Estimating generalized propensity scores with survey and attrition weighted data.

Prior work in causal inference has shown that using survey sampling weights in the propensity score estimation stage and the outcome model stage for binary treatments can result in a more robust estimator of the effect of the binary treatment being analyzed. However, to date, extending this work to continuous treatments and exposures has not been explored nor has consideration been given for how to handle attrition weights in the propensity score model. Nonetheless, generalized propensity score (GPS) analyses are being used for estimating continuous treatment effects on outcomes when researchers have observational data, and those data sets often have survey or attrition weights that need to be accounted for in the analysis. Here, we extend prior work and show with analytic results that using survey sampling or attrition weights in the GPS estimation stage and the outcome model stage for continuous treatments can result in a more robust estimator than one that does not. Simulation study results show that, although using weights in both estimation stages is sufficient for robust estimation, it is not necessary and unbiased estimation is possible in some cases under various approaches to using weights in estimation. Analysts do not know if the conditions of our simulation studies hold, so use of weights in both estimation stages might provide insurance for reducing potential bias. We discuss the implications of our results in the context of an empirical example.

Joint Imputation of General Data.

High-dimensional complex survey data of general structures (e.g., containing continuous, binary, categorical, and ordinal variables), such as the US Department of Defense's Health-Related Behaviors Survey (HRBS), often confound procedures designed to impute any missing survey data. Imputation by fully conditional specification (FCS) is often considered the state of the art for such datasets due to its generality and flexibility. However, FCS procedures contain a theoretical flaw that is exposed by HRBS data-HRBS imputations created with FCS are shown to diverge across iterations of Markov Chain Monte Carlo. Imputation by joint modeling lacks this flaw; however, current joint modeling procedures are neither general nor flexible enough to handle HRBS data. As such, we introduce an algorithm that efficiently and flexibly applies multiple imputation by joint modeling in data of general structures. This procedure draws imputations from a latent joint multivariate normal model that underpins the generally structured data and models the latent data via a sequence of conditional linear models, the predictors of which can be specified by the user. We perform rigorous evaluations of HRBS imputations created with the new algorithm and show that they are convergent and of high quality. Lastly, simulations verify that the proposed method performs well compared to existing algorithms including FCS.

Role of light walking pace on cognition: Findings from the Maine-Syracuse Longitudinal Study.

Moderate- to vigorous intensities of physical activity are recommended for health promotion, including brain health. Regular physical activity is considered a modifiable factor to delay -perhaps prevent- onset of dementias such as Alzheimer's disease. Little is known about the benefits of light physical activity. We analyzed data from a 998 community-dwelling, cognitively unimpaired participants from the Maine-Syracuse Longitudinal Study (MSLS) and investigated the role of light physical activity, defined by walking pace, across two time points. Results revealed light levels of walking pace were associated with higher performance at the first timepoint and less decline by time 2 in the domains of verbal abstract reasoning and visual scanning and tracking, which includes both processing speed and executive function skills. When examining change over time (N = 583), increasing walking pace was associated with less decline at time two for the domains of visual scanning and tracking, working memory, visual spatial ability, and working memory, but not verbal abstract reasoning. These findings highlight the relevance of light physical activity and the need to investigate its contribution to cognitive function. From a public health perspective, this may encourage more adults to adopt a light level of exercise and still reap health benefits.

Determining optimal combination regimens for patients with multiple myeloma.

While many novel therapies have been approved in recent years for treating patients with multiple myeloma, there is still no established curative regimen, especially for patients with high-risk disease. In this work, we use a mathematical modeling approach to determine combination therapy regimens that maximize healthy lifespan for patients with multiple myeloma. We start with a mathematical model for the underlying disease and immune dynamics, which was presented and analyzed previously. We add the effects of three therapies to the model: pomalidomide, dexamethasone, and elotuzumab. We consider multiple approaches to optimizing combinations of these therapies. We find that optimal control combined with approximation outperforms other methods, in that it can quickly produce a combination regimen that is clinically-feasible and near-optimal. Implications of this work can be used to optimize doses and advance the scheduling of drugs.

The efficacy of combination treatment with elotuzumab and lenalidomide is dependent on crosstalk between natural killer cells, monocytes and myeloma cells.

