What Factors Are Associated With Revision Cubital Tunnel Release Within 3 Years?

BACKGROUND: It has been shown that patient demographics such as age, payer factors such as insurance type, clinical characteristics such as preoperative opioid use, and disease grade but not surgical procedure are associated with revision surgery to treat cubital tunnel syndrome. However, prior studies evaluating factors associated with revision surgery after primary cubital tunnel release have been relatively small and have involved patients from a single institution or included only a single payer. QUESTIONS/PURPOSES: (1) What percentage of patients who underwent cubital tunnel release underwent revision within 3 years? (2) What factors are associated with revision cubital tunnel release within 3 years of primary cubital tunnel release? METHODS: We identified all adult patients who underwent primary cubital tunnel release from January 1, 2011, to December 31, 2017, in the New York Statewide Planning and Research Cooperative System database using Current Procedural Terminology codes. We chose this database because it includes all payers and nearly all facilities in a large geographic area where cubital tunnel release may be performed. We used Current Procedural Terminology modifier codes to determine the laterality of primary and revision procedures. The mean age of the cohort overall was 53 ± 14 years, 43% (8490 of 19,683) were women, and 73% (14,308 of 19,683) were non-Hispanic White. The Statewide Planning and Research Cooperative System database organization does not include a listing of all state residents and thus does not allow for censoring of patients who move out of state. All patients were followed for 3 years. We developed a multivariable hierarchical logistic regression model to model factors independently associated with revision cubital tunnel release within 3 years. Key explanatory variables included age, gender, race or ethnicity, insurance, patient residential location, medical comorbidities, concomitant procedures, whether the procedure was unilateral or bilateral, and year. The model also controlled for facility-level random effects to account for the clustering of observations among these entities. RESULTS: The risk of revision cubital tunnel release within 3 years of the primary procedure was 0.7% (141 of 19,683). The median time to revision cubital tunnel release was 448 days (interquartile range 210 to 861 days). After controlling for patient-level covariates and facility random effects, and compared with their respective counterparts, the odds of revision surgery were higher for patients with workers compensation insurance (odds ratio 2.14 [95% confidence interval 1.38 to 3.32]; p < 0.001), a simultaneous bilateral index procedure (OR 12.26 [95% CI 5.93 to 25.32]; p < 0.001), and those who underwent submuscular transposition of the ulnar nerve (OR 2.82 [95% CI 1.35 to 5.89]; p = 0.006). The odds of revision surgery were lower with increasing age (OR 0.79 per 10 years [95% CI 0.69 to 0.91]; p < 0.001) and a concomitant carpal tunnel release (OR 0.66 [95% CI 0.44 to 0.98]; p = 0.04). CONCLUSION: The risk of revision cubital tunnel release was low. Surgeons should be cautious when performing simultaneous bilateral cubital tunnel release and when performing submuscular transposition in the setting of primary cubital tunnel release. Patients with workers compensation insurance should be informed they are at increased odds for undergoing subsequent revision cubital tunnel release within 3 years. Future work may seek to better understand whether these same effects are seen in other populations. Future work might also evaluate how these and other factors such as disease severity could affect functional outcomes and the trajectory of recovery. LEVEL OF EVIDENCE: Level III, therapeutic study.

Using MaxDiff Analysis to Elicit Patients' Treatment Preferences for Distal Radius Fractures in Patients Aged 60 Years and Older.

PURPOSE: The objective of our study was to determine how the attributes of surgical and nonsurgical distal radius fracture (DRF) treatments affect patient treatment preferences. METHODS: Two hundred fifty patients aged 60 years and older were contacted from a single-hand surgeon's practice, and 172 chose to participate. We built a series of best-worst scaling experiments for the MaxDiff analysis to determine the relative importance of treatment attributes. Hierarchical Bayes analysis was used to generate individual-level item scores (ISs) for each attribute that together have a total sum of 100. RESULTS: One hundred general hand clinic patients without a history of a DRF and 43 patients with a history of a DRF completed the survey. For the general hand clinic patients, the most important attributes to avoid when choosing a DRF treatment (in descending order) were the longer time to full recovery (IS, 24.9; 95% confidence interval [CI]: 23.4-26.3), longer time spent in a cast (IS, 22.8; 95% CI, 21.5-24.2), and higher complication rates (IS, 18.4; 95% CI, 16.9-19.8). Meanwhile, for patients with a history of a DRF, the most important attributes to avoid (in descending order) were a longer time to full recovery (IS, 25.6; 95% CI, 23.3-27.9), longer time spent in a cast (IS, 22.8; 95% CI, 19.9-25.7), and abnormal alignment of the radius on x-ray (IS, 18.3; 95% CI, 15.4-21.3). For both the groups, the least concerning attributes based on the IS were appearance-scar, appearance-bump, and the need for anesthesia. CONCLUSIONS: Eliciting patient preferences is a vital component of shared decision-making and advancing patient-centered care. As conceptualized in this MaxDiff analysis, when choosing a DRF treatment, patients mostly want to avoid a longer time to full recovery and a longer time in a cast, whereas patients have the least concern about appearance and need for anesthesia. CLINICAL RELEVANCE: Eliciting patient preferences is a vital component of shared decision-making. Our results may provide guidance to surgeons in discussions on the relative benefits of surgical and nonsurgical DRF treatments, by quantifying the most and least important factors to patients.

