyses, to identify risk and protective factors associated with ED visits in the first 30 days after surgery. Results: Eighty-seven of 3,261 patients presented to the ED within 30 days of their operation (2.7%). The most common reasons for ED visits were related to pain (28.7%), swelling (26.4%), and concerns for infection (20.7%). Univariate analysis indicated history of drug use, number of procedures, smoking history, and serum albumin <3.5 mg/dL as risk factors for returns to the ED. Multivariate analysis identified history of drug use, number of procedures, and serum albumin <3.5 mg/dL as independent risk factors. Smoking history failed to achieve statistical significance as an independent risk factor. Both univariate and multivariate analyses identified age >60 years as protective for postoperative ED visits. Conclusions: ED visits within the first 30 days after elective hand surgery are relatively common, despite remarkably low complication rates among these procedures. This information may help to improve risk stratification in these patients, and to aid in the development of enhanced postoperative follow-up strategies to reduce unnecessary utilization of emergency medical services. Level of Evidence: Level III (Therapeutic).
Collapse
Affiliation(s)
- Timothy C Benage
- Department of Orthopaedic Surgery, John Peter Smith Health Network, Fort Worth, TX, USA
| | - Michael A Del Core
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Alexander J Bass
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Junho Ahn
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - William F Pientka
- Department of Orthopaedic Surgery, John Peter Smith Health Network, Fort Worth, TX, USA
| | - Ann S Golden
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| |
Collapse
|
9
|
Sandrowski K, Kwok M, Gallant G, Abboudi J, Takei R, Sodha S, Aita D, Wang M, Jones C, Beredjiklian PK. A Prospective Evaluation of Postoperative Readmissions After Outpatient Hand and Upper Extremity Surgery. Cureus 2021; 13:e15247. [PMID: 34178551 PMCID: PMC8227494 DOI: 10.7759/cureus.15247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Introduction Hand and upper extremity surgeries are largely performed in free-standing ambulatory surgery centers (ASCs). Rates of unexpected hospitalizations or visits to the urgent care or emergency departments in the month following hand and upper extremity surgery have been widely varied in the literature. We prospectively followed patients after hand and upper extremity outpatient surgery to determine the rate of unplanned health care utilization with the hypothesis that hospital admissions, emergency room visits, and urgent care center visits would be higher than the rates currently reported by retrospective studies. Methods All patients undergoing outpatient hand and upper extremity surgery by five hand surgeons were prospectively followed to monitor for hospital readmissions, emergency room visits, and urgent care presentations. The patients’ postoperative course was evaluated for direct transfers from the surgical center to the hospital. In addition, any urgent care or emergency room visits and hospital admissions for the first month after surgery were tabulated. Points of review of the patients’ postoperative course included the following: (1) phone contact on the first postoperative day, (2) routine ASC postoperative phone calls two to three days postoperatively, (3) first postoperative office at approximately one to two weeks, and (4) phone contact or office evaluation one-month postoperatively based on surgeon preference for follow-up. Results A total of 583 patients were identified for participation, of whom 22 patients were excluded; thus, 561 patients were included for evaluation, with 47.2% women (n=265) and 52.8% men (n=296). The average age was 54 years (range: 14-102 years). Nine (1.6%) patients presented postoperatively for further evaluation at an urgent care or hospital (95% C.I. 0.8-3.1%). Five patients presented to an emergency room and four patients presented to an urgent care facility. Of those patients, two were admitted to the hospital due to shortness of breath (0.35%; 95% CI: -0.08 to 1.4%). Emergency room and urgent care visits that did not lead to admission accounted for 1.25% (95% CI: 0.6-2.6%). No patients were transferred from the ASC to the hospital or emergency room. Conclusion There was a low rate of postoperative utilization of urgent care and emergency room services with hand and upper extremity surgery performed at free-standing, ASCs. Hospital readmissions were rare, and no patients required transfer from an ambulatory care center to the hospital. Outpatient hand and upper extremity surgery is safe in an ambulatory care center, with low postoperative transfers and readmissions in the month following surgery.
