March’s Twitter-based journal club discussion was centered on the following two leading articles from this month’s issue of JHS:
- Optimizing the Use of Operating Rooms by Transitioning Common Hand Surgeries Into the Office Setting (https://www.jhandsurg.org/article/S0363-5023(22)00712-2/fulltext)
- Evaluation of Preoperative Factors Affecting Midterm Patient-Reported Outcomes Following Ligament Reconstruction Tendon Interposition: A Prognostic Study (https://www.jhandsurg.org/article/S0363-5023(22)00687-6/fulltext)
We thank those who attended and shared their insights with us! Please plan to join us for April’s discussion. To do so, you can find the instructions for using the TwChat platform here.
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:
March’s #JHSJC is happening now! Let’s get the discussion going! #OR #OperatingRoom #preop #PatientReportedOutcomes #LRTI #cost #WALANT #HandSurgery #PROMIS #QuickDASH
Brent Graham @BgTalkinman:
Welcome to the March session! Let’s start with the Starr et al paper on moving cases to the office-based procedure room. https://jhandsurg.org/article/S0363-5023(22)00712-2/fulltext #jhsjc
We have had a recent paper I(https://jhandsurg.org/article/S0363-5023(22)00509-3/fulltext) showing that the uptake of proc rm/WALANT cases has been slower than expected. One obstacle might be reluctance by institutions to support that bc of a fear of lost revenue. #jhsjc
This paper modeled what could happen if time saved in the ASC by moving hand cases to the PR was replaced by more remunerative cases. #jhsjc
Warren @whammert to @BgTalkinman:
I think there are a variety of reasons and dependent on both surgeon and facility #jhsjc
Brent Graham @BgTalkinman to @whammert:
Can you give some examples of how that might vary? #jhsjc
I understand that the figures might vary from place-to-place but isn’t the principle generalizable? #jhsjc
Warren @whammert to @BgTalkinman:
Having been at two institutions, some are more willing and have the resources to do this. A procedure room in the office is the most ideal situation, but requires space, staffing, and instrumentation. #jhsjc
Doing cases in an ASC procedure room requires anesthesia buy in and they can feel they should bill for each case. #jhsjc
definitely generalizable, but requires buy-in from many and some surgeons might not have the will to continue to push to get there #jhsjc
Brent Graham @BgTalkinman to @whammert:
Check out #TheHandSurgeryLandscape article in Jan (https://www.jhandsurg.org/article/S0363-5023(22)00605-0/fulltext) that talked about creating that space. #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
also a lot of patients arent willing to do procedure room/WALANT #jhsjc
Warren @whammert to @theaviram:
I think there are some, but after doing this for over 15 years, I have found a very small number just don’t want straight local cases. #jhsjc
Brent Graham @BgTalkinman to @theaviram:
Is that a matter of unfamiliarity that will eventually change? #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
I think some of it a familiarity issue, some of it is a trust issue, some is a pain issue. I see all the articles, I try to do as much WALANT as I can, but a lot of patients in my clinic demographic just wont do it willingly #jhsjc
Brent Graham @BgTalkinman to @theaviram:
Understood! I can’t honestly say I have ever done a WALANT case so I’m obviously no expert! #jhsjc
Brent Graham @BgTalkinman to @whammert:
Isn’t this just the problem? If it is safe, efficient and cost-effective, what role does anesthesia have? #jhsjc
Warren @whammert to @BgTalkinman:
If doing in an ASC and anesthesia controls the ASC, they can be a challenge. It takes work and time and some just don’t have that drive as it is easier just to do the cases with anesthesia #jhsjc
Brent Graham @BgTalkinman to @whammert:
What do you think it will take to change that attitude? It’s safe, efficient. Will that not improve the bottom line for surgeons? #jhsjc
Warren @whammert to @BgTalkinman:
I suppose a few things – anesthesia has to have completely booked rooms or they will feel like they are losing. There has to be some compromise and some are more likely than others. #jhsjc
Brent Graham @BgTalkinman:
Following up on some of these points, what are the ramifications of this kind of information for surgeon-owned facilities? Do they just consider the cost savings implies by the difference in the margins? #jhsjc
Warren @whammert to @BgTalkinman:
I have not worked in this type of center, but would think it would be easier there if the surgeon desired to do the cases under straight local. Still billing a facility fee, so more costly than office procedure room, but eliminates anesthesia fees #jhsjc
