Risk of Total Wrist Arthrodesis Following Proximal Row Carpectomy: An Analysis of 1,070 Patients.

PURPOSE: Proximal row carpectomy (PRC) is a motion-sparing procedure with good patient-reported and clinical outcomes. Although some studies have investigated the risk of conversion to total wrist arthrodesis (TWA) after PRC, additional larger studies evaluating the specific risk factors that lead to failure are required. This study aimed to investigate the patient and procedure factors that are associated with increased risk for conversion to TWA in a large cohort of patients who underwent PRC. METHODS: The current procedural technology codes identified patients in a National Veteran's Health database undergoing a PRC over a 26-year period. Risk factors of interest comprised age, posterior interosseous nerve neurectomy, wrist arthritis pattern, bilateral surgery, smoking, comorbidities, and preoperative opioid use. The primary outcome was the rate of conversion to TWA. Cox proportional hazard regression was used to create hazard ratios of selected factors for reoperation. RESULTS: There were 1,070 PRCs performed, with a mean follow-up of 79.8 ± 59.6 months. A total of 5.3% (57/1,070) wrists underwent conversion to TWA. Younger age at the time of PRC (<50 years) significantly increased the risk of TWA (hazard ratio, 3.8; 95% confidence interval, 2.2-6.6). With every 1-year increase in age, there was a reduction of 4% (hazard ratio, 0.96; 95% confidence interval: 0.94-0.98) in the hazard of conversion to TWA. No other factors, including concomitant posterior interosseous nerve neurectomy or bilateral PRC, increased the risk of conversion to TWA. CONCLUSIONS: Proximal row carpectomy is a motion-preserving salvage procedure with a low rate of conversion to wrist arthrodesis. Younger patient age increases the risk of conversion to arthrodesis, whereas posterior interosseous nerve neurectomy, bilateral PRCs, and comorbidity status do not appear to have an impact on the risk of arthrodesis. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Minimizing Costs for Dorsal Wrist Ganglion Treatment: A Cost-Minimization Analysis.

PURPOSE: Dorsal wrist ganglions are treated commonly with aspiration, or open or arthroscopic excision in operating room (OR) or procedure room (PR) settings. As it remains unclear which treatment strategy is most cost-effective in yielding cyst resolution, our purpose was to perform a formal cost-minimization analysis from the societal perspective in this context. METHODS: A microsimulation decision analytic model evaluating 5 treatment strategies for dorsal wrist ganglions was developed, ending in either resolution or a single failed open revision surgical excision. Strategies included immediate open excision in the OR, immediate open excision in the PR, immediate arthroscopic excision in the OR, or 1 or 2 aspirations before each of the surgical options. Recurrence and complications rates were pooled from the literature for each treatment type. One-way sensitivity and threshold analyses were performed. RESULTS: The most cost-minimal strategy was 2 aspiration attempts before open surgical excision in the PR setting ($1,603 ± 1,595 per resolved case), followed by 2 aspirations before open excision in the OR ($1,969 ± 2,165 per resolved case). Immediate arthroscopic excision was the costliest strategy ($6,539 ± 264 per resolved case). Single aspiration preoperatively was more cost-minimal than any form of immediate surgery ($2,918 ± 306 and $4,188 ± 306 per resolved case performed in the PR and OR, respectively). CONCLUSIONS: From the societal perspective, performing 2 aspirations before surgical excision in the PR setting was the most cost-minimal treatment strategy, although in reference to surgeons who do not perform this procedure in the PR setting, open excision in the OR was nearly as cost-effective. As patient preferences may preclude routinely performing 2 aspirations, performing at least 1 aspiration before surgical excision improves the cost-effectiveness of dorsal wrist ganglions treatment. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic Decision Analysis II.

Scaphotrapeziotrapezoid Arthrodesis: Systematic Review.

