Catastrophic Health Expenditures Associated With Open Reduction Internal Fixation of Distal Radius Fractures.

PURPOSE: Distal radius fracture is one of the most common upper-extremity traumatic injuries. These injuries result in time off work and potential financial consequences for patients. Therefore, we aimed to understand the risk of catastrophic health expenditures (CHEs) after open reduction and internal fixation of distal radius fractures and examine the association between patient characteristics and the risk of CHE. METHODS: We used data from patients undergoing open reduction and internal fixation of a distal radius fracture from a large, urban, level I trauma center (2018-2020). The risk of CHE was defined as out-of-pocket expenses of ≥40% of postsubsistence income. We used multivariable logistic regression to assess the impact of age, sex, race, and insurance status on the risk of CHE. RESULTS: In our cohort of 394 patients, 121 patients (30.7%) were at risk of CHE after their distal radius fracture. After controlling for patient characteristics and insurance status, patients aged 26-34 years were 5.7 times more likely to be at risk of CHE (odds ratio, 5.73; 95% CI, 1.81-18.13) than patients aged ≥65 years. Patients who were uninsured were six times more likely to be at risk of CHE than patients with employer-sponsored health insurance (odds ratio, 6.02; 95% CI, 1.94-18.66). Lastly, non-White patients were at a higher risk of CHE (odds ratio, 3.63; 95% CI, 1.70-7.79) than White patients. CONCLUSIONS: Distal radius fractures are unexpected and place patients at risk of financial harm, with one in three patients at risk of CHEs. Policies aimed at minimizing cost-sharing after traumatic injury may help alleviate the financial consequences of health care delivery and reduce disparities. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analysis II.

Utilization of Diagnostic Testing for Carpal Tunnel Syndrome: A Survey of the American Society for Surgery of the Hand.

PURPOSE: In 2016, the American Academy of Orthopaedic Surgeons (AAOS) changed the clinical practice guidelines (CPGs) for the diagnosis of carpal tunnel syndrome, relaxing the recommendation for electrodiagnostic studies (EDS) prior to offering surgery. However, it is unknown how the updated guidelines changed the practice patterns of hand surgeons. METHODS: A web-based multiple-choice survey was sent to the members of the American Society for Surgery of the Hand. We assessed the current diagnostic practice patterns of hand surgeons. The survey was pretested using expert review with content and survey methodology experts and cognitively tested to ensure readability and understandability. RESULTS: The final cohort consisted of 770 hand surgeons. Approximately 26% of respondents required EDS prior to seeing a patient in consultation, and 56% of members routinely ordered EDS after evaluating a patient with carpal tunnel syndrome if testing was not performed prior to evaluation. The top reasons for obtaining EDS were to provide additional information for unclear diagnoses (97% selected), for patients with worker's compensation (82% selected), for grading the severity (73% selected), and to provide a baseline examination in the event of persistent symptoms (72% selected). However, only 38% of respondents believed that the current AAOS CPGs were appropriate, and 43% of respondents did not know what the guidelines recommended. CONCLUSIONS: Despite the change in AAOS CPGs, EDS continues to be ubiquitously used for the diagnosis of carpal tunnel syndrome. Nevertheless, a substantial proportion of hand surgeons are unaware of the recommendations for EDS within the AAOS CPGs. CLINICAL RELEVANCE: These findings highlight the importance of explicitly defining which patients and which clinical scenarios would benefit from additional diagnostic testing and identifying strategies for more widespread dissemination of guidelines.

Trust and Distrust in Opioid Decision-Making: A Qualitative Assessment of Patient-Doctor Relationship.

