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).

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.

Patient-Derived Framework for Quality in Hand Surgery: A Qualitative Analysis.

PURPOSE: Despite the growing attention to evaluating care from the patient perspective, the most common definitions and measurements of quality are currently defined by physicians and health systems. Studies have demonstrated how a lack of patient input can lead to discrepancies between patients' and physicians' assessments of quality and, subsequently, worse patient outcomes. Although quality measures are increasingly used in hand surgery, insufficient work has examined whether these quality measures align with what matters to patients. We completed a qualitative study to assess how patients define high-quality care through the pre-, peri-, and postoperative phases of care in hand surgery. METHODS: Based on our prior work, we created an open-ended interview guide and conducted semistructured interviews with 43 hand surgery patients at 5 tertiary-care institutions during various phases of care. We completed a thematic analysis to generate subcodes and open codes, to identify themes in high-quality care from the patient perspective. RESULTS: Patients defined high-quality care as a process of (1) setting and meeting clear expectations; (2) achieving functional goals after surgery; and (3) feeling comfortable with and cared for by the care team. We identified the following 4 patient-centered themes that contributed to high-quality care: (1) communication between the patient and care team through all phases of care; (2) efficient and accurate diagnosis and treatment; (3) satisfactory treatment outcomes and postsurgical experience; and (4) acceptable systemic aspects of care. CONCLUSIONS: Efforts to improve health care delivery should include areas of care that are important to patients. Our results suggest that measuring aspects of care that often go without assessments, such as communication, can maximize care quality as defined by patients. CLINICAL RELEVANCE: The themes identified in this study can inform efforts towards patient-centered quality measure development.

Barriers and Facilitators of Outcome Collection During Hand Surgery Outreach: A Quality Improvement Study.

BACKGROUND: Surgical outreach trips to low- and middle-income countries have been increasing. Outcome collection on these trips, however, has been inconsistent and often incomplete. We conducted a qualitative study of surgeons, administrators, and patients to identify the barriers and facilitators to outcome collection on hand surgery outreach trips to Hospital 175 in Ho Chi Minh City, Vietnam. METHODS: A purposive sample of surgeons, administrators, and patients from Hospital 175 were interviewed about their beliefs regarding outcome collection. We used a semi-structured interview guide based on the Theoretical Domains Framework to systematically explore barriers and facilitators. Interviews were recorded, transcribed, and analyzed using content analysis. Beliefs underlying similar responses were identified and aggregated to describe barriers and facilitators of outcome measurement. RESULTS: Twelve surgeons and administrative staff (3 visiting and 9 local) and 5 patients were interviewed before saturation was achieved. All stakeholders believed outcome collection on hand surgery outreach trips is important. Barriers identified were primarily related to environmental context and resources (eg, cost of returning) and memory, attention, and decision process (eg, difficulty in remembering patient follow-up intervals). The most commonly identified barriers address the distance patients live from the hospital/clinic, the resources required for them to return, and the lack of an organized system to assist in follow-up. CONCLUSIONS: Multiple barriers to outcome collection exist at Hospital 175 in Vietnam. Understanding these barriers informs context-specific implementation approaches to collect outcomes on hand surgery outreach trips, which may improve the safety and quality of care provided.

Understanding the Patient Experience: Analysis of 2-Word Assessment and Its Relationship to Likelihood to Recommend in Outpatient Hand Surgery.

BACKGROUND: Actionable feedback from patients after a clinic visit can help inform ways to better deliver patient-centered care. A 2-word assessment may serve as a proxy for lengthy post-visit questionnaires. We tested the use of a 2-word assessment in an outpatient hand clinic. METHODS: New patients were asked to provide a 2-word assessment of the following: (1) their physician; (2) their overall experience; and (3) recommendations for improvement and their likelihood to recommend (LTR) after their clinic visit. Sentiment analysis was used to categorize results into positive, neutral, or negative sentiment. Recommendations for improvement were classified into physician issue, system issue, or neither. We evaluated the relationship between LTR status, sentiment, actionable improvement opportunities, and classification (physician issue, system issue, or neither). Recommendations for improvement were classified into themes based on prior literature. RESULTS: Sixty-seven (97.1%) patients noted positive sentiment toward their physician; 67 (97.1%) noted positive sentiment toward their overall experience. About 31% of improvement recommendations were system-based, 5.9% were physician-based, and 62.7% were neither. Patients not LTR were more likely to leave actionable opportunities for improvement than those LTR (P = .01). Recommendations for improvement were classified into predetermined themes relating to: (1) physician interaction; (2) check-in process; (3) facilities; (4) unnecessary visit; and (5) appointment delays. CONCLUSION: Patients not likely to recommend provided actionable opportunities for improvement using a simple 2-word assessment. Implementation of a 2-word assessment in a hand clinic can be used to obtain actionable, real-time patient feedback that can inform operational change and improve the patient experience.

