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Kevin C. Chung - One of the best experts on this subject based on the ideXlab platform.

  • association of interfacility transfer and patient and hospital characteristics with Thumb replantation after traumatic Amputation
    JAMA Network Open, 2021
    Co-Authors: Jessica I Billig, Jacob S Nasser, Hoyune E Cho, Chinghan Chou, Kevin C. Chung
    Abstract:

    Importance Given that 40% of hand function is achieved with the Thumb, replantation of traumatic Thumb injuries is associated with substantial quality-of-life benefits. However, fewer replantations are being performed annually in the US, which has been associated with less surgical expertise and increased risk of future replantation failures. Thus, understanding how interfacility transfers and hospital characteristics are associated with outcomes warrants further investigation. Objective To assess the association of interfacility transfer, patient characteristics, and hospital factors with Thumb replantation attempts and success. Design, Setting, and Participants This cross-sectional study used data from the US National Trauma Data Bank from 2009 to 2016 for adult patients with isolated traumatic Thumb Amputation injury who underwent revision Amputation or replantation. Data analysis was performed from May 4, 2020, to July 20, 2020. Exposures Interfacility transfer, defined as transfer of a patient from 1 hospital to another to obtain care for traumatic Thumb Amputation. Main Outcomes and Measures Replantation attempt and replantation success, defined as having undergone a replantation without a subsequent revision Amputation during the same hospitalization. Multilevel logistic regression models were used to assess the associations of interfacility transfer, patient characteristics, and hospital factors with replantation outcomes. Results Of 3670 patients included in this analysis, 3307 (90.1%) were male and 2713 (73.9%) were White; the mean (SD) age was 45.8 (16.5) years. A total of 1881 patients (51.2%) were transferred to another hospital; most of these patients were male (1720 [91.4%]) and White (1420 [75.5%]). After controlling for patient and hospital characteristics, uninsured patients were less likely to have Thumb replantation attempted (odds ratio [OR], 0.61; 95% CI, 0.47-0.78) or a successful replantation (OR, 0.64; 95% CI, 0.49-0.84). Interfacility transfer was associated with increased odds of replantation attempt (OR, 1.34; 95% CI, 1.13-1.59), with 13% of the variation at the hospital level. Interfacility transfer was also associated with increased replantation success (OR, 1.23; 95% CI, 1.03-1.47), with 14% of variation at the hospital level. Conclusions and Relevance In this cross-sectional study, interfacility transfer and particularly hospital-level variation were associated with increased Thumb replantation attempts and successes. These findings suggest a need for creating policies that incentivize hospitals with replantation expertise to provide treatment for traumatic Thumb Amputations, including promotion of centralization of replantation care.

  • an in depth review of physician reimbursement for digit and Thumb replantation
    Journal of Hand Surgery (European Volume), 2019
    Co-Authors: Rachel C Hooper, Jennifer M Sterbenz, Lin Zhong, Kevin C. Chung
    Abstract:

    Purpose To examine physician and hospital reimbursement for digit and Thumb replantation compared with revision Amputation. Methods Using the 2009–2016 Truven Health MarketScan Research Databases, we identified patients with a digit or Thumb Amputation . Following application of our inclusion and exclusion criteria, we divided patients into replantation and revision Amputation groups. We extracted the mean physician and hospital reimbursement associated with each patient encounter. For comparison, we examined the work Relative Value Unit (wRVU) and Medicare Physician Fee Schedule (MPFS) for the respective procedures in addition to several common hand surgery procedures. Results We identified 51,716 patients. Following application of our inclusion and exclusion criteria, 219 replantation and 6,209 revision Amputation patients were included in our analysis. For replantation, the mean physician and hospital reimbursements ranged from $3,938 to $7,753 and $30,683 to $56,256, respectively. For revision Amputation, the mean physician and hospital reimbursements ranged from $1,030 to $1,206 and $2,877 to $4,188, respectively. On multivariable analysis, hospitals performing replantation earned $37,788 more per case compared with revision Amputation. Using the wRVU and MPFS data, we determined that replantation reimburses at $78/wRVU compared with higher earnings for revision Amputation ($108), carpal tunnel release ($101), cubital tunnel release ($97), trigger finger release ($116), open reduction and internal fixation (ORIF) distal radius fracture ($87), flexor tendon repair ($98), extensor tendon repair ($122), repair of digital nerve ($89), and ORIF articular fracture ($82), respectively. Conclusions Low physician reimbursement for replantation compared with less complex hand procedures makes it difficult to recruit and retain hand surgeons for this purpose. By understanding the wRVU and MPFS system, hand surgeons and professional societies can explore ways to promote change in the way replantation is valued by the Centers for Medicare and Medicaid Services (CMS) as well as by hospital administrators. Type of study/level of evidence Economic/Decision Analysis III.

