The influence of insurance status on access to and utilization of a tertiary hand surgery referral center

Minimally invasive colorectal cancer surgery: an observational study of medicare advantage and fee-for-service beneficiaries

BACKGROUND

Enrollment of Medicare beneficiaries in medicare advantage (MA) plans has been steadily increasing. Prior research has shown differences in healthcare access and outcomes based on Medicare enrollment status. This study sought to compare utilization of minimally invasive colorectal cancer (CRC) surgery and postoperative outcomes between MA and Fee-for-Service (FFS) beneficiaries.

METHODS

A retrospective cohort study of beneficiaries  ≥ 65.5 years of age enrolled in FFS and MA plans was performed of patients undergoing a CRC resection from 2016 to 2019. The primary outcome was operative approach, defined as minimally invasive (laparoscopic) or open. Secondary outcomes included robotic assistance, hospital length-of-stay, mortality, discharge disposition, and hospital readmission. Using balancing weights, we performed a tapered analysis to examine outcomes with adjustment for potential confounders.

RESULTS

MA beneficiaries were less likely to have lymph node (12.9 vs 14.4%, p < 0.001) or distant metastases (15.5% vs 17.0%, p < 0.001), and less likely to receive chemotherapy (6.2% vs 6.7%, p < 0.001), compared to FFS beneficiaries. MA beneficiaries had a higher risk-adjusted likelihood of undergoing laparoscopic CRC resection (OR 1.12 (1.10-1.15), p < 0.001), and similar rates of robotic assistance (OR 1.00 (0.97-1.03), p = 0.912), compared to FFS beneficiaries. There were no differences in risk-adjusted length-of-stay (β coefficient 0.03 (- 0.05-0.10), p = 0.461) or mortality at 30-60-and 90-days (OR 0.99 (0.95-1.04), p = 0.787; OR 1.00 (0.96-1.04), p = 0.815; OR 0.98 (0.95-1.02), p = 0.380). MA beneficiaries had a lower likelihood of non-routine disposition (OR 0.77 (0.75-0.78), p < 0.001) and readmission at 30-60-and 90-days (OR 0.76 (0.73-0.80), p < 0.001; OR 0.78 (0.75-0.81), p < 0.001; OR 0.79 (0.76-0.81), p < 0.001).

CONCLUSIONS

MA beneficiaries had less advanced disease at the time of CRC resection and a greater likelihood of undergoing a laparoscopic procedure. MA enrollment is associated with improved health outcomes for elderly beneficiaries undergoing operative treatment for CRC.

Impact of Insurance Type on Access to Pediatric Surgical Care

Background

This study aimed to measure the impact of insurance type on access to pediatric surgical care, clinical and surgical scheduling decisions, provider-driven cancelations, and missed care opportunities (MCOs). We hypothesize that patients with public health insurance experience longer scheduling delays and more frequently canceled surgical appointments compared with patients with private health insurance.

Methods

This retrospective study reviewed the demographics and clinical characteristics of patients who underwent a surgical procedure within the plastic and oral surgery department at our institution in 2019. Propensity score matching and linear regressions were used to estimate the effect of insurance type on hospital scheduling and patient access outcomes while controlling for procedure type and sex.

Results

A total of 457 patients were included in the demographic and clinical characteristics analyses; 354 were included in propensity score matching analyses. No significant differences in the number of days between scheduling and occurrence of initial consultation or number of clinic cancelations were observed between insurance groups (P > 0.05). However, patients with public insurance had a 7.4 times higher hospital MCO rate (95% CI [5.2-9.7]; P < 0.001) and 4.7 times the number of clinic MCOs (P = 0.007).

Conclusions

No significant differences were found between insurance groups in timely access to surgical treatment or cancelations. Patients with public insurance had more MCOs than patients with private insurance. Future research should investigate how to remove barriers that impact access to care for marginalized patients.

Association of Socioeconomic Status With Worse Overall Survival in Patients With Bone and Joint Cancer

BACKGROUND

The effect of socioeconomic status (SES) on the outcomes of patients with metastatic cancer to bone has not been adequately studied. We analyzed the association between the Yost Index, a composite geocoded SES score, and overall survival among patients who underwent nonprimary surgical resection for bone metastases.

METHODS

This population-based study used data from the National Cancer Institute's Surveillance, Epidemiology, and End Results database (2010 to 2018). We categorized bone and joint sites using International Classification of Disease-O-3 recodes. The Yost Index was geocoded using a factor analysis and categorized into quintiles using census tract-level American Community Service 5-year estimates and seven measures: median household income, median house value, median rent, percent below 150% of the poverty line, education index, percent working class, and percent unemployed. Multivariate Cox regression models were used to calculate adjusted hazard ratios of overall survival and 95% confidence intervals.

RESULTS

A total of 138,158 patients were included. Patients with the lowest SES had 34% higher risk of mortality compared with those with the highest SES (adjusted hazard ratio of 1.34, 95% confidence interval: 1.32 to 1.37, P < 0.001). Among patients who underwent nonprimary surgery of the distant bone tumor (n = 11,984), the age-adjusted mortality rate was 31.3% higher in the lowest SES patients compared with the highest SES patients (9.9 versus 6.8 per 100,000, P < 0.001). Patients in the lowest SES group showed more racial heterogeneity (63.0% White, 33.5% Black, 3.1% AAPI) compared with the highest SES group (83.9% White, 4.0% Black, 11.8% AAPI, P < 0.001). Higher SES patients are more likely to be married (77.5% versus 59.0%, P < 0.0001) and to live in metropolitan areas (99.6% versus 73.6%, P < 0.0001) compared with lower SES patients.

DISCUSSION

Our results may have implications for developing interventions to improve access and quality of care for patients from lower SES backgrounds, ultimately reducing disparities in orthopaedic surgery.

Building a Multidisciplinary Clinic Dedicated to Upper-Extremity Limb Loss

Complete care of the patient with upper limb loss mandates a long-term, multifaceted approach. Increased functionality and quality of life require collaborative efforts between the patient's surgeon, prosthetist, hand therapists, mental health professionals, and peers. An individual surgeon may find that initiating and maintaining a practice offering total integrated treatment for upper-extremity amputees is a formidable task, but with specific, actionable recommendations, the process can be demystified. The upper-extremity surgeon must be facile with operative techniques such as targeted muscle reinnervation (TMR), regenerative peripheral nerve interface (RPNI), and soft tissue reconstruction and focus on team recruitment strategy and promotion of the clinic within the community. Consistent communication and team decision-making shape each patient's preoperative and postoperative course. We aim to relay effective interventions at each step of recovery from each clinic member and describe clinic workflow designed to reinforce holistic care. We present a blueprint for creating a functional and comprehensive multidisciplinary center for patients with upper-extremity limb loss for those providers interested in providing care, but who are missing the logistical roadmap for how to do so.

Medicaid and Indigent Patients Experience Delayed Fixation of Distal Radius Fractures, Resulting in Worse Consequential Radiographic Outcomes

Distal radius fractures are the most common upper extremity injury. Patients referred to safety-net tertiary facilities following a fracture experience significant delays in treatment because of financial and language barriers as well as poor access to care at outlying community hospitals. This delay in treatment can affect postoperative functional outcomes and complication rates because of failure to restore anatomic alignment. The purpose of this multicenter study was to assess for risk factors associated with delayed fixation of distal radius fractures and evaluate the impact of delayed treatment on radiographic alignment. Patients with a distal radius fracture treated surgically during a 2-year period were identified. Measures included time from injury to surgery, demographic information, fracture classification, and radiographic parameters. The effect of surgery delay on radiographic outcomes was assessed with delayed surgery defined as 11 or more days out from injury. A total of 183 patients met study inclusion criteria. Medicaid and indigent patients were more likely to experience a delay in surgical treatment. Specifically, 70% of these patients were treated in a delayed fashion. Delayed treatment of 11 days or more was associated with worse radial height and inclination on postoperative radiographic imaging. Medicaid and indigent patients are more likely to experience delayed fixation in the treatment of distal radius fractures. This delayed surgery negatively affects postoperative radiographic outcomes. These findings suggest a need to improve access to care for Medicaid and indigent patients and to proceed with operative intervention within 10 days for distal radius fractures. [Orthopedics. 2024;47(2):e93-e97.].

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Social Disparities in the Management of Trigger Finger: An Analysis of 31 411 Cases

BACKGROUND

Cost and compliance are 2 factors that can significantly affect the outcomes of non-operative and operative treatment of trigger finger (TF) and both may be influenced by social factors. The purpose of this study was to investigate socioeconomic disparities in the surgical treatment for TF.

