April #JHSJC Transcript

The pandemic didn’t stop us from having a great discussion on two articles from Volume 45, Issue 4 of The Journal of Hand Surgery: Risk of Infection in Trigger Finger Release Surgery Following Corticosteroid Injection and Physical and Occupational Therapy Use and Cost After Common Hand Procedures.

Feel free to continue the conversation below in the comments! And please check out previous #JHSJC transcripts (please scroll to the bottom of the page).

Brent Graham @BgTalkinman:
There’s a pandemic but we can still discuss our papers together! Welcome to #JHSJC for April!
Please use the #jhsjc hashtag!
Let’s start with first article on post-injection infection risk after trigger finger surgery #jhsjc

Nina Suh @NinaSuh9:
This manuscript was very clinical relevant! I loved the study question #jhsjc

Brent Graham @BgTalkinman to @NinaSuh9:
Agreed, very relevant to almost all hand surgeons #jhsjc

RyanC @RPCalfeeSTL:
a couple of interesting recent papers on injections and infection risk #jhsjc

Warren @whammert:
But will they change practice? Would you not offer an injection, when that can be curative, due to risk of infection? #jhsjc

Brent Graham @BgTalkinman:
No randomization but about half the pts had an injection and half didn’t, overall infection rate 0.5%. Does that figure ring true? #jhsjc

Nina Suh @NinaSuh9:
I would still offer injection but gives evidence to delay the surgery for failure of steroid #jhsjc

RyanC @RPCalfeeSTL:
although still rare it makes me space out surgery from injection #jhsjc

Warren @whammert to @RPCalfeeSTL:
how far? I have always said 6 weeks, but was due to my concern for healing rather than infection #jhsjc

Avi Giladi @theaviram to @whammert:
might delay time to surgery after injection at least #jhsjc

Brent Graham @BgTalkinman to @whammert:
That is the question. Is that infection rate sufficient to affect timing of surgery? #jhsjc

Brent Graham @BgTalkinman to @theaviram:
Would you now tell a patient that they must wait 90 days after an injection to have surgery? #jhsjc

RayRavenMD, MHCI, MBA @RayRavenMD to @whammert:
I may consider not giving an injection for the patient who has surgery planned but wants some temporary relief. The question is, how long should I wait? #JHSJC

Avi Giladi @theaviram to @whammert and @RPCalfeeSTL:
the growing evidence associating steroids and post-operative complications after hand surgery is concerning #jhsjc

Warren @whammert to @BgTalkinman and @theaviram:
I would find that long if the injection didn’t work at 4-6 weeks #jhsjc

Brent Graham @BgTalkinman to @RPCalfeeSTL:
Do you advise pts that before the injection? #jhsjc

RayRavenMD, MHCI, MBA @RayRavenMD to @whammert:
I may consider not giving an injection for the patient who has surgery planned but wants some temporary relief. #jhsjc
The question is, how long should I wait between injection and surgery? #jhsjc

Brett McClelland @BrettMcClella18:
What about the other end of the result… Would you offer surgery within 30 days if injection failed? #jhsjc

Jonas Matzon @JonasMatzon to @whammert and @RPCalfeeSTL:
6wks is what we used to tell people as well, but we couldn’t find any data behind it…hence the study #jhsjc

Avi Giladi @theaviram to @RayRavenMD and @whammert:
evidence for CMC injections has led me to avoid them when possible. might do same for trigger if surgery likely #jhsjc

RyanC @RPCalfeeSTL:
I like 6 weeks even though this says 90 d. I also think of lutsky jhs 2019 about inj during surgery being a risk #jhsjc

Brent Graham @BgTalkinman to @RayRavenMD and @whammert:
Will patients refuse an injection if they will have to wait 3 months if the injection fails? #jhsjc

Warren @whammert to @JonasMatzon and @RPCalfeeSTL:
SO 6 weeks was bad, but less than 30 was not? Why? #jhsjc

Brent Graham @BgTalkinman to @RPCalfeeSTL:
Same authors! Did that recommend something different? I can’t remember. #jhsjc

Brent Graham @BgTalkinman to @JonasMatzon, @whammert, and @RPCalfeeSTL:
What do you tell them now? #jhsjc

Brett McClelland @BrettMcClella18:
Yes, I was also confused by the less than 30 day result. #jhsjc

Jonas Matzon @JonasMatzon to @whammert and @RPCalfeeSTL:
Not sure. The 0-30 group had very low numbers. Also, the were clustered towards 30 #jhsjc