  • emergency department wait time and treatment of traumatic digit Amputation do race and insurance matter
    Plastic and Reconstructive Surgery, 2017
    Co-Authors: Elham Mahmoudi, Peter R Swiatek, Kevin C. Chung
    Abstract:

    BACKGROUND Little is known about the association between the quality of trauma care and management of nonfatal injuries. The authors used emergency department wait times as a proxy for hospital structure, process, and availability of on-call surgeons with microsurgical skills. They evaluated the association between average hospital emergency department wait times and likelihood of undergoing digit replantation for patients with traumatic Amputation digit injuries. The authors hypothesized that hospitals with shorter emergency department wait times were associated with higher odds of replantation. METHODS Using the 2007 to 2012 National Trauma Data Bank, the authors' final sample included 12,126 patients. Regression modeling was used to first determine factors that were associated with longer emergency department wait times among patients with digit Amputation injuries. Second, the authors examined the association between emergency department wait times for this population at a hospital level and replantation after all types of digit Amputation and after complicated Thumb Amputation injuries only. RESULTS For patients with simple and complicated Thumb Amputation injuries, and patients with complicated Thumb Amputation injuries only, longer emergency department wait times were associated with lower odds of replantation. In addition, being minority and having no insurance were associated with longer emergency department wait times; teaching hospitals were associated with shorter emergency department wait times; and finally, for patients with complicated Thumb Amputation injuries only, there was no association between patients' minority or insurance status and replantation. CONCLUSION Variation in emergency department wait time and its effects on treatment of traumatic digit Amputation may reflect maldistribution of hand or plastic surgeons with the required microsurgical skills among trauma centers across the United States. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

  • a population based study of replantation after traumatic Thumb Amputation 2007 2012
    Journal of Hand Surgery (European Volume), 2017
    Co-Authors: Elham Mahmoudi, Helen E Huetteman, Kevin C. Chung
    Abstract:

    Purpose The recommended surgical treatment after Thumb Amputation is replantation. In the United States, fewer than 40% of Thumb Amputation injuries are replanted, and little is known about factors associated with the probability of replantation. We aimed to investigate recent trends and examine patient and hospital characteristics that are associated with increased probability of attempted Thumb replantation. We hypothesized that higher-volume teaching hospitals and level-I trauma centers attempted more replantations. Methods We used 2007–2012 data from the National Trauma Data Bank. Our final sample included 2,206 traumatic Thumb Amputation patients treated in 1 of 365 centers during the study period. First, we used a 2-level hierarchical logistic model to estimate the odds of replantation. In addition, we used a treatment effect estimation method, with the inverse propensity score weighting to examine the difference in Thumb replantation if the only variation among patients was their presumptive payer. Results There was a higher probability of attempted replantation at teaching hospitals than nonteaching hospitals (odds ratio [OR], 1.40). Patients were less likely to undergo replantation at a level II (OR, 0.53) or a level III (OR, 0.33) trauma center. The uninsured were less likely to undergo replantation (OR, 0.61) than those with private insurance. Conclusions Having insurance coverage and being treated in a high-volume, teaching, level-I trauma hospital increased the odds of replantation after traumatic Thumb Amputation. Regionalization may lead to a higher number of indicated cases of replantation actually being attempted. Type of study/level of evidence Therapeutic II.

