Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor.
The George Washington University School of Medicine and Health Sciences, Washington, DC.
JAMA Netw Open. 2021 Feb 1;4(2):e2036297. doi: 10.1001/jamanetworkopen.2020.36297.
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.
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.
Interfacility transfer, defined as transfer of a patient from 1 hospital to another to obtain care for traumatic thumb amputation.
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.
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.
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.
由于拇指在手部功能中占 40%，因此外伤性拇指损伤的再植与生活质量的显著改善有关。然而，美国每年进行的再植手术却越来越少，这与手术专业知识的减少以及未来再植失败的风险增加有关。因此，进一步研究了解医院间转移和医院特征与结果之间的关系是有必要的。
评估医院间转移、患者特征和医院因素与拇指再植尝试和成功的关系。
设计、地点和参与者：这项横断面研究使用了 2009 年至 2016 年美国国家创伤数据库的数据，纳入了接受过再植或 Revision 手术的成年外伤性拇指完全离断伤患者。数据分析于 2020 年 5 月 4 日至 2020 年 7 月 20 日进行。
医院间转移，定义为将患者从一家医院转移到另一家医院以获得外伤性拇指离断伤的治疗。
再植尝试和再植成功，定义为在同一次住院期间接受了再植但没有随后进行 Revision 手术。采用多水平逻辑回归模型评估医院间转移、患者特征和医院因素与再植结果的关系。
在本分析中，纳入了 3670 名患者，其中 3307 名（90.1%）为男性，2713 名（73.9%）为白人；平均（SD）年龄为 45.8（16.5）岁。共有 1881 名患者（51.2%）被转移到另一家医院；这些患者大多为男性（1720 名[91.4%]）和白人（1420 名[75.5%]）。在控制了患者和医院特征后，未参保的患者拇指再植尝试的可能性较小（比值比[OR]，0.61；95%CI，0.470.78）或再植成功的可能性较小（OR，0.64；95%CI，0.490.84）。医院间转移与再植尝试的可能性增加有关（OR，1.34；95%CI，1.131.59），其中 13%的差异存在于医院水平。医院间转移也与再植成功率的增加有关（OR，1.23；95%CI，1.031.47），其中 14%的差异存在于医院水平。
在这项横断面研究中，医院间转移，特别是医院层面的差异，与拇指再植尝试和成功的增加有关。这些发现表明，需要制定政策鼓励有再植专业知识的医院为外伤性拇指离断伤提供治疗，包括促进再植治疗的集中化。