RyanC @RPCalfeeSTL:
just noted that ipsilat inj during surgery increased risk #jhsjc
I think 0-30d finding a number issue. Can’t imagine safer there #jhsjc

Brent Graham @BgTalkinman to @BrettMcClella18:
Hi Brett. Hope things are well down under. What is your usual recommendation? #jhsjc

Brent Graham @BgTalkinman to @JonasMatzon, @whammert, and @RPCalfeeSTL:
That was my thought – sampling issue #jhsjc

Jonas Matzon @JonasMatzon:
Also, there will always be a time period from day 0 to timing of 1st infection that will be infection “free” #jhsjc

Brent Graham @BgTalkinman to @JonasMatzon:
How so? #jhsjc

Brett McClelland @BrettMcClella18 to @BgTalkinman:
Australia faring well in the COVID landscape thanks Brent. Usual recommendation is a review at 6w to assess need for Sx #jhsjc

Brent Graham @BgTalkinman to @BrettMcClella18:
That’s the TWH way! #jhsjc

Jonas Matzon @JonasMatzon to @BgTalkinman and 2 others:
We tell them that they should wait until 3M post-injection for surgery #jhsjc

Brent Graham @BgTalkinman to @JonasMatzon and 2 others:
Do pts refuse injections if they are told that? #jhsjc

Avi Giladi @theaviram to @BgTalkinman @JonasMatzon and 2 others:
some of mine refuse injection if they know they need to wait #jhsjc

Jonas Matzon @JonasMatzon:
That hasn’t been my experience. Fortunately, injections usually work greater than 3M #jhsjc

Brent Graham @BgTalkinman to @theaviram and 3 others:
That’s what I might have expected. #jhsjc

Nina Suh @NinaSuh9:
I have also found that people refuse injection if sx will be delayed if injection failure #jhsjc

Brent Graham @BgTalkinman to @JonasMatzon:
There’s a paper coming soon showing that 3 injections is more cost effective unless surgery costs are quite low #jhsjc

David Ring @DrDavidRing:
How long do you wait until you decide a steroid injection will not work for trigger digit?

Brent Graham @BgTalkinman to @JonasMatzon:
The paper notes that most of the injections were done by others than the hand surgeon. What is the significance of that? #jhsjc

RayRavenMD, MHCI, MBA @RayRavenMD to @BgTalkinman and @whammert:
that has been my experience. #jhsjc

RayRavenMD, MHCI, MBA @RayRavenMD to @DrDavidRing:
Hey @DrDavidRing, don’t you just tell them they need to adapt and live with it? lol. #jhsjc

Brent Graham @BgTalkinman:
Are injections less effective if not done by a hand surgeon? #jhsjc

Jonas Matzon @JonasMatzon:
Most of those patients were excluded because we could not find dates/timing of injections. Patients in injection-yes group were ours #jhsjc

Avi Giladi @theaviram to @BgTalkinman:
dont think any less effective. good evidence that approach and even accuracy in the sheath aren’t critical #jhsjc

Brent Graham @BgTalkinman:
Are infections more likely if the injection was done by a non-hand surgeon? #jhsjc

Brent Graham @BgTalkinman to @JonasMatzon:
Thanks for clarifying – I don’t think I got that. #jhsjc

RayRavenMD, MHCI, MBA @RayRavenMD to @BgTalkinman:
good question. Probably not. #jhsjc

drkucz @DrKuczMD to @DrDavidRing:
One of the few times my research is relevant to the conversation! In JHS no less! Advocating for 2 injections in diabetics. #jhsjc @DrDavidRing https://www.researchgate.net/publication/325197688_Management_of_Diabetic_Trigger_Finger

Brent Graham @BgTalkinman:
There has been evidence about the cost-effectiveness of multiple injections. How does that play into this risk? #jhsjc

Brent Graham @BgTalkinman to @theaviram:
Agreed. #jhsjc

Jonas Matzon @JonasMatzon to @DrDavidRing:
We just submitted a paper on this question and our data says 3 wks. #jhsjc

Brent Graham @BgTalkinman to @JonasMatzon:
I don’t think it was studied but is the risk likely to be increased by multiple injections? #jhsjc

Jonas Matzon @JonasMatzon to @BgTalkinman:
Great question – we don’t know. #jhsjc

Brett McClelland @BrettMcClella18:
My only experience with non hand-surgeon injections has been that they are much more painful! #jhsjc

Warren @whammert to @BrettMcClella18:
for you or the patient:) #jhsjc

Warren @whammert to @JonasMatzon and @DrDavidRing:
so not effective after 3 weeks, but recommend another 9 weeks prior to surgery? #jhsjc

