Implementation of an electronic health record system during global surgical outreach: A prospective evaluation of success and sustainability.

BACKGROUND: The burden of musculoskeletal conditions continues to grow in low- and middle-income countries. Among thousands of surgical outreach trips each year, few organizations electronically track patient data to inform real-time care decisions and assess trip impact. We report the implementation of an electronic health record (EHR) system utilized at point of care during an orthopedic surgical outreach trip. METHODS: In March 2023, we implemented an EHR on an orthopedic outreach trip to guide real-time care decisions. We utilized an effectiveness-implementation hybrid type 3 design to evaluate implementation success. Success was measured using outcomes adopted by the World Health Organization, including acceptability, appropriateness, feasibility, adoption, fidelity, and sustainability. Clinical outcome measures included adherence to essential quality measures and follow-up numerical rating system (NRS) pain scores. RESULTS: During the 5-day outreach trip, 76 patients were evaluated, 25 of which underwent surgery beforehand. The EHR implementation was successful as defined by: mean questionnaire ratings of acceptability (4.26), appropriateness (4.12), feasibility (4.19), and adoption (4.33) at least 4.00, WHO behaviorally anchored rating scale ratings of fidelity (6.8) at least 5.00, and sustainability (80%) at least 60% follow-up at 6 months. All clinical quality measures were reported in greater than 80% of cases with all measures reported in 92% of cases. NRS pain scores improved by an average of 2.4 points. CONCLUSIONS: We demonstrate successful implementation of an EHR for real-time clinical use on a surgical outreach trip. Benefits of EHR utilization on surgical outreach trips may include improved documentation, minimization of medical errors, and ultimately improved quality of care.

Orthopedic surgery in Palau-Current capacity, needs, and future directions.

BACKGROUND: Palau, an island nation in Micronesia, is a medically underserved area with a shortage of specialty care services. Orthopedic diagnoses in Palau remain among the three most common reasons for costly off-island medical referral. The purpose of this study was to assess Palau's current orthopedic surgery capacity and needs to inform interventions to build capacity to improve care access and quality. METHODS: Orthopedic needs and capacity assessment tools developed by global surgical outreach experts were utilized to gather information and prompt discussions with a broad range of Palau's most knowledgeable stakeholders (n = 6). Results were reported descriptively. RESULTS: Finance, community impact, governance, and professional development were the lowest-scored domains from the Capacity Assessment Tool for orthopedic surgery (CAT-os), indicating substantial opportunity to build within these domains. According to administrators (n = 3), governance and finance were the greatest capacity-building priorities, followed by professional development and partnership. Belau National Hospital (BNH) had adequate surgical infrastructure. Skin grafting, soft tissue excision/resection, infection management, and amputation were the most commonly selected procedures by stakeholders reporting orthopedic needs. CONCLUSIONS: This study utilizes a framework for orthopedic capacity-building in Palau which may inform partnership between Palau's healthcare system and orthopedic global outreach organizations with the goal of improving the quality, safety, and value of the care delivered. This demonstration of benchmarking, implementation planning, and subsequent re-evaluation lays the foundation for the understanding of capacity-building and may be applied to other medically underserved areas globally to improve access to high-quality orthopedic care.

Patient-Reported Outcome Measures: How to Maximize Their Utility and Mitigate Health Care Disparities.

Patient-reported outcome measures (PROMs) provide a standardized assessment from the patient about their own health status. Although originally developed as research tools, PROMs can be used in clinical orthopaedic care to complement objective functional measures (eg, range of motion). When PROMs are used during clinical care, they can improve patient outcomes, engagement, well-being, and patient-physician communication. Therefore, PROMs are increasingly integrated into shared decision-making approaches to guide treatment decisions, enhance treatment plans, and predict outcomes. They are also being used in quality measurement and value-based health care arrangements. However, methods to communicate PROMs with patients have not been fully developed, and there continue to be barriers to implementing their collection and communication at scale. In addition, measuring care quality and communicating PROMs with patients may have unintended consequences, such as when used in measurement without accounting for confounding factors (eg, psychological and social health), or in perpetuating health care disparities when used imprecisely (eg, lack of linguistic or cultural validation). It is important to describe the current state of PROM use in orthopaedic surgery, highlight opportunities and challenges of PROM use in clinical care, and provide a roadmap for how to incorporate PROMs to equitably improve patient health and build orthopaedic surgery practices.

Are Clinical Practice Guidelines Representative of Patients With Distal Radius Fractures? A Review of Patient Demographics and Patient-Reported Outcome Measures Used to Inform Guidelines.