A Qualitative Study of Patient Themes for the Quality of the Total Joint Arthroplasty Experience.

Patients have limited involvement in the development of quality measures that address the experience of undergoing total joint arthroplasty (TJA). Current quality measures may not fully assess the aspects of care that are important to patients. The goal of this study was to understand quality of care in TJA from the patient perspective by exploring patients' knowledge gaps, experiences, and goals. The authors completed a prospective qualitative analysis of patients who had undergone hip or knee TJA. Patients completed an open-ended, structured questionnaire about the surgical and recovery process as it relates to quality of care. The authors used a phenomenologic approach and purposeful sampling to enroll 74 patients 6 to 8 weeks after TJA. Responses underwent thematic analysis. Codes were used to identify themes that were important to patients in quality of care in TJA. The authors identified 3 themes: (1) returning to activity without pain or complication, which included psychological, functional, and complication-related goals; (2) negotiating the physical and psychological challenges of recovery, which encompassed the need for assistance from the caregiver as well as psychological and physical barriers to recovery; and (3) being prepared and informed for the process of surgery, including physical, logistical, and psychological preparation. Both patients and health systems may benefit from efforts to address these patient-centered themes of quality care through quality measures for TJA (eg, improving the psychological challenges of recovery). Future quality measures, such as assessment of patient experience, may be made more patient centered if they measure and improve aspects of care that matter to patients. [Orthopedics. 2021;44(2):117-122.].

Engaging Patients to Ask More Questions: What's the Best Way? A Pragmatic Randomized Controlled Trial.

PURPOSE: Hand conditions are common, and often require a discussion of the tradeoffs of different treatment options. Our goal was to evaluate whether providing patients with a Question Prompt List (QPL) for common hand conditions improves their perceived involvement in care compared with providing patients with 3 generic questions. METHODS: We performed a prospective, single-center, pragmatic randomized controlled trial. We created a QPL pamphlet for patients with common hand conditions. New patients with common hand conditions were enrolled between April 2019 and July 2019 and were randomized into either the QPL group (with 35 hand-specific questions) or the AskShareKnow group (3 generic questions: [1] What are my options? [2] What are the possible benefits and harms of those options? [3] How likely are each of these benefit and harms to happen to me?). Both groups received the questions prior to meeting with their surgeon. We used the Perceived Involvement in Care Scale (PICS), a validated instrument designed to evaluate patient participation in decision-making, as our primary outcome. The maximum PICS score is 13, and a higher score indicates higher perceived involvement. RESULTS: One hundred twenty-six patients participated in the study, with 63 patients in the QPL group and 63 patients in the AskShareKnow group. The demographic characteristics were similar in the 2 groups. The mean AskShareKnow group PICS score was 8.3 ± 2.2 and the mean QPL PICS score was 7.5 ± 2.8, which was not deemed clinically significant. CONCLUSIONS: The QPLs do not increase perceived involvement in care in patients with hand conditions compared with providing patients with 3 generic questions. CLINICAL RELEVANCE: Various approaches have been evaluated to help improve patient involvement in their care. In hand surgery, 3 generic questions were no different than a lengthy QPL with respect to patient involvement in their care.

Clinical Care Redesign to Improve Value for Trigger Finger Release: A Before-and-After Quality Improvement Study.

