Changes in illness perception, pain catastrophizing, and psychological distress following hand surgeon consultation: A prospective study.

BACKGROUND: Baseline mindset factors are important factors that influence treatment decisions and outcomes. Theoretically, improving the mindset prior to treatment may improve treatment decisions and outcomes. This prospective cohort study evaluated changes in patients' mindset following hand surgeon consultation. Additionally, we assessed if the change in illness perception differed between surgical and nonsurgical patients. METHODS: The primary outcome was illness perception, measured using the total score of the Brief Illness Perception Questionnaire (B-IPQ, range 0-80). Secondary outcomes were the B-IPQ subscales, pain catastrophizing (measured using the Pain Catastrophizing Scale (PCS)), and psychological distress (measured using the Patient Health Questionnaire-4). RESULTS: A total of 276 patients with various hand and wrist conditions completed the mindset questionnaires before and after hand surgeon consultation (median time interval: 15 days). The B-IPQ total score improved from 39.7 (±10.6) before to 35.8 (±11.3) after consultation (p < 0.0001, Cohen's d = 0.36); scores also improved for the B-IPQ subscales Coherence, Concern, Emotional Response, Timeline, Treatment Control, and Identity and the PCS. There were no changes in the other outcomes. Surgical patients improved on the B-IPQ subscales Treatment Control and Timeline, while nonsurgical patients did not. CONCLUSIONS: Illness perception and pain catastrophizing improved following hand surgeon consultation, suggesting that clinicians may actively influence the patients' mindset during consultations, and that they may try to enhance this effect to improve outcomes. Furthermore, surgical patients improved more in illness perceptions, indicating that nonsurgical patients may benefit from a more targeted strategy for changing mindset.

High Quality of Care Delivery Improves Patient Satisfaction and Quality of Life Outcomes After Breast Augmentation.

BACKGROUND: Breast augmentation is one of the most common aesthetic procedures worldwide. Most studies focused on evaluating the outcome with validated patient-reported outcome measures (PROMs) and factors that may influence them. However, the influence of care delivery, which can be measured with patient-reported experience measures (PREMs), is scarce in breast augmentation patients. OBJECTIVES: This study aimed to evaluate the associations between PREMs and PROMs in patients who underwent breast augmentation. METHODS: A multicenter cohort study was conducted in breast augmentation patients. Patients completed PREMs, including aspects such as communication between physician and patient, expectation management, welcome, and hygiene and the BREAST-Q PROM Satisfaction with Breasts, Psychosocial-, Physical- and Sexual well-being, preoperatively and six-months postoperatively. Regression analyses were used to investigate the associations between PREMs and PROMs. RESULTS: Overall, 329 patients were included between 2018-2022. Univariate regression analysis showed a positive association between PREMs and PROMs scales. The aspects of the feeling of being heard (B=-38.39 and B=-18.90), the opportunity to ask questions (B=-9.21) and trust in their physician (B=-39.08) had the highest association with the change in the four BREAST-Q scales. The multivariable regression analysis showed that the variance in PROMs related to changes in PREMs (19%) was hardly influenced by patient characteristics (1%). CONCLUSIONS: Patient outcomes are more positive after breast augmentation when patients feel they are being heard, have the opportunity to ask questions and have trust in their physician. Future studies should be targeted at optimizing patient-reported experience to investigate whether this would improve patient-reported outcomes.

Algorithm Versus Expert: Machine Learning Versus Surgeon-Predicted Symptom Improvement After Carpal Tunnel Release.