Patients with refractory relapsed multiple myeloma respond to combination treatment with elotuzumab and lenalidomide. The mechanisms underlying this observation are not fully understood. Furthermore, biomarkers predictive of response have not been identified to date. To address these issues, we used a humanized myeloma mouse model and adoptive transfer of human natural killer (NK) cells to show that elotuzumab and lenalidomide treatment controlled myeloma growth, and this was mediated through CD16 on NK cells. In co-culture studies, we showed that peripheral blood mononuclear cells from a subset of patients with refractory relapsed multiple myeloma were effective killers of OPM2 myeloma cells when treated with elotuzumab and lenalidomide, and this was associated with significantly increased expression of CD54 on OPM2 cells. Furthermore, elotuzumab- and lenalidomide-induced OPM2 cell killing and increased OPM2 CD54 expression were dependent on both monocytes and NK cells, and these effects were not mediated by soluble factors alone. At the transcript level, elotuzumab and lenalidomide treatment significantly increased OPM2 myeloma cell expression of genes for trafficking and adhesion molecules, NK cell activation ligands and antigen presentation molecules. In conclusion, our findings suggest that multiple myeloma patients require elotuzumab- and lenalidomide-mediated upregulation of CD54 on autologous myeloma cells, in combination with NK cells and monocytes to mediate an effective anti-tumor response. Furthermore, our data suggest that increased myeloma cell CD54 expression levels could be a powerful predictive biomarker for response to elotuzumab and lenalidomide treatment.

The quality of occupational healthcare for carpal tunnel syndrome, healthcare expenditures, and disability outcomes: A prospective observational study.

INTRODUCTION/AIMS: In prior work, higher quality care for work-associated carpal tunnel syndrome (CTS) was associated with improved symptoms, functional status, and overall health. We sought to examine whether quality of care is associated with healthcare expenditures or disability. METHODS: Among 343 adults with workers' compensation claims for CTS, we created patient-level aggregate quality scores for underuse (not receiving highly beneficial care) and overuse (receiving care for which risks exceed benefits). We assessed whether each aggregate quality score (0%-100%, 100% = better care) was associated with healthcare expenditures (18-mo expenditures, any anticipated need for future expenditures) or disability (days on temporary disability, permanent impairment rating at 18 mo). RESULTS: Mean aggregate quality scores were 77.8% (standard deviation [SD] 16.5%) for underuse and 89.2% (SD 11.0%) for overuse. An underuse score of 100% was associated with higher risk-adjusted 18-mo expenditures ($3672; 95% confidence interval [CI] $324 to $7021) but not with future expenditures (-0.07 percentage points; 95% CI -0.48 to 0.34), relative to a score of 0%. An overuse score of 100% was associated with lower 18-mo expenditures (-$4549, 95% CI -$8792 to -$306) and a modestly lower likelihood of future expenditures (-0.62 percentage points, 95% CI -1.23 to -0.02). Quality of care was not associated with disability. DISCUSSION: Improving quality of care could increase or lower short-term healthcare expenditures, depending on how often care is currently underused or overused. Future research is needed on quality of care in varied workers' compensation contexts, as well as effective and economical strategies for improving quality.

Actions to improve quality: results from a national hospital survey.

OBJECTIVES: CMS measures and reports hospital performance to drive quality improvement (QI), but information on actions that hospitals have taken in response to quality measurement is lacking. We aimed to develop national estimates of QI actions undertaken by hospitals and to explore their relationship to performance on CMS quality measures. STUDY DESIGN: Nationally representative cross-sectional survey of acute care hospitals in 2016 (n = 1313 respondents; 64% response rate). METHODS: We assessed 23 possible QI changes. Using multivariate linear regression, we estimated the relationship between reported QI changes and performance on composite measures derived from 26 Hospital Inpatient Quality Reporting Program measures (scaled 0-100), controlling for case mix and facility characteristics. RESULTS: Hospitals reported implementing a mean of 17 QI changes (median [interquartile range], 17 [15-20]). Large hospitals reported significantly higher adoption rates than small hospitals for 18 QI changes. Most hospitals that reported making QI changes (63%-96% for the 23 changes) responded that the specific change made helped improve performance. In multivariate regression analyses, adoption of 92% of QI changes (90th percentile among hospitals), compared with adoption of 50% of QI changes (10th percentile), was associated with a 2.3-point higher overall performance score (95% CI, 0.7-4.0) and higher process (8.7 points; 95% CI, 5.7-11.7) and patient experience (3.0 points; 95% CI, 0.1-5.9) composite scores. CONCLUSIONS: Hospitals reported widespread adoption of QI changes in response to CMS quality measurement and reporting. Higher QI adoption rates were associated with modestly higher process, patient experience, and overall performance composite scores.

