Search

PURPOSE The need to rapidly implement telemedicine in primary care during the coronavirus disease 2019 (COVID-19) pandemic was addressed differently by various practices. Using qualitative data from semistructured interviews with primary care practice leaders, we aimed to report commonly shared experiences and unique perspectives regarding telemedicine implementation and evolution/maturation since March 2020. METHODS We administered a semistructured, 25-minute, virtual interview with 25 primary care practice leaders from 2 health systems in 2 states (New York and Florida) included in PCORnet, the Patient-Centered Outcomes Research Institute clinical research network. Questions were guided by 3 frameworks (health information technology evaluation, access to care, and health information technology life cycle) and involved practice leaders' perspectives on the process of telemedicine implementation in their practice, with a specific focus on the process of maturation and facilitators/barriers. Two researchers conducted inductive coding of qualitative data open-ended questions to identify common themes. Transcripts were electronically generated by virtual platform software. RESULTS Twenty-five interviews were administered for practice leaders representing 87 primary care practices in 2 states. We identified the following 4 major themes: (1) the ease of telemedicine adoption depended on both patients' and clinicians' prior experience using virtual health platforms, (2) regulation of telemedicine varied across states and differentially affected the rollout processes, (3) visit triage rules were unclear, and (4) there were positive and negative effects of telemedicine on clinicians and patients. CONCLUSIONS Practice leaders identified several challenges to telemedicine implementation and highlighted 2 areas, including telemedicine visit triage guidelines and telemedicine-specific staffing and scheduling protocols, for improvement. Key words: telemedicine; primary care; COVID-19 pandemic; East Coast; primary health care; https://doi.org/10.1370/afm.2967, INTRODUCTION The abrupt onset of the coronavirus disease 2019 (COVID-19) pandemic required a rapid implementation of telemedicine--the synchronous delivery of health care in an audio-plus-video or audio-only modality--in primary care. [...]

Background: Studies have demonstrated beneficial outcomes associated with timely surgical treatment of hip fracture. Subsequently, practice recommendations changed with 24–48 h as the recommended time for surgery from admission; however, recent data on timing of hip fracture surgery and how this impacts outcomes are lacking. Methods: This retrospective cohort study included patients who had a primary diagnosis of hip fracture and underwent a subsequent surgical repair within 3 days of admission (Premier Healthcare claims 2006–2021 data). The primary exposure of interest was time from hip fracture diagnosis to surgery (categorized as 0–1 day, 2 days, and 3 days). Outcomes included any major complication, mortality, and intensive care unit (ICU) admission. Mixed‐effects models measured the association between timing of surgery and outcomes. We report odds ratios (OR) and 95% confidence intervals. Results: Among 501,267 surgical hip fracture patients, 26.0%, 56.0%, and 18.1% of patients received surgery on days 0–1, 2, and 3, respectively. The median ages were 83, 84, and 84 years old, and there were 73.3%, 72.2%, and 68.8% female in each group respectively. Compared with repair on day 0–1, hip fracture surgical treatment on day 2 or day 3 was associated with increased odds of major complications (OR 1.06, 95% CI 1.03–1.08 and OR 1.17, 95% CI 1.13–1.2), mortality (OR 1.08, 95% CI 1.02–1.14 and OR 1.2, 95% CI 1.12–1.28), and ICU admission (OR 1.06, 95% CI 1.04–1.09 and OR 1.36, 95% CI 1.32–1.4) after adjusting major comorbidities; all p < 0.001. Conclusion: Despite the publication of society guidelines in 2015, most fracture patients still received surgery on day 2 or day 3 of admission and were associated with worse outcomes. Balancing optimization of clinical factors with timing of surgery can be challenging, and further research is needed. Nonetheless, our findings reiterate the importance of timely surgical intervention. [ABSTRACT FROM AUTHOR]

