#JHSJC

October #JHSJC Transcript

We had a great turnout for our October discussion! Thank you to everyone who participated. We looked at two articles from Volume 45, Issue 10 of The Journal of Hand Surgery: The Influence of Cost Information on Treatment Choice: A Mixed-Methods Study and Thumb Carpometacarpal Arthritis: Prognostic Indicators and Timing of Further Intervention Following Corticosteroid Injection.

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).

J Hand Surg Am- ASSH @JHandSurg:
October #JHSJC starts now!

J Hand Surg Am- ASSH @JHandSurg:
Article #1: The Influence of Cost Information on Treatment Choice: A Mixed-Methods Study By @robinkamalmd et al. https://www.jhandsurg.org/article/S0363-5023(20)30316-6/fulltext
#OrthoTwitter #MedTwitter #HandSurgery – #JHSJC

J Hand Surg Am- ASSH @JHandSurg:
2/4 #Article1Q1: The participants were recruited from Amazon Turk (MTurk), a strategy that has been used in other papers published by the Journal of Hand Surgery. How likely is it that this is a representative sample of the general US population? #JHSJC

J Hand Surg Am- ASSH @JHandSurg:
3/4 #Article1Q2: Most respondents acknowledged that health care costs are important, but a much smaller proportion considered that when making personal decisions about treatment. What does that say about the challenges of trying to bring costs under control? #JHSJ

J Hand Surg Am- ASSH @JHandSurg:
4/4 #Article1Q3: Should cost information be made available to all patients who are choosing treatment or, if the results of this study are accurate, and the focus is on controlling costs, is disclosing the costs counter-productive? #JHSJC

Brent Graham @BgTalkinman:
Comments on the use of Amazon Turk as a method of recruiting participants… #jhsjc

Brent Graham @BgTalkinman:
The concern is whether MTurk participants are representative of the general US population. Thoughts? #jhsjc
The paper comments on the fact that the respondents were from all areas of the US. Is that helpful? #jhsjc
Respondents acknowledged the #healthcarecost crisis but were 40% more likely to choose the expensive treatment if they knew the costs #jhsjc

Warren @whammert to @BgTalkinman:
A lot of americans feel like they are paying for insurance, so they should get the best treatment #jhsjc

Brent Graham @BgTalkinman to @whammert:
Is the assumption there that the “best” treatment is the most expensive? #jhsjc

Dr. Ray Raven @RayRavenMD to @BgTalkinman and @whammert:
that would be the case in LA and NYC! #jhsjc

Brent Graham @BgTalkinman to @whammert:
That attitude seems to be part of the problem. That seems an obstacle to controlling costs. #jhsjc

Warren @whammert to @BgTalkinman:
sometimes – right or wrong. #jhsjc

Robin Kamal @robinkamalmd to @BgTalkinman and @whammert:
don’t we believe that to be the case in other industries? #jhsjc

Warren @whammert to @BgTalkinman:
Hard to have sympathy for insurance companies for many – they make a lot of money #jhsjc

Brent Graham @BgTalkinman to @whammert:
Is that the cause of it –“sticking it to the man”? #jhsjc

Robin Kamal @robinkamalmd to @BgTalkinman and @whammert:
if your cell phone screen is protected by insurance don’t you drop your phone a little more freely? #jhsjc

Dr. Ray Raven @RayRavenMD to @robinkamalmd, @BgTalkinman, and @whammert:
Most definitely. #jhsjc

Brent Graham @BgTalkinman:
in the podcast (https://www.jhandsurg.org/pb-assets/Health%20Advance/journals/yjhsu/October_2020-1601559661467.mp3), the authors bring up the issue of “raiding the #healthcare commons”. #jhsjc

David Ring @DrDavidRing to @BgTalkinman and @whammert:
https://www.youtube.com/watch?v=yfRVCaA5o18&feature=youtu.be #JHSJC The meaning/context (placebo) effect.