Adapting the Delivery of Functional Family Therapy Around the World During a Global Pandemic.

This paper describes accommodations that were implemented to support the global delivery of Functional Family Therapy (FFT) in community-based settings during COVID-19. FFT is an evidence-based family therapy that has been used with youth and families in juvenile justice, child welfare, mental health, and school settings. FFT LLC, an organization that disseminates FFT into community settings, currently supports over 350 community-based agencies that deliver FFT globally. Using the implementation framework articulated by Fixsen et al. (Implementation research: a synthesis of the literature, University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network, 2005), this paper describes key sets of implementation drivers (i.e., competency, organizational, and leadership) that facilitated the accommodations made to meet the challenge of maintaining fidelity to FFT as training and clinical services were transitioned to online platforms. To evaluate if accommodations were associated with fidelity and outcomes, descriptive information about treatment delivery and basic outcomes (e.g., therapist fidelity to model, youth behavioral outcomes) from March 15, 2020, to September 1, 2020 were compared to the same period from 2019. During 2020, FFT LLC supported therapists who served over 11,000 families and conducted over 35,000 tele-sessions with families. Overall, results showed similar completion rates (79% vs. 75%), therapist fidelity (3.77 vs. 3.94), and therapist-reported outcomes in 2019 and 2020 (respectively), suggesting that delivering the FFT model can be implemented with fidelity using teletherapy formats.

Pulmonary artery aneurysm associated with a nonstenotic bicuspid pulmonic valve: A role for genetics?

BACKGROUND: Bicuspid pulmonic valves are quite uncommon, being described in only 0.1% of donor's hearts, while pulmonary artery aneurysms (PAAs) are even rarer, having been found in 8 out of 109,571 autopsies. This rarity makes it difficult to characterize the relationship between them. MATERIALS AND METHODS: We describe the case of a 66-year-old female who was found to have a bicuspid pulmonic valve and PAA (5.1 cm) on imaging by her cardiologist. DISCUSSION AND CONCLUSION: This case raises the question of whether the association between bicuspid semilunar valve disease and vascular wall anomalies is more genetic or hemodynamic. Even on the aortic side, despite the robust association between bicuspid aortic valves and thoracic aortic aneurysms, the mechanism still remains unclear. In our patient there was no significant gradient across the bicuspid pulmonic valve, suggesting that hemodynamics are not the primum mobile of this association.

Nonparametric Estimation of Population Average Dose-Response Curves using Entropy Balancing Weights for Continuous Exposures.

Weighted estimators are commonly used for estimating exposure effects in observational settings to establish causal relations. These estimators have a long history of development when the exposure of interest is binary and where the weights are typically functions of an estimated propensity score. Recent developments in optimization-based estimators for constructing weights in binary exposure settings, such as those based on entropy balancing, have shown more promise in estimating treatment effects than those methods that focus on the direct estimation of the propensity score using likelihood-based methods. This paper explores recent developments of entropy balancing methods to continuous exposure settings and the estimation of population dose-response curves using nonparametric estimation combined with entropy balancing weights, focusing on factors that would be important to applied researchers in medical or health services research. The methods developed here are applied to data from a study assessing the effect of non-randomized components of an evidence-based substance use treatment program on emotional and substance use clinical outcomes.

Stentectomy for LAD "full metal jacket" with in-stent restenosis: How to do it.

We report our technique for the surgical revascularization of symptomatic severe in-stent restenosis of a "full metal jacket" (≥60 mm overlapping stents) of the left anterior descending coronary artery without suitable distal targets: on-pump cardioplegic-arrest stent removal (stentectomy) with endarterectomy and skeletonized left internal mammary artery onlay patch reconstruction. We also describe our follow-up protocol, including antiplatelet/anticoagulation and angiography. With proper patient selection, multidisciplinary collaboration, and surgical expertise, this advanced coronary procedure can be beneficial to a growing population of patients otherwise deemed to be untreatable.

Home health agency adoption of quality improvement activities and association with performance.

