Apurva S. Shah

Using Time-Driven Activity-Based Costing to Identify Value Improvement Opportunities in Healthcare

EXECUTIVE SUMMARY As healthcare providers cope with pricing pressures and increased accountability for performance, they should be rededicating themselves to improving the value they deliver to their patients: better outcomes and lower costs. Time‐driven activity‐based costing offers the potential for clinicians to redesign their care processes toward that end. This costing approach, however, is new to healthcare and has not yet been systematically implemented and evaluated. This article describes early time‐driven activity‐based costing work at several leading healthcare organizations in the United States and Europe. It identifies the opportunities they found to improve value for patients and demonstrates how this costing method can serve as the foundation for new bundled payment reimbursement approaches.

Shoulder motion, strength, and functional outcomes in children with established malunion of the clavicle.

Background: Recent investigations of displaced clavicle fractures in adults have demonstrated a higher prevalence of nonunion, symptomatic malunion, diminished functional outcome, and decreased strength with nonoperative treatment. Although these data have led to increased surgical management of displaced fractures, little published information is available regarding the consequences of malunion in the pediatric population. The purpose of this investigation was to assess pain, functional outcome, range of motion, and strength in children with displaced clavicle fractures treated nonoperatively. Methods: Clinical evaluation of 16 patients with mid-diaphyseal clavicle fractures and >2 cm of initial displacement was performed; all had undergone nonoperative treatment and went on to radiographic malunion. The mean age at the time of injury was 12.2±3.3 years. Pain, aesthetic appearance, and satisfaction with treatment were rated by patients on a visual analog scale (VAS) (range 0 to 10 with 10 indicating the worst score). Patient-based outcomes were assessed with the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the Pediatric Outcomes Data Collection Instrument (PODCI). Bilateral shoulder motion was measured by a physical therapist. Isokinetic strength testing of the bilateral shoulders was performed with a Biodex dynometer. Range of motion and strength were analyzed with a multivariable regression, controlling for hand dominance. The mean follow-up was 27.2 months after injury. Results: All displaced fractures treated nonoperatively achieved union. Overall, there was reduced forward flexion and abduction on the injured side compared with the contralateral sides of 7.3 and 6.5 degrees, respectively, adjusted for hand dominance (P<0.05). Biodex testing did not detect any significant difference in abduction or adduction torque or power between affected and unaffected shoulders. The mean VAS score for pain was 1.6, with 4 patients reporting pain ≥to 3. The mean VAS scores for satisfaction with aesthetic appearance was 2.7, with 4 patients reporting scores >5. The mean VAS scores for satisfaction with treatment was 2.0, with only 1 patient scoring >5. The mean DASH score was 4.9±7.5, with 3 patients scoring ≥10. The mean scores on the DASH sports and performing arts module was 1.9±4.2, with only 1 patient scoring ≥10. The mean global PODCI score was 94.5±6.0. The mean PODCI scores for upper extremity function, sports, and pain were 97.9±5.5, 95.4±5.3, and 84.6±20.5, respectively. Only 1 patient was symptomatic enough to require corrective osteotomy. Conclusions: Skeletally immature patients with established clavicle fracture malunions do not develop clinically meaningful loss of shoulder motion or abduction/adduction strength. Routine surgical fixation for displaced, nonsegmental clavicle fractures may not be justified based upon concerns regarding shoulder motion and strength alone. Further investigation is required to determine the risk factors and causes of pain and functional compromise in the minority of pediatric patients with symptomatic malunions. Level of Evidence: Level IV.

Risk factors for 30-day postoperative complications and mortality following open reduction internal fixation of distal radius fractures

PURPOSE To identify the incidence and risk factors for 30-day postoperative morbidity and mortality following operative treatment of distal radius fractures in a multicenter cohort. METHODS We retrospectively queried the American College of Surgeons National Surgical Quality Improvement Program database for the years 2005-2011 for cases of closed distal radius fractures treated operatively with internal fixation. Patient demographics, comorbidities, and operative characteristics were analyzed. Thirty-day postoperative complications were identified and separated into categories of major morbidity or mortality, minor morbidity, and any complication. Risk factors were identified using univariate and multivariate analyses. RESULTS We identified 1,673 cases of closed distal radius fractures managed with internal fixation. The overall incidence of having any early complication was 3%. Major morbidity was 2.1%, which included 4 patient deaths, and minor morbidity was 1%. The most common major morbidity was a return to the operating room (16 patients). The most common minor morbidity was urinary tract infection (6 patients). The multivariate analysis demonstrated ASA class III or IV, dependent functional status, hypertension, and myocardial infarction/congestive heart failure to be significant risk factors for any early complication. There was a 10.0% complication rate in the inpatient group and a 1.3% complication rate in the outpatient group. CONCLUSIONS The incidence of early complications following internal fixation for closed distal radius fractures was low, especially in the outpatient group. In the setting of an isolated injury to the distal radius, the data presented here can provide prognostic information for patients during informed consent for what is considered to be an elective procedure. Surgeons should consider risk of morbidity and mortality when considering surgery for patients with noteworthy cardiopulmonary disease, increased ASA class, or poor functional status. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.