METHODS

Adult patients (≥18 years old) were identified using International Classification of Diseases 9 and 10 Clinical Modification diagnostic codes for TF and Current Procedural Terminology (CPT) procedural codes (CPT: 26055) in the New York Statewide Planning and Research Cooperative System database. Each diagnosis was linked to procedure data to determine which patients went on to have TF release. A multivariable logistic regression was performed to assess the likelihood of receiving surgery. The variables included in the analysis were age, sex, race, social deprivation index (SDI), Charlson Comorbidity Index, and primary insurance type. A P-value < .05 was considered significant.

RESULTS

Of the 31 411 TF patients analyzed, 8941 (28.5%) underwent surgery. Logistic regression analysis showed higher odds of receiving surgery in females (odds ratio [OR]: 1.108) and those with workers compensation (OR: 1.7). Hispanic (OR: 0.541), Asian (OR: 0.419), African American (OR: 0.455), and Other race (OR: 0.45) had decreased odds of surgery. Medicaid (OR: 0.773), Medicare (OR: 0.841), and self-pay (OR: 0.515) reimbursement methods had reduced odds of receiving surgery. Higher social deprivation was associated with decreased odds of surgery (OR: 0.988).

CONCLUSIONS

There are disparities in demographic characteristics among those who receive TF release for trigger finger related to race, primary insurance, and social deprivation.

Health Disparities in Hand and Upper Extremity Surgery: A Scoping Review

PURPOSE

Social determinants of health (SDOH) are linked to poor health care outcomes across the different medical specialties. We conducted a scoping review to understand the existing literature and identify further areas of research to address disparities within hand surgery.

METHODS

A systematic search of PubMed, Scopus, and Cochrane was conducted. Inclusion criteria were English studies examining health disparities in hand surgery. The following were assessed: the main SDOH, study design/phase/theme, and main disease/injury/procedure. A previously described health disparities research framework was used to determine study phase: detecting (identifying risk factors), understanding (analyzing risk factors), and reducing (assessing interventions). Studies were categorized according to themes outlined at the National Institute of Health and American College of Surgeons: Summit on Surgical Disparities.

RESULTS

The initial search yielded 446 articles, with 49 articles included in final analysis. The majority were detecting-type (31/49, 63%) or understanding-type (12/49, 24%) studies, with few reducing-type studies (6/49, 12%). Patient factors (31/49, 63%) and systemic/access factors (16/49, 33%) were the most frequently studied themes, with few investigating clinical care/quality factors (4/49, 8%), clinician factors (3/49, 6%), and postoperative/rehabilitation factors (1/49, 2%). The most commonly studied SDOH include insurance status (13/49, 27%), health literacy (10/49, 20%), and social deprivation (6/49, 12%). Carpal tunnel syndrome (9/49, 18%), upper extremity trauma (9/49, 18%), and amputations (5/49, 10%) were frequently assessed. Most investigations involved retrospective or database designs (29/49, 59%), while few were prospective, cross-sectional, or mixed-methods.

CONCLUSIONS

Despite an encouraging upward trend in health disparities research, existing studies are in the early phases of investigation.

CLINICAL RELEVANCE

Most of the literature focuses on patient factors and systemic/access factors in regard to insurance status. Further work with prospective, cross-sectional, and mixed-method studies is needed to better understand health disparities in hand surgery, which will inform future interventions.

The Effect of Joining the ASSH Hand Trauma Center Network on the Volume and Severity of Pediatric Hand Trauma Transfers

Purpose

The purpose of our study was to evaluate how the volume and severity of pediatric hand trauma is affected after enrollment into the American Society for Surgery of the Hand Trauma Center Network.

Methods

We performed a retrospective review using the patient database from our affiliated level-I pediatric trauma center. With this patient database, we compiled all emergent hand trauma transfers from February 2018 to January 2022. We compared the monthly volume, Injury Severity Score, and quarterly payor status between hand trauma transfer patients before and after enrollment into the Hand Trauma Center Network in February 2019.

Results

The average number of monthly transfers increased after joining the Hand Trauma Center Network compared with the years after February 2019. Additionally, the percentage of patients using commercial insurance increased after joining the Hand Trauma Center Network when compared with that before February 2019. Lastly, the percentage of patients using Medicaid decreased after February 2019.

Conclusions

Based on our findings, we believe that new institutions and providers can expect anywhere from a 10% to a 60% increase in hand trauma burden without a significant change in the severity of the trauma cases after joining the network.

Type of study/level of evidence

Prognostic IV.

Billing and Utilization Trends for Hand Surgery Indicate Worsening Barriers to Accessing Care

BACKGROUND

Hospitals and providers may increase hand surgery charges to compensate for decreasing reimbursement. Higher charges, combined with increasing utilization of ambulatory surgical centers (ASCs), may threaten the accessibility of affordable hand surgery care for uninsured and underinsured patients.

METHODS

We queried the Physician/Supplier Procedure Summary to collect the number of procedures, charges, and reimbursements of hand procedures from 2010 to 2019. We adjusted procedural volume by Medicare enrollment and monetary values to the 2019 US dollar. We calculated weighted means of charges and reimbursement that were then used to calculate reimbursement-to-charge ratios (RCRs). We calculated overall change and r2 from 2010 to 2019 for all procedures and stratified by procedural type, service setting, and state where service was rendered.

RESULTS

Weighted mean charges, reimbursement, and RCRs changed by + 21.0% (from $1,227 to $1,485; r2 = 0.93), +10.8% (from $321 to $356; r2 = 0.69), and -8.4% (from 0.26 to 0.24; r2 = 0.76), respectively. The Medicare enrollment-adjusted number of procedures performed in ASCs increased by 63.8% (r2 = 0.95). Trends in utilization and billing varied widely across different procedural types, service settings, and states.

CONCLUSIONS

Charges for hand surgery procedures steadily increased, possibly reflecting an attempt to make up for reimbursements perceived to be inadequate. This trend places uninsured and underinsured patients at greater risk for financial catastrophe, as they are often responsible for full or partial charges. In addition, procedures shifted from inpatient to ASC setting. This may further limit access to affordable hand care for uninsured and underinsured patients.

Budget Neutrality and Medicare Physician Fee Schedule Reimbursement Trends for Radiologists, 2005 to 2021

PURPOSE

The Medicare program, by law, must remain budget neutral. Increases in volume or relative value units (RVUs) for individual services necessitate declines in either the conversion factor or assigned RVUs for other services for budget neutrality. This study aimed to assess the contribution of budget neutrality on reimbursement trends per Medicare fee-for-service beneficiary for services provided by radiologists.

METHODS

The study used aggregated 100% of Medicare Part B claims from 2005 to 2021. We computed the percentage change in reimbursement per beneficiary, actual and inflation adjusted, to radiologists. These trends were then adjusted by separately holding constant RVUs per beneficiary and the conversion factor to demonstrate the impact of budget neutrality.

RESULTS

Unadjusted reimbursement to radiologists per beneficiary increased 4.2% between 2005 and 2021, but when adjusted for inflation, it declined 24.9%. Over this period, the conversion factor declined 7.9%. Without this decline, the reimbursement per beneficiary would have been 9 percentage points higher in 2021 compared with actual. RVUs per beneficiary performed by radiologists increased 13.1%. Keeping RVUs per beneficiary at 2005 levels, reimbursement per beneficiary would have been 12.1 percentage points lower than observed in 2021.

CONCLUSIONS

Given budget neutrality, a substantial decline has occurred in inflation-adjusted reimbursement to radiologists per Medicare beneficiary. Decreases due to both inflation and the decline in conversion factor are only partially offset by increased RVUs per beneficiary, meaning more services per patient with less overall pay, an equation likely to heighten access challenges for Medicare beneficiaries and shortages of radiologists.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Barriers and facilitators to surgical access in underinsured and immigrant populations

BACKGROUND

Marginalized communities are at risk of receiving inequitable access to surgical care. We aimed to examine the barriers and facilitators to access to surgery in underinsured and immigrant populations.

METHODS

A systematic review of disparities in access to surgical care was performed between January 1, 2000-March 2, 2022. Methodological quality was assessed with the Mixed Methods Appraisal Tool. A convergent integrated approach was used to code common themes between studies.

