Tennessee Emergency Hand Care Distributions and Disparities: Emergent Hand Care Disparities

Abstract

Background Hand trauma is the most frequently treated injury in emergency departments, but presently there is a crisis of insufficient emergency coverage. This study evaluates the discrepancy of emergent and elective hand care trends based on socioeconomic factors in the state of Tennessee. Methods We identified 119 hospitals in Tennessee that contained operating and emergency room facilities. Of these, 111 hospitals participated in a survey to determine the availability of elective and emergency hand surgery. Wilcoxon rank-sum test or permutation chi-square test and logistic regression were used to analyze reported measures.Results Our results revealed that hospitals in counties with the lowest per capita income and median household income are less likely to have hand specialists or offer hand call. There are also significantly fewer hospitals that have hand specialists and offer hand call that are located in medically underserved areas. In the state of TN, level 1 trauma facilities are required by the Tennessee Department of Health to have staffed hand specialists and 24/7 hand call. Our study revealed that while 7/8 (87.5 %) level 1 trauma facilities have hand specialists, only 2/8 (25 %) provide 24/7 hand specialist call. Conclusion Our results strongly suggest the presence of a health care disparity for hand trauma in counties with a low income and in medically underserved areas.

Inequalities in Specialist Hand Surgeon Distribution across the United States

“…This finding is consistent with previous work that found that poor counties in Tennessee are underserved by hand surgeons. 7 It has also been demonstrated in other health care systems: in Germany, every percentage change in the prevalence of people with comprehensive health insurance is associated with a 2.1 percent increase in hospital specialist density. 15 Furthermore, it is likely that this pattern contributes to the difficulties some hospitals face in accessing specialist hand services.…”

“…Other contributory factors may include physician preference for elective ambulatory care without on-call responsibility 6 and socioeconomic incentives. 7 Financial incentives might play a role in surgeon density, and government payers are likely a significant contributor in low-socioeconomicstatus states. Further studies should consider subspecialist hand surgeon income in well-served and underserved states to determine whether this is a factor driving distribution.…”

“…5 In Florida, only 38.5 percent of hospitals treating injured patients have a specialist hand surgeon available at all times 6 and, although Level I trauma centers in Tennessee are mandated to have a hand specialist available out of hours, only 25 percent fulfilled this requirement in 2013. 7 A previous effort made by the American Society for Surgery of the Hand Task Force described the national number of hand surgery fellowships, applicants, graduates, and board certification status (Subspecialty Certificate in Surgery of the Hand). However, this study focused on the typical career pathways of hand surgeons rather than the actual distribution of hand surgeons across the United States.…”

The Use of Telemedicine Decreases Unnecessary Hand Trauma Transfers

“…A survey in 2010 determined that 51% of emergency departments (EDs) reported inadequate orthopedic coverage, while 80% reported inadequate hand surgery coverage specifically. 3,4 With the shortage of hand surgeons to evaluate and treat the existing volume of traumatic hand injuries, telemedicine in this subspecialty has been suggested as a possible adjunct in care and a useful solution. 5,6 There is an estimated incidence of 1130 upper extremity injuries per 100 000 persons per year, but in some instances with limited access or lack of access to a specialty provider for consultation.…”

Comparison of Hand Emergency Triage before and after Specialty Templates (2007 vs. 2012)

“…There is a known lack of emergency hand services in the US [8]. Counties that are medically underserved and with low income tend to have difficulty finding emergency hand coverage [1]. Surgical specialists have been steadily dropping their hand call privileges due to financial pressures, medico-legal risk, specialty competence, and time requirements [4].…”