November #JHSJC Transcript

Thank you to everyone who participated in the November #JHSJC discussion! We send a special thank you to our Guest Hosts, Charles A. Goldfarb, MD (@Congenitalhand) and Christopher J. Dy, MD, MPH, FACS (@ChrisDyMD)!

We looked at two articles from Volume 45, Issue 11 of The Journal of Hand Surgery: Distal Biceps Tendon Rupture Surgery: Changing Incidence in Finnish and Swedish Men Between 1997 and 2016 and Declining Trend in Medicare Physician Reimbursements for Hand Surgery From 2002 to 2018.

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).

Christopher J. Dy MD MPH FACS @ChrisDyMD:
Thanks everybody for checking out tonight’s #JHSJC. 8p CST. We are ready in our house! #surgparenting #dadlife

J Hand Surg Am- ASSH @JHandSurg:
It’s time for our November #JHSJC Twitter #JournalClub with Guest Hosts from #TheUpperHand-
@Congenitalhand and @ChrisDyMD

Charles Goldfarb @Congenitalhand:
welcome to #jhsjc. @ChrisDyMD and I are happy to ‘host’!

Christopher J. Dy MD MPH FACS @ChrisDyMD:
Let’s do this! #JHSJC

Dr. Ray Raven @RayRavenMD:
1/2 #JHSJC Distal Biceps Tendon Rupture Surgery:
One point brought up was the relevance of studying this condition in two countries that have #SinglePayer health care systems that allow tracking of relatively rare occurrences like #DBT rupture-
2/2 How likely is that these findings are generalizable to the #UnitedStatesHealthCareSystem which is much more fragmented? Are the findings consistent with the experience of North American surgeons? #JHSJC

Charles Goldfarb @Congenitalhand to @RayRavenMD:
Well- @RayRavenMD we all know how much better the #scandanavian countries host registries. So huge head start towards great data #jhsjc
I appreciate the strong data and I trust it. Am I wrong? #jhsjc

Christopher J. Dy MD MPH FACS @ChrisDyMD @Congenitalhand and @RayRavenMD:
Do we have a good sense of how reliable their registry efforts are? I am assuming much better than those in the USA since our ‘big data’ studies come from admin data not collected for research purposes. #JHSJC
My sense based on all health svc research is that the surgery/procedure code part of this study is most reliable. but their Diagnosis and Surgery trends are parallel.

Charles Goldfarb @Congenitalhand:
Do we think the Scandanavian findings apply to the US? Higher # of repairs, higher number of ruptures? #jhsjc
his feels correct to me. The ‘ease’ of surgery seems to have made surgery a more appropriate choice for many surgeons. Right? Wrong? #JHSJC

Robert Foster MD @RobertFosterMD1:
I wonder if the true incidence of ruptures has increased, or just the knowledge that we repair them leads to referrals not made b4? #jhsjc
I remember the surgery being difficult and painful, and now it seems MUCH easier and less painful. #jhsjc

Christopher J. Dy MD MPH FACS @ChrisDyMD to @Congenitalhand and @RayRavenMD:
Distal biceps repair is not a risk-free surgery. It would be interesting to see if value is derived from the increase in surgeries. Thoughts? #JHSJC

Christopher J. Dy MD MPH FACS @ChrisDyMD to @Congenitalhand:
Ah yes, this is the pair of injuries i fear every time i exercise!!! #JHSJC

Orrin Franko @OrrinFrankoMD to @Congenitalhand and @RayRavenMD:
I find it odd that we always focus on either a national registry, or nothing. It’s easy to make inexpensive, easy registries that can enroll thousands of patients at no cost, fully automated. #jhsjc

Dr. Ray Raven @RayRavenMD to @OrrinFrankoMD:
Thanks for joining Orrin! #jhsjc

Robert Foster MD @RobertFosterMD1
Data re:repairs seems strong while incid of tears may vary by ref/ pursuit of care.Perhaps many # before were tx’d w/ benign neglect #jhsjc

Christopher J. Dy MD MPH FACS @ChrisDyMD to @Congenitalhand, @OrrinFrankoMD and 2 others:
Fig 4 is interesting. Eyeball estimate of roughly half of the diagnosed tears are fixed in this study. Is that about right? #JHSJC

Dr. Ray Raven @RayRavenMD:
Assuming that the massive increases in incidence of this kind of surgery are real, what are the likely causes? #jhsjc

Orrin Franko @OrrinFrankoMD to @Congenitalhand and @RayRavenMD:
what the US may not have in detailed data, we make up for in volume. We should have most hand patients enrolled in some registry. This can be done. #JHSJC

Robert Foster MD @RobertFosterMD1:
beauty of Nat’l Reg means every one is counted – no variation by insurance #jhsjc

Christopher J. Dy MD MPH FACS @ChrisDyMD to @RobertFosterMD1:
Excellent point…. but do you think there are differences in patient characteristics/preferences/expectations, as well as supply-induced demand (ie: surgeon indications) based on populations and health care system?

