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The Effect of Decentralization in Digital Replantation: A Study of the National Inpatient Sample
Joshua W. Hustedt, MD, MHS1; Daniel D. Bohl, MD, MPH2; Michael Murri, BS3; Patricia Drace, MD4; Lloyd Champagne, MD5
1University of Arizona-Phoenix College of Medicine, Phoenix, AZ; 2Rush University Medical Center, Chicago, IL; 3Baylor College of Medicine, Houston, TX; 4Banner University Medical Center, Phoenix, AZ; 5Arizona Center for Hand Surgery, Phoenix, AZ

Introduction: Recent reports suggest a decrease in success rates in digital replantation in the United States. We hypothesize that this may be occurring due to the decentralization of replants away from centers of excellence.
Materials and Methods: All amputation injuries and digital replantations captured by the National Inpatient Sample during 1998-2012 were identified. Procedures were characterized as occurring at high-volume hospitals (>20 replants per year) versus low-volume hospitals, and as being performed by high-volume surgeons (>5 replants per year) versus low-volume surgeons. A successful procedure was defined as one in which a replantation occurred without a subsequent revision amputation. Hospital and surgeon volume were tested for association with both the year of procedure and the success of the procedure.
Results: 101,693 amputation injuries resulting in 15,822 replantations were identified. The overall rate of success of replants dropped from 74.5% during 2004-06 to 65.7% during 2010-12 (p<0.001). The percentage of high-volume centers decreased from 15.5% during 2004-06 to 8.9% during 2007-09 (p<0.001). Similarly, the percentage of high-volume surgeons decreased from 14.4% during 1998-2000 to 2.6% during 2007-09 (p<0.001). High-volume surgeons had a higher rate of success than low-volume surgeons (79.3% versus 72.2%; p<0.001). Similarly, high-volume hospitals had a higher rate of success than low-volume hospitals (77.1% versus 70.9%; p<0.001). High-volume surgeons operating at high-volume hospitals had higher success rates than low-volume surgeons operating at low-volume hospitals (92.0% versus 72.1%; p<0.001). In addition, high-volume surgeons operating at high-volume hospitals attempted replantation at greater rates than low-volume surgeons operating at low-volume centers (21.5% vs 11.0%; p<0.001). Overall, an amputation injury presenting to a high-volume surgeon at a high-volume hospital had a 2.5 times greater likelihood of obtaining a successful replantation than a low-volume surgeon at a low-volume hospital.
Conclusions: These data suggest that one possible reason for decreased success rates of digital replantation in the United States is the decentralization of digital replantation away from high-volume surgeons at high-volume hospitals. The establishment of national centers of excellence for digital replantation referral may increase overall replantation success rates in the United States.


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