Pamela L. Hudak

Development of an upper extremity outcome measure: The DASH (disabilities of the arm, shoulder, and head)

This paper describes the development of an evaluative outcome measure for patients with upper extremity musculoskeletal conditions. The goal is to produce a brief, self-administered measure of symptoms and functional status, with a focus on physical function, to be used by clinicians in daily practice and as a research tool. This is a joint initiative of the American Academy of Orthopedic Surgeons (AAOS), the Council of Musculoskeletal Specialty Societies (COMSS), and the Institute for Work and Health (Toronto, Ontario). Our approach is consistent with previously described strategies for scale development. In Stage 1, Item Generation, a group of methodologists and clinical experts reviewed 13 outcome measurement scales currently in use and generated a list of 821 items. In Stage 2a, Initial Item Reduction, these 821 items were reduced to 78 items using various strategies including removal of items which were generic, repetitive, not reflective of disability, or not relevant to the upper extremity or to one of the targeted concepts of symptoms and functional status. Items not highly endorsed in a survey of content experts were also eliminated. Stage 2b, Further Item Reduction, will be based on results of field testing in which patients complete the 78-item questionnaire. This field testing, which is currently underway in 20 centers in the United States, Canada, and Australia, will generate the final format and content of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Future work includes plans for validity and reliability testing.

Measuring disability of the upper extremity: a rationale supporting the use of a regional outcome measure.

OBJECTIVE Many existing upper extremity outcome measures have been designed for a specific anatomic site (e.g., shoulder) or a specific disease entity (e.g., carpal tunnel syndrome). The purpose of this paper is to examine whether questionnaire items taken from very specific measures are considered relevant only to that specific region or are applicable to the whole extremity. METHODS Fifteen practicing clinicians categorized a sample of 132 items from existing questionnaires according to whether the items reflected disability specific to an anatomic site or were relevant to the whole extremity. RESULTS Seventy-two percent of the items were categorized as relevant to the extremity as a whole, while only 21% of the items were categorized as specific to an anatomic site. CONCLUSION Items in existing specific upper extremity questionnaires are also relevant to other regions and conditions. This finding is in agreement with kinesiologic and biomechanical theories that the upper extremity acts as a single functional unit. Questionnaires designed for the whole extremity could provide a more practical and still valid measure of upper extremity disability.

You're perfect for the procedure! Why don't you want it? Elderly arthritis patients' unwillingness to consider total joint arthroplasty surgery: a qualitative study.

Objective . To explore the process by which elderly persons make decisions about a surgical treatment, total joint arthroplasty (TJA). Methods . In-depth interviews with 17 elderly individuals identified as potential candidates for TJA who were unwilling to undergo the procedure. Results . For the majority of participants, decision making involved ongoing deliberation of the surgical option, often resulting in a deferral of the treatment decision. Three assumptions may constrain elderly persons from making a decision about surgery. First, some participants viewed osteoarthritis not as a disease but as a normal part of aging. Second, despite being candidates for TJA according to medical criteria, many participants believed candidacy required a level of pain and disability higher than their current level. Third, some participants believed that if they either required or would benefit from TJA, their physicians would advise surgery. Conclusion . These assumptions may limit the possibility for shared decision making. Clinical Implications . Emphasis should be directed toward thinking about ways in which discussions about TJA might be initiated (and by whom) and considering how patients’ views on and knowledge of osteoarthritis in general might be addressed.

Surgery is certainly one good option: quality and time-efficiency of informed decision-making in surgery.