Brent Graham @BgTalkinman to @DrDavidRing:
What do you mean? #jhsjc

Dr. Ray Raven @RayRavenMD to @DrDavidRing:
can you elaborate? will look at video later. #jhsjc

Warren @whammert to @DrDavidRing:
The mind is powerful indeed- placebo is real #jhsjc

Warren @whammert to @BgTalkinman:
I think there is a feeling you are paying for something so you should have your choice of treatment #jhsjc

Dr. Ray Raven @RayRavenMD to @robinkamalmd, @BgTalkinman, and @whammert:
Moral Hazard #jhsjc

Brent Graham @BgTalkinman:
That seems like a potentially insurmountable obstacle to controlling #healthcarecost if the current payment model remains dominant. #jhsjc

Robin Kamal @robinkamalmd to @BgTalkinman:
need insurance design that makes high value care free and low value care $$$, trialed in Michigan #jhsjc

Dr. Ray Raven @RayRavenMD to @robinkamalmd:
Well stated, @robinkamalmd! #jhsjc

Warren @whammert to @robinkamalmd:
That would be very interesting – link to Michigan trial? #jhsjc

Robin Kamal @robinkamalmd to @whammert and @BgTalkinman:
https://ihpi.umich.edu/center-value-based-insurance-design-v-bid #jhsjc

Brent Graham @BgTalkinman to @RayRavenMD, @robinkamalmd, and @whammert:
The “#moralhazard ” of raiding the healthcare commons is a manifestation of no collectivism #jhsjc

Brent Graham @BgTalkinman to @robinkamalmd, @RayRavenMD, @DrDavidRing, and @whammert:
Seemingly the only way to guide behaviour is through penalties and rewards? #jhsjc
How does placebo play a role here? #jhsjc

Warren @whammert to @BgTalkinman and 2 others:
I believe referring to better tx more expensive #jhsjc

Thompson Zhuang @ThompsonZhuang:
Several participants’ responses alluded to idea of since insurance already paying for it, might as well get expensive/”best” treatment! #jhsjc

Avi Giladi @theaviram to @BgTalkinman:
even worse, penalties often better motivator (not incentives). but hard to penalize those who can’t do what’s needed #jhsjc

Brent Graham @BgTalkinman to @ThompsonZhuang, @whammert, @DrDavidRing, and @robinkamalmd:
Ah, I understand! Thx! #jhsjc

Avi Giladi @theaviram to @ThompsonZhuang:
agree. just had a patient ask to go to therapy (didn’t need) because “insurance will pay, so why not” #jhsjc

Lauren Shapiro @laurenms09 to @BgTalkinman:
I think one issue is that people believe high cost always equals high quality which isn’t always the case. #JHSJC https://t.co/UaxDD9OZCP

Joe Rosenbaum, MD @JRHandSurg to @BgTalkinman, @whammert, and @DrDavidRing:
Also refer to the thousands that pts will pay for unproven stem cell injections #placebo #jhsjc #jhsjc

Brent Graham @BgTalkinman to @ThompsonZhuang:
So is the problem explaining how treatments that are equally effective may cost different amounts? #jhsjc

Thompson Zhuang @ThompsonZhuang to @BgTalkinman:
perhaps de-emphasizing total cost and focusing on equal efficacy? #jhsjc

Brent Graham @BgTalkinman to @ThompsonZhuang:
yes! #jhsjc

Warren @whammert:
IF you are in a MVC, how many would pay to have their car fixed with cheaper parts rather than submitting to insurance #jhsjc

Brent Graham @BgTalkinman to @whammert:
Its a good point and maybe understanding that is how people think may inform how to better educate them. #jhsjc

Warren @whammert to @BgTalkinman:
agree, but would have to include insurance reform as well #jhsjc

Brent Graham @BgTalkinman
Good discussion — sadly, actual reform seems very, very far in the future. #jhsjc