Brent Graham @BgTalkinman to @JonasMatzon and @DrDavidRing:
I’ve usually waited 6 weeks because there are sometimes late responders. #jhsjc
I wouldn’t be surprised if most of the response was in first 3 weeks. #jhsjc

Brett McClelland @BrettMcClella18 to @BgTalkinman, @JonasMatzon, and @DrDavidRing:
I agree that we see some folks with a great response in week 4 or 5! #jhsjc

Brent Graham @BgTalkinman to @BrettMcClella18:
I don’t doubt that. #jhsjc

Jonas Matzon @JonasMatzon to @whammert:
Unless an appt is scheduled, most pts don’t come back at 3 wks for persistent symptoms (per Ring’s paper) #jhsjc

Avi Giladi @theaviram to @BgTalkinman and @JonasMatzon:
re: multiple injections, we published a study showing that for CMC more injections = increase surg risk #jhsjc

Christopher J. Dy MD MPH FACS @ChrisDyMD:
haven’t settled the kids down for the evening, but i’m here for it! – #jhsjc

Brent Graham @BgTalkinman
Multiple injections and infection risk – any data or ideas about that? That is what payers will eventually ask for. #jhsjc

Brent Graham @BgTalkinman to @theaviram and @JonasMatzon:
Was that over a similar time course – 90 days? #jhsjc

Avi Giladi @theaviram to @BgTalkinman and @JonasMatzon:
time course was less impactful than the number of injections. JHSE publication (sorry!) #jhsjc

Brent Graham @BgTalkinman to @theaviram:
You’re allowed! #jhsjc

Brett McClelland @BrettMcClella18 to @BgTalkinman:
The spanner in the works here is the infection risk data on contra-lateral injections. Does total injection = R+L? #jhsjc

Brent Graham @BgTalkinman to @theaviram and @JonasMatzon:
It’s a concern because that could form part of value-based payment in the future – multiple injections. #jhsjc

Megan Conti Mica, MD @megancontimica to @RayRavenMD and @BgTalkinman:
I would lean towards no. Don’t give us too much credit! #jhsjc

Brent Graham @BgTalkinman:
Great discussion! Lots of further questions to explore. Thanks @JonasMatzon for joining in! #jhsjc
Let’s move on to the paper about therapy use and cost. podcast: https://www.jhandsurg.org/pb/assets/raw/Health%20Advance/journals/yjhsu/April_2020-1585746010900.mp3 #jhsjc

Nina Suh @NinaSuh9:
I was quite surprised with the difference with the South! #jhsjc

Brent Graham @BgTalkinman to @NinaSuh9:
No matter the topic, regional differences are always found, especially where evidence is lacking. #jhsjc

Warren @whammert to @BgTalkinman and @NinaSuh9:
I agree variation, not just from different regions. Some use therapists as physician extenders #jhsjc

Brent Graham @BgTalkinman to @whammert:
You’ve gone right to the heart of the matter ! Glad it was you and not me that said it! #jhsjc

Brent Graham @BgTalkinman:
question 1: why is therapy use increasing for #CMC arthroplasty? Might be understandable for #DRF #jhsjc
I will admit that q100% of pts that have #CMC arthroplasty by me get #PT/#OT so I might be an outlier; don’t understand the increase #jhsjc

Brent Graham @BgTalkinman to @whammert and @NinaSuh9:
No data of course, but that was the first thing I thought of. How much does that explain the findings for you? #jhsjc

Warren @whammert to @BgTalkinman:
it also generates revenue as these are not global visits #jhsjc

Brent Graham @BgTalkinman to @whammert:
Meaning that they are added to the reimbursement by being outside the expected MD follow-up? #jhsjc

Nina Suh @NinaSuh9:
oh I hadn’t thought of the MD extender concept but I could see how that would increase utilization #jhsjc

Robert Rhoad, MD @Rhoad:
Recent experience now suggests many patients may prefer f/u Telemedicine Hand therapy #jhsjc

Brent Graham @BgTalkinman:
geo variation doesn’t always mean the high utilizers are wrong. Low utilizers may not be providing enough service #jhsjc

Warren @whammert to @BgTalkinman:
yes – therapy co payment for each visit, while those with PA or NP are global/ free visits. #jhsjc

Brett McClelland @BrettMcClella18:
We see colossal variation in Therapy rates here in Australia, and presumably financial incentives play a significant role. #jhsjc