BACKGROUND AND OBJECTIVES: Surgeons rely on clinical experience when making predictions about treatment effects. Incorporating algorithm-based predictions of symptom improvement after carpal tunnel release (CTR) could support medical decision-making. However, these algorithm-based predictions need to outperform predictions made by surgeons to add value. We compared predictions of a validated prediction model for symptom improvement after CTR with predictions made by surgeons. METHODS: This cohort study included 97 patients scheduled for CTR. Preoperatively, surgeons estimated each patient's probability of improvement 6 months after surgery, defined as reaching the minimally clinically important difference on the Boston Carpal Tunnel Syndrome Symptom Severity Score. We assessed model and surgeon performance using calibration (calibration belts), discrimination (area under the curve [AUC]), sensitivity, and specificity. In addition, we assessed the net benefit of decision-making based on the prediction model's estimates vs the surgeon's judgement. RESULTS: The surgeon predictions had poor calibration and suboptimal discrimination (AUC 0.62, 95%-CI 0.49-0.74), while the prediction model showed good calibration and appropriate discrimination (AUC 0.77, 95%-CI 0.66-0.89, P = .05). The accuracy of surgeon predictions was 0.65 (95%-CI 0.37-0.78) vs 0.78 (95%-CI 0.67-0.89) for the prediction model ( P = .03). The sensitivity of surgeon predictions and the prediction model was 0.72 (95%-CI 0.15-0.96) and 0.85 (95%-CI 0.62-0.97), respectively ( P = .04). The specificity of the surgeon predictions was similar to the model's specificity ( P = .25). The net benefit analysis showed better decision-making based on the prediction model compared with the surgeons' decision-making (ie, more correctly predicted improvements and/or fewer incorrectly predicted improvements). CONCLUSION: The prediction model outperformed surgeon predictions of improvement after CTR in terms of calibration, accuracy, and sensitivity. Furthermore, the net benefit analysis indicated that using the prediction model instead of relying solely on surgeon decision-making increases the number of patients who will improve after CTR, without increasing the number of unnecessary surgeries.

Explaining Personalized Activity Limitations in Patients With Hand and Wrist Disorders: Insights from Sociodemographic, Clinical, and Mindset Characteristics.

OBJECTIVES: To investigate the association of sociodemographic, clinical, and mindset characteristics on outcomes measured with a patient-specific patient-reported outcome measure (PROM); the Patient Specific Functional Scale (PSFS). Secondly, we examined whether these factors differ when a fixed-item PROM, the Michigan Hand Outcome Questionnaire (MHQ), is used as an outcome. DESIGN: Cohort study, using the aforementioned groups of factors in a hierarchical linear regression. SETTING: Twenty-six clinics for hand and wrist conditions in the Netherlands. PARTICIPANTS: Two samples of patients with various hand and wrist conditions and treatments: n=7111 (PSFS) and n=5872 (MHQ). INTERVENTIONS: NA. MAIN OUTCOME MEASURES: The PSFS and MHQ at 3 months. RESULTS: The PSFS exhibited greater between-subject variability in baseline, follow-up, and change scores than the MHQ. Better PSFS outcomes were associated with: no involvement in litigation (ß[95% confidence interval=-0.40[-0.54;-0.25]), better treatment expectations (0.09[0.06;0.13]), light workload (0.08[0.03;0.14]), not smoking (-0.07[-0.13;-0.01]), men sex (0.07[0.02;0.12]), better quality of life (0.07[0.05;0.10]), moderate workload (0.06[0.00;0.13]), better hand satisfaction (0.05[0.02; 0.07]), less concern (-0.05[-0.08;-0.02]), less pain at rest (-0.04[-0.08;-0.00]), younger age (-0.04[-0.07;-0.01]), better comprehensibility (0.03[0.01;0.06]), better timeline perception (-0.03[-0.06;-0.01]), and better control (-0.02[-0.04;-0.00]). The MHQ model was highly similar but showed a higher R2 than the PSFS model (0.41 vs 0.15), largely due to the R2 of the baseline scores (0.23 for MHQ vs 0.01 for PSFS). CONCLUSIONS: Health care professionals can improve personalized activity limitations by addressing treatment expectations and illness perceptions, which affect PSFS outcomes. Similar factors affect the MHQ, but the baseline MHQ score has a stronger association with the outcome score than the PSFS. While the PSFS is better for individual patient evaluation, we found that it is difficult to explain PSFS outcomes based on baseline characteristics compared with the MHQ. Using both patient-specific and fixed-item instruments helps health care professionals develop personalized treatment plans that meet individual needs and goals.

Driving Factors of Recommending a Hand Surgery Clinic After Surgery.

