Refining quality measures for electrodiagnostic testing in suspected carpal tunnel syndrome to account for acceptable variations in practice: Expert review process.

INTRODUCTION/AIMS: Using a set of process-of-care quality measures for electrodiagnostic testing in suspected carpal tunnel syndrome (CTS), the research team previously documented large variations in electrodiagnostic testing practices and adherence to quality measures. This study sought to enhance the applicability and validity of the quality measures by integrating acceptable variations in testing practices. METHODS: We recruited 13 expert electrodiagnostic medicine specialists from five specialty societies. The experts iteratively refined five quality measures, and then rated the validity of the refined quality measures (1-9 scale). During this process, the experts reviewed data on adherence to existing quality measures and variations in electrodiagnostic testing practices, and considered recently published quality measures from the American Association of Neuromuscular and Electrodiagnostic Medicine. RESULTS: Three quality measures (electrodiagnostic testing before surgery for CTS, temperature assessment during electrodiagnostic testing, and electrodiagnostic criteria for severe median neuropathy) underwent few refinements and were rated valid (medians 8-9). Two measures (essential components of electrodiagnosis, criteria for interpreting electrodiagnostic tests as median neuropathy) were judged valid (medians 8) after revisions. For these measures, experts' ratings on the recommended components of sensory or mixed nerve conduction studies varied: agreement among the experts about the use of sensory peak latency was greater than for onset latency or sensory velocity. DISCUSSION: This study produced quality measures that provide minimum standards for electrodiagnostic testing for suspected CTS that are more comprehensive and nuanced than prior versions. Future work can assess the feasibility, reliability, and validity of these refined measures in diverse physician practices.

Care coordination across healthcare systems: development of a research agenda, implications for practice, and recommendations for policy based on a modified Delphi panel.

OBJECTIVE: For large, integrated healthcare delivery systems, coordinating patient care across delivery systems with providers external to the system presents challenges. We explored the domains and requirements for care coordination by professionals across healthcare systems and developed an agenda for research, practice and policy. DESIGN: The modified Delphi approach convened a 2-day stakeholder panel with moderated virtual discussions, preceded and followed by online surveys. SETTING: The work addresses care coordination across healthcare systems. We introduced common care scenarios and differentiated recommendations for a large (main) healthcare organisation and external healthcare professionals that contribute additional care. PARTICIPANTS: The panel composition included health service providers, decision makers, patients and care community, and researchers. Discussions were informed by a rapid review of tested approaches to fostering collaboration, facilitating care coordination and improving communication across healthcare systems. OUTCOME MEASURES: The study planned to formulate a research agenda, implications for practice and recommendations for policy. RESULTS: For research recommendations, we found consensus for developing measures of shared care, exploring healthcare professionals' needs in different care scenarios and evaluating patient experiences. Agreed practice recommendations included educating external professionals about issues specific to the patients in the main healthcare system, educating professionals within the main healthcare system about the roles and responsibilities of all involved parties, and helping patients better understand the pros and cons of within-system and out-of-system care. Policy recommendations included supporting time for professionals with high overlap in patients to engage regularly and sustaining support for care coordination for high-need patients. CONCLUSIONS: Recommendations from the stakeholder panel created an agenda to foster further research, practice and policy innovations in cross-system care coordination.

The quality of electrodiagnostic tests for carpal tunnel syndrome: Implications for surgery, outcomes, and expenditures.

INTRODUCTION: The quality of electrodiagnostic tests may influence treatment decisions, particularly regarding surgery, affecting health outcomes and health-care expenditures. METHODS: We evaluated test quality among 338 adults with workers' compensation claims for carpal tunnel syndrome. Using simulations, we examined how it influences the appropriateness of surgery. Using regression, we evaluated associations with symptoms and functional limitations (Boston Carpal Tunnel Questionnaire), overall health (12-item Short Form Health Survey version 2), actual receipt of surgery, and expenditures. RESULTS: In simulations, suboptimal quality tests rendered surgery inappropriate for 99 of 309 patients (+32 percentage points). In regression analyses, patients with the highest quality tests had larger declines in symptoms (-0.50 point; 95% confidence interval [CI], -0.89 to -0.12) and functional impairment (-0.42 point; 95% CI, -0.78 to -0.06) than patients with the lowest quality tests. Test quality was not associated with overall health, actual receipt of surgery, or expenditures. DISCUSSION: Test quality is pivotal to determining surgical appropriateness and associated with meaningful differences in symptoms and function.

Quality of electrodiagnostic testing for carpal tunnel syndrome: adherence to quality measures.

INTRODUCTION: Research has shown that quality of health-care services is often suboptimal. Little is known about the quality of electrodiagnostic testing. METHODS: We prospectively recruited 477 adults with workers' compensation claims for carpal tunnel syndrome (CTS) from 30 occupational health clinics and evaluated whether electrodiagnostic testing adhered to five process-oriented quality measures. RESULTS: Among patients who had surgery for CTS, nearly all underwent recommended preoperative electrodiagnostic testing (measure #1, 170 of 174, 97.7%). Most electrodiagnostic tests included essential components (measure #2, 295 of 379, 77.8%). However, few reports documented skin temperature (measure #3, 93 of 379, 24.5%) and criteria were seldom met for interpreting test findings as consistent with CTS (measure #4, 41 of 284, 14.4%) or "severe" CTS (measure #5, 8 of 46, 17.4%). DISCUSSION: Most patients underwent testing before surgery, but test quality was often suboptimal. This work lays the groundwork for future efforts to monitor and improve the quality of electrodiagnostic testing for CTS.