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Werner RA, Chodoroff B. How can we get physicians to change their clinical behavior and embrace best practices? Muscle Nerve 2020; 62:2-4. [PMID: 32297345 DOI: 10.1002/mus.26890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/04/2020] [Accepted: 04/07/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Robert A Werner
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, Ann Arbor, Michigan
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Aragaki D, Basu A, Conlon C, Shetty Md Ms KD, Robbins M, Benner D, Nuckols TK. Quality of electrodiagnostic testing for carpal tunnel syndrome: adherence to quality measures. Muscle Nerve 2020; 62:50-59. [PMID: 32133653 DOI: 10.1002/mus.26858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 02/28/2020] [Accepted: 02/29/2020] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Research has shown that quality of health-care services is often suboptimal. Little is known about the quality of electrodiagnostic testing. METHODS We prospectively recruited 477 adults with workers' compensation claims for carpal tunnel syndrome (CTS) from 30 occupational health clinics and evaluated whether electrodiagnostic testing adhered to five process-oriented quality measures. RESULTS Among patients who had surgery for CTS, nearly all underwent recommended preoperative electrodiagnostic testing (measure #1, 170 of 174, 97.7%). Most electrodiagnostic tests included essential components (measure #2, 295 of 379, 77.8%). However, few reports documented skin temperature (measure #3, 93 of 379, 24.5%) and criteria were seldom met for interpreting test findings as consistent with CTS (measure #4, 41 of 284, 14.4%) or "severe" CTS (measure #5, 8 of 46, 17.4%). DISCUSSION Most patients underwent testing before surgery, but test quality was often suboptimal. This work lays the groundwork for future efforts to monitor and improve the quality of electrodiagnostic testing for CTS.
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Affiliation(s)
- Dixie Aragaki
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Aashna Basu
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Craig Conlon
- Employee Health, The Permanente Medical Group, Oakland, California, USA
| | | | | | | | - Teryl K Nuckols
- RAND Corporation, Santa Monica, California, USA.,Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Nuckols TK, Conlon C, Robbins M, Dworsky M, Lai J, Roth CP, Levitan B, Seabury S, Seelam R, Benner D, Asch SM. Quality of care and patient-reported outcomes in carpal tunnel syndrome: A prospective observational study. Muscle Nerve 2018; 57:896-904. [PMID: 29272038 DOI: 10.1002/mus.26041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2017] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Higher quality care for carpal tunnel syndrome (CTS) may be associated with better outcomes. METHODS This prospective observational study recruited adults diagnosed with CTS from 30 occupational health centers, evaluated physicians' adherence to recommended care processes, and assessed results of the Boston Carpal Tunnel Questionnaire (BCTQ) and Short Form Health Survey version 2 (SF-12v2) at recruitment and at 18 months. RESULTS Among 343 individuals, receiving better care (80th vs. 20th percentile for adherence) was associated with greater improvements in BCTQ Symptom Severity scores (-0.18, 95% confidence interval [CI] -0.32 to -0.05), BCTQ Functional Status scores (-0.21, 95% CI -0.34 to -0.08), and SF12-v2 Physical Component scores (1.75, 95% CI 0.33-3.16). Symptoms improved more when physicians assessed and managed activity, patients underwent necessary surgery, and employers adjusted job tasks. DISCUSSION Efforts should be made to ensure that patients with CTS receive essential care processes including necessary surgery and activity assessment and management. Muscle Nerve 57: 896-904, 2018.
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Affiliation(s)
- Teryl K Nuckols
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA.,Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Craig Conlon
- Employee Health, The Permanente Medical Group, Oakland, California, USA
| | - Michael Robbins
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA
| | - Michael Dworsky
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA
| | - Julie Lai
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA
| | - Carol P Roth
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA
| | - Barbara Levitan
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA
| | - Seth Seabury
- University of Southern California, USC Schaeffer Center, Los Angeles, California, USA
| | - Rachana Seelam
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA
| | | | - Steven M Asch
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA.,VA Palo Alto Health Care System, Menlo Park, California, USA.,Division of General Medical Disciplines, Stanford University School of Medicine, Palo Alto, California, USA
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Nuckols T, Conlon C, Robbins M, Dworsky M, Lai J, Roth CP, Levitan B, Seabury S, Seelam R, Asch SM. Quality of Care for Work-Associated Carpal Tunnel Syndrome. J Occup Environ Med 2017; 59:47-53. [PMID: 28045797 PMCID: PMC5382986 DOI: 10.1097/jom.0000000000000916] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the quality of care provided to individuals with workers' compensation claims related to Carpal tunnel syndrome (CTS) and identify patient characteristics associated with receiving better care. METHODS We recruited subjects with new claims for CTS from 30 occupational clinics affiliated with Kaiser Permanente Northern California. We applied 45 process-oriented quality measures to 477 subjects' medical records, and performed multivariate logistic regression to identify patient characteristics associated with quality. RESULTS Overall, 81.6% of care adhered to recommended standards. Certain tasks related to assessing and managing activity were underused. Patients with classic/probable Katz diagrams, positive electrodiagnostic tests, and higher incomes received better care. However, age, sex, and race/ethnicity were not associated with quality. CONCLUSIONS Care processes for work-associated CTS frequently adhered to quality measures. Clinical factors were more strongly associated with quality than demographic and socioeconomic ones.