PURPOSE: Clinical practice guidelines (CPGs) are recommendations developed for broad application to optimize high-quality care and decision-making. The composition of patients and outcome measures used in studies informing CPGs; however, has not been rigorously evaluated. With growing evidence that outcomes in musculoskeletal surgery vary by sociocultural factors, we aimed to: (1) review the linguistic, racial, and ethnic representation of the patients in the studies informing CPGs for distal radius fractures and (2) assess their use of linguistically and culturally adapted patient-reported outcome measures (PROMs). METHODS: The American Academy of Orthopaedic Surgeons website was used to identify relevant studies. Key variables were extracted, including inclusion and exclusion criteria, language of study, patient language and proficiency, patient race and ethnicity, and use of translated or culturally adapted PROMs. If provided, the clinical trial registration page for the study was evaluated. Descriptive statistics were used to describe the frequency of each variable. RESULTS: Fifty-four published texts were evaluated. Participant language was reported in four (7%) of the published texts and six (11%) when including the clinical trial registration information. Of the published texts, one (2%) reported ethnic group/race data and 40 (74%) used PROMs. Of those using PROMs, eight (20%) of 40 reported the use of translated PROMs, and three (8%) of 40 reported the use of culturally adapted PROMs. CONCLUSIONS: There is a lack of reporting of linguistic, racial, and ethnic data and inconsistent use of PROMs, particularly those that are translated and culturally adapted, in studies included in the American Academy of Orthopaedic Surgeons CPG for distal radius fractures. As sociocultural characteristics and PROMs are associated with outcomes, ensuring they are broadly represented in studies, may improve equity and shared decision-making. CLINICAL RELEVANCE: Greater inclusion and reporting of demographic data and PROMs are required in musculoskeletal studies to ensure broad applicability and advance health equity.

The Association Between Social Determinants of Health and Distal Radius Fracture Outcomes.

PURPOSE: The purpose of this study was to determine if adverse social determinants of health (SDOH) are associated with differential complication rates following surgical fixation of distal radius fractures and assess which SDOH domain (economic, educational, social, health care, or environmental) is most associated with postoperative complications. METHODS: Using a national administrative claims database, we conducted a retrospective cohort analysis of patients undergoing open treatment for an isolated distal radius fracture between 2010 and 2020. Patients were stratified based on the presence/absence of at least one SDOH code and propensity score matched to create two cohorts balanced by age, sex (male or female), insurance type, and comorbidities. Social determinants of health examined included economic, educational, social, health care, and environmental factors. Multivariable logistic regression analyses were performed to assess the isolated effect of SDOH on 90-day and 1-year complication rates. RESULTS: After propensity matching, 57,025 patients in the adverse SDOH cohort and 57,025 patients in the control cohort were included. Patients facing an adverse SDOH were significantly more likely to experience 90-day complications, including emergency department visits (Odds ratio (OR): 3.18 [95% confidence interval (CI): 3.07-3.29]), infection (OR: 2.37 [95% CI: 2.12-2.66]), wound dehiscence (OR: 2.06 [95% CI: 1.72-2.49]), and 1-year complications, including complex regional pain syndrome (OR: 1.35 [95% CI: 1.15-1.58]), malunion/nonunion (OR: 1.18 [95% CI: 1.08-1.29]), and hardware removal (OR: 1.13 [95% CI: 1.07-1.20]). Additionally, patients facing an adverse SDOH had a significantly increased risk of 90-day complications, regardless of fracture severity, and patients with economic and social challenges had the highest odds of both 90-day and 1-year postoperative complications. CONCLUSIONS: Social determinants of health are associated with increased complications following distal radius fracture fixation, even when controlling for demographic and clinical factors. We recommend routine screening for adverse SDOH and inclusion of SDOH data into health records to not only inform quality improvement initiatives and risk adjustment for outcome-based quality measurements but also to allow providers to begin to discuss and address such barriers during the perioperative period. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis II.

Is There Variation in Time to and Type of Treatment for Hip Osteoarthritis Based on Insurance?

BACKGROUND: Disparities in care access based on insurance exist for total hip arthroplasty (THA), but it is unclear if these lead to longer times to surgery. We evaluated whether rates of THA versus nonoperative interventions (NOI) and time to THA from initial hip osteoarthritis (OA) diagnosis vary by insurance type. METHODS: Using a national claims database, patients who had hip OA undergoing THA or NOI from 2011 to 2019 were identified and divided by insurance type: Medicaid-managed care; Medicare Advantage; and commercial insurance. The primary outcome was THA incidence within 3 years after hip OA diagnosis. Multivariable logistic regression models were created to assess the association between THA and insurance type, adjusting for age, sex, region, and comorbidities. RESULTS: Medicaid patients had lower rates of THA within 3 years of initial diagnosis (7.4 versus 10.9 or 12.0%, respectively; P < .0001) and longer times to surgery (297 versus 215 or 261 days, respectively; P < .0001) compared to Medicare Advantage and commercially-insured patients. In multivariable analyses, Medicaid patients were also less likely to receive THA (odds ratio (OR) = 0.62 [95% confidence intervals (CI): 0.60 to 0.64] versus Medicare Advantage, OR = 0.63 [95% CI: 0.61 to 0.64] versus commercial) or NOI (OR = 0.92 [95% CI: 0.91 to 0.94] versus Medicare Advantage, OR = 0.81 [95% CI: 0.79 to 0.82] versus commercial). CONCLUSIONS: Medicaid patients experienced lower rates of and longer times to THA than Medicare Advantage or commercially-insured patients. Further investigation into causes of these disparities, such as costs or access barriers, is necessary to ensure equitable care.

Identifying Strategies to Reduce Low-Value Preoperative Testing for Low-Risk Procedures: a Qualitative Study of Facilities with High or Recently Improved Levels of Testing.

