September #JHSJC Transcript

We’ll be posting all #JHSJC transcripts from here on out (including past conversations!), so be sure to check back in case you miss a discussion! You can read the transcripts for June #JHSJC here and July #JHSJC here!

September’s #JHSJC was a lively discussion addressing two articles from Volume 44, Issue 9 of The Journal of Hand Surgery: The Effects of Medicaid Expansion on Triage and Regional Transfer After Upper-Extremity Trauma and Failure Rates of Base of Thumb Arthritis Surgery: A Systematic Review. 

Feel free to continue the conversation below in the comments!

Brent Graham @BgTalkinman:
After a 1 month hiatus it’s time for our post-meeting journal club! Sign in with the hashtag so we know you are here. #jhsjc

Sanj Kakar MD @sanjkakar:
#jhsjc

Brent Graham @BgTalkinman:
Let’s start with paper 1 on the effects of Medicaid expansion on transfers with upper extremity trauma. #jhsjc

Andrew Tyser @andrewtysermd:
ok! #jhsjc

Nikolas Kazmers @NKazmers:
Looking forward to the discussion. #jhsjc

Andrew D. Sobel, MD @AndrewSobelMD:
#jhsjc

Brent Graham @BgTalkinman:
Here is the link to that article: https://doi.org/10.1016/j.jhsa.2019.05.020; the podcast is here: https://www.jhandsurg.org/pb/assets/raw/Health%20Advance/journals/yjhsu/September_2019.mp3 #jhsjc

Ray Raven MD, MBA, MHCI @RayRavenMD:
#jhsjc

Brent Graham @BgTalkinman:
The paper showed that the appropriateness of transfer stayed the same and that od walk-ins to their ER decreased. #jhsjc

Andrew Tyser @andrewtysermd:
Figure 4 was the most interesting part of this study to me. Across the board decrease in appropriate non-transfer patients. #jhsjc

Brent Graham @BgTalkinman:
The setting for the study is a little unusual bc the hospital is “legislatively-designated” as an UE trauma center. #jhsjc

Brent Graham @BgTalkinman to @andrewtysermd:
My sense is that means greater access to healthcare. What is your take on that? #jhsjc

Andrew Tyser @andrewtysermd to @BgTalkinman:
Agreed–those without prior insurance utilizing in new ways #jhsjc

Brent Graham @BgTalkinman to @andrewtysermd:
That’s good — isn’t it? #jhsjc

Andrew Tyser @andrewtysermd to @BgTalkinman:
I consider improved access a very good thing, yes! #jhsjc

Brent Graham @BgTalkinman:
Let’s hear from others whose states have expanded Medicaid. Is that finding surprising? #jhsjc

Sanj Kakar MD @sanjkakar:
#jhsjc these trauma centers tend to be the safety net for many patient transfers, both inappropriate and not

Andrew Tyser @andrewtysermd:
I found the main finding of the article encouraging, in a way–Medicaid expansion did not seem to affect transfer appropriateness #jhsjc

Brent Graham @BgTalkinman:
Do you think more previously uninsured pts, now with Medicaid are in urban areas? #jhsjc

Ray Raven MD, MBA, MHCI @RayRavenMD:
#JAMA study found that patients covered by Medicaid were more likely to be transferred to another hospital than privately insured patients when seeking treatment for some conditions, #jhsjc

Brent Graham @BgTalkinman:
That might explain the finding for this center located in an urban location. #jhsjc

Sanj Kakar MD @sanjkakar:
#jhsjc that would make sense to me

Nikolas Kazmers @NKazmers to @BgTalkinman and @andrewtysermd:
Good news folks have access, bad that the trend for more inappropriate non-transfer visits burdens the ER #jhsjc

Brent Graham @BgTalkinman:
Does their status as a “legislatively-designated” center affect the generalizability of the findings? …or should that be expected for the locations where this care is most likely to occur? #jhsjc

Ray Raven MD, MBA, MHCI @RayRavenMD:
#JAMA study found pts covered by Medicaid more likely transferred than privately insured when seeking Tx for some conditions #jhsjc