Complications and Clinical Outcomes Following Zone I Flexor Tendon Repair Using All-Inside Suture Fixation.

PURPOSE: The purpose of this study was to evaluate complications and outcomes of an all-inside repair technique for flexor digitorum profundus (FDP) avulsions. METHODS: A retrospective review of a single institution database identified all FDP avulsions that were repaired using an all-inside technique by a single surgeon. In this method, 2 Keith needles are drilled from the volar to dorsal aspect, exiting proximal to the nail matrix and within the extensor tendon. Nonabsorbable sutures were placed in the flexor tendon and passed through the bone tunnels, tying dorsally over the distal phalanx. The demographics characteristics, injury characteristics, the surgical procedure, postoperative complications, and outcomes were reviewed. RESULTS: Seventeen patients were included in the study. The average age was 40 years (range, 21-68 years), and 2 patients were women. Seventeen fingers were included: 14 ring fingers, 1 index finger, and 2 little fingers. Six patients had an associated distal phalanx fracture and one had an associated distal interphalangeal joint dislocation. The average time between injury and surgery was 9 days (range, 2-18 days). Four patients had complications: 3 with erythema related to infection, which appeared to be a reaction to the suture prompting removal, and 1 with a subungual mass related to the suture at removal. One patient had persistent pain. Postoperative range of motion, assessed using the Strickland criteria, was excellent or good in 5 (33%) of 15 patients, but this was predominantly due to motion at the proximal joints as overall DIP motion was limited. Patients had a mean distal interphalangeal joint range of motion of 24° (range, 0° to 55°). CONCLUSIONS: In our series, repair of FDP avulsions via all-inside suture fixation is associated with limited distal interphalangeal joint motion and an incidence of infection (24%) at final follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Minimal Clinically Important Difference for PROMIS Physical Function and Pain Interference in Patients Following Surgical Treatment of Distal Radius Fracture.

PURPOSE: We estimated the minimal clinically important difference (MCID) for the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) computer adaptive tests (CATs) following surgical treatment of distal radius fracture (DRF). METHODS: Adult patients surgically treated between November 2017 and November 2020 for isolated DRF were identified. Demographic and patient-reported outcome data were extracted from the electronic health record. Outcomes of interest were the PROMIS PF and PI CATs. Inclusion criteria were met if: (1) PROMIS PF and PI scores were available at preoperative and postoperative visits; and (2) a postoperative clinical anchor question asking about overall response to treatment was answered. An anchor-based MCID estimate was determined by calculating the average absolute score change in PROMIS PF and PI for patients who indicated a mild change to the anchor question. A distribution-based MCID estimate was also calculated using the standard error of measurement and effect sizes of change. RESULTS: The changes in PROMIS PF and PI scores were significantly different between patients who gave responses of much change (n = 73), mild change (n = 51), and no change (n = 19) to the clinical anchor question. The average score changes in the mild change group for PROMIS PF and PI were 5.2 (SD, 3.7) and 6.8 (SD, 4.3) points, respectively, representing the anchor-based MCID estimates. The PROMIS PI anchor-based estimate was moderately correlated with the preoperative score (r = -0.41), time between visits (r = -0.39), and age (r = 0.30). The distribution-based MCID estimates were 3.8 (SD, 1.3) and 3.7 (SD, 1.3) points for the PROMIS PF and PI, respectively. CONCLUSIONS: The MCIDs were estimated as 5.2 and 6.8 for the PROMIS PF and PI CATs, respectively, following surgery for DRF. CLINICAL RELEVANCE: As reports continue to publish a consistent range of MCID values, researchers can be confident in these values and begin using them across a broader spectrum of conditions treated by hand surgeons.

How to Shoot and Edit High-Quality Surgical Videos for Hand and Upper Extremity Surgery.

A surgical video can improve patient care, surgical education, as well as scientific presentations and publications. Previous authors have outlined a basic understanding of how to produce high-quality surgical videos. With continuous technological improvements in video-filming hardware and editing software, multiple options for producing high-quality surgical videos are available. This article described important aspects of filming and editing videos to create a video that the surgeon can watch before performing the procedure. The authors reviewed camera terminology, including resolution, optical and digital zoom, shutter speed, and frame rate, as well as equipment options or setup for recording high-quality surgical videos. We provided information regarding computer requirements and editing on Windows and Macintosh operating systems, optimizing educational value for the viewer.

Value-Based Health Care in Hand Surgery: Where Are We & Where Do We Go From Here?

Health care delivery is broken. The cost of care continues to skyrocket and the outcomes most important to patients are often a mystery. Further, care is often delivered via a fee-for-service model where surgeons are rewarded for the quantity, not the quality, of services provided. Such a health care delivery system is not sustainable and does not incentivize stakeholders to focus on the most important element of the health care delivery "puzzle": the patient. Fortunately, we are in the midst of transforming our health care delivery system, with a focus on optimizing the value of care delivery (ie, health outcomes achieved per dollar spent across a full care cycle). In hand surgery, progress has been made as part of this health system evolution. However, there remains much to accomplish. In this article, the authors review the 6 components of a strategic agenda for moving to a high-value health care delivery system for hand surgery, focusing on where we are today and where we need to go from here.

Editorial Commentary: Patient-Reported Outcomes Measurement Information System (PROMIS) Needs an Anchor to Correlate Pain and Satisfactory Function in New Patient Orthopaedic Visits.

