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Hand Trauma Network in the United States: ASSH Member Perspective Over the Last Decade

      Purpose

      Upper extremity trauma is common, however the provision of emergency call for hand trauma can be challenging for hospital systems and hand surgeons. Over the past decade, the American Society for Surgery of the Hand (ASSH) has developed the Hand Trauma Network and an Emergency Hand Care Committee to refine care for hand trauma patients.

      Methods

      The ASSH administered surveys to members about the provision of emergency hand call in 2010 and 2019. Demographic information was collected including surgeon age, years in practice, board certification, practice setting, and ACS trauma level. Other survey questions included willingness and obligation to take call, as well as barriers to providing emergency call. Financial aspects of call were also queried.

      Results

      Survey responses were obtained from 672 surgeons in 2010 and 1005 surgeons in 2019. There was a decrease in surgeons with obligatory hand call from 2010 to 2019 (70% vs 50%, P < .05) and an increase in the number of surgeons not taking hand call in 2019 (34%) compared to 2010 (18%, P < .05). In both surveys, the main barrier for providing hand call was “lifestyle considerations,” 39% (2010) and 47% (2019). There was no change in the percentage of surgeons working at facilities that provide 24/7 emergency hand call services or the percentage of hand surgeons paid to take call.

      Conclusions

      Certain aspects of providing emergency hand surgery care have not changed substantially in the past decade, including the number of centers that provide emergency hand coverage. A greater number of surgeons are not taking any hand call. Further efforts are required to promulgate advances in hand trauma call by the ASSH.

      Clinical relevance

      The development of the ASSH Hand Trauma Network has not yet resulted in substantive improvement in the number of facilities that provide emergency hand coverage or the number of hand surgeons providing emergency hand care.

      Key words

      JHS Podcast

      August 2, 2021

      JHS Podcast Episode 65

      Dr. Graham interviews Dr. Kyle Eberlin, lead author of the article “Hand Trauma Network in the United States: ASSH Member Perspective Over the Last Decade” that appears in the August 2021 issue of the Journal of Hand Surgery.