PURPOSE: Since a patient's recommendation of a clinic to others is an important indicator of patient experience, more insight is needed into the underlying factors that motivate such recommendations. This retrospective cohort study assessed the relative contribution of the following: (1) patient-related characteristics, (2) treatment outcome, (3) satisfaction with treatment outcome, and (4) patients' experience with the process of care to patients' recommendation of a specific clinic after elective surgery. METHODS: Patients of specialized outpatient hand surgery clinics (N = 6,895) reported the likelihood of recommending the clinic to friends or family 3-5 months after surgery by filling in the Net Promoter Score. Potential predictors of the Net Promoter Score were preoperative patient characteristics, patient-reported treatment outcomes, satisfaction with treatment outcome, and experience with several health care delivery domains. Linear regression analyses were used to examine the contribution of the predictors. RESULTS: Mean age of the patients was 53 (SD, 14) years, 62.5% were women, and 62.5% were employed. Preoperative patient characteristics explained 1% of the variance in clinic recommendations. An additional 6% was explained by the treatment outcome, 21.6% by satisfaction with treatment outcome, and 33.8% by patients' experience with care delivery (total explained variance was 62.3%). The strongest independent predictors of clinic recommendations were positive experiences with the quality of the facilities and the communication skills of the physician. CONCLUSIONS: Patient recommendations are more strongly driven by patients' experience with care delivery than by treatment outcome and patient characteristics. CLINICAL RELEVANCE: In elective surgery, improving patient experiences is pivotal in boosting patient recommendation of the clinic.

Tailoring and evaluating treatment with the Patient-Specific Needs Evaluation: A Patient-Centered Approach.

BACKGROUND: No patient-reported instrument assesses patient-specific information needs, treatment goals, and Personal Meaningful Gain (PMG, a novel construct evaluating individualized, clinically relevant improvement). This study reports the development of the Patient-Specific Needs Evaluation (PSN) and examines its discriminative validity (i.e., its ability to distinguish satisfied from dissatisfied patients) and test-retest reliability in patients with hand or wrist conditions. METHODS: A mixed-methods approach was used to develop and validate the PSN, following COSMIN guidelines, including pilot testing, a survey (pilot: n=223, final PSN: n=275), cognitive debriefing (n=16), expert input, and validation. Discriminative validity was assessed by comparing the satisfaction level of patients who did or did not achieve their PMG (n=1,985) and test-retest reliability using absolute agreement, Cohen's kappa, and ICCs (n=102). We used a sample of 2,860 patients to describe responses to the final PSN. RESULTS: The PSN has only five questions (completion time ±3 minutes) and is freely accessible online. The items and response options were considered understandable by 90-92% and complete by 84-89% of the end-users. The PSN had excellent discriminative validity (Cramer's V: 0.48, p<0.001) and moderate to high test-retest reliability (Kappa: 0.46-0.68, ICCs: 0.53-0.73). CONCLUSIONS: The PSN is a freely available patient-centered decision-support tool that helps clinicians tailor their consultations to the patient's individual needs and goals. It contains the PMG, a novel construct evaluating individualized, clinically relevant treatment outcomes. The PSN may function as a conversation starter, facilitate expectation management, and aid shared decision-making. The PSN is implementation-ready and can be readily adapted to other patient populations. LEVEL OF EVIDENCE: I.

Long-Term Outcomes of Nonsurgical Treatment of Thumb Carpometacarpal Osteoarthritis: A Cohort Study.

BACKGROUND: Although nonsurgical treatment of thumb carpometacarpal (CMC-1) osteoarthritis (OA) provides short-term improvement, the durability of these effects beyond 1 year is unknown. In this study, we investigated patient-reported pain and limitations in activities of daily living (ADL) at >5 years following nonsurgical treatment (i.e., exercise therapy and use of an orthosis) for CMC-1 OA. We hypothesized that pain and limitations in ADL would not worsen after 12 months. Secondary outcomes were satisfaction with treatment results and health-related quality of life at >5 years of follow-up and the rate of conversion to surgery. METHODS: This was a multicenter, prospective cohort study using 2 overlapping samples. The change in the Michigan Hand Outcomes Questionnaire (MHQ) subscales of pain and ADL between 12 months and >5 years was the primary outcome as measured in the first sample (n = 170), which consisted of patients who did not undergo conversion to surgery. Additional measurement time points included baseline and 3 months. We evaluated conversion to surgery in a second sample, which included all patients who responded to the invitation for this follow-up study (n = 217). RESULTS: At a median follow-up of 6.6 years (range, 5.1 to 8.7 years), the score on the MHQ pain subscale did not differ significantly from that at 12 months. The score on the MHQ ADL improved by 4.4 points (95% confidence interval [CI],1.5 to 7.2) compared with 12 months, but this was not clinically relevant. At >5 years, 5% of the patients rated their satisfaction as "poor," 14% as "moderate," 26% as "fair," 39% as "good," and 16% as "excellent." The median EuroQol-5 Dimensions-5 Levels (EQ-5D-5L) index score was 0.852 (range, 0.135 to 1). The rate of conversion to surgery was 22% (95% CI,16.4% to 27.7%) at a median follow-up of 7 years (range, 5.5 to 9.0 years). CONCLUSIONS: We found positive outcomes at >5 years of follow-up for nonsurgical treatment of CMC-1 OA, with no worsening of pain or of limitations in ADL after 12 months. Our findings support nonsurgical treatment as the first treatment choice and suggest that treatment effects are sustainable. LEVEL OF EVIDENCE: Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