PURPOSE: Surgeons often prescribe opioid analgesics for pain management after surgery. However, we understand little about how patients perceive opioid prescribing and make decisions to use opioids for postoperative pain management. In this study, we aimed to gain an understanding of patients' decision-making process on postoperative opioid use. METHODS: We conducted semi-structured interviews with 30 adult patients undergoing elective surgery at our institution. The interviews were content-coded for thematic analysis. We used trust in the medical setting as a conceptual framework to interpret and find the inherent theory in the data. RESULTS: We found that participants based their opioid decisions on their trust or distrust toward various elements of their postoperative pain management. Participants believed that the surgeons "know," thereby, reinforcing their trust in surgeons' postoperative opioid prescribing to be in the participants' best interest. Moreover, the positive reputation of the institution strengthened the participants' trust. However, participants conveyed nuanced trust because of their distrust toward the opioid medications themselves, which were viewed as "suspicious," and the pharmaceutical companies, that were "despised." Despite this distrust, participants had confidence in their inherent ability to protect themselves from opioid use disorders. CONCLUSIONS: Understanding how patients perceive and form decisions on postoperative opioid use based on their trust and distrust toward various factors involved in their care highlights the importance of the patient-doctor relationship and building trust to effectively address postoperative pain and reduce opioid-related harms. CLINICAL RELEVANCE: Through a strengthened therapeutic alliance between patients and surgeons, we can improve our strategies to overcome the ongoing opioid epidemic through patient-centered approaches.

The Impact of Community Care Referral on Time to Surgery for Veterans With Carpal Tunnel Syndrome.

BACKGROUND: The US Department of Veterans Affairs (VA) enacted policies offering Veterans care in the community, aiming to improve access challenges. However, the impact of receipt of community care on wait times for Veterans receiving surgical care is poorly understood. OBJECTIVES: To compare wait times for surgery for Veterans with carpal tunnel syndrome who receive VA care plus community care (mixed care) and those who receive care solely within the VA (VA-only). RESEARCH DESIGN: Retrospective cohort study. SUBJECTS: Veterans undergoing carpal tunnel release (CTR) between January 1, 2010 and December 31, 2016. MEASURES: Our primary outcome was time from primary care physician (PCP) referral to CTR. RESULTS: Of the 29,242 Veterans undergoing CTR, 23,330 (79.8%) received VA-only care and 5912 (20.1%) received mixed care. Veterans receiving mixed care had significantly longer time from PCP referral to CTR (median mixed care: 378 days; median VA-only care: 176 days, P<0.001). After controlling for patient and facility covariates, mixed care was associated with a 37% increased time from PCP referral to CTR (adjusted hazard ratio, 0.63; 95% confidence interval, 0.61-0.65). Each additional service provided in the community was associated with a 23% increase in time to surgery (adjusted hazard ratio, 0.77; 95% confidence interval, 0.76-0.78). CONCLUSIONS: VA-only care was associated with a shorter time to surgery compared with mixed care. Moreover, there were additional delays for each service received in the community. With likely increases in Veterans seeking community care, strategies must be used to identify and mitigate sources of delay through the spectrum of care between referral and definitive treatment.

Variation in Use of Electrodiagnostic Testing: Analysis From the Michigan Collaborative Hand Initiative for Quality in Surgery.

PURPOSE: To evaluate factors that predict the use of electrodiagnostic testing (EDS) for patients undergoing carpal tunnel release (CTR). METHODS: In this cohort study, we analyzed 553 patients who underwent primary CTR from 8 practices between July 1, 2019 and December 1, 2019 by 32 surgeons in the Michigan Collaborative Hand Initiative for Quality in Surgery (M-CHIQS). The M-CHIQS is a collaborative initiative aimed at improving quality in hand surgery. Demographic and clinical characteristics were collected, including the 6-item carpal tunnel symptoms scale (CTS-6) scores and EDS timing. Multilevel logistic regression was used to assess practice and surgeon variation in EDS use related to clinical diagnostic criteria. RESULTS: Of the 553 patients who underwent CTR during the study period, 461 (83.3%) received preoperative EDS. After controlling for patient clinical and demographic characteristics, CTS-6 scores were not associated with receiving any preoperative EDS (lower probability of CTS: odds ratio [OR], 0.94; 95% confidence interval [95% CI], 0.59-1.51), preconsultation EDS (low probability of CTS: OR, 1.00; 95% CI, 0.73-1.38), or postconsultation EDS (low probability of CTS, OR, 1.10; 95% CI, 0.77-1.60). For use of any EDS, 9.3% of the variation in testing was explained at the practice level and 31.1% of the variation in testing was explained at the surgeon level. CONCLUSIONS: Variation in EDS use is explained primarily at the practice and surgeon levels and is not related to patient clinical criteria. We recommend that providers and practices assess their use of preoperative EDS and limit its use to patients with an unclear clinical CTS diagnosis, as stated in current clinical practice guidelines. Likewise, providers should be encouraged to use the CTS-6 before prescribing EDS. CLINICAL RELEVANCE: Limiting the use of EDS to patients with an unclear clinical diagnosis of CTS will reduce costs and improve patient care by eliminating the discomfort and time associated with this test.