Collapse
Affiliation(s)
- Kristin Sandrowski
- Division of Hand Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
| | - Moody Kwok
- Division of Hand Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
| | - Greg Gallant
- Division of Hand Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
| | - Jack Abboudi
- Division of Hand Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
| | - Robert Takei
- Division of Hand Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
| | - Samir Sodha
- Division of Hand Surgery, Rothman Orthopaedic Institute, Paramus, USA.,Orthopaedic Surgery, Hackensack University Medical Center, New York, USA
| | - Daren Aita
- Division of Hand Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
| | - Mark Wang
- Division of Hand Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
| | - Christopher Jones
- Division of Hand Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
| | | |
Collapse
|
10
|
Can Pediatric Orthopaedic Surgery be Done Safely in a Freestanding Ambulatory Surgery Center? Review of 3780 Cases. J Pediatr Orthop 2021; 41:e85-e89. [PMID: 32852367 DOI: 10.1097/bpo.0000000000001670] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose of this study was to determine the intraoperative and 30-day postoperative complication rates in a large consecutive cohort of pediatric patients who had orthopaedic surgery at a freestanding ambulatory surgery center (ASC). The authors also wanted to identify the rates of same-day, urgent hospital transfers, and 30-day hospital admissions. The authors hypothesized that pediatric orthopaedic procedures at a freestanding ASC can be done safely with a low rate of complications. METHODS A retrospective review identified patients aged 17 years or younger who had surgery at a freestanding ASC over a 9-year period. Adverse outcomes were divided into intraoperative complications, postoperative complications, need for the secondary procedure, unexpected hospital admission on the same day of the procedure, and unexpected hospital admission within 30 days of the index procedure. Complications were graded as grade 1, the complication could be treated without additional surgery or hospitalization; grade 2, the complication resulted in an unplanned return to the operating room (OR) or hospital admission; or grade 3, the complication resulted in an unplanned return to the OR or hospitalization with a change in the overall treatment plan. RESULTS Adequate follow-up was available for 3780 (86.1%) surgical procedures. Overall, there were 9 (0.24%) intraoperative complications, 2 (0.08%) urgent hospital transfers, 114 (3%) complications, and 16 (0.42%) readmissions. Seven of the 9 intraoperative complications resolved before leaving the OR, and 2 required return to the OR.Neither complications nor hospitalizations correlated with age, race, gender, or length or type of surgery. There was no correlation between the presence of medical comorbidities, body mass index, or American Society of Anesthesiologists score and complication or hospitalization. CONCLUSIONS Pediatric orthopaedic surgical procedures can be performed safely in an ASC because of multiple factors that include dedicated surgical teams, single-purpose ORs, and strict preoperative screening criteria. The rates of an emergency hospital transfer, surgical complications, and 30-day readmission, even by stringent criteria, are lower than those reported for outpatient procedures performed in the hospital setting. LEVEL OF EVIDENCE Level IV-case series.
Collapse
|
11
|
Billig JI, Nasser JS, Chen JS, Lu YT, Chung KC, Kuo CF, Sears ED. Comparison of Safety and Insurance Payments for Minor Hand Procedures Across Operative Settings. JAMA Netw Open 2020; 3:e2015951. [PMID: 33048128 PMCID: PMC8094424 DOI: 10.1001/jamanetworkopen.2020.15951] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Surgical procedures can be performed in different settings, but the association between the operative setting and patient safety and cost to the patient and payer is unknown. OBJECTIVE To examine differences in complications, total payments, and out-of-pocket (OOP) spending for minor hand surgical procedures performed in office, ambulatory surgery center (ASC), and hospital outpatient department (HOPD) operative settings. DESIGN, SETTING, AND PARTICIPANTS A retrospective, population-based cohort study was conducted using deidentified claims data from private employer-sponsored health insurance from January 1, 2009, to December 31, 2017. Patients aged 18 years or older undergoing carpal tunnel release, trigger finger release, excision of wrist ganglion, and excision of small hand masses (N = 468 365) were included. EXPOSURES Operative setting, defined as procedures performed in the clinic setting, ASC, and HOPD. MAIN OUTCOMES AND MEASURES Complications during the 90-day postoperative period, total payments (total facility and payer reimbursement), and OOP spending. RESULTS Of the 468 365 patients, 296 378 women (63.3%) and 171 987 men (36.7%) underwent minor hand surgical procedures from 2009 to 2017, with 284 889 procedures (60.8%) performed in HOPDs, 158 659 procedures (33.9%) performed in ASCs, and 24 817 procedures (5.3%) performed in the office setting. Ninety-day complications occurred in 3.4% of procedures performed in HOPDs, 3.3% in ASCs, and 2.9% in office settings (P < .001). After controlling for patient characteristics, procedures performed outside of the office had higher odds of complications (HOPDs: odds ratio [OR], 1.32; 95% CI, 1.22-1.43; ASCs: OR, 1.24; 95% CI, 1.14-1.34). Compared with the office setting, procedures performed in HOPDs incurred an extra $1216 in total payments (95% CI, $1184-$1248) and $115 in OOP expenses (95% CI, $109-$121). Procedures performed in ASCs cost an additional $709 (95% CI, $676-$741) and $140 in OOP expenses (95% CI, $134-$146). Transitioning ASC and HOPD procedures to the office setting could have saved an estimated $6 million annually in OOP expenses during the study period. CONCLUSIONS AND RELEVANCE The findings of this study suggest that minor hand surgery performed in the office setting is safe and less costly compared with ambulatory and hospital-based operations. Shifting minor surgical procedures to the office setting may lead to substantial cost savings for payers and patients without compromising care quality.