Background: Trigger finger release (TFR) is a commonly performed procedure. However, there is great variation in the setting, care pathway, anesthetic, and cost. We compared the institutional cost for isolated TFR before and after redesigning our clinical care pathway. Methods: Total direct cost to the health system (excluding the surgeon and anesthesiology costs) and time spent by the patient at the surgery center were collected for 1 hand surgeon's procedures at an ambulatory surgery center over a 3-year period. We implemented a redesigned pathway that altered phases of care and anesthetic use by transitioning from intravenous (IV) sedation to wide awake local anesthesia with no tourniquet. Cost data were reported as percentage change in the median and compared both pre- to post-implementation and with 2 control surgeons using the traditional pathway within the same center. Power analysis was based on prior work on a carpal tunnel pathway. Significance was defined by a P-value < .05. Results: Ten TFRs (90% local with IV sedation) and 44 TFRs (89% local alone) were performed pre- and post-implementation, respectively. From pre- to post-implementation, the study surgeon's total direct cost decreased by 18%, while the control surgeons decreased by 2%. Median time spent at the surgery center decreased by 41 minutes post-implementation with significantly shorter setup time in the operating room (OR), total time in the OR, and time spent in recovery prior to discharge. Conclusions: Redesigning the care pathway for TFR led to a decrease in institutional cost and patient time spent at the surgery center.

Patient Willingness to Pay for Faster Return to Work or Smaller Incisions.

Background: Value-based health care models such as bundled payments and accountable care organizations can penalize health systems and physicians for excess costs leading to low-value care. Health systems can minimize these extra costs by constraining diagnostic (eg, magnetic resonance imaging utilization) or treatment options with debatable necessity in the setting of clinical equipoise. Instead of restricting more expensive treatments, it is plausible that health systems could instead recoup the extra costs of these treatments by charging patients supplementary out-of-pocket charges (cost sharing). The primary aim of this exploratory study was to assess hand surgery patient willingness to pay supplementary out-of-pocket charges for a procedure that theoretically leads to an earlier return to work or smaller incisions when there are 2 procedures that lead to similar results (clinical equipoise). Methods: A total of 122 patients completed a questionnaire that included demographic information, a financial distress assessment, a series of scenarios asking patients the degree to which they are willing to pay extra for the procedure choice, as well as their perspective of how much insurers should be responsible for these additional costs. Results: Patients were willing to pay out-of-pocket to some degree for a procedure that leads to earlier return to work and smaller incision size when compared with a similar alternative procedure, but noted that insurers should bear a greater burden of costs. Approximately 10% of patients were willing to pay maximum amounts ($2500+) for earlier return to work (3, 7, and 14 days earlier) and smaller incision sizes of any length. Conclusions: Some patients may be willing to pay out-of-pocket and cost share for procedures that lead to earlier return to work and smaller incisions in the setting of clinical equipoise. As such, when developing and implementing alternative payment models, health systems could potentially offer services with debatable necessity in the setting of equipoise for a supplementary out-of-pocket charge.

Financial Distress Is Associated With Delay in Seeking Care for Hand Conditions.

Background: As medical costs continue to rise, financial distress due to these costs has led to poorer health outcomes and patient cost-coping behavior. Here, we test the null hypothesis that financial distress is not associated with delay of seeking care for hand conditions. Methods: Eighty-seven new patients presenting to the hand clinic for nontraumatic conditions completed our study. Patients completed validated instruments for measuring financial distress, pain catastrophizing, and pain. Questions regarding delay of care were included. The primary outcome was self-reported delay of the current hand clinic visit. Results: Patients who experience high financial distress differed significantly from those who experience low financial distress with respect to age, race, annual household income, and employment status. Those experiencing high financial distress were more likely to report having delayed their visit to the hand clinic (57% vs 30%), higher pain catastrophizing scores (17.7 vs 7.6), and higher average pain in the preceding week (4.5 vs 2.3). After adjusting for age, sex, and pain, high financial distress (adjusted odds ratio [OR] = 4.90) and pain catastrophizing score (adjusted OR = 0.96) were found to be independent predictors of delay. Financial distress was highly associated with annual household income in a multivariable linear regression model. Conclusions: Patients with nontraumatic hand conditions who experience higher financial distress are more likely to delay their visit to the hand clinic. Within health care systems, identification of patients with high financial distress and targeted interventions (eg, social or financial services) may help prevent unnecessary delays in care.

Does a Question Prompt List Improve Perceived Involvement in Care in Orthopaedic Surgery Compared with the AskShareKnow Questions? A Pragmatic Randomized Controlled Trial.