RESULTS

Of 1315 publications, a total of 66 studies were included for systematic review. Eight studies specifically discussed immigrant patient populations. Barriers and facilitators to surgical access were categorized by patient and health systems related factors.

CONCLUSIONS

Established facilitators to improve surgical access are centered on patient-level factors while interventions to address systems-related barriers are limited and may be an area for further investigation. Research focused on access to surgery in immigrant populations remains sparse.

Access to Reconstructive Hand Surgery in the United States-Investigating the Obstacles: A Scoping Review

BACKGROUND

Mechanisms that affect access to surgical hand care appear to be complex and multifaceted. This scoping review aims to investigate the available literature describing such mechanisms and provide direction for future investigation.

METHODS

The methodological framework outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews was used to guide this review. In November 2021, MEDLINE and EMBASE databases were searched. A narrative summary of the characteristics and key findings of each paper is used to present the data to facilitate the integration of diverse evidence.

RESULTS

Of 471 initial studies, 49 were included in our final analysis. Of these, 33% were cohort studies; 27% reported that underinsured patients are less likely to get an appointment with a hand specialist or to receive treatment. Overburdened emergency departments accounted for the second-most reported reason (16%) for diminished access to surgical hand care. Elective procedure financial incentives, poor emergency surgical hand coverage, distance to treatment, race, and policy were also notably reported across the literature.

CONCLUSIONS

This study describes the vast mechanisms that hinder access to surgical hand care and highlights their complexity. Possible solutions and policy changes that may help improve access have been described.

Disparities in Treatment of Closed Distal Radius Fractures in Patients Aged 18-64 Years and ≥65 Years by Insurance Type

PURPOSE

Type of and time to definitive treatment for distal radius fractures can influence the outcomes. The impact of social determinants of health (eg, insurance type) on distal radius fracture care remains unknown despite having health equity implications. Thus, we evaluate the association between insurance type and rate of surgery, the time to surgery, and the complication rate for distal radius fractures.

METHODS

We conducted a retrospective cohort study using the PearlDiver Database. We identified adults with closed distal radius fractures. Patients were divided into subgroups by age (18-64 years, 65+ years) and further stratified on the basis of the insurance type (Medicare Advantage, Medicaid-managed care, and commercial). The primary outcome was the rate of surgical fixation. Secondary outcomes included the time to surgery and 12-month complication rates. Logistic regression modeling was used to calculate the odds ratios for each outcome, adjusting for age, sex, geographic region, and comorbidities.

RESULTS

In patients aged ≥65 years, a lower proportion of Medicaid patients underwent surgery within 21 days of diagnosis compared with Medicare or commercially insured patients (12.1% vs 15.9% or 17.5%, respectively). Complication rates did not differ between Medicaid and other insurance types. In patients aged <65 years, fewer Medicaid patients underwent surgery compared with commercially insured patients (16.2% vs 21.1%). However, in this younger group, Medicaid patients had higher adjusted odds of malunion/nonunion (adjusted odds ratio [aOR] = 1.39 [95% CI, 1.31-1.47]) and subsequent repair (aOR = 1.38 [95% CI, 1.25-1.53]).

DISCUSSION

Although older Medicaid patients experienced lower surgical rates, this may not lead to differential clinical outcomes. However, Medicaid patients aged <65 years experienced lower surgical rates that correlated with the increased rates of malunion or nonunion.

CLINICAL RELEVANCE

In younger patients with a closed distal radius fracture and Medicaid insurance, system and patient-directed efforts should be considered to address delayed time to surgery and a higher odds for malunion/nonunion.

Trends in Physician Payments for Hand Surgery Consultations and Clinic Visits

PURPOSE

The primary objective of this study was to identify the trends in reimbursement for hand surgeons for new patient visits, outpatient consultations, and inpatient consultations from the years 2010-2018. In addition, we sought to investigate the influence of payer mix and coding level of service on physician reimbursement in these settings.

METHODS

The PearlDiver Patients Records Database was used to identify clinical encounters and their respective physician reimbursements for analysis within this study. This database was queried using Current Procedural Terminology codes to identify relevant clinical encounters for inclusion, filtered for the presence of valid demographic information and by physician specialty for the presence of a hand surgeon, and tracked by primary diagnoses. Cost data were then calculated and analyzed regarding the payer type and level of care.

RESULTS

In total, 156,863 patients were included in this study. The mean reimbursement for inpatient consultations, outpatient consultations, and new patient encounters increased by 92.75% ($134.85 to $259.93), 17.80% ($161.33 to $190.04), and 26.78% ($102.58 to $130.05), respectively. When normalized to 2018 dollars to adjust for inflation, the percent increases were 67.38%, 2.24%, and 10.09%, respectively. Commercial insurance reimbursed hand surgeons to a greater degree than any other payer type. Mean physician reimbursement differed depending on the level of service billed, with the level of service V reimbursing 4.41 times more than the level of service I visits for new outpatient visits, 3.66 times more for new outpatient consultations, and 3.04 times more for new inpatient consultations.

CONCLUSIONS

This study helps to provide physicians, hospitals, and policymakers with objective information regarding the trends in reimbursement to hand surgeons. Although this study indicates increasing reimbursements for consultations and new patient visits to hand surgeons, the margins shrink when adjusted for inflation.

LEVEL OF EVIDENCE

Economic Analysis IV.

Public Insurance Is Associated With Decreased Rates of Surgical Management for Glenohumeral Instability: An Analysis of the Rhode Island All-Payers Claims Database

Background

Socioeconomic status has been shown to influence patients' ability to access health care.

Purpose

To evaluate the socioeconomic status and/or insurance provider of patients and to determine whether these differences influence the management of shoulder instability.

Study Design

Descriptive epidemiology study.

Methods

The Rhode Island All-Payers Claims Database (APCD) was used to identify all patients between the ages of 5 and 64 years who made an insurance claim related to a shoulder instability event between January 1, 2011, and December 31, 2019. Chi-square analysis and multivariate logistic regression were utilized to determine whether insurance status, social deprivation index (SDI), or median income by zip code were significant predictors of treatment methodology and recurrent instability. Kaplan-Meier failure analysis and Cox regression were used to assess for variation in the cumulative rates of surgical intervention and recurrent instability over 20-year age groups (5-24, 25-44, and 45-64 years).

Results

There were 3310 patients from the APCD query included in the analysis. Bivariate analysis demonstrated significant variation in the rates of surgical stabilization between patients with public and commercial insurance providers (P < .001). Patients with public insurance received surgery 1.8% of the time compared with 5.8% of the time in patients with commercial insurance. After controlling for recurrent instability, age, instability type (subluxation or dislocation) and directionality, and sex, patients with public insurance were 79% less likely to receive surgery within 30 days (P = .035) and 64% less likely to receive surgery within 1 year (P = .002). This disparity was most notable in the 5- to 24-year (hazard ratio [HR] = 0.28; 95% CI, 0.13-0.61) and 25- to 44-year (HR = 0.26; 95% CI, 0.08-0.89) age groups. Neither SDI quartile nor income quartile based on patient primary zip code had a clinically significant influence on rates of surgery or recurrent instability.

Conclusion

These data demonstrate that patients with public insurance have a decreased likelihood of undergoing surgical stabilization to address glenohumeral instability compared with patients with commercial insurance.

Role of Health Equity Research and Policy for Diverse Populations Requiring Hand Surgery Care

Health equity requires allocation of resources to eliminate the systematic disparities in health, imposed on marginalized groups, which adversely impact outcomes. A socioecological approach is implemented to elucidate the role of health equity research and policy for underrepresented minority and socioeconomically disadvantaged populations. Through investigation of the individual, community, institution, and public policy, we investigate problems and propose solutions to ensure fair and just treatment of all patients requiring hand surgery.