PURPOSE: Scaphotrapeziotrapezoid (STT) arthrodesis surgery is used for various types of wrist pathologies. The objective of our study was to perform a systematic review of complications and outcomes after STT arthrodesis. METHODS: Several major databases were used to perform a systematic literature review in order to obtain articles reporting complications and outcomes following STT arthrodesis. The primary purpose was to identify rates of nonunion and conversion to total wrist arthrodesis. Secondary outcomes included wrist range of motion, grip strength, and Disabilities of the Arm Shoulder and Hand scores. A multivariable analysis was performed to evaluate factors associated with the primary and secondary outcomes of interest. RESULTS: Out of the 854 records identified in the primary literature search, 30 studies were included in the analysis. A total of 1,429 procedures were performed for 1,404 patients. The pooled nonunion rate was 6.3% (95% CI, 3.5-9.9) and the rate of conversion to total wrist arthrodesis following the index STT was 4.2% (95% CI, 2.2-6.7). The mean pooled wrist flexion was 40.7° (95% CI, 30.8-50.5) and extension was 49.7° (95% CI, 43.5-55.8). At final follow-up, the mean pooled grip strength was 75.9% (95% CI, 69.3-82.5) of the nonsurgical contralateral hand. Compared with all other known indications, Kienbock disease had a statistically significant lower nonunion rate (14.1% vs 3.3%, respectively). Mixed-effects linear regression using patient-level data revealed that increasing age was significantly associated with complications, independent of occupation and diagnosis. CONCLUSIONS: Our study demonstrated a low failure rate and conversion to total wrist arthrodesis after STT arthrodesis and acceptable postoperative wrist range of motion and strength when compared to the contralateral hand. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Evaluating the impact of social deprivation on Press Ganey® Outpatient Medical Practice Survey Scores.

BACKGROUND: Social deprivation has been shown to affect access to health care services, and influences outcomes for a variety of physical and psychological conditions. However, the impact on patient satisfaction remains less clear. The objective of this study was to determine if social deprivation is an independent predictor of patient satisfaction, as measured by the Press Ganey® Outpatient Medical Practice Survey (PGOMPS). METHODS: We retrospectively reviewed unique new adult patient (≥ 18 years of age) seen at a tertiary academic hospital and rural/urban outreach hospitals/clinics between January 2014 and December 2017. Satisfaction was defined a priori as achieving a score above the 33rd percentile. The 2015 Area Deprivation Index (ADI) was used to determine social deprivation (lower score signifies less social deprivation). Univariate and multivariable binary logistic regression were used to determine the impact of ADI on PGOMPS total and provider sub-scores while controlling for variables previously shown to impact scores (wait time, patient age, sex, race, specialty type, provider type, and insurance status). RESULTS: Univariate analysis of PGOMPS total scores revealed a 4% decrease in odds of patient satisfaction per decile increase in ADI (p < 0.001). Patients within the most deprived quartile were significantly less likely to report satisfaction compared to the least deprived quartile (OR 0.79, p < 0.001). Multivariable analysis revealed that the odds of achieving satisfaction decreased 2% for each decile increase in ADI on the Total Score (p < 0.001), independent of other variables previously shown to impact scores. For PGOMPS Provider Sub-Score, univariate analysis showed that patients in the lowest ADI quartile were significantly less likely be satisfied, as compared to the least deprived quartile (OR 0.77; 95% CI 0.70-0.86; p < 0.001). A 5% decrease in a patient being satisfied was observed for each decile increase in ADI (OR 0.95; 95% CI 0.94-0.96; p < 0.001). CONCLUSIONS: Social deprivation was an independent predictor of outpatient visit dissatisfaction, as measured by the Press Ganey® Outpatient Medical Practice Survey. These results necessitate consideration when developing health care delivery policies that serve to minimize inequalities between patients of differing socioeconomic groups.

Minimal Clinically Important Difference of the PROMIS Upper-Extremity Computer Adaptive Test and QuickDASH for Ligament Reconstruction Tendon Interposition Patients.

PURPOSE: To calculate the minimal clinically important difference (MCID) of the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Computer Adaptive Test (UE CAT) and Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) for ligament reconstruction tendon interposition (LRTI) patients. METHODS: Adult patients treated with LRTI for trapeziometacarpal OA by fellowship-trained hand surgeons between December 2014 and February 2018 at an academic tertiary institution were included. Outcomes were prospectively collected at each visit by tablet computer, including the QuickDASH, PROMIS UE, Pain Interference, Depression, and Anxiety CATs. Inclusion required a response to the anchor question "How much relief and/or improvement do you feel you have experienced as a result of your treatment?" on a 6-option Likert scale, as well as preoperative (≤120 days before surgery) and follow-up (2-26 weeks) outcomes. We calculated MCID both by an anchor-based approach using the mean score of the minimal change group, and with the 0.5 SD method. RESULTS: Of 145 included participants, mean age was 63 ± 8 years and 74% were female. Anchor-based MCID estimates for the total cohort were 4.2 for the PROMIS UE CAT and 8.8 for the QuickDASH. The MCID estimates using the 0.5 SD method were 4.8 and 11.7, respectively. CONCLUSIONS: We propose MCID values of 4.2 to 4.8 for the PROMIS UE CAT and 8.8 to 11.7 for the QuickDASH when powering clinical studies or when assessing improvement among a cohort of patients who have undergone LRTI surgery. CLINICAL RELEVANCE: Minimal clinically important difference estimates are helpful when interpreting clinical outcomes after LRTI and for powering prospective trials.