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) Home Health Quality Reporting Program (HHQRP) uses performance measurement to spur improvements in home health agencies' (HHAs') quality of care. We examined quality improvement (QI) activities HHAs reported making to improve on HHQRP quality measures, and whether reported QI activities were associated with better measure performance. METHODS: We used responses (N = 1052) from a Web- and mail-based survey of a stratified random sample of HHAs included in CMS Home Health Compare in October 2019. We estimated national adoption rates for 27 possible QI activities related to organizational culture, health information technology, care process redesign, provider incentives, provider training, changes to staffing responsibilities, performance monitoring, and measure-specific QI initiatives and technical assistance. We used multivariate linear regression to examine the associations between HHA characteristics and QI adoption, and between QI adoption and CMS Home Health Quality of Patient Care Star Rating. RESULTS: HHAs reported implementing an average of 16 QI activities (interquartile range 11-19 activities). Larger HHA size was associated with adopting 1.6 additional QI activities (p < 0.001). HHAs with higher proportions of disabled, black, or Hispanic patients adopted QI activities at similar or higher rates as other HHAs. Of the 27 QI activities, 23 were considered helpful by more than 80% of adopting HHAs. Compared with adopting 44% of QI activities (10th percentile among HHAs), adopting 89% of QI activities (90th percentile) was associated with a 0.4-star higher Star Rating (95% confidence interval 0.2-0.6). CONCLUSIONS: HHAs report implementing a significant number of QI activities in response to CMS measurement programs; implementation of a greater number of activities is associated with better performance on publicly reported measures. To guide future HHA QI investments, work is needed to identify the optimal combination of QI activities and the specific QI activities that yield the greatest performance improvements.

Optimizing Graft Extraction From the Femoral Condyle for Fresh Osteochondral Allograft Transplantation in Treating Osteochondritis Dissecans of the Capitellum: Best Fit Based on Radius of Curvature.

BACKGROUND: Osteochondritis dissecans (OCD) of the capitellum is a common cause of pain and dysfunction in adolescents that engage in repetitive elbow loading. For large, unstable lesions fresh osteochondral allograft transplantation (FOCAT) from the femoral condyle has been described as an effective treatment. Current practice involves significant guesswork in obtaining an appropriately sized graft, with anatomic variations resulting in poor graft fit. No studies currently exist that analyze and identify the best distal femur FOCAT graft site to repair OCD lesions of the capitellum based on the radius of curvature (ROC) and simulated matching. METHODS: Computed tomography scans of the elbow were used to estimate the subchondral bone ROC of capitella in adolescents aged 11 to 21 years. The capitellar location used corresponds to the most commonly reported site of OCD lesions in the elbow. Computed tomography scans of the lower extremity were used to estimate the subchondral bone ROC of 4 potential donor femoral condyle grafts. ROC from distinct regions at the posterior section of both the medial and lateral femoral condyles were measured: 2 areas representing 10 mm grafts from the center (MC1 and LC1), and 2 areas estimating 10 mm grafts posterior and adjacent to the physeal scar (MC2 and LC2). Intraobserver and interobserver reliability measurements were preformed to corroborate precision and validate the method. RESULTS: The mean ROC of healthy subchondral bone at the region of the capitellum were OCD lesions most commonly occur was 9.79±1.39 mm. The mean ROC of MC1 was 18.61±2.26 mm. The average ROC of the MC2 was 15.23±1.43 mm. The average ROC of LC1 was 16.47±1.34 mm. The average ROC of LC2 was 18.19±3.09 mm. After 15,000 simulated condyle-to-capitellar site matchings based on these measurements, a good fit graft was achieved at a frequency of 15%. DISCUSSION: No site measured from the femoral condyle demonstrated a subchondral ROC that exactly matched the subchondral ROC of the capitellum at the center location where OCD lesions most commonly occur; of the locations measured, a 10 mm section from MC2 demonstrated the closest match. On the basis of this analysis, extracting a graft from MC2 has the potential to further optimize FOCAT fit to the capitellum. LEVEL OF EVIDENCE: Level III.

Alterations of NK Cell Phenotype in the Disease Course of Multiple Myeloma.

Accumulating evidence demonstrates important roles for natural killer (NK) cells in controlling multiple myeloma (MM). A prospective flow cytometry-based analysis of NK cells in the blood and bone marrow (BM) of MM patient subgroups was performed (smoldering (SMM), newly diagnosed (ND), relapsed/refractory, (RR) and post-stem cell transplantation (pSCT)). Assessments included the biomarker expression and function of NK cells, correlations between the expression of receptors on NK cells with their ligands on myeloma cells, and comparisons between MM patient subgroups and healthy controls. The most striking differences from healthy controls were found in RR and pSCT patients, in which NK cells were less mature and expressed reduced levels of the activating receptors DNAM-1, NKG2D, and CD16. These differences were more pronounced in the BM than in blood, including upregulation of the therapeutic targets TIM3, TIGIT, ICOS, and GITR. Their expression suggests NK cells became exhausted upon chronic encounters with the tumor. A high expression of SLAMF7 on blood NK cells correlated with shorter progression-free survival. This correlation was particularly evident in ND patients, including on mature CD56dim NK cells in the BM. Thus, our NK cell analysis identified possible therapeutic targets in MM and a biomarker with prognostic potential for disease progression.