In today's health care climate, the patient perspective is becoming increasingly important. As the health care paradigm shifts toward value-based health care, patient-reported outcomes are becoming increasingly important for not only research but for routine clinical care. While there are many outcome instruments used for musculoskeletal care, the addition of the simple question of "how are you doing" or "are your symptoms manageable" can provide additional valuable insight to the provider and help improve care using a shared decision model. In other words, if you want to know how the patient is doing, you have to ask them. This biopsychosocial approach demonstrates caring for the entire patient. The Patient-Reported Outcomes Measurement Information System (PROMIS) is a patient-reported outcome instrument that was developed using the biopsychosocial model and has the advantage of being administered as a computer adaptive test. It can be used across health care and is comparable across medical specialties as the scores are standardized to US population-based norms. When used in isolation, PROMIS provides an idea of how the patient is doing compared with the population but does not give the insight as to how the patient is coping with their condition. The addition of an anchor question, such as their patient acceptable symptom state, adds further understanding to the individual patient.

Impact of Insurance Type on Self-Reported Symptom Severity at the Preoperative Visit for Carpal Tunnel Release.

PURPOSE: Prior studies evaluated the impact of insurance type on access to hand care. However, there is limited literature quantifying whether patient symptoms are worse at the time of intervention. Our primary null hypothesis was that insurance type would not be associated with Patient-Reported Outcomes Measure Information System (PROMIS) Upper-Extremity (UE), Physical Function (PF), Pain Interference (PI), and Depression scores at the preoperative visit before carpal tunnel release (CTR). METHODS: Between December 2016 and November 2018, patients with known carpal tunnel syndrome presenting to a tertiary academic hand clinic for the preoperative visit within 3 months of CTR, completed PROMIS UE, PF, PI, and Depression computer adaptive tests. Patient characteristics were recorded, including insurance type as commercial, Medicare, Medicaid, or workers' compensation. Multivariable linear regression was used to determine which variables were associated with PROMIS scores at the preoperative visit before CTR. RESULTS: A total of 301 patients were included in the analysis. All PROMIS domains were significantly different by insurance type; Medicaid patients had the worst preoperative score for all domains in bivariate analysis. In multivariable linear regression modeling, commercial insurance was associated with better preoperative PROMIS UE, PF, PI, and Depression scores. CONCLUSIONS: Commercial insurance is associated with significantly better preoperative PROMIS PF, PI, and Depression scores compared with other insurance types (ie, Medicaid, Medicare, and Workers' compensation). This may be the result of a number of factors, including differences in access to hand care or life circumstances that allow for only certain individuals to seek hand care early on in the disease process. However, further research is warranted to determine more definitively why this association exists. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Evaluation of PROMIS' Ability to Detect Immediate Postoperative Symptom Improvement Following Carpal Tunnel Release.

PURPOSE: We sought to determine whether subjective clinical improvement immediately after carpal tunnel release (CTR) was captured by Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE), Physical Function (PF), Pain Interference (PI), and Depression. METHODS: Between September 2018 and January 2020, patients presenting to a single academic medical center hand clinic were asked to complete PROMIS UE, PF, PI, and Depression computer adaptive tests. In addition, patients who had CTR were asked to answer the following at their first postoperative clinic visit: "Since my last clinic visit, my condition is: (1) much better; (2) mildly better; (3) no change; (4) mildly worse; (5) much worse." For each patient, the last clinic visit was the final preoperative visit. The PROMIS domain scores were compared before and after surgery using paired t tests. The percentage of patients subjectively reporting better symptoms was calculated. RESULTS: A total of 156 patients fit our inclusion criteria. The average number of days between the final preoperative visit and CTR was 7 (range, 0-30), and the average number of days between CTR and the first postoperative visit was 9 (range, 3-21). A total of 116 patients (74%) reported their carpal tunnel syndrome was better at their first postoperative visit. However, PROMIS UE, PF, and PI scores were significantly worse at the first postoperative visit, although not at clinically appreciable levels. There was no statistical or clinical difference in PROMIS Depression scores from pre- to postoperative time points. CONCLUSIONS: Nearly 75% of patients subjectively report their carpal tunnel syndrome is better at their first follow-up visit within 3 weeks of CTR; however, PROMIS does not capture this improvement. CLINICAL RELEVANCE: Hand surgeons evaluating patients shortly following CTR should be aware of the potential limitation of PROMIS to accurately capture immediate postoperative clinical outcomes. Disease-specific Patient-Reported Outcome Measures, such as the Boston Carpal Tunnel Questionnaire, may be preferred during this immediate postoperative timeframe.

Risk Factors for Failed Nonsurgical Treatment Resulting in Surgery on Thumb Carpometacarpal Arthritis.