Factors Associated with Treatment Outcome Satisfaction Six Months after Upper Blepharoplasty: A Large Cohort Study.

Background: Upper blepharoplasty is the most popular facial cosmetic surgery. Although there are a variety of reasons to undergo this procedure, all patients expect an optimal cosmetic result. However, little is known about the factors that influence satisfaction with treatment outcome. Objectives: We assessed to what extent patient characteristics, clinician-rated and postsurgical outcome measures, and patient-reported satisfaction with facial appearance and quality-of-life are associated with patient-reported satisfaction with treatment outcome after a primary upper blepharoplasty. Methods: This study was performed in 583 patients with an upper blepharoplasty between 2016 and 2021. The primary outcome was satisfaction with treatment outcome 6 months postoperatively using the FACE-Q. Determinants were baseline patient characteristics (demographics), preoperative and postoperative clinician-rated and surgical outcome measures, and preoperative and postoperative FACE-Q appearance and quality-of-life scales. Hierarchical linear regression analysis was used to determine how much of the variance in satisfaction with outcome could be explained by these groups of determinants. Results: A total of 63% of the variance could be explained by the five groups of determinants of which 8% was explained by the baseline patient characteristics and clinician-rated and patient-reported outcomes together, another 8% by the postoperative clinician-rated outcomes, and the remaining 47% by the postoperative patient-reported outcomes. Conclusions: Patient characteristics, clinician-rated outcome measures, and baseline FACE-Q appearance and quality-of-life scores were of limited value in explaining satisfaction with treatment outcome. However, the postoperative FACE-Q appearance scale and the decision to undergo a blepharoplasty were strongly associated with satisfaction with treatment outcome.

Changes in illness perception, pain catastrophizing, and psychological distress following hand surgeon consultation: A prospective study.

BACKGROUND: Baseline mindset factors are important factors that influence treatment decisions and outcomes. Theoretically, improving the mindset prior to treatment may improve treatment decisions and outcomes. This prospective cohort study evaluated changes in patients' mindset following hand surgeon consultation. Additionally, we assessed if the change in illness perception differed between surgical and nonsurgical patients. METHODS: The primary outcome was illness perception, measured using the total score of the Brief Illness Perception Questionnaire (B-IPQ, range 0-80). Secondary outcomes were the B-IPQ subscales, pain catastrophizing (measured using the Pain Catastrophizing Scale (PCS)), and psychological distress (measured using the Patient Health Questionnaire-4). RESULTS: A total of 276 patients with various hand and wrist conditions completed the mindset questionnaires before and after hand surgeon consultation (median time interval: 15 days). The B-IPQ total score improved from 39.7 (±10.6) before to 35.8 (±11.3) after consultation (p < 0.0001, Cohen's d = 0.36); scores also improved for the B-IPQ subscales Coherence, Concern, Emotional Response, Timeline, Treatment Control, and Identity and the PCS. There were no changes in the other outcomes. Surgical patients improved on the B-IPQ subscales Treatment Control and Timeline, while nonsurgical patients did not. CONCLUSIONS: Illness perception and pain catastrophizing improved following hand surgeon consultation, suggesting that clinicians may actively influence the patients' mindset during consultations, and that they may try to enhance this effect to improve outcomes. Furthermore, surgical patients improved more in illness perceptions, indicating that nonsurgical patients may benefit from a more targeted strategy for changing mindset.

"Patient-Reported Satisfaction and Health-Related Quality of Life in Patients with Breast Augmentation: A follow-up of six months".