Avi Giladi @theaviram to @BgTalkinman:
much of the available data actually shows expansion most benefits rural #jhsjc

Brent Graham @BgTalkinman to @theaviram:
The author weighs in! How does that fit in with what you observed? You are in a city. #jhsjc

Andrew Tyser @andrewtysermd to @BgTalkinman:
I tend to think results are generalizable. Prob most regional centers play at least a similar role to CNHC. #jhsjc

Brent Graham @BgTalkinman to @RayRavenMD:
Yes! However, this study showed that the appropriateness of transfer was not associated with insurance status. #jhsjc

Sanj Kakar MD @sanjkakar:
#jhsjc I would imagine so if your institution has the same designation. Dr Raven’s point is well taken and unfortunately is all too common. Credit should be given to the ASSH for the development of the hand trauma network #assh #jhs @RayRavenMD

Ray Raven MD, MBA, MHCI @RayRavenMD:
Study also found uninsured pts more likely to be discharged than privately insured. #Medicaid pts seemed to have the same odds. #jhsjc

Sanj Kakar MD @sanjkakar:
#jhsjc I found that conclusion surprising

Brent Graham @BgTalkinman to @sanjkakar:
Is that kind of designation common? #jhsjc

Ray Raven MD, MBA, MHCI @RayRavenMD to @BgTalkinman:
Yes, for-profit hospitals were more likely to transfer uninsured patients in #JAMA study. #jhsjc

Avi Giladi @theaviram to @BgTalkinman:
the findings didnt exactly align with what we expected. i hope it indicates the rural patients did find care closer to home but cant say for sure #jhsjc

Brent Graham @BgTalkinman to @RayRavenMD:
In the podcast I asked the authors the role of the ER physician as gatekeeper. I wonder about the generalizability. #jhsjc

Does anyone have a similar experience, even if anecdotal, in their own state with Medicaid expansion?

or Thoughts regarding the Severity Matrix used in this study? Does it have face validity? #jhsjc

Karan Desai, MD @TheKaranDesai to @BgTalkinman and @RayRavenMD:
This only works if you have set tiered designations for diagnoses. Otherwise I suspect would still lead to high level of inappropriate transfers #jhsjc

Brent Graham @BgTalkinman:
It wasn’t developed for this purpose but it seemed appropriate for the way the authors used it here. #jhsjc

Ray Raven MD, MBA, MHCI @RayRavenMD to @BgTalkinman:
no anecdotal experience here #jhsjc

Karan Desai, MD @TheKaranDesai to @BgTalkinman:
I believe this trend is similar in New York. #jhsjc

Brent Graham @BgTalkinman to @TheKaranDesai and @RayRavenMD:
#jhsjc How so?

Brent Graham @BgTalkinman to @TheKaranDesai:
Do you mean statewide or in NYC? #jhsjc

Warren @whammert to @BgTalkinman:
we seem to have increase in less desirable insurances following expansion, but no noticeable change in referrals, upstate/ Rochester at least #jhsjc

Brent Graham @BgTalkinman to @TheKaranDesai @RayRavenMD:
#jhsjc Agreed! That may be why the appropriateness of the referrals decreased. Still good that there was better access but ER physicians have to act with discretion.

Avi Giladi @theaviram:
would be helpful to know if rural centers also saw the increase in “inappropriate” walk-ins to the ER that could have had outpatient follow-up #jhsjc

Ray Raven MD, MBA, MHCI @RayRavenMD to @TheKaranDesai and @BgTalkinman:
Transfers tend to happen more in regions where additional resources exist. #jhsjc

Sanj Kakar MD @sanjkakar:
#jhsjc there are many causes of transfers, appropriate and inappropriate, for which insurance status is part of the reason. Others include ability to treat conditions, time of day, practice set up etc

Brent Graham @BgTalkinman to @whammert:
This study (https://www.jhandsurg.org/article/S0363-5023(17)30793-1/fulltext) showed that there were fewer uninsured but reimbursement was flat. #jhsjc

Karan Desai, MD @TheKaranDesai to @BgTalkinman and @RayRavenMD:
This is why I believe a creation of set standards for transfers is the only way to make ER physicians comply. #jhsjc

jeanwhoffman @MusicCityEMCCM to @TheKaranDesai @BgTalkinman and @RayRavenMD:
May I remind you the ED sees everyone regardless of their ability to pay. Specialist availability is what dictates transfer. We don’t need to be told to “comply”

Brent Graham @BgTalkinman to @MusicCityEMCCM @TheKaranDesai and @RayRavenMD:
I guess the concern is that when the hand specialist is mandated to respond, it’s easier for the ER physician to make the referral. Obviously, that isn’t true everywhere but my point was that it may have been relevant to this study re: generalizability.