PURPOSE: The thumb carpometacarpal (CMC) joint is the second most common site of osteoarthritis in the hand, yet reported symptoms and ultimate treatment decisions are not simply a function of radiographic appearance. This study aimed to determine the patient- and/or disease-related factors associated with patients undergoing surgical treatment of thumb CMC arthritis. METHODS: This retrospective cohort study analyzed 1,994 patients with thumb CMC arthritis treated at 2 institutions between February 2015 and November 2018. Patient demographic and clinical information was obtained from medical records to characterize treatment modalities before hand surgeon evaluation, mental and physical comorbidities, and Patient-Reported Outcomes Measurement Information System assessments. After bivariate analysis, a multivariable logistic regression model evaluated factors associated with undergoing thumb CMC surgery. RESULTS: This cohort was predominately female (70%) and white (91%), mean age at first appointment, 62 ± 10 years. A total of 170 patients underwent surgery for thumb CMC arthritis (9%) at a median of 114 days (interquartile range, 27-328) after the first visit. Patient-Reported Outcomes Measurement Information System Depression scores correlated with Pain Interference and Physical Function scores. A history of diagnosed depression or anxiety was associated with less perceived Physical Function at presentation. However, only prior contralateral thumb CMC surgery, younger patient age, and treating institution were associated with undergoing surgery in regression modeling. CONCLUSIONS: Pain and functional limitations associated with thumb CMC arthritis are influenced by mental health comorbidities, but these factors do not predict surgical treatment. Instead, patients' prior surgical experience and surgeon attitudes toward thumb CMC arthritis appear to have a strong influence on the odds of patients undergoing surgery for thumb CMC arthritis. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Operative Treatment is Not Associated with More Relief of Depression Symptoms than Nonoperative Treatment in Patients with Common Hand Illness.

BACKGROUND: Depression symptoms are prevalent in the general population, and as many as one in eight patients seeing a hand surgeon may have undiagnosed major depression. It is not clear to what degree lower mood is the consequence or cause of greater symptoms and limitations. If depressive symptoms are a consequence of functional limitations, they might be expected to improve when pathophysiology and impairment are ameliorated. Because surgical treatment is often disease-modifying or salvage, surgery might have a greater impact than nonoperative treatment, which is more often palliative (symptom relieving) than disease-modifying. QUESTIONS/PURPOSES: (1) For which hand or wrist conditions are depression symptoms lower after operative compared with nonoperative treatment? (2) Among the subset of patients with the highest depression scores, are depression symptoms lower after operative treatment compared with nonoperative treatment? (3) Among the subset of patients who had nonoperative treatment, are depression symptoms lower after a corticosteroid injection compared with no specific biomedical intervention? METHODS: At an academic orthopaedic department, 4452 patients had a new office visit for carpal tunnel syndrome, benign neoplasm, primary hand osteoarthritis, de Quervain's tendinopathy, or trigger digit. We analyzed the 1652 patients (37%) who had a return visit at least 3 months later for the same diagnosis. Patients completed the Patient-reported Outcomes Measurement Information System (PROMIS) Depression computerized adaptive test at every office visit (higher scores indicate more depression symptoms) and PROMIS Pain Interference (higher scores indicates greater hindrance in daily life owing to pain). Patients with a return visit were more likely to have surgical treatment and had greater Pain Interference scores at the first visit. Thirteen percent of patients (221 of 1652) had incomplete or missing scores at the initial visit and 33% (550 of 1652) had incomplete or missing scores at the final return visit. We used multiple imputations to account for missing or incomplete data (imputations = 50). In a multivariable linear regression analysis, we compared the mean change in Depression scores between patients treated operatively and those treated nonoperatively, accounting for PROMIS Pain Interference scores at the first visit, age, gender diagnosis, provider, and treatment duration. A post-hoc power analysis demonstrated that the smallest patient cohort (benign lump, n = 176) provided 99% power (α = 0.05) with eight predictor variables to detect a change of 2 points in the PROMIS Depression score (minimally important difference = 3.5). RESULTS: After controlling for potentially confounding variables such as pain interference and age, only carpal tunnel release was associated with a slightly greater decrease in depression symptoms compared with nonoperative treatment (regression coefficient [RC] = -3 [95% confidence interval -6 to -1]; p = 0.006). In patients with the highest PROMIS Depression scores for each diagnosis, operative treatment was not associated with an improvement in depression symptoms (carpal tunnel release: RC = 5 [95% CI -7 to 16]; p = 0.44). Moreover, a corticosteroid injection was not associated with fewer depression symptoms than no biomedical treatment (carpal tunnel release: RC = -3 [95% CI -8 to 3]; p = 0.36). CONCLUSIONS: Given that operative treatment of hand pathology is not generally associated with a decrease in depression symptoms, our results support treating comorbid depression as a separate illness rather than as a secondary effect of pain or physical limitations. LEVEL OF EVIDENCE: Level II, therapeutic study.

Trends in the Management of Traumatic Upper Extremity Amputations.