Orrin Franko @OrrinFrankoMD to @RobertFosterMD1:
agreed. But there is theory, and then there is reality. National registry is nearly insurmountable challenge in this country. Better to collect some data than no data in my opinion. Many would argue with me. #JHSJC

Orrin Franko @OrrinFrankoMD to @Congenitalhand, @ChrisDyMD, and 2 others:
I can comment as a young surgeon. Residency and fellowship were based on literature, suggesting non-operative treatment is reasonable. However my early clinical experience suggests otherwise. A couple non-op have been disappointed, all surgical patients have been happy. #JHSJC

Rob Gray @robgraymd to @RayRavenMD:
People hear others’ experiences and seek care earlier. Like variations in care by geography, positive outcomes lead to increased utilization #jhsjc

Avi Giladi @theaviram to @RayRavenMD:
as an avid fitness person, I acknowledge that HIIT likely contributes some to the increased incidence in middle-aged men #jhsjc

Orrin Franko @OrrinFrankoMD to @Congenitalhand and 3 others:
I fully recognize that may not reflect science, but patients don’t care about science. They just want to be happy and get back to sports. #JHSJC

Avi Giladi @theaviram to @OrrinFrankoMD:
athletes have little patience for downtime (me too). knowing cause of injuries would help epi value of this study #jhsjc

Christopher J. Dy MD MPH FACS @ChrisDyMD to @OrrinFrankoMD, @Congenitalhand, and 2 others:
The regret of what could have been (if i had the surgery, i could have scored 7 TD’s in one game again, just like Polk High!) is powerful. #AlBundy #JHSJC

Lauren Wessel @lwesselmd to @ChrisDyMD, @RobertFosterMD1, and 4 others:
I think that my main takeaway from this study is that high-quality RCTs on the treatment of distal biceps tendon ruptures are needed to identify optimal treatment, especially given the rising incidence and frequency of surgical intervention.. Would you agree? #JHSJC

Robert Foster MD @RobertFosterMD1
I submit that the repair has become MUCH easier, and the rehab starkly easier now without post-op splint/cast (gold std in 2000) #jhsjc and I Agree with @lwesselmd that this provides great justification data. #JHSJC

Orrin Franko @OrrinFrankoMD to @RobertFosterMD1:
having not been around for the prior generation of treatment, I agree. Fairly straightforward operation, can be done in 25-30 mins. Watch out for the nerve and you’re otherwise golden. #JHSJC

Christopher J. Dy MD MPH FACS @ChrisDyMD to @Congenitalhand, @lwesselmd, and 4 others:
Perhaps not in America, but our European colleagues have had much more success with randomization in surgical trials so i bet they could pull this off! #JHSJC

Dr. Ray Raven @RayRavenMD to @ChrisDyMD and @Congenitalhand:
Exactly. I have seen more than a hand full of complications over the last 15 years. 1 of my own. #JHSJC

Dr. Ray Raven @RayRavenMD to @Congenitalhand, @robgraymd, and others:
True, although I have had plenty of patients, from 40-70’s, who have been very happy with nonop Tx. #JHSJC
Time to panic?

Orrin Franko @OrrinFrankoMD to @RayRavenMD:
yes, probably. But panicking won’t fix anything… #JHSJC

Orrin Franko @OrrinFrankoMD to @ChrisDyMD, @Congenitalhand, and 2 others:
I find patients are much more tolerant of complications when they’ve chosen surgery and informed about the risk. But much more disappointed when they have to live with chronic weakness or pain #JHSJC

Rob Gray @robgraymd to @lwesselmd, @ChrisDyMD, and 4 others:
I don’t think so. If you’re going to fix it you have to do it and fast—that’s not up for debate. In the absence of complications, repair>neglect. Maybe not by much but better. Only thing that would change practice would be high complications #jhsjc

Christopher J. Dy MD MPH FACS @ChrisDyMD to all:
OK, all you cool cats and kittens in #JHSJC… time to switch to article 2 – Medicare reimbursement is declining for common #handsurgery procedures.