BACKGROUND: To evaluate the success of a breast augmentation, it is essential to measure outcomes from the patient perspective since a successful aesthetic result is especially determined by the patient. This study aimed to evaluate patient-reported satisfaction with their breasts, psychosocial, physical, and sexual well-being in patients undergoing breast augmentation using validated questionnaires. METHODS: This is a multicenter cohort study based on ongoing routinely-collected data. Patient-reported satisfaction and health-related quality of life were assessed with the BREAST-Q Augmentation Module at intake and six months postoperatively. RESULTS: A total of 1405 patients were included. Large changes in BREAST-Q scores (range, 0-100) between intake and six months postoperatively were seen: satisfaction with their breasts (mean, effect size: +57, 3.8), psychosocial well-being (+38, 2.1), physical well-being (-14, -1.2), and sexual well-being (+44, 2.4). Moreover, improvements in all four scales were not dependent on their intake scores and all postoperative scores reached similar levels. A decreased physical well-being of the chest was measured post-surgery. The satisfaction with the breasts scale correlated moderately to strongly with the psychosocial and sexual well-being scale 6 months post-surgery. Subgroup analysis based on patient characteristics found no differences in outcomes, except for BMI. CONCLUSION: Significant improvement in patient-reported satisfaction with their breasts, psychosocial, and sexual well-being can be seen six months after breast augmentation despite a declined physical well-being after treatment. Postoperative satisfaction levels do not depend on preoperative scores. These insights can contribute to improve preoperative communication between surgeon and patient regarding the expected outcomes.

The Ultrashort Mental Health Screening Tool Is a Valid and Reliable Measure With Added Value to Support Decision-making.

BACKGROUND: Mental health influences symptoms, outcomes, and decision-making in musculoskeletal healthcare. Implementing measures of mental health in clinical practice can be challenging. An ultrashort screening tool for mental health with a low burden is currently unavailable but could be used as a conversation starter, expectation management tool, or decision support tool. QUESTIONS/PURPOSES: (1) Which items of the Pain Catastrophizing Scale (PCS), Patient Health Questionnaire (PHQ-4), and Brief Illness Perception Questionnaire (B-IPQ) are the most discriminative and yield a high correlation with the total scores of these questionnaires? (2) What is the construct validity and added clinical value (explained variance for pain and hand function) of an ultrashort four-item mental health screening tool? (3) What is the test-retest reliability of the screening tool? (4) What is the response time for the ultrashort screening tool? METHODS: This was a prospective cohort study. Data collection was part of usual care at Xpert Clinics, the Netherlands, but prospective measurements were added to this study. Between September 2017 and January 2022, we included 19,156 patients with hand and wrist conditions. We subdivided these into four samples: a test set to select the screener items (n = 18,034), a validation set to determine whether the selected items were solid (n = 1017), a sample to determine the added clinical value (explained variance for pain and hand function, n = 13,061), and a sample to assess the test-retest reliability (n = 105). Patients were eligible for either sample if they completed all relevant measurements of interest for that particular sample. To create an ultrashort screening tool that is valid, reliable, and has added value, we began by picking the most discriminatory items (that is, the items that were most influential for determining the total score) from the PCS, PHQ-4, and B-IPQ using chi-square automated interaction detection (a machine-learning algorithm). To assess construct validity (how well our screening tool assesses the constructs of interest), we correlated these items with the associated sum score of the full questionnaire in the test and validation sets. We compared the explained variance of linear models for pain and function using the screening tool items or the original sum scores of the PCS, PHQ-4, and B-IPQ to further assess the screening tool's construct validity and added value. We evaluated test-retest reliability by calculating weighted kappas, ICCs, and the standard error of measurement. RESULTS: We identified four items and used these in the screening tool. The screening tool items were highly correlated with the PCS (Pearson coefficient = 0.82; p < 0.001), PHQ-4 (0.87; p < 0.001), and B-IPQ (0.85; p < 0.001) sum scores, indicating high construct validity. The full questionnaires explained only slightly more variance in pain and function (10% to 22%) than the screening tool did (9% to 17%), again indicating high construct validity and much added clinical value of the screening tool. Test-retest reliability was high for the PCS (ICC 0.75, weighted kappa 0.75) and B-IPQ (ICC 0.70 to 0.75, standard error of measurement 1.3 to 1.4) items and moderate for the PHQ-4 item (ICC 0.54, weighted kappa 0.54). The median response time was 43 seconds, against more than 4 minutes for the full questionnaires. CONCLUSION: Our ultrashort, valid, and reliable screening tool for pain catastrophizing, psychologic distress, and illness perception can be used before clinician consultation and may serve as a conversation starter, an expectation management tool, or a decision support tool. The clinical utility of the screening tool is that it can indicate that further testing is warranted, guide a clinician when considering a consultation with a mental health specialist, or support a clinician in choosing between more invasive and less invasive treatments. Future studies could investigate how the tool can be used optimally and whether using the screening tool affects daily clinic decisions. LEVEL OF EVIDENCE: Level II, diagnostic study.