  • racial variation in treatment of traumatic finger Thumb Amputation a national comparative study of replantation and revision Amputation
    Plastic and Reconstructive Surgery, 2016
    Co-Authors: Elham Mahmoudi, Kevin C. Chung, Peter R Swiatek, John Z Ayanian
    Abstract:

    BACKGROUND Traumatic finger/Thumb Amputations are some of the most prevalent traumatic injuries affecting Americans each year. Rates of replantation after traumatic finger/Thumb Amputation, however, have been declining steadily across U.S. hospitals, which may make these procedures less accessible to minorities and vulnerable populations. The specific aim of this study was to examine racial variation in finger replantation after traumatic finger/Thumb Amputation. METHODS Using a two-level hierarchical model, the authors retrospectively compared replantation rates for African American patients with those of whites, adjusting for patient and hospital characteristics. Patients younger than 65 years with traumatic finger/Thumb Amputation injuries who sought care at a U.S. trauma center between 2007 and 2012 were included in the study sample. RESULTS The authors analyzed 13,129 patients younger than 65 years with traumatic finger/Thumb Amputation. Replantation rates declined over time from 19 percent to 14 percent (p = 0.004). Adjusting for patient and hospital characteristics, African Americans (OR, 0.81; 95 percent CI, 0.66 to 0.99; p = 0.049) were less likely to undergo replantation procedures than whites, and uninsured patients (OR, 0.73; 95 percent CI, 0.62 to 0.84; p < 0.0001) were less likely than those who were privately insured. CONCLUSIONS Despite advancements in microsurgical techniques and the increasing use of reconstructive surgery in other fields, finger/Thumb replantation rates are declining in the United States and vulnerable populations are less likely to undergo replantation after Amputation injuries. Regionalization of care for these injuries may not only provide a higher quality care but also reduce variations in treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.

M Huey D Tien - One of the best experts on this subject based on the ideXlab platform.

  • compound flap from the great toe and vascularized joints from the second toe for posttraumatic Thumb reconstruction at the level of the proximal metacarpal bone
    Microsurgery, 2009
    Co-Authors: M Tsumin D Tsai, M Laura D Dagostino, M Yousheng D Fang, M Huey D Tien
    Abstract:

    The purpose of this study is to describe the harvesting technique, anatomic variations, and clinical applications of a compound flap from the great toe and vascularized joint from the second toe used for Thumb reconstruction. Five fresh cadaver dissections were studied, focusing attention on the dorsal or plantar vascular dominance, position of the communicating branch between the dorsal and plantar system, the Gilbert classification, and the size of the first dorsal metatarsal artery (FDMA) and first plantar metatarsal artery (FPMA) to the great toe and second toe. Five compound flaps were performed on five patients with traumatic Thumb Amputation at the level of proximal metacarpal bone. The patients' ages ranged from 14 to 47. Follow-up period was 11-24 months. The anatomic study showed that FPMA had larger caliber in 40% of dissections, FDMA in 40%, and had the same caliber in 20%. The Gilbert classification of FDMA was 40% class I and 60% class III. In the clinical applications, four patients achieved good functional opposition and motion of transferred joints with good pinch and grip strength. There was one flap failure, and donor-site morbidity was minimal. The compound flap offers advantages over traditional toe transfer by providing two functional joints. It can be used for Amputation of the Thumb at carpometacarpal joint level. Finally, the compound flap maintains growth potential in children through transfer of vascularized epiphyses. The disadvantages of this compound flap include a technically challenging harvest and a longer operative time.