Surgical Timing for Carpal Tunnel Syndrome: A Comparison of Health Care Delivery in the Veterans Administration and Private Sector.

PURPOSE: The U.S. Department of Veterans Affairs (VA) health care system monitors time from referral to specialist visit. We compared wait times for carpal tunnel release (CTR) at a VA hospital and its academic affiliate. METHODS: We selected patients who underwent CTR at a VA hospital and its academic affiliate (AA) (2010-2015). We analyzed time from primary care physician (PCP) referral to CTR, which was subdivided into PCP referral to surgical consultation and surgical consultation to CTR. Electrodiagnostic testing (EDS) was categorized in relation to surgical consultation (prereferral vs postreferral). Multivariable Cox proportional hazard models were used to examine associations between clinical variables and surgical location. RESULTS: Between 2010 and 2015, VA patients had a shorter median time from PCP referral to CTR (VA: 168 days; AA: 410 days), shorter time from PCP referral to surgical consultation (VA: 43 days; AA: 191 days), but longer time from surgical consultation to CTR (VA: 98 days; AA: 55 days). Using multivariable models, the VA was associated with a 35% shorter time to CTR (AA hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.52-0.82) and 75% shorter time to surgical consultation (AA HR, 0.25; 95% CI, 0.20-0.03). Receiving both prereferral and postreferral EDS was associated with almost a 2-fold prolonged time to CTR (AA HR, 0.49; 95% CI, 0.36-0.67). CONCLUSIONS: The VA was associated with shorter overall time to CTR compared with its AA. However, the VA policy of prioritizing time from referral to surgical consultation may not optimally incentivize time to surgery. Repeat EDS was associated with longer wait times in both systems. CLINICAL RELEVANCE: Given differences in where delays occur in each health care system, initiatives to improve efficiency will require targeting the appropriate sources of preoperative delay. Judicious use of EDS may be one avenue to decrease wait times in both systems.

The Increasing Financial Burden of Outpatient Elective Surgery for the Privately Insured.

OBJECTIVE: To examine temporal trends of OOP expenses, total payments, facility fees, and professional fees for outpatient surgery. SUMMARY BACKGROUND DATA: Approximately 48 million outpatient surgeries are performed annually with a limited financial understanding of these procedures. High OOP expenses may influence treatment decisions, delay care, and cause financial burden for patients. METHODS: We conducted a retrospective cohort study of patients with employer-sponsored insurance undergoing common outpatient surgical procedures (cholecystectomy, cataract surgery, meniscectomy, muscle/tendon procedures, and joint procedures) from 2011 to 2017. Total payments for surgical encounters paid by the insurer/employer and patient OOP expenses were calculated. We used multivariable linear regression to predict total payments and OOP expenses, with costs adjusted to the 2017 US dollar. RESULTS: We evaluated 5,261,295 outpatient surgeries (2011-2017). Total payments increased by 29%, with a 53% increase in facility fees and no change in professional fees. OOP expenses grew by 50%. After controlling for procedure type, procedures performed in ambulatory surgery centers conferred an additional $2019 in predicted total payments (95%CI:$2002-$2036) and $324 in OOP expenses (95%CI:$319-$328) compared to predicted cost for office-based procedures. Hospital-based procedures cost an additional $2649 in predicted total payments (95%CI:$2632-$2667) and $302 in predicted OOP expenses (95%CI:$297-$306) compared to office procedures. CONCLUSION: Increases in outpatient surgery total payments were driven primarily by facility fees and OOP expenses. OOP expenses are rising faster than total payments, highlighting the transition of costs to patients. Healthcare cost reduction policies should consider the largest areas of spending growth such as facility fees and OOP expenses to minimize the financial burden placed on patients.

