Dataset Information

Association of Interfacility Transfer and Patient and Hospital Characteristics With Thumb Replantation After Traumatic Amputation.

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.

SUBMITTER: Billig JI

PROVIDER: S-EPMC7859845 | biostudies-literature | 2021 Feb

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Association of Interfacility Transfer and Patient and Hospital Characteristics With Thumb Replantation After Traumatic Amputation.

Billig Jessica I JI Nasser Jacob S JS Cho Hoyune E HE Chou Ching-Han CH Chung Kevin C KC

JAMA network open 20210201 2

<h4>Importance</h4>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.<h4>Object ...[more]

PMID: 33533928

Similar Datasets

Project description:BackgroundThe purpose of this study was to perform a cost-utility analysis to compare revision amputation and replantation treatment of finger amputation injuries across a spectrum of injury scenarios.MethodsThe study was conducted from the societal perspective. Decision tree models were created for the reference case (two-finger amputation injury) and seven additional injury scenarios for comparison. Inputs included cost, quality of life, and probability of each health state. A Web-based time trade-off survey was created to determine quality-adjusted life-years for health states; 685 nationally representative adult community members were invited to participate in the survey. Overall cost and quality-adjusted life-years for revision amputation and replantation were calculated for each decision tree. An incremental cost-effectiveness ratio was calculated if a treatment was more costly but more effective.ResultsThe authors had a 64 percent response rate (n = 437). Replantation treatment had greater costs and quality-adjusted life-years compared with revision amputation in all injury scenarios. Replantation of single-digit injuries had the highest incremental cost-effectiveness ratio ($136,400 per quality-adjusted life-year gained). Replantation of three- and four-digit amputation injuries had relatively low cost-to-benefit ratios ($27,100 and $23,800 per quality-adjusted life-year, respectively). Replantation for distal thumb amputation had a relatively low incremental cost-effectiveness ratio ($26,300 per quality-adjusted life-year) compared with replantation of nonthumb distal amputations ($60,200 per quality-adjusted life-year).ConclusionsThe relative cost per quality-adjusted life-year gained with replantation treatment varied greatly among the injury scenarios. Situations in which indications for replantation are debated had higher cost per quality-adjusted life-year gained. This study highlights variability in value for replantation among different injury scenarios.

Project description:Introduction:Traumatic intracranial hemorrhage (TIH), brain injury with radiographic hemorrhage, is a common emergency department (ED) presentation, and encompasses a wide range of clinical syndromes. Patients with moderate and severe neurotrauma (Glasgow Coma Scale [GCS] < 13) with intracranial hemorrhage require care at a trauma center with neurosurgical capabilities. However, many patients with mild traumatic intracranial hemorrhage (mTIH), defined as radiographic bleeding and GCS ? 13, do not require operative intervention or intensive care unit monitoring, but are still routinely transferred to tertiary care centers. We hypothesized that a significant proportion of patients are managed non-operatively and are discharged within 24 hours of admission. Methods:This was a retrospective, observational study of consecutive patients age ? 16 years, GCS ? 13 who were transferred to an urban, medical school-affiliated, 100,000 annual visit ED over a seven-year period with blunt isolated mTIH. The primary outcome was discharge within 24 hours of admission. We measured rates of neurosurgical intervention, computed tomography hemorrhage progression, and neurologic deterioration as well as other demographic and clinical variables. Results:There were 1079 transferred patients with isolated mTIH. Of these, 92.4% were treated non-operatively and 35.8% were discharged within 24 hours of presentation to the tertiary ED. Patient characteristics associated with rapid discharge after transfer include a GCS of 15 (odds ratio [OR] 2.9, 95% confidence interval [CI], 1.9 - 4.4), subdural hematoma ? 6mm (OR 3.1, 95% CI, 2.2 - 4.5) or the presence of an isolated subarachnoid hemorrhage (OR 1.7, 95% CI, 1.3 - 2.4). Of patients with length of stay < 24 hours, 79.8% were discharged directly from the ED or ED observation unit. Conclusion:Patients transferred to tertiary care centers are frequently discharged after brief observation without intervention. Risk can be predicted by clinical and radiographic data. Further prospective research is required to determine a safe cohort of patients who could be managed at community sites.