Dr. Ray Raven @RayRavenMD to all:
1/2 #JHSJC
Article #2:
Declining Trend in Medicare Physician Reimbursements for Hand Surgery From 2002 to 2018.
2/2 #JHSJC
The data source for the study was the #Medicare Physician #FeeSchedule database, a sample of 100 “payment localities across the nation”. Can it be assumed that this is an unbiased and representative data source that is generalizable?

Christopher J. Dy MD MPH FACS @ChrisDyMD to @Congenitalhand, @RayRavenMD, and 5 others:
One of the things that i wished this article would have commented on was…. where the diverted funds go? were there upticks in other areas of #orthopedics or #plasticsurgery? We are facing a similar pinch in 6 weeks… #JHSJC

Dr. Ray Raven @RayRavenMD to @ChrisDyMD, @theaviram, and 5 others:
Remain calm at all times. #JHSJC

Christopher J. Dy MD MPH FACS @ChrisDyMD to @lwesselmd, @RayRavenMD, and 5 others:
Depends on if #ObamaCare survives yet again! Numerous studies (some of ours, too) have demonstrated increase in utilization and demand after #MedicaidExpansion even in setting of very meager reimbursement. Question is how much reimbursement matters…. #JHSJC

Azeem Tariq Malik @Azeemt94 to @RayRavenMD:
Likely representative since the fee schedule captures and reports data for all payment localities present in the nation #jhsjc

Orrin Franko @OrrinFrankoMD to @Congenitalhand, @ChrisDyMD, and 6 others:
I don’t think the tide can be stopped. What’s more interesting is how this will affect practice models. Historically lower pay means a shift towards larger organizations. However the data seems clear that surgeons do better in smaller practices with controlled overhead #jhsjc

Robert Foster MD @RobertFosterMD1:
Reimbursement has always dropped, but how can it be stopped/ slowed/ reversed? #jhsjc

Dr. Ray Raven @RayRavenMD to @RobertFosterMD1:
Answer: #Outcomes data! #PROS are key to physician reimbursement. Other component is the cost of care for common conditions. #jhsjc

Orrin Franko @OrrinFrankoMD to @ChrisDyMD, @lwesselmd, and 6 others:
Well, #NYT today suggests supreme court will not strike it down #jhsjc

Christopher J. Dy MD MPH FACS @ChrisDyMD to @OrrinFrankoMD, @Congenitalhand, and 6 others:
Great point. We have a diversity of practice models here in this chat. @OrrinFrankoMD @RayRavenMD @RobertFosterMD1 @robgraymd private practice, me @Congenitalhand @theaviram academic practice…. have you felt this or noticed this decline in your practices? #JHSJC

Orrin Franko @OrrinFrankoMD to @ChrisDyMD, @Congenitalhand, and 6 others:
I don’t have enough time in the game to comment on that. But I am confident that my low overhead practice can be nimble and adjust to circumstances faster than others. That gives me confidence and some protection. #jhsjc

Christopher J. Dy MD MPH FACS @ChrisDyMD to @Azeemt94 and @RayRavenMD:
The author is in the building! Thanks for logging in. Nice paper, great for discussion #JHSJC

Orrin Franko @OrrinFrankoMD to @ChrisDyMD, @Congenitalhand, and 6 others:
small, independent private practice will rely on legislative efforts by larger organizations who will be affected more dramatically. #JHSJC

Avi Giladi @theaviram to @RayRavenMD and @RobertFosterMD1:
caution going to PROs until we understand what drives reporting good/bad outcomes. not always the care! #jhsjc

Robert Foster MD @RobertFosterMD1 to @RayRavenMD:
Will there be more money for more data/ better outcomes? or is it a competition for best outcomes #jhsjc
best outcomes get biggest piece of shrinking pie… #jhsjc

Dr. Ray Raven @RayRavenMD to @RobertFosterMD1:
Great question. Likely answer is money will be shifted. Competition will be more important, as with other markets. #jhsjc

Robert Foster MD @RobertFosterMD1 to @RayRavenMD:
I have not seen a measure of quality that works, nor do I know how to go about it myself. #jhsjc

Avi Giladi @theaviram to @RayRavenMD and @RobertFosterMD1:
more for increased data collection! interest in improving outcomes will follow without tying comp to it #jhsjc

Avi Giladi @theaviram to @RobertFosterMD1 and @RayRavenMD:
agree re: outcome-based quality measures. inadequate. i love PROs but worry about linking them to comp #jhsjc

Azeem Tariq Malik @Azeemt94:
There is some evidence to suggest that physician group practices are more quicker/adept at controlling costs in newer models. #jhsjc