PURPOSE: Treatment for upper extremity amputations includes revision amputation or attempted replantation. The rate of digital replantation has been declining in the United States. Prior studies discovered the presence of socioeconomic disparities associated with these injuries. The goals of this study were to investigate yearly trends of traumatic upper extremity amputations and evaluate the presence of disparities with access to care in these injuries. METHODS: The 2008 to 2014 New York Statewide Planning and Research Cooperative System (SPARCS) inpatient and outpatient databases were utilized to identify patients who had traumatic upper extremity amputations. We queried the database for patient characteristics, resource utilization characteristics, insurance status, major in-hospital complications, and mortality. Patients at low-, medium-, and high-volume institutions were compared. We performed multivariable logistic regressions for the binary variable replantation (yes/no) controlling for age, sex, race, insurance status, amputation level, admission hour, and comorbidities. RESULTS: A total of 2,492 patients met our inclusion criteria: 92.1% sustained digital amputations and 7.9% sustained arm amputations. The annual rate of inpatient finger amputations decreased significantly (1.9 per 100,000 people in 2008 vs 1.4 per 100,000 people in 2014) during the study period while that of outpatient finger amputations increased significantly (12.0 per 100,000 people in 2008 vs 15.5 per 100,000 people in 2014). Multivariable analysis demonstrated incrementally lower odds for replantation with increasing age and increased odds for replantation in patients with private insurance (odds ratio, 1.64; 95% confidence interval, 1.08-2.50). The number of replantation surgeries at medium-volume institutions decreased by 45% while remaining steady in low- and high-volume institutions. CONCLUSIONS: Our findings corroborate the findings of other studies that underscore the existence of disparities with respect to insurance status in these injuries. Replantations occur more frequently at high-volume hospitals and are more common in younger patients with private insurance. This finding suggests that patients with traumatic amputations may benefit from treatment at high-volume institutions. Further research to help improve access to such institutions is warranted. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Understanding PROMIS.

Patient reported outcomes (PROs) are becoming increasingly emphasized in health care. Some medical and orthopedic specialties have 1 or 2 primary PROs that are used across the discipline, whereas hand surgery has multiple PROs. The multitude of PROs gives hand surgeons flexibility because each provides slightly different information, but the number of options can present a daunting task when choosing which to use. The latest generation of PROs leverages computer adaptive testing and includes assessments of physical, mental, and social health. The Patient-Reported Outcomes Measurement Information System was funded by the National Institutes of Health to include a comprehensive set of health instruments that are not disease-specific; it has undergone several forms of validation and has been found to be comparable across medical specialties. This article discusses the details of the Patient-Reported Outcomes Measurement Information System, how it compares with other outcomes instruments, and how it can be used in practice.

Convolutional Neural Network for Second Metacarpal Radiographic Osteoporosis Screening.

PURPOSE: Osteoporosis and osteopenia are extremely common and can lead to fragility fractures. The purpose of this study was to determine whether a computer learning system could classify whether a hand radiograph demonstrated osteoporosis based on the second metacarpal cortical percentage. METHODS: We used the second metacarpal cortical percentage as the osteoporosis predictor. A total of 4,000 posteroanterior (PA) radiographs of the hand were standardized through laterality correction, vertical alignment correction, segmentation, proxy osteoporosis predictor, and full pipeline. Laterality was classified using a LeNet convolutional neural network (CNN). Vertical alignment classification used 2,000 PA x-rays to determine vertical alignment of the second metacarpal. We employed segmentation to determine which pixels belong to the second metacarpal from 1,000 PA x-rays using the FSN-8 CNN. The full pipeline was tested on 265 previously unseen PA x-rays. RESULTS: Laterality classification accuracy was 99.62%, with a specificity of 100% and sensitivity of 99.3%. Rotation of the hand within 10° of vertical was accurate in 93.2% of films. Segmentation was 94.8% accurate. Proxy osteoporosis predictor was 88.4% accurate. Full pipeline accuracy was 93.9%. In the testing data set, the CNN had a sensitivity of 82.4% and specificity of 95.7%. In the balanced data set, 6 of 39 osteoporotic films were classified as nonosteoporotic; sensitivity was 82.4% and specificity, 94.3%. CONCLUSIONS: We have created a series of CNN that can accurately identify osteoporosis from non-osteoporosis. Furthermore, our CNN is able to make adjustments to images based on laterality and vertical alignment. CLINICAL RELEVANCE: Convolutional neural network and computer learning can be used as an adjunct to dual-energy x-ray absorptiometry scans or to screen and make appropriate referrals for further workup in patients with suspected osteoporosis.

The Association Between Symptoms of Depression and Office Visits in Patients With Nontraumatic Upper-Extremity Illness.

PURPOSE: Because psychological and social factors increase symptoms and limitations, it is possible that they are also related to higher use of care. METHODS: We used a database of an academic outpatient orthopedic department in which patient-reported outcome measures were routinely collected and identified 3,620 patients with de Quervain tendinopathy, ganglion, trapeziometacarpal arthritis, trigger digit, or carpal tunnel syndrome who remained in care at least 3 months. At every office visit, patients completed the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Computerized Adaptive Test (CAT), PROMIS Pain Interference CAT, and PROMIS Depression CAT. We conducted multivariable Poisson regression analysis of factors associated with the total number of office visits, accounting for PROMIS scores at the first office visit, age, surgical treatment, sex, diagnosis, and clinician team. RESULTS: Operative treatment had the greatest influence on the number of office visits. Other variables associated with the number of visits were female sex, younger age, higher PROMIS Depression scores, and higher Pain Interference scores. CONCLUSIONS: Treatment choice had the greatest influence on the number of subsequent visits for atraumatic conditions. The fact that the total number of office visits is associated with greater symptoms of depression and greater pain interference, independent of treatment choice, suggests a relation between mental health and resource use. CLINICAL RELEVANCE: Quality improvement efforts and future research might address whether adding strategies to decrease symptoms of depression and optimize coping strategies (to reduce pain interference) might improve upper-extremity health more efficiently than standard treatment alone.

Responsiveness of the PROMIS and its Concurrent Validity with Other Region- and Condition-specific PROMs in Patients Undergoing Carpal Tunnel Release.

