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Background: Unstable elbow injuries sometimes require External fixation (ExF) or an Internal Joint Stabilizer (IJS) to maintain joint reduction. No studies have compared the clinical outcomes and surgical costs of these 2 treatment modalities. The purpose of this study was to determine whether clinical outcome and surgical encounter total direct costs (SETDCs) differ between ExF and IJS for unstable elbow injuries. Methods: This retrospective study identified adult patients (aged ≥ 18 years) with unstable elbow injures treated by either an IJS or ExF between 2010 and 2019 at a single tertiary academic center. Patients postoperatively completed 3 patient-reported outcome measures (the Disability of the Arm, Shoulder, and Hand, the Mayo Elbow Performance score, and EQ-5D-DL). Postoperative range of motion was measured in all patients, and complications tallied. SETDCs were determined and compared between the 2 groups. Results: A total of 23 patients were identified, with 12 in each group. Clinical and radiographic follow-up for the IJS group averaged 24 months and 6 months, respectively, and for the ExF group, 78 months and 5 months, respectively. The 2 groups had similar final range of motion, the Mayo Elbow Performance score, and 5Q-5D-5L scores; ExF patients had better the Disability of the Arm, Shoulder, and Hand scores. IJS patients had fewer complications and were less likely to require additional surgery. The SETDCs were similar between the 2 groups, but the relative contributors to cost differed significantly between the groups. Conclusions: Patients treated with an ExF or IJS had similar clinical outcomes, but complications and second surgeries were more likely in ExF patients. The overall SETDC was also similar for ExF and IJS, but relative contributions of the cost subcategories differed.
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BACKGROUND: Operating Room (OR) is a high-pressure setting where multiple complex surgical, educational, and administrative facets interplay. Contrary to resident training, the dynamics of undergraduate medical students' learning process is highly demanding, opportunistic, unstandardized, and suboptimal owing to many reasons. Upon reviewing the existing published literature regarding the medical students' experience in the OR setting, it was clear that this field is still to date, unstructured, and ambiguous, with many grey areas that need to be worked on. To achieve an optimized and enhanced theatre experience, it is of immense importance to recognize the recurrent themes affecting medical students within this setting and deduce ways to overcome these challenges. This study explores and prioritizes factors influencing OR-based student learning quality and develops guidelines for structured clinical encounters within the OR setting. METHODS: The study involved an extensive literature review and thematic analysis to generate themes and subthemes, which were subjected to a modified Delphi technique where students and teachers participated to identify, debate, and produce a consensus on the relative value of these factors. Finally, expert-validated guidelines were developed for OR curricular designs. RESULTS: Operating theater-based student learning is multifactorial. Structured learning through optimized course planning, content selection, assessment, and administration are decisive in determining the quality of OR learning experience. The teacher's interest, attitude, and students' desire and preparedness to learn play a central role in OR-based student learning, suggesting an enhanced need for adequate faculty training. Similarly, emotional, socio-environmental, and organizational factors can influence students' learning in a significant way. A new model for undergraduate student learning in OR has been proposed based on these factors and the stakeholders' interplay. In this model, the teacher's role is responsible despite OR learning being student- led. Guidelines for the OR curricular designs have been developed. CONCLUSION: Structured learning process within the OR setting can lead to optimized lesson planning, content selection, assessment, and administration for a more meaningful and enriched OR learning experience.
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Educación Médica , Estudiantes de Medicina , Humanos , Quirófanos , Estudiantes de Medicina/psicología , Aprendizaje , ActitudRESUMEN
BACKGROUND: Distal humerus fracture open reduction and internal fixation (ORIF) represents a substantial cost burden to the health care system. The purpose of this study was to describe surgical encounter cost variation for distal humerus ORIF, and to determine demographic-, injury-, and treatment-specific factors that influence cost. METHODS: We retrospectively identified adult patients (≥18 years) treated for isolated distal humerus fractures between July 2014 and July 2019 at a single tertiary academic referral center. For each case, surgical encounter total direct costs (SETDCs) were obtained via our institution's information technology value tools, which prospectively record granular direct cost data for every health care encounter. Costs were converted to 2019 dollars using the personal consumption expenditure indices for health and summarized with descriptive statistics. Univariate and multivariate linear regression models were used to identify factors influencing SETDC. RESULTS: Surgical costs varied widely for the 47 included patients, with a standard deviation (SD) of 33% and interquartile range of 76%-124% relative to the mean SETDC. Implant and facility costs were responsible for 46.2% and 32.6% of the SETDC, respectively. Implant costs also varied considerably, with an SD of 21% and range from 13%-36% relative to the mean SETDC. Multivariate analysis demonstrated that SETDC increased 24% (P < .001) on performing an olecranon osteotomy, and by 15% for each additional 1 hour of surgical time (P < .001). These findings were independent of age, sex, body mass index, open fracture, need for an additional small plate construct as a reduction aid, and fracture pattern (all insignificant in the multivariate analysis, with P >.05 for each factor). CONCLUSION: Substantial variations in surgical encounter total direct costs for distal humerus ORIF exist, as do wide variations in associated implant costs that comprise nearly half of the entire surgical cost. Performing an olecranon osteotomy, and increased surgical time, significantly increased surgical costs. Although use of an olecranon osteotomy may not be a completely controllable factor as it is confounded by fracture severity and operative time, this may suggest that surgeons should try to use an olecranon osteotomy judiciously. Although complexity of the fracture pattern was statistically insignificant, it is confounded by the need for an olecranon osteotomy and increased surgical time and likely is a clinically relevant and nonmodifiable driver of surgical cost. These findings highlight opportunities to reduce cost variation, and potentially improve the value of care, for distal humerus ORIF patients.