Christopher J. Dy MD MPH FACS @ChrisDyMD to @Azeemt94:
Did you give thought to examining changes in utilization over time? It would be interesting to see if reimbursement tracks with utilization inversely. i have tried to do this in my work but it is too complex #JHSJC

Azeem Tariq Malik @Azeemt94
Hard to say. Aim of tying reimbursements to quality was the push towards value i.e. better outcomes while controlling costs. #jhsjc

Dr. Ray Raven @RayRavenMD to @Azeemt94:
which is the way it probably should be for many health conditions #jhsjc

Christopher J. Dy MD MPH FACS @ChrisDyMD to @Azeemt94:
The early evidence with hip/knee replacement and BPCI suggests that cherry picking is limited (admittedly studies are mixed)…. but anecdotally, it is probably real and the Type 2 error is due to challenges with admin data studies #JHSJC

Azeem Tariq Malik @Azeemt94 to @ChrisDyMD, @Congenitalhand, and 3 others:
We are trying to. Hard to find a good all-payer claims dataset that tracks outpatient hand surgical procedures, and allows us to make national estimates for utilization. Most are either from one private payor or medicare only #JHSJC

Christopher J. Dy MD MPH FACS @ChrisDyMD to @Azeemt94:
Did you consider looking at changes/trends in other specialties to see where the funds went? Unfortunately as @Congenitalhand it seems to be a zero-sum game with CMS/congress in terms of allocated funds for health care. #JHSJC

Azeem Tariq Malik @Azeemt94 to @ChrisDyMD and @Congenitalhand:
Well – the interesting thing is reimbursements are being slashed all across the board.
We did something similar for shoulder surgeries
27% decline in reimbursements. #JHSJC

Orrin Franko @OrrinFrankoMD to @RobertFosterMD1 and @RayRavenMD
Best evidence from existing PRO registries is that there is very little variation, especially in hand surgery and among common procedures. #jhsjc
trying to link payment with quality will literally be splitting hairs and never be equitable #jhsjc

Azeem Tariq Malik @Azeemt94 to @ChrisDyMD:
Agreed. Admin studies get tricky at one point #JHSJC

Avi Giladi @theaviram to @OrrinFrankoMD:
there is variation enough, and quality can be driven based on evidence/decisions/utilization as well. #jhsjc

Dr. Ray Raven @RayRavenMD to @OrrinFrankoMD and @RobertFosterMD1:
I’m not sure I agree. We do it just fine in other markets. Might work for some common conditions #jhsjc

Christopher J. Dy MD MPH FACS @ChrisDyMD to @OrrinFrankoMD, @theaviram, and 2 others:
So what’s the key to slowing this push and stopping the train? It seems like once the “stakeholders” get ahold of a promising idea, they can’t see forest from trees ie: recognize emergent strategy (like @Congenitalhand espouses). #JHSJC

Orrin Franko @OrrinFrankoMD to @theaviram:
I would be interested to see data that supports that. Small amounts of variation can be easily explained by practice demographics or collection methods. Whether true or not, the uncertainty will prevent widespread adoption #jhsjc

Dr. Ray Raven @RayRavenMD to @theaviram and @OrrinFrankoMD:
absolutely agree! #ValueBasedCare #PROS #CostEffectiveCare #jhsjc

Christopher J. Dy MD MPH FACS @ChrisDyMD to @OrrinFrankoMD, @theaviram, and 2 others:
So what’s the key to slowing this push and stopping the train? It seems like once the “stakeholders” get ahold of a promising idea, they can’t see forest from trees ie: recognize emergent strategy (like @Congenitalhand espouses). #JHSJC

Avi Giladi @theaviram:
trying to show the holes, and then how to fill them. or coming up with a better way ourselves #jhsjc

Azeem Tariq Malik @Azeemt94 to @ChrisDyMD and @Congenitalhand:
I think CMS slashed THA and TKA reimbursement this year. I think there is a federal push towards cutting costs but doing so via cutting physician reimbursements is not the solution. Physician reimbursement only constitutes 5-10% of payments in an episode of care/bundle #JHSJC

Orrin Franko @OrrinFrankoMD to @theaviram:
rather than linking pay to quality, it will be much easier to establish threshold levels for utilization or outcomes. #JHSJC

Azeem Tariq Malik @Azeemt94 to @OrrinFrankoMD and @theaviram:
Interesting thoughts on threshold levels! #jhsjc