BACKGROUND: The Patient-reported Outcome Measurement Information System (PROMIS) continues to be an important universal patient-reported outcomes measure (PROM) in orthopaedic surgery. However, there is concern about the performance of the PROMIS as a general health questionnaire in hand surgery compared with the performance of region- and condition-specific PROMs such as the Michigan Hand Questionnaire (MHQ) and the Boston Carpal Tunnel Questionnaire (BCTQ), respectively. To ensure that PROMIS domains capture patient-reported outcomes to the same degree as region- and condition-specific PROMs do, comparing PROM performance is necessary. QUESTIONS/PURPOSES: (1) Which PROMs demonstrate high responsiveness among patients undergoing carpal tunnel release (CTR)? (2) Which of the PROMIS domains (Physical Function [PF], Upper Extremity [UE], and Pain Interference [PI]) demonstrate concurrent validity with the HHQ and BCTQ domains? METHODS: In this prospective study, between November 2014 and October 2016, patients with carpal tunnel syndrome visiting a single surgeon who elected to undergo CTR completed the BCTQ, MHQ, and PROMIS UE, PF, and PI domains at each visit. A total of 101 patients agreed to participate. Of these, 31 patients (31%) did not return for a followup visit at least 6 weeks after CTR and were excluded, leaving a final sample of 70 patients (69%). We compared the PROMIS against region- and condition-specific PROMs in terms of responsiveness and concurrent validity. Responsiveness was determined using Cohen's d or the effect-size index (ESI). The larger the absolute value of the ESI, the greater the effect size. Using the ESI allows surgeons to better quantify the impact of CTR, with a medium ESI (that is, 0.5) representing a visible clinical change to a careful observer. Concurrent validity was determined using Spearman's correlation coefficient with correlation strengths categorized as excellent (> 0.7), excellent-good (0.61-0.70), good (0.4-0.6), and poor (< 0.4). Significance was set a priori at p < 0.05. RESULTS: Among PROMIS domains, the PI demonstrated the best responsiveness (ESI = 0.74; 95% CI, 0.39-1.08), followed by the UE (ESI = -0.66; 95% CI, -1.00 to -0.31). For the MHQ, the Satisfaction domain had the largest effect size (ESI = -1.48; 95% CI, -1.85 to -1.09), while for the BCTQ, the Symptom Severity domain had the best responsiveness (ESI = 1.54; 95% CI, 1.14-1.91). The PROMIS UE and PI domains demonstrated excellent-good to excellent correlations to the total MHQ and BCTQ-Functional Status scores (preoperative UE to MHQ: ρ = 0.68; PI to MHQ: ρ = 0.74; UE to BCTQ-Functional Status: ρ = 0.74; PI to BCTQ-Functional Status: ρ = 0.67; all p < 0.001), while the PROMIS PF demonstrated poor correlations with the same domains (preoperative PF to MHQ; ρ = 0.33; UE to BCTQ-Functional Status: ρ = 0.39; both p < 0.01). CONCLUSIONS: The PROMIS UE and PI domains demonstrated slightly worse responsiveness than the MHQ and BCTQ domains that was nonetheless acceptable. The PROMIS PF domain was unresponsive. All three PROMIS domains correlated with the MHQ and BCTQ, but the PROMIS UE and PI domains had notably stronger correlations to the MHQ and BCTQ domains than the PF domain did. We feel that the PROMIS UE and PI can be used to evaluate the clinical outcomes of patients undergoing CTR, while also providing more robust insight into overall health status because they are general PROMs. However, we do not recommend the PROMIS PF for evaluating patients undergoing CTR. LEVEL OF EVIDENCE: Level II, diagnostic study.

Patient Characteristics, Treatment, and Presenting PROMIS Scores Associated with Number of Office Visits for Traumatic Hand and Wrist Conditions.