  • compound flap from the great toe and vascularized joints from the second toe for posttraumatic Thumb reconstruction at the level of the proximal metacarpal bone
    Microsurgery, 2009
    Co-Authors: M Tsumin D Tsai, M Laura D Dagostino, M Yousheng D Fang, M Huey D Tien
    Abstract:

    The purpose of this study is to describe the harvesting technique, anatomic variations, and clinical applications of a compound flap from the great toe and vascularized joint from the second toe used for Thumb reconstruction. Five fresh cadaver dissections were studied, focusing attention on the dorsal or plantar vascular dominance, position of the communicating branch between the dorsal and plantar system, the Gilbert classification, and the size of the first dorsal metatarsal artery (FDMA) and first plantar metatarsal artery (FPMA) to the great toe and second toe. Five compound flaps were performed on five patients with traumatic Thumb Amputation at the level of proximal metacarpal bone. The patients' ages ranged from 14 to 47. Follow-up period was 11–24 months. The anatomic study showed that FPMA had larger caliber in 40% of dissections, FDMA in 40%, and had the same caliber in 20%. The Gilbert classification of FDMA was 40% class I and 60% class III. In the clinical applications, four patients achieved good functional opposition and motion of transferred joints with good pinch and grip strength. There was one flap failure, and donor-site morbidity was minimal. The compound flap offers advantages over traditional toe transfer by providing two functional joints. It can be used for Amputation of the Thumb at carpometacarpal joint level. Finally, the compound flap maintains growth potential in children through transfer of vascularized epiphyses. The disadvantages of this compound flap include a technically challenging harvest and a longer operative time. © 2008 Wiley-Liss, Inc. Microsurgery, 2009.

M Tsumin D Tsai - One of the best experts on this subject based on the ideXlab platform.

  • compound flap from the great toe and vascularized joints from the second toe for posttraumatic Thumb reconstruction at the level of the proximal metacarpal bone
    Microsurgery, 2009
    Co-Authors: M Tsumin D Tsai, M Laura D Dagostino, M Yousheng D Fang, M Huey D Tien
    Abstract:

    The purpose of this study is to describe the harvesting technique, anatomic variations, and clinical applications of a compound flap from the great toe and vascularized joint from the second toe used for Thumb reconstruction. Five fresh cadaver dissections were studied, focusing attention on the dorsal or plantar vascular dominance, position of the communicating branch between the dorsal and plantar system, the Gilbert classification, and the size of the first dorsal metatarsal artery (FDMA) and first plantar metatarsal artery (FPMA) to the great toe and second toe. Five compound flaps were performed on five patients with traumatic Thumb Amputation at the level of proximal metacarpal bone. The patients' ages ranged from 14 to 47. Follow-up period was 11-24 months. The anatomic study showed that FPMA had larger caliber in 40% of dissections, FDMA in 40%, and had the same caliber in 20%. The Gilbert classification of FDMA was 40% class I and 60% class III. In the clinical applications, four patients achieved good functional opposition and motion of transferred joints with good pinch and grip strength. There was one flap failure, and donor-site morbidity was minimal. The compound flap offers advantages over traditional toe transfer by providing two functional joints. It can be used for Amputation of the Thumb at carpometacarpal joint level. Finally, the compound flap maintains growth potential in children through transfer of vascularized epiphyses. The disadvantages of this compound flap include a technically challenging harvest and a longer operative time.

  • compound flap from the great toe and vascularized joints from the second toe for posttraumatic Thumb reconstruction at the level of the proximal metacarpal bone
    Microsurgery, 2009
    Co-Authors: M Tsumin D Tsai, M Laura D Dagostino, M Yousheng D Fang, M Huey D Tien
    Abstract:

    The purpose of this study is to describe the harvesting technique, anatomic variations, and clinical applications of a compound flap from the great toe and vascularized joint from the second toe used for Thumb reconstruction. Five fresh cadaver dissections were studied, focusing attention on the dorsal or plantar vascular dominance, position of the communicating branch between the dorsal and plantar system, the Gilbert classification, and the size of the first dorsal metatarsal artery (FDMA) and first plantar metatarsal artery (FPMA) to the great toe and second toe. Five compound flaps were performed on five patients with traumatic Thumb Amputation at the level of proximal metacarpal bone. The patients' ages ranged from 14 to 47. Follow-up period was 11–24 months. The anatomic study showed that FPMA had larger caliber in 40% of dissections, FDMA in 40%, and had the same caliber in 20%. The Gilbert classification of FDMA was 40% class I and 60% class III. In the clinical applications, four patients achieved good functional opposition and motion of transferred joints with good pinch and grip strength. There was one flap failure, and donor-site morbidity was minimal. The compound flap offers advantages over traditional toe transfer by providing two functional joints. It can be used for Amputation of the Thumb at carpometacarpal joint level. Finally, the compound flap maintains growth potential in children through transfer of vascularized epiphyses. The disadvantages of this compound flap include a technically challenging harvest and a longer operative time. © 2008 Wiley-Liss, Inc. Microsurgery, 2009.

Darrell Brooks - One of the best experts on this subject based on the ideXlab platform.

  • selected outcomes of Thumb replantation after isolated Thumb Amputation injury
    Journal of Hand Surgery (European Volume), 2010
    Co-Authors: Jayant P Agarwal, Matthew J Trovato, Shailesh Agarwal, Paul N Hopkins, Darrell Brooks
    Abstract:

    Purpose The aim of this study was to assess Thumb survival, pinch strength, grip strength, and need for secondary surgery in patients undergoing Thumb replantation after isolated Thumb Amputation injury. Methods We conducted a retrospective review of 52 consecutive isolated Thumb replantations performed over a 4.5-year period. Charts were reviewed for mechanism of injury, level of Amputation, and surgical technique. Primary outcomes of interest included survival and secondary surgery (eg, tenolysis, neurolysis) rates. Functional outcome was assessed by pinch and grip strengths after a mean follow-up period of 10 months from the initial injury. Results The overall Thumb survival rate was 92% (48 of 52). One hundred percent of Zone I injuries (13 of 13), 94% of zone II injuries (29 of 31), and 75% of zone III injuries (6 of 8) survived; overall survival was 94% in sharp injuries (32 of 34), 89% in avulsion injuries (8 of 9), and 89% in crush injuries (8 of 9). Secondary surgery was performed in 18 patients with increasing need across the 3 zones (0%, 42%, and 63%, respectively; p for trend=.002). Pinch and grip strengths of 17 patients after an average follow-up period of 10 months were significantly worse after crush/avulsion injuries (p = .007 and .07, respectively) and injuries requiring joint intervention (p = .004 and .02, respectively); grip strength was also found to be negatively associated with increasing zone of injury. Conclusions This retrospective study shows that a high rate of survival can be achieved after Thumb replantation using current techniques. In addition, the need for secondary surgery is strongly related to zone of injury, with zone I injuries requiring the least amount of secondary surgery. Finally, pinch and grip strengths may be worse after crush or avulsion injuries and injuries requiring joint intervention. Type of study/level of evidence Therapeutic IV.

Elham Mahmoudi - One of the best experts on this subject based on the ideXlab platform.

  • emergency department wait time and treatment of traumatic digit Amputation do race and insurance matter
    Plastic and Reconstructive Surgery, 2017
    Co-Authors: Elham Mahmoudi, Peter R Swiatek, Kevin C. Chung
    Abstract:

    BACKGROUND Little is known about the association between the quality of trauma care and management of nonfatal injuries. The authors used emergency department wait times as a proxy for hospital structure, process, and availability of on-call surgeons with microsurgical skills. They evaluated the association between average hospital emergency department wait times and likelihood of undergoing digit replantation for patients with traumatic Amputation digit injuries. The authors hypothesized that hospitals with shorter emergency department wait times were associated with higher odds of replantation. METHODS Using the 2007 to 2012 National Trauma Data Bank, the authors' final sample included 12,126 patients. Regression modeling was used to first determine factors that were associated with longer emergency department wait times among patients with digit Amputation injuries. Second, the authors examined the association between emergency department wait times for this population at a hospital level and replantation after all types of digit Amputation and after complicated Thumb Amputation injuries only. RESULTS For patients with simple and complicated Thumb Amputation injuries, and patients with complicated Thumb Amputation injuries only, longer emergency department wait times were associated with lower odds of replantation. In addition, being minority and having no insurance were associated with longer emergency department wait times; teaching hospitals were associated with shorter emergency department wait times; and finally, for patients with complicated Thumb Amputation injuries only, there was no association between patients' minority or insurance status and replantation. CONCLUSION Variation in emergency department wait time and its effects on treatment of traumatic digit Amputation may reflect maldistribution of hand or plastic surgeons with the required microsurgical skills among trauma centers across the United States. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