Assessment of the impact of implementation of a zero blood alcohol concentration law in Uruguay on moderate/severe injury and fatal crashes: a quasi-experimental study.

BACKGROUND AND AIMS: Debates regarding lowering the blood alcohol concentration (BAC) limit for drivers are intensifying in the United States and other countries, and the World Health Organization recommends that the limit for adults should be 0.05%. In January 2016, Uruguay implemented a law setting a zero BAC limit for all drivers. This study aimed to assess the effect of this policy on the frequency of moderate/severe injury and fatal traffic crashes. DESIGN: A quasi-experimental study in which a synthetic control model was used with controls consisting of local areas in Chile as the counterfactual for outcomes in Uruguay, matched across population counts and pre-intervention period outcomes. Sensitivity analyses were also conducted. SETTING: Uruguay and Chile. CASES: Panel data with crash counts by outcome per locality-month (2013-2017). INTERVENTION AND COMPARATOR: A zero blood alcohol concentration law implemented on 9 January 2016 in Uruguay, alongside a continued 0.03 g/dl BAC threshold in Chile. MEASUREMENTS: Per-capita moderate/severe injury (i.e. moderate or severe), severe injury and fatal crashes (2013-2017). FINDINGS: Our base synthetic control model results suggested a reduction in fatal crashes at 12 months [20.9%; P-value = 0.018, 95% confidence interval (CI) = -0.340, -0.061]. Moderate/severe injury crashes did not decrease significantly (10.2%, P = 0.312, 95% CI = -0.282, 0.075). The estimated effect at 24 months was smaller and with larger confidence intervals for fatal crashes (14%; P = 0.048, 95% CI = -0.246, -0.026) and largely unchanged for moderate/severe injury crashes (-9.4%, P = 0.302, 95% CI = -0.248, 0.058). Difference-in-differences analyses yielded similar results. As a sensitivity test, a synthetic control model relying on an inferior treatment-control match pre-intervention (measured by mean squared error) yielded similar-sized differences that were not statistically significant. CONCLUSIONS: Implementation of a law setting a zero blood alcohol concentration threshold for all drivers in Uruguay appears to have resulted in a reduction in fatal crashes during the following 12 and 24 months.

Therapist Strategies for Managing Midtreatment Problems in Evidence-based Interventions in Community Settings.

The National Institute of Health has made it a priority to identify, develop, and refine strategies to disseminate and implement effective interventions (National Institute of Health, 2015). This study examined qualitative reports of the strategies therapists used to manage common implementation problems they encountered during midtreatment in Multisystemic Therapy® (MST) and Functional Family Therapy (FFT), two widely disseminated evidence- and family-based treatments for substance abusing and delinquent adolescents. Experienced therapists from dissemination sites across the U.S. described cases in which they encountered midtreatment problems they perceived as serious threats to treatment success. They indicated why each case terminated and rated the outcome of the case. Qualitative analyses examined 16 treatment failures and then 16 treatment successes to identify contextual obstacles that accompanied the problems therapists identified, along with strategies they reported using with families that ultimately succeeded or failed. Therapists reported that midtreatment problems were often embedded in additional related difficulties and that they employed multiple relationship techniques and process-focused strategies to try to resolve these problems. For the most part, therapists described obstacles and strategies for successful and unsuccessful families in similar ways. Patterns of themes and subthemes suggested, however, that therapists in successful cases may be more likely to report "on-script" strategies and therapists in unsuccessful cases may describe more "off-script" strategies as well as more generic relationship building and advice-giving strategies.