Brent Graham @BgTalkinman to @whammert:
At the risk of sounding more ruthless than I am – what leverage do they have, especially when money gets tighter like it inevitably will? #jhsjc
Warren @whammert to @BgTalkinman:
The person or group controlling the room/ surgery center has the leverage – until someone above changes. If that group says no, the alternative is to leave, which can be more of a hassle than many want – especially of other things are good #jhsjc
Brent Graham @BgTalkinman to @whammert:
How would your institution respond to this data? In other words, will this be seen as an opportunity, a threat to revenues or something in-between – potentially beneficial but requiring a substantial adjustment to processes? #jhsjc
Warren @whammert to @BgTalkinman:
It depends on who at any institution is asked – the big picture is this makes sense from a financial perspective, but is similar to increasing OR efficiency – it is helpful if another case can be added and otherwise probably doesn’t make a diference #jhsjc
Avi Giladi @theaviram to @whammert:
you also would need to have enough of this higher impact cases to fill the slots. not always reality. #jhsjc
Warren @whammert to @BgTalkinman:
So it should be, but you have to find the correct decision makers who will listen and figure which battles you want to fight #jhsjc
Brent Graham @BgTalkinman to @whammert and @theaviram:
How do think this will look in 5 years? #jhsjc
Warren @whammert to @BgTalkinman:
I think it will be more common, but still not completely adopted and not like what I perceive Canada to be #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
I think it looks about the same. slow creep increase. most institutions dont think this far ahead. #jhsjc
Brent Graham @BgTalkinman to @theaviram:
Where I work, that would not be a problem at all. There would be backlogs that the institution would be happy to reduce, especially if it increased revenues. #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
yeah the Canadian backlog is not a US problem, that’s for sure #jhsjc
Brent Graham @BgTalkinman to @theaviram:
I guess that means that the balance between cases that can be done and the number of places where care can be delivered must be very tight. #jhsjc
Brent Graham @BgTalkinman:
Let’s move on to the other paper – predicting mid-term results of #LRTI with pre-op #PROMs #jhsjc
The main findings were that a higher pre-op QuickDASH score was associated with a greater change in QuickDASH at final follow-up; a higher PI score was associated a smaller change in QuickDASH, independent of the baseline QuickDASH score. #jhsjc
A higher pre-operative UE score was associated with a lower change in UE at follow-up. Higher pre-operative PI resulted in a lower change in post-operative UE score, independent of the pre-operative UE. #jhsjc
Although there were 434 eligible patients, only 93 were in the final study group. The most frequent reason for exclusion was the absence of pre-operative PROMs. How, if at all, might that have had an impact on the findings? #jhsjc
Warren @whammert to @BgTalkinman:
I think their findings were anticipated and similar to other findings with PROMIS throughout the body. And consistent wiht retrospective database study #jhsjc
Brent Graham @BgTalkinman to @whammert and @theaviram:
These scales were intended to measure changes in aggregates of patients, in other words groups. These findings notwithstanding, should they be used to predict outcomes in individuals? #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
We increasingly understand that many factors impact PRO scores, but the more we have tried to use them for individual tracking the less useful they are (imho). #jhsjc
Warren @whammert to @BgTalkinman:
I think for individuals, direction of change are more important than absolute numbers. The numbers (MDC, MCID,…) are more important for powering studies and larger cohorts #jhsjc
Brent Graham @BgTalkinman to @whammert:
I completely agree that the main value of #MCID isn’t in assessing treatment results – although we see a lot manuscripts assuming that. That’s why considering substantial clinical benefit makes more sense. #jhsjc
Warren @whammert to @BgTalkinman:
I agree and working along this line #jhsjc
Brent Graham to @BgTalkinman to @whammert:
I think this is an interesting insight – direction of change having more meaning. How does that affect your interpretation of these findings? #jhsjc
Warren @whammert to @BgTalkinman:
I think the patients will improve – the magnitude of improvement and final score is likely more related to mental health #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