Comparison of Complication Risk Following Trigger Digit Release Performed in the Office Versus the Operating Room: A Population-Based Assessment.

PURPOSE: Trigger digit release (TDR) performed in an office-based procedure room (PR) setting minimizes surgical costs compared with that performed in an operating room (OR); yet, it remains unclear whether the rates of major complications differ by setting. We hypothesized that surgical setting does not have an impact on the rate of major complications after TDR. METHODS: Adult patients who underwent isolated TDR from 2006 to 2015 were identified from the MarketScan commercial database (IBM) using the provider current procedural terminology code 26055 with a concordant diagnosis on the same claim line (International Classification of Diseases, ninth revision, clinical modification 727.03). The PR cohort was defined by presence of a place-of-service code for an in-office procedure without OR or ambulatory center revenue codes, or anesthesiologist claims, on the day of the surgery. The OR cohort was defined by presence of an OR revenue code. We identified major medical complications, surgical site complications, as well as iatrogenic neurovascular and tendon complications within 90 days of the surgery using International Classification of Diseases, ninth revision, clinical modification diagnosis and/or current procedural terminology codes. Multivariable logistic regression was used to compare the risk of complications between the PR and OR groups while controlling for Elixhauser comorbidities, smoking, and demographics. RESULTS: For 7,640 PR and 29,962 OR cases, the pooled rate of major medical complications was 0.99% (76/7,640) and 1.47% (440/29,962), respectively. The PR setting was associated with a significantly lower risk of major medical complications in the multivariable analysis (adjusted odds ratio 0.76; 95% confidence interval 0.60-0.98). The pooled rate of surgical site complications was 0.67% (51/7,640) and 0.88% (265/29,962) for the PR and OR cases, respectively, with no difference between the surgical settings in the multivariable analysis (adjusted odds ratio 0.81; 95% confidence interval 0.60-1.10). Iatrogenic complications were infrequently observed (PR 5/7,640 [0.07%]; OR 26/29,962 [0.09%]). CONCLUSIONS: Compared with performing TDR in the OR using a spectrum of commonly used anesthesia types, performing TDR in the PR using local-only anesthesia was associated with a comparably low risk of major medical complications, surgical complications, and iatrogenic complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Evaluating the Safety of the Hand Surgery Procedure Room: A Single-Center Cohort of 1,404 Surgical Encounters.

PURPOSE: Performing hand surgeries in the procedure room (PR) setting instead of the operating room effectively reduces surgical costs. Understanding the safety or complication rates associated with the PR is important in determining the value of its use. Our purpose was to describe the incidence of medical and surgical complications among patients undergoing minor hand surgeries in the PR. METHODS: We retrospectively reviewed all adult patients who underwent an operation in the PR setting between December 2013 and May 2019 at a single tertiary academic medical center by 1 of 5 fellowship-trained orthopedic hand surgeons. Baseline patient characteristics were described. Complication rates were obtained via chart review. RESULTS: For 1,404 PR surgical encounters, 1,796 procedures were performed. Mean patient age was 59 ± 15 years, 809 were female (57.6%), and average follow-up was 104 days. The most common surgeries were carpal tunnel release (39.9%), trigger finger release (35.9%), and finger mass or cyst excision (9.6%). Most surgeries were performed using a nonpneumatic wrist tourniquet (58%), whereas 42% used no tourniquet. No patient experienced a major medical complication. No procedure was aborted owing to intolerance. No patient required admission. No intraoperative surgical or medical complications occurred. Observed complications included delayed capillary refill requiring phentolamine administration after a trigger thumb release performed using epinephrine without a tourniquet (n = 1; 0.1%), complex regional pain syndrome (n = 3; 0.2%), infection requiring surgical debridement (n = 2; 0.2%), and recurrent symptoms requiring reoperation (n = 8; 0.7%). CONCLUSIONS: In this cohort of patients in whom surgery was performed in a PR, there were no major intraoperative surgical or medical complications. There was a low rate of postoperative infection, development of complex regional pain syndrome, and a low need for revision surgery. These observations do not support the concern for safety as a barrier to performing minor hand surgery in the PR setting. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Reliability of Telephone Acquisition of the PROMIS Upper Extremity Computer Adaptive Test.

