Jeroen K. J. Bossen

What are the Factors Influencing Outcome Among Patients Admitted to a Hospital With a Proximal Humeral Fracture

BackgroundFracture of the proximal humerus is common in older patients during the decline of their physical health.Questions/purposesOur purpose was to evaluate the association between specific risk factors in patients with fractures of the proximal humerus and any inpatient adverse events, mortality, and discharge to a short-term or long-term care facility.MethodsThe National Hospital Discharge Survey (NHDS) provided estimates of all adult patients who were admitted to hospitals after fractures of the proximal humerus in the United States between 1990 and 2007. The influences of sex, age, days of care, diagnosis and procedures (based on ICD-9 codes) on inpatient adverse events and death, and discharge to a short-term or long-term care facility, were studied in bivariate and multivariable analyses.ResultsAmong an estimated 867,282 patients admitted for proximal humerus fractures, 20% experienced adverse events, and 2.3% died in the hospital. Older age, concomitant femur and femoral neck fractures or head trauma, operative fracture care, congestive heart failure, and chronic alcoholism were associated with inpatient adverse events. Intubation, acute myocardial infarctions, malignancies, and skull fractures were associated with inpatient deaths. Older age, lower limb fractures, specific comorbidities (obesity, congestive heart failure, dementia), and inpatient adverse events (pneumonia, anemia treated with transfusion) were associated with discharges to short-term or long-term care facilities.ConclusionsKnowledge of risk factors for inpatient adverse events, mortality, and discharge to facilities can help make treatment decisions, improve overall care, discharge planning, and resource utilization for patients with proximal humeral fractures.Level of EvidenceLevel II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Informed Shared Decision-Making and Patient Satisfaction

BACKGROUND Evidence suggests that when patients have a role in medical decisions they are more satisfied with their health care. OBJECTIVE To assess predictors of patient satisfaction, ratings of the providers informed shared decision-making (ISDM), and disability among patients with orthopedic pain complaints. RESEARCH DESIGN A total of 130 patients with nontraumatic painful conditions of the upper extremity were enrolled. Medical encounters were audio recorded and coded by 2 independent coders. Eight ISDM elements and a total ISDM score were evaluated. Bivariate and multivariable analyses were used to answer the study questions. MEASURES Participants completed the Princess Margaret Hospital Patient Satisfaction with their Doctor Questionnaire to measure satisfaction; the Disabilities of Arm, Shoulder and Hand questionnaire; the Patient Health Questionnaire-9 to measure depression; the Whiteley Index to assess heightened illness concerns; and the pain catastrophizing scale to assess coping strategies in response to pain. RESULTS Less health anxiety, female gender, the ISDM element Identify choice, and any specific diagnosis determined 22% of the variation in satisfaction. Less health anxiety and unemployed unable to work compared with full-time working status were associated with a better rating of shared decision-making on the ISDM. Catastrophic thinking, female gender, symptoms of depression, and any specific diagnosis were associated with greater disability. Catastrophic thinking and symptoms of depression were the greatest contributors to the variation in disability. CONCLUSIONS Psychologic factors are the strongest determinants of patient satisfaction, ratings of shared decision-making on the ISDM, and upper-extremity disability. Health anxiety is the most important factor in ratings of patient satisfaction and ISDM, whereas depression and catastrophizing are salient predictors of disability. LEVEL OF EVIDENCE Prognostic level I.

Do Previsit Expectations Correlate With Satisfaction of New Patients Presenting for Evaluation With an Orthopaedic Surgical Practice

BackgroundPatient satisfaction is associated with increased compliance, improved treatment outcomes, and decreased risk of litigation. Factors such as patient understanding and psychological well-being are recognized influences on satisfaction. Less is known about the relationship between previsit expectations and satisfaction.Questions/purposes(1) Are there correlations among previsit expectations, met expectations, and patient satisfaction? (2) What are the categories of expectations, and which one(s) correlate with satisfaction?MethodsEighty-six new patients presenting to a hand surgery practice of a tertiary referral hospital with 70% direct primary care referrals, mostly with elective concerns, indicated their previsit expectations (Patient Intention Questionnaire [PIQ]). Immediately after the visit, the same patients rated the degree to which their previsit expectations were met (Expectation Met Questionnaire [EMQ]) and their satisfaction level (Medical Interview Satisfaction Scale). These tools have been used in primary care office settings and claim good psychometric properties, and although they have not been strictly validated for responsiveness and other test parameters, they have good face validity. We then conducted a multivariable backward linear regression to determine whether (1) scores on the PIQ; and (2) scores on the EMQ are associated with satisfaction.ResultsSatisfaction correlated with met expectations (r = 0.36; p < 0.001) but not with previsit expectations (r = −0.01, p = 0.94). We identified five primary categories of previsit expectations that accounted for 50% of the variance in PIQ: (1) “Information and Explanation”; (2) “Emotional and Understanding”; (3) “Emotional Problems”; (4) “Diagnostics”; and (5) “Comforting”. The only category of met expectations that correlated with satisfaction was Information and Explanation (r = 0.43; p < 0.001).ConclusionsAmong patients seeing a hand surgeon, met expectations correlate with satisfaction. In particular, patients with met expectations regarding information and explanation were more satisfied with their visit. Efforts to determine the most effective methods for conveying unexpected information warrant investigation.Level of EvidenceLevel II, prognostic study.