Patient-Reported Outcomes: Understanding Surgical Efficacy and Quality from the Patient's Perspective.

In surgery, quality assessment encourages improved care delivery, better outcomes, and helps determine surgical efficacy. Quality is important from a patient, provider, payer, and policy maker standpoint. However, given the growth of outpatient procedures, expansion of surgical indications to enhance function, and the decline of perioperative morbidity and mortality, many traditional quality metrics, such as mortality, readmissions, and complications, may not fully capture quality. As such, patient-reported outcomes (PROs) can be used to complement the established clinical outcomes and describe surgical efficacy and quality from the patient's point of view. Generic and disease-specific PRO measures capture health-related quality of life, functional status, and pain. These measures permit a more holistic understanding of how surgery affects different aspects of a patient's health, augment other clinical outcomes, and are commonly used to determine efficacy in clinical trials. Moreover, our national reimbursement structure is currently evolving to include PROs for certain surgical conditions in measures of quality and with direct linkage to payments. Even so, there continues to be challenges in the implementation of PRO measures in everyday surgical practice, with questions of optimal administration and how to integrate these measures into provider work flow. Despite these challenges, PROs provide vital information regarding surgical efficacy and quality and are critical in the delivery of patient-centered care.

National Prevalence of Complications and Cost of Small Joint Arthroplasty for Hand Osteoarthritis and Post-Traumatic Arthritis.

PURPOSE: Osteoarthritis (OA) of the hand is commonly treated using implant arthroplasty. Despite the increasing prevalence of hand OA, population-based evidence regarding the complication profile and associated cost for patients undergoing proximal interphalangeal (PIP) joint and metacarpophalangeal (MCP) joint arthroplasty are lacking. Therefore, we aimed to evaluate the complication profiles and variation in cost of care for patients undergoing PIP and MCP joint arthroplasty. METHODS: We analyzed insurance claims from 2009 to 2016 using the Truven MarketScan Databases for adult patients undergoing a PIP and MCP joint arthroplasty following OA or post-traumatic arthritis diagnosis. Multivariable logistic regression was performed to investigate the association of patient-level factors and complications at 2 years after surgery. Cumulative direct cost, defined as the cost of the index surgery and 2-year postoperative episode, and patient-level characteristics were examined. RESULTS: We analyzed a total of 2,859 patients who underwent MCP joint arthroplasty (36%) or PIP joint arthroplasty (64%). On average, these procedures have a 35% complication rate. However, patients undergoing PIP joint arthroplasty were more likely to suffer a prosthetic fracture than patients undergoing MCP joint arthroplasty (3.4% vs 1.5%, respectively). Each complication resulted in an additional cost of $1,076. CONCLUSIONS: This nationwide analysis provides a population estimate of the complication profile and associated costs of MCP and PIP joint arthroplasty for hand OA and post-traumatic arthritis. Minimizing postoperative complications after MCP and PIP joint arthroplasty is one avenue to decrease health care costs. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Inappropriate Preoperative Gabapentinoid Use Among Patients With Carpal Tunnel Syndrome.