Ray Raven MD, MBA, MHCI @RayRavenMD to @MusicCityEMCCM @TheKaranDesai and @BgTalkinman:
What you posted is not actually supported by the literature. Would be helpful for you to research then maybe you can make a difference. Also, context is very important. see #jhsjc thread.

Brent Graham @BgTalkinman to @whammert:
Are private insurers paying less – more patients with insurance but flat reimbursement. #jhsjc

Nikolas Kazmers @NKazmers to @sanjkakar:
Totally agree – there are may factors that could explain the observations beyond Medicaid expansion. #jhsjc

Ray Raven MD, MBA, MHCI @RayRavenMD to @TheKaranDesai and @BgTalkinman:
I agree. This will be extremely difficult but it needs to be done. #jhsjc

Warren @whammert to @BgTalkinman:
My impression is fewer with no insurance and fewer with private insurance, so more with medicaid and options #jhsjc

Nikolas Kazmers @NKazmers:
ie trends in table 4 are in effect prior to 2014 #jhsjc

Brent Graham @BgTalkinman to @whammert:
That’s very interesting! Is that where this is going? Is that a reasonable conclusion from this data? #jhsjc

Karan Desai, MD @TheKaranDesai to @RayRavenMD and @BgTalkinman:
Would help providers, regional centers and their financial burden, and most importantly patients from transfer costs and wasted time #jhsjc

Warren @whammert:
That is the impression in our region and throughout the medical center -not just ortho or hand #jhsjc

Avi Giladi @theaviram:
would be helpful to know more about what happens in rural non-specialized centers re: volume of low-acuity visits #jhsjc

Brent Graham @BgTalkinman to @theaviram:
Agreed! Looking forward to hearing more about that. That will seem to be the measure of the real intent of this effort. #jhsjc

Ray Raven MD, MBA, MHCI @RayRavenMD to @theaviram:
I agree. More studies to come. But check out the ones in #JAMA. #jhsjc

Brent Graham @BgTalkinman:
Great discussion! Let’s switch to the paper on arthroplasty failure rates. (https://www.jhandsurg.org/article/S0363-5023(18)30698-1/fulltext) #jhsjc

Christopher J. Dy @ChrisDyMD to @BgTalkinman and @RayRavenMD:
Sorry I am late to join! Following along after an on-call case #jhsjc

Brent Graham @BgTalkinman to @ChrisDyMD:
NP! #jhsjc

Brent Graham @BgTalkinman:
Implant arthroplasty for trapeziometacarpal joint: what is its role right now? #jhsjc

Ray Raven MD, MBA, MHCI @RayRavenMD:
Several soft-tissue procedures exist to reconstruct #BasalJoint in #arthritis of the #thumb and most have reasonably good results. #jhsjc

What value does implant add to procedure if outcome isn’t any better and in some cases, risk of complication is increased? #jhsjc

Warren @whammert to @BgTalkinman:
I think we need to show equivalent or better results at comparable costs to justify the implants #jhsjc

Brent Graham @BgTalkinman:
There are many implants available, this study seems to show clearly that they are much more likely to fail (and cost more) than LRTI #jhsjc

Ray Raven MD, MBA, MHCI @RayRavenMD to @whammert and @BgTalkinman:
I couldn’t agree more Warren. #jhsjc

Brent Graham @BgTalkinman to @RayRavenMD:
I agree and yet they are on the scene. #jhsjc

Sanj Kakar MD @sanjkakar:
#jhsjc hard to generalize the outcomes as prosthetic joint replacement is a technically demanding procedure. Many of these studies assume the same surgical skill between surgeons but as we know, that can vary from place to place and study to study