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      The distal upper extremity is the most common anatomic location for injuries in patients presenting for emergency evaluation in the United States.
      • Ootes D.
      • Lambers K.T.
      • Ring D.C.
      The epidemiology of upper extremity injuries presenting to the emergency department in the United States.
      ,
      • de Putter C.E.
      • Selles R.W.
      • Polinder S.
      • Panneman M.J.
      • Hovius S.E.
      • van Beeck E.F.
      Economic impact of hand and wrist injuries: health-care costs and productivity costs in a population-based study.
      For many traumatic hand injuries, urgent evaluation by a hand surgeon is critical to optimize outcomes; for this reason, patients are often transferred to the facility most equipped to render appropriate care.
      • Misra S.
      • Wilkens S.C.
      • Chen N.C.
      • Eberlin K.R.
      Patients transferred for upper extremity amputation: participation of regional trauma centers.
      ,
      • Patterson J.M.
      • Boyer M.I.
      • Ricci W.M.
      • Goldfarb C.A.
      Hand trauma: a prospective evaluation of patients transferred to a level I trauma center.
      Amputations, mutilating injuries, and dysvascular hand injuries require microvascular expertise to restore the viability of the injured parts, and these injuries can have a profound impact on patient function. These injuries may require multiple staged operations to achieve functional success.
      • Chinta M.S.
      • Wilkens S.C.
      • Vlot M.A.
      • Chen N.C.
      • Eberlin K.R.
      Secondary surgery following initial replantation/revascularization or completion amputation in the hand or digits.
      In 1986, Congress passed the Emergency Medical Treatment and Active Labor Act to provide regulations for patient transfer between facilities. Following revision of this act in 2003, hospitals are no longer mandated to have a specialist coverage (including hand surgeons) available at all times but may transfer a patient to another hospital if a higher level of care is required and available at a different facility.
      • Southard P.
      2003 “clarification” of controversial EMTALA requirement for 24/7 coverage of emergency departments by on-call specialists, significant impact on trauma centers.
      The decision about patient transfer for specialty hand surgery evaluation is complex, and there are many factors involved in the decision.
      • Drolet B.C.
      • Lifchez S.D.
      • Jacoby S.M.
      • et al.
      Perceptions of emergency medicine residency and hand surgery fellowship program directors in the appropriate disposition of upper extremity emergencies.
      ,
      • Friebe I.
      • Isaacs J.
      • Mallu S.
      • Kurdin A.
      • Mounasamy V.
      • Dhindsa H.
      Evaluation of appropriateness of patient transfers for hand and microsurgery to a level I trauma center.
      Although prohibited by law, the insurance status of the patient and the time of the week/day appear to play a role in the decision for transfer.
      • Bauer A.S.
      • Blazar P.E.
      • Earp B.E.
      • Louie D.L.
      • Pallin D.J.
      Characteristics of emergency department transfers for hand surgery consultation.
      ,
      • Eberlin K.R.
      • Hartzell T.L.
      • Kuo P.
      • Winograd J.
      • Day C.
      Patients transferred for emergency upper extremity evaluation: does insurance status matter?.
      Many emergency departments in the United States struggle with a limited supply of on-call specialists, including hand surgeons.
      • Rudkin S.E.
      • Oman J.
      • Langdorf M.I.
      • et al.
      The state of ED on-call coverage in California.
      • Rudkin S.E.
      • Langdorf M.I.
      • Oman J.A.
      • Kahn C.A.
      • White H.
      • Anderson C.L.
      The worsening of ED on-call coverage in California: 6-year trend.
      • Menchine M.D.
      • Baraff L.J.
      On-call specialists and higher level of care transfers in California emergency departments.
      This is particularly true for microvascular hand surgery emergencies; many surgeons are unable or unwilling to offer these complex operations, even at the American College of Surgeons (ACS) level 1 and level 2 trauma centers.
      • Peterson B.C.
      • Mangiapani D.
      • Kellogg R.
      • Leversedge F.J.
      Hand and microvascular replantation call availability study: a national real-time survey of level-I and level-II trauma centers.
      There are many reasons for this phenomenon, including the complexity of care required for these injuries, declining reimbursement, and the inopportune timing of these injuries.
      • Whipple L.A.
      • Kelly T.
      • Aliu O.
      • Roth M.Z.
      • Patel A.
      The crisis of deficiency in emergency coverage for hand and facial trauma: exploring the discrepancy between availability of elective and emergency surgical coverage.
      In 2007, the American Society for Surgery of the Hand (ASSH) realized the need for improved coordination and regionalization of hand trauma services in the United States and began work on the ASSH Hand Trauma Consortium in conjunction with the ACS.
      • Gittings D.J.
      • Mendenhall S.D.
      • Levin L.S.
      A decade of progress toward establishing regional hand trauma centers in the United States.
      This multiyear project has resulted in the inception of the ASSH Hand Trauma Center Network, designed to shape the landscape of hand trauma care in the United States. The purpose of this study was to summarize the findings of the ASSH’s membership surveys from the years 2010 and 2019 and to discuss future directions for the provision of emergency hand care in the United States.

      Materials and Methods

      In 2010 and 2019, the ASSH distributed a questionnaire regarding the provision of hand call to all its members. In 2010, a total of 672 surgeons completed at least part of the questionnaire (22.6%), and in 2019, a total of 1,005 surgeons completed at least part of the questionnaire (21.6%). Participation in the survey was anonymous and voluntary.
      The questionnaires assessed surgeon characteristics, including age, years in practice, board certification, practice setting, and ACS trauma certification level, and this information was collected for the year prior to distribution (ie, for the years 2009 and 2018). Additionally, the nature and financial aspects of hand call were collected. Furthermore, the factors (type and amount of reimbursement) that were reported to “increase the willingness” to take hand call in 2010, and whether the surgeons actually had experienced these factors in 2019, were recorded. The questionnaires were also used to determine the main barriers of taking hand call and whether the surgeons felt hand call was a professional obligation.
      The data were presented as frequencies and percentages per year the questionnaire was completed. To identify differences between 2010 and 2019 with regard to survey participant characteristics and hand call characteristics, the Fisher exact test was used for the explanatory variables “board certification,” “24/7 hand coverage,” and “obligation to take hand call by the hospital” and a bivariate logistic regression model was used for the explanatory variables “participant age,” “years in practice,” and “average call frequency per month.” A P value of .05 indicated statistical significance. Additionally, Cronbach’s α was calculated for all the explanatory variables.