The impact of socioeconomic status on hand injury severity

Socioeconomic status (SES) is an important factor affecting different aspects of human health, including self-care and healthcare service use. The relation between SES and hand injury severity is not well defined; therefore, the present study aimed to investigate the relation between SES and hand injury severity. This cross-sectional descriptive and analytical study included 215 patients with hand injury. Demographic, clinical, and SES-related factors were collected by questionnaire. Injury severity was assessed on Hand Injury Severity Score (HISS). Statistical analysis used the Student t-test, chi-square test and a multinomial regression model to calculate the odds ratio (OR) of each predictive factor. Mean age was 38.02 ± 13.49 years (range, 12-80 years). 73.5% of the participants were men. Patients with low SES were significantly more likely to develop severe hand injury (OR = 5.25 and 9.25 at HISS levels 3 and 4, respectively). In addition, there was a significant association between being born in rural areas and severe (HISS level 3, OR = 2.63) or major (HISS level 4, OR = 2.63) hand injury. Also, major (HISS level 4) hand injuries were significantly more prevalent in patients living in rural areas (OR = 4.23) and those injured in road accidents (OR = 1.98) or practicing sports (OR = 3.51). The study concluded that patients with low SES were 5-10-fold more likely to suffer from severe and major hand injuries, and thus provided valuable information for Iranian policymakers to take preventive measures for hand injuries. It is recommended to improve postoperative care in patients with low SES who underwent hand surgery, take the necessary measures to decrease the incidence of road accident injuries, facilitate early referral of patients with hand injury to trauma centers, and improve postoperative follow-up until full recovery. LEVEL OF EVIDENCE: III.

Socioeconomic status does not change decision-making in the treatment of distal radius fractures at a level 1 trauma center

Objectives

To compare operative rates, total hospital charges, and length of stay between different socioeconomic cohorts in treating distal radius fractures (DRFs).

Design

A retrospective cohort study.

Setting

Large public level 1 trauma center.

Patients

A retrospective search of all trauma activations over a 7-year period (2013-2020) yielded 816 adult patients diagnosed with DRF. Patients were separated into cohorts of socioeconomic status based on 2010 US Census data and insurance status.

Intervention

DRFs were treated either nonoperatively using closed reduction and splinting or operatively using open reduction and internal fixation, closed reduction percutaneous pinning, or external fixator application.

Main Outcome Measurements

Operative rates of DRF, total hospital charges, and length of stay.

Results

Patients who were uninsured or in the low-income socioeconomic cohort had no significant difference in operative rates, total hospital costs, or length of stay when compared with their respective insured or standard income groups. Younger patients and those with OTA/AO type C, bilateral, or open DRFs were more likely to undergo operative intervention.

Conclusions

This study demonstrates that low socioeconomic status based on annual household income and insurance status was not associated with differences in operative rates on DRFs, length of stay, or total hospital charges. These results suggest that outcome disparities between groups may be caused by postoperative differences rather than treatment decision-making. Although this study investigates access to surgical care at a publicly funded level 1 trauma center, disparities may still exist in other models of care.

Level of Evidence

Prognostic Level III.

An Analysis of Procedural Medicare Reimbursement Rates in Hand Surgery: 2000 to 2019

BACKGROUND

Medicare reimbursement trends across multiple surgical subspecialties have been analyzed; however, little has been reported regarding the long-term trends in reimbursement of hand surgery procedures. The aim of this study is to analyze trends in Medicare reimbursement for commonly performed hand surgeries.

METHODS

Using the Centers for Medicare and Medicaid Services Physician and Other Supplier Public Use File, we determined the 20 hand surgery procedure codes most commonly billed to Medicare in 2016. Reimbursement rates were collected and analyzed for each code from The Physician Fee Schedule Look-Up Tool for years 2000 to 2019. We compared the change in reimbursement rate for each procedure to the rate of inflation in US dollars, using the Consumer Price Index (CPI) over the same time period.

RESULTS

The reimbursement rate for each procedure increased on average by 13.9% during the study period while the United States CPI increased significantly more by 46.7% (P < .0001). When all reimbursement data were adjusted for inflation to 2019 dollars, the average reimbursement for all included procedures in this study decreased by 22.6% from 2000 to 2019. The average adjusted reimbursement rate for all procedures decreased by 21.92% from 2000 to 2009 and decreased by 0.86% on average from 2009 to 2019 (P < .0001).

CONCLUSION

When adjusted for inflation, Medicare reimbursement for hand surgery has steadily decreased over the past 20 years. It will be important to consider the implications of these trends when evaluating healthcare policies and the impact this has on access to hand surgery.

Risk Factors for Operating Room No-Show in an Academic Otolaryngology Practice

OBJECTIVES/HYPOTHESIS

A no-show to the operating room date negatively impacts a hospital and can lead to increased costs for an institution in terms of time, materials, and manpower. Our objectives are to identify the factors associated with operating room no-shows in order to increase clinical efficiency, reduce hospital costs, and increase patient access to care.

STUDY DESIGN

Single institution retrospective chart review.

METHODS

A retrospective review was performed of all surgeries within the Otolaryngology department performed at a single tertiary academic center between 2006 and 2019. Demographic and surgical data were collected from the charts. Descriptive, univariate, and multivariate statistics were performed on the data.

RESULTS

There were a total of 1,752 no-shows and 46,440 patients who did show with an overall no-show rate of 3.63%. A multivariate logistic regression analysis was performed to compare patients who did not show for surgery to those who did. Analysis found multiple risk factors for not showing to surgery that were statistically significant (P < .05) and included decreasing age, planned outpatient case, head and neck oncology subspecialty, increasing distance from the facility, higher number of clinic no-shows, and not having private insurance. African-American race was more likely to show for surgery as scheduled.

CONCLUSIONS

Numerous factors may play a role on whether or not a patient attends a scheduled surgical date. Some of these factors may be preventable or modifiable to mitigate increased hospital costs associated with no-show to surgery and increase access to care.

LEVEL OF EVIDENCE

3 Laryngoscope, 132:1738-1742, 2022.

Variability in Medicaid Reimbursement in Hand Surgery May Lead to Inequality in Access to Patient Care

BACKGROUND

Medicare (MCR) and Medicaid (MCD) remain the dominant providers of government-funded health insurance in the United States. The purpose of this study was to evaluate the variability between MCR and MCD reimbursements for common hand and wrist surgical procedures. We hypothesized that MCD reimbursement rates would have substantial variation between states, whereas MCR rates would remain relatively constant.

METHODS

Using the Medicare Physician Fee Schedule Database, the 2019 reimbursements for 7 common hand and wrist procedures were recorded via the respective Current Procedural Terminology codes. The MCD reimbursement rates were then obtained from each state's physician fee schedule database. Comparisons of reimbursement for these procedures were then calculated between states and between MCD and MCR while adjusting for cost of living using the Medicare Wage Index. Finally, the coefficients of variation were computed to compare the extent of variability between the insurance types.

RESULTS

Across all procedures, reimbursement rates for MCD ranged from 30.6% to 240% of the average MCR reimbursement, with the mean reimbursement for MCD valued at 78.3% of MCR. Endoscopic carpal tunnel release (CTR) is valued similarly by MCD compared with open CTR with an average of 77.7% and 78.2% reimbursement of MCR, respectively. The coefficients of variation for MCD reimbursements ranged from 0.25 to 0.45, whereas the value was 0.06 for all MCR procedures.

CONCLUSIONS

These findings demonstrate a wide variation in MCD payments between states. When compared with MCR, the lower average state MCD reimbursement questions the sustainability for hand surgeons to accept these patients in practice.

Public Insurance Payment Does Not Compensate Hospital Cost for Care of Long-Bone Fractures Requiring Additional Surgery to Promote Union

OBJECTIVES

To quantify the total hospital costs associated with the treatment of lower extremity long-bone fracture aseptic and septic unhealed fracture, to determine if insurance adequately covers these costs, and to examine whether insurance type correlates with barriers to accessing care.

DESIGN

Retrospective cohort study.

SETTING

Academic Level II trauma center.

PATIENTS

All patients undergoing operative treatment of OTA/AO classification 31, 32, 33, 41, 42, and 43 fractures between 2012 and 2020 at a single Level II trauma center with minimum of 1-year follow-up.

MAIN OUTCOME MEASURES

The primary outcome was the total cost of treatment for all hospital-based episodes of care. Distance traveled from primary residence was measured as a surrogate for barriers to care.

RESULTS

One hundred seventeen patients with uncomplicated fracture healing, 82 with aseptic unhealed fracture, and 44 with septic unhealed fracture were included in the final cohort. The median cost of treatment for treatment of septic unhealed fracture was $148,318 [interquartile range(IQR) 87,241-256,928], $45,230 (IQR 31,510-68,030) for treatment of aseptic unhealed fracture, and $33,991 (IQR 25,609-54,590) for uncomplicated fracture healing. The hospital made a profit on all patients with commercial insurance, but lost money on all patients with public insurance. Among patients with unhealed fracture, those with public insurance traveled 4 times further for their care compared with patients with commercial insurance (P = 0.004).