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BACKGROUND: Given the similar outcomes of various fixation constructs for single-incision distal biceps repair, a critical evaluation of the factors that drive the cost of the procedure is the key to optimizing treatment value. The purpose of this study was to quantify variation in costs for surgical treatment of complete distal biceps ruptures, as well as identify factors affecting costs. METHODS: We retrospectively identified adult patients consecutively treated surgically for complete distal biceps ruptures between July 2011 and January 2018 at a single academic medical center. Using our institution's information technology value tool, we recorded the surgical encounter total direct costs (SETDCs) for each patient. Univariate and multivariate gamma regression models were used to determine factors affecting SETDCs. RESULTS: Of 121 included patients, 102 (86%), 7 (6%), and 12 (10%) underwent primary repair, revision, and reconstruction. SETDCs varied widely, with a standard deviation of 40% and a range of 58% to 276% of the average SETDC. The main contributors to SETDCs were facility utilization costs (53%) and implant costs (29%). Implant costs also varied, with a standard deviation of 16%, ranging up to 121% of the mean SETDC. Multivariate analysis demonstrated that reconstructions were 72% more costly than primary repairs (P < .001). No significant cost differences were found between cortical button and dual-suture anchor fixation (P = .058). American Society of Anesthesiologists class, body mass index, revision surgery, time to surgery, location, administration of postoperative block, and surgeon performing the procedure did not significantly affect the SETDC. CONCLUSION: Surgical encounter and implant costs vary widely for distal biceps rupture treatment. However, no significant difference in SETDC was identified between repair with a cortical button vs. dual-suture anchor repair. The greater costs associated with reconstruction surgery should be taken into consideration.
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Costos Directos de Servicios , Músculo Esquelético/lesiones , Traumatismos de los Tendones/cirugía , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reoperación , Estudios Retrospectivos , Rotura/cirugía , Anclas para Sutura/economía , Traumatismos de los Tendones/diagnóstico , Traumatismos de los Tendones/economía , Resultado del Tratamiento , Cicatrización de HeridasRESUMEN
Background Proximal row carpectomy (PRC) and four-corner arthrodesis (FCA) are common treatments for stage II scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrists, with similar functional and patient-reported outcomes reported in the peer-reviewed literature. Questions Study questions included (1) whether surgical encounter total direct costs (SETDCs) differ between PRC and FCA, and (2) whether SETDC differs by method of fixation for FCA. Patients and Methods Consecutive adult patients (≥ 18 years) undergoing PRC and FCA between July 2011 and May 2017 at a single tertiary care academic institution were identified. Patients undergoing additional simultaneous procedures were excluded. Using our institution's information technology value tools, we extracted prospectively collected cost data for each surgical encounter. SETDCs were compared between PRC and FCA, and between FCA subgroups (screws, plating, or staples). Results Of 42 included patients, mean age was similar between the 23 PRC and 19 FCA patients (51.2 vs. 54.5 years, respectively). SETDCs were significantly greater for FCA than PRC by 425%. FCA involved significantly greater facility costs (2.3-fold), supply costs (10-fold), and operative time (121 vs. 57 minutes). Implant costs were absent for PRC, which were responsible for 55% of the SETDC for FCA. Compared with compression screws, plating and staple fixation were significantly more costly (70% and 240% greater, respectively). Conclusion SETDCs were 425% greater for FCA than PRC. Implant costs for FCA alone were 130% greater than the entire surgical encounter for PRC. For FCA, SETDC varied depending on the method of fixation. Level of Evidence This is a level III, cost analysis study.