Collapse
Affiliation(s)
- Jessica I. Billig
- Veterans Affairs (VA)/National Clinician Scholars Program, VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Section of Plastic Surgery, Michigan Medicine, Ann Arbor
| | - Jacob S. Nasser
- Medical student, George Washington School of Medicine, Washington, DC
| | - Jung-Sheng Chen
- Center for Artificial Intelligence in Medicine, Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yu-Ting Lu
- Section of Plastic Surgery, Michigan Medicine, Ann Arbor
| | - Kevin C. Chung
- Section of Plastic Surgery, Michigan Medicine, Ann Arbor
| | - Chang-Fu Kuo
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Rheumatology, Orthopaedics, and Dermatology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Erika D. Sears
- Section of Plastic Surgery, Michigan Medicine, Ann Arbor
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| |
Collapse
|
12
|
Timing of Complications following Hand Surgery. J Hand Microsurg 2020; 14:31-38. [DOI: 10.1055/s-0040-1709212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Abstract
Introduction Our purposes were to (1) characterize the timeline of eight postoperative complications following hand surgery, (2) assess complication timing for the procedures that account for the majority of adverse events, and (3) determine any differences in complication timing between outpatient and inpatient procedures.
Materials and Methods Patients undergoing hand, wrist, and forearm procedures from 2005 to 2016 were identified in the National Surgical Quality Improvement Program database. Timing of eight adverse events was characterized. Cox proportional hazards modeling was used to compare adverse event timing between inpatient and outpatient procedures.
Results A total of 59,040 patients were included. The median postoperative day of diagnosis for each adverse event was as follows: myocardial infarction 1, pulmonary embolism 2, acute kidney injury 3, pneumonia 8, deep vein thrombosis 9, sepsis 13, urinary tract infection 15, and surgical site infection 16. Amputations, fasciotomies, and distal radius open reduction internal fixation accounted for the majority of adverse events. Complication timing was significantly earlier in inpatients compared with outpatients for myocardial infarction.
Conclusion This study characterizes postoperative adverse event timing following hand surgery. Surgeons should have the lowest threshold for testing for each complication during the time period of greatest risk.
Level of Evidence This is a therapeutic, Level III study.
Collapse
|
13
|
Adamson P, Peters W, Janney C, Panchbhavi V. The safety of foot and ankle procedures at an ambulatory surgery center. J Orthop 2020; 21:203-206. [PMID: 32273657 DOI: 10.1016/j.jor.2020.03.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/26/2020] [Indexed: 10/24/2022] Open
Abstract
Background This study evaluates the safety of foot and ankle outpatient surgeries at a freestanding ambulatory surgery centers. Methods A total of 1352 cases were evaluated for adverse events in a retrospective review of all foot and ankle cases performed over a 5-year period at a single center. Results The rate of adverse events was 2.3%, with 31 identified over the 5-year period (23 infections, 5 symptomatic thromboembolisms, 3 postoperative hospital transfers). Discussion The rate of postoperative adverse events in outpatient foot and ankle procedures is low. These surgeries can be performed safely in an outpatient setting at an ASC. Level of evidence Level IV, Case Series.