CONCLUSIONS

Septic unhealed fracture of lower extremity long-bone fractures is an outsized burden on the health care system. Public insurance for both septic and aseptic unhealed fracture does not cover hospital costs. The increased distances traveled by our Medi-Cal and Medicare population may reflect the economic disincentive for local hospitals to care for publicly insured patients with unhealed fractures.

LEVEL OF EVIDENCE

Economic Level V. See Instructions for Authors for a complete description of levels of evidence.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Clinical Relevance

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

Renal Artery Aneurysms in the Inpatient Setting

BACKGROUND

The risk of rupture of renal artery aneurysms (RAAs) remains undefined. A recent paper from the Vascular Low-Frequency Disease Consortium (VLFDC) identified only 3 ruptures in 760 patients. However, over 80% of patients in the VLFDC study were treated at large academic centers, which may not reflect the pattern of care of RAAs nationwide. Thus, the purpose of this study was to evaluate the pattern of nonelective versus elective surgery requiring inpatient admission for RAAs, including nephrectomies, and their outcomes using a national database.

METHODS

The National Inpatient Sample (NIS) database from 2012 to 2018 was utilized. Patients with a primary diagnosis of RAAs were identified using ICD-9 and ICD-10 codes. Ruptured RAAs (rRAAs) were identified utilizing surrogate ICD codes. The primary outcome variables for this study were proportion of RAAs requiring non-elective surgery and in-hospital mortality.

RESULTS

A total of 590 inpatient admissions for RAA were identified with 554 procedures at 467 hospitals across the country. Of the 590 inpatient admissions, 380 (64.4%) admissions were deemed nonelective. There was an increasing proportion of nonelective admissions over the study period. The overall rate of nephrectomies was 7.1% (n = 42). In-hospital mortality rate for the cohort was 1.4% (n = 8) with no differences in in-hospital mortality in the elective versus nonelective setting (1.0% vs. 1.6%; P = 0.718). In the nonelective setting, patients requiring a nephrectomy (n = 23) had significantly higher rates of in-hospital mortality compared those not requiring a nephrectomy (8.7% vs. 1.1%, P = 0.045). rRAA (n = 50) patients had significantly higher in-hospital mortality compared to the remainder of the cohort (6.0% vs. 0.9%, P = 0.024). rRAA patients were also more likely to undergo a nephrectomy compared to the remainder of the cohort (16.0% vs. 6.3%, P = 0.019).

CONCLUSIONS

These data demonstrate that treatment of RAAs are primarily done in the nonelective setting with a high proportion of ruptures, which could continue to rise as the threshold for repair has decreased.

The Impact of Social Deprivation and Hand Therapy Attendance on Range of Motion After Flexor Tendon Repair

PURPOSE

To examine the influence of social deprivation and hand therapy attendance on active range of motion (AROM) outcomes following flexor tendon repair.

METHODS

We performed a retrospective analysis of patients who underwent primary zone I-III flexor tendon repair between November 2016 and November 2020. Area deprivation index (ADI) was used to quantify social deprivation. Medical record review determined each patient's demographic characteristics, injury details, total hand therapy visits, and final AROM outcome. Active range of motion was converted to Strickland's percentage for analysis. Spearman correlation and simple and multivariable linear regression models were used to assess relationships between explanatory variables and outcomes.

RESULTS

There were a total of 109 patients, with a mean ADI of 53 and mean therapy attendance of 13 visits. Higher ADI and lower therapy attendance were correlated, and each was associated with significantly decreased Strickland's percentage. In the multivariable model, therapy attendance, ADI, zone 2 injury, and age maintained significant associations with Strickland's percentage.

CONCLUSIONS

Socially deprived patients attend fewer therapy sessions and obtain poorer AROM after flexor tendon repair. Social deprivation is likely to contribute to poor outcomes both by its association with decreased therapy attendance and by other potential pathways that make it difficult for deprived patients to achieve good surgical outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Socioeconomic Status Impacts Access to Orthopaedic Specialty Care

»

Financial, personal, and structural barriers affect access to all aspects of orthopaedic specialty care.

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Disparities in access to care are present across all subspecialties of orthopaedic surgery in the United States.

»

Improving timely access to care in orthopaedic surgery is crucial for both health equity and optimizing patient outcomes.

»

Options for improving orthopaedic access include increasing Medicaid/Medicare payments to physicians, providing secondary resources to assist patients with limited finances, and reducing language barriers in both clinical care and patient education.

Definitive surgical femur fracture fixation in Northern Tanzania: implications of cost, payment method and payment status

Introduction

Kilimanjaro Christian Medical Centre (KCMC) covers major orthopaedic trauma for a catchment population of 12.5 million people in northern Tanzania. Femur fractures, the most common traumatic orthopaedic injury at KCMC (39%), require open reduction and internal fixation (ORIF) for definitive treatment. It is unclear whether payment affects care. This study sought to explore associations of payment method with episodes of care for femur fracture ORIFs at KCMC.

Methods

we performed a retrospective review of orthopaedic records between February 2018 and July 2018. Patients with femur fracture ORIF were eligible; patients without charts were excluded. Ethical clearance was obtained from the KCMC ethics committee. Statistical analysis utilized descriptive statistics, Chi-squared and Fisher’s exact Tests, and Student´s t-tests where appropriate.

Results

of 76 included patients, 17% (n=13) were insured, 83% (n=63) paid out-of-pocket, 11% (n=8) had unpaid balance, and 89% (n=68) fully paid. Average patient charge ($417) was 42% of per capita GDP ($998). Uninsured patients had higher bills ($429 vs $356; p=0.27) and were significantly more likely to pay an advance payment (95.2% vs 7.7%; p<0.001). Inpatient care was equivalent regardless of payment. Unpaid patients were less likely to receive follow-up (76.5% vs. 25%; p=0.006) and waited longer from injury to admission (31.5 vs 13.3 days; p<0.001), from admission to surgery (30.1 vs 11.1 days; p<0.001), and from surgery to discharge (18.4 vs 7.1 days; p<0.001).

Conclusion

equal standard of care is provided to all patients. However, future efforts may decrease disparities in advance payment, timeliness, and follow-up.

Insurance Status and Disparities in Outpatient Care after Traumatic Injuries of the Hand: A Retrospective Cohort Study

BACKGROUND

Hand-injured patients seen in the emergency department can often be followed as outpatients for definitive care and rehabilitation. Many face barriers to continuing care in the outpatient setting that impact quality of care delivery. The authors aimed to evaluate patterns of outpatient follow-up after initial emergency department evaluation of traumatic hand injuries, identify factors associated with poor follow-up, and suggest areas for improvement.

METHODS

In this retrospective cohort study, the authors reviewed records of adult patients with acute hand injuries referred for outpatient follow-up after initial plastic surgery consultation in the emergency department of a single urban Level I trauma center over a 12-month period (n = 300). Patients were grouped by insurance (i.e., no insurance, Medicaid, Medicare, or private). Outcomes included completion of outpatient follow-up, hand therapy participation, and emergency department return visits.

RESULTS

Factors significantly associated with failure to follow up included male sex (OR, 3.58; 95 percent CI, 1.57 to 8.16), uninsured status (OR, 3.47; 95 percent CI, 1.48 to 8.16), Medicaid insurance (OR, 4.46; 95 percent CI, 1.31 to 15.25), and lack of a driver's license (OR, 3.35; 95 percent CI, 1.53 to 7.34). Hand therapy attendance and unexpected emergency department return visits also varied significantly by insurance type (p < 0.001).

CONCLUSIONS

There is a significant disparity in the use of outpatient care after emergency department visits for acute hand injuries. Uninsured and Medicaid-insured patients are significantly less likely to initiate recommended hand specialty follow-up, and significantly less likely to complete follow-up even when established with an outpatient clinic. Future research should evaluate targeted interventions for at-risk patients.

Financial Distress Is Associated With Delay in Seeking Care for Hand Conditions

Background: As medical costs continue to rise, financial distress due to these costs has led to poorer health outcomes and patient cost-coping behavior. Here, we test the null hypothesis that financial distress is not associated with delay of seeking care for hand conditions. Methods: Eighty-seven new patients presenting to the hand clinic for nontraumatic conditions completed our study. Patients completed validated instruments for measuring financial distress, pain catastrophizing, and pain. Questions regarding delay of care were included. The primary outcome was self-reported delay of the current hand clinic visit. Results: Patients who experience high financial distress differed significantly from those who experience low financial distress with respect to age, race, annual household income, and employment status. Those experiencing high financial distress were more likely to report having delayed their visit to the hand clinic (57% vs 30%), higher pain catastrophizing scores (17.7 vs 7.6), and higher average pain in the preceding week (4.5 vs 2.3). After adjusting for age, sex, and pain, high financial distress (adjusted odds ratio [OR] = 4.90) and pain catastrophizing score (adjusted OR = 0.96) were found to be independent predictors of delay. Financial distress was highly associated with annual household income in a multivariable linear regression model. Conclusions: Patients with nontraumatic hand conditions who experience higher financial distress are more likely to delay their visit to the hand clinic. Within health care systems, identification of patients with high financial distress and targeted interventions (eg, social or financial services) may help prevent unnecessary delays in care.