Determinants of Disability After Fingertip Injuries

BACKGROUND Psychological factors, such as depression, catastrophic thinking, and self-efficacy, account for more of the variation in upper extremity disability than motion and other impairments, but their influence in the setting of hand trauma is less well studied. OBJECTIVE The aim of this study was to determine which factors account for variation in disability 1 month after fingertip injuries. METHODS We enrolled 82 patients with finger injuries distal to the proximal interphalangeal joint, and 70 patients completed the study. Questionnaires and measurements were taken at the initial visit and approximately 1 month later. Patients completed the short version of the Disabilities of the Arm Shoulder and Hand questionnaire, the pain self-efficacy questionnaire, and the Patient Health Questionnaire to assess depressive symptoms. Bivariate and multivariable analyses determined factors associated with QuickDASH scores. RESULTS The mean disabilities of the arm shoulder and hand questionnaire score was 35 at the initial visit (the U.S. norm is 10) and 17 approximately 1 month later. The best model explained 54% of the variation in disabilities of the arm shoulder and hand questionnaire 1 month after injury and included symptoms of depression (Patient Health Questionnaire; partial R2 0.43) and injury mechanism (saw injury compared with sport injury; partial R2 0.14). The criterion symptoms of depression was also the factor most strongly associated with both pain intensity and time off work. CONCLUSIONS In patients with fingertip injury, symptoms of depression account for most of the variability in hand and arm-specific disability, pain intensity, and days to return to work. Identification and treatment of symptoms of depression might facilitate recovery from fingertip injuries.

Predictors of readmission in orthopaedic trauma surgery.

Objectives: This study of patients who had operative treatment of skeletal trauma addresses (1) the association between readmission within 30 days of discharge and comorbidities and (2) differences in factors associated with all-cause readmissions and those because of a surgical adverse event. Design: Retrospective study. Setting: Tertiary care referral center. Patients: Three thousand four hundred fifty-two operations for skeletal trauma between 2008 and 2012 with comorbidities quantified using the updated Charlson comorbidity index (CCI). Outcome Measurement: Readmission to the hospital within 30 days of surgery and the subset of readmissions because of adverse events related directly to surgery. Results: There was a significant association between readmission within 30 days of surgery and higher CCI (P < 0.001), older age (P < 0.001), and marital status (widowed) (P < 0.001). The factors associated with readmission related to an adverse event were identical. The best multivariable logistic regression models for all-cause 30-day readmission and 30-day readmission related to a surgical adverse event included CCI and older age in both models (odds ratio 1.1, P < 0.01, pseudo R2 = 0.03). Conclusions: Older patients and patients with greater comorbidity are more likely to be readmitted within 30 days of surgery for musculoskeletal trauma, whether for a surgical adverse event or another reason. The best multivariable models predicted very little of the variability in readmission, which reflects the complexity of readmission and the difficulty reducing the risk to a few specific factors. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Does Rewording MRI Reports Improve Patient Understanding and Emotional Response to a Clinical Report

BackgroundDiagnostic MRI reports can be distressing for patients with limited health literacy. Humans tend to prepare for the worst particularly when we are in pain, and words like “tear” can make us feel damaged and in need of repair. Research on words used in provider-patient interactions have shown an affect on response to treatment and coping strategies, but the literature on this remains relatively sparse.Questions/purposesThe aim of this observational cross-sectional study is to determine whether rewording of MRI reports in understandable, more dispassionate language will result in better patient ratings of emotional response, satisfaction, usefulness, and understanding. Furthermore, we wanted to find out which type of report patients would choose to receive.MethodsOne hundred patients visiting an orthopaedic hand and upper extremity outpatient office for reasons unrelated to the presented MRI report were enrolled. Four MRI reports, concerning upper extremity conditions, were reworded to an eighth-grade reading level and with the use of neutral descriptive words and the most optimistic interpretations based on current best evidence. After reading each report, emotional response was measured using the Self Assessment Manikin (SAM). Subjects also completed questions about satisfaction, usefulness, and understanding of the report.ResultsAccording to the results of the SAM questionnaire, the reworded MRI reports resulted in significantly higher pleasure and dominance scores and lower arousal scores. The mean satisfaction, usefulness, and understanding scores of the reworded report were significantly higher compared with the original reports. Seventy percent of the patients preferred the reworded reports over the original reports.ConclusionsEmotional response, satisfaction, usefulness, and understanding were all superior in MRI reports reworded for lower reading level and optimal emotional content and optimism. Given that patients increasingly have access to their medical records and diagnostic reports, attention to health literacy and psychologic aspects of the report may help optimize health and patient satisfaction.Level of EvidenceLevel II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Surgeon confidence in an outpatient setting

BackgroundWe have the impression that provider uncertainty arises from either nonspecific pathology or disproportionate symptoms and disability, both of which correlate with symptoms of depression, heightened illness concern, and low patient self-efficacy. This study tested the primary null hypothesis that there is no correlation between provider confidence and patient self-efficacy.MethodsEighty-five patients visiting an orthopedic hand and upper extremity surgeon completed the Pain Self-Efficacy Questionnaire (PSEQ). The surgeon’s confidence in the diagnosis, optimal treatment, expected outcome, and the anticipated satisfaction of the patient and the referring doctor were measured with five questions rated on 5-point Likert scales (Physician Confidence Scale).ResultsOverall physician confidence was high and there was no correlation between the PSEQ score and the Physician Confidence Scale. Provider confidence was significantly lower for nonspecific diagnoses, but there was no significant difference between the mean PSEQ for the 72 patients with a specific diagnosis and the 12 patients with nonspecific diagnoses.ConclusionsPhysician confidence did not relate with self-efficacy in this study.Level of Evidence: Prognostic, level II