2022 has come to an end! For the final JHS Journal Club event of the year, we discussed Moving Minor Hand Surgeries Out of the Operating Room and Into the Office-Based Procedure Room: A Population-Based Trend Analysis and Zurich Appearance Score for Hands: Development and Validation of an Instrument for Assessing Hand Appearance in Congenital Upper Limb Differences. You can find both of those articles in the December 2022 issue of JHS.
Thank you to those who observed and joined in! Please plan to join us again by using the TwChat platform. Please review the information here on how to use it.
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:
The final #JHSJC of 2022 is happening now! Let’s get the discussion going.
Brent Graham @BgTalkinman:
Welcome to the December session! We will be here for an hour discussing 2 papers from the December issue. Details about the papers are at http://jhsfocus.org/jhsjc #jhsjc
Brent Graham @BgTalkinman:
Let’s start with the lead article by Randall et al on trends in office-based surgery #jhsjc (https://www.jhandsurg.org/article/S0363-5023(22)00509-3/fulltext)
RyanC @RPCalfeeSTL:
Interested in other’s experiences. Our practice largely limited to OR space for procedures #jhsjc
Brent Graham @BgTalkinman:
Given the accumulating evidence that has shown office-based surgery to be safe and much less costly than the alternative in the OR, the study looked at whether surgery is increasing in that setting. #jhsjc
Over the 11-year period of the study, there was an increase in total procedures performed and in procedures performed in the procedure room but the increase was small, ranging btw 1.6% (open CTR) and 10.1% (hand or finger mass excision) for the various procedures. #jhsjc
Has office-based surgery increased in your area? #jhsjc
RyanC @RPCalfeeSTL:
I was surprised the increase wasn’t larger. I thought sufficient time to capture what I thought was a real change in practice for many. #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
Agreed – and it was what the authors expected as well. Here is my interview with them: https://t.co/QR5HZzH2h5 #jhsjc
Brent Graham @BgTalkinman:
The study was performed on data collected between 2006 and 2017. Is that an appropriate period to accurately identify trends in procedure room usage? In other words, is the observed uptake of this approach spuriously low because of the time the data was collected? #jhsjc
I will answer my own question – my guess is that this location for surgery of this nature is increasing more recently, ie since the study was performed. Do others have any opinions about that? #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
good point. Maybe more increase in past 4-5 years. #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
That seems likely to me but I would like to hear what others have seen. What proportion of hand surgery cases are done in this setting at your hospital? #jhsjc
Dafang Zhang @DafangZhang to @BgTalkinman:
I found this study really interesting, and I agree @BgTalkinman that office based minor hand procedures have increased since the pandemic at our institution, largely by necessity #jhsjc
Brent Graham @BgTalkinman to @DafangZhang:
Do these findings reflect what is going on at your institution? #jhsjc
RyanC @RPCalfeeSTL to @DafangZhang:
Does this reflect limited OR access after pandemic? Staff related? #jhsjc
Dafang Zhang @DafangZhang to @RPCalfeeSTL:
Yes, exactly! #jhsjc that has been a big driver of change. We surgeons don’t always feel societal costs as a pain point, but not being able to get a case booked is definitely a pain point. 😅
Brent Graham @BgTalkinman to @DafangZhang:
To me that – not being able to get a case booked – would seem like a stimulus to more office-based cases. #jhsjc
RyanC @RPCalfeeSTL to @DafangZhang:
agree with you. For our system – things not well set up for office based procedures: lighting, instruments, etc. No motivation for hospital system to help that transition #jhsjc
Dafang Zhang @DafangZhang to @RPCalfeeSTL:
Totally. From a practical standpoint, institutional resources play a big role, whether the practice location is set up for minor procedures. Lighting, staff, equipment turnover. In some of our practice office locations in Boston, yes, but others, no. #jhsjc
Dafang Zhang @DafangZhang to @BgTalkinman:
I do think the majority of minor hand surgeries (including 5 in this study) are done in OR setting in our institution, though in last 2 years a greater minority has transitioned to minor procedure room #jhsjc
Brent Graham @BgTalkinman:
Another methodologic concern: About 75% of potentially eligible records were excluded for a variety of reasons, but the most common reason was an inability to identify the location in which the procedure took place. How might that have had an impact on the observations? #jhsjc
Brent Graham @BgTalkinman:
In the podcast the authors indicated that they thought it likely most of these exclusions were cases done in the OR #jhsjc
Brent Graham @BgTalkinman to @DafangZhang:
Given the clear evidence that this approach to procedures of this nature is safe and much less costly, what are the obstacles preventing office-based surgery from gaining more traction? #jhsjc
Dafang Zhang @DafangZhang to @BgTalkinman:
I think that’s a great question and probably multiple factors. I think you and authors make great points about cost considerations, but societal costs may not always overcome the inertia for change.