PURPOSE: Gabapentinoids are commonly prescribed for the treatment of neuropathic pain but are not recommended for the primary treatment of carpal tunnel syndrome (CTS). We sought (1) to investigate the preoperative use of gabapentinoids for the treatment of CTS and (2) to determine whether preoperative exposure is associated with persistent gabapentinoid and opioid use after carpal tunnel release. METHODS: We performed a retrospective cohort study using IBM MarketScan Research Databases (2010-2017) of patients who did not fill a gabapentinoid or opioid prescription within 3 months of a new CTS diagnosis undergoing surgical release. Our primary outcomes included preoperative gabapentinoid prescription fills associated with CTS and persistent prescription fills of gabapentinoids and opioids at 91 to 180 days after surgery. Multivariable logistic regression models were used to evaluate the association between patient-level factors and persistent gabapentinoid and opioid use. RESULTS: Of the 56,593 patients without a previous gabapentinoid or opioid prescription prior to diagnosis of CTS, 3,474 patients (6%) filled a gabapentinoid prescription before carpal tunnel release. Overall, 835 patients (24% of the preoperative users) continued to fill gabapentinoid prescriptions at 91 to 180 days after surgery. Of the preoperative gabapentinoid users, 20% (702 patients) continued to fill opioid prescriptions at 91 to 80 days after release. After adjusting for patient characteristics, preoperative gabapentinoid use was associated with increased odds of persistent postoperative gabapentinoid use (preoperative gabapentinoid, 22% adjusted probability; 95% confidence interval [95% CI], 20.3%-23.0%, no preoperative gabapentinoid use, 1%; 95% CI, 1.2%-1.4%) and persistent postoperative opioid use (preoperative gabapentinoid, 18% adjusted probability; 95% CI, 17%-20%), no preoperative gabapentinoid, 9%; 95% CI, 8.6%-9.1%). CONCLUSIONS: Despite a lack of evidence to support the use of gabapentinoids for CTS, 6% of patients are prescribed a gabapentinoid prior to surgery, and prolonged use is common. Given the effectiveness of surgical release and the risks associated with gabapentinoids, greater attention is needed to ensure that gabapentinoids are prescribed appropriately, avoided when possible, and stopped after surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

An Evaluation of the Choice for Contralateral Prophylactic Mastectomy and Patient Concerns About Recurrence in a Reconstructed Cohort.

BACKGROUND: Rising contralateral prophylactic mastectomy rates are a subject of national concern. This study assessed (1) factors critical to patients when deciding on contralateral prophylactic mastectomy and (2) patients' quality of life related to concerns about recurrence after unilateral or bilateral breast reconstruction. METHODS: Patients with stage 0 to III breast cancer who underwent unilateral mastectomy or contralateral prophylactic mastectomy and breast reconstruction at a single institution between 2000 and 2012 were identified. Demographic and clinical data were extracted by chart review. Women's fears about breast cancer recurrence were assessed using the Concerns About Recurrence Scale, and motivational factors for contralateral prophylactic mastectomy were identified using the Decisions for Contralateral Prophylactic Mastectomy Survey. RESULTS: Survey responses were received from 157 patients (59%) who underwent unilateral reconstruction and 109 (41%) who underwent bilateral reconstruction. The top 3 reasons for choosing contralateral prophylactic mastectomy were (1) decreasing the risk of contralateral breast disease (97%), (2) peace of mind (96%), and (3) improved survival (93%). Women who chose contralateral prophylactic mastectomy reported significantly greater overall fear and worry compared with the unilateral group, specifically, greater fears of dying and worries about adequately fulfilling roles of daily life (P < 0.05). CONCLUSIONS: Despite no proven survival benefit, women chose contralateral prophylactic mastectomy primarily to optimize oncologic outcomes. Among breast reconstruction patients, women who underwent contralateral prophylactic mastectomy had greater anxiety and overall fear of breast cancer recurrence compared with those who chose unilateral mastectomy. These findings are important to consider when counseling women contemplating contralateral prophylactic mastectomy.

Subtype and pathway specific responses to anticancer compounds in breast cancer.