BACKGROUND: Healthcare agencies and perioperative professional organizations recommend avoiding preoperative screening tests for low-risk surgical procedures. However, low-value preoperative tests are still commonly ordered even for generally healthy patients and active strategies to reduce this testing have not been adequately described. OBJECTIVE: We sought to learn from hospitals with either high levels of testing or that had recently reduced use of low-value screening tests (aka "delta sites") about reasons for testing and active deimplementation strategies they used to effectively improve practice. DESIGN: Qualitative study of semi-structured telephone interviews. PARTICIPANTS: We identified facilities in the US Veterans Health Administration (VHA) with high or recently improved burden of potentially low-value preoperative testing for carpal tunnel release and cataract surgery. We recruited perioperative clinicians to participate. APPROACH: Questions focused on reasons to order preoperative screening tests for patients undergoing low-risk surgery and, more importantly, what strategies had been successfully used to reduce testing. A framework method was used to identify common improvement strategies and specific care delivery innovations. KEY RESULTS: Thirty-five perioperative clinicians (e.g., hand surgeons, ophthalmologists, anesthesiologists, primary care providers, directors of preoperative clinics, nurses) from 29 VHA facilities participated. Facilities that successfully reduced the burden of low-value testing shared many improvement strategies (e.g., building consensus among stakeholders; using evidence/norm-based education and persuasion; clarifying responsibility for ordering tests) to implement different care delivery innovations (e.g., pre-screening to decide if a preop clinic evaluation is necessary; establishing a dedicated preop clinic for low-risk procedures). CONCLUSIONS: We identified a menu of common improvement strategies and specific care delivery innovations that might be helpful for institutions trying to design their own quality improvement programs to reduce low-value preoperative testing given their unique structure, resources, and constraints.

Capacity Building During Short-Term Surgical Outreach Trips: A Review of What Guidelines Exist.

INTRODUCTION: While short-term surgical outreach trips improve access to care in low- and middle-income countries (LMIC), there is rising concern about their long-term impact. In response, many organizations seek to incorporate capacity building programs into their outreach efforts to help strengthen local health systems. Although leading organizations, like the World Health Organization (WHO), advocate for this approach, uniform guidelines are absent. METHODS: We performed a systematic review, using search terms pertaining to capacity building guidelines during short-term surgical outreach trips. We extracted information on authorship, guideline development methodology, and guidelines relating to capacity building. Guidelines were classified according to the Global-QUEST framework, which outlines seven domains of capacity building on surgical outreach trips. Guideline development methodology frequencies and domain classifications frequencies were calculated; subsequently, guidelines were aggregated to develop a core guideline for each domain. RESULTS: A total of 35 studies were included. Over 200 individual guidelines were extracted, spanning all seven framework domains. Guidelines were most frequently classified into Coordination and Community Impact domains and least frequently into the Finance domain. Less than half (46%) of studies collaborated with local communities to design the guidelines. Instead, guidelines were predominantly developed through author trip experience. CONCLUSION: As short-term surgical trips increase, further work is needed to standardize guidelines, create actionable steps, and promote collaborations in order to promote accountability during short-term surgical outreach trips.

The Price-Quality Mismatch: Are Negotiated Prices for Total Joint Arthroplasty Associated With Hospital Quality in a Large California Health System?

BACKGROUND: Price variations in healthcare can be caused by quality or factors other than quality such as market share, negotiating power with insurers, or hospital ownership model. Efforts to improve care value (defined as the ratio between health outcomes and price) by making healthcare prices readily accessible to patients are driven by the assumption this can help patients more easily identify high-quality, low-price clinicians and health systems, thus reducing price variations. However, if price variations are driven by factors other than quality, then strategies that involve payments for higher-quality care are unlikely to reduce price variation and improve value. It is unknown whether prices for total joint arthroplasty (TJA) are correlated with the quality of care or whether factors other than quality are responsible for price variation. QUESTIONS/PURPOSES: (1) How do prices insurers negotiate for TJA paid to a single, large health system vary across payer types? (2) Are the mean prices insurers negotiate for TJA associated with hospital quality? METHODS: We analyzed publicly available data from 22 hospitals in a single, large regional health system, four of which were excluded owing to incomplete quality information. We chose to use data from this single health system to minimize the confounding effects of between-hospital reputation or branding and geographic differences in the cost of providing care. This health system consists of large and small hospitals serving urban and rural populations, providing care for more than 3 million individuals. For each hospital, negotiated prices for TJA were classified into five payer types: commercial in-network, commercial out-of-network, Medicare Advantage (plans to which private insurers contract to provide Medicare benefits), Medicaid, and discounted cash pay. Traditional Medicare plans were not included because the prices are set statutorily, not negotiated. We obtained hospital quality measures from the Centers for Medicare and Medicaid Services. Centers for Medicare and Medicaid Services quality measures included TJA-specific complication and readmission rates in addition to hospital-wide patient survey star rating (measure of patient care experience) and total performance scores (aggregate measure of clinical outcomes, safety, patient experience, process of care, and efficiency). We evaluated the association between the mean negotiated hospital prices and Centers for Medicare and Medicaid Services quality measures using Pearson correlation coefficients and Spearman rho across all payer types. Statistical significance was defined as p < 0.0025. RESULTS: The mean ± SD overall negotiated price for TJA was USD 54,500 ± 23,200. In the descriptive analysis, the lowest negotiated prices were associated with Medicare Advantage (USD 20,400 ± 1800) and Medicaid (USD 20,300 ± 8600) insurance plans, and the highest prices were associated with out-of-network care covered by commercial insurance plans (USD 78,800 ± 9200). There was no correlation between the mean negotiated price and TJA complication rate (discounted cash price: r = 0.27, p = 0.29; commercial out-of-network: r = 0.28, p = 0.26; commercial in-network: r = -0.07, p = 0.79; Medicare Advantage: r = 0.11, p = 0.65; Medicaid: r = 0.03, p = 0.92), readmission rate (discounted cash price: r = 0.19, p = 0.46; commercial out-of-network: r = 0.24, p = 0.33; commercial in-network: r = -0.13, p = 0.61; Medicare Advantage: r = -0.06, p = 0.81; Medicaid: r = 0.09, p = 0.74), patient survey star rating (discounted cash price: r = -0.55, p = 0.02; commercial out-of-network: r = -0.53, p = 0.02; commercial in-network: r = -0.37, p = 0.13; Medicare Advantage: r = -0.08, p = 0.75; Medicaid: r = -0.02, p = 0.95), or total hospital performance score (discounted cash price: r = -0.35, p = 0.15; commercial out-of-network: r = -0.55, p = 0.02; commercial in-network: r = -0.53, p = 0.02; Medicare Advantage: r = -0.28, p = 0.25; Medicaid: r = 0.11, p = 0.69) for any of the payer types evaluated. CONCLUSION: There is substantial price variation for TJA that is not accounted for by the quality of care, suggesting that a mismatch between price and quality exists. Efforts to improve care value in TJA are needed to directly link prices with the quality of care delivered, such as through matched quality and price reporting mechanisms. Future studies might investigate whether making price and quality data accessible to patients, such as through value dashboards that report easy-to-interpret quality data alongside price information, moves patients toward higher-value care decisions. CLINICAL RELEVANCE: Efforts to better match the quality of care with negotiated prices such as matched quality and price reporting mechanisms, which have been shown to increase the likelihood of choosing higher-value care in TJA, could improve the value of care.