Collapse
Affiliation(s)
- Peter Adamson
- University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77550, USA
| | - Wesley Peters
- University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77550, USA
| | - Cory Janney
- Naval Medical Center San Diego, 34800 Bob Wilson Drive, Suite 112, San Diego, CA, 92134, USA
| | - Vinod Panchbhavi
- University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77550, USA
| |
Collapse
|
14
|
Perioperative Risks Are Similar for Normal versus Selected High-Body Mass Index Patients Undergoing Outpatient Hand and Elbow Surgery. Plast Reconstr Surg 2020; 144:836e-840e. [PMID: 31688759 DOI: 10.1097/prs.0000000000006152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Many ambulatory surgery centers use body mass index as a screening tool to make admissions decisions because of complication risks associated with high-body mass index patients. The objective of this investigation was to evaluate perioperative complications in a cohort of high-body mass index patients undergoing hand and elbow surgery at an ambulatory surgery center. The authors' hypothesis was that anesthesia-related complications for this cohort would be similar to those of a normal-body mass index group. METHODS The authors retrospectively reviewed data from all hand and elbow procedures performed on patients with a high body mass index (>40 kg/m). One hundred eighty-nine high-body mass index patients and 189 normal-body mass index patients were included in the analysis. RESULTS The average weight-based dosage of propofol was similar in both groups but was lower in the high-body mass index group for midazolam and fentanyl. Two high-body mass index patients had oxygen desaturations in the postanesthesia care unit. No patients developed complications related to anesthesia. In the high-body mass index group, one patient developed hypotension in the postanesthesia care unit, was admitted to the emergency room for monitoring, but was discharged the following morning. CONCLUSIONS Outpatient hand surgical care of high-body mass index patients can be performed safely. Body mass index alone should not be considered as an absolute contraindication for surgery. Careful patient selection, evaluation of comorbidities, and close involvement of the anesthesia and medical teams are critical. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
Collapse
|
15
|
Qin C, Helfrich MM, Curtis DM, Ho S, Athiviraham A. The effect of surgical setting on anterior cruciate ligament reconstruction outcomes. PHYSICIAN SPORTSMED 2019; 47:411-415. [PMID: 30848164 DOI: 10.1080/00913847.2019.1592335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Objective: Ambulatory surgical centers (ASC's) have emerged as an alternative to the traditional hospital- based outpatient department (HOPD). We aim to determine the effect of surgical setting on adverse events following anterior cruciate ligament reconstruction (ACLR).Methods: The Humana Claims Database was queried for all patients undergoing ACLR in the HOPD or ASC setting, using the PearlDiver supercomputer. To eliminate selection bias in our study, the HOPD and ASC cohorts were propensity score matched on baseline demographics, comorbidities, and operative factors. Comparisons between the matched cohorts were made using chi-square tests. Logistic regression models were created to determine the effect of surgical setting on adverse events.Results: A total of 13,647 patients were queried in our study, 5,298 of whom underwent surgery in an ASC and 8,349 of whom underwent surgery in an HOPD. Analysis of the post-matched cohort revealed no differences between cohorts for mechanical failure, nerve injury, pulmonary embolism, septic joint, wound infection, revision surgery and readmission. Rates of deep vein thrombosis (1.18% vs 1.84%; p = .03) were significantly lower in the ASC group. On logistic regression, ASC was associated with decreased risk for deep vein thrombosis (.87, .83-.93) and pulmonary embolism (.85, .78-.95).Conclusion: ACLR performed in ASC is associated with reduced risk of venous thromboembolism and no difference in surgical morbidity and readmissions versus ACLR performed in HOPD. Development of a standardized algorithm for patient selection in the ASC setting is needed to preserve acceptability of ASC-based ACLR in cost-savings and patient safety models.
Collapse
Affiliation(s)
- Charles Qin
- Department of Orthopaedic Surgery and Rehabilitation, University of Chicago, Chicago, IL, USA
| | - Mia M Helfrich
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Daniel M Curtis
- Department of Orthopaedic Surgery and Rehabilitation, University of Chicago, Chicago, IL, USA
| | - Sherwin Ho
- Department of Orthopaedic Surgery and Rehabilitation, University of Chicago, Chicago, IL, USA
| | - Aravind Athiviraham
- Department of Orthopaedic Surgery and Rehabilitation, University of Chicago, Chicago, IL, USA
| |
Collapse
|
16
|
Abstract
BACKGROUND Surgeons frequently use optical loupes to magnify the surgical field; they are typically unprotected when positioned directly over the wound, where particulate shedding containing microorganisms could potentially lead to surgical site infections (SSIs). SSIs are rare in some orthopaedic subspecialties such as hand surgery; however, in other subspecialties, for example, the spine, where surgeons often use loupes, SSIs can have devastating consequences. QUESTIONS/PURPOSES (1) What is the degree of bacterial and fungi organism colonization of surgical loupes and storage cases? (2) Is there a difference in the degree of colonization at the beginning and the end of a surgery day? (3) Does an alcohol swab reduce bacterial colonization of surgical loupes? METHODS The surgical loupes of 21 orthopaedic surgeons from a large, regional orthopaedic practice were cultured over a 3-month period and form the basis of this study. Five loupe storage cases were also cultured. In two different subgroup comparisons, the presence of microorganisms was evaluated just before the start and immediately after the end of the surgical day (n = 9) and before and 1 minute after