BACKGROUND: Overuse of healthcare resources is burdensome on society. Prior research has demonstrated that many patients with traumatic musculoskeletal injuries continue to seek care long after appropriate healing is well established, suggesting an overuse of services. However, few studies have examined the factors-including patient-reported outcomes-associated with an increased number of clinic visits for traumatic hand and wrist conditions. QUESTIONS/PURPOSES: (1) After accounting for surgical treatment, surgeon, and demographic factors, is a patient's PROMIS Pain Interference score associated with the total number of office visits? (2) Is PROMIS Depression, combination of PROMIS Depression and Pain Interference, or Physical Function scores associated with the number of office visits? METHODS: Between June 2015 and May 2018, 1098 patients presenting for a new patient visit at a single, urban academic medical center for distal radius fracture, wrist or hand sprain, tendon rupture, traumatic finger amputation, or scaphoid fracture were identified. Of those, 823 (75%) patients completed all PROMIS domains and presented before the trailing period and thus were included in this retrospective study. We recorded a number of variables including: Total number of office visits, age, sex, race, marital status, diagnosis, provider, and operative or nonoperative treatment. Multivariable Poisson regression analysis was conducted to determine whether Patient-Reported Outcomes Measurement Information System Pain Interference (PROMIS PI), Physical Function (PROMIS PF), and Depression scores measured at the first visit were associated with the total number of office visits, after accounting for the other factors we measured. RESULTS: Higher PROMIS PI scores were associated with greater number of clinic visits (0.0077; 95% CI, 0.0018-0.014; p = 0.010). Although PROMIS Depression scores were not associated with the number of office visits (0.0042; 95% CI, -0.0099 to 0.0094; p = 0.112), higher PROMIS PF scores were associated with fewer office visits when accounting for confounding variables (-0.0077; 95% CI, -0.0012 to -0.0029; p = 0.001). Additionally, across all individual PROMIS models, there was an association between the variables "operative treatment" (PI: 0.85; 95% CI, 0.72-0.98; p < 0.001; Depression: 0.87; 95% CI, 0.74-1.0; p < 0.001; PF: 0.85; 95% CI, 0.72-0.99; p < 0.001) and "traumatic finger amputation" (PI: 0.22; 95% CI, 0.016-0.42; p = 0.034; Depression: 0.2; 95% CI, 0.086-0.47; p = 0.005; PF: 0.21; 95% CI, 0.014-0.41; p = 0.036) with an increased total number of office visits. Provider team 5 (PI: -0.62; 95% CI, -0.98 to -0.27; p = 0.001; Depression: -0.61; 95% CI, -0.96 to -0.26; p = 0.001; PF: -0.60; 95% CI, -0.96 to -0.25; p = 0.001) was associated with fewer office visits. In both the PROMIS Depression and PROMIS PF regression models, increasing age (Depression: -0.0048; 95% CI, -0.0088 to -0.00081; p = 0.018; PF: -0.0045; 95% CI, -0.0085 to -0.0006; p = 0.024) was also associated with fewer total number of office visits. CONCLUSIONS: This study helps surgeons understand that patients who present at their initial office visit for traumatic hand and wrist conditions displaying worse pain coping strategies and decreased physical function will have more office visits. We recommend that surgeons engage in a comprehensive care approach that is empathetic, fosters effective pain coping strategies (and so might decrease PROMIS PI scores), and educates patients about expectations by providing educational materials and/or including other health professionals (such as, social work, physical therapy, mental health professional) as needed. This may decrease healthcare use in patients with traumatic hand and wrist conditions. LEVEL OF EVIDENCE: Level IV, prognostic study.

Determining the Generalizability of the PROMIS Depression Domain's Floor Effect and Completion Time in Patients Undergoing Orthopaedic Surgery.

BACKGROUND: Depression is common and can decrease the likelihood that a patient undergoing an orthopaedic procedure will improve after that intervention. Research at a single institution using the Patient-reported Outcomes Measurement Information System (PROMIS) showed that the PROMIS Depression domain had a substantial floor effect (lowest depressive symptoms measurable) in patients with orthopaedic conditions, although the instrument is designed to follow a population-based normal distribution. Patients with the lowest scores (floor) completed the questionnaire more quickly than those who did not have the lowest scores, which suggests that patients may not want to report or discuss depressive symptoms with their orthopaedic surgeon. QUESTIONS/PURPOSES: (1) Do the scores of a large population of patients with orthopaedic conditions completing the PROMIS Physical Function (PF), Pain Interference (PI), and Depression questionnaires follow the normal population distribution used to calibrate the PROMIS instrument? (2) Do the scores of a large population of patients with foot and ankle, spine, upper extremity, multiple orthopaedic subspecialty, or other orthopaedic conditions completing the PROMIS Depression questionnaire follow the normal population distribution used to calibrate the PROMIS instrument? (3) Do all orthopaedic patients with the lowest possible score (floor effect) on the PROMIS Depression questionnaire answer questions more quickly than those who do not? METHODS: Between February 12, 2015 and July 19, 2018, a total of 513,042 patients with orthopaedic conditions at a single urban, tertiary academic medical center were asked to complete the PROMIS PF, PI, and Depression domains. The PROMIS PF, PI, and Depression questionnaires were administered at 433,939 patient encounters (85%), and 325,251 of 433,939 (75%) completed all three questionnaires and were included in our final sample. The remaining encounters were excluded from all analyses because of incomplete PROMIS data. Using this large sample size, we determined the distributions of the PROMIS PF, PI, and Depression domains for all patients with orthopaedic conditions by visual inspection. We calculated the percentage of patients with the lowest possible score on the PROMIS Depression domain ("floor group") for all patients with orthopaedic conditions, as well for patients presenting to orthopaedic subspecialists (foot and ankle, spine, upper extremity, multiple subspecialties, or other specialists). We compared patient and PROMIS characteristics between patients in the floor group and all others ("standard group") using a bivariate analysis, including the total time it took to complete the questionnaires and average time it took to answer each question. RESULTS: Of the three PROMIS domains analyzed, only the PROMIS PF demonstrated a normal distribution on visual inspection. PROMIS PI scores had a measurable ceiling effect (more pain symptoms) (15,520 of 325,251 patient encounters; 5%), while PROMIS Depression scores demonstrated a clear floor effect (65,226 of 325,251; 20%). When analyzed by subspecialty, there was a clear floor effect for the PROMIS Depression in the specialties of foot and ankle (6031 of 29,273 patient encounters; 21%), spine (7611 of 58,266; 13%), upper extremity (9851 of 42,864; 23%), multiple subspecialties (276 of 1662; 17%), and other (41, 454 of 193,185; 22%). Generally, those in the floor group spent less time per question on the PROMIS Depression questionnaire than did those in the standard group (5.3 seconds ± 2.6 seconds versus 8.1 seconds ± 4.6 seconds; mean difference, 2.8 seconds; p < 0.001). CONCLUSIONS: The substantial floor effect of the PROMIS Depression in the setting of hasty completion raises the question of whether such results truly indicate that these patients have minimal depression or whether they simply do not report their true mental health status in an orthopaedic setting. When such patients are seen in clinic, surgeons may benefit from using the PROMIS Depression as an educational opportunity to explain the importance of mental health in orthopaedic care and ensure the questionnaire is completed accurately. This study builds on previous work by suggesting these findings apply to other general and subspecialty orthopaedic patient populations at academic medical centers. Future work may seek to determine the best way of ensuring that the PROMIS Depression questionnaire is completed accurately in orthopaedic clinics. LEVEL OF EVIDENCE: Level II, diagnostic study.