The Volar Intra-Articular Extended Window Approach for Intra-Articular Distal Radius Fractures.

The number of distal radius fractures treated surgically is increasing, with the volar Henry approach most commonly used. Traditionally, to directly visualize intra-articular fracture reductions, a dorsal approach is also used, which can lead to increased morbidity and operative time. We describe the volar intra-articular extended window approach for intra-articular distal radius fractures, which allows direct visualization of fracture reduction from the same volar approach to the distal radius. The volar intra-articular extended window approach is performed by creating a capsulotomy in the volar wrist capsule between the long and short radiolunate ligaments while maintaining the integrity of the short radiolunate ligament to prevent postoperative carpal instability. Using this approach allows the surgeon to directly visualize the radiocarpal joint to assess reduction and ensure that no screws are placed intra-articular.

Are Patient-Reported Outcome Measures for Distal Radius Fractures Validated for Spanish and Culture? A Systematic Review.

PURPOSE: Patient-reported outcome measures (PROMs) are used commonly to assess function to direct treatment and evaluate outcomes for patients with distal radius fractures. Most PROMs have been developed and validated in English with minimal report of the demographics of patients studied. The validity of applying these PROMs among Spanish-speaking patients is unknown. The purpose of this study was to evaluate the quality and psychometric properties of Spanish-language adaptations of PROMs for distal radius fractures. METHODS: We conducted a systematic review to identify published studies of adaptations of Spanish-language PROMs evaluating patients with distal radius fractures. We evaluated the methodologic quality of the adaptation and validation using Guidelines for the Process of Cross-Cultural Adaptation of Self-Report Measures, Quality Criteria for Psychometric Properties of Health Status Questionnaire, and the Consensus-based Standards for the Selection of Health Measurement Instruments Checklist for Cross-Cultural Validity. The level of evidence was evaluated based upon prior methodology. RESULTS: Five instruments reported in eight studies were included: the Patient-Rated Wrist Evaluation (PRWE), Disability of Arm Shoulder and Hand, Upper Limb Functional Index, Lawton Instrumental Activities of Daily Living Scale, and Short Musculoskeletal Function Assessment. The PRWE was the most frequently included PROM. No study followed all six processes for adaptation or assessed all measurement properties. No study demonstrated the completion of more than eight of the 14 aspects of cross-cultural validity. The PRWE had moderate evidence to support half of the domains of measurement properties evaluating the level of evidence. CONCLUSIONS: None of the five instruments identified received a good rating on all three checklists. Only the PWRE demonstrated moderate evidence on half of the measurement domains. CLINICAL RELEVANCE: Given the lack of strong evidence to support the quality of these instruments, we recommend adaptation and testing of PROMs for this population before use. Currently, PROMs in Spanish-speaking patients should be used with caution so as not to perpetuate health care disparities.

Disparities in Treatment of Closed Distal Radius Fractures in Patients Aged 18-64 Years and ≥65 Years by Insurance Type.