Brent Graham @BgTalkinman to @DafangZhang:
Yeah – the remedy for inertia always seems to be money. #jhsjc
Brent Graham @BgTalkinman:
What role are the institutions playing in stifling this – in the interest of not losing revenue associated with OR use? #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
There will soon be a paper in @JHandSurg showing how re-purposing the time vacated in the OR by moving cases to the office setting could prove to be a money-maker for institutions. #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
that could be helpful evidence #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
It’s a theoretical model but it shows that if lucrative cases filled that time eg arthroplasty cases – it could be a win for everyone. I agree that change is slow without the magic ingredient of $$. #jhsjc
Brent Graham @BgTalkinman:
Let’s move on to the other paper describing the Zurich hand appearance scale: https://www.jhandsurg.org/article/S0363-5023(22)00508-1/fulltext #jhsjc
The authors used what was, in my opinion, a methodologically rigorous approach to developing a scale to measure something that I believe is much more important to patients than we tend to acknowledge, appearance. #jhsjc
They validated their scale in a sample of lay people and focused on congenital hand differences, which I think was a good choice at this stage in the scale development – I don’t see any reason this couldn’t become more generalized. #jhsjc
The scale showed high internal consistency, moderate inter-rater reliability. The validity of the instrument was thought to be good. #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
Yes they really worked to provide evidence for validity here. True the appearance probably does matter #jhsjc
Brent Graham @BgTalkinman:
The images studied by the authors included both photographs of actual hands (5 cases) and computer-generated “photorealistic” images. Would that be expected to have an impact on the validity of the scale? #jhsjc
Appearance is a domain included in some patient-reported measures like the MHQ. This scale is different – it asked members of the public to comment on someone else’s hand and compare it to their own. Is this approach that would be useful in other fields of hand surgery? #jhsjc
The approach used by the investigators was methodologically rigorous from its development through to the psychometric testing. Would a similar approach be likely to be as successful for another highly subjective area of patient reporting such as satisfaction? #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
computer generated images could introduce some bias but the figure they provided seemed very reasonable for this study #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
That was my impression as well. It opens the possibility of fine-tuning the way various hand appearances could be presented. That could widen the scope of how the scale could be used. #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
certainly the approach could be used for other aspects of care. As you often point out, satisfaction is complicated and many elements including process of care as well as results #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
I ask that question bc I am waiting for someone (please!!) to take the same kind of approach to that. The measurement of patient satisfaction is woefully underdeveloped. Our lead article in January 2023 will show just how little this area has been developed. #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
Looking forward to that article #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
This article on a scale for hand appearance shows that a careful, well-thought out approach can result in creation of a really useful instrument measuring a notoriously subjective – but crucially important – construct. Patient satisfaction should be next! #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
Love it. Likely a topic then for an upcoming JHSJC! #jhsjc
Brent Graham @BgTalkinman:
Let’s wrap it up here! My best wishes to all for a happy and safe holiday! We return Jan 10. #jhsjc
Brent Graham @BgTalkinman:
Welcome Eurozone colleagues! We will be here for the next hour discussing the paper by Randall et al in the December issue of @JHandSurg. #jhsjc
article: https://t.co/S5AlXMyCDl; podcast in which I interviewed the authors: https://t.co/QR5HZzH2h5 #jhsjc
The study sought to measure changes in the utilization of office-based procedure rooms for small hand surgery procedures using the MarketScan Commercial Database. #jhsjc
Facility location, procedure room or operating room, was tracked for five hand surgery procedures: open carpal tunnel release, trigger digit release, DeQuervain release, hand or finger benign mass excision, and hand or finger cyst excision. #jhsjc
Over the 11-year period of the study, there was an increase in total procedures performed and in procedures performed in the procedure room however, the increase was small, ranging between 1.6% (open CTR) and 10.1% (hand/finger mass excision) for the various procedures. #jhsjc
75% of potentially eligible records were excluded for a variety of reasons, most commonly an inability to identify the location in which the procedure took place. How might that have had an impact on the observations? #jhsjc
In my interview with the authors, they indicated that they thought most of the excluded cases were likely to have been performed in the OR. #jhsjc
The study was performed on data collected between 2006 and 2017. Is that an appropriate period to accurately identify trends in procedure room usage? In other words, is the observed uptake of this approach spuriously low because of the time the data was collected? #jhsjc
What is the role of procedure rooms for these kinds of cases in the UK and in Europe? #jhsjc
I will assume that this topic doesn’t resonate with European readers. I am signing off but I’m happy to interact with anyone who happens across my tweets about this. Use the #jhsjc hashtag so that I can locate your tweet.