  • a population based study of replantation after traumatic Thumb Amputation 2007 2012
    Journal of Hand Surgery (European Volume), 2017
    Co-Authors: Elham Mahmoudi, Helen E Huetteman, Kevin C. Chung
    Abstract:

    Purpose The recommended surgical treatment after Thumb Amputation is replantation. In the United States, fewer than 40% of Thumb Amputation injuries are replanted, and little is known about factors associated with the probability of replantation. We aimed to investigate recent trends and examine patient and hospital characteristics that are associated with increased probability of attempted Thumb replantation. We hypothesized that higher-volume teaching hospitals and level-I trauma centers attempted more replantations. Methods We used 2007–2012 data from the National Trauma Data Bank. Our final sample included 2,206 traumatic Thumb Amputation patients treated in 1 of 365 centers during the study period. First, we used a 2-level hierarchical logistic model to estimate the odds of replantation. In addition, we used a treatment effect estimation method, with the inverse propensity score weighting to examine the difference in Thumb replantation if the only variation among patients was their presumptive payer. Results There was a higher probability of attempted replantation at teaching hospitals than nonteaching hospitals (odds ratio [OR], 1.40). Patients were less likely to undergo replantation at a level II (OR, 0.53) or a level III (OR, 0.33) trauma center. The uninsured were less likely to undergo replantation (OR, 0.61) than those with private insurance. Conclusions Having insurance coverage and being treated in a high-volume, teaching, level-I trauma hospital increased the odds of replantation after traumatic Thumb Amputation. Regionalization may lead to a higher number of indicated cases of replantation actually being attempted. Type of study/level of evidence Therapeutic II.

  • racial variation in treatment of traumatic finger Thumb Amputation a national comparative study of replantation and revision Amputation
    Plastic and Reconstructive Surgery, 2016
    Co-Authors: Elham Mahmoudi, Kevin C. Chung, Peter R Swiatek, John Z Ayanian
    Abstract:

    BACKGROUND Traumatic finger/Thumb Amputations are some of the most prevalent traumatic injuries affecting Americans each year. Rates of replantation after traumatic finger/Thumb Amputation, however, have been declining steadily across U.S. hospitals, which may make these procedures less accessible to minorities and vulnerable populations. The specific aim of this study was to examine racial variation in finger replantation after traumatic finger/Thumb Amputation. METHODS Using a two-level hierarchical model, the authors retrospectively compared replantation rates for African American patients with those of whites, adjusting for patient and hospital characteristics. Patients younger than 65 years with traumatic finger/Thumb Amputation injuries who sought care at a U.S. trauma center between 2007 and 2012 were included in the study sample. RESULTS The authors analyzed 13,129 patients younger than 65 years with traumatic finger/Thumb Amputation. Replantation rates declined over time from 19 percent to 14 percent (p = 0.004). Adjusting for patient and hospital characteristics, African Americans (OR, 0.81; 95 percent CI, 0.66 to 0.99; p = 0.049) were less likely to undergo replantation procedures than whites, and uninsured patients (OR, 0.73; 95 percent CI, 0.62 to 0.84; p < 0.0001) were less likely than those who were privately insured. CONCLUSIONS Despite advancements in microsurgical techniques and the increasing use of reconstructive surgery in other fields, finger/Thumb replantation rates are declining in the United States and vulnerable populations are less likely to undergo replantation after Amputation injuries. Regionalization of care for these injuries may not only provide a higher quality care but also reduce variations in treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.