BACKGROUND: Most conditions in orthopaedic surgery are preference-sensitive, where treatment choices are based on the patient's values and preferences. One set of tools increasingly used to help align treatment choices with patient preferences are question prompt lists (QPLs), which are comprehensive lists of potential questions that patients can ask their physicians during their encounters. Whether or not a comprehensive orthopaedic-specific question prompt list would increase patient-perceived involvement in care more effectively than might three generic questions (the AskShareKnow questions) remains unknown; learning the answer would be useful, since a three-question list is easier to use compared with the much lengthier QPLs. QUESTION/PURPOSE: Does an orthopaedic-specific question prompt list increase patient-perceived involvement in care compared with the three generic AskShareKnow questions? METHODS: We performed a pragmatic randomized controlled trial of all new patients visiting a multispecialty orthopaedic clinic. A pragmatic design was used to mimic normal clinical care that compared two clinically acceptable interventions. New patients with common orthopaedic conditions were enrolled between August 2019 and November 2019 and were randomized to receive either the intervention QPL handout (orthopaedic-specific QPL with 45 total questions, developed with similar content and length to prior QPLs used in hand surgery, oncology, and palliative care) or a control handout (the AskShareKnow model questions, which are: "What are my options? What are the benefits and harms of those options? How likely are each of those benefits and harms to happen to me?") before their visits. A total of 156 patients were enrolled, with 78 in each group. There were no demographic differences between the study and control groups in terms of key variables. After the visit, patients completed the Perceived Involvement in Care Scale (PICS), a validated instrument designed to evaluate patient-perceived involvement in their care, which served as the primary outcome measure. This instrument is scored from 0 to 13, with higher scores indicating higher perceived involvement. RESULTS: There was no difference in mean PICS scores between the intervention and control groups (QPL 8.3 ± 2.3, control 8.5 ± 2.3, mean difference 0.2 [95% CI -0.53 to 0.93 ]; p = 0.71. CONCLUSION: In patients undergoing orthopaedic surgery, a QPL does not increase patient-perceived involvement in care compared with providing patients the three AskShareKnow questions. Implementation of the three AskShareKnow questions can be a more efficient way to improve patient-perceived involvement in their care compared with a lengthy QPL. LEVEL OF EVIDENCE: Level II, therapeutic study.

The Patient Perspective on Patient-Reported Outcome Measures Following Elective Hand Surgery: A Convergent Mixed-Methods Analysis.

PURPOSE: Patient-reported outcome measures (PROMs) have traditionally been used for research purposes, but are now being used to evaluate outcomes from the patient's perspective and inform ongoing management and quality of care. We used quantitative and qualitative approaches to evaluate the short-version Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and the Patient-Specific Functional Scale (PSFS) with regard to patient preference and measurement of patient goals and their responsiveness after treatment. METHODS: Patients 18 years or older undergoing elective hand surgery received the QuickDASH and PSFS questionnaires before and at 6 weeks after surgery. Two additional questions intended to elicit patients' preferences regarding the QuickDASH and PSFS were included. Responsiveness was measured by change in pre- to postoperative score. We analyzed patients' responses to the 2 additional questions to identify themes in PROM preferences. Results from the quantitative and qualitative analyses were combined into a convergent mixed-methods (eg, quantitative and qualitative) analysis. RESULTS: Thirty-eight patients completed preoperative questionnaires; 25 (66%) completed postoperative questionnaires. Seventeen patients (77%) preferred the PSFS, 3 (14%) had no preference, 2 (9%) preferred the QuickDASH. The average change from pre- to postoperative QuickDASH was -10 (SD, 20), and that of the PSFS was -27 (SD, 26). Ten patients (40%) reported QuickDASH score changes above the minimal clinically importance difference (MCID), 17 patients (68%) reported PSFS score changes above the MCID. Content analysis revealed 4 themes in preference for a PROM: instrument simplicity (ease of instrument understanding and completion), personalized assessment (individualization and relevance), goal directed (having measurable aims or objectives), distinct items (concrete or specific instrument items or functions). CONCLUSIONS: Most patients felt the PSFS better measured their goals because it is a simple, personalized instrument with distinct domains. CLINICAL RELEVANCE: Whereas standardized PROMs may better compare across populations, physicians, or conditions, employing PROMs that address patient-specific goals may better assess aspects of care most important to patients. A combination of these 2 types of PROMs can be used to assess outcomes and inform quality of care.

The Importance of Concordance Between Patients and Their Subspecialists.