Background: Increasing overlap exists between surgeries performed by podiatrists and orthopaedic surgeons. Large-scale cost comparisons between the two are lacking despite the current climate of cost containment in health care. Using national Medicare data, we aimed to compare per-case Medicare payments between podiatrists and orthopaedic surgeons for ankle fracture fixation. Methods: This retrospective cohort study included patients in an outpatient setting undergoing either unimalleolar, bimalleolar, or trimalleolar ankle fracture repair from the national Medicare Limited Data Set (2013-2019). Type of surgeon (podiatrist or orthopaedic surgeon) was determined using publicly available information. The primary outcome was total Medicare payments specific to the procedure, as a surrogate for cost. A subset analysis was also done to directly compare costs of orthopaedic surgeons to podiatric surgeons while excluding other fees (eg, hospital facility fees and surgery-related imaging payments). Additionally, patient demographics and hospital characteristics were compared to determine if any factors associated with costs may influence group differences. Univariable tests assessed significance of group differences. Results: Overall, 16 927 unimalleolar, 17 244 bimalleolar, and 11 717 trimalleolar fracture repairs were included; 86.7% and 13.3%, 92.4% and 7.6%, and 92.2% and 7.8% were performed by an orthopaedic surgeon or podiatrist, respectively. Median age (70-71 years) and median Charlson-Deyo Comorbidity Index (0) did not significantly differ between patients treated by either surgeon type. Median procedure-specific Medicare payments for all 3 categories of ankle fracture repairs (uni-, bi-, trimalleolar) were significantly lower for orthopaedic surgeons compared to podiatrists: $4156 vs $4300, $4205 vs $4379, and $4396 vs $4525, respectively (all P <.001). Conclusion: Our investigation using a national Medicare data set (2013-2019) found that the 3 types of ankle fractures (unimalleolar, bimalleolar, and trimalleolar) performed by orthopaedic surgeons in an outpatient setting were less expensive and that cost differences do not appear to be driven by patient characteristics. These results and further research into the causes of the cost differences may help improve the cost-effectiveness of ankle fracture surgery. [ABSTRACT FROM AUTHOR]

Background: Although the coexistence of cervical and lumbar spinal conditions is fairly common, surgical treatments are usually staged, even though simultaneous fusion of the cervical and lumbar spine may be a viable option for appropriate candidates. Purpose: We sought to investigate the outcomes of staged vs simultaneous cervical and lumbar fusions in terms of differences in postoperative complications and resource use. Methods: We performed a retrospective cohort study using claims data from the 2006 to 2020 all-payer Premier Health Database. Data were extracted for patients who underwent both a cervical and a lumbar fusion procedure either simultaneously (same hospitalization) or staged (within 1 year). Multivariable regression models measured the association between simultaneous or staged procedures and combined complications (including venous thromboembolism, infection, acute renal failure, or vascular/pulmonary/gastrointestinal complications), intensive care unit (ICU) admission, and prolonged length of stay. We report odds ratios (ORs) and 95% confidence intervals (CI). Results: Overall, 560 (5.2%) and 10 187 (94.8%) of total 10 747 cervical and lumbar fusion procedures were performed simultaneously and staged, respectively. When comparing outcomes after simultaneous procedures to those after staged procedures (for which outcomes from the cervical and lumbar procedures were pooled), simultaneous procedures were associated with higher rates of ICU admission and longer hospital stays, but there were no differences in rates of combined complications. Conclusion: Our retrospective, nationwide database study found that simultaneous cervical and lumbar fusion is relatively rare and its rates of complications do not differ meaningfully from those of staged procedures. However, we found an association between simultaneous cervical and lumbar fusion and higher rates of ICU admission and prolonged length of stay. Further study is warranted. [ABSTRACT FROM AUTHOR]

Purpose Ankle arthrodesis and total ankle arthroplasty (TAA) are often associated with significant postoperative pain. While this may be mitigated by the use of peripheral nerve blocks (PNB), large-scale data are lacking. Using national data, we aimed to evaluate PNB utilization pattern and its impact on outcomes. Methods This retrospective cohort study utilized data from the nationwide database (2006-2016) on TAA (n = 5,290) and ankle arthrodesis (n = 14,709) procedures. PNB use was defined from billing; outcomes included opioid utilization, length and cost of stay, discharge to a skilled nurse facility, and opioid-related complications. Mixed-effects models estimated the association between PNB use and outcomes, separate by procedure type and inpatient/outpatient setting. We report odds ratios and 95% confidence intervals (CI). Results Overall, PNB was utilized in 8.7% of TAA and 9.9% of ankle arthrodesis procedures, with increased utilization from 2006 to 2016 of 2.6% to 11.3% and 5.2% to 12.0%, respectively. After adjustment for relevant covariates, PNB use was significantly associated with decreased total opioid utilization specifically in the inpatient setting in TAA ( - 16.9% CI - 23.9%; - 9.1%) and ankle arthrodesis procedures ( - 18.9% CI - 24.4; - 13.0%), this was particularly driven by a decrease in opioid utilization on the day of surgery. No clinically relevant effects were observed for other outcomes. Conclusion PNB utilization is associated with substantial reductions in opioid utilization, particularly in the inpatient setting. Our study is in support of a wider use of this analgesic technique, which may translate into more benefits in terms of clinical outcomes and resource utilization. Level of Evidence III., Author(s): Jimmy J. Chan [sup.1], Evan Garden [sup.1], Jesse C. Chan [sup.1], Jashvant Poeran [sup.2], Nicole Zubizarreta [sup.2], Madhu Mazumdar [sup.2], Leesa M. Galatz [sup.1], Ettore Vulcano [sup.1] Author Affiliations: [...]