Breast cancers are comprised of molecularly distinct subtypes that may respond differently to pathway-targeted therapies now under development. Collections of breast cancer cell lines mirror many of the molecular subtypes and pathways found in tumors, suggesting that treatment of cell lines with candidate therapeutic compounds can guide identification of associations between molecular subtypes, pathways, and drug response. In a test of 77 therapeutic compounds, nearly all drugs showed differential responses across these cell lines, and approximately one third showed subtype-, pathway-, and/or genomic aberration-specific responses. These observations suggest mechanisms of response and resistance and may inform efforts to develop molecular assays that predict clinical response.

Digital artery flow hemodynamics: An ultrasonographic study.

BACKGROUND: There is a lack of data regarding the baseline hemodynamic blood flow parameters of the wrist and digits. Therefore, we aimed to quantify the digital and radial artery blood flow parameters using ultrasound and assess the influence of patient characteristics on hemodynamics. METHODS: We analyzed ultrasonographic data from 25 patients (50 hands) between October 2019 and December 2021. Variables of interest included dimensions of the radial artery and index finger (IF) ulnar and radial digital arteries at the palmodigital crease and their corresponding flow parameters. We compared variables among men and women and patients with and without diabetes using Wilcoxon Rank Sum test. RESULTS: Our cohort consisted of 18 women (36 hands) and three participants with diabetes (six hands). The mean diameter of the IF radial digital artery was 7 mm, and that of the ulnar digital artery was 10 mm. The average peak systolic velocity for the radial digital artery was 21.31 cm/sec, and for the ulnar digital artery, it was 30.03 cm/sec. Comparing men and women, the only significant difference found was in the time-averaged mean velocity for the ulnar digital artery (men:5.66 cm/sec vs. women:9.68 cm/sec, P = 0.02) and volume of flow for the ulnar digital artery (men:10.87cc/min vs. women:18.58cc/min, P = 0.03). We found no differences in blood flow parameters comparing participants with and without diabetes. CONCLUSION: These data provide a baseline measurement of digital flow hemodynamics that can be used in future studies to model vascular flow after replantation.

Cohort study of new off-label gabapentin prescribing in chronic opioid users.

INTRODUCTION: Gabapentin is commonly prescribed as an off-label adjunct to opioids because of its safer risk profile. Recent evidence has shown an increased risk of mortality when coprescribed with opioids. Therefore, we aimed to evaluate whether the addition of off-label gabapentin in patients with chronic opioid use is associated with a reduction in opioid dosage. METHODS: We performed a retrospective cohort study of patients with chronic opioid use with a new off-label gabapentin prescription (2010-2019). Our primary outcome of interest was a reduction in opioid dosage measured via oral morphine equivalents (OME) per day after the addition of a new off-label gabapentin prescription. RESULTS: In our cohort of 172,607 patients, a new off-label gabapentin prescription was associated with a decrease in opioid dosage in 67,016 patients (38.8%) (median OME/day reduction:13.8), with no change in opioid dosage in 24,468 patients (14.2%), and an increase in opioid dosage in 81,123 patients (47.0%) (median OME/day increase: 14.3). A history of substance/alcohol use disorders was associated with a decrease in opioid dosage after the addition of a new off-label gabapentin (aOR 1.20, 95% CI 1.16 to 1.23). A history of pain disorders was associated with a decrease in opioid dosage after the initiation of a new gabapentin prescription including arthritis (aOR 1.12, 95% CI 1.09 to 1.15), back pain (aOR 1.10, 95% CI 1.07 to 1.12), and other pain conditions (aOR 1.08, 95% CI 1.06 to 1.10). CONCLUSIONS: In this study of patients with chronic opioid use, an off-label gabapentin prescription did not reduce opioid dosage in the majority of patients. The coprescribing of these medications should be critically evaluated to ensure optimal patient safety.

Racial Disparities in the Cost of Unplanned Hospitalizations after Breast Reconstruction.