Los Institutos Nacionales de Salud (NIH, por sus siglas en inglés) han priorizado la detección, el desarrollo y la perfección de estrategias para difundir e implementar intervenciones eficaces (National Institute of Health, 2015). Este estudio analizó los informes cualitativos de las estrategias que usaron los terapeutas para manejar los problemas comunes de implementación que encontraron durante la mitad del tratamiento en la terapia multisistémica (Multisystemic Therapy® , MST) y en la terapia familiar funcional (Functional Family Therapy, FFT), dos tratamientos factuales y basados en la familia ampliamente difundidos para adolescentes con problemas de delincuencia y de abuso de sustancias. Un grupo de terapeutas experimentados de centros de difusión de todo Estados Unidos describió casos en los cuales encontraron problemas en la mitad del tratamiento que ellos percibieron como amenazas graves para el éxito del tratamiento. Estos terapeutas indicaron por qué cada caso terminó y calificaron el resultado del caso. Los análisis cualitativos analizaron 16 fallas del tratamiento y luego 16 aciertos del tratamiento para detectar obstáculos contextuales que acompañaban a los problemas mencionados por los terapeutas, junto con estrategias que informaron haber usado con familias y que finalmente fueron satisfactorias o fallaron. Los terapeutas informaron que los problemas en la mitad del tratamiento generalmente formaban parte de otras dificultades relacionadas y que ellos emplearon varias técnicas relacionales y estrategias centradas en los procesos para intentar resolver estos problemas. En su mayoría, los terapeutas describieron los obstáculos y las estrategias utilizadas con las familias favorables y con las desfavorables de maneras similares. Sin embargo, los patrones de temas y subtemas indicaron que los terapeutas de los casos favorables pueden ser más propensos a informar estrategias "dentro del libreto" y que los terapeutas de los casos desfavorables pueden describir más estrategias "fuera del libreto", así como estrategias más genéricas de construcción de relaciones y de asesoramiento.

Nursing Home Responses to Performance-based Accountability: Results of a National Survey.

OBJECTIVES: The Centers for Medicare & Medicaid Services (CMS) Nursing Home Quality Initiative aims to improve quality through performance measurement. We describe quality improvement (QI) changes that skilled nursing facilities (SNFs) reported making in response to CMS performance measurements and whether reported QI changes were associated with better performance on CMS performance measures. DESIGN: Nationally representative survey. SETTING: A total of 15,475 SNFs that reported quality performance on Nursing Home Compare in 2016. PARTICIPANTS: A total of 1,182 SNFs (58% of random sample of 2,045 SNFs). MEASUREMENTS: Adoption of 22 possible QI changes, grouped into seven categories (organizational culture, health information technology, care process redesign, provider incentives, changes to staffing responsibilities, performance monitoring, and measure-specific QI initiatives and technical assistance); performance on the CMS Nursing Home Compare Five-Star Quality Rating System's quality measure rating. RESULTS: SNFs reported making an average of 13 QI changes (interquartile range = 11-16 changes). SNFs mostly commonly reported becoming a learning organization (87%) and providing training to staff on QI strategies (87%). After controlling for patient and facility characteristics, larger SNFs were more likely to obtain assistance on measure reporting from QI organizations and use provider champions than smaller SNFs by 14 and 11 percentage points, respectively. Rural SNFs and SNFs with higher proportions of disabled, black, or Hispanic residents adopted QI changes at similar rates as other SNFs. Of the 22 QI changes, 20 were considered at least somewhat helpful by more than 80% of adopting SNFs. Implementation of all 22 QI changes (vs no changes) was associated with a .48-star higher quality measure rating (95% confidence interval = .003-.98 stars; P = .05). CONCLUSION: In response to CMS measurement programs, SNFs reported making substantial QI investments that were associated with better performance on CMS quality measures. To guide future SNF investments in QI, work is needed to identify the QI changes that yield the greatest performance improvements.

The quality of electrodiagnostic tests for carpal tunnel syndrome: Implications for surgery, outcomes, and expenditures.

INTRODUCTION: The quality of electrodiagnostic tests may influence treatment decisions, particularly regarding surgery, affecting health outcomes and health-care expenditures. METHODS: We evaluated test quality among 338 adults with workers' compensation claims for carpal tunnel syndrome. Using simulations, we examined how it influences the appropriateness of surgery. Using regression, we evaluated associations with symptoms and functional limitations (Boston Carpal Tunnel Questionnaire), overall health (12-item Short Form Health Survey version 2), actual receipt of surgery, and expenditures. RESULTS: In simulations, suboptimal quality tests rendered surgery inappropriate for 99 of 309 patients (+32 percentage points). In regression analyses, patients with the highest quality tests had larger declines in symptoms (-0.50 point; 95% confidence interval [CI], -0.89 to -0.12) and functional impairment (-0.42 point; 95% CI, -0.78 to -0.06) than patients with the lowest quality tests. Test quality was not associated with overall health, actual receipt of surgery, or expenditures. DISCUSSION: Test quality is pivotal to determining surgical appropriateness and associated with meaningful differences in symptoms and function.