PURPOSE: Our primary purpose was to evaluate the reliability of telephone administration of the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) Computer Adaptive Test (CAT) version 2.0 in a hand and upper extremity population, and secondarily to make comparisons with the abbreviated version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH). METHODS: Patients more than 1 year out from hand surgeries performed at a single tertiary institution were enrolled. Half of the patients completed telephone PROMIS UE CAT and QuickDASH surveys first, followed by computer-based surveys 1 to 10 days later, and the other half completed them in the reverse order. Telephone surveys were readministered 2 to 6 weeks later to evaluate test-retest reliability. Concordance correlation coefficients (CCCs) were used to assess agreement between telephone and computer-based scores, and intraclass correlation coefficients (ICCs) were used to assess test-retest reliability. The proportion of patients with discrepancies in follow-up scores that exceeded estimates of the minimal clinically important difference (MCID) was evaluated. RESULTS: For the 89 enrolled patients, the PROMIS UE CAT CCC was 0.82 (83% confidence interval [83% CI], 0.77-0.86; good), which was significantly lower than 0.92 (83% CI, 0.89-0.94; good to excellent) for the QuickDASH. The PROMIS UE CAT ICC did not differ significantly from the QuickDASH (0.85 and 0.91, respectively). Differences in telephone versus computer scores exceeded 5 points (MCID estimate) for the PROMIS UE CAT in 34% of patients versus 5% of patients exceeding 14 points (MCID estimate) for the QuickDASH. CONCLUSIONS: Significantly better reliability was observed for the QuickDASH than the PROMIS UE CAT when comparing telephone with computer-based score acquisition. Over one-third of patients demonstrated a clinically relevant difference in scores between the telephone and the computer-administered tests. We conclude that the PROMIS UE CAT should only be administered through computer-based methods. CLINICAL RELEVANCE: These findings suggest that differences in collection methods for the PROMIS UE CAT may systematically affect the scores obtained, which may erroneously influence the interpretation of postoperative scores for hand surgery patients.

Evaluating the performance of PROMIS and QuickDASH instruments in an intercollegiate Division 1 athlete population.

BACKGROUND: Athletes demonstrate high levels of physical function, leading to difficulties in patient-reported outcome scoring and interpretation. In particular, the ability of patient-reported outcome (PRO) instruments to adequately discriminate between high levels of upper extremity function-that is, the ceiling effect-is limited. This study evaluated performance characteristics of the shortened version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) survey and Patient-Reported Outcomes Measurement Information System (PROMIS) metrics in a population of Division 1 intercollegiate athletes, with specific attention to ceiling effects. METHODS: At a single institution, Division I intercollegiate athletes cleared for full participation in the 2018-2019 season were eligible. The following PROs were collected prospectively via tablet computer: PROMIS upper extremity (UE) computer adaptive test (CAT), PROMIS physical function (PF) CAT, QuickDASH, and QuickDASH Sports/Performing Arts Module. Descriptive statistics, and ceiling and floor effects, were calculated. The proportion of athletes with maximal scores on each PRO were compared to normative values using the 1-sample Wilcoxon signed rank test. RESULTS: A total of 268 participants were included; the mean age was 19.9 ± 1.5 years, 49% were female, and 61% were overhead athletes. Large ceiling effects were observed for the UE CAT (46%), QuickDASH (58%), and QuickDASH Sports Module (82%). The PF CAT demonstrated a relatively low ceiling effect of 6.7%. Athlete scores were all significantly better than published age-matched values from a normative population for all instruments, with the exception of no difference on the QuickDASH for males. DISCUSSION AND/OR CONCLUSION: The PROMIS UE CAT and QuickDash instruments are limited in their ability to assess and discriminate upper extremity function in highly functioning individuals such as Division I athletes. The PROMIS PF CAT, a measure of general physical function, did not suffer from a large ceiling effect.

The Prognostic Value of Preoperative Patient-Reported Function and Psychological Characteristics on Early Outcomes Following Trapeziectomy With Ligament Reconstruction Tendon Interposition for Treatment of Thumb Carpometacarpal Osteoarthritis.

PURPOSE: Biopsychosocial factors are associated with patient-reported upper extremity disability; however, their impact on postoperative outcomes remains less clear. Our purpose was to test the hypothesis that high levels of preoperative patient-reported upper extremity and psychological disability are associated with lower magnitudes of improvement following trapeziectomy with ligament reconstruction tendon interposition (LRTI). METHODS: Adult patients undergoing LRTI by fellowship-trained hand surgeons between February 2014 and March 2017 were considered for inclusion. Patient-reported outcomes were collected by tablet computer, including the shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) Computer Adaptive Test (CAT), PROMIS Depression CAT, and PROMIS Anxiety CAT. Univariate and multivariable linear regression analyses were performed to identify factors associated with QuickDASH improvement. RESULTS: Of 119 included patients, the mean age was 62.7 ± 7.2 years and 74% were women. At a mean of 14 weeks after surgery, the QuickDASH improved by a mean of -10 ± 20 points. The QuickDASH improvement was significantly greater for patients with preoperative QuickDASH scores greater than the median (score change, -19 ± 20) versus those at or below the median (-2 ± 16), and for patients with preoperative PI CAT scores greater than the median (-17 ± 21) versus at or below the median (-4 ± 17). No differences were observed between groups when Anxiety or Depression CAT baseline scores were similarly dichotomized. Multivariable modelling revealed that higher preoperative QuickDASH scores were associated with greater improvement on the QuickDASH; however, no association was observed for preoperative PI CAT, Depression CAT, and Anxiety CAT scores. CONCLUSIONS: Patients with higher levels of preoperative upper extremity disability experienced more improvement in the early postoperative period following LRTI. Baseline pain interference, depression, and anxiety were not associated with early outcomes. These findings may be useful when identifying patients who may experience the most functional improvement in the immediate postoperative period following LRTI. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Upper Extremity Function, Peer Relationships, and Pain Interference: Evaluating the Biopsychosocial Model in a Pediatric Hand Surgery Population Using PROMIS.