Concordance, the concept of patients having shared demographic/socioeconomic characteristics with their physicians, has been associated with improved patient satisfaction and outcomes in primary care but has not been studied in subspecialty care. The objective of this study was to investigate whether patients value concordance with their specialty physicians. The authors assessed the importance of concordance in subspecialist care in 2 cohorts of participants. The first cohort consisted of patients seeking care at a multispecialty orthopedic clinic. The second cohort consisted of volunteer participants recruited from an online platform. Each participant completed a survey scored on an ordinal scale which characteristics of their physicians they find important for their primary care physician (PCP) and a specialist. The characteristics included age, sex, ethnicity, sexual orientation, primary language spoken, and religion. The difference in concordance scores for PCPs and specialists were compared with paired t tests with a Bonferroni correction. A total of 118 patients were recruited in clinic, and a total of 982 volunteers were recruited online. In the clinic cohort, the level of importance for patient-physician concordance of age, ethnicity, language, and religion was not significantly different between PCPs and specialists. In the volunteer cohort, the level of importance for concordance of age, sex, national origin, language, and religion was not significantly different between PCPs and specialists. The volunteers recruited online had significantly higher concordance scores than the patients recruited in clinic for most variables. Patients find patient-physician concordance as important in specialty care as they do in primary care. This may have similar effects on patient outcomes in specialty care. [Orthopedics. 2020;43(5):315-319.].

A Simple Goal Elicitation Tool Improves Shared Decision Making in Outpatient Orthopedic Surgery: A Randomized Controlled Trial.

Introduction. Shared decision making involves educating the patient, eliciting their goals, and collaborating on a decision for treatment. Goal elicitation is challenging for physicians as previous research has shown that patients do not bring up their goals on their own. Failure to properly elicit patient goals leads to increased patient misconceptions and decisional conflict. We performed a randomized controlled trial to test the efficacy of a simple goal elicitation tool in improving patient involvement in decision making. Methods. We conducted a randomized, single-blind study of new patients presenting to a single, outpatient surgical center. Prior to their consultation, the intervention group received a demographics questionnaire and a goal elicitation worksheet. The control group received a demographics questionnaire only. After the consultation, both groups were asked to complete the Perceived Involvement in Care Scale (PICS) survey. We compared the mean PICS scores for the intervention and control groups using a nonparametric Mann-Whitney Wilcoxon test. Secondary analysis included a qualitative content analysis of the patient goals. Results. Our final cohort consisted of 96 patients (46 intervention, 50 control). Both groups were similar in terms of demographic composition. The intervention group had a significantly higher mean (SD) PICS score compared to the control group (9.04 [2.15] v. 7.54 [2.27], P < 0.01). Thirty-nine percent of patient goals were focused on receiving a diagnosis or treatment, while 21% of patients wanted to receive education regarding their illness or their treatment options. Discussion. A single-step goal elicitation tool was effective in improving patient-perceived involvement in their care. This tool can be efficiently implemented in both academic and nonacademic settings.

Development and Testing of a Question Prompt List for Common Hand Conditions: An Exploratory Sequential Mixed-Methods Study.

PURPOSE: A question prompt list (QPL) is a tool that lists possible questions a patient may want to ask their surgeon. Its purpose is to improve patient-physician communication and increase patient engagement. Although QPLs have been developed in other specialties, one does not exist for hand conditions. We sought to develop a QPL for use in the hand surgery clinic using a mixed-methods design. METHODS: We drafted a QPL based on prior work outside of hand surgery and then used an exploratory sequential mixed-methods design (both qualitative and quantitative methods) to finalize the QPL. Qualitative evaluation included both a written questionnaire completed by a patient advisory board, hand therapists, and hand surgeons, as well as cognitive interviews conducted with clinic patients using the tool. Revisions to the QPL were made after each phase of qualitative analysis. The final QPL was then evaluated quantitatively using the system usability score (SUS) questionnaire to assess its usability. RESULTS: A patient advisory board consisting of 6 patients, 5 hand therapists, and 6 hand surgeons completed the written questionnaire. Thirteen patients completed a cognitive interview of the QPL. We completed a content analysis of the qualitative data and incorporated the findings into the QPL. Twenty patients then reviewed the final QPL pamphlet and completed the SUS questionnaire. The resulting SUS score of 78.8 indicated above-average usability of the QPL tool. CONCLUSIONS: The QPL developed in this study, from the perspective of multiple stakeholders, provides a usable tool to engage and prompt patients in asking questions during their visit with their hand surgeon with the potential to improve communication and patient-centered care. CLINICAL RELEVANCE: This study provides clinicians with a QPL developed for use in the hand surgery clinic setting, aimed at facilitating more thorough patient-provider discussion.