cleaning with an alcohol swab (n = 6). A total of 36 cultures were evaluated. Surgeons who declined to participate in the study were excluded. The number of loupes selected for all of the analyses were samples of convenience and limited by surgeon availability. The degree of bacterial and fungal presence was graded using a point system: 0 = no growth; 1 = limited growth (meaning few scattered colonies); 2 = moderate growth; 3 = extensive but scattered growth; and 4 = growth consuming the entire plate. Demographic data were assessed using descriptive statistics. Additionally, the Student's t and Wilcoxon signed-rank tests were used to detect differences in categorical bacterial growth between paired samples. A p value of 0.05 represented statistical significance. Kappa statistics of reliability were performed to evaluate interobserver agreement of microorganism growth in the culture plates. RESULTS Bacteria were present in 19 of 21 (90%) sets of loupes. Five species of bacteria were noted. Fungi were present in 10 of 21 (48%) sets of loupes. Bacterial contamination was identified in two storage cases (40%) and fungi were present in five cases (100%). In a subset of nine loupes tested, the degree of bacterial presence had a median of 2 (range, 1-4; 95% confidence interval [CI], 1.0-2.6) in samples collected before starting the surgical day compared with 3 (range, 2-4; 95% CI, 2.0-3.3) at the end of the day (p = 0.004). In a separate study arm comprised of six loupes, 1 minute after being cleaned with an alcohol swab, bacterial presence on loupes decreased from a median of 2 (range, 2-3; 95% CI, 1.9-2.5) to a median of 1 (range, 0-2; 95% CI, 0.5-1.5; p = 0.012). CONCLUSIONS Loupes are a common reservoir for bacteria and fungi. Given the use of loupes directly over the surgical field and the lack of a barrier, care should be taken to decrease the bacterial load by cleaning loupes and airing out storage cases, which may decrease the risk of surgical field contamination and iatrogenic wound infections. CLINICAL RELEVANCE Routine cleaning and disinfecting of optical loupes with alcohol pads can reduce microorganism colonization and should be implemented by surgeons who regularly use loupes in the operating room. Theoretically, particulate shedding from the loupes into the surgical field containing microorganisms could increase the risk of SSI, although this has not been proven clinically.
Collapse
|
17
|
Christian RA, Gibbs DB, Nicolay RW, Selley RS, Saltzman MD. Risk factors for admission after shoulder arthroscopy. J Shoulder Elbow Surg 2019; 28:882-887. [PMID: 30553800 DOI: 10.1016/j.jse.2018.09.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 09/01/2018] [Accepted: 09/05/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Shoulder arthroscopy is a common orthopedic procedure typically performed on an outpatient basis. Occasionally, patients require an unplanned hospital admission. An understanding of the incidence and risk factors for admission after shoulder arthroscopy may assist surgeons in determining which patients may be susceptible to unplanned admission after surgery. METHODS All consecutive shoulder arthroscopy procedures performed during a 10-year period were reviewed. A 2:1 control-case matching technique was used. Univariate analysis was performed to identify differences between patients admitted after surgery and the control group. Multivariate analysis was performed to identify variables associated with admission. RESULTS There were 5598 arthroscopic shoulder procedures performed, with 233 patients (4.2%) requiring admission. The most common reason for admission was respiratory monitoring. Risk factors for admission by multivariate analysis were chronic obstructive pulmonary disease (odds ratio [OR], 2.73; 95% confidence interval [CI], 1.51-4.95), diabetes (OR, 2.11; 95% CI, 1.28-3.48), obstructive sleep apnea (OR, 1.90; 95% CI, 1.13-3.21), age (OR, 1.02; 95% CI, 1.01-1.04), body mass index (OR, 1.04; 95% CI, 1.01-1.07), and operative time (OR, 1.01; 95% CI, 1.00-1.01). Regional with monitored anesthesia care decreased risk compared with general anesthesia and regional with general anesthesia (OR, 0.44; 95% CI, 0.30-0.63). CONCLUSION Chronic obstructive pulmonary disease, obstructive sleep apnea, diabetes, increasing age, increasing body mas index, and increasing operative time were all risk factors for admission after shoulder arthroscopy. The absence of general anesthesia was found to decrease the risk of admission.
Collapse
Affiliation(s)
- Robert A Christian
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Daniel B Gibbs
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Richard W Nicolay
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ryan S Selley
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Matthew D Saltzman
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| |
Collapse
|
18
|
Pivot D, Hoch G, Astruc K, Lepelletier D, Lefebvre A, Lucet JC, Beaussier M, Philippe HJ, Vons C, Triboulet JP, Grandbastien B, Aho Glélé L. A systematic review of surgical site infections following day surgery: a frequentist and a Bayesian meta-analysis of prevalence. J Hosp Infect 2019; 101:196-209. [DOI: 10.1016/j.jhin.2018.07.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 07/24/2018] [Indexed: 01/19/2023]
|
19
|
Ingram J, Mauck BM, Thompson NB, Calandruccio JH. Cost, Value, and Patient Satisfaction in Carpal Tunnel Surgery. Orthop Clin North Am 2018; 49:503-507. [PMID: 30224011 DOI: 10.1016/j.ocl.2018.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The cost of carpal tunnel release (CTR) surgery can be decreased and patient satisfaction increased by a few relatively simple changes. Although cost estimates vary in the literature, most investigators agree that open CTR costs less than endoscopic CTR, and the clinic procedure room or ambulatory surgery center is cheaper than the ambulatory surgery center, which is less than the hospital. Patient satisfaction can be increased by making office visits more patient-centered and improving the quality of dialogue between the surgeon and patient.