PURPOSE: The relationship between biopsychosocial factors and patient-reported function is less clear in pediatric than in adult hand surgery patients. Our primary hypothesis was that pain interference (PI) and peer relationships (PR) would demonstrate association with upper extremity function. Secondarily, we hypothesized that the magnitude of this effect would increase with age. METHODS: Patients aged 5 to 17 years presenting to a tertiary academic clinic between October 2017 and January 2019 were included. The parent/guardian was administered the following instruments after indicating they, rather than the patient, were answering the questions on a tablet computer: Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) Parent Proxy (PP) Computer Adaptive Test (CAT) v2.0, PROMIS PI PP CAT v2.0, and the PROMIS PR PP CAT v2.0. Ceiling/floor effects and Spearman correlations were calculated. Multivariable Tobit modeling was performed to determine whether biopsychosocial factors and upper extremity function were associated. Multivariable regression coefficients were compared between age cohorts using a separate multivariable model to evaluate the interaction between age and other predictors. RESULTS: Of 139 included participants, the mean age was 11.7 ± 3.7 years and 50% were female. For patients 11 years of age or younger, UE was weakly correlated with PI (coefficient, -0.34; 95% confidence interval, -0.56 to -0.08) and was not correlated with PR. For patients older than 11 years, UE had moderate correlation with PI (coefficient, -0.60; 95% confidence interval, -0.72 to -0.45) and was not correlated with PR. Multivariable analysis demonstrated a significant negative association between PI and UE, with a significantly larger magnitude of effect for patients older than 11 years of age. CONCLUSIONS: The biopsychosocial model applies to pediatric hand surgery patients. The association between greater pain interference and worse patient-reported upper extremity function, as assessed using parent proxy instruments, was significantly stronger for patients older than 11 years than those 11 years old or younger. CLINICAL RELEVANCE: This study suggests that the biopsychosocial model applies to pediatric hand patients.

The Minimal Clinically Important Difference of the PROMIS and QuickDASH Instruments in a Nonshoulder Hand and Upper Extremity Patient Population.

PURPOSE: The minimal clinically important difference (MCID) is used in research and clinical settings as a benchmark to gauge improvement following treatment. The purpose of this study was to provide anchor-based MCID estimates for Patient-Reported Outcomes Measurement Information System (PROMIS) and legacy instruments in a nonshoulder hand and upper extremity population. METHODS: Adult patients (≥18 years) seeking care at a tertiary academic outpatient hand surgery clinic completed patient-reported outcome measures on tablet computers between January 2015 and August 2017. Data were collected at baseline and at 6 ± 2 weeks of follow-up. The PROMIS Upper Extremity (UE), Physical Function (PF), and Pain Interference (PI) Computer Adaptive Test (CAT) instruments were administered, along with the shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH). A mean change anchor-based method was used to estimate MCIDs by comparing scores between anchor groups reporting no change versus slightly improved in terms of function and pain. RESULTS: Scores for each instrument significantly improved over the study period. With significant differences in scores between groups reporting no change and slightly improved function, anchor-based MCID estimates were calculated as follows: 2.1 for the PROMIS UE CAT, 1.7 for the PROMIS PF CAT, and 6.8 for the QuickDASH. There was no significant difference in PROMIS PI CAT scores between anchor groups when queried for level of pain improvement, precluding estimation of an anchor-based MCID. CONCLUSIONS: We have provided anchor-based MCID estimates for the PROMIS UE CAT, PROMIS PF CAT, and the QuickDASH for a general nonshoulder hand and upper extremity population. These values may be useful in future research for informing power calculations and when interpreting whether the magnitude of change on these instruments is clinically significant at a population level. CLINICAL RELEVANCE: This study provides clinicians with a reference for values that may reflect clinically meaningful changes in scores for patient-reported outcome instruments commonly utilized in the current hand surgery literature.