BACKGROUND: Given the national attention to disparities in health care, understanding variation provided to minorities becomes increasingly important. This study will examine the effect of race on the rate and cost of unplanned hospitalizations after breast reconstruction procedures. METHODS: The authors performed an analysis comparing patients undergoing implant-based and autologous breast reconstruction in the Healthcare Cost and Utilization Project. The authors evaluated the rate of unplanned hospitalizations and associated expenditures among patients of different races. Multivariable analyses were performed to determine the association among race and readmissions and health care expenditures. RESULTS: The cohort included 17,042 patients. The rate of an unplanned visit was 5%. The rates of readmissions among black patients (6%) and Hispanic patients (7%) in this study are higher compared with white patients (5%). However, after controlling for patient-level characteristics, race was not an independent predictor of an unplanned visit. In our expenditure model, black patients [adjusted cost ratio, 1.35 (95% CI, 1.11 to 1.66)] and Hispanic patients [adjusted cost ratio, 1.34 (95% CI, 1.08 to 1.65)] experienced greater cost for their readmission compared with white patients. CONCLUSIONS: Although race is not an independent predictor of an unplanned hospital visit after surgery, racial minorities bear a higher cost burden after controlling for insurance status, further stimulating health care disparities. Adjusted payment models may be a strategy to reduce disparities in surgical care. In addition, direct and indirect measures of disparities should be used when examining health care disparities to identify consequences of inequities more robustly.

Predictors and Variation in Steroid Injection Use for Carpal Tunnel Syndrome from a Multicenter Quality Collaborative.

BACKGROUND: Steroid injections are commonly used as first-line treatment for carpal tunnel syndrome (CTS); however, research has shown that their benefit is generally short-term and many patients go on to receive carpal tunnel release. The study purpose was to determine the variation in steroid injection use by hand surgeons. METHODS: We analyzed data from a 9-center hand surgery quality collaborative. Data from 1,586 patients (2,381 hands) were included if they underwent elective CTR at one of the sites. Mixed effects logistic regression models were used to examine the association of receipt of steroid injection and association of receipt of more than one steroid injection among patient-level covariates. RESULTS: Steroid injection use significantly varied by practice, ranging from 12-53% of patients. The odds of receiving a steroid injection were 1.4 times higher for females (p<0.01), 1.6 times higher for patients with chronic pain syndrome (p<0.01), 0.5 times lower for patients with moderate electromyography (EMG) and 0.4 times lower for patients with severe EMG classification (both p<0.01). Patients with high CTS-6 scores (p=0.02) and patients with moderate (p=0.04) or severe EMG (p=0.05) had lower odds of receiving multiple steroid injections. Complete symptomatic improvement after steroid injection was significantly reported by patients with high CTS-6 score (p=0.03) or patients with severe EMG classification (p=0.02). CONCLUSIONS: We found wide patient-level and practice-level variation in the use of steroid injections prior to undergoing CTR. These findings underscore the need for improved data and standard practice guidelines regarding which patients benefit from steroid injection.

Gabapentinoid Prescribing for Carpal Tunnel Syndrome.

BACKGROUND: Gabapentinoids, including gabapentin and pregabalin, are commonly prescribed for neuropathic pain, but robust evidence recommends against using gabapentinoids for the treatment of carpal tunnel syndrome (CTS). We aimed to quantify national prescribing patterns of gabapentinoids for CTS. METHODS: We performed a retrospective population-based cohort study using claims data of gabapentinoid-naïve patients with a new diagnosis of CTS (2009-2016). Our primary outcome was a new gabapentinoid fill for CTS. We assessed temporal trends and characteristics associated with a gabapentinoid fill. Multivariable logistic regression was used to evaluate the association between patient-level factors and a new gabapentinoid fill for CTS. RESULTS: Of the 248 324 previously gabapentinoid-naïve patients with CTS, 9589 patients (4%) filled a gabapentinoid prescription. Sixty-one percent were prescribed by primary care providers or medical subspecialists. Patients with a history of neck pain (odds ratio [OR]: 1.31, 95% confidence interval [CI], 1.25-1.38), back pain (OR: 1.25, 95% CI, 1.20-1.31), arthritis (OR: 1.25, 95% CI, 1.18-1.31), and other pain conditions (OR: 1.26, 95% CI, 1.20-1.31) were associated with an increased odds of a new gabapentinoid fill. In addition, patients with a history of alcohol or substance use disorder were significantly associated with a new gabapentinoid prescription fill (OR: 1.33, 95% CI, 1.20-1.47). CONCLUSIONS: Despite evidence recommending against the use of gabapentinoids for CTS, gabapentinoids were frequently initiated among those with higher risk for misuse, including substance use disorders. Given the effectiveness of bracing or surgery for CTS and the risks associated with gabapentinoids, efforts aimed at disseminating evidence-based treatment for CTS are critical to minimize the harms of gabapentinoid misuse.