Outcomes of an exercise program in patients with dorsal or volar midcarpal laxity: a cohort study of 213 patients.

PURPOSE: Describing the outcomes of an exercise program on wrist and hand function for patients with midcarpal instability (MCI). MATERIALS AND METHODS: This study has a prospective cohort design. Two hundred and thirteen patients with MCI were included. The intervention was a 3-month exercise program consisting of hand therapy and home exercises. The primary outcome was perceived wrist and hand function evaluated with the Patient-Rated Wrist/Hand Evaluation (PRWHE) three months after treatment onset. Secondary outcomes were conversion to surgery, pain, and satisfaction with treatment results. RESULTS: PRWHE total scores improved from 51 ± 19 (mean ± SD) to 33 ± 24 at 3 months (95% CI: 36-30, p < 0.001). All visual analog scales for pain demonstrated clinically relevant improvements at 6 weeks and 3 months (p < 0.001). At 3 months, 81% of the participants would undergo the treatment again. After a median follow-up of 2.8 years, 46 patients (22%) converted to surgery. CONCLUSIONS: We found clinically relevant improvements in hand and wrist function and pain. Most participants would undergo treatment again and 78% of the participants did not convert to surgery. Hence, non-invasive treatment should be the primary treatment choice for patients with MCI.

Midcarpal instability (MCI) is a disabling condition and treatment options are limited.Patients with MCI can benefit from an exercise program aiming to improve the strength and coordination of the wrist muscles.Participants improved in hand/wrist function and 78% did not convert to surgery.Non-invasive treatment should be the primary treatment choice for these patients.

Prevalence of Complications and Association With Patient-Reported Outcomes After Trapeziectomy With a Weilby Sling: A Cohort Study.

PURPOSE: The primary aim of this study was to report complications during the first year after trapeziectomy with Weilby sling using a standardized tool designed by the International Consortium for Health Outcome Measures. The secondary aim was to determine the association of complications and patient-reported outcomes 12 months after surgery. METHODS: We included patients who underwent trapeziectomy with Weilby sling between November 2013 and December 2018. All complications during the first year were scored using the International Consortium for Health Outcomes Measurement Complications in Hand and Wrist conditions (ICHAW) tool. Pain and hand function were measured before surgery and 12 months after surgery using the Michigan Hand Outcomes Questionnaire (MHQ). Minimally Important Change thresholds of 18.6 for MHQ pain and 9.4 for MHQ function were used to determine clinical importance. RESULTS: Of 531 patients after trapeziectomy with Weilby sling, 65% had an uneventful recovery, 16% experienced ICHAW Grade 1 deviations only, and 19% experienced Grade 2 or 3 deviations, including requiring antibiotics, corticosteroid injections, or additional surgery. On average, patients improved in pain and hand function, even in the presence of ICHAW events. Although all ICHAW grades were associated with poorer patient-reported outcomes 12 months after surgery, Grade 2 and 3 exceeded the Minimally Important Change threshold for pain and/or function. CONCLUSIONS: In 531 patients, 65% had an uneventful recovery, 16% experienced ICHAW Grade 1 deviations only, and 19% experienced grade 2 or 3 deviations. We recommend describing Grade 1 as "adverse protocol deviations" and grade 2 and 3 as complications, because of clinically relevant poorer patient-reported outcomes 12 months after surgery. The ICHAW is a promising tool to evaluate systematically and compare complications in hand surgery, although we recommend further evaluation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Factors associated with self-reported pain and hand function following dorsal wrist ganglion excision.

This study aimed to analyse which factors contribute to pain and limited hand function after dorsal wrist ganglion excision. We included 308 patients who underwent surgery between September 2017 and August 2021. Patients completed baseline questionnaires and the patient-rated wrist/hand evaluation questionnaire at baseline and 3 months postoperatively. We observed an improvement in postoperative pain and hand function, but individual outcomes were highly variable. We performed stepwise linear regression analyses to examine which patient characteristics, disease characteristics and psychological factors were associated with postoperative pain and hand function. Higher postoperative pain intensity was associated with recurrence following previous surgery, treatment of the dominant hand, higher baseline pain intensity, lower credibility the patient attributes to the treatment and longer symptom duration. Worse hand function was associated with recurrence following prior surgery, worse baseline hand function and lower treatment credibility. Clinicians should take these findings into account during patient counselling and expectation management.Level of evidence: II.