Outcome Measurement for Distal Radius Fractures

Distal radius fractures (DRFs) are among the most common upper extremity injuries. Multiple medical conditions now are evaluated by standardized outcome sets that enable comparability. Recent international working groups have provided consensus statements for outcomes measurement after DRFs. These statements emphasized the growing importance of patient-reported outcome measures as well as traditional measures, including pain assessment, radiographic alignment, performance, and assessment of complications. A standardized instrument and timeline for measuring outcomes following DRFs offers clinicians, researchers, and health care economists a powerful tool. This article reviews the current evidence and provides recommendations for a DRF standardized outcome set.

Increased Utilization of Total Joint Arthroplasty After Medicaid Expansion

BACKGROUND

The expansion of state Medicaid programs under the U.S. Affordable Care Act has led to a dramatic increase in the number of Americans with health insurance coverage. Prior analyses of a limited number of states have suggested that greater utilization of total hip arthroplasty (THA) and total knee arthroplasty (TKA) should be expected after Medicaid expansion. The purpose of our study was to examine whether increased utilization of THA and TKA occurred across a broader range of states after Medicaid expansion.

METHODS

We analyzed administrative data from the Healthcare Cost and Utilization Project from 9 states (Arkansas, Arizona, Colorado, Iowa, Massachusetts, Maryland, Nevada, New York, and Vermont) that expanded Medicaid in 2014 and 2 states that did not expand Medicaid (Florida and Missouri). We included patients who were 18 to 64 years of age and had a primary THA or TKA from 2012 to 2015 with Medicaid as the primary payer. Other payers (including dual-eligible Medicaid and Medicare beneficiaries) were excluded. We performed multivariable regression modeling with the number of Medicaid-insured THAs or TKAs as the dependent variable and the interaction between the state Medicaid expansion status and year as the main policy independent variable, with adjustment for community characteristics.

RESULTS

Among all 11 states, there were 39,452 total joint arthroplasties (42% THA and 58% TKA) funded by Medicaid from 2012 to 2015. After adjusting for community characteristics, within expansion states, compared with 2013, THA and TKA increased 15% in 2014 (p < 0.0001) and 23% in 2015 (p < 0.0001) within expansion states. Within non-expansion states, compared with 2013, there were significant utilization decreases of 18% in 2014 (p < 0.0001) and 11% in 2015 (p = 0.0002).

CONCLUSIONS

Medicaid expansion was associated with significant increases in Medicaid-funded THA and TKA utilization in 9 states. As additional states consider expanding Medicaid programs and as alternative health reforms that increase insurance eligibility are debated, surgeons, administrators, and policymakers should prepare for a surge in the utilization of THA and TKA.

Impact of Insurance Type on Self-Reported Symptom Severity at the Preoperative Visit for Carpal Tunnel Release

PURPOSE

Prior studies evaluated the impact of insurance type on access to hand care. However, there is limited literature quantifying whether patient symptoms are worse at the time of intervention. Our primary null hypothesis was that insurance type would not be associated with Patient-Reported Outcomes Measure Information System (PROMIS) Upper-Extremity (UE), Physical Function (PF), Pain Interference (PI), and Depression scores at the preoperative visit before carpal tunnel release (CTR).

METHODS

Between December 2016 and November 2018, patients with known carpal tunnel syndrome presenting to a tertiary academic hand clinic for the preoperative visit within 3 months of CTR, completed PROMIS UE, PF, PI, and Depression computer adaptive tests. Patient characteristics were recorded, including insurance type as commercial, Medicare, Medicaid, or workers' compensation. Multivariable linear regression was used to determine which variables were associated with PROMIS scores at the preoperative visit before CTR.

RESULTS

A total of 301 patients were included in the analysis. All PROMIS domains were significantly different by insurance type; Medicaid patients had the worst preoperative score for all domains in bivariate analysis. In multivariable linear regression modeling, commercial insurance was associated with better preoperative PROMIS UE, PF, PI, and Depression scores.

CONCLUSIONS

Commercial insurance is associated with significantly better preoperative PROMIS PF, PI, and Depression scores compared with other insurance types (ie, Medicaid, Medicare, and Workers' compensation). This may be the result of a number of factors, including differences in access to hand care or life circumstances that allow for only certain individuals to seek hand care early on in the disease process. However, further research is warranted to determine more definitively why this association exists.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Socioeconomic and Demographic Disparities in Early Surgical Stabilization Following Emergency Department Presentation for Shoulder Instability

Purpose

To describe which patients are the most likely to undergo surgical management within the same calendar year as their emergency department visit for anterior shoulder instability.

Methods

The State Emergency Department Databases and State Ambulatory Surgery and Services Databases from Florida were used. All patients presenting to the emergency department for anterior shoulder subluxation or dislocation between January 1 and September 30, 2017, were selected. Bivariate analysis was performed for associations with demographic variables. A binary logistic regression was performed with all significant factors to assess which were predictors of undergoing surgery the same calendar year.

Results

While controlling for all significant factors, we found that patients with recurrent dislocations were 3.14 times more likely to have surgery within the same year (P = .037). Patients younger than 40 years were also 2.04 times more likely to have surgery than those aged 40 years or older (P < .001). White patients were 2.47 times more likely to have surgery than black patients (P < .001). On bivariate analysis, there was an association between greater income quartile and higher odds of undergoing surgery within 30 days.

Conclusions

Following an emergency department visit for acute shoulder instability, the following variables were associated with undergoing surgical stabilization within the same calendar year: previous dislocation, age younger than 40, and white race. Patients living in the greatest income quartile of patients had a significantly greater percentage of patients having surgery within 30 days. This demonstrates that disparities and barriers to care may exist for patients with shoulder instability.

Level of Evidence

Level III, Retrospective Comparative Study.

A Geographic Population-level Analysis of Access to Total Shoulder Arthroplasty in the State of Texas

INTRODUCTION

Managing costs and improving access to care are two important goals of healthcare policy. The purposes of this study were to (1) evaluate the changes in distribution of total shoulder arthroplasty (TSA) cases in the state of Texas from 2010 to 2015 and (2) to evaluate patient access to TSA surgery centers as measured by driving miles.

METHODS

Inpatient (IP) and outpatient (OP) records were obtained from 2010 to 2015 from the Texas Department of State Health Services. All primary elective anatomic or reverse TSAs for patients with Texas-based home residence zip codes were included. Driving miles between patient zip codes and their chosen TSA surgery centers were estimated, and the results were compared between IP (high-volume [HV-IP] or low-volume [LV-IP]) and OP centers. Paired student t-tests, multivariate regressions, and mixed-model analysis of variance (ANOVA) were performed for volume comparisons, interactions between TSA centers types, and yearly trend data, respectively.

RESULTS

Between 2010 and 2015, a total of 21,092 TSA procedures were performed across 321 surgery centers in the state of Texas (19,629 IP [93.1%] and 1,463 OP [6.9%]). During this time, the cumulative volume of IP TSA per 100,000 Texas residents increased by 109.1%, whereas the cumulative volume of OP TSA increased by 143.7%. Approximately 85.5% of included patients resided within 50 miles of any TSA surgery center; however, only 47.0% of the total Texas population resided within 50 miles of any TSA surgery center. This relationship remained true at every time point irrespective of their volume designations (OP, IP, HV-IP, and LV-IP).

CONCLUSION

Despite the overall increase in TSA volume over time, the majority all TSA utilization in the state of Texas occurred in patients who resided within 50 miles of a TSA center. Increasing volume seems to reflect concentration of care into HV-IP and OP centers. Strategies to improve access to TSA care for underserved areas should be considered.

LEVEL OF EVIDENCE

Level II.