Nonsurgical Treatment of Carpal Tunnel Syndrome: A Survey of Hand Surgeons.

Background: The nonsurgical treatment of carpal tunnel syndrome (CTS) consists of multiple modalities: splinting, corticosteroid injections, hand therapy, and oral medications. However, data supporting the effectiveness of these different modalities are varied, thus creating controversy regarding the optimal nonsurgical treatment. It is unknown how current hand surgeons utilize nonsurgical treatments for CTS. Methods: An anonymous web-based survey was sent to 3289 members of the American Society for Surgery of the Hand to assess nonsurgical treatment patterns for CTS. We pretested the survey using expert survey and content review and cognitively tested the survey for readability and understandability. Results: We analyzed surveys from 770 hand surgeons. Of the respondents, 41.2% of respondents recommend steroid injections for the treatment of CTS, 81.3% of respondents do not believe that oral steroids are beneficial for the treatment of CTS, and 3.6% of respondents typically prescribe gabapentinoids for the treatment of CTS. In total, 561 (72.9%) respondents always, usually, or sometimes encounter patients with more than two steroid injections for CTS before hand surgeon evaluation. Conclusions: There is variation in the use of nonsurgical modalities for the treatment of CTS among American Society for Surgery of the Hand members. However, patients do not obtain long-term benefit from multiple steroid injections and gabapentinoids for the treatment of CTS, highlighting the importance of dissemination of evidence-based nonsurgical management of CTS. Collectively, these findings underscore the importance of providing clear guidelines as to which patients benefit most from nonsurgical treatments.

Dissemination of Plastic Surgery Research: An Analysis of PRS and PRS-GO.

Plastic and Reconstructive Surgery (PRS) recently developed an open access counterpart, PRS Global Open (PRS-GO), to increase dissemination of research in an efficient and widespread manner. We aimed to (1) examine the differences in the dissemination of research published in PRS and PRS-GO, and (2) identify differences in the authorship between the journals. Methods: We extracted data on Altmetric Attention Scores, article mentions, citations, and author characteristics using the Altmetric Explorer Database from January 1, 2018, to January 1, 2020. We stratified research outputs into traditional dissemination and social media dissemination. Additionally, multivariable linear regression models were used to examine differences in dissemination between the journals. Results: A total of 1798 articles were included in the analysis (PRS = 1031, PRS-GO = 767). The average Altmetric Attention Score was higher for PRS compared with PRS-GO (PRS = 15.2, PRS-GO = 8.1). Articles in PRS had a greater Altmetric Attention Score (ß-coefficient: 7.50, P < 0.001), higher measures of traditional dissemination (ß-coefficient: 3.11, P < 0.001), and higher measures of social media dissemination than articles in PRS-GO (ß-coefficient: 4.38, P = 0.73). Conclusions: Despite being an open access journal, PRS-GO had significantly fewer measures of social media and traditional dissemination compared with PRS. Given that numerous factors may influence the dissemination of scientific literature, it is imperative that publications identify specific ways to provide a fair advantage for both researchers and readers. Additional initiatives to engage readership for open access may include creative campaigns targeting an appropriate audience.