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Risk Factors for Emergency Department Visits After Upper Extremity Surgery

Shetty, Pragna N. MPH; Sanghavi, Kavya K. MPH; Giladi, Aviram M. MD, MS

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Plastic and Reconstructive Surgery - Global Open: September 2020 - Volume 8 - Issue 9S - p 101-102
doi: 10.1097/
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PURPOSE: The “global period” after most upper extremity surgeries includes coverage of postoperative visits and routine care with no additional copay or coinsurance for 90 days. Despite this, patients often present to their local emergency department (ED) after surgery with concerns that could be addressed in clinic, resulting in increased costs, overutilization of ED services, and in many systems, negative quality scores for the hospital or surgeon. We examined patient-reported questionnaire data to identify if patient responses indicate risk of subsequent presentation at an emergency department within the 90-day global period after surgery.

METHODS AND MATERIALS: All adult patients who underwent surgery at our hand center between January 1, 2018 and August 31, 2019 and consented to data use for research were included. The patients’ medical record numbers were used to identify ED visits anywhere in our health system within 90 days of surgery. Presenting diagnosis was used to identify patients with surgery-related complaints. Preoperative and postoperative questionnaires, including the brief Michigan Hand Questionnaire (bMHQ), the Patient-Reported Outcome Measuring Information System (PROMIS) Upper Extremity (UE) and Pain Interference (PI), pain scores, and postoperative satisfaction scores from the first postoperative visit were collected prospectively. Satisfaction and pain were scored from 0 to 10; 10 is highest satisfaction and highest pain score.

RESULTS: Our cohort included 2,056 patients, with 1,033 (50.2%) females and 1,023 (49.8%) males. Sixty-one (3.0%) presented to the ED with hand-related or surgery-related complaints within 90 days after surgery. Preoperative pain scores were higher in the group that presented to the ED compared to those that did not (7 versus 4; P < 0.001), and for every unit increase in preoperative pain, patients were 1.2 times more likely to return to the ED within the global period (P < 0.001) after surgery. Patients who presented to the ED also had preoperative bMHQ scores 14.6 points lower (P < 0.001) and preoperative PROMIS PI scores 5.2 points higher than their counterparts (P = 0.005). Postoperative satisfaction scores were significantly lower in patients who subsequently presented to the ED (8.1 versus 9.1; P < 0.001), whereas other postoperative questionnaire scores were not found to significantly predict likelihood of an ED visit.

CONCLUSIONS: Patients who presented to the ED within the global period had significantly higher preoperative pain scores, significantly worse preoperative bMHQ and PROMIS PI scores, and significantly lower postoperative satisfaction scores. These patient-reported scores were associated with an increased likelihood of presenting to the ED for management of a hand or postoperative issue during the global period. These patients should be identified early and counseled on their healthcare options in order to improve value-based care and decrease healthcare utilization.

Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved.