Psychosocial Factors Are Associated with Electronic Portal Registration.

BACKGROUND: Electronic health records often include a portal for secure patient-clinician communication. There is evidence that use of electronic portals increases satisfaction, treatment adherence, safety, and clinical outcomes. We want everyone to enjoy these benefits and we noticed low and uneven portal use. We studied factors that we can address to improve portal use. QUESTIONS/PURPOSES: After controlling for differences in patient characteristics, what psychological and demographic factors are associated with an increased likelihood of registering for an electronic health record portal among people seeking musculoskeletal specialty care? METHODS: We reviewed data on 5672 adult English or Spanish-speaking patients seen in a musculoskeletal specialty office between October 2017 and December 2019. Eighteen percent (996 patients) had missing measures of symptoms of depression and anxiety due to intermittent problems with survey technology, leaving 4676 for analysis, 42% (1970 of 4676) men and 58% (2706 of 4676) women with a mean age of 51±15, 76% (3569 of 4676) of patients were English speaking, 22% (1015 of 4676) were Spanish speaking, and 2% (92 of 4676) spoke another language. Seventy-seven percent (3620 of 4676) of patients were residents of Austin, Texas, USA, 4% (159) were from Pflugerville, Texas, USA, 3% (143) were from Del Valle, Texas, USA, and 16% (754 of 4676) were from other areas of Texas. Ninety nine percent of patients were residents of Texas (4645 of 4676). Twenty-three percent of patients visited the upper extremity team (1077 of 4676), 37% the lower extremity team (1721 of 4676), 21% the back and neck team (1002 of 4676), and 19% the sport medicine team (876 of 4676). Seventy eight percent of patients (3654 of 4676) registered in portal and 22% (1022 of 4676) did not. The omitted population were not different from our study population in terms of age, gender, language, residence, and region of symptoms. We used a two-question measure of symptoms of depression (Patient Health Quality-2 [PHQ-2]) and a two-question measure of symptoms of anxiety (General Anxiety Disorder-2 [GAD-2]). The primary outcome was portal registration. To account for potential confounding, a multivariable logistic regressions model was used to determine the influence of age, spoken language, city and state of residence, care team, number of completed visits and GAD and PHQ scores on portal registration. RESULTS: After controlling for potentially confounding variables such as state of residence, we found younger age (odds ratio 0.98 [95% CI 0.97 to 0.99]; p < 0.01), speaking English (OR 1.85 [95% CI 1.14 to 3.02]; p = 0.01) rather than Spanish (OR 0.27 [95% CI 0.17 to 0.45]; p < 0.01), seeking care for back or neck symptoms, (OR 3.84 [95% CI 2.60 to 5.66]; p < 0.01) and higher number of completed visits (OR 1.03 [95% CI 1.01 to 1.05]; p < 0.01) were associated with an increased likelihood of portal registration while living in Austin, Texas, USA (OR 0.68 [95% CI 0.53 to 0.87]; p < 0.01) and Del Valle, Texas, USA (OR 0.47 [95% CI 0.30 to 0.74]; p < 0.01) compared with Pflugerville, Texas, USA, or other cities, seeking care for upper extremity (OR 0.74 [95% CI 0.58 to 0.94]; p = 0.01) or lower extremity symptoms (OR 0.68 [95% CI 0.53 to 0.86]; p < 0.01), and greater symptoms of anxiety (GAD score) (OR 0.97 [95% CI 0.95 to 0.99]; p < 0.01) or depression (PHQ score) (OR 0.97 [95% CI 0.95 to 0.98]; p < 0.01) were associated with lower likelihood of registering for the portal. English language, city of residence, and seeking care for back or neck symptoms (due to insurance contracts) were all associated with higher socioeconomic status in our setting. CONCLUSIONS: The association of better mental and social health (financial, employment, housing and food security; connectedness) with registration in a communication portal directs us to be more intentional about efforts to specifically welcome disadvantaged people to participate in the portal and to study the impact and effectiveness of such efforts. LEVEL OF EVIDENCE: Level III, therapeutic study.

Influenza Vaccination Is Not Associated with Increased Number of Visits for Shoulder Pain.

BACKGROUND: Shoulder injury from vaccination was approved for automatic compensation from the Vaccine Injury Compensation Program (VICP)-a federal government program started in 1988 to shield the manufacturers of childhood vaccines from liability. The approval was made on the basis of case reports rather than experimental evidence. This, combined with the addition of influenza vaccination to the VICP in 2005 (which broadened coverage to include adults) and other social factors, was associated with a rapid rise in the number of claims of shoulder injury from vaccination over the last decade, which now account for more than half of all claims to the VICP. Given the high prevalence of newly symptomatic sources of shoulder pain such as rotator cuff tendinopathy, combined with the high prevalence of annual influenza vaccinations, there is a substantial risk of overlap leading to the post hoc ergo propter hoc fallacy ("after this, therefore because of this") contributing to misdiagnosis and inappropriate management of patients that perceive injury from vaccination. Records of medical care after a large number of vaccinations have a good chance of detecting serious shoulder pathology, even it is uncommon, which would result in an increased prevalence of visits for shoulder problems and specific types of shoulder pathology. QUESTIONS/PURPOSES: Is there a difference in the proportion of visits for shoulder pain within 3 months before and after vaccination among students and faculty receiving an influenza vaccination in the shoulder? METHODS: We studied people who were vaccinated for influenza between 2009 and 2018 at a university health service. During the study period, a comprehensive billing database identified 24,206 influenza vaccinations administered to 12,870 people (median age 20 years, range 16-77; 57% women). We had 80% power to detect a 0.1% increase in the proportion of shoulder problems after vaccination compared with before vaccination. Visits with coded ICD-9 shoulder diagnoses were identified from the electronic medical record. We compared the proportion of shoulder evaluations within 3 months before and 3 months after vaccination. RESULTS: With the numbers available, the proportion of visits for shoulder problems were not different before (1.1% [52 of 4801]) and after vaccination (1% [40 of 3977], risk ratio 1.1 [95% CI 0.8 to 1.5]; p = 0.72). Among all vaccinations, 49% (11,834 of 24,206) were preceded or followed by an appointment within 3 months before (20% [4801 of 24,206]), after (16% [3977]), or both before and after (13% [3056]) vaccine administration, and 1.4% (170) of these visits were related to a shoulder issue. The most common reason for shoulder-related appointments was atraumatic shoulder pain (79% [134 of 170]). CONCLUSIONS: Shoulder symptoms sufficient to seek care are notably common, even among relatively young adults, and are not more common after vaccination. Although this does not rule out an important rare pathology specific to vaccination, it seems important to consider the potential harms of assuming, based largely on chronology, that persistent shoulder pain after vaccination-something expected to be common based merely on the anticipated frequency of overlap of vaccination and common shoulder problems-represents harm from vaccine. LEVEL OF EVIDENCE: Level III, therapeutic study.

Factors Associated with a Second Opioid Prescription Fill in Total Knee Arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) creates a relatively large degree of nociception, making it a good setting to study variation in pain intensity and pain alleviation. The purpose of this study is to investigate factors associated with a second prescription of opioid medications within 30 days of primary TKA. METHODS: Using an insurance database, we studied 1372 people over a 6-year period with no mental health comorbidities including substance misuse and no comorbid pain illness at the time of TKA. Factors associated with a second prescription of opioid medication within 30 days of TKA were sought among patient demographics and the overall prescription morphine milligram equivalents. Patient and prescription-related risk factors were evaluated utilizing logistic relative risk regression. We reserved a year of data, 222 people, to evaluate the performance of the derived model. RESULTS: More than half the patients filled a second prescription for opioids within 30 days of TKA. Factors associated with a second prescription of opioid medication within 30 days of TKA included age (P < .01), current smoker (P = .01), and the total morphine milligram equivalents of the initial prescription (P < .01). Applied to the 222 people we reserved for validation, the model was 81% sensitive and 14% specific for a second prescription within 30 days, with a positive predictive value of 74%, and a negative predictive value of 20%. CONCLUSION: People that are given more opioids tend to request more opioids, but our model had limited diagnostic performance characteristics indicating that we are not accounting for the key factors associated with a second opioid prescription. Future studies might address undiagnosed patient social and mental health opportunities, factors known to associate with pain intensity and satisfaction with pain alleviation. LEVEL OF EVIDENCE: Diagnostic Level III.

What Is the Effect of Vitamin C on Finger Stiffness After Distal Radius Fracture? A Double-blind, Placebo-controlled Randomized Trial.

BACKGROUND: It is proposed that vitamin C administration can reduce disproportionate pain and stiffness after distal radius fracture; however, randomized trials that tested this hypothesis have had inconsistent results. QUESTIONS/PURPOSES: (1) Is administering vitamin C after distal radius fracture associated with better ROM, patient-reported upper extremity function, and pain scores? (2) What factors are associated with post-fracture finger stiffness and worse upper extremity function? METHODS: This is a double-blind, randomized, placebo-controlled, noncrossover study. Between August 2014 and July 2017, we approached 204 consecutive patients, of which 195 were eligible, and 134 chose to participate. Participants were randomized to receive once-daily 500 mg vitamin C (67 participants) or placebo (67 participants) within 2 weeks after distal radius fracture. All patients received usual care at the discretion of their surgeon. The mean age of participants was 49 ± 17 years, 99 patients (74%) were women, and 83 (62%) were treated nonoperatively. The primary outcome was the distance between the fingertip and distal palmar crease 6 weeks after fracture. This measure is easy to obtain and previously has been shown to correlate with aggregate ROM of all finger joints. The secondary outcomes were total active finger motion, total active thumb motion, upper extremity-specific limitations, and pain intensity.An a priori power analysis suggested 126 patients would provide 80% power to detect a difference of 2 cm (SD 4.0) fingertip distance to palmar crease with α set at 0.05 using a two-tailed Student's t-test. Accounting for 5% lost to followup, we included 134 patients.All analyses were intention-to-treat. Ten participants of the intervention group and five of the placebo group were lost to followup. Their missing data were addressed by multiple imputation, after which we performed linear regression analysis for our outcome variables. RESULTS: Administration of vitamin C was not associated with ROM, function, or pain scores at 6 weeks (distance to palmar crease: ß -0.23; 95% CI -1.7 to 1.2; p = 0.754; finger ROM: ß 4.9; 95% CI, -40 to 50; p = 0.829; thumb ROM: ß 0.98; 95% CI, -18 to 20; p = 0.918, Patient-Reported Outcomes Measurement Information System [PROMIS] score: ß 0.32; 95% CI, -2.6 to 3.2; p = 0.828; pain score: ß -0.62; 95% CI, -0.62 to 0.89; p = 0.729) nor at 6 months (PROMIS score: ß -0.21; 95% CI, -3.7 to 3.3; p = 0.904; pain score: ß 0.31; 95% CI, -0.74 to 1.4; p = 0.559). At 6 weeks, we found that more finger stiffness was mildly associated with greater age (ß -1.5; 95% CI, -2.8 to -0.083; p = 0.038). Thumb stiffness was mildly associated with greater age (ß -0.72; 95% CI, -1.3 to -0.18; p = 0.009) and strongly associated with operative treatment (ß -32; 95% CI, -50 to -13; p = 0.001). Greater pain interference was modestly associated with greater functional limitations at 6 weeks (ß -0.32; 95% CI, -0.52 to -0.12; p = 0.002) and 6 months (ß -0.36; 95% CI, -0.60 to -0.11; p = 0.004). CONCLUSIONS: Vitamin C does not seem to facilitate recovery after distal radius fracture, but amelioration of maladaptation to nociception (pain interference) merits greater attention. LEVEL OF EVIDENCE: Level I, therapeutic study.

What Role Does Positive Psychology Play in Understanding Pain Intensity and Disability Among Patients with Hand and Upper Extremity Conditions?

BACKGROUND: A large body of research shows that psychologic distress and ineffective coping strategies substantially contribute to more severe pain and increased physical limitations among patients with orthopaedic disorders. However, little is known about the relationship between positive psychology (constructs that enable individuals to thrive and adapt to challenges) and pain and physical limitations in this population. QUESTIONS/PURPOSES: (1) Which positive-psychology factors (satisfaction with life, gratitude, coping through humor, resilience, mindfulness, and optimism) are independently associated with fewer upper-extremity physical limitations after controlling for the other clinical and demographic variables? (2) Which positive-psychology factors are independently associated with pain intensity after controlling for relevant clinical and demographic variables? METHODS: In a cross-sectional study, we recruited patients presenting for a scheduled appointment with an orthopaedic surgeon at a hand and upper-extremity clinic of a major urban academic medical center. Of 125 approached patients, 119 (44% men; mean age, 50 ± 17 years) met screening criteria and agreed to participate. Patients completed a clinical and demographic questionnaire, the Numerical Rating Scale to assess pain intensity, the Patient-reported Outcomes Measurement Information System (PROMIS) Upper Extremity Physical Function computerized adaptive test to assess physical limitations, and six measures assessing positive-psychology constructs: The Satisfaction with Life Scale, the Gratitude Questionnaire, the Coping Humor Scale, the Brief Resilience Scale, the Cognitive and Affective Mindfulness Scale-Revised, and the Life Orientation Test-Revised. We first examined bivariate associations among physical limitations, pain intensity, and all positive-psychology factors as well as demographic and clinical variables. All variables that demonstrated associations with physical limitations or pain intensity at p < 0.05 were included in two-stage multivariable hierarchical regression models. RESULTS: After controlling for the potentially confounding effects of prior surgical treatment and duration since pain onset (step1; R total = 0.306; F[7,103] = 6.50), the positive-psychology variables together explained an additional 15% (R change = 0.145, F change [5, 103] = 4.297, p = 0.001) of the variance in physical limitations. Among the positive-psychology variables tested, mindfulness was the only one associated with fewer physical limitations (ß = 0.228, t = 2.293, p = 0.024, 4% variance explained). No confounding demographic or clinical variables were found for pain intensity in bivariate analyses. All positive-psychology variables together explained 23% of the variance in pain intensity (R = 0.23; F[5,106] = 6.38, p < 0.001). Among the positive-psychology variables, satisfaction with life was the sole factor independently associated with higher intensity (ß = -0.237, t = -2.16, p = 0.033, 3% variance explained). CONCLUSIONS: Positive-psychology variables explained 15% of the variance in physical limitations and for 23% of the variance in pain intensity among patients with heterogenous upper extremity disorders within a hand and upper extremity practice. Of all positive-psychology factors, mindfulness and satisfaction with life were most important for physical limitations and pain intensity, respectively. As positive-psychology factors are more easily modifiable through skills-based interventions than pain and physical limitations, results suggest implementation of such interventions to potentially improve outcomes in this population. Skills-based interventions targeting mindfulness and satisfaction with life may be of particular benefit. LEVEL OF EVIDENCE: Level II, prognostic study.

What Is the Relationship of Fear Avoidance to Physical Function and Pain Intensity in Injured Athletes?

BACKGROUND: Fear avoidance can play a prominent role in maladaptive responses to an injury. In injured athletes, such pain-related fear or fear avoidance behavior may have a substantial influence on the recovery process. Specifically, it may explain why some are able to reach their preinjury abilities, whereas others are unable to return to sport. QUESTIONS/PURPOSES: (1) Is fear avoidance in athletes associated with decreased physical function after injury? (2) To what degree is fear avoidance associated with athletes' pain intensity? METHODS: In a cross-sectional study, we recruited injured athletes-defined as patients with sports-related injury, weekly engagement in sport activities, participation in competitive events as part of a team or club, self-identification as an athlete, and a desire to return to sport after recovery-from an orthopaedic sports medicine center at a major urban university hospital. Of 130 approached patients, 102 (84% men; mean ± SD age 25 ± 8.5 years) met the inclusion criteria. Participants completed a demographic questionnaire, the Athlete Fear Avoidance Questionnaire, which assesses injury-related fear and avoidance behavior specifically in an athletic population, the Pain Catastrophizing Scale, the Hospital Anxiety and Depression Scale, and two Patient-Reported Outcomes Measurement Information System measures: Physical Function Computerized Adaptive Testing (CAT) and Pain Intensity CAT. RESULTS: After controlling for age, injury region (upper versus lower extremity), catastrophic thinking, and emotional distress, we found that an increase in athletes' fear avoidance was associated with a decrease in physical function (b = -0.32; p = 0.002). The model explained 30% of the variation in physical function with 7.3% explained uniquely by fear avoidance. After controlling for initial appointment/followup, surgery for the current condition, multiple pain conditions, history of prior sport-related injury/surgery, pain medication prescription, catastrophic thinking, and emotional distress, athletes' fear avoidance was not associated with pain (b = -0.14; p = 0.249). The model explained 40% of the variation in pain intensity and pain catastrophizing (b = 0.30; p = 0.001) uniquely explained 7.1% of this variation. CONCLUSIONS: In injured athletes, fear avoidance is independently associated with decreased physical function, whereas pain catastrophizing is associated with high pain intensity. Both level of an athlete's fear avoidance and catastrophic thinking about pain should be accounted for in clinical interventions aimed at helping athletes improve recovery and return to sport. LEVEL OF EVIDENCE: Level II, prognostic study.

Factors Associated With Met Expectations in Patients With Hand and Upper Extremity Disorders: A Pilot Study.

PURPOSE: The degree to which patients' expectations are met during an office visit consistently correlates with patients' satisfaction, whereas the relationship between previsit expectations and satisfaction varies. OBJECTIVE: The aim of this pilot study was to preliminarily assess the relationship of psychosocial factors, pain intensity, and magnitude of disability to previsit expectations, met expectations, and satisfaction with medical care in patients with hand and upper extremity conditions in a surgical outpatient clinic. METHODS: A cohort of 85 outpatients with upper extremity illnesses indicated their previsit expectations (Patients Intention Questionnaire), degree to which these expectations were met (Expectations Met Questionnaire), level of depressive symptoms (Patient Health Questionnaire-2), confidence about the ability to achieve one's goals in spite of pain (Pain Self-Efficacy Questionnaire), pain intensity (Numerical Rating Scale for pain), disability (Disabilities of the Arm Shoulder and Hand, short version; QuickDASH), and satisfaction with the medical visit (Medical Interview Satisfaction Scale). RESULTS: Higher previsit expectations were associated with more depressive symptoms, lower pain self-efficacy, higher pain intensity, and fewer years of education. Patients in the low and moderate met expectations categories had significantly more symptoms of depression, fewer years of education, and more pain compared to those in the high-met expectations category. Fewer years of education and higher pain intensity predicted higher previsit expectations and explained 19% of variance. CONCLUSION: Psychosocial factors affect both previsit expectations and met expectations during an outpatient visit to a hand surgeon. Met expectations, but not previsit expectations, affect satisfaction. LEVEL OF EVIDENCE: Prognostic, level II.

Is Social Support Associated With Upper Extremity Disability?

BACKGROUND: Pain intensity and disability correlate with psychosocial factors such as depression and pain interference (the degree to which pain interferes with activities of daily living) as much or more than pathophysiology in upper extremity illness. However, other factors like emotional support (perception of being cared for and valued as a person), instrumental support (perception of availability of tangible assistance when needed), positive psychosocial impact (perception and focus on the positive side of a difficult situation, sometimes characterized as posttraumatic growth, benefit-finding, or meaning making), also might be associated with disability in patients with upper extremity orthopaedic illness. This is the first published study, to our knowledge, addressing the potential association of emotional support, instrumental support, and positive psychosocial illness impact with disability in patients with upper extremity illness. QUESTIONS/PURPOSES: We asked: (1) Is there a correlation between the QuickDASH and the Patient-reported Outcomes Measurement Information System (PROMIS(®)) emotional support Computer Adaptive Testing (CAT)? (2) Is there a correlation between the QuickDASH and PROMIS(®) instrumental support CAT? (3) Is there a correlation between the QuickDASH and PROMIS(®) positive psychosocial illness impact CAT? (4) Among the PROMIS(®) measures of depression, emotional support, instrumental support, positive illness impact, and pain interference, which accounts for the most variance in QuickDASH scores? METHODS: One hundred ninety-three patients with upper extremity illness (55% women; average age, 51 ± 18 years) of 213 approached (91% recruitment rate) completed the QuickDASH, and five different PROMIS(®) CATs: pain interference (the degree to which pain interferes with accomplishing one's goals), depression, emotional support, psychosocial illness impact, and instrumental support. We recruited patients from the practice of three surgeons in hand service of the department of orthopaedic surgery at a major urban university hospital. RESULTS: Pearson Product Moment Correlations showed that emotional support (r = -0.18; p = 0.014) and instrumental support (r = -0.19; p = 0.008) were weakly and inversely associated with the QuickDASH), while positive psychosocial illness impact was moderately and inversely associated with the QuickDASH (r = -0.36; p < 0.001). In multivariable analyses, pain interference, but not the social support measures, was the only psychosocial factor associated with the QuickDASH and alone explained 66% of variance. CONCLUSIONS: Emotional support, instrumental support and positive psychosocial illness impact are all individually associated with disability to a small degree, but pain interference (the degree to which pain interferes with accomplishing one's goals) has the strongest influence on magnitude of disability. LEVEL OF EVIDENCE: Level 1, prognostic study.

Quantitative three-dimensional computed tomography analysis of glenoid fracture patterns according to the AO/OTA classification.

HYPOTHESIS/BACKGROUND: This study measures the characteristics of glenoid fractures to determine if the AO Foundation and Orthopaedic Trauma Association (AO/OTA) classification captures the most common fracture patterns. The primary null hypothesis was that surface area and degree of fragmentation do not differ among the different fracture types. Secondarily, we tested if there was a relationship between high- vs. low-energy trauma and fracture classification. METHODS: Three-dimensional models were created for a consecutive series of 53 fractures. The fracture classifications, the number of fragments, and the fragmented articular surface area were related to the type of injury. The difference of articular surface size and number of fragments among classification groups was analyzed with the Kruskal-Wallis test. RESULTS: There is a significant difference in fractured articular surface area among classification groups. Compared with transverse and multifragmented fractures, both anterior and posterior fractures involved significantly less of the articular surface area. High-energy trauma is associated with transverse and multifragmented fractures in 93% of the cases. It is associated with a greater number of fracture fragments and fracture of a larger percentage of the glenoid surface area, with a mean fractured surface of 60% for high-energy fractures and 25% for low-energy injuries. DISCUSSION/CONCLUSION: Quantitative 3-dimensional CT analysis confirms that the current AO/OTA classification adequately characterizes and discriminates glenoid fracture patterns. The classification groups are related to the fragmented articular surface area and the number of fragments. Also, the mechanism of injury is related to the classification group, which supports the clinical relevance of the classification.

Do 360-degree feedback survey results relate to patient satisfaction measures?

BACKGROUND: There is evidence that feedback from 360-degree surveys-combined with coaching-can improve physician team performance and quality of patient care. The Physicians Universal Leadership-Teamwork Skills Education (PULSE) 360 is one such survey tool that is used to assess work colleagues' and coworkers' perceptions of a physician's leadership, teamwork, and clinical practice style. The Clinician & Group-Consumer Assessment of Healthcare Providers and System (CG-CAHPS), developed by the US Department of Health and Human Services to serve as the benchmark for quality health care, is a survey tool for patients to provide feedback that is based on their recent experiences with staff and clinicians and soon will be tied to Medicare-based compensation of participating physicians. Prior research has indicated that patients and coworkers often agree in their assessment of physicians' behavioral patterns. The goal of the current study was to determine whether 360-degree, also called multisource, feedback provided by coworkers could predict patient satisfaction/experience ratings. A significant relationship between these two forms of feedback could enable physicians to take a more proactive approach to reinforce their strengths and identify any improvement opportunities in their patient interactions by reviewing feedback from team members. An automated 360-degree software process may be a faster, simpler, and less resource-intensive approach than telephoning and interviewing patients for survey responses, and it potentially could facilitate a more rapid credentialing or quality improvement process leading to greater fiscal and professional development gains for physicians. QUESTIONS/PURPOSES: Our primary research question was to determine if PULSE 360 coworkers' ratings correlate with CG-CAHPS patients' ratings of overall satisfaction, recommendation of the physician, surgeon respect, and clarity of the surgeon's explanation. Our secondary research questions were to determine whether CG-CAHPS scores correlate with additional composite scores from the Quality PULSE 360 (eg, insight impact score, focus concerns score, leadership-teamwork index score, etc). METHODS: We retrospectively analyzed existing quality improvement data from CG-CAHPS patient surveys as well as from a department quality improvement initiative using 360-degree survey feedback questionnaires (Quality PULSE 360 with coworkers). Bivariate analyses were conducted to identify significant relationships for inclusion of research variables in multivariate linear analyses (eg, stepwise regression to determine the best fitting predictive model for CG-CAHPS ratings). In all higher order analyses, CG-CAHPS ratings were treated as the dependent variables, whereas PULSE 360 scores served as independent variables. This approach led to the identification of the most predictive linear model for each CG-CAHPS' performance rating (eg, [1] overall satisfaction; [2] recommendation of the physician; [3] surgeon respect; and [4] clarity of the surgeon's explanation) regressed on all PULSE scores with which there was a significant bivariate relationship. Backward stepwise regression was then used to remove unnecessary predictors from the linear model based on changes in the variance explained by the model with or without inclusion of the predictor. RESULTS: The Quality PULSE 360 insight impact score correlated with patient satisfaction (0.50, p = 0.01), patient recommendation (0.58, p = 0.002), patient rating of surgeon respect (0.74, p < 0.001), and patient impression of clarity of the physician explanation (0.69, p < 0.001). Additionally, leadership-teamwork index also correlated with patient rating of surgeon respect (0.46, p = 0.019) and patient impression of clarity of the surgeon's explanation (0.39, p = 0.05). Multivariate analyses supported retention of insight impact as a predictor of patient overall satisfaction, patient recommendation of the surgeon, and patient rating of surgeon respect. Both insight impact and leadership-teamwork index were retained as predictors of patient impression of explanation. Several other PULSE 360 variables were correlated with CG-CAHPS ratings, but none were retained in the linear models post stepwise regression. CONCLUSIONS: The relationship between Quality PULSE 360 feedback scores and measures of patient satisfaction reaffirm that feedback from work team members may provide helpful information into how patients may be perceiving their physicians' behavior and vice versa. Furthermore, the findings provide tentative support for the use of team-based feedback to improve the quality of relationships with both coworkers and patients. The 360-degree survey process may offer an effective tool for physicians to obtain feedback about behavior that could directly impact practice reimbursement and reputation or potentially be used for bonuses to incentivize better team professionalism and patient satisfaction, ie, "pay-for-professionalism." Further research is needed to expand on this line of inquiry, determine which interventions can improve 360-degree and patient satisfaction scores, and explain the shared variance in physician performance that is captured in the perceptions of patients and coworkers.

Patients with greater symptom intensity and more disability are more likely to be surprised by a hand surgeon's advice.

BACKGROUND: A clash between a patient's assumptions and a doctor's advice can feel adversarial which might influence satisfaction ratings and compliance with treatment recommendations. A better understanding of sources of patients' bewilderment might lead to improved strategies for conveying counterintuitive information that improve patient comfort and wellbeing. QUESTIONS/PURPOSES: This study addressed the following questions: (1) Are magnitude of disability, pain intensity, symptoms of depression, or health anxiety associated with a higher level of surprise when a patient is presented with diagnostic information and/or therapeutic recommendations? (2) Does the surgeon accurately perceive the patient's bewilderment? (3) Does the surgeon's perception of patient bewilderment correlate with diagnosis or a patient's magnitude of disability, pain intensity, symptoms of depression, or health anxiety? PATIENTS AND METHODS: In this prospective cohort study, we invited new patients who met prespecified criteria during a 3-month period in one hand-surgery practice to enroll; of 93 patients invited, 84 (90%) agreed to participate. Patients reported demographics and completed the short versions of the DASH questionnaire (QuickDASH), the Patient Health Questionnaire, the Pain Self-Efficacy Questionnaire, and the Short Health Anxiety Inventory; rated their pain intensity; and rated the degree to which the information given by the surgeon was unexpected or surprising on an 11-point ordinal scale. The surgeon also rated his impression of the patient's surprise on an 11-point ordinal scale. RESULTS: Only greater symptom intensity and magnitude of disability (QuickDASH) correlated with greater unexpected information when rated by the patient (ß = 0.058; p < 0.001). There was a correlation between patient surprise and the surgeon's perception of the patient's surprise (r = 0.58; p < 0.001). Greater surgeon-perceived patient surprise correlated with nonspecific illness (p = 0.007; ß = 3.0). CONCLUSIONS: Patients with greater symptom intensity and magnitude of disability, and perhaps also patients with nonspecific diagnoses, are more likely to be surprised by a hand surgeon's advice. Future research might address the ability of previsit preparation (using decision aids or other alternative means of education) to ameliorate the discordance between patient assumptions and hand surgeon advice.

Do previsit expectations correlate with satisfaction of new patients presenting for evaluation with an orthopaedic surgical practice?

BACKGROUND: Patient satisfaction is associated with increased compliance, improved treatment outcomes, and decreased risk of litigation. Factors such as patient understanding and psychological well-being are recognized influences on satisfaction. Less is known about the relationship between previsit expectations and satisfaction. QUESTIONS/PURPOSES: (1) Are there correlations among previsit expectations, met expectations, and patient satisfaction? (2) What are the categories of expectations, and which one(s) correlate with satisfaction? METHODS: Eighty-six new patients presenting to a hand surgery practice of a tertiary referral hospital with 70% direct primary care referrals, mostly with elective concerns, indicated their previsit expectations (Patient Intention Questionnaire [PIQ]). Immediately after the visit, the same patients rated the degree to which their previsit expectations were met (Expectation Met Questionnaire [EMQ]) and their satisfaction level (Medical Interview Satisfaction Scale). These tools have been used in primary care office settings and claim good psychometric properties, and although they have not been strictly validated for responsiveness and other test parameters, they have good face validity. We then conducted a multivariable backward linear regression to determine whether (1) scores on the PIQ; and (2) scores on the EMQ are associated with satisfaction. RESULTS: Satisfaction correlated with met expectations (r=0.36; p<0.001) but not with previsit expectations (r=-0.01, p=0.94). We identified five primary categories of previsit expectations that accounted for 50% of the variance in PIQ: (1) "Information and Explanation"; (2) "Emotional and Understanding"; (3) "Emotional Problems"; (4) "Diagnostics"; and (5) "Comforting". The only category of met expectations that correlated with satisfaction was Information and Explanation (r=0.43; p<0.001). CONCLUSIONS: Among patients seeing a hand surgeon, met expectations correlate with satisfaction. In particular, patients with met expectations regarding information and explanation were more satisfied with their visit. Efforts to determine the most effective methods for conveying unexpected information warrant investigation. LEVEL OF EVIDENCE: Level II, prognostic study.

The pain self-efficacy questionnaire: validation of an abbreviated two-item questionnaire.

BACKGROUND: The Pain Self-Efficacy Questionnaire (PSEQ) is a validated tool to assess pain self-efficacy and is strongly correlated with disability. Reducing the number of questions of the original PSEQ to screen for self-efficacy will result in more efficient screening and less burden for the patient. OBJECTIVE: The aim of this study was to prospectively validate the shortened version of the PSEQ. METHOD: Overall, 249 new and follow-up patients visiting our outpatient orthopedic hand surgery clinic were prospectively enrolled and asked to complete the PSEQ, short version of the Disabilities of the Arm Shoulder and Hand, and 2-question version of the Patient Health Questionnaire (PHQ-2) depression questionnaires. The patients completed the questionnaires in the office and online 2 weeks after their visit. At the follow-up visit, the PSEQ was substituted with the 2-question version of the Pain Self-Efficacy Questionnaire (PSEQ-2). The factors associated with higher short forms of the Disabilities of the Arm, Shoulder and Hand scores were investigated in a bivariate and multivariable analysis. Paired t-test was used to compare the mean values of the short and long questionnaires at enrollment. RESULTS: There was a large correlation (r = 0.90; p < 0.001) between the original PSEQ and the PSEQ-2 at enrollment. The Cronbach α were comparable for the PSEQ and the PSEQ-2 (α = 0.95 compared with α = 0.91). There was a small but statistically significant difference between the average scores of the PSEQ and PSEQ-2 (4.4 vs 4.8; p < 0.001). For the shortened PSEQ, a smaller-but still large-correlation was found with the short forms of the Disabilities of the Arm, Shoulder and Hand (r = 0.71 vs r = 0.61). Both the PSEQ-2 and the PSEQ were the most important predictors of the short forms of the Disabilities of the Arm, Shoulder and Hand scores. A substantial test-retest reliability was found for the PSEQ-2 (0.66). CONCLUSION: The PSEQ-2 can be used to quickly assess patients׳ pain self-efficacy.

A randomized controlled trial of nonoperative treatment versus open reduction and internal fixation for stable, displaced, partial articular fractures of the radial head: the RAMBO trial.

BACKGROUND: The choice between operative or nonoperative treatment is questioned for partial articular fractures of the radial head that have at least 2 millimeters of articular step-off on at least one radiograph (defined as displaced), but less than 2 millimeter of gap between the fragments (defined as stable) and that are not associated with an elbow dislocation, interosseous ligament injury, or other fractures. These kinds of fractures are often classified as Mason type-2 fractures. Retrospective comparative studies suggest that operative treatment might be better than nonoperative treatment, but the long-term results of nonoperative treatment are very good. Most experts agree that problems like reduced range of motion, painful crepitation, nonunion or bony ankylosis are infrequent with both nonoperative and operative treatment of an isolated displaced partial articular fracture of the radial head, but determining which patients will have problems is difficult. A prospective, randomized comparison would help minimize bias and determine the balance between operative and nonoperative risks and benefits. METHODS/DESIGN: The RAMBO trial (Radial Head - Amsterdam - Amphia - Boston - Others) is an international prospective, randomized, multicenter trial. The primary objective of this study is to compare patient related outcome defined by the 'Disabilities of Arm, Shoulder and Hand (DASH) score' twelve months after injury between operative and nonoperative treated patients. Adult patients with partial articular fractures of the radial head that comprise at least 1/3rd of the articular surface, have ≥ 2 millimeters of articular step-off but less than 2 millimeter of gap between the fragments will be enrolled. Secondary outcome measures will be the Mayo Elbow Performance Index (MEPI), the Oxford Elbow Score (OES), pain intensity through the 'Numeric Rating Scale', range of motion (flexion arc and rotational arc), radiographic appearance of the fracture (heterotopic ossification, radiocapitellar and ulnohumeral arthrosis, fracture healing, and signs of implant loosening or breakage) and adverse events (infection, nerve injury, secondary interventions) after one year. DISCUSSION: The successful completion of this trial will provide evidence on the best treatment for stable, displaced, partial articular fractures of the radial head. TRIAL REGISTRATION: The trial is registered at the Dutch Trial Register: NTR3413.

Measurement of upper extremity disability using the Patient-Reported Outcomes Measurement Information System.

PURPOSE: Current questionnaires used to measure upper extremity-specific disability can be time-consuming and subject to ceiling effects. The National Institutes of Health developed Patient-Reported Outcomes Measurement Information System (PROMIS) measures based on computer adaptive testing (CAT), a technique that is more efficient and less subject to floor and ceiling effects than traditional questionnaires with a fixed number of questions. This study tested the correlation of the Physical Function-Upper Extremity CAT with the Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. METHODS: Patients presenting to our orthopedic outpatient clinic were invited to participate in this observational cross-sectional study between August and October 2013. A study sample of 84 patients completed the QuickDASH and PROMIS Physical Function-Upper Extremity CAT, and 3 other PROMIS measures, as well as the 2-question Pain Self-efficacy Questionnaire and the 2-question Patient Health Questionnaire. RESULTS: A strong correlation was found between QuickDASH and PROMIS Physical Function-Upper Extremity CAT, with a significantly shorter completion time for the latter. CONCLUSIONS: We recommend the PROMIS Upper Extremity CAT because it is valid, reliable, and easy to use, and it provides easy reference to population norms (a score of 50 represents the norm in the United States population, and every 10 points represents a standard deviation from the norm). TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic I.

Treatment choice affects inpatient adverse events and mortality in older aged inpatients with an isolated fracture of the proximal humerus.

BACKGROUND: This study tests the null hypothesis that, among patients aged 65 and older admitted to a United States hospital with an isolated fracture of the proximal humerus (no other injuries or fractures), there are no differences between operative (fixation or arthroplasty) and nonoperative treatments with respect to inpatient adverse events, inpatient mortality, and discharge to a long-term care facility rates accounting for comorbidities. METHODS: Using a large national database representing an estimated 132,005 patients aged 65 and older admitted to a US hospital with an isolated proximal humerus fracture between 2003 and 2007. Sixty-one percent did not have surgery, 22% were treated with open reduction and internal fixation (ORIF), and 17% were treated with arthroplasty. RESULTS: The risk of an in hospital adverse event was 21% overall and was 4.4 times greater with arthroplasty and 2.7 times greater with ORIF compared to nonoperative treatment. The risk of in hospital death was 1.8% overall and was 2.8 times greater with ORIF compared to nonoperative treatment. Patients treated operatively were less likely to be discharged to a long-term facility compared to patients treated nonoperatively. CONCLUSION: In spite of a tendency to treat the most infirm patients (those that are not discharged to home) nonoperatively, operative treatment (open reduction and internal fixation in particular) is an independent risk factor for inpatient adverse events and mortality in older-aged patients admitted to the hospital with an isolated fracture of the proximal humerus and should perhaps be offered more judiciously. LEVEL OF EVIDENCE: Level III, retrospective cohort study, treatment study.

Charlson comorbidity indices and in-hospital deaths in patients with hip fractures.

BACKGROUND: The Charlson Comorbidity Index (CCI) and its modifications are comorbidity-based measures that predict mortality. It was developed for patients without trauma and inconsistently predicted mortality and adverse events in several previous studies of patients with trauma. PURPOSE: We therefore (1) determined whether the three different CCIs were predictors for in-hospital deaths in patients with hip fractures, (2) verified if the CCI mortality prediction had changed with time, (3) evaluated other predictors of in-hospital death in patients with hip fractures, and (4) determined if the CCI has predicted in-hospital adverse events. METHODS: We retrospectively reviewed a nationwide probability sample survey, the National Hospital Discharge Survey. More than 6 million adult patients with hip fractures and their associated comorbidities were scored by the original 1987 CCI, the 1994 age-adjusted CCI, and the 2011 updated, reweighted CCI. The three mortality indices' predictive values and predictors of in-hospital adverse events were compared. RESULTS: For patients with hip fractures, all three CCI variations predicted in-hospital mortality. The receiver operating curves (ROC) of the models were less than 0.68, but they improved when we used statistical models that included age, sex, concomitant injuries, and other comorbidities not contained in the CCI models (ROC > 0.74). The age-adjusted CCI accuracy was slightly better than the other two CCIs. Adverse events during hospital stays were associated with a higher CCI, pertrochanteric fracture (versus transcervical), abdominal, chest, or head trauma, atrial fibrillation, multiple fractures, female sex, and longer hospital stays; however, the accuracy of this model was poor (ROC = 0.65). CONCLUSIONS: While all three CCI variations predicted in-hospital mortality in patients with hip fractures, other factors may be of value in patients with trauma.