PURPOSE: Type of and time to definitive treatment for distal radius fractures can influence the outcomes. The impact of social determinants of health (eg, insurance type) on distal radius fracture care remains unknown despite having health equity implications. Thus, we evaluate the association between insurance type and rate of surgery, the time to surgery, and the complication rate for distal radius fractures. METHODS: We conducted a retrospective cohort study using the PearlDiver Database. We identified adults with closed distal radius fractures. Patients were divided into subgroups by age (18-64 years, 65+ years) and further stratified on the basis of the insurance type (Medicare Advantage, Medicaid-managed care, and commercial). The primary outcome was the rate of surgical fixation. Secondary outcomes included the time to surgery and 12-month complication rates. Logistic regression modeling was used to calculate the odds ratios for each outcome, adjusting for age, sex, geographic region, and comorbidities. RESULTS: In patients aged ≥65 years, a lower proportion of Medicaid patients underwent surgery within 21 days of diagnosis compared with Medicare or commercially insured patients (12.1% vs 15.9% or 17.5%, respectively). Complication rates did not differ between Medicaid and other insurance types. In patients aged <65 years, fewer Medicaid patients underwent surgery compared with commercially insured patients (16.2% vs 21.1%). However, in this younger group, Medicaid patients had higher adjusted odds of malunion/nonunion (adjusted odds ratio [aOR] = 1.39 [95% CI, 1.31-1.47]) and subsequent repair (aOR = 1.38 [95% CI, 1.25-1.53]). DISCUSSION: Although older Medicaid patients experienced lower surgical rates, this may not lead to differential clinical outcomes. However, Medicaid patients aged <65 years experienced lower surgical rates that correlated with the increased rates of malunion or nonunion. CLINICAL RELEVANCE: In younger patients with a closed distal radius fracture and Medicaid insurance, system and patient-directed efforts should be considered to address delayed time to surgery and a higher odds for malunion/nonunion.

Is There a Critical Dorsal Lunate Facet Size in Distal Radius Fractures That Leads to Dorsal Carpal Subluxation? A Biomechanical Study of the Dorsal Critical Corner.

PURPOSE: Intra-articular distal radius fractures are common and can be associated with carpal instability. Failure to address articular fragments linked to maintaining carpal stability can lead to radiocarpal subluxation or dislocation. The purpose of this study was to evaluate the size of a dorsal osteotomy in the dorsal/volar plane of the lunate facet that leads to dorsal carpal subluxation. METHODS: Dorsal lunate facet fractures were simulated twice in each of nine fresh-frozen cadavers. After completing a partial dorsal osteotomy in the radial/ulnar plane between the scaphoid and lunate facets, an osteotomy in the dorsal/volar plane was completed. Using a cutting jig, first an estimated 5-mm osteotomy, and then a 10-mm osteotomy (from the dorsal rim of the distal radius) were completed. The wrist was mounted in a custom jig and loaded with 100 N. Displacement of the lunate in the dorsal/volar plane compared with displacement in an intact specimen was evaluated and used to assess carpal subluxation. RESULTS: Lunate translation was 0 mm ± 0 mm in the intact state. The 5-mm osteotomy averaged 29% of the distal radius dorsal lunate facet in the dorsal/volar plane, and lunate translation was 0.7 mm ± 1.7 mm. The 10-mm osteotomy averaged 54% of the dorsal lunate facet in the dorsal/volar plane, and lunate translation was 2.8 mm ± 2.6 mm. Assuming a linear relationship from the osteotomies created, an osteotomy of an estimated ≥40% of the distal radius in the dorsal to volar plane resulted in substantial dorsal subluxation, although this specific osteotomy was not assessed in our study. CONCLUSIONS: Sequentially increased dorsal osteotomies of the dorsal lunate facet result in increased dorsal carpal subluxation. CLINICAL RELEVANCE: Distal radius fractures that include >40% of the "dorsal critical corner" are at risk for dorsal carpal subluxation and may require supplementary fixation.

Has the Use of Electrodiagnostic Studies for Carpal Tunnel Syndrome Changed After the 2016 American Academy of Orthopaedic Surgeons Clinical Practice Guideline?

PURPOSE: A 2016 American Academy of Orthopaedic Surgeons (AAOS) clinical practice guideline (CPG) de-emphasized the need for electrodiagnostic studies (EDS) for carpal tunnel syndrome (CTS). We tested the hypothesis that use of EDS decreased after the AAOS CPG. METHODS: Using a national administrative claims database, we measured the proportion of patients with a diagnosis of CTS who underwent EDS within 1 year after diagnosis between 2011 and 2019. Using an interrupted time series design, we defined 2 time periods (pre-CPG and post-CPG) and compared EDS usage between the periods using segmented regression analysis. We conducted a subgroup analysis of preoperative EDS usage in patients who underwent carpal tunnel release. RESULTS: Of 2,081,829 patients with CTS, 315,449 (15.2%) underwent EDS within 1 year after diagnosis. The segmented regression analysis showed a decrease in the level of EDS usage after publication of the AAOS CPG (-11.50 per 1,000 patients [95% CI, -1.47 to -0.95 per 1,000 patients]); however, the rate of EDS usage increased in the post-CPG period (+1.75 per 1,000 patients per quarter [95% CI, 0.97-2.54 per 1,000 patients per quarter]). Of 473,753 eligible patients who underwent carpal tunnel release, 139,186 (29.4%) underwent EDS within 6 months before surgery. After publication of the AAOS CPG, preoperative EDS usage decreased by -23.57 per 1,000 patients (95% CI, -37.72 to -9.42 per 1,000 patients). However, these decreasing trends in EDS usage predated the 2016 AAOS CPG. CONCLUSIONS: The overall and preoperative EDS usage for CTS has been decreasing since at least 2014, predating the 2016 AAOS CPG, reflecting the rapid implementation of evidence into practice. However, EDS usage has increased in the post-CPG period, and a considerable proportion of patients who underwent carpal tunnel release still received EDS. CLINICAL RELEVANCE: Given its high costs and disputed value, routine EDS usage should be considered for further deimplementation initiatives.