Ray Raven MD, MBA, MHCI @RayRavenMD to @sanjkakar:
and results are difficult to reproduce! #jhsjc

Brent Graham @BgTalkinman to @whammert:
How much value should be attached to faster recovery, better pinch strength? Aren’t those usually cited as the advantages? #jhsjc

Ray Raven MD, MBA, MHCI @RayRavenMD:
#jhsjc #FDA should require #CostEffectiveAnalysis for all new #PrecsriptionDrugs and implants when effective solutions already exists!

Warren @whammert to @sanjkakar:
true, but even the the small series do not show better outcomes. #jhsjc

Brent Graham @BgTalkinman to @sanjkakar:
I am very interested in that idea. Surgeons be encouraged to do the proc that is the best combo of easy and effective? #jhsjc

Ray Raven MD, MBA, MHCI @RayRavenMD to @BgTalkinman and @whammert:
i don’t like the trade-off of higher failure rates. #jhsjc

Andrew Tyser @andrewtysermd:
no current role for implants in my opinion #jhsjc

Brent Graham @BgTalkinman to @andrewtysermd:
I agree. That is how I’ve been practicing. #jhsjc

Karan Desai, MD @TheKaranDesai to @BgTalkinman:
Applaud the authors for trying to tease this out but a review with such varying individual studies cannot give definitive claim. Are there any good randomized controlled studies comparing implants vs. non implant procedure? #jhsjc

Warren @whammert to @BgTalkinman:
theoretical advantages – pinch strength is a concern in younger patient with higher demand, but not the simple #jhsjc

Ray Raven MD, MBA, MHCI @RayRavenMD:
#ValueBasedCare means continually improving #HealthCare to achieve quality while implementing changes to lower the cost of delivery #jhsjc

Brent Graham @BgTalkinman to @sanjkakar:
https://www.jhandsurg.org/article/S0363-5023(18)30017-0/fulltext this article is about the surgeon component of procedure failure in flexor tendon repair #jhsjc

Ray Raven MD, MBA, MHCI @RayRavenMD:
What percentage of #Orthopedic #Surgeons do you think know the cost of implants they use to the facility? #jhsjc

Christopher J. Dy @ChrisDyMD to @RayRavenMD:
It is pretty low. There was a prior health affairs study that showed that point for orthopedics. Okike was first author. #jhsjc

Brent Graham @BgTalkinman to @ChrisDyMD and @RayRavenMD:
Do you mean in the journal “Health Affairs”? #jhsjc

Ray Raven MD, MBA, MHCI @RayRavenMD to @BgTalkinman and @ChrisDyMD:
yes. #jhsjc

Christopher J. Dy @ChrisDyMD to @RayRavenMD and @BgTalkinman:
https://doi.org/10.1377/hlthaff.2013.0453

Nikolas Kazmers @NKazmers:
Interesting that many see little to no role of fusion due to complications, which performed better than arthroplasty groups too! #jhsjc

Warren @whammert to @RayRavenMD:
probably single digits or just above #jhsjc

Brent Graham @BgTalkinman to @whammert and @sanjkakar:
The “Solutions Center” was filled with devices of this nature! Is there a role for ASSH in that? #jhsjc

Sanj Kakar MD @sanjkakar:
#jhsjc I agree that prosthetic joint replacement isn’t for the general population but it still has a role in the right patient e.g. a 40 year old male with Eaton stage 3 is a different case to a 75 year old patient with similar disease. Also don’t forget surgical skill

Karan Desai, MD @TheKaranDesai to @BgTalkinman and @sanjkakar:
This is very cool. Failure of all of our data in medicine is that it fails to account for technical skill #jhsjc

Brent Graham @BgTalkinman to @sanjkakar:
#JHSJC I agree entirely about surgical skill. These devices are marketed to everyone, not just the expert.