Brent Graham @BgTalkinman
Let’s move on to the article about care following #steroid injection for 1st #CMC #arthritis #jhsjc

J Hand Surg Am- ASSH @JHandSurg:
Let’s move on to the next article! #JHSJC #OrthoTwitter #MedTwitter #HandSurgery –
Article #2: Thumb Carpometacarpal Arthritis: Prognostic Indicators and Timing of Further Intervention Following Corticosteroid Injection by @RozentalTamara et al. https://www.jhandsurg.org/article/S0363-5023(20)30185-4/fulltext

J Hand Surg Am- ASSH @JHandSurg:
1/4 #OrthoTwitter #MedTwitter #HandSurgery – #JHSJC

2/4 #Article2Q1: The study was conducted in an urban setting at a single academic tertiary center and included 4 surgeons. Are the findings likely to be generalizable? #JHSJC

3/4 #Article2Q2: Eaton III/IV; smoking; ipsilateral hand surgery – were associated w/ greater likelihood of surgery. The association b/w more advanced stage at time of first injection and eventual surgery has some face validity. What is the meaning of other two variables? #JHSJC

4/4 #Article2Q3: Are steroid injections useful or does it simply delay the inevitable need for surgery? If surgery was equally accessible for all patients, is there a role for this kind of non-operative management? #JHSJC

Dr. Ray Raven @RayRavenMD:
For #Article2Q1: The study was conducted in an urban setting at a single academic tertiary center and included 4 surgeons. Are the findings likely to be generalizable? #JHSJC

Brent Graham @BgTalkinman:
This is a single centre study. Do the findings seem valid, ie consistent with your observations? https://www.jhandsurg.org/article/S0363-5023(20)30185-4/fulltext #jhsjc

Joe Rosenbaum, MD @JRHandSurg to @JHandSurg:
There’s a spectrum of pts who come in for this problem, ranging from those who def want surgery to those who would do anything to avoid it… I’m not certain what to make of the findings in this study as I think that’s the primary indicator in my practice to who chooses op #jhsjc

Joe Rosenbaum, MD @JRHandSurg to @DrDavidRing and @BgTalkinman:
Certainly much higher than in my practice… which, though I am young, is very low. Most people I meet with CMC OA don’t want anything to do with a trapeziectomy. #jhsjc

J Hand Surg Am- ASSH @JHandSurg:
Article2Q2: Eaton III/IV; smoking; ipsilateral hand surgery – were associated w/ greater likelihood of surgery. The association b/w more advanced stage at time of first injection and eventual surgery has some face validity. What is the meaning of other two variables? #JHSJC

Article2Q3: Are steroid injections useful or does it simply delay the inevitable need for surgery? If surgery was equally accessible for all patients, is there a role for this kind of non-operative management? #JHSJC

Brent Graham @BgTalkinman:
The association between ipsilateral hand sx/smoking need for subsequent treatment (injection/surg) makes no sense to me. Thoughts? #jhsjc

David Ring @DrDavidRing to @JHandSurg:
TMC arthrosis is as common as grey hair. Is steroid injection the reinforcement of medicalization of the normal aging of the human body? #HighRateofSurgery #JHSJC

Brent Graham @BgTalkinman to @DrDavidRing and @JHandSurg:
maybe- I have grey hair and a painful thumb. I still want it to feel better. #jhsjc

Joe Rosenbaum, MD @JRHandSurg to @BgTalkinman:
I agree. The only thoughts I have are judgemental (bordering on paternalistic) assumptions about the psyche of smokers #jhsjc

Avi Giladi @theaviram to @BgTalkinman:
an incredibly important research question, but the limitations in these data are hard to overlook re: transferability #jhsjc

Brent Graham @BgTalkinman to @theaviram:
Elaborate on that. Generalizability? #jhsjc

Avi Giladi @theaviram to @BgTalkinman:
cohort size, loss to follow-up, demographics, make some findings likely unique to this group, not more broadly. #jhsjc