Do Patients Want to Be Involved in Their Carpal Tunnel Surgery Decisions? A Multicenter Study.

PURPOSE: Carpal tunnel syndrome requires multiple decisions during its management, including regarding preoperative studies, surgical technique, and postoperative wound management. Whether patients have varying preferences for the degree to which they share in decisions during different phases of care has not been explored. The goal of our study was to evaluate the degree to which patients want to be involved along the care pathway in the management of carpal tunnel syndrome. METHODS: We performed a prospective, multicenter study of patients undergoing carpal tunnel surgery at 5 academic medical centers. Patients received a 27-item questionnaire to rate their preferred level of involvement for decisions made during 3 phases of care for carpal tunnel surgery: preoperative, intraoperative, and postoperative. Preferences for participation were quantified using the Control Preferences Scale. These questions were scored on a scale of 0 to 4, with patient-only decisions scoring 0, semiactive decisions scoring 1, equally collaborative decisions scoring 2, semipassive decisions scoring 3, and physician-only decisions scoring 4. Descriptive statistics were calculated. RESULTS: Seventy-one patients completed the survey between November 2018 and April 2019. Overall, patients preferred semipassive decisions in all phases of care (median score, 3). Patients preferred equally collaborative decisions for preoperative decisions (median score, 2). Patients preferred a semipassive decision-making role for intraoperative and postoperative decisions (median score, 3), suggesting these did not need to be equally shared. CONCLUSIONS: Patients with carpal tunnel syndrome prefer varying degrees of involvement in the decision-making process of their care and prefer a semipassive role in intraoperative and postoperative decisions. CLINICAL RELEVANCE: Strategies to engage patients to varying degrees for all decisions during the management of carpal tunnel syndrome, such as decision aids for preoperative surgical decisions and educational handouts for intraoperative decisions, may facilitate aligning decisions with patient preferences for shared decision-making.

Medicaid insurance is associated with treatment disparities for proximal humerus fractures in a national database analysis.

BACKGROUND: Proximal humerus fractures (PHFs) are the third most common type of fragility fracture in the elderly and are increasing in incidence. Disparities in treatment type, time to surgery (TTS), and complications based upon insurance type have been identified for other orthopedic conditions. Given the incidence and burden of PHFs, we sought to evaluate if insurance type was associated with treatment received, TTS, and complications in the treatment of PHFs. METHODS: We used PearlDiver, a national administrative claims database that consists of 122 million patient records. Patients diagnosed with an isolated PHF between 2010 and 2019 were identified by International Classification of Diseases, Ninth and Tenth Revision diagnostic codes and stratified by insurance type (Medicaid, private, or Medicare). Outcomes evaluated were rate of surgery within 3 months of diagnosis with open reduction and internal fixation, hemiarthroplasty, or reverse shoulder arthroplasty; average TTS; 90-day readmissions and medical postoperative complications (deep vein thrombosis, urinary tract infection, pneumonia, sepsis, acute respiratory failure, cerebrovascular event, and acute renal failure); and 1-year surgical postoperative complications (stiffness, noninfectious wound complications, dislocation, and infection). Multivariable logistic regressions adjusting for age, sex, and Elixhauser comorbidity index were utilized to determine the association between insurance type and surgery rate/complications. RESULTS: We included 245,396 patients for analysis. Fourteen percent of Medicaid patients (1789/12,498) underwent surgery compared to 17% (25,347/149,830) of privately insured patients and 16% (13,305/83,068) of Medicare patients (pairwise, P < .001). TTS (Medicaid: 11.7 days, private: 10.6 days [P < .001]; Medicare: 10.7 days [P = .003]) varied by insurance type. Private or Medicare-insured patients were less likely to be readmitted (adjusted odds ratio: 0.77 [95% confidence interval (CI): 0.63-0.93] for private vs. Medicaid and 0.71 [95% CI: 0.59-0.88] for Medicare vs. Medicaid) and experienced fewer 90-day postoperative complications (adjusted odds ratio: 0.73 [95% CI: 0.62-0.85] for private vs. Medicaid, 0.65 [95% CI: 0.55-0.77] for Medicare vs. Medicaid), such as acute renal failure. TTS was also associated with differing rates of readmissions and complications. CONCLUSION: There are differences in rates of surgery, TTS, and complications after PHFs based on insurance type, representing opportunities for quality improvement initiatives. Potential methods to address these disparities include implementing standardized PHF protocols and/or reimbursement models and quality metrics that reward equitable treatment. Further research and policy adaptations should be incorporated to decrease barriers that patients face and minimize health care inequities seen in the treatment of PHFs based on insurance type.

Decision Making and Cost in Healthcare: The Patient Perspective.