Management of Pediatric Trigger Thumb and Trigger Finger

&NA; Pediatric trigger thumb and trigger finger represent distinct conditions and should not be treated like adult acquired trigger finger. Over the last two decades, our understanding of the natural history of pediatric trigger thumb and the etiology and surgical management of pediatric trigger finger has improved. Pediatric trigger thumb may spontaneously resolve, although resolution may take several years. Open surgical release of the A1 pulley of the thumb is an alternative option that nearly uniformly restores thumb interphalangeal joint motion. Surgical management of pediatric trigger finger with isolated release of the A1 pulley has been associated with high recurrence rates. Awareness of the anatomic factors that may contribute to triggering in the pediatric finger and willingness to explore and address other involved components of the flexor mechanism can prevent surgical failure.

Morbid Obesity and Congestive Heart Failure Increase Operative Time and Room Time in Total Hip Arthroplasty

BACKGROUND Obesity is increasingly common in patients having total hip arthroplasty, and previous studies have shown a correlation with increased operative time in total hip arthroplasty. Decreasing operative time and room time is essential to meeting the increased demand for total hip arthroplasty, and factors that influence these metrics should be quantified to allow for targeted reduction in time and adjusted reimbursement models. This is the first study to use a multivariate approach to identify which factors increase operative time and room time in total hip arthroplasty. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was used to identify a cohort of 30,361 patients having total hip arthroplasty between 2006 and 2012. Patient demographics, comorbidities including body mass index, and anesthesia type were used to create generalized linear models identifying independent predictors of increased operative time and room time. RESULTS Morbid obesity (body mass index >40) independently increased operative time by 13 minutes and room time 18 by minutes. Congestive heart failure led to the greatest increase in overall room time, resulting in a 20-minute increase. Anesthesia method further influenced room time, with general anesthesia resulting in an increased room time of 18 minutes compared with spinal or regional anesthesia. CONCLUSION Obesity is the major driver of increased operative time in total hip arthroplasty. Congestive heart failure, general anesthesia, and morbid obesity each lead to substantial increases in overall room time, with congestive heart failure leading to the greatest increase in overall room time.

Musculoskeletal Injuries Resulting from Use of Hoverboards: Safety Concerns With an Unregulated Consumer Product

Hoverboards were recently introduced to the US consumer market and experienced rapid popularity. Given the high frequency of musculoskeletal injury with other wheeled recreation devices, we sought to analyze hoverboard injuries in children. A retrospective review of patients with musculoskeletal injury related to hoverboard use was performed at a tertiary care children’s hospital. From November 2015 to January 2016, 2.3% of all fractures were related to hoverboards. Common injury mechanisms were fall (79%) and finger entrapment between wheel and wheel-well (10%). The most frequently fractured sites included the distal radius (43%) and phalanx (17%). Common surgical procedures were nailbed repair and pinning for Seymour fracture and percutaneous pinning for distal radius fracture. There exists high risk for distal radius fractures from falls and phalanx fractures from finger entrapment between the wheel and wheel-well. Hoverboard safety can be improved with regular use of wrist guards and improved wheel-well design.

Delivery of Patient-Reported Outcome Instruments by Automated Mobile Phone Text Messaging

Background: Patient-reported outcome (PRO) instruments allow patients to interpret their health and are integral in evaluating orthopedic treatments and outcomes. The purpose of this study was to define: (1) correlation between PROs collected by automated delivery of text messages on mobile phones compared with paper delivery; and (2) patient use characteristics of a technology platform utilizing automated delivery of text messages on mobile phones. Methods: Paper versions of the 12-Item Short Form Health Survey (SF-12) and the short form of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) were completed by patients in orthopedic hand and upper extremity clinics. Over the next 48 hours, the same patients also completed the mobile phone portion of the study outside of the clinic which included text message delivery of the SF-12 and QuickDASH, assigned in a random order. Correlations between paper and text message delivery of the 2 PROs were assessed. Results: Among 72 patients, the intraclass correlation coefficient (ICC) between the written and mobile phone delivery of QuickDASH was 0.91 (95% confidence interval [CI], 0.85-0.95). The ICC between the paper and mobile phone delivery of the SF-12 physical health composite score was 0.88 (95% CI, 0.79-0.93) and 0.86 (95% CI, 0.75-0.92) for the SF-12 mental health composite score. Conclusions: We find that text message delivery using mobile phones permits valid assessment of SF-12 and QuickDASH scores. The findings suggest that software-driven automated delivery of text communication to patients via mobile phones may be a valid method to obtain other PRO scores in orthopedic patients.