BACKGROUND Informed decision-making has been widely promoted in several medical settings, but little is known about the actual practice in orthopaedic surgery and there are no clear guidelines on how to improve the process in this setting. This study was designed to explore the quality of informed decision-making in orthopaedic practice and to identify excellent time-efficient examples with older patients. METHODS We recruited orthopaedic surgeons, and patients sixty years of age or older, in a Midwestern metropolitan area for a descriptive study performed through the analysis of audiotaped physician-patient interviews. We used a valid and reliable measure to assess the elements of informed decision-making. These included discussions of the nature of the decision, the patients role, alternatives, pros and cons, and uncertainties; assessment of the patients understanding and his or her desire to receive input from others; and exploration of the patients preferences and the impact on the patients daily life. The audiotapes were scored with regard to whether there was a complete discussion of each informed-decision-making element (an IDM-18 score of 2) or a partial discussion of each element (an IDM-18 score of 1) as well as with a more pragmatic metric (the IDM-Min score), reflecting whether there was any discussion of the patients role or preference and of the nature of the decision. The visit duration was studied in relation to the extent of the informed decision-making, and excellent time-efficient examples were sought. RESULTS There were 141 informed-decision-making discussions about surgery, including knee and hip replacement as well as wrist/hand, shoulder, and arthroscopic surgery. Surgeons frequently discussed the nature of the decision (92% of the time), alternatives (62%), and risks and benefits (59%); they rarely discussed the patients role (14%) or assessed the patients understanding (12%). The IDM-18 scores of the 141 discussions averaged 5.9 (range, 0 to 15; 95% confidence interval, 5.4 to 6.5). Fifty-seven percent of the discussions met the IDM-Min criteria. The median duration of the visits was sixteen minutes; the extent of informed decision-making had only a modest relationship with the visit duration. Time-efficient strategies that were identified included use of scenarios to illustrate distinct choices, encouraging patient input, and addressing primary concerns rather than lengthy recitations of pros and cons. CONCLUSIONS In this study, which we believe is the first to focus on informed decision-making in orthopaedic surgical practice, we found opportunities for improvement but we also found that excellent informed decision-making is feasible and can be accomplished in a time-efficient manner.

Prognosis of nonspecific work-related musculoskeletal disorders of the neck and upper extremity.

Reviews of work-related musculoskeletal disorders (WMD) of the neck and upper extremity have typically supplied little information on prognosis. This paper reports on the methods and results of a systematic search for evidence on clinical course and prognosis of nonspecific WMD i.e., those without specific clinical diagnoses. Articles were deemed relevant if they provided primary data on current or former worker cases of WMD followed over time. WMD status had to be based on clinical evaluations. The 13 studies which met these criteria were evaluated using clinical epidemiological criteria for validity of prognostic studies. None of the studies was sufficiently strong across the criteria to provide more than weaker evidence on prognosis. Prognostic factors with promise include duration of symptoms and workplace demands. In order to improve the evidence on prognosis of WMD, we recommend closer attention to the following: clear operational definition of cases; documentation of prognostic factors including duration of symptoms and severity at baseline; incorporation of multiple follow-up assessments; inclusion of a range of outcomes; and analysis using stratified or multivariate methods.

Testing a new theory of patient satisfaction with treatment outcome.

Objectives:Theories of patient satisfaction with treatment outcome have not been developed and tested in healthcare settings. The objectives of this study were to test a new theory linking patient satisfaction and embodiment (body—self unity) and examine it in relation to other competing theories. Design:We conducted a prospective cohort study. Setting:This study was conducted at a tertiary care hospital. Patients:We studied 122 individuals undergoing elective hand surgery. Methods:Satisfaction with treatment outcome approximately 4 months after surgery was examined against the following factors (representing 7 theories of satisfaction): 1) overall clinical outcome, 2) patients’ a priori self-selected important clinical outcomes, 3) foresight expectations, 4) hindsight expectations, 5) psychologic state, 6) psychologic state in those with poor outcomes, and 7) embodiment. Analysis:Seven hypotheses were tested first using univariate analyses and then multivariable regression analysis. Results:Satisfaction with treatment outcome was significantly associated with embodiment. Three confounders—the extent to which surgery successfully addressed patients’ most important reason for surgery, hindsight expectations, and workers’ compensation—were also significant. The final model explained 84% of the variance in a multidimensional measure of satisfaction with treatment outcome. Conclusion:This research suggests that satisfaction with treatment outcome could be facilitated by developing strategies to improve body–self unity, and eliciting and addressing the patients most important reason for undergoing treatment.

It's not what you say ...: racial disparities in communication between orthopedic surgeons and patients.