      Results

      Most surgeons who participated were aged 31–60 years, both in 2010 (89%) and 2019 (81%); however, in 2019, there were more surgeons aged 71–80 years who participated compared to that in 2010 (15% vs 9%, respectively; P < .05) (Table 1). The surgeons were also queried about the percentage of their practices performed in different locations (each individual surgeon response totaled 100%). In 2010, the surgeons spent 47% of their practice at a free-standing ambulatory surgery center (ASC), followed by a community hospital (42%), university hospital (31%), or ASC associated with a general hospital (31%). In 2019, the surgeons practiced at a free-standing ASC 58% of their time, at university hospitals or community hospitals 41% of their time, and at an ASC associated with a general hospital 40% of their time.
      Table 1Survey Participant Characteristics
      Participant Characteristics20102019
      (n = 672)(n = 1,005)
      Age, n (%)
       <30 years1 (0.15)0
       31–40 years208 (31)288 (29)
       41–50 years204 (31)278 (28)
       51–60 years182 (27)244 (24)
       61–70 years59 (8.8)151 (15)
       71–80 years15 (2.2)34 (3.4)
       >80 years1 (0.15)9 (0.9)
      Years in practice, n (%)
       <5 years183 (27)273 (27)
       6–10 years104 (16)150 (15)
       11–15 years89 (13)118 (12)
       16–20 years112 (17)103 (10)
       21–25 years79 (12)126 (13)
       26–30 years60 (9.0)103 (10)
       >30 years43 (6.4)131 (13)
      Board certification, n (%)
       American Board of Orthopaedic Surgery521 (79)778 (78)
       American Board of Plastic Surgery89 (14)147 (15)
       American Board of Surgery46 (7.0)46 (4.6)
       American Osteopathic Board of Orthopedic Surgery025 (2.5)
      Practice setting (%)
       County hospital12%16%
       University hospital31%41%
       Community hospital42%41%
       Specialty hospital (associated with general hospital)7%10%
       Specialty hospital (free standing)11%14%
       ASC (associated with general hospital)31%40%
       ASC (free standing)47%58%
       Other12%25%
      Trauma level
       Level 1not recorded366 (37)
       Level 2not recorded344 (35)
       Level 3not recorded162 (16)
       Level 4not recorded21 (2.1)
       Level 5not recorded12 (1.2)
       Unknownnot recorded82 (8.3)
      In both 2010 and 2019, 27% of the surgeons were in practice for less than 5 years, whereas the remaining surgeons were relatively evenly spread with regards to years in practice. There were more surgeons with 16–20 years of practice in 2010 (17%) compared to that in 2019 (10%) (P < .05). Additionally, there were more surgeons with more than 30 years of practice in 2019 compared to that in 2010 (13% vs 6%, respectively; P < .05). Lastly, it was noted that there was an increase in surgeons certified by the American Osteopathic Board of Orthopedic Surgery (2010: 0; 2019: 25%) and a decrease in the percentage of surgeons certified by the American Board of Surgery (for general surgeons, 2010: 7%; 2019: 5%).