Effects of Baseline Opioid Medication Use on Patient-Reported Functional and Psychological Impairment Among Hand Clinic Patients.

PURPOSE: To test the null hypothesis that baseline opioid use is not associated with functional or psychological impairment among new hand surgery clinic patients, as measured by Patient-Reported Outcomes Measurement Information System (PROMIS) instruments. METHODS: New adult (≥ 18 years) patient visits to a tertiary academic orthopedic nonshoulder hand and upper extremity clinic between February 2014 and April 2018 were eligible. Collected outcomes include the question, "Are you currently taking narcotic pain medications?", the PROMIS Upper Extremity (UE) computerized adaptive testing (CAT), abbreviated version of the Disorders of the Arm, Shoulder, and Hand (QuickDASH), PROMIS Physical Function (PF) CAT, PROMIS Pain Interference (PI) CAT, PROMIS Depression CAT, and PROMIS Anxiety CAT. Patients responding to the opioid question, plus the UE CAT or QuickDASH, were included. Bivariate and multivariable logistic regression modelling were used to assess factors associated with baseline scores. RESULTS: Of 5997 included patients, 1,046 (17.4%) reported baseline opioid use. Patients in the opioid group demonstrated significantly worse scores on all patient-reported outcomes, and a significantly greater proportion of patients with PROMIS Depression CAT scores exceeding 60 (associated with a clinical diagnosis of depression; 29.5% vs 15.5%). Lower functional scores were observed in the opioid group after controlling for age, sex, other activity-limiting comorbidities, and either depression (UE CAT -7.0; QuickDASH +18.1; and PF CAT -6.6 points), anxiety (UE CAT -6.3; QuickDASH +16.4; PF CAT -6.3), or PI (UE CAT -3.7; QuickDASH +9.5; and PF CAT -4.2 points). Pain interference was greater among opiate users when controlling for age, sex, other activity-limiting comorbidities, and baseline function or psychological status: PI was 2.5, 5.0, or 4.3 points greater when controlling for the PROMIS UE CAT, Depression CAT, or Anxiety CAT. CONCLUSIONS: New patients presenting to a hand surgery clinic who endorse use of opioid medications at baseline report significantly decreased physical function, increased psychological burden, and greater levels of pain interference than nonusers. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

Minimal Clinically Important Difference After Carpal Tunnel Release Using the PROMIS Platform.

PURPOSE: In light of recently-proposed quality measures for carpal tunnel release (CTR), elucidating the minimal clinically important difference (MCID) for selected outcome measures will be important when interpreting treatment responses. Our purpose was to estimate the MCID of the Patient-Reported Outcomes Measurement Information System (PROMIS) instruments and the short Disabilities of the Arm, Shoulder, and Hand (QuickDASH) following CTR. METHODS: Adult patients undergoing isolated unilateral CTR between July 2014 and October 2016 were identified. Outcomes included the PROMIS Upper Extremity (UE) Computer Adaptive Test (CAT), Physical Function (PF) CAT, QuickDASH, and Pain Interference (PI) CAT. For inclusion, pretreatment baseline (within 60 days of surgery) and postoperative (6-90 days) UE or PF CAT scores were required, as well as a response on a 5-point Likert scale to the question "How much relief and/or improvement do you feel you have experienced as a result of your treatment?" The MCID was calculated using SD and minimum detectable change (MDC) distribution methods. RESULTS: In response to the Likert scale question, 88.6% of patients reported improvement at a mean of 14.8 days after surgery. The infrequency of patients reporting no change (5 of 44; 11.4%) precluded calculation of a statistically sound anchor-based MCID value. The MCID values, as calculated using the one-half SD method, were 3.6, 4.6, 10.4, and 3.4 for the UE CAT, PF CAT, QuickDASH, and PI CAT, respectively. CONCLUSIONS: We have calculated MCID values for the UE CAT, PF CAT, QuickDASH, and PI CAT for patients undergoing CTR. Although the small number of patients reporting no change and minimal change after surgery precluded an anchor-based MCID calculation, we report estimates using the one-half SD method for the MCID following CTR. CLINICAL RELEVANCE: These MCID estimates will be helpful when interpreting CTR clinical outcomes and for powering prospective trials.

Evaluation of Version 2.0 of the PROMIS Upper Extremity Computer Adaptive Test in Nonshoulder Upper Extremity Patients.