Andrew Tyser @andrewtysermd to @BgTalkinman and @sanjkakar:
these studies are presumably done by those with surgical skill / experience with these implants #jhsjc

Ray Raven MD, MBA, MHCI @RayRavenMD to @sanjkakar:
#FDA should require #CostEffectiveAnalysis for new #PrecsriptionDrugs and implants when effective solutions already exist! #jhsjc

Avi Giladi @theaviram to @andrewtysermd @BgTalkinman and @sanjkakar:
yes it would seem that these smaller series are from those with experience #jhsjc

Andrew Tyser @andrewtysermd:
furthermore predict failure rates in the hands of the hand surgeon population at large #jhsjc

Brent Graham @BgTalkinman to @andrewtysermd and @sanjkakar:
#jhsjc Frankly this is an issue with many surgical procedures, not just in hand surgery. It’s never talked about.

Nikolas Kazmers @NKazmers:
If a surgery for a common problem is beyond most surgeons’ capabilites, is that surgeon’s fault or does it make that a bad option? #jhsjc

Karan Desai, MD @TheKaranDesai to @andrewtysermd @BgTalkinman and @sanjkakar:
some of them have a very small sample size though so you never know #jhsjc

Brent Graham @BgTalkinman to @andrewtysermd:
To me that is the main value of this study. Suggests that without extensive experience LRTI should be the choice. #jhsjc

Avi Giladi @theaviram to @TheKaranDesai @andrewtysermd and 2 others:
but failure rates of trapeziectomy are low, hard to outperform #jhsjc

Warren @whammert to @NKazmers:
if not reproducible by other surgeons, the operation might as well not exist #jhsjc

Nikolas Kazmers @NKazmers:
Hard to beat easy, cheap, and reliable! #jhsjc

Brent Graham @BgTalkinman to @TheKaranDesai @sanjkakar and @andrewtysermd:
That is an extremely important pt however most surgeons won’t have a lot of experience #jhsjc
Also, the overall trend is very clear even with the small samples. #jhsjc

Karan Desai, MD @TheKaranDesai to @theaviram @andrewtysermd and 2 others:
Totally agree. Gold standard #jhsjc

Brent Graham @BgTalkinman to @NKazmers:
LRTI is an excellent option and within the technical attainment of most surgeons – unlike implant arthroplasty #jhsjc

Nikolas Kazmers @NKazmers to @BgTalkinman:
Agree – have ‘good’ surgeons produced good results with arthroplasty? #jhsjc

Brent Graham @BgTalkinman to @whammert and @NKazmers:
Completely agree. This is why we need replication studies #jhsjc

Nikolas Kazmers @NKazmers:
It can’t be that every surgeon reporting arthroplasty results in this sys review are ‘bad surgeons’. #jhsjc

Congrats to the authors for a very insightful, useful study. #jhsjc

Andrew Tyser @andrewtysermd:
should companies that make and market such arthroplasties as “solutions” be required to track and report outcomes/failures? #jhsjc

Brent Graham @BgTalkinman to @NKazmers:
There are studies with good results but publication bias is a potential problem – that’s why this is an important study #jhsjc

Brent Graham @BgTalkinman to @andrewtysermd:
Don’t they have to do something of that nature for FDA approval? #jhsjc
Hmmm…I’m surprised. #jhsjc

Brent Graham @BgTalkinman to @whammert and @andrewtysermd:
I heard Peter Weiss talk about that exact topic – the substantial equivalence – at the meeting. #jhsjc

Brent Graham @BgTalkinman:
This will never be the topic of an RCT so this kind of study seems very important. #jhsjc

One methodology point: the study assumed a linear rate of failure. My guess is that the true failure rate is worse than they reported #jhsjc

Brent Graham @BgTalkinman to @TheKaranDesai:

jhsjc My guess is that there is a subset who do well for long periods and the majority fail within a relatively brief period. Probably not many who have very long survival.

Sanj Kakar MD @sanjkakar:
jhsjc great twitter journal club tonight?????

Ray Raven MD, MBA, MHCI @RayRavenMD to @sanjkakar:
I agree Sanj. Your participation always adds to the quality and depth of the discussion. Thank you. #jhsjc

Brent Graham @BgTalkinman:
Really terrific discussion tonight! Thanks to all! Back next month! #jhsjc