Collapse
Affiliation(s)
- Joseph Ingram
- Campbell Clinic-University of Tennessee, Department of Orthopaedic Surgery and Biomedical Engineering, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
| | - Benjamin M Mauck
- Campbell Clinic-University of Tennessee, Department of Orthopaedic Surgery and Biomedical Engineering, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA
| | - Norfleet B Thompson
- Campbell Clinic-University of Tennessee, Department of Orthopaedic Surgery and Biomedical Engineering, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA
| | - James H Calandruccio
- Campbell Clinic-University of Tennessee, Department of Orthopaedic Surgery and Biomedical Engineering, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA
| |
Collapse
|
20
|
Safety of Outpatient Shoulder Surgery at a Freestanding Ambulatory Surgery Center in Patients Aged 65 Years and Older: A Review of 640 Cases. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2018; 2:e075. [PMID: 30211375 PMCID: PMC6132319 DOI: 10.5435/jaaosglobal-d-17-00075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction With increasing utilization of surgery centers, it is important to demonstrate the safety of outpatient shoulder surgery in freestanding ambulatory surgery centers. No studies have specifically looked at the Medicare-age population and the rate of outpatient shoulder procedure complications in these patients at an ambulatory surgery center. Methods Six hundred forty patients were included in our study between 2000 and 2015. The incidence of major complications was identified, including acute infection requiring intravenous antibiotics or irrigation and débridement, postoperative transfer to a hospital, wrong-site surgical procedures, retention of a foreign object, postoperative symptomatic thromboembolism, medication errors, and bleeding/wound complications. Results There was a total of seven occurrence reports in seven patients, for a reported adverse event rate of 1.01%. Conclusions Our findings are consistent with currently reported outpatient hospital-based data and illustrate the safety of outpatient shoulder procedures at a freestanding ambulatory surgery center in Medicare-age patients.
Collapse
|
21
|
Abstract
Outpatient surgery, especially in free-standing ambulatory surgery centers (ASC), provides a safe, cost-effective option for a variety of surgical procedures and has become the preferred choice over inpatient and hospital-based outpatient surgery for most hand and wrist procedures. Complication rates after ASC hand surgery are low (0.2%-2.5%). Patient dissatisfaction with ASC surgery is primarily associated with postoperative nausea and vomiting and inadequate pain control.
Collapse
Affiliation(s)
- Norfleet B Thompson
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA
| | - James H Calandruccio
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
| |
Collapse
|
22
|
Kingery MT, Cuff GE, Hutzler LH, Popovic J, Davidovitch RI, Bosco JA. Total Joint Arthroplasty in Ambulatory Surgery Centers: Analysis of Disqualifying Conditions and the Frequency at Which They Occur. J Arthroplasty 2018; 33:6-9. [PMID: 28870744 DOI: 10.1016/j.arth.2017.07.048] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 07/13/2017] [Accepted: 07/29/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The frequency of total joint arthroplasties (TJAs) performed in ambulatory surgery centers (ASCs) is increasing. However, not all TJA patients are healthy enough to safely undergo these procedures in an ambulatory setting. We examined the percentage of arthroplasty patients who would be eligible to have the procedure performed in a free-standing ASC and the distribution of comorbidities making patients ASC-ineligible. METHODS We reviewed the charts of 3444 patients undergoing TJA and assigned ASC eligibility based on American Society of Anesthesiologists (ASA) status, a set of exclusion criteria, and any existing comorbidities. RESULTS Overall, 70.03% of all patients undergoing TJA were eligible for ASC. Of the ASA class 3 patients who did not meet any exclusion criteria but had systemic disease (51.11% of all ASA class 3 patients), 53.69% were deemed ASC-eligible because of sufficiently low severity of comorbidities. The most frequent reasons for ineligibility were body mass index >40 kg/m2 (32.66% of ineligible patients), severity of comorbidities (28.00%), and untreated obstructive sleep apnea (25.19%). CONCLUSION A large proportion of TJA patients were found to be eligible for surgery in an ASC, including over one-third of ASA class 3 patients. ASC performed TJA provides an opportunity for increased patient satisfaction and decreased costs, selecting the right candidates for the ambulatory setting is critical to maintain patient safety and avoid postoperative complications.