PURPOSE: The Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Computer Adaptive Test (UE CAT) was recently updated to version 2.0 (v2.0). We hypothesized that the PROMIS UE CAT v2.0 would exhibit improved performance characteristics compared with the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) when administered to a nonshoulder upper extremity patient population. METHODS: The UE CAT v2.0, Physical Function (PF) CAT v2.0, and the QuickDASH were each prospectively administered via tablet computer to all patients presenting to a tertiary hand and upper extremity clinic between April 2017 and October 2017. Patient responses were analyzed, and the mean, range, floor and ceiling effect, and correlations between instruments were calculated. RESULTS: Among 825 patients, the mean UE CAT v2.0 score was 38.3 (SD 10.7) with a range of 15 to 61 and interquartile range of 15.4. The UE CAT v2.0 had a strong correlation with the QuickDASH (r = -0.749) and the PF CAT v2.0 (r = 0.719). No patient scored between 56 and 60, indicating a gap in scoring in that range. The UE CAT v2.0 demonstrated a floor effect of 1%, a ceiling effect of 6.9%, and a high internal consistency with a Cronbach alpha of 0.99. CONCLUSIONS: The PROMIS UE CAT v2.0 demonstrated improved ceiling effects, range, and a decreased gap in scoring compared with prior versions. Limitations of the PROMIS UE CAT v2.0 are still present, but updates have led to an incremental improvement over prior versions, demonstrating the ability to influence PROMIS instrument performance through upgrades. CLINICAL RELEVANCE: The updated PROMIS UE CAT v2.0 still demonstrates a ceiling effect and gap in scores at the upper end of the instrument, both of which may limit discrimination between different levels of upper extremity function for high-functioning patients.

Patient Satisfaction in the Hand Surgery Clinic: An Analysis of Factors That Impact the Press Ganey Survey.

PURPOSE: Our purpose was to test the null hypothesis that no patient or clinic visit characteristics affect satisfaction of hand surgery outpatients, as measured by the Press Ganey Outpatient Medical Practice Survey (PGOMPS). METHODS: Adult patients (≥ 18 years) evaluated by 5 fellowship-trained hand surgeons between January 2014 and December 2016 for a new patient clinic visit at a single tertiary academic medical center, were included. Prospectively collected PGOMPS data were reviewed retrospectively for each visit. Chart review was performed to collect demographic and visit characteristics data. Satisfaction was defined a priori as achieving a PGOMPS score above the 33rd percentile. Both the PGOMPS Total Score (primary outcome) and Provider Subscore (secondary outcome) were analyzed using univariate and multivariable logistic regression. RESULTS: Of 748 included patients, the mean age was 51.7 ± 15.5 years, and 64% were women. Leading diagnoses included tendinitis (19%), neuropathy (19%), arthritis (16%), and fracture-dislocation (13%). Multivariable modelling of the PGOMPS Total Score revealed that older age, shorter wait times, and scheduling surgery were significantly associated with greater satisfaction. The PGOMPS Provider Sub-Score multivariable modelling revealed that older age, shorter wait times, scheduling surgery, and administering injections were significantly associated with greater satisfaction. Diagnostic category and insurance status did not affect satisfaction. CONCLUSIONS: Increasing patient age, decreased wait time, and receiving an intervention (scheduling of surgery or receiving an injection) are associated with increased satisfaction among newly presenting hand surgery clinic patients as measured by the Press Ganey Outpatient Medical Practice Survey. Diagnosis and access to health care (insurance status and distance to clinic) did not influence patient satisfaction. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

Unusual presentation of aneurysmal subarachnoid haemorrhage.

The classic presentation of aneurysmal subarachnoid haemorrhage is sudden severe headache, associated with decreased level of consciousness. The authors present a most dramatic presentation of aneurysmal subarachnoid haemorrhage.

Evaluation of Factors Driving Cost Variation for Distal Radius Fracture Open Reduction Internal Fixation.

PURPOSE: Distal radius fracture open reduction and internal fixation (ORIF) represents a considerable cost burden to the health care system. We aimed to elucidate demographic-, injury-, and treatment-specific factors influencing surgical encounter costs for distal radius ORIF. METHODS: We retrospectively reviewed adult patients treated with isolated distal radius ORIF between November 2014 and October 2016 at a single tertiary academic medical center. Using our institution's information technology value tools-which allow for comprehensive payment and cost data collection and analysis on an item-level basis-we determined relative costs (RC) for each factor potentially influencing total direct costs (TDC) for distal radius ORIF using univariate and multivariable gamma regression analyses. RESULTS: Of the included 108 patients, implants and facility utilization costs were responsible for 48.3% and 37.9% of TDC, respectively. Factors associated with increased TDC include plate manufacturer (RC 1.52 for the most vs least expensive manufacturer), number of screws (RC 1.03 per screw) and distal radius plates used (RC 1.67 per additional plate), surgery setting (RC 1.32 for main hospital vs ambulatory surgery center), treating service (RC 1.40 for trauma vs hand surgeons), and surgical time (RC 1.04 for every 10 min of additional surgical time). Open fracture was associated with increased costs (RC 1.55 vs closed fracture), whereas other estimates of fracture severity were nonsignificant. In the multivariable model controlling for injury-specific factors, variables including implant manufacturer, and number of distal radius plates and screws used, remained as significant drivers of TDC. CONCLUSIONS: Substantial variations in surgical direct costs for distal radius ORIF exist, and implant choice is the predominant driver. Cost reductions may be expected through judicious use of additional plates and screws, if hospital systems use bargaining power to reduce implant costs, and by efficiently completing surgeries. CLINICAL RELEVANCE: This study identifies modifiable factors that may lead to cost reduction for distal radius ORIF.