Treatment Invasiveness and Illness Perceptions Are Strongly Associated With Outcome Expectations in Patients Treated for Hand or Wrist Conditions: A Cross-sectional Study.

BACKGROUND: Multiple studies have shown that more-positive outcome expectations are associated with better treatment outcomes. Although this has not been shown to represent a causal relationship, there nonetheless is an interest in positively modifying outcome expectations to improve treatment outcomes. However, little is known about what is independently associated with outcome expectations in clinical practice. For example, it is unknown to what extent expectations are associated with treatment or patient characteristics such as sociodemographics or with patient-reported outcome measures (PROMs) on patient perceptions of physical or mental health or illness. Studying factors associated with outcome expectations may provide relevant information for clinicians and researchers aiming to improve outcome expectations. Improving expectations might, in turn, improve treatment outcomes. QUESTION/PURPOSE: Which factors (that is, sociodemographics, PROMs, illness perceptions, treatment, surgeon, and location) are independently associated with outcome expectations in patients with hand or wrist conditions? METHODS: This was a cross-sectional study. Between July 2018 and December 2021, we screened 21,327 patients with a diagnosed hand or wrist condition with complete baseline sociodemographic data such as age and workload. Sixty percent (12,765 of 21,327) of patients completed all relevant PROMs. We excluded patients receiving rare treatments, leaving 58% (12,345 of 21,327) for inclusion in the final sample. Those who participated were more often scheduled for surgical treatment and had higher expectations. We performed a multilevel analysis involving two steps. First, we evaluated whether patients receiving the same treatment, being counseled by the same surgeon, or being treated at the same location have more similar outcome expectations. We found that only patients receiving the same treatment had more similar outcome expectations. Therefore, we used a multilevel regression model to account for this correlation within treatments, and added treatment characteristics (such as nonsurgical versus minor or major surgery) to potential explanatory factors. Second, in the multilevel hierarchical regression analysis, we added sociodemographics (Model 1), PROMs for physical and mental health (Model 2), illness perceptions (Model 3), and treatment characteristics (most-definitive model) to assess the explained variance in outcome expectations per step and the relative association with outcome expectations. RESULTS: Sociodemographic factors such as age and workload explained 1% of the variance in outcome expectations. An additional 2% was explained by baseline PROMs for physical and mental health, 9% by illness perceptions, and 18% by treatment characteristics, resulting in an explained variance of 29% of the most-definitive model. A large number of patient and treatment characteristics were associated with outcome expectations. We used standardized betas to compare the magnitude of the effect of the different continuous and categorical variables. Among the associated variables, minor surgery (standardized beta [ß] = 0.56 [95% confidence interval 0.44 to 0.68]; p < 0.001) and major surgery (ß = 0.61 [95% CI 0.49 to 0.73]; p < 0.001) had the strongest positive association with outcome expectations (receiving surgery is associated with higher outcome expectations than nonsurgical treatment). A longer illness duration expected by the patient (-0.23 [95% CI -0.24 to -0.21]; p < 0.001) and being treated for the same condition as before (-0.08 [95% CI -0.14 to -0.03]; p = 0.003) had the strongest negative association with outcome expectations. CONCLUSION: Outcome expectations are mainly associated with the invasiveness of the treatment and by patients' illness perceptions; patients before surgical treatment have more positive expectations of the treatment outcome than patients before nonsurgical treatment, even after accounting for differences in clinical and psychosocial profiles. In addition, patients with a more-positive perception of their illness had more-positive expectations of their treatment. Our findings suggest expectation management should be tailored to the specific treatment (such as surgical versus nonsurgical) and the specific patient (including their perception of their illness). It may be more beneficial to test and implement expectation management strategies for nonsurgical treatments such as physical therapy than for surgical treatments, given that our findings indicate a greater need to do so. An additional advantage of such a strategy is that successful interventions may prevent converting to surgical interventions, which is a goal of the stepped-care principles of standard care. Future studies might investigate the causality of the association between pretreatment expectations and outcomes by performing an experimental study such as a randomized controlled trial, in which boosting expectations is compared with usual care in nonsurgical and surgical groups. LEVEL OF EVIDENCE: Level III, prognostic study.