Brent Graham @BgTalkinman to @Rhoad:
Does that mean that they don’t actually see the therapist in person? #jhsjc

Robert Rhoad, MD @Rhoad to @BgTalkinman:
yes, establish initial relationship at appt, then f/u with virtual visit. Adapted during the shutdown #jhsjc

Nina Suh @NinaSuh9 to @BrettMcClella18:
how is the variation different? #jhsjc

Brent Graham @BgTalkinman to @whammert and @BrettMcClella:
don’t make me sad! #jhsjc

Brent Graham @BgTalkinman to @whammert:
What happens when that becomes part of the bundled fee? #jhsjc

Brent Graham @BgTalkinman to @Rhoad:
That could have some important added value if there is no passive modalities with no support in evidence given . #jhsjc

Warren @whammert to @BgTalkinman:
complicate question as it depends on who owns the therapy unit, but have to think it will decrease visits. #jhsjc

Robert Rhoad, MD @Rhoad to @BgTalkinman:
we anticipate good value plus patient satisfaction #jhsjc

Brett McClelland @BrettMcClella18 to @NinaSuh9:
some therapists are happy with home-based programmes and contact every 2-6 weeks, others 2-4 times per week!!! #jhsjc
and of course Workers’ Compensation is a whole different kettle of fish. #jhsjc

Brent Graham @BgTalkinman to @whammert:
The average out of pocket expense was less than $100. Does that ring true to you in upstate NY? #jhsjc

Avi Giladi @theaviram to @Rhoad and @BgTalkinman:
we started teletherapy pre-COVID and it was overall well received. now it’s crucial! payments are the challenge #jhsjc

Warren @whammert to @BgTalkinman:
I really don’t know as I work at a university and they own the therapy unit, but I don’t see financials #jhsjc

Brent Graham @BgTalkinman to @BrettMcClella18 and @NinaSuh9:
The main impact of therapy has been shown to be pt educ. Telehealth like @Rhoad suggests fits that model #jhsjc

Robert Rhoad, MD @Rhoad to @theaviram and @BgTalkinman:
agreed, but I’m impressed how patients have taken to it #jhsjc

Brent Graham @BgTalkinman to @theaviram and @Rhoad:
Ontario is a big place without many people (except in Toronto) so it has been used a lot. #jhsjc

Robert Rhoad, MD @Rhoad to @BgTalkinman and @theaviram:
like many things, success also depends on engaged, motivated therapist #jhsjc

Brent Graham @BgTalkinman:
It can be assumed that PT/OT will be very much in the crosshairs when value-based payments come. How will that change these findings? #jhsjc

Jeffrey Stepan MD, MSc @JeffStepanMD:
How much of this increase in OT visits could be due to better coding within the database over time? #jhsjc
Would be nice to see internal validity check: trend OT use after flexor tendon repair during time period – shouldn’t see much change #jhsjc

Warren @whammert to @BgTalkinman:
I think it has to decrease therapy overall – more scrutiny from groups or institutions for referral and justification #jhsjc

Brent Graham @BgTalkinman to @whammert:
your view fits with the data bc the increases were mostly number of pts; cost/visit was static #jhsjc

Avi Giladi @theaviram to @JeffStepanMD:
therapy use after flexor tendon not nearly as consistent as you’d think. we tried looking at it #jhsjc

Brent Graham @BgTalkinman to @JeffStepanMD:
I would have thought that to be true for #CMC arthroplasty because that hasn’t changed for decades – visits increased #jhsjc

Brent Graham @BgTalkinman to @theaviram and @JeffStepanMD:
That is amazing! Certainly more justified – I guess – than after trigger finger or deQ. #jhsjc

Brent Graham @BgTalkinman to @whammert:
Agreed. In the absence of evidence it is very hard to justify in many instances. #jhsjc

Robert Rhoad, MD @Rhoad:
Therapy visit volume alter between HOPD unit (expensive) vs non-HOPD? #jhsjc

Brent Graham @BgTalkinman to @JeffStepanMD:
I’m sure that the coders are compelled to leave no stone related to payment unturned but I suspect its more sinister #jhsjc

Brent Graham @BgTalkinman to @Rhoad and @JeffStepanMD:
I mean physician/institution driven more than coding variations #jhsjc

Brent Graham @BgTalkinman to @RobertFosterMD1 and @whammert:
Wow! How can anybody afford that? There is a major adjustment coming when value-based payments become more established. #jhsjc

Brent Graham @BgTalkinman:
Fantastic discussion! Thanks to all! Stay inside! It will be over at some point! We will be back here next month. #jhsjc

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