Christopher J. Dy MD MPH FACS @ChrisDyMD to @Azeemt94 and @Congenitalhand:
The trends are frustrating mainly because many entities peg their reimbursements to Medicare. The downtrends will have the effect of limiting access to those under #ACA/#ObamaCare plans that unfortunately contract lower than Medicare. #JHSJC

Avi Giladi @theaviram to @OrrinFrankoMD:
we have a lot of internal data, with wide variation, not explained by provider, for simple procedures (ie CTR) #jhsjc

Orrin Franko @OrrinFrankoMD to @theaviram:
please share more! So what explains it? #JHSJC

Avi Giladi @theaviram to @Azeemt94 and @OrrinFrankoMD:
thresholds are much safer place to start, agreed. but must collect data well before planning to weaponize #jhsjc

Azeem Tariq Malik @Azeemt94 to @ChrisDyMD, @Congenitalhand, and @lwesselmd:
Agreed. I think that is what we want to explore, but difficulty finding a good all-payer claims dataset with outpatient data to study ACA plans. Would be a cracker study though. #JHSJC

Dr. Ray Raven @RayRavenMD to @OrrinFrankoMD and @RobertFosterMD1:
but cost is another thing. Remember, #HealthCareValue = (#Outcome X #PatientExperience)/ #CostOfCare #jhsjc

Orrin Franko @OrrinFrankoMD to @theaviram and @Azeemt94:
so why wait? I have a hand registry that’s basically free, open to anyone. It’s like pulling teeth trying to get people to participate. And it’s fully automated. #jhsjc

Avi Giladi @theaviram to @OrrinFrankoMD:
pain meds. QOL. expectations. hopefully you’ll be reading in JHS and other journals soon! reviews take time… #jhsjc

Dr. Ray Raven @RayRavenMD to @OrrinFrankoMD and @theaviram:
I think we should do both! #jhsjc

Orrin Franko @OrrinFrankoMD to @theaviram:
got it. I consider many of those surgeon factors. Perhaps not surgical technique, but surgeon protocols make those decisions… #jhsjc

Avi Giladi @theaviram to @OrrinFrankoMD:
linking to clinical care is important, and challenges with PHI, DUA, costs for external registry are complicated. #jhsjc

Christopher J. Dy MD MPH FACS @ChrisDyMD to @Azeemt94:
So what’s the follow-up work that you have planned to build on these findings? you don’t have to give away the details, but big picture? #JHSJC

Azeem Tariq Malik @Azeemt94 to @ChrisDyMD:
Haha of course! I think – we’ve looked at physician reimbursements. Trying to look at variation and trends in “facility” reimbursements for these procedures. And whether costs have changed over time between physician-owned vs. hospital-owned ASCs #JHSJC

Dr. Ray Raven @RayRavenMD to @Azeemt94:
Lots of evidence for this, I agree! #JHSJC

Christopher J. Dy MD MPH FACS @ChrisDyMD to @Azeemt94:
Good luck to you! Those are great angles to pursue. On a personal note, we should talk about some collaborations!

Orrin Franko @OrrinFrankoMD to @theaviram:
I think there are ways to make it inexpensive. And PHI encryption should not be a challenge these days. #JHSJC

Avi Giladi @theaviram to @OrrinFrankoMD:
perhaps re pain meds. not re patient mental/physical health, social factors, etc. Impact on PROs is very real #jhsjc

Orrin Franko @OrrinFrankoMD to @theaviram:
totally agree. But then you’re talking about patient factors that are difficult to change. #jhsjc

Robert Foster MD @RobertFosterMD1:
Much reimbursement that would go to helpful specialist care is wasted on expensive useless urgent care and ER visits ….that often lead to misinformation and delay #jhsjc

Orrin Franko @OrrinFrankoMD to @RobertFosterMD1:
100% #jhsjc

Charles Goldfarb @Congenitalhand:
Thank you all for joining. Great discussion! #JHSJC

Christopher J. Dy MD MPH FACS @ChrisDyMD to @Congenitalhand:
That was a fun #JHSJC discussion! Until next month…. @RayRavenMD @BgTalkinman @RobertFosterMD1 @OrrinFrankoMD @theaviram @lwesselmd @Azeemt94 @theaviram @JHandSurg #handsurgery

J Hand Surg Am- ASSH @JHandSurg:
That’s a wrap! #OrthoTwitter #MedTwitter #HandSurgery –
Great discussion! Thank you for participating in #JHSJC Twitter #JournalClub with Guest Hosts from #TheUpperHand- @Congenitalhand & @ChrisDyMD

Keep the responses going!

See you next month!
@RayRavenMD and @BgTalkinman!

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