Obesity increases complexity of distal radius fracture in fall from standing height

Objectives: To investigate the relationship between obesity and distal radius fracture severity after low-energy trauma and to identify patient-specific risk factors predictive of increasing fracture severity. Design: Retrospective review. Setting: Level 1 Trauma Center. Patients/Participants: Four hundred twenty-three adult subjects with a history of fracture of the distal radius resulting from a fall from standing height. Intervention: Demographic data and injury characteristics were obtained. Preoperative wrist radiographs were reviewed and classified by the OTA classification system. Distal radius fractures were categorized as simple [closed and extra-articular (OTA 23-A)] and complex [intra-articular (OTA 23-B or 23-C) or open fracture or concomitant ipsilateral upper extremity fracture]. Multivariate logistic regression was completed to model the probability of incurring a complex fracture. Main Outcome Measurements: Simple versus complex fracture pattern. Results: Average age at the time of injury was 53.8 years (range, 18.9–98.4). Seventy-nine percent of subjects were female. The average body-mass index was 28.1 (range, 13.6–59.5). Two hundred forty-four patients (58%) suffered complex distal radius fractures per study criteria. Obese patients (body-mass index > 30) demonstrated increased fracture severity as per the OTA classification (P = 0.039) and were more likely to suffer a complex injury (P = 0.032). Multivariate regression identified male gender, obesity, and age ≥50 as independent risk factors for sustaining a complex fracture pattern. Conclusions: Obesity is associated with more complex fractures of the distal radius after low-energy trauma, particularly in elderly patients. This relationship may have important epidemiologic implications predictive of future societal fracture burden and severity in an obese, aging population. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Presentation and Treatment of Poland Anomaly

Background: Poland anomaly is a sporadic, phenotypically variable congenital condition usually characterized by unilateral pectoral muscle agenesis and ipsilateral hand deformity. Methods: A comprehensive review of the medical literature on Poland anomaly was performed using a Medline search. Results: Poland anomaly is a sporadic, phenotypically variable congenital condition usually characterized by unilateral, simple syndactyly with ipsilateral limb hypoplasia and pectoralis muscle agenesis. Operative management of syndactyly in Poland anomaly is determined by the severity of hand involvement and the resulting anatomical dysfunction. Syndactyly reconstruction is recommended in all but the mildest cases because most patients with Poland anomaly have notable brachydactyly, and digital separation can improve functional length. Conclusions: Improved understanding the etiology and presentation of Poland anomaly can improve clinician recognition and management of this rare congenital condition.

Safety and Efficacy of Derotational Osteotomy for Congenital Radioulnar Synostosis.

Background: Congenital radioulnar synostosis (CRUS) refers to an abnormal connection between the radius and ulna due to embryological failure of separation. Derotational osteotomy has been advocated for children with functional limitations, although historically this procedure has been associated with a 36% complication rate including compartment syndrome and loss of correction. Methods: A retrospective evaluation of consecutive patients who underwent derotational osteotomy for CRUS at a single institution was performed. Children with functional limitations secondary to excessive pronation were indicated for surgery with a goal of correction to 10 to 20 degrees of pronation. All patients were treated with a standardized surgical technique including careful subperiosteal elevation, rotational osteotomy at the level of the synostosis, control of the osteotomy fragments, appropriate pinning techniques, and prophylactic forearm fasciotomies. Electronic medical records, preoperative radiographs, and postoperative radiographs were reviewed. Results: Derotational osteotomy was performed in 31 forearms in 26 children (13 bilateral, 13 unilateral) with a mean age of 6.8 years (range, 3.0 to 18.8 y). The mean clinical follow-up was 46 months (range, 6 to 148 mo). The mean preoperative pronation deformity was 85 degrees (range, 60 to 100 degrees). The mean correction achieved was 77 degrees (range, 40 to 95 degrees), resulting in a mean final position of 8 degrees of pronation (range, 0 to 30 degrees). All patients successfully achieved union by 8 weeks postoperatively. There were no cases of compartment syndrome, vascular compromise, or loss of fixation. The overall complication rate was 12% (2 transient anterior interosseous nerve palsies, 1 transient radial nerve palsy, 1 symptomatic muscle herniation). Both transient anterior interosseous nerve palsies occurred in patients with rotational corrections exceeding 80 degrees. Conclusions: Derotational osteotomy can be safely and effectively performed in children with CRUS. Meticulous surgical technique, including control of the osteotomy, judicious pin fixation, and prophylactic fasiotomies, may diminish the risk of neurovascular compromise and loss of correction. Transient anterior interosseous nerve palsies occurred, and may be related to large rotational corrections. Level of Evidence: Level IV—case series.