Using pre-intervention scores to predict post-intervention scores doesn’t make sense to me. Does a person with worse PI and associated less change in QuickDASH have a worse outcome? or do they need less change to be happy? #jhsjc
Brent Graham @BgTalkinman to @theaviram:
I guess that shouldn’t be surprising given variation btwn individuals. I think measuring aggregated results was the intent of the developers of most of these #PROMs #jhsjc
Warren @whammert to @theaviram:
All things equal, worse starting scores have the greatest room for improvement. But the magnitude of change and final score is dependent on other variables #jhsjc
Avi Giladi @theaviram to @whammert:
but I do not think it’s just the treatment that impacts the magnitude of change, that’s what makes this all so inconsistent when used at the patient-specific level. #jhsjc
Brent Graham @BgTalkinman to @theaviram:
That is a very insightful observation. But doesn’t the literature seem to suggest that they need more change toibe happy? Most studies seem to indicate that they are often less satisfied and have poorer results . #jhsjc
Brent Graham @BgTalkinman to @whammert:
Does that have value in giving a patient a prognosis? #jhsjc
Warren @whammert to @BgTalkinman:
I think it can help – some patients forget their previous level of function and showing them the direction of score can be helpful. and when starting lower, you can indicate there will be improvement, but likely still have difficulty wiht some function #jhsjc
Brent Graham @BgTalkinman to @whammert:
Good point. #jhsjc
Warren @whammert to @theaviram:
Agree -i think the mental aspects of health have been under appreciated by many and we are starting to understand this due to work of David Ring, Ryan Calfee, and many others #jhsjc
Brent Graham @BgTalkinman to @whammert:
I completely agree, so do you think that a high pre-treatment PI shoulds be an indication for some other supports before surgery – assuming those are available. #jhsjc
Brent Graham @BgTalkinman to @theaviram:
Do you mean that some of the other biopsychosocial variables modulate those therapeutic effects? #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
it’s a lot of things. BPS impacts. timing of data collection impacts. on an individual level it’s not clear PRO score reflects “outcome” as well as we think based on the population studies. #jhsjc
Brent Graham @BgTalkinman to @theaviram:
I agree with that. #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
I think the pre-op scores are indicators of challenge. but I dont think they predict outcomes as much as they predict behaviors. #jhsjc
Brent Graham @BgTalkinman to @theaviram:
I also find that an interesting insight. #jhsjc
Warren @whammert to @BgTalkinman:
I think PI might have the most effect on outcome and rehabilitation following elective surgery. And can be used to set expectations about difficulty wiht recovery, therapy, and return to activities #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
notable PRO outliers likely need more “something” — pain counseling, resources, pre-operative education, etc. And I dont think that is questionnaire specific, PI outliers would likely also be GMH or EuroQol outliers too #jhsjc
Brent Graham @BgTalkinman to @theaviram and @whammert:
I agree completely. To come full circle, I think that is what this study may be showing – high PI may be associated with a less satisfactory result so identifying that might be an opportunity to provide some type of proactive support. #jhsjc
Warren @whammert to @BgTalkinman:
yes this was a predictable result given what I have seen with PROMIS and extrapolating to DASH #jhsjc
Avi Giladi @theaviram to @BgTalkinman and @whammert:
But not reasonable to withhold care due to worse preop scores. that’s where this gets very messy #jhsjc
Warren @whammert to @theaviram:
I don’t advocate withholding care, but shared decision making and setting expectations for outcomes and pace of recovery and return to function #jhsjc
Brent Graham @BgTalkinman to @theaviram and @whammert:
That is my concern. At the beginning of this discussion I asked what possible unintended effects this could have and that would be my main worry. #jhsjc
Avi Giladi @theaviram to @whammert and @BgTalkinman:
I definitely do not think either of you advocate for withholding care! but even saying to a patient “your lower scores tell me you might not like this surgery as much” is not an easy conversation either. And not sure it resonates with the patient. #jhsjc
Brent Graham @BgTalkinman:
Thank you @whammert and @aviram! You are experts and thought leaders in this field. Your insights are really informative! We will be back April 11! #jhsjc
