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The United States healthcare system is currently experiencing profound change. Pressure to improve the quality of patient care and control costs have caused a rapid shift away from traditional volume driven fee-for-service reimbursement to value-based payment models. Under the 2015 Medicare Access CHIP (Children's Health Insurance Program) Reauthorization Act (MACRA), providers will be evaluated based on quality and cost efficiency and ultimately receive adjusted reimbursement based on their performance. Although current performance metrics do not incorporate patient reported measures, many wonder if and how patient-reported outcome measures (PROMs) will eventually fit into value-based payment reform. On November 17, 2016 the 2nd annual Patient-Reported Outcomes in Healthcare Conference brought together international stakeholders from all aspects of health care to discuss the potential role of patient reported outcomes in value-based healthcare reform. The purpose of this report is to summarize findings from this conference in the context of recent literature and guidelines to inform implementation of patient reported outcomes in value-based payment models. Recommendations for evaluating key perspectives and measurement goals are made to facilitate appropriate use of patient reported outcome measures to best benefit and amplify the voice our patients.

Articular cartilage tissue-engineering investigations often implement bioassays for chondrogenesis in vitro using articular chondrocytes or mesenchymal stem cells in cell pellets that contract with time in culture, suggesting an association between the processes of contraction of the cell pellet and cartilage formation. The objective of the present study was to investigate this relationship further using adult canine articular chondrocyte-seeded type II collagen-GAG scaffolds. The collagen-GAG scaffolds were chemically cross-linked to achieve a range of cross-link densities. Chondrocyte-seeded scaffolds of varying cross-link densities were then cultured for 2 weeks to evaluate the effect of crosslink density on scaffold contraction and chondrogenesis. Scaffolds with low cross-link densities experienced cell-mediated contraction, increased cell number densities, a greater degree of chondrogenesis (viz., chondrocytic morphology of cells, synthesis of type II collagen), and an apparent increase in the rate of degradation of the scaffold compared to more highly cross-linked scaffolds that resisted cellular contraction. The results of this study suggest the promise of "dynamic pore reduction" for scaffolds for articular cartilage tissue engineering. In this approach, scaffolds would have an initial pore diameter large enough to facilitate cell seeding and a mechanical stiffness low enough to allow for cell-mediated contraction to yield a reduced pore volume to favor chondrogenesis. This approach may provide a useful alternative to traditional means of increasing cell number density and retention of synthesized molecules that promote cartilage formation in tissue-engineered constructs.

Vascularized toe joint transfer has a worse active arc of motion and a higher complication rate when compared with silicone implant arthroplasty for both proximal interphalangeal and metacarpophalangeal joints. Early data suggest that PyroCarbon implants may be associated with higher rates of major complications. Given the lack of improvement in outcomes for posttraumatic finger joint reconstruction over the past 40 years, research efforts should focus on future development of novel arthroplasty devices.

Purpose Despite the high prevalence and impact of distal radius fractures (DRFs) on older patients, the current available literature regarding DRFs in older adults lacks adequate comparative treatment data. The purpose of this prospective, controlled outcomes study is to compare outcomes using the volar locking plating system (VLPS) for DRFs in both older and younger adults. Methods Consecutive, eligible patients were enrolled into our prospective study over a two-year period on the basis of strict inclusion/exclusion criteria. Subjects were entered into two cohorts based on age: 20–40 years and ≥ 60 years. Patient outcomes and complication rates were evaluated at three, six and twelve months after surgery. Outcome measures included the Michigan Hand Outcomes Questionnaire (MHQ), grip strength, active wrist and forearm range of motion, the Jebsen-Taylor test, and radiographic parameters. Results 55 patients (30 young and 25 older adults) with unilateral, inadequately reduced DRFs were enrolled and received surgical treatment with the VLPS. We observed no statistically significant difference in any of the outcomes for all three follow-up periods. While older age patients continued to improve throughout their twelve month postoperative visits, younger patients achieved their maximum recovery during the six month follow-up period, suggesting different recovery patterns. At the twelve-month assessment, older patients were able to achieve a higher mean MHQ score than their younger counterparts (normalized mean: 85% and 82%, respectively). Complication rates were similar between the two groups for all three time periods, with most occurring on or before the three month postoperative visit. Conclusions This study indicates that the VLPS is successful in managing DRFs in older patients and without increased complications compared to younger patients. For the older patients without prohibitive surgical risks, internal fixation using the VLPS yields comparable outcomes to younger patients. Level of Evidence Level II prospective comparative study

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Purpose Quality of life (QOL) among adolescents with neonatal brachial plexus palsy (NBPP) is an important but unexplored topic. To date, few NBPP studies use comprehensive patient-reported outcome measures, and none specifically address the adolescent population. This study explores the long-term QOL and patient expectations among adolescents with NBPP using qualitative and quantitative approaches. Methods Eighteen adolescents with residual NBPP impairment between the ages of 10 to 17 years along with their parents were included in our study. Adolescents and their parents underwent separate one hour tape-recorded semi-structured interviews, which were audio recorded and transcribed. We also collected quantitative patient outcome measures to quantify the degree of each adolescent’s functional impairment and to increase our understanding of long-term quality of life and patient expectations. Results Thirteen females and five males with a mean age of 11.6 years participated in our study. Through qualitative analysis we identified the following factors contributing to overall QOL from the patient and parent perspective: social impact and peer acceptance, emotional adjustment, aesthetic concerns and body image, functional limitations, physical and occupational therapy, finances, pain, and family dynamics. Despite residual impairment, most adolescents and their parents reported a good overall QOL according to quantitative outcome measures, with adolescents reporting slightly higher QOL than their parents. However, both adolescents and their parents report relatively modest satisfaction with their current condition and express expectations for improvement in multiple areas. Discussion Understanding patient expectations and QOL in NBPP adolescents are essential for medical decision-making and advancing care. Our study results showed that functional and aesthetic factors were responsible for the majority of observed differences in QOL among NBPP adolescents. We also found that the PODCI might be more sensitive than the CHQ in assessing patient expectations and quality of life among this patient population.

Applicants value personal contact and time spent in general surgery when selecting residency programs. As the number of integrated programs continues to grow, programs will benefit from learning what factors their applicants value most.