Erika Davis Sears

Validity and Responsiveness of the Jebsen–Taylor Hand Function Test

PURPOSE The aim of this study was to demonstrate the validity and responsiveness of the Jebsen-Taylor Hand Function Test (JTT) in measuring hand function in patients undergoing hand surgery, compared with the Michigan Hand Outcomes Questionnaire (MHQ). METHODS A prospective cohort of patients with rheumatoid arthritis (n = 37), osteoarthritis (n= 10), carpal tunnel syndrome (n = 18), and distal radius fracture (n = 46) were evaluated preoperatively and at 9 to 12 months of follow-up. We administered the JTT and MHQ. We performed correlation and receiver operating characteristic analyses to evaluate the validity of the JTT as a measure of disability. Effect size and standardized response means were calculated to determine responsiveness. RESULTS Correlation studies revealed poor correlation of the JTT with MHQ total scores and subsets that relate to hand function. Patients with high MHQ scores generally perform well on the JTT; however, patients with good JTT scores do not necessarily have high MHQ scores. Receiver operating characteristic curves for each condition showed that the change in JTT total score had poor ability to discriminate between high and low MHQ score subjects, with an area under the curve result of 0.52 to 0.66 for each condition. Effect size and standardized response means for all states showed greater responsiveness with the MHQ for each condition compared with the JTT. CONCLUSIONS We found poor correlation between the change in JTT and absolute JTT scores after surgery compared with change in MHQ and absolute MHQ scores. In addition, the JTT had poor discriminant validity based on the MHQ as a reference. This study showed that the time to complete activities does not correlate well with patient-reported outcomes. We conclude that the JTT should not be used as a measure of disability or clinical change after surgical intervention. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic III.

Traumatic brain injury may be an independent risk factor for stroke

Objective: To explore whether traumatic brain injury (TBI) may be a risk factor for subsequent ischemic stroke. Methods: Patients with any emergency department visit or hospitalization for TBI (exposed group) or non-TBI trauma (control) based on statewide emergency department and inpatient databases in California from 2005 to 2009 were included in a retrospective cohort. TBI was defined using the Centers for Disease Control definition. Our primary outcome was subsequent hospitalization for acute ischemic stroke. The association between TBI and stroke was estimated using Cox proportional hazards modeling adjusting for demographics, vascular risk factors, comorbidities, trauma severity, and trauma mechanism. Results: The cohort included a total of 1,173,353 trauma subjects, 436,630 (37%) with TBI. The patients with TBI were slightly younger than the controls (mean age 49.2 vs 50.3 years), less likely to be female (46.8% vs 49.3%), and had a higher mean injury severity score (4.6 vs 4.1). Subsequent stroke was identified in 1.1% of the TBI group and 0.9% of the control group over a median follow-up period of 28 months (interquartile range 14–44). After adjustment, TBI was independently associated with subsequent ischemic stroke (hazard ratio 1.31, 95% confidence interval 1.25–1.36). Conclusions: In this large cohort, TBI is associated with ischemic stroke, independent of other major predictors.

Patient expectations and patient-reported outcomes in surgery: A systematic review

BACKGROUND Recent events in health care reform have brought national attention to integrating patient experiences and expectations into quality metrics. Few studies have comprehensively evaluated the effect of patient expectations on patient-reported outcomes (PROs) after surgery. The purpose of this study is to systematically review the available literature describing the relationship between patient expectations and postoperative PROs. METHODS We performed a search of the literature published before November 1, 2012. Articles were included in the review if (1) primary data were presented, (2) patient expectations regarding a surgical procedure were measured, (3) PROs were measured, and (4) the relationship between patient expectations and PROs was specifically examined. PROs were categorized into 5 subgroups: Satisfaction, quality of life (QOL), disability, mood disorder, and pain. We examined each study to determine the relationship between patient expectations and PROs as well as study quality. RESULTS From the initial literature search yielding 1,708 studies, 60 articles were included. Fulfillment of expectations was associated with improved PROs among 24 studies. Positive expectations were correlated with improved PROs for 28 studies (47%), and poorer PROs for 9 studies (15%). Eighteen studies reported that fulfillment of expectations was correlated with improved patient satisfaction, and 10 studies identified that positive expectations were correlated with improved postoperative. Finally, patients with positive preoperative expectations reported less pain (8 studies) and disability (15 studies) compared with patients with negative preoperative expectations. CONCLUSION Patient expectations are inconsistently correlated with PROs after surgery, and there is no accepted method to capture perioperative expectations. Future efforts to rigorously measure expectations and explore their influence on postoperative outcomes can inform clinicians and policymakers seeking to integrate PROs into measures of surgical quality.

The Outcomes of Outcome Studies in Plastic Surgery : A Systematic Review of 17 Years of Plastic Surgery Research

Background: The authors assessed the state of outcomes studies in plastic surgery since the initiation of the modern outcomes movement in 1988 and propose future research directions. Methods: A systematic review of health outcomes research in plastic surgery was conducted. Studies were extracted from the journals Plastic and Reconstructive Surgery and Annals of Plastic Surgery from 1988 to 2004, yielding 3520 articles, 1670 of which did not meet the inclusion criteria; thus, 1850 articles were reviewed. Studies were analyzed with respect to topic of interest, category of outcome study, study design, endpoint of results, and level of impact on health outcomes, rated on a scale of 1 to 4 using a revised version of the Agency for Healthcare Research and Quality’s outcomes impact scale. A level 4 study demonstrates the greatest direct impact on patient outcomes. Results: Ninety percent of studies had a level 1 impact; 10 percent had a level 4 impact. Breast surgery was most represented, constituting 26 percent of studies. Morbidity and objective clinical outcomes were the most frequent endpoints, cited in 52 percent and 32 percent of studies, respectively. Economic analyses were the least frequently encountered outcome study category, represented in only 0.6 percent of studies. Conclusions: Most studies in this review had a level 1 impact, signifying that most outcomes studies in plastic surgery do not show a direct policy impact in patient outcomes. However, they are important in confirming the effectiveness of interventions already in clinical practice and raising new research questions. There is a need for more economic analysis research in plastic surgery outcomes studies.