      Assessing the hand call characteristics, there was a decrease in surgeons practicing at a hospital with obligatory hand call from 2010 to 2019 (70% vs 50%, respectively; P < .05) (Table 2). Furthermore, there was a decrease in the number of surgeons taking 1–4 days of call per month (12% vs 20%, respectively; P < .05) and an increase in surgeons taking no hand call in 2019 compared to that in 2010 (34% vs 18%, respectively; P < .05) . In 2010, 73% of responding members reported 24/7 coverage for hand surgery emergencies at their facility/institution, and the percentage of responding members who reported 24/7 coverage for the same in 2019 was 70%.
      Table 2Hand Call Characteristics Reported by Surgeons
      Hand Call Characteristics20102019
      (n = 672)(n = 1,005)
      Hospital provides 24 hours a day, 7 days a week coverage, n (%)482 (73)689 (70)
      Obligation to take hand call by hospital, n (%)465 (70)490 (50)
      Average call frequency per month, n (%)
       <1 day11 (1.6)not recorded
       1–4 days132 (20)118 (12)
       5–8 days240 (36)349 (37)
       9–12 days61 (9.1)98 (10)
       13–16 days27 (4.0)36 (3.8)
       >17 days37 (5.5)27 (2.8)
       Did not take call121 (18)325 (34)
      In both 2010 and 2019, the main barrier for providing hand call was “lifestyle considerations,” 39% and 47%, respectively (Fig. 1). Notably, “increased liability risks” were a consideration in 2010 (12%) but were only seldom reported as a barrier in 2019 (2%). Other disparities were seen in the percentage of surgeons reporting “inefficient hospital environment” (2010: 5%; 2019: 9%) and “poor reimbursement by payors” (2010: 6%; 2019: 11%). The surgeons were divided on the financial benefit of taking hand call but the majority considered it a professional obligation (53–58%), and both were similar between 2010 and 2019 (Figure 2, Figure 3).
      Figure thumbnail gr1
      Figure 1Barriers to the provision of hand call services.
      Figure thumbnail gr2
      Figure 2Financial impact on hand surgeons taking call.
      Figure thumbnail gr3
      Figure 3Obligation of hand surgeons to take call.
      In the 2010 survey, 34% of surgeons were paid to take emergency hand surgery call, and this proportion did not change in 2019 (34%). In 2010, 90% of surgeons reported that a fixed reimbursement rate per hand call in addition to billed services would increase their willingness to take hand call. However, in 2019 only 48% received this type of reimbursement. Generally, $1,500 per call day was thought to be fair compensation by most surgeons (71%) as a fixed reimbursement, but in 2019, the actual fixed reimbursement was less than $1,000 in most cases (Table 3).
      Table 3Financial Perspectives Reported by Surgeons
      Financial ConsiderationsDesired in 2010Received in 2019
      Fixed reimbursement rate per call in addition to billed services90%48%
      Incentive fixed reimbursement
       $0 to $1,000 per call day35.2%32.5%
       $1,001 to $1,500 per call day36.2%12.0%
       $1,501 to $2,000 per call day13.6%2.4%
       >$2,000 per call day11.4%1.3%
      Guaranteed rate reimbursement based on Medicare case-rate
       Below Medicare rates1.0%3.4%
       Between 1x and 2x Medicare rates77.0%8.0%
       Above 2x Medicare rates15.0%0.4%
       Did not receive individual case on-call compensation in 2018n/a88.1%
      n/a, not available.
      In 2019, 42% of respondents (421/1,005) were unaware if their center was a participant in the ASSH Hand Trauma Center Network.