Cost Implications of Varying the Surgical Technique, Surgical Setting, and Anesthesia Type for Carpal Tunnel Release Surgery.

PURPOSE: Carpal tunnel release (CTR) is a common surgical procedure, representing a financial burden to the health care system. The purpose of this study was to test whether the choice of CTR technique (open carpal tunnel release [OCTR] vs endoscopic carpal tunnel release [ECTR]), surgical setting (operating room vs procedure room [PR]), and anesthetic type (local, monitored anesthesia care [MAC], Bier block, general) affected costs or payments. METHODS: Consecutive adult patients undergoing isolated unilateral CTR between July 2014, and October 2017, at a single academic medical center were identified. Patients undergoing ECTR converted to OCTR, revision surgery, or additional procedures were excluded. Using our institution's information technology value tools, we calculated total direct costs (TDCs), total combined payment (TCP), hospital payment, surgeon payment, and anesthesia payment for each surgical encounter. Cost data were normalized using each participant's surgical encounter cost divided by the average cost in the data set and compared across 8 groups (defined by surgery type, operation location, and anesthesia type). RESULTS: Of 479 included patients, the mean age was 55.3 ± 16.1 years, and 68% were female. Payer mix included commercial (45%), Medicare (37%), Medicaid (13%), workers' compensation (2%), self-pay (1%), and other (3%) insurance types. The TDC and TCP both differed significantly between each CTR group, and OCTR in the PR under local anesthesia was the lowest. The OCTR/local/operating room, OCTR/MAC/operating room, and ECTR/operating room, were associated with 6.3-fold, 11.0-fold, and 12.4-16.6-fold greater TDC than OCTR/local/PR, respectively. CONCLUSIONS: Performing OCTR under local anesthetic in the PR setting significantly minimizes direct surgical encounter costs relative to other surgical methods (ECTR), anesthetic methods (Bier block, MAC, general), and surgical settings (operating room). CLINICAL RELEVANCE: This study identifies modifiable factors that may lead to cost reductions for CTR surgery.

Psychometric properties of the Press Ganey® Outpatient Medical Practice Survey.

BACKGROUND: The Press Ganey® Medical Practice Survey ("Press Ganey® survey") is a patient-reported questionnaire commonly used to measure patient satisfaction with outpatient health care in the United States. Our objective was to evaluate the reliability and validity of the Press Ganey® survey in a single institution setting. METHODS: We analyzed surveys from 34,503 unique respondents seen by 624 providers from 47 specialties and 94 clinics at the University of Utah in 2013. The University of Utah is a health care system that provides primary through tertiary care for over 200 medical specialties. Surveys were administered online. The Press Ganey® survey consisted of 24 items organized into 6 scales: Access (4 items), Moving Through the Visit (2), Nurse Assistant (2), Care Provider (10), Personal Issues (4) and Overall Assessment (2). Missingness, ceiling and floor rates were summarized. Cronbach's alpha was used to evaluate internal consistency reliability. Confirmatory factor analysis was used to assess convergent and discriminant validities. RESULTS: Missingness was 0.01% for the total score and ranged from 0.8 to 11.4% across items. The ceiling rate was high at 29.3% for the total score, and ranged from 55.4 to 84.1% across items. Floor rates were 0.01% for the total score, and ranged from 0.1 to 2.1% across items. Internal consistency reliability ranged from 0.79 to 0.96, and item-scale correlations ranged from 0.49 to 0.9. Confirmatory factor analysis supported convergent and discriminant validities. CONCLUSION: The Press Ganey® survey demonstrated suitable psychometric properties for most metrics. However, the high ceiling rate can have a notable impact on quarterly percentile scores within our institution. Multi-institutional studies of the Press Ganey® survey are needed to inform administrative decision making and institution reimbursement decisions based on this survey.