Unsustainable spending and unsatisfactory outcomes have prompted a reanalysis of healthcare policy towards value. Several strategies have been proposed as part of this effort including cost sharing plans to shift costs to patients and gain-sharing models to shift risk to health systems. The patient perspective is rarely elicited in policy formation despite efforts to increase patient-centered care. We conducted a prospective study of 118 patients presenting to hand clinic to assess patient perspective of who should constrain treatment options (patient, physician, insurance company, hospital) and be responsible for costs in scenarios of clinical equipoise. We found that patients believed that insurance companies and hospitals should not constrain which treatment options are available to a patient and that physicians and patients should together influence the availability of treatment options. Patients were willing to cost share with insurance companies when choosing more expensive treatments or in the setting of non-life-threatening diseases. In addressing rising healthcare costs, patient perspectives can inform policies designed to increase value. Asking patients to cost share when choosing a more expensive treatment option in the setting of clinical equipoise could be a strategy for health systems to increase value. Level of Evidence: III (Journal of Surgical Orthopaedic Advances 32(1):023-027, 2023).

A framework to make PROMs relevant to patients: qualitative study of communication preferences of PROMs.

PURPOSE: Patient-reported outcome measures are tools for evaluating symptoms, magnitude of limitations, baseline health status, and outcomes from the patient's perspective. Healthcare professional organizations and payers increasingly recommend PROMs for clinical care, but there lacks guidance regarding effective communication of PROMs with orthopedic surgery patients. This qualitative study aimed to identify (1) patient attitudes toward the use and communication of PROMs, and (2) what patients feel are the most relevant or important aspects of PROM results to discuss with their physicians. METHODS: Participants were recruited from a multispeciality orthopedic clinic. Three PROMs: the EuroQol-5 Dimension, the Patient-Specific Functional Scale, and the Patient-Reported Outcome Measurement Information System Physical Function Computer Adaptive Test were shown and a semi-structured interview was conducted to elicit PROMs attitudes and preferences. Interviews were transcribed and inductive-deductively coded. Coded excerpts were aggregated to (1) identify major themes and (2) analyze how themes interacted. RESULT: Three themes emerged: (1) Beliefs toward the purpose of PROMs, (2) PROMs as a reflection of self, and (3) PROMs to facilitate communication and guide healthcare decisions. These themes informed a framework outlining the patient perspective on communicating PROMs during clinical care. CONCLUSION: Patient attitudes toward the use and communication of PROMs start with the incorporation of patient beliefs, which can facilitate or act as a barrier to engagement. Patients should ideally believe that PROMs are an accurate reflection of personal health state before incorporation into care. Clinicians should endeavor to communicate the purpose of a chosen PROM in line with a patient's unique needs and what they feel is most relevant to their own care. Aspects of PROMs results which may be helpful to address include providing context for what scores mean and how they are calculated, and using scores as a way to weigh risks and benefits of treatment and tracking progress over time. Future research can focus on the effect of communication strategies on patient outcomes and engagement in care.

Is Low-value Testing Before Low-risk Hand Surgery Associated With Increased Downstream Healthcare Use and Reimbursements? A National Claims Database Analysis.

BACKGROUND: Minor hand procedures can often be completed in the office without any laboratory testing. Preoperative screening tests before minor hand procedures are unnecessary and considered low value because they can lead to preventable invasive confirmatory tests and/or procedures. Prior studies have shown that low-value testing before low-risk hand surgery is still common, yet little is known about their downstream effects and associated costs. Assessing these downstream events can elucidate the consequences of obtaining a low-value test and inform context-specific interventions to reduce their use. QUESTIONS/PURPOSES: (1) Among healthy adults undergoing low-risk hand surgery, are patients who receive a preoperative low-value test more likely to have subsequent diagnostic tests and procedures than those who do not receive a low-value test? (2) What is the increased 90-day reimbursement associated with subsequent diagnostic tests and procedures in patients who received a low-value test compared with those who did not? METHODS: In this retrospective, comparative study using a large national database, we queried a large health insurance provider's administrative claims data to identify adult patients undergoing low-risk hand surgery (carpal tunnel release, trigger finger release, Dupuytren fasciectomy, de Quervain release, thumb carpometacarpal arthroplasty, wrist ganglion cyst, or mass excision) between 2011 and 2017. This database was selected for its ability to track patient claims longitudinally with direct provision of reimbursement data in a large, geographically diverse patient population. Patients who received at least one preoperative low-value test, including complete blood count, basic metabolic panel, electrocardiogram, chest radiography, pulmonary function test, and urinalysis within the 30-day preoperative period, were matched with propensity scores to those who did not. Among the 73,112 patients who met our inclusion criteria (mean age 57 ± 14 years; 68% [49,847] were women), 27% (19,453) received at least one preoperative low-value test and were propensity score-matched to those who did not. Multivariable regression analyses were performed to assess the frequency and reimbursements of subsequent diagnostic tests and procedures in the 90 days after surgery while controlling for potentially confounding variables such as age, sex, comorbidities, and baseline healthcare use. RESULTS: When controlling for covariates such as age, sex, comorbidities, and baseline healthcare use, patients in the low-value test cohort had an adjusted odds ratio of 1.57 (95% confidence interval [CI] 1.50 to 1.64; p < 0.001) for a postoperative use event (a downstream diagnostic test or procedure) compared with those who did not have a low-value test. The median (IQR) per-patient reimbursements associated with downstream utilization events in patients who received a low-value test was USD 231.97 (64.37 to 1138.84), and those who did not receive a low-value test had a median of USD 191.52 (57.1 to 899.42) (adjusted difference when controlling for covariates: USD 217.27 per patient [95% CI 59.51 to 375.03]; p = 0.007). After adjusting for inflation, total additional reimbursements for patients in the low-value test cohort increased annually. CONCLUSION: Low-value tests generate downstream tests and procedures that are known to provide minimal benefit to healthy patients and may expose patients to potential harms associated with subsequent, unnecessary invasive tests and procedures in response to false positives. Nevertheless, low-value testing remains common and the rising trend in low-value test-associated spending demonstrates the need for multicomponent interventions that target change at both the payer and health system level. Such interventions should disincentivize the initial low-value test and the cascade that may follow. Future work to identify the barriers and facilitators to reduce low-value testing in hand surgery can inform the development and revision of deimplementation strategies. LEVEL OF EVIDENCE: Level III, therapeutic study.