Collapse
Affiliation(s)
- Matthew T Kingery
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Germaine E Cuff
- Department of Anesthesiology, NYU Langone Medical Center, Perioperative Care and Pain Medicine, New York, New York
| | - Lorraine H Hutzler
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Jovan Popovic
- Department of Anesthesiology, NYU Langone Medical Center, Perioperative Care and Pain Medicine, New York, New York
| | - Roy I Davidovitch
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Joseph A Bosco
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| |
Collapse
|
23
|
Stagg BC, Talwar N, Mattox C, Lee PP, Stein JD. Trends in Use of Ambulatory Surgery Centers for Cataract Surgery in the United States, 2001-2014. JAMA Ophthalmol 2018; 136:53-60. [PMID: 29167902 PMCID: PMC5833604 DOI: 10.1001/jamaophthalmol.2017.5101] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 10/02/2017] [Indexed: 11/14/2022]
Abstract
Importance Cataract surgery is commonly performed at ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs). These venues differ in many ways, including surgical efficiency, patient throughput, patient safety, and costs per surgery. Objective To determine trends in use of ASCs and HOPDs for cataract surgery from 2001 to 2014 and factors affecting the site of surgery. Design, Setting, and Participants This retrospective longitudinal cohort analysis involved individuals 40 years and older who underwent cataract surgery between January 2001 and December 2014 from a nationwide US managed care network. Data were analyzed from February 2016 to February 2017. Main Outcomes and Measures We identified all enrollees who underwent cataract surgery and determined whether the surgery was performed at an ASC or HOPD. We calculated the proportion of surgeries performed at each site each year from 2001 to 2014. Multivariable logistic regression identified characteristics of enrollees who had cataract surgery at an ASC vs a HOPD. We also assessed geographic variation in the proportion of cataract surgeries performed at ASCs in 306 communities throughout the United States. Results Of the 369 320 enrollees included in this study, 208 319 (56.4%) were female, and the mean (SD) age was 66.3 (10.4) years. All enrollees underwent cataract surgery (531 325 surgeries) from 2001 to 2014. Of these, 237 046 (64.2%) underwent cataract surgery at an ASC. The proportion of cataract surgeries performed at ASCs increased from 43.6% in 2001 to 73.0% in 2014. Compared with enrollees with incomes less than $40 000, those with incomes greater than $100 000 were 20% more likely to undergo cataract surgery at an ASC (odds ratio, 1.20; 95% CI, 1.12-1.29). Enrollees with better overall health were no more likely to undergo cataract surgery at an ASC (odds ratio, 1.00; 95% CI, 0.99-1.00) than at an HOPD. Enrollees who lived in communities without certificate of need laws were more than twice as likely to have surgery at an ASC (odds ratio, 2.49; 95% CI, 2.35-2.63). The proportion of cataract surgeries performed at ASCs from 2012 to 2014 varied considerably, from 1.6% in La Crosse, Wisconsin, to 98.8% in Pueblo, Colorado. Conclusions and Relevance We observed a large shift in the site of cataract surgery from HOPDs to ASCs from 2001 to 2014. Future research is needed to assess the effect of this transition in site of surgical care on patient access to surgery, surgical outcomes, patient safety, and societal costs.
Collapse
Affiliation(s)
- Brian C. Stagg
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor
- National Clinician Scholars Program, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor
| | - Nidhi Talwar
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor
| | - Cynthia Mattox
- Department of Ophthalmology, New England Eye Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Paul P. Lee
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor
- Center for Eye Policy and Innovation, University of Michigan, Ann Arbor
| | - Joshua D. Stein
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor
- Center for Eye Policy and Innovation, University of Michigan, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
| |
Collapse
|
24
|
Rabarin F, Jeudy J, Cesari B, Petit A, Bigorre N, Saint-Cast Y, Fouque PA, Raimbeau G. Acute finger-tip infection: Management and treatment. A 103-case series. Orthop Traumatol Surg Res 2017; 103:933-936. [PMID: 28554808 DOI: 10.1016/j.otsr.2017.03.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 01/22/2017] [Accepted: 03/06/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Acute fingertip infections (AFTI) are common. Surgical treatment is the norm in case of effusion. There is, however, no consensus on treatment modalities, or on adjuvant antibiotic therapy (AT). We present the results of a consecutive cohort of 103 AFTIs treated in emergency consultation. MATERIALS AND METHOD One hundred and one patients were treated by excision and extensive lavage under digital anesthesia, with systematic bacteriological sampling. Patient history, treatment history, location, type of bacteria, complications or recurrences and AT prescription were recorded and analyzed. All patients were reviewed at first dressing (5-7 days) and recontacted at 1 month, to record any pain, stiffness or recurrence. Three groups were distinguished: A: without preoperative AT (n=71); B: under AT before surgery (n=14); C: with postoperative AT (for severe comorbidity) (n=16). RESULTS Mean age was 39.7 years (range: 14-84 years). The three main types of bacteria were: Staphylococcus aureus (58.3%), polymicrobial flora (16.5%), and Streptococcus (12.6%). Mean time to first dressing was 5.7 days. There were no recurrences, whatever the bacterial type or patient group. In 5 patients in group A (8.2%), AT was later prescribed at day 5 (3 for hypercicatrization and 2 for maceration). In groups B and C, progression was unproblematic. At 1 month, all patients considered themselves cured; finger-tip sensitivity was conserved in 10, and 16 were awaiting complete nail regrowth. DISCUSSION Hospital admission, operative treatment under general anesthesia, and AT are factors exacerbating cost and increase the management burden of AFTI. Treatment in emergency consultation seems perfectly feasible. AT does not seem useful in the absence of severe comorbidities if resection is complete. Analysis of bacterial susceptibility and renewal of the initial dressing at 1 week enable progression to be monitored and treatment changed as necessary.