Maximization Personality, Disability and Symptoms of Psychosocial Disease in Hand Surgery Patients.

There are different frameworks to describe how people make decisions. One framework, maximization, is an approach where individuals approach choices with a goal of finding the 'best' possible alternative. We sought to determine the relationship between maximization and patient reported disability in patients with hand problems. We performed a cross-sectional study of 119 patients who presented to a hand surgery clinic. Patients completed a questionnaire that included sociodemographics, QuickDASH, Decisional Conflict Scale, Pain Catastrophizing Scale, Patient Health Questionnaire, Health Anxiety Inventory and General Self-Efficacy. Maximization did not correlate with subjective disability in patients with hand problems. Depression, pain catastrophizing and a diagnosis of upper extremity fracture had the greatest independent association with disability.In patients presenting for an initial hand surgery consultation, maximization was not associated with variation in patient reported disability or symptoms of psychosocial disease. Alternative factors influencing patient decision-making and outcomes should be explored. (Journal of Surgical Orthopaedic Advances 29(2):106-111, 2020).

Patient Preferences for Shared Decision Making: Not All Decisions Should Be Shared.

INTRODUCTION: To assess bounds of shared decision making in orthopaedic surgery, we conducted an exploratory study to examine the extent to which patients want to be involved in decision making in the management of a musculoskeletal condition. METHODS: One hundred fifteen patients at an orthopaedic surgery clinic were asked to rate preferred level of involvement in 25 common theoretical clinical decisions (passive [0], semipassive [1 to 4], equally shared involvement between patient and surgeon [5], semiactive [6 to 9], active [10]). RESULTS: Patients preferred semipassive roles in 92% of decisions assessed. Patients wanted to be most involved in scheduling surgical treatments (4.75 ± 2.65) and least involved in determining incision sizes (1.13 ± 1.98). No difference exists in desired decision-making responsibility between patients who had undergone orthopaedic surgery previously and those who had not. Younger and educated patients preferred more decision-making responsibility. Those with Medicare desired more passive roles. DISCUSSION: Despite the importance of shared decision making on delivering patient-centered care, our results suggest that patients do not prefer to share all decisions.

The Usability and Feasibility of Conjoint Analysis to Elicit Preferences for Distal Radius Fractures in Patients 55 Years and Older.

PURPOSE: Eliciting patient preferences is one part of the shared decision-making process-a process of decision making focused on the values and preferences of the patient. We evaluated the usability and feasibility of a point-of-care conjoint analysis tool for preference elicitation for shared decision making in the treatment of distal radius fractures in patients over the age of 55 years. METHODS: Twenty-seven patients 55 years of age or older with a displaced distal radius fracture were recruited from a hand and upper extremity clinic. A conjoint analysis tool was created describing the attributes of care (eg, return of grip strength) of surgical and nonsurgical treatment. This tool was administered to patients to determine their preferences for the treatment attributes when choosing between surgical and nonsurgical treatment. Patients completed a System Usability Scale (SUS) to evaluate usability, and time to complete the tool was measured to evaluate feasibility. RESULTS: Patients considered the conjoint analysis tool to be usable (SUS, 91.4; SD, 10.9). Mean time to complete the tool was 5.1 minutes (SD, 1.4 minutes). The most important attributes driving the decision for surgical treatment were return of grip strength at 1 year and time spent in a cast or brace. The most important attributes driving the decision for nonsurgical treatment were use of anesthesia during treatment and return of grip strength at 1 year. CONCLUSIONS: A point-of-care conjoint analysis tool for distal radius fractures in patients 55 years and older can be used to elicit patient preferences to inform the shared decision-making process. Further investigation evaluating the effect of preference elicitation on treatment choice, involvement in decision making, and patient-reported outcomes are needed. CLINICAL RELEVANCE: A conjoint analysis tool is a simple, structured process physicians can use during shared decision making to highlight trade-offs between treatment options and elicit patient preferences to inform treatment choices.

National Trends in the Diagnosis of CRPS after Open and Endoscopic Carpal Tunnel Release.