Brent Graham @BgTalkinman:
I don’t inject – they are hard, they don’t make the cartilage recover it seems like delaying the inevitable if there are symptoms. #jhsjc

Joe Rosenbaum, MD @JRHandSurg to @BgTalkinman:
Is surgery inevitable though? I see many patients with painless Eaton stage 4 OA. How do they get there? #jhsjc

Brent Graham @BgTalkinman to @JRHandSurg:
I am speaking of people who present with symptoms of pain. I’ve never understood why an injection would help. #jhsjc

Robin Kamal @robinkamalmd to @BgTalkinman
I agree, I avoid injections #jhsjc

Warren @whammert to @BgTalkinman:
I will inject, realizing it is not a cure, but can decrease synovitis and improve at least temporarily #jhsjc

Brent Graham @BgTalkinman:
There is a lot of evidence showing treatment results and x-ray appearance don’t correlate. How does that fit in with these findings? #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
Steroids = palliative at best. Medicalize normal human aging. #Value #JHSJC

Warren @whammert to @DrDavidRing and @BgTalkinman:
yes – normal aging, but so is hair color – not for me, but important to some #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
So, if there are symptoms, surgery? I admit that has been my approach a long time. #jhsjc

Warren @whammert to @BgTalkinman and @JRHandSurg:
pain from synovitis – injection can help that #jhsjc

Brent Graham @BgTalkinman to @whammert and @DrDavidRing:
What I am getting at is I’m old, my thumb hurts I want to play the guitar. Is an injection a treatment for me? #jhsjc

Joe Rosenbaum, MD @JRHandSurg to @BgTalkinman:
I don’t claim to understand it, but willing to perform if patients want it, since they do seem to alleviate symptoms. #jhsjc

David Ring @DrDavidRing to @CMHarperMD:
Injection says “come to the surgical light” or “your can’t manage without my treatment” = #Medicalization
Can #CMHarperMD pledge to #CorrectMisconceptions and help people #ChooseWisely #JHSJC

Joe Rosenbaum, MD @JRHandSurg to @DrDavidRing and @CMHarperMD:
I don’t necessarily agree. Many just want to get over a “hump” of some synovitis. And know it isn’t a cure. #jhsjc

Orrin Franko @OrrinFrankoMD to @DrDavidRing and @BgTalkinman:
Most patients understand it’s not a cure but they love the temporary relief, builds trust, and gives time to make an informed decision. #JHSJC

Brent Graham @BgTalkinman to @OrrinFrankoMD:
Do you do it again? Will you tell them now that 1/3 will have surgery within 5 years anyway? #jhsjc

Joe Rosenbaum, MD @JRHandSurg to @BgTalkinman and @OrrinFrankoMD:
I wouldn’t tell them that because I don’t think it’s generalizable to my practice. My rate is much lower #jhsjc

Brent Graham @BgTalkinman to @JRHandSurg, @BgTalkinman, and @OrrinFrankoMD:
Why is it lower? Are the pts in this study different from yours? #jhsjc

Joe Rosenbaum, MD @JRHandSurg to @BgTalkinman and @OrrinFrankoMD:
Surely multifactorial. How surgery is “sold” to pt, pt population, surgeon age probably even plays in #jhsjc

Brent Graham @BgTalkinman to @theaviram:
All true and the authors more or less acknowledge all of that. What should be concluded for the avg clinician? #jhsjc

Avi Giladi @theaviram to @BgTalkinman:
I think what we know, and this study supports, is that injections are a band-aid, not a solution. #jhsjc

Warren @whammert to @BgTalkinman and @DrDavidRing:
might help you play this weekend, but not a cure – the weekend might be good enough for some #jhsjc

Warren @whammert to @BgTalkinman and @OrrinFrankoMD:
can be temporizing – want to play golf during the summer and have surgery in winter… #jhsjc