Minimal Clinically Important Differences for PROMIS Physical Function, Upper Extremity, and Pain Interference in Carpal Tunnel Release Using Region- and Condition-Specific PROM Tools.

PURPOSE: Uncertainty exists about what change in Patient-Reported Outcomes Measurement Information System (PROMIS) scores represents a clinically relevant improvement (minimal clinically important difference [MCID]) in hand surgery care. Using a region-specific patient-reported outcome measure (PROM) (Michigan Hand Question [MHQ]) and a condition-specific PROM (Boston Carpal Tunnel Questionnaire [BCTQ]), MCID values were determined for PROMIS Physical Function (PF), Upper Extremity (UE), and Pain Interference (PI) computerized adaptive testing among patients undergoing carpal tunnel release (CTR). METHODS: Patients undergoing CTR with a single surgeon from November 2014 to April 2017 were asked to complete the BCTQ, MHQ, and PROMIS PF, UE, and PI at each visit. Patients who had completed questionnaires both at a preoperative and either a 6-week or a 3-month postoperative visit were included. The PROMIS PF, UE, and PI MCID values were calculated using previously determined MCID estimates in the literature with both region- (ie, MHQ) and condition-specific (ie, BCTQ) PROM anchors. The PROMIS domain MCID estimates were also determined using the distribution-based method. RESULTS: A total of 70 patients fit our inclusion criteria. Using MHQ Function and Pain, PROMIS UE, PF, and PI MCIDs were 6.3, 1.8, and -8.9, respectively. Using the average of the 2 BCTQ domains, PROMIS UE, PF, and PI MCIDs were 8.0, 2.8, and -9.7, respectively. Using the distribution-based method, PROMIS UE, PF, and PI MCIDs were 4.2, 2.7, and -4.1, respectively. CONCLUSIONS: Using region- and condition-specific PROMs, we were able to provide MCID estimates of PROMIS UE, PF, and PI for patients undergoing CTR. CLINICAL RELEVANCE: Estimating PROMIS UE, PF, and PI MCIDs in CTR using validated region- and condition-specific PROMs provides hand surgeons a way to evaluate CTR outcomes not previously described in the literature. Surgeons should understand that these values are only estimates and future work is needed to verify whether they reflect clinical improvement.

A Comparison of PROMIS UE Versus PF: Correlation to PROMIS PI and Depression, Ceiling and Floor Effects, and Time to Completion.

PURPOSE: This study aimed to (1) determine the correlation of Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) with PROMIS Upper Extremity (UE) and compare the correlations of PF and UE with PROMIS Pain Interference (PI) and PROMIS Depression; (2) compare the ability of PF and UE to capture health outcomes across the spectrum in patients seeking hand care; and (3) compare the time to completion for PROMIS PF to that for PROMIS UE. METHODS: Patients presenting to a hand clinic between October, 2015 and October, 2017 were asked to complete PROMIS PF, UE, PI, and Depression computerized adaptive tests. Spearman correlation coefficients (ρ) were calculated between the domains. Ceiling and floor effects and time to completion of each domain were compared. RESULTS: A total of 20,489 unique visits representing 10,344 patients met inclusion criteria. On average, PROMIS UE demonstrated more functional disability than did PROMIS PF (PF: 43.9 [95% confidence interval (CI), 43.7-44.0] vs UE: 38.5 [95% CI, 38.4-38.7]). PROMIS PF and UE were positively correlated (ρ = 0.79) and both were inversely correlated with PROMIS PI (PF: ρ = -0.72; UE: ρ = -0.72). PROMIS PF and UE were both inversely correlated with PROMIS Depression (PF: ρ = -0.44; UE: ρ = -0.44). PROMIS PF demonstrated better ceiling (0.6% vs 7.5%) and floor effects (0.07% vs 0.4%). The PROMIS UE CAT was completed in about the same time as the PROMIS PF CAT (UE: 59.8 seconds [95% CI, 59.3-60.3 seconds] vs PF: 54.1 seconds [95% CI, 53.8-54.5 seconds]). CONCLUSIONS: PROMIS PF captures functional outcomes similar to those of the UE domain with better performance (ie, ceiling and floor effects) in patients with hand pathologies. CLINICAL RELEVANCE: Hand surgeons should consider the trade-off of using PROMIS PF instead of PROMIS UE or vice versa when selecting a domain for patient care. Although PROMIS PF may capture slight variations in function at the extremes better than the current PROMIS UE, this may not be as clinically important as capturing large changes in upper-extremity function more specifically, which PROMIS UE accomplishes.