Background:Excellent communication between surgeons and patients is critical to helping patients to make informed decisions and is a key component of both high quality of care and patient satisfaction. Understanding racial disparities in communication is essential to provide quality care to all patients. Objective:To examine the content and process of informed decision-making (IDM) between orthopedic surgeons and elderly white versus African American patients. To assess the association of race and patient satisfaction with surgeon communication. Research Design:Analysis of audiotape recordings of office visits between orthopedic surgeons and patients. Participants:Eighty-nine orthopedic surgeons and 886 patients age 60 years or older in Chicago, Illinois. Methods:Tapes were analyzed by coders for content using 9 elements of IDM and for process using 4 global ratings of the relationship-building component of communication (responsiveness, respect, listening, and sharing). Ratings by race were compared using χ2 analysis. Patients completed a questionnaire rating satisfaction with surgeon communication and the visit overall. Logistic analysis was used to assess the effect of race on satisfaction. Results:Overall there were practically no significant differences in the content of the 9 IDM elements based on race. However, coder ratings of relationship were higher on 3 of 4 global ratings (responsiveness, respect, and listening) in visits with white patients compared with African American patients (P < 0.01). Patient ratings of communication and overall satisfaction with the visit were significantly higher for white patients. Conclusions:The content of IDM conversations does not differ by race. Yet differences in the process of relationship building and in patient satisfaction ratings were clearly present. Efforts to enhance cultural communication competence of surgeons should emphasize the skills of building relationships with patients in addition to the content of IDM.

Understanding the Meaning of Satisfaction With Treatment Outcome

Objective:Although satisfying patients is an important goal in health care, what is meant by satisfaction in relation to treatment outcome is not clear. The objective of this study was to explore patients’ perspectives on the meaning of satisfaction with treatment outcome. Design:We conducted a qualitative exploratory study. Setting:This study was conducted at an adult tertiary care hospital. Patients:Individuals who had undergone elective hand surgery were included in this study. Intervention:In-depth, open-ended interviews in which 31 participants described their experience of a hand condition, how they evaluated the outcome of surgical interventions, and what it meant to be satisfied or dissatisfied with these outcomes were examined. Analysis:Interview transcripts were analyzed using Gadows conceptualization of embodiment states: “object body” (disunity between the affected hand and the self) or “cultivated immediacy” (harmony between the hand and the self). Results:Eight of 9 dissatisfied individuals were categorized as “object body” and 15 of 19 satisfied individuals were in, or in transition to, “cultivated immediacy.” These states fluctuated and were also dependent on context (eg, social setting) and time since surgery. Conclusion:In relation to the outcome of hand surgery, satisfaction was experienced as a relative lack of tension between the patients sense of self and the affected hand (ie, satisfaction was having a hand that could be lived with unself-consciously). Emotional and social effects of interventions and the influence of context should be considered in future measures of satisfaction with treatment outcome. Finally, interventions directed toward facilitating patients’ experience of body–self unity could promote satisfaction with treatment outcome.

The Reliability of Physical Examination for Carpal Tunnel Syndrome

The goal of this study was to determine the interobserver and intraobserver reliability of static and moving two-point discrimination, Semmes-Weinstein monofilament testing, Tinel’s test, manual motor testing of abductor pollicis brevis, vibration and Phalen’s test in the diagnosis of carpal tunnel syndrome. Twelve patients with suspected carpal tunnel syndrome were examined in an outpatient setting. The interobserver reliability was satisfactory for all tests except for Semmes-Weinstein monofilament testing. Intraobserver reliability was also satisfactory for all tests. Static two point discrimination had higher reliability than moving two-point discrimination. Seven tests for the diagnosis of carpal tunnel syndrome were reliable in the hands of skilled health care professionals. Hand surgeons and hand therapists examined patients more reliably than occupational health workers.

Small talk, high stakes: Interactional disattentiveness in the context of prosocial doctor-patient interaction

The literature on “small talk” has not described the way in which this talk, even as it “oils the social wheels of work talk” (Holmes 2000), enables disattending to the instrumental tasks in which one or both participants may be engaged. Small talk in simultaneity can disattend to the movements, bodily invasions, and recording activities functional for the instrumental tasks of medicine. Small talk in sequence occurs in sensitive sequential environments. Surgeons may use small talk to focus away from psychosocial or other concerns of patients that may focus off the central complaint or treatment recommendation related to that complaint. Patients may use small talk to disattend to physician recommendations regarding disfavored therapies (such as exercise). Overall, small talk often may be used to ignore, mask, or efface certain kinds of agonistic relations in which doctor and patient are otherwise engaged. We explore implications of this research for the conversation analytic literature on doctor–patient interaction and the broader sociolinguistic literature on small talk. (Medicine, doctor–patient interaction, conversation analysis, small talk, complaining, recommending)*