Avi Giladi @theaviram to @BgTalkinman, @whammert, and @DrDavidRing:
how many here would ever have CMC injection done? what about CMC surgery? #jhsjc

Orrin Franko @OrrinFrankoMD to @BgTalkinman, @whammert, and @DrDavidRing:
Absolutely. Why not? #jhsjc

Brent Graham @BgTalkinman to @theaviram:
I personally wouldn’t have an injection done bc done by a knowledgable surg the results of CMC arthroplasty are very good #jhsjc

Orrin Franko @OrrinFrankoMD to @BgTalkinman and @theaviram:
Define “very good” for cmc Arthroplasty outcomes. ASSH2020 “best poster” shows less success than typically thought. #jhsjc

David Ring @DrDavidRing to @BgTalkinman and @OrrinFrankoMD:
Surgery = Success, Pain = #Failure #JHSJC

Brent Graham @BgTalkinman to @DrDavidRing:
To be honest, if I’m the patient that seems like a good summary! #jhsjc

David Ring @DrDavidRing to @BgTalkinman, @JRHandSurg, and @OrrinFrankoMD:
Study after study documents that 1) TMC arthrosis is universal with age; 2) people usually see a specialist a single time and then manage on their own. #Responsibility #JHSJC

Brent Graham @BgTalkinman to @OrrinFrankoMD
I hope that is a JHS submission. #jhsjc

Orrin Franko @OrrinFrankoMD to @BgTalkinman and @theaviram:
Thanks! It will be. #jhsjc
here is reference: https://t.co/zlNlyPdrMI
If I said LRTI has <50% high satisfaction does that change your decision? #JHSJC

Joe Rosenbaum, MD @JRHandSurg to @BgTalkinman and @OrrinFrankoMD:
How conservative the surgeon is or not, how recently they had a complication from surgery, how early on in the progress of disease their patients are referred to them… #jhsjc

Brent Graham @BgTalkinman to @OrrinFrankoMD:
I mean relief of pain and no further treatment required. I’ve done it >1200 times. #jhsjc

Warren @whammert to @DrDavidRing, @BgTalkinman, and 2 others:
Death, taxes, and CMC arthritis – but one has a good treatment #jhsjc

Brent Graham @BgTalkinman to @whammert:
Ha! #jhsjc

Joe Rosenbaum, MD @JRHandSurg to @DrDavidRing, @BgTalkinman, and @OrrinFrankoMD:
I typically give patients this perspective. Many are satisfied and don’t return. Others want to do something. Brace, therapy. Or injection. In 13 months of practice, exactly zero have asked me to do a surgery and I’ve repeated an injection maybe once #jhsjc

Jane McEachan @jmceachan to @BgTalkinman:
The study says much about inherent cognitive bias surrounding the recommendations we make to patients regarding treatment of this condition. Natural history??? Patients present with pain and doctors offer ‘treatment’.

Brent Graham @BgTalkinman to @jmceachan:
I acknowledge that “cognitive bias” exists however patients do have problems for which they seek solutions and that is our obligation – to offer some tx choices with descriptions of the advantages and disadvantages of each option. #jhsjc
We really don’t have this discussion when we are talking about patients with hip OA. There are no discussions about cognitive bias when the cause of the hip problem is obvious and advanced. 1st CMC arthroplasty works as well or better than THJR. #JHSJC

Jane McEachan @jmceachan to @BgTalkinman:
Completely agree. High quality information is key to informed decision making Actually, the cognitive bias is discussed by the authors in this paper, and the paper itself is very clear. #JHSJC

J Hand Surg Am- ASSH @JHandSurg:
Always an interesting conversation! We truly appreciate everyone’s participation. See you next month! #JHSJC #orthotwitter #MedTwitter #handsurgery

Brent Graham @BgTalkinman:
We are at the end of our hour! Thanks for your participation! We are back here on November 10. #jhsjc

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