Background Complex regional pain syndrome (CRPS) occurs in 2 to 8% of patients that receive open or endoscopic carpal tunnel release (CTR). Because CRPS is difficult to treat after onset, identifying risk factors can inform prevention. We determined the incidence of CRPS following open and endoscopic CTR using a national claims database. We also examined whether psychosocial conditions were associated with CRPS after CTR. Methods We accessed insurance claims using diagnostic and procedural codes. We calculated the incidence of CRPS following open carpal tunnel release and endoscopic carpal tunnel release within 1 year. The response variable was the presence of CRPS after CTR. Explanatory variables included procedure type, age, gender, and preoperative diagnosis of anxiety or depression. Results The number of open CTRs (85% of total) outweighs the number of endoscopic procedures. In younger patients, the percentage of endoscopic CTRs is increasing. Rates of CRPS are nearly identical between surgery types for both privately insured (0.3%) and Medicare patients (0.1%). Middle aged (range: 40-64 years) and female patients had significantly higher rates of CRPS than did the general population. Preoperative psychosocial conditions did not correlate with the presence of CRPS in surgical patients. Clinical Relevance The decision between endoscopic and open CTR should not be made out of concern for development of CRPS postsurgery, as rates are low and similar for both procedures. Rates of CRPS found in this study are much lower than rates found in previous studies, indicating inconsistency in diagnosis and reporting or generalizability of prior work. Preoperative psychosocial disorders and CRPS are unrelated.

Can the QuickDASH PROM be Altered by First Completing the Tasks on the Instrument?

BACKGROUND: Health systems and payers use patient-reported outcome measures (PROMs) to inform quality improvement and value-based payment models. Although it is known that psychosocial factors and priming influence PROMs, we sought to determine the effect of having patients complete functional tasks before completing the PROM questionnaire, which has not been extensively evaluated. QUESTIONS/PURPOSES: (1) Will QuickDASH scores change after patients complete the tasks on the questionnaire compared with baseline QuickDASH scores? (2) Will the change in QuickDASH score in an intervention (task completion) group be different than that of a control group? (3) Will a higher proportion of patients in the intervention group than those in the control group improve their QuickDASH scores by greater than a minimally clinically important difference (MCID) of 14 points? METHODS: During a 2-month period, 140 patients presented at our clinic with a hand or upper-extremity problem. We approached patients who spoke and read English and were 18 years old or older. One hundred thirty-two (94%) patients met the inclusion criteria and agreed to participate (mean ± SD age, 52 ± 17 years; 60 men [45%], 72 women [55%]; 112 in the intervention group [85%] and 20 in the control group [15%]). First, all patients who completed the QuickDASH PROM (at baseline) were recruited for participation. Intervention patients completed the functional tasks on the QuickDASH and completed a followup QuickDASH. Control patients were recruited and enrolled after the intervention group completed the study. Participants in the control group completed the QuickDASH at baseline and a followup QuickDASH 5 minutes after (the time required to complete the functional tasks). Paired and unpaired t-tests were used to evaluate the null hypotheses that (1) QuickDASH scores for the intervention group would not change after the tasks on the instrument were completed and (2) the change in QuickDASH score in the intervention group would not be different than that of the control group (p < 0.05). To evaluate the clinical importance of the change in score after tasks were completed, we recorded the number of patients with a change greater than an MCID of 14 points on the QuickDASH. Fisher's exact test was used to evaluate the difference between groups in those reaching an MCID of 14. RESULTS: In the intervention group, the QuickDASH score decreased after the intervention (39 ± 24 versus 25 ± 19; mean difference, -14 points [95% CI, 12 to 16]; p < 0.001). The change in QuickDASH scores was greater in the intervention group than that in the control group (-14 ± 11 versus -2 ± 9 [95% CI, -17 to -7]; p < 0.001). A larger proportion of patients in the intervention group than in the control group demonstrated an improvement in QuickDASH scores greater than the 14-point MCID ([43 of 112 [38%] versus two of 20 [10%]; odds ratio, 5.4 [95% CI, 1 to 24%]; p = 0.019). CONCLUSIONS: Reported disability can be reduced, thereby improving PROMs, if patients complete QuickDASH tasks before completing the questionnaire. Modifiable factors that influence PROM scores and the context in which scores are measured should be analyzed before PROMs are broadly implemented into reimbursement models and quality measures for orthopaedic surgery. Standardizing PROM administration can limit the influence of context, such as task completion, on outcome scores and should be used in value-based payment models. LEVEL OF EVIDENCE: Level II, therapeutic study.