Use of autologous and microsurgical breast reconstruction by U.S. plastic surgeons

Background: Concern exists that plastic surgeons are performing fewer autologous and microsurgical breast reconstructions, despite superior long-term outcomes. The authors describe the proportion of U.S. plastic surgeons performing these procedures and evaluate motivating factors and perceived barriers. Methods: A random national sample of American Society of Plastic Surgeons members was surveyed (n = 325; response rate, 76 percent). Surgeon and practice characteristics were assessed, and two multiple logistic regression models were created to evaluate factors associated with (1) high-volume autologous providers and (2) microsurgical providers. Qualitative assessments of motivating factors and barriers to microsurgery were also performed. Results: Fewer than one-fifth of plastic surgeons perform autologous procedures for more than 50 percent of their breast cancer patients, and only one-quarter perform any microsurgical breast reconstruction. Independent predictors of a high-volume autologous practice include involvement with resident education (odds ratio, 2.57; 95 percent CI, 1.26 to 5.24) and a microsurgical fellowship (odds ratio, 2.09; 95 percent CI, 1.04 to 4.27). Predictors of microsurgical breast reconstruction include involvement with resident education (odds ratio, 6.8; 95 percent CI, 3.32 to 13.91), microsurgical fellowship (odds ratio, 2.4; 95 percent CI, 1.16 to 4.95), and high breast reconstruction volume (odds ratio, 6.68; 95 percent CI, 1.76 to 25.27). The primary motivator for microsurgery is superior outcomes, and the primary deterrents are time and reimbursement. Conclusions: The proportion of U.S. plastic surgeons with a high-volume autologous or microsurgical breast reconstruction practice is low. Involvement with resident education appears to facilitate both, whereas time constraints and reimbursement are primary deterrents. Future efforts should focus on improving the feasibility and accessibility of all types of breast reconstruction.

The Use of Opioid Analgesics following Common Upper Extremity Surgical Procedures: A National, Population-Based Study.

Background: The misuse of opioid analgesics is a major public health concern, and guidelines regarding postoperative opioid use are sparse. The authors examined the use of opioids following outpatient upper extremity procedures to discern the variation by procedure type and patient factors. Methods: The authors studied opioid prescriptions among 296,452 adults older than 18 years who underwent carpal tunnel release, trigger finger release, cubital tunnel release, or thumb carpometacarpal arthroplasty from 2009 to 2013 using insurance claims drawn from the Truven Health MarketScan Commercial Claims and Encounters, which encompasses over 100 health plans in the United States. Using multivariable regression, the authors compared the receipt of opioids, number of days supplied, indicators of inappropriate prescriptions, and number of refills by patient factors. Results: In this cohort, 59 percent filled a postoperative prescription for opioid medication, and 8.8 percent of patients had an indicator of inappropriate prescribing. The probability of filling an opioid prescription declined linearly with advancing age. On multivariate analysis, patients who had previously received opioids were more likely to fill a postoperative opioid prescription (66 percent versus 59 percent), receive longer prescriptions (24 versus 5 days), receive refills following surgery (24 percent versus 5 percent), and have at least one indicator of potentially inappropriate prescribing (19 percent versus 6 percent). Conclusions: Current opioid users are more likely to require postoperative opioid analgesics for routine procedures and more likely to receive inappropriate prescriptions. More evidence is needed to identify patients who derive the greatest benefit from opioids to curb opioid prescriptions when alternative analgesics may be equally effective and available. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Economic Analysis of Revision Amputation and Replantation Treatment of Finger Amputation Injuries

Background: The purpose of this study was to perform a cost-utility analysis to compare revision amputation and replantation treatment of finger amputation injuries across a spectrum of injury scenarios. Methods: The study was conducted from the societal perspective. Decision tree models were created for the reference case (two-finger amputation injury) and seven additional injury scenarios for comparison. Inputs included cost, quality of life, and probability of each health state. A Web-based time trade-off survey was created to determine quality-adjusted life-years for health states; 685 nationally representative adult community members were invited to participate in the survey. Overall cost and quality-adjusted life-years for revision amputation and replantation were calculated for each decision tree. An incremental cost-effectiveness ratio was calculated if a treatment was more costly but more effective. Results: The authors had a 64 percent response rate (n = 437). Replantation treatment had greater costs and quality-adjusted life-years compared with revision amputation in all injury scenarios. Replantation of single-digit injuries had the highest incremental cost-effectiveness ratio (

Clinical factors associated with replantation after traumatic major upper extremity amputation.

136,400 per quality-adjusted life-year gained). Replantation of three- and four-digit amputation injuries had relatively low cost-to-benefit ratios (

Decision analysis in plastic surgery: a primer.

27,100 and

Relationship between timing of emergency procedures and limb amputation in patients with open tibia fracture in the United States, 2003 to 2009.

23,800 per quality-adjusted life-year, respectively). Replantation for distal thumb amputation had a relatively low incremental cost-effectiveness ratio (