Collapse
Affiliation(s)
- F Rabarin
- Centre de la main, chirurgie de la main, 47, rue de la Foucaudière, 49800 Trélaze, France.
| | - J Jeudy
- Centre de la main, chirurgie de la main, 47, rue de la Foucaudière, 49800 Trélaze, France
| | - B Cesari
- Centre de la main, chirurgie de la main, 47, rue de la Foucaudière, 49800 Trélaze, France
| | - A Petit
- Centre de la main, chirurgie de la main, 47, rue de la Foucaudière, 49800 Trélaze, France
| | - N Bigorre
- Centre de la main, chirurgie de la main, 47, rue de la Foucaudière, 49800 Trélaze, France
| | - Y Saint-Cast
- Centre de la main, chirurgie de la main, 47, rue de la Foucaudière, 49800 Trélaze, France
| | - P-A Fouque
- Centre de la main, chirurgie de la main, 47, rue de la Foucaudière, 49800 Trélaze, France
| | - G Raimbeau
- Centre de la main, chirurgie de la main, 47, rue de la Foucaudière, 49800 Trélaze, France
| | -
- Centre de la main, chirurgie de la main, 47, rue de la Foucaudière, 49800 Trélaze, France
| |
Collapse
|
25
|
Labrum JT, Ilyas AM. The Opioid Epidemic: Postoperative Pain Management Strategies in Orthopaedics. JBJS Rev 2017; 5:e14. [DOI: 10.2106/jbjs.rvw.16.00124] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
|
26
|
Radiopaque Element to Evaluate Adequacy of Debridement of Bony Lesions. Tech Hand Up Extrem Surg 2017; 21:77-80. [PMID: 28383357 DOI: 10.1097/bth.0000000000000153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A technique for using an x-ray detectable radiopaque element from a surgical sponge to assess the adequacy of debridement of carpal bone cysts, Kienböck disease (lunate avascular necrosis), enchondroma of the digits, and scaphoid nonunions is described. The technique is simple to perform, inexpensive, and presents minimal additional risk to the patient. The technique has been used over the past 16 years and has enabled adequate debridement of these hand and wrist maladies by radiographically demonstrating the adequacy of the debridement to be bone grafted. It avoids the problems associated with liquid contrast dye and has proven to be very safe, effective, and inexpensive.
Collapse
|
27
|
Gaspar MP, Kane PM, Jacoby SM, Gaspar PS, Osterman AL. Evaluation and Management of Sleep Disorders in the Hand Surgery Patient. J Hand Surg Am 2016; 41:1019-1026. [PMID: 27702465 DOI: 10.1016/j.jhsa.2016.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 05/11/2016] [Accepted: 08/19/2016] [Indexed: 02/02/2023]
Abstract
Despite posing a significant public health threat, sleep disorders remain poorly understood and often underdiagnosed and mismanaged. Although sleep disorders are seemingly unrelated, hand surgeons should be mindful of these because numerous conditions of the upper extremity have known associations with sleep disturbances that can adversely affect patient function and satisfaction. In addition, patients with sleep disorders are at significantly higher risk for severe, even life-threatening medical comorbidities, further amplifying the role of hand surgeons in the recognition of this condition.
Collapse
Affiliation(s)
- Michael P Gaspar
- Philadelphia Hand Center, PC, Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA.
| | - Patrick M Kane
- Philadelphia Hand Center, PC, Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Sidney M Jacoby
- Philadelphia Hand Center, PC, Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Patrick S Gaspar
- Department of Anesthesiology, Harborside Surgical Center, Oxon Hill, MD
| | - A Lee Osterman
- Philadelphia Hand Center, PC, Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA
| |
Collapse
|