Jacob S. Nasser

Diagnostic Testing Requested Before Surgical Evaluation for Carpal Tunnel Syndrome

PURPOSEnWe sought to evaluate how often physicians who perform carpal tunnel release in the state of Michigan routinely request electrodiagnostic studies (EDS) or other diagnostic tests prior to an initial consultation and whether provider or practice characteristics had an influence on requirements for preconsultation diagnostic tests.nnnMETHODSnThrough online data sources, we identified 356 providers in 261 practices throughout the state of Michigan with profiles confirming hand surgery practice or surgical treatment of carpal tunnel syndrome (CTS). We recorded American Society for Surgery of the Hand (ASSH) membership, teaching facility status, practice size, and primary specialty for each provider. Using a standardized telephone script, 219 providers were contacted by telephone to determine whether any diagnostic tests were needed before an appointment. Using multivariable logistic regression, we evaluated the relationship between the requirement for preconsultation testing and surgeon and practice characteristics.nnnRESULTSnAmong the 134 providers who were confirmed to perform carpal tunnel release, 57% (nxa0= 76) required and 9% (nxa0= 12) recommended a diagnostic test prior to the initial consultation. Of the 88 physicians who required/recommended testing, 85% (nxa0= 75) requested EDS, 22% (nxa0= 19) requested magnetic resonance imaging, 13% (nxa0= 11) requested a computed tomography scan, and 9% (nxa0= 8) requested an x-ray. Patients were asked to have multiple studies by 19 (22%) of the 88 surgeons who requested/recommended testing. In the multivariable analysis, ASSH membership, size of practice, and teaching facility status did not have a significant relationship with the requirement for preconsultation testing.nnnCONCLUSIONSnMost surgeons who treat CTS in the state of Michigan routinely request EDS before evaluation, rather than reserving the test for cases in which the diagnosis is unclear.nnnCLINICAL RELEVANCEnIn the quest for high-value care, providers must consider whether the benefit of diagnostic tests for CTS likely outweighs the costs, inconvenience, and potential for treatment delay.

The Desired Role of Health Care Providers in Guiding Older Patients With Distal Radius Fractures: A Qualitative Analysis

PURPOSEnUnderstanding patient preferences for shared decision making is valuable for surgeons to advance patient-centered care, particularly in cases where there is not a clearly superior treatment option, like distal radius fracture. The existing evidence presents conflicting views on the desired role of the provider among older patients when making medical decisions. We aimed to investigate the perceived versus desired role of the provider in older adult patients with distal radius fracture.nnnMETHODSnThirty patients (≥62 years old) who had sustained a distal radius fracture within the past 5 years were recruited from the screening process of the Wrist and Radius Injury Surgical Trial at the principal investigators site using purposive sampling. A trained member of the research team conducted interviews in a semistructured format with the help of an interview guide. Findings were derived following the principles of grounded theory.nnnRESULTSnParticipants experienced varied levels of shared decision making with the hand surgeon. Subjects perceived role of the surgeon did not always match their desired role. Most patients placed distinct trust in the recommendations of hand specialists regarding the technical aspects of the treatment. Nonetheless, respondents wanted to provide input when decisions pertained to outcomes or functionality. Many patients sought outside support from family or friends in the health care field, regardless of the outside sources medical specialty.nnnCONCLUSIONSnDespite conflicting evidence, most older adult patients desire a shared approach when making treatment decisions. Exchanging information and preferences on outcomes of each treatment option may be more important to the patient than detailing the specific technical aspects of their care.nnnCLINICAL RELEVANCEnTo provide high quality care, surgeons should evaluate the desired role of the patient to make treatment decisions at the start of their interaction. Surgeons must be aware of outside medical influences that guide their patients decision-making processes.