Do Proposed Quality Measures for Carpal Tunnel Release Reveal Important Quality Gaps and Are They Reliable?

BACKGROUND: The American Academy of Orthopaedic Surgeons recently proposed quality measures for the initial surgical treatment of carpal tunnel syndrome (CTS). One measure addressed avoidance of adjunctive surgical procedures during carpal tunnel release; and a second measure addressed avoidance of routine use of clinic-based occupational and/or physical therapy (OT/PT) after carpal tunnel release. However, for quality measures to serve their intended purposes, they must be tested in real-world data to establish that gaps in quality exist and that the measures yield reliable performance information. QUESTIONS/PURPOSES: (1) Is there an important quality gap in clinical practice for avoidance of adjunctive surgical procedures during carpal tunnel release? (2) Is there an important quality gap in avoiding routine use of clinic-based occupational and/or physical therapy after carpal tunnel release? (3) Do these two quality measures have adequate beta-binomial signal-to-noise ratio (SNR) and split-sample reliability (SSR)? METHODS: This retrospective comparative study used a large national private insurance claims database, the 2018 Optum Clinformatics® Data Mart. Ideally, healthcare quality measures are tested within data reflective of the providers and payors to which the measures will be applied. We previously tested these measures in a large public healthcare system and a single academic medical center. In this study, we sought to test the measures in the broader context of patients and providers using private insurance. For both measures, we included the first carpal tunnel release from 28,083 patients performed by one of 7236 surgeons, irrespective of surgical specialty (including, orthopaedic, plastic, neuro-, and general surgery). To calculate surgeon-level descriptive and reliability statistics, analyses were focused on the 66% (18,622 of 28,083) of patients who received their procedure from one of the 24% (1740 of 7236) of surgeons with at least five carpal tunnel releases in the database. No other inclusion/exclusion criteria were applied. To determine whether the measures reveal important gaps in treatment quality (avoidance of adjunctive procedures and routine therapy), we calculated descriptive statistics (median and interquartile range) of the performance distribution stratified by surgeon-level annual volume of carpal tunnel releases in the database (5+, 10+, 15+, 20+, 25+, and 30+). Like the Centers for Medicare & Medicaid Services (CMS), we considered a measure "topped out" if median performance was greater than 95%, meaning the opportunity for further quality improvement is low. We calculated the surgeon-level beta-binomial SNR and SSR for each measure, each stratified by the number of carpal tunnel releases performed by each surgeon in the database. These are standard measures of reliability in health care quality measurement science. The SNR quantifies the proportion of variance that is between rather than within surgeons, and the SSR is the correlation of performance scores when each surgeons' patients are split into two random samples and then corrected for sample size. RESULTS: We found that 2% (308 of 18,622) of carpal tunnel releases involved an adjunctive procedure. The results showed that avoidance of adjunctive surgical procedures during carpal tunnel release had a median (IQR) performance of 100% (100% to 100%) at all case volumes. Only 8% (144 of 1740) of surgeons with at least five cases in the database had less than 100% performance, and only 5% (84 of 1740) had less than 90% performance. This means adjunctive procedures were rarely performed and an important quality gap does not exist based on the CMS criterion. Regarding the avoidance of routine therapy, there was a larger quality gap: For surgeons with at least five cases in the database, median performance was 89% (75% to 100%), and 25% (435 of 1740) of these surgeons had less than 75% performance. This signifies that the measure is not topped out and may reveal an important quality gap. Most patients receiving clinic-based OT/PT had only one visit in the 6 weeks after surgery. Median (IQR) SNRs of the first measure, which addressed avoidance of adjunctive surgical procedures, and the second measure, which addresses avoidance of routine use clinic-based OT/PT, were 1.00 (1.00 to 1.00) and 0.86 (0.67 to 1.00), respectively. The SSR for these measures were 0.87 (95% CI 0.85 to 0.88) and 0.75 (95% CI 0.73 to 0.77), respectively. All of these reliability statistics exceed National Quality Forum's emerging minimum standard of 0.60. CONCLUSION: The first measure, the avoidance of adjunctive surgical procedures during carpal tunnel release, lacked an important quality gap suggesting it is unlikely to be useful in driving improvements. The second measure, avoidance of routine use of clinic-based OT/PT, revealed a larger quality gap and had very good reliability, suggesting it may be useful for quality monitoring and improvement purposes. CLINICAL RELEVANCE: As healthcare systems and payors use the second measure, avoidance of routine use of clinic-based OT/PT, to encourage adherence to clinical practice guidelines (such as provider profiling, public reporting, and payment policies), it will be critically important to consider what proportion of patients receiving OT/PT should be considered routine practice and therefore inconsistent with guidelines. The value or potential harm of this measure depends on this judgement.