Factors affecting the successful implementation of the referral system: A scoping review

An effective referral system ensures that there is a close relationship among all levels of health care, and individuals can receive the best possible care. The main purpose of the present study was to summarize studies that have addressed factors affecting the successful implementation of the referral system. A scoping review was performed to identify English and Farsi papers that were indexed in PubMed, Scopus, Science Direct, Trip Database, Cochrane Library, Embase, Google Scholar, SID, and Magiran until November 2020. Data was collected from the included studies by a reviewer and was checked by a second reviewer the collected data was analyzed using narrative methods. About 1245 relevant studies were identified in the first stage. After checking titles and abstracts, 63 studies were included. The factors that affected the referral system were classified in 4 themes and fourteen subthemes including technology (electronic referral, coordination, response and feedback), processes (effectiveness, efficiency), organizational (management, policy and planning, rules and regulations), patient centered individual (insurance coverage, social capital, transportation, awareness, attitude, satisfaction, and social influence). Therefore, a wide range of factors are affecting the performance of referral systems. For implementing an effective referral system, it is necessary to consider these factors.

Declining Trend in Medicare Physician Reimbursements for Hand Surgery From 2002 to 2018

PURPOSE

To evaluate trends in Medicare physician reimbursements for 20 common hand procedures/surgeries from 2002 to 2018.

METHODS

The Physician Fee Schedule Look-up Tool was used to retrieve average reimbursement rates for 20 common hand surgeries/procedures from 2002 to 2018. All reimbursement data were adjusted for inflation to 2018 dollars.

RESULTS

After adjusting all data for inflation, the average reimbursement for all included procedures decreased by 20.9% from 2002 to 2018, with a compound annual growth rate of -3.25%. Reimbursement percentage decreases were the greatest prior to 2010 (18.4% decrease), followed by a relative stabilization (0.94% increase) from 2010 to 2014, after which physicians experienced a decrease of 3.9% in reimbursements between 2014 and 2018, following implementation of the Medicare Access and Children's Health Insurance Program Reauthorization Act in 2015. The most significant decreases in reimbursements over time were noted for primary tendon/muscle repair (-49.6%), wrist arthroscopy for triangular fibrocartilage repair/debridement (-44.0%), trigger finger release in facility (-40.1%), excision of extensor tendon sheath (-38.2%), ganglion cyst excision (-36.7%), wrist arthroscopy for diagnostic/synovial biopsy (-35.7%), wrist arthroscopy for drainage/infection/lavage (-35.1%), wrist arthrodesis (-30.6%), endoscopic carpal tunnel release (-27.2%), total wrist arthroplasty (-26.6%), carpometacarpal/basal joint arthroplasty (-25.1%), and open carpal tunnel release (-22.3%). The only procedures with a significant increase in reimbursement over time were trigger finger release in office (+4.2%), open reduction internal fixation distal radius fracture (+2.5%), and cubital tunnel release (+1.5%).

CONCLUSIONS

After adjusting for inflation, Medicare physician reimbursements for a major proportion of hand surgical procedures have decreased over time.

CLINICAL RELEVANCE

Health-policy makers need to understand the impact of decreasing reimbursements to develop policies of reimbursements that will not only ensure provider satisfaction but also maintain access to care for patients.

Trends in the Management of Traumatic Upper Extremity Amputations

PURPOSE

Treatment for upper extremity amputations includes revision amputation or attempted replantation. The rate of digital replantation has been declining in the United States. Prior studies discovered the presence of socioeconomic disparities associated with these injuries. The goals of this study were to investigate yearly trends of traumatic upper extremity amputations and evaluate the presence of disparities with access to care in these injuries.

METHODS

The 2008 to 2014 New York Statewide Planning and Research Cooperative System (SPARCS) inpatient and outpatient databases were utilized to identify patients who had traumatic upper extremity amputations. We queried the database for patient characteristics, resource utilization characteristics, insurance status, major in-hospital complications, and mortality. Patients at low-, medium-, and high-volume institutions were compared. We performed multivariable logistic regressions for the binary variable replantation (yes/no) controlling for age, sex, race, insurance status, amputation level, admission hour, and comorbidities.

RESULTS

A total of 2,492 patients met our inclusion criteria: 92.1% sustained digital amputations and 7.9% sustained arm amputations. The annual rate of inpatient finger amputations decreased significantly (1.9 per 100,000 people in 2008 vs 1.4 per 100,000 people in 2014) during the study period while that of outpatient finger amputations increased significantly (12.0 per 100,000 people in 2008 vs 15.5 per 100,000 people in 2014). Multivariable analysis demonstrated incrementally lower odds for replantation with increasing age and increased odds for replantation in patients with private insurance (odds ratio, 1.64; 95% confidence interval, 1.08-2.50). The number of replantation surgeries at medium-volume institutions decreased by 45% while remaining steady in low- and high-volume institutions.

CONCLUSIONS

Our findings corroborate the findings of other studies that underscore the existence of disparities with respect to insurance status in these injuries. Replantations occur more frequently at high-volume hospitals and are more common in younger patients with private insurance. This finding suggests that patients with traumatic amputations may benefit from treatment at high-volume institutions. Further research to help improve access to such institutions is warranted.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Random forest modeling using socioeconomic distress predicts hernia repair approach

BACKGROUND

Surgical techniques for abdominal wall hernia repair have advanced, yet it is unclear if all patient populations experience these innovations equally. We hypothesized that in patients undergoing abdominal wall herniorrhaphy, there would be socioeconomic variation between robotic, laparoscopic, and open approaches.

METHODS

We performed a retrospective review of patients undergoing abdominal wall herniorrhaphy at a tertiary care center from 2013 through 2019. Patients were stratified by approach: laparoscopic (LH), open (OH), or robotic (RH). Insurance type was categorized as private, Medicare, or Medicaid/uninsured. Using zip code data, we obtained a Distressed Communities Index (DCI), which is comprised of 7 unique socioeconomic variables. We employed random forest (RF) modeling to predict surgical approach and determined each factor's variable importance (VI) for our model.

RESULTS

There were 559 patients; 39.7% (n = 222) LH, 33.3% (n = 186) OH, and 27% (n = 151) RH. The DCI (p < 0.01) and rates of poverty (p = 0.01), adults without diplomas (p < 0.01), and unemployment (p < 0.01) were highest in the OH group while job growth (p = 0.02) and median income ratio (p < .01) were highest in the RH group. The LH group had a greater proportion of privately insured patients than Medicaid/ uninsured patients (43.4% vs 15.9%, p < 0.01). The most important variables identified by our RF model were job growth (for RH), insurance type (for LH), and no high school diploma (for OH).

CONCLUSION

Insurance type, job growth, and educational attainment may influence operative approach and can contribute to the existing disparities in hernia surgery. Surgeons should address these inequalities and commit to parity in the delivery of surgical care.

Predictors of Insurance Claim Rejection in Hand and Upper Extremity Surgery

INTRODUCTION

Insurance claim rejections represent a challenge for healthcare providers because of the potential for lost revenue and administrative costs of reworking claims.

METHODS

The billing records of five hand and upper extremity surgeons at a tertiary academic center were queried for all patient billing activity over a 1-year period yielding a total of 14,421 unique patient encounters.

RESULTS

A total of 11,839 unique patient encounters were included, and the overall claim rejection rate was 19.3%. Claim rejection rate varied significantly by payer (P < 0.0001) and was lowest in private insurance (14.0%) and highest in Medicare (31.2%). The use of multiple Current Procedure Terminology codes for an encounter was independently associated with an increased risk of claim rejection for both office (25.6%, relative risk [RR] 1.27, 95% confidence interval [CI] 1.03 to 1.49, P = 0.0032) and surgical (25.6%, RR 1.67, 95% CI 1.28 to 2.18, P = 0.0002) settings. After multivariate regression adjustment, modifier 25 was associated with a decreased risk of claim rejection (23.3%, RR 0.72, 95% CI 0.61 to 0.85, P < 0.0001).

DISCUSSION

Insurance claim rejection occurs frequently (19.3%) in hand/upper extremity surgery and varies by insurance type, with the highest rejection rate occurring in Medicare (31.2%). For a given encounter, the use of multiple Current Procedure Terminology codes and specific modifiers are predictive of rejection risk.

LEVEL OF EVIDENCE

Level III, prognostic.