Understanding Patient Preferences in Proximal Interphalangeal Joint Surgery for Osteoarthritis: A Conjoint Analysis

PURPOSEnWe sought to compare preferences for arthroplasty versus arthrodesis among patients with proximal interphalangeal (PIP) joint osteoarthritis (OA) by quantifying the patient-assigned utility of each operations attributes.nnnMETHODSnWe undertook a multistep process to identify relevant surgical attributes, including a literature review, surgeon survey, and pretest patient pilot test to build a set of discrete choice experiments. Patients with PIP joint osteoarthritis were identified using a single university electronic medical record and were recruited via electronic message or postcard. Participants completed a demographic survey and 11 discrete choice experiments designed using Sawtooth Softwares Discover tool. Utility and importance scores were generated for each attribute.nnnRESULTSnPretest analysis identified out-of-pocket cost, joint stiffness, need for future surgery, change in grip strength, and total recovery time as the most important surgical attributes. Initial response rate to the conjoint survey was 75% and survey completion rate was 61%. The study sample was predominantly white (91%) and female (72%), mean age 64.3 years (range, 34-90 years), and mean daily pain score was 4.32 (range, 0-10). Attribute importance scores demonstrated that joint stiffness (32%) and grip strength (29%) were most important to patients. Cost (17%) and need for future surgery (19%) were intermediate patient-preference drivers. Recovery time was the least important attribute (2%).nnnCONCLUSIONSnIn aggregate, patients prefer surgical attributes characteristic of arthroplasty (ability to preserve joint motion and grip strength) relative to those associated with arthrodesis (decreased need for reoperation, lower costs, and shorter reoperation times).nnnTYPE OF STUDY/LEVEL OF EVIDENCEnEconomic/Decision Analysis III.

The golden year: How functional recovery sets the stage for tendon transfer surgery among patients with tetraplegia—a qualitative analysis

Background: Tendon transfer surgery can effectively improve hand function for patients with tetraplegia but remains poorly utilized. Little is known regarding how patients rehabilitation experiences influence their perception of function, identity, and coping to shape their reconstructive context. Methods: We performed a cross‐sectional qualitative analysis of 19 participants with C4–C7 cervical spinal injuries: 9 patients had undergone reconstruction; 10 had not. Semistructured interviews were conducted using an interview guide focusing on rehabilitation experience, the relationship between function and identity, and how patient experience evolved. Interview transcripts were analyzed using grounded theory. Results: The study sample was predominantly male (79%), white (89%), and American Spinal Injury Association grades A–D (grade A: 42%; grade B: 32%; grade C: 16%; grade D: 10%). Recognizing rehabilitations necessity, functional gains, and constructive patient–therapist relationships promoted engagement in therapy. Poor insurance coverage and financial constraints decreased rehabilitation access. Function affected identity through the degree to which it tied participants to a “patient” role. Early in recovery, patients function, roles, and attitudes were fluid but solidified over time; how satisfied patients were with these final positions influenced how they coped. Conclusion: The balance of patients positive and negative coping has been found to influence patients progression to surgery. This study describes how function and identity contribute to coping. Participants function and identity evolved during a finite period we call “the golden year,” before reaching a fixed point around which they built their lives. The norms patients establish during this time may affect receptiveness to surgery.

Abstract: A Critical Assessment of Surveys in Plastic and Reconstructive Surgery

RESULTS: 145 RCTs were identified, of which fiftyseven RCTs were registered (39%). Forty-nine RCTs were included in the final analysis. Forty-three of trials (88%) had a discrepancy between registered and published outcomes 23 trials (47%) for primary outcome(s), and 37 trials (76%) for secondary outcome(s). The prevalence of unreported registered outcomes was 13% (primary) and 38% (secondary). Registered primary outcomes were published as secondary outcomes in 30% of trials. Publishing new non-registered secondary outcomes (65%) and changing the assessment timing of published primary outcomes (61%) were the most common types of discrepancies. Discrepancies favored a statistically significant positive outcome in nineteen of the forty-three trials (44%) with an outcome discrepancy.