      Discussion

      This study summarizes the findings of 2 ASSH surveys administered to members over the past 10 years. The collected data encapsulate the sentiment of ASSH members who responded to the survey about the nature, frequency, and compensation related to the provision of emergency hand surgery call and the care of microvascular emergencies in the upper extremity. These surveys may have important implications for practicing hand surgeons in the United States.
      The Hand Trauma Network was developed by the ASSH in conjunction with the ACS, the American Society of Plastic Surgeons, and the American Academy of Orthopedic Surgery to designate centers of excellence for the provision of hand trauma. In order to be included, centers (1) must be available 24/7 for hand traumatic emergencies that include revascularization and replantation, (2) have an on-call list of available surgeons, (3) may include residents and/or fellows, (4) do not need to be a level I ACS trauma center, and (5) must have a director to verify and report data related to hand trauma.
      • Gittings D.J.
      • Mendenhall S.D.
      • Levin L.S.
      A decade of progress toward establishing regional hand trauma centers in the United States.
      This effort is underway and is designed to help patients, hospitals, and hand surgeons best facilitate care for such hand surgery emergencies.
      Overall, these findings demonstrate that certain aspects of the provision of emergency hand surgery care have not changed dramatically in the past decade, including the number of facilities that provide 24/7 emergency hand surgery call services and the percentage of hand surgeons paid to take a call. These data indicate that, despite the efforts of the ASSH to encourage regionalization of hand surgery trauma, the baseline landscape in the United States has not improved and it remains unclear how many hand surgeons are needed to provide appropriate coverage for hand injuries requiring microvascular expertise.
      • Gittings D.J.
      • Mendenhall S.D.
      • Levin L.S.
      A decade of progress toward establishing regional hand trauma centers in the United States.
      However, we did find that a greater percentage of hand surgeons takes no emergency call or limited emergency call in 2019 compared to that in 2010. This may be due to a lack of interest and/or absence of a perceived professional obligation to take an emergency call, or that regionalization has resulted in fewer centers caring for greater numbers of patients with hand trauma. In fact, there is evidence that there has been progressive decentralization of care for hand and digital amputations, resulting in lower rates of attempted replantation and decreasing the success of replantation surgery.
      • Hustedt J.W.
      • Bohl D.D.
      • Champagne L.
      The detrimental effect of decentralization in digital replantation in the United States: 15 years of evidence from the national inpatient sample.
      ,
      • Cho H.E.
      • Zhong L.
      • Kotsis S.V.
      • Chung K.C.
      Finger Replantation Optimization Study (FRONT): update on national trends.
      These responses indicate that the ASSH has additional work to do in order to further promulgate the proposed regionalization using the ASSH Hand Trauma Center Network that has been developed over the past 10 years. The inception of this network had, and continues to have, considerable challenges because participation is voluntary. Despite the extensive efforts undertaken by the ASSH in the last decade, in 2019, 42% of respondents were still not aware if their institution is part of the ASSH Hand Trauma Network. This represents a clear opportunity for improvement in the organization’s messaging to its membership and other physician groups. Although the included centers are self-designated and voluntary, these efforts will help improve awareness of centers positioned to provide emergency care for hand surgery emergencies and may streamline patient transport and referrals.
      Importantly, the most recent survey included additional data on the incentives desired by hand surgeons to take emergency hand call. The majority of ASSH members, if paid to take call, were paid less than $1,000 daily for the provision of on-call services. Additionally, only 76% of members were allowed to keep the funds for themselves; presumably, the remaining funds were directed toward the surgeons’ practices or institutions.
      There are some limitations to these data. First, the surveys administered in different years had slightly different questions and were given to members at different times. Additionally, the questions were phrased differently, and the composition of the membership at the time of each survey was not identical. The statistical analyses of the data are limited by the degree of objective and quantifiable nature of the collected data. In addition, there was a low response rate for each of the 2 surveys (22.6% and 21.6%), which may introduce participation bias into the study. Survey respondents may not be representative of the entire ASSH, and it is possible that a higher percentage of surgeons who responded considers hand trauma call a professional obligation compared with the ASSH membership as a whole. However, the calculated Cronbach’s α coefficient was 0.95, representing excellent internal consistency.
      This study also highlights the desires of practicing ASSH hand surgery members in the United States with regard to the provision of emergency hand surgery call. There are many implications for practicing hand surgeons as a result of these data. In total, these data underscore the need for greater awareness of the need for regionalization of hand surgery trauma and to identify centers of expertise that can provide these services to patients at all times and without gaps in care. These data should serve as a call for each hospital, state, and region to further develop and formalize their referral patterns for hand surgery trauma. These results also highlight the need for greater awareness within the ASSH of this important initiative as well as further dissemination of this information to state and regional emergency medicine providers to ensure that referring providers are aware of available resources.
      In response to the data gathered from these studies, the following recommendations have been proposed by the ASSH Emergency Hand Care Committee:
      • 1.
        The continued development of an emergency hand care center database, an effort already established by the ASSH and ACS (Fig. 4).
        Figure thumbnail gr4
        Figure 4Map of the ASSH National Hand Trauma Center Network.
      • 2.
        Further collaborations with emergency medicine providers and hospital emergency department professionals to educate them about the nuances of hand trauma care, and foster collaboration as a system of regionalization is further developed.
      • 3.
        Because of the often arduous nature of the provision of emergency hand care, it is recommended that hand care providers are compensated with additional remuneration beyond their base salary or other incentives. The nature of the remuneration should be dependent on region, frequency of call, and other market factors.

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