Lending a Hand to Health Care Disparities: A Cross-sectional Study of Variations in Reimbursement for Common Hand Procedures

Background: Despite the role of one's hands in human function and quality of life, financial disincentives to perform common hand procedures in patients with government-sponsored insurance plans may lead to longer wait times and decreased access to care. Here, we identify the variations in reimbursement for 4 common hand procedures as a step toward understanding these financial implications to develop safeguards to minimize effects on access to care. Methods: Billing data were collected over a 10-year period for patients undergoing carpal tunnel release (open, Current Procedural Terminology 64721; endoscopic, 29848), cubital tunnel release (64718), ganglion cyst excision (25111), and interposition arthroplasty (25447). Patients were placed into cohorts according to insurance type-private insurance, Medicare, Medicaid, or worker's compensation-and these were directly compared. Results: A total of 3489 procedures between 2005 and 2015 were identified in this study (carpal tunnel 65.8%, cubital tunnel 28.7%, ganglion cyst excision 4.1%, and interposition arthroplasty 13.8%). In all, 54.7% of patients had private insurance; 26.3%, Medicare; 10.5%, worker's compensation; and 8.5%, Medicaid. Reimbursement, as a percentage of charge, differed significantly by payor type for all cases and by procedure. On average, worker's compensation plans reimbursed 65.5% of submitted charges; private insurance, 50.6%; Medicare, 25.1%; and Medicaid, 24.6%. Conclusions: We found that wide variations in reimbursement for common hand procedures exist and may preclude some surgeons from offering certain procedures to a subset of patients. Understanding these discrepancies is a key first step in minimizing a potential care delivery disparity for this patient population.

Are There Nationwide Socioeconomic and Demographic Disparities in the Use of Outpatient Orthopaedic Services?

BACKGROUND

Although disparities in the use of healthcare services in the United States have been well-documented, information examining sociodemographic disparities in the use of healthcare services (for example, office-based and emergency department [ED] care) for nonemergent musculoskeletal conditions is limited.

QUESTIONS/PURPOSES

This study was designed to answer two important questions: (1) Are there identifiable nationwide sociodemographic disparities in the use of either office-based orthopaedic care or ED care for common, nonemergent musculoskeletal conditions? (2) Is there a meaningful difference in expenditures associated with these same conditions when care is provided in the office rather than the ED?

METHODS

This study analyzed data from the 2007 to 2015 Medical Expenditure Panel Survey (MEPS). The MEPS is a nationally representative database administered by the Agency for Healthcare Research and Quality that tracks patient interactions with the healthcare system and expenditures associated with each visit, making it an ideal data source for our study. Differences in the use of office-based and ED care were assessed across different socioeconomic and demographic groups. Healthcare expenditures associated with office-based and ED care were tabulated for each of the musculoskeletal conditions included in this study. The MEPS database defines expenditures as direct payments, including out-of-pocket payments and payments from insurances. In all, 63,514 participants were included in our study. Fifty-one percent (32,177 of 63,514) of patients were aged 35 to 64 years and 29% were older than 65 years (18,445 of 63,514). Women comprised 58% (37,031 of 63,514) of our population, while men comprised 42% (26,483 of 63,514). Our study was limited to the following eight categories of common, nonemergent musculoskeletal conditions: osteoarthritis (40%, 25,200 of 63,514), joint derangement (0.5%, 285 of 63,514), other joint conditions (43%, 27,499 of 63,514), muscle or ligament conditions (6%, 3726 of 63,514), bone or cartilage conditions (8%, 5035 of 63,514), foot conditions (1%, 585 of 63,514), fractures (7%, 4189 of 63,514), and sprains or strains (18%, 11,387 of 63,514). Multivariable logistic regression was used to ascertain which demographic, socioeconomic, and health-related factors were independently associated with differences in the use of office-based orthopaedic services and ED care for musculoskeletal conditions. Furthermore, expenditures over the course of our study period for each of our musculoskeletal categories were calculated per visit in both the outpatient and the ED settings, and adjusted for inflation.

RESULTS

After controlling for covariates like age, gender, region, insurance status, income, education level, and self-reported health status, we found substantially lower use of outpatient musculoskeletal care among patients who were Hispanic (odds ratio 0.79 [95% confidence interval 0.72 to 0.86]; p < 0.001), non-Hispanic black (OR 0.77 [95% CI 0.70 to 0.84]; p < 0.001), lesser-educated (OR 0.72 [95% CI 0.65 to 0.81]; p < 0.001), lower-income (OR 0.80 [95% CI 0.73 to 0.88]; p < 0.001), and nonprivately-insured (OR 0.85 [95% CI 0.79 to 0.91]; p < 0.001). Public insurance status (OR 1.30 [95% CI 1.17 to 1.44]; p < 0.001), lower income (OR 1.53 [95% CI 1.28 to 1.82]; p < 0.001), and lesser education status (OR 1.35 [95% CI 1.14 to 1.60]; p = 0.001) were also associated with greater use of musculoskeletal care in the ED. Healthcare expenditures associated with care for musculoskeletal conditions was substantially greater in the ED than in the office-based orthopaedic setting.

CONCLUSIONS

There are substantial sociodemographic disparities in the use of office-based orthopaedic care and ED care for common, nonemergent musculoskeletal conditions. Because of the lower expenditures associated with office-based orthopaedic care, orthopaedic surgeons should make a concerted effort to improve access to outpatient care for these populations. This may be achieved through collaboration with policymakers, greater initiatives to provide care specific to minority populations, and targeted efforts to improve healthcare literacy.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Navigating the Intersection of Evidence and Policy in Hand Surgery Practice

Collaboration with organizations beyond the clinical setting is necessary to identify safety hazards that contribute to the high incidence and severity of hand conditions. Hand surgeons are acutely aware of obstacles patients face while navigating the health care system. Advocacy efforts encourage the development of equitable insurance policies and improve health resource allocation so that hand surgeons can treat a larger patient population. Participation in quality initiatives supports the development of evidence-based clinical guidelines. Further evidence must be generated to ensure that surgeons remain proficient in the latest techniques and uphold high standards of care as hand surgery procedures evolve.

Using Emergency Department Data to Inform Specialty Strategy: Analyzing the Distribution of 13,777 Consecutive Immediate Orthopaedic Consults in an Urban Community Emergency Department

Although an estimated 20% of emergency department (ED) visits are musculoskeletal in nature, it is unclear which of these require urgent orthopaedic consultation and which orthopaedic subspecialties are best suited for these consults. When an ED's internal staff does not have necessary orthopaedic coverage, transfer to other facilities is required. However, transfers pose major inconveniences and financial burdens to patients and can lead to long ED wait times, hospital financial loss from walk outs, decreased patient safety, and decreased staff morale. Therefore, it is beneficial for a hospital to have the appropriate staff readily available for consults. Data can be used to assess the orthopaedic needs of an ED. We evaluated the nature of urgent ED consults requesting the timely presence of an orthopaedic provider.

Associations Between Insurance Type and the Presentation of Cubital Tunnel Syndrome

PURPOSE

In the setting of cubital tunnel syndrome (CuTS), delays in diagnosis can have permanent effects including sensory loss, muscle weakness, and atrophy of intrinsic hand muscles. This study sought to evaluate the association of insurance type on the severity of CuTS. We hypothesized that publicly insured patients will have delayed presentation to the orthopedics office and more significant condition severity.

METHODS

A retrospective chart review was conducted for all patients evaluated for CuTS between December 2013 and January 2018 by a fellowship-trained orthopedic hand and upper extremity surgeon at our tertiary referral center. Insurance type, demographics, and measures of CuTS severity were compared.

RESULTS

Patients presenting with CuTS of severity greater than or equal to McGowan stage 2A had 4.4-fold greater odds of being publicly insured than privately. Motor and sensory velocities across the elbow were diminished at 42.2 ± 13.9m/s and 33.0 ± 20.8m/s in publicly insured patients compared with 47.5 ± 11.3 m/s and 47.0 ± 16.4m/s for privately insured patients. The same trend was present for motor and sensory amplitudes at 6.6 ± 3.8 μV and 16.9 ± 17.8 μV in publicly insured patients compared with 8.5 ± 3.2 μV and 26.0 ± 18.9 μV in privately insured patients. Patients with public insurance were symptomatic for longer prior to their initial visit, on average 82.8 ± 86.5 weeks, compared with 42.4 ± 58.9 weeks for patients with private insurance.

CONCLUSIONS

Publicly insured patients were significantly delayed in seeing an orthopedic surgeon for evaluation and treatment of CuTS and presented with more severe clinical and electrodiagnostic findings compared with privately insured patients. These findings suggest that insurance type, among other socioeconomic factors, may be a barrier to CuTS care.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prevalence IV.