Determining the Minimally Important Change of the Michigan Hand outcomes Questionnaire in patients undergoing trigger finger release.

INTRODUCTION: The Michigan Hand outcomes Questionnaire (MHQ) is a widely used instrument to evaluate treatment results for hand conditions. Establishing the Minimally Important Change (MIC) is essential for interpreting change in outcome that is clinically relevant. PURPOSE OF THE STUDY: The purpose of this study was to determine the MIC of the MHQ total and subscale scores in patients undergoing trigger finger release. STUDY DESIGN: This is a prospective cohort study conducted between December 2011 and February 2020. METHODS: Patients completed the MHQ prior to surgery and 3 months postoperatively. The MIC of the MHQ was determined using 5 anchor-based methods (ie, 2 anchor mean change methods and 3 receiver operating characteristic methods). The median MIC value was determined to represent the triangulated MIC. RESULTS: A total of 1814 patients were included. The MIC for the MHQ total score ranged from 7.7 to 10.9, with a triangulated estimate of 9.3. The MIC estimates for 5 of 6 of the MHQ subscales ranged from 7.7 to 20.0. No MICs could be determined for the MHQ subscale "aesthetics" due to low correlations between the anchor questions and MHQ change scores. CONCLUSIONS: These MIC estimates can contribute to the interpretation of clinical outcomes following trigger finger release and for assessment of power in prospective trials.

Rasch Analysis of the Michigan Hand Questionnaire.

OBJECTIVES: The Michigan Hand Questionnaire (MHQ) is a commonly used evaluation for hand problems, but previous work reports conflicting evidence regarding the subscale structures. Rasch analysis uses probabilistic modeling of items and responses: if scale items can be fit to the Rasch model, it provides evidence of construct validity and interval-level measurement for precise statistical estimates. We conducted Rasch analysis on the MHQ to evaluate model fit, unidimensionality of the subscales, bias across person factors, and conversion to interval metrics. METHODS: We conducted a secondary Rasch analysis of MHQ data from 924 persons with thumb basal joint osteoarthritis using the RUMM2030 software. Modeling was based on responses for the most affected hand and person factors including age, sex, type of work, whether the dominant side was the most affected, and surgical status. The analysis plan followed the published recommendations for examinations of person and item fit, with iterative adjustments as required. RESULTS: A total of 11 of the 37 items required rescoring to create orderly progression of scoring thresholds. Only the overall hand function and pain subscales could be fit to the Rasch model, demonstrating unidimensionality and good reliability of fit estimates. Dividing the activities of daily living subscale into unilateral and bilateral activities also allowed unilateral activities to fit the model. Persistent misfitting in other subscales suggested local dependency and response bias across multiple person factors. CONCLUSIONS: This Rasch analysis of the MHQ raises concerns regarding the validity and fundamental measurement properties of this widely used outcome evaluation when used as a summary score.

Collaborative hand surgery clinical research without sharing individual patient data; proof of principle study.

High-quality research in hand surgery is increasingly important. A vital component is national and international multicenter collaborative research because of better generalizability and larger sample sizes. However, sharing patient data between centers can be hampered by regulations and privacy issues or reluctance to share patient data. Therefore, in this paper, we illustrate an approach for collaborative clinical research without sharing patient data while obtaining similar outcomes. To illustrate that this collaborative clinical research approach without sharing patient data leads to similar outcomes compared to aggregating all individual patient data in one database, we simulate an approach of performing meta-analyses on summary statistics of individual-center data. In the simulation, we compare the results to conventional analyses in an existing multicenter database of patients treated for Dupuytren's disease at three different centers with either limited fasciectomy (LF) or needle aponeurotomy (PNF). We share example data and all analysis code in a public GitHub Library. We found similar results for the meta-analysis approach without sharing individual patient data as in the conventional approach for 1) the proportion of patients treated for recurrences, 2) the Total MHQ score after both treatments, 3) the comparison of Total MHQ score after both treatments, and 4) the comparison of both treatments when correcting for confounders with regression analysis. CLINICAL SIGNIFICANCE: We illustrate how collaborative studies can be performed without sharing individual patient data while obtaining similar results as with conventional analyses. This approach can help speed up collaborative research without losing precision in outcome analysis.