Project description:ImportanceTraumatic digit amputation is the most common type of amputation injury, but the cost-effectiveness of its treatments is unknown.ObjectiveTo assess the cost-effectiveness of finger replantation compared with revision amputation.Design, setting, and participantsThis economic evaluation was conducted using data from the Finger Replantation and Amputation Challenges in Assessing Impairment, Satisfaction, and Effectiveness (FRANCHISE), a retrospective, multicenter cohort study at 19 centers in the United States and Asia that enrolled participants from August 1, 2016, to April 12, 2018. Model variables were based on the FRANCHISE database, Centers for Medicare & Medicaid Services, and published literature. A total of 257 participants with unilateral traumatic finger amputations treated with revision amputation or replantation distal to the metacarpophalangeal joint and at least 1 year of follow-up after treatment were included in the analysis.ExposuresRevision amputation or replantation of traumatic finger amputations.Main outcomes and measuresMain outcome measures were quality-adjusted life-years (QALYs), total costs (in US dollars), and incremental cost-effectiveness ratios (ICERs). A willingness-to-pay threshold of $100 000 per QALY was used to assess cost-effectiveness.ResultsOf the 257 study participants (mean [SD] age, 46.7 [15.9] years; 221 [86.0%] male), 178 underwent finger replantation and 79 underwent revision amputation. In a base case of a 46.7-year-old patient, replantation was associated with QALY gains of 0.30 (95% credible interval [CrI], -0.72 to 1.38) for single-finger (not thumb), 0.39 (95% CrI, -1.00 to 1.90) for thumb, 1.69 (95% CrI, -0.13 to 3.76) for multifinger excluding thumb, and 1.27 (95% CrI, -2.21 to 5.04) for multifinger including thumb injury patterns. Corresponding ICERs for replantation compared with revision amputation were $99 157 per QALY for single-finger (not thumb), $66 278 per QALY for thumb, $18 388 per QALY for multifinger excluding thumb, and $21 528 per QALY for multifinger including thumb injury patterns. Sensitivity analysis revealed that age at time of injury, life expectancy, postinjury utility, wages, and time off work for recovery had the strongest associations with cost-effectiveness. Probabilistic sensitivity analysis revealed the following chances of replantation being cost-effective: 47% in single-finger (not thumb), 52% in thumb, 78% in multifinger excluding thumb, and 64% in multifinger including thumb injury patterns.Conclusions and relevanceWith proper patient selection, replantation of all finger amputation patterns, whether single-finger or multifinger injuries, may be cost-effective compared with revision amputation. Multifinger replantations had a higher probability of being cost-effective than single-finger replantations. Cost-effectiveness may depend on injury pattern and patient factors and thus appears to be important for consideration when patients and surgeons are deciding whether to replant or amputate.

Project description:RationalePatients with ventilator-dependent respiratory failure have improved outcomes at centers with greater expertise; yet, most patients are not treated in such facilities. Efforts to align care for respiratory failure and hospital capability would necessarily require interhospital transfer.ObjectivesTo characterize the prevalence and the patient and hospital factors associated with interhospital transfer of adults residing in Florida with ventilator-dependent respiratory failure.MethodsWe performed a retrospective, observational study using Florida Healthcare Cost and Utilization Project data. We selected patients 18 years of age and older with International Classification of Diseases, Ninth Revision, codes of respiratory failure and mechanical ventilation during 2012 and 2013, and we identified cohorts of patients that did and did not undergo interhospital transfer. We obtained patient sociodemographic and clinical variables and categorized hospitals into subtypes on the basis of patient volume and services provided: large, medium (nonprofit or for-profit), and small.ResultsInterhospital transfer was our primary outcome measure. Patient sociodemographics, clinical variables, and hospital types were used as covariates. We identified 2,580 patients with ventilator-dependent respiratory failure who underwent interhospital transfer. Overall, transfer was uncommon, with only 2.9% of patients being transferred. In a hierarchical model, age less than 65 years (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.77-2.45) and tracheostomy (OR, 3.19; 95% CI, 2.80-3.65) were associated with higher odds of transfer, whereas having Medicaid was associated with lower odds of transfer than having commercial insurance (OR, 0.65; 95% CI, 0.56-0.75). Additionally, care in medium-sized for-profit hospitals was associated with lower odds of transfer (OR, 1.37 vs. 2.70) than care in medium nonprofit hospitals, despite similar hospital characteristics.ConclusionsIn Florida, interhospital transfer of patients with ventilator-dependent respiratory failure is uncommon and more likely among younger, commercially insured, medically resource-intensive patients. For-profit hospitals are less likely to transfer than nonprofit hospitals. In future studies, researchers should test for geographic variations and examine the clinical implications of selectivity in interhospital transfer of patients with ventilator-dependent respiratory failure.

Dataset Information

Association of Interfacility Transfer and Patient and Hospital Characteristics With Thumb Replantation After Traumatic Amputation.

Importance

Objective

Design, setting, and participants

Exposures

Main outcomes and measures

Results

Conclusions and relevance

Publications

Association of Interfacility Transfer and Patient and Hospital Characteristics With Thumb Replantation After Traumatic Amputation.

Similar Datasets

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