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Affiliation(s)
- Teryl Nuckols
- RAND Corporation, 1776 Main Street, Santa Monica, CA, USA. 90407
- Division of General Internal Medicine, Cedars-Sinai Medical Center, 8700 Beverly Drive, Becker 113, Los Angeles, CA 90048
| | - Craig Conlon
- Employee Health, The Permanente Medical Group, 1950 Franklin Street, 16th Floor, Oakland, CA 94612
| | - Michael Robbins
- RAND Corporation, 1776 Main Street, Santa Monica, CA, USA. 90407
| | - Michael Dworsky
- RAND Corporation, 1776 Main Street, Santa Monica, CA, USA. 90407
| | - Julie Lai
- RAND Corporation, 1776 Main Street, Santa Monica, CA, USA. 90407
| | - Carol P. Roth
- RAND Corporation, 1776 Main Street, Santa Monica, CA, USA. 90407
| | - Barbara Levitan
- RAND Corporation, 1776 Main Street, Santa Monica, CA, USA. 90407
| | - Seth Seabury
- University of Southern California, USC Schaeffer Center, 635 Downey Way, VPD Suite 210, Los Angeles, CA 90089
| | - Rachana Seelam
- RAND Corporation, 1776 Main Street, Santa Monica, CA, USA. 90407
| | - Steven M. Asch
- RAND Corporation, 1776 Main Street, Santa Monica, CA, USA. 90407
- VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA, 94025
- Division of General Medical Disciplines, Stanford University School of Medicine, Medical School Office Building X336, 1265 Welch Road, Stanford, Palo Alto, CA 94305
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Conlon C, Asch S, Hanson M, Avins A, Levitan B, Roth C, Robbins M, Dworsky M, Seabury S, Nuckols T. Assessing the Value of High-Quality Care for Work-Associated Carpal Tunnel Syndrome in a Large Integrated Health Care System: Study Design. Perm J 2016; 20:15-220. [PMID: 27723446 DOI: 10.7812/tpp/15-220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT Little is known about quality of care for occupational health disorders, although it may affect worker health and workers' compensation costs. Carpal tunnel syndrome (CTS) is a common work-associated condition that causes substantial disability. OBJECTIVE To describe the design of a study that is assessing quality of care for work-associated CTS and associations with clinical outcomes and costs. DESIGN Prospective observational study of 477 individuals with new workers' compensation claims for CTS without acute trauma who were treated at 30 occupational health clinics from 2011 to 2013 and followed for 18 months. MAIN OUTCOME MEASURES Timing of key clinical events, adherence to 45 quality measures, changes in scores on the Boston Carpal Tunnel Questionnaire and 12-item Short Form Health Survey Version 2 (SF-12v2), and costs associated with medical care and disability. RESULTS Two hundred sixty-seven subjects (56%) received a diagnosis of CTS and had claims filed around the first visit to occupational health, 104 (22%) received a diagnosis before that visit and claim, and 98 (21%) received a diagnosis or had claims filed after that visit. One hundred seventy-eight (37%) subjects had time off work, which started around the time of surgery in 147 (83%) cases and lasted a median of 41 days (interquartile range = 42 days). CONCLUSIONS The timing of diagnosis varied, but time off work was generally short and related to surgery. If associations of quality of care with key medical, economic, and quality-of-life outcomes are identified for work-associated CTS, systematic efforts to evaluate and improve quality of medical care for this condition are warranted.
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Affiliation(s)
- Craig Conlon
- Medical Director of Employee Health Services for Kaiser Permanente in Oakland, CA.
| | - Steven Asch
- Chief of Health Services Research for the Veterans Administration Palo Alto Health Care System in Menlo Park, and Co-Chief of the Division of General Medical Disciplines at Stanford University in Palo Alto, CA.
| | - Mark Hanson
- Senior Project Associate for the RAND Corporation in Santa Monica, CA.
| | - Andrew Avins
- Research Scientist at the Division of Research in Oakland, CA.
| | - Barbara Levitan
- Survey Researcher for the RAND Corporation in Santa Monica, CA.
| | - Carol Roth
- Project Associate for the RAND Corporation in Santa Monica, CA.
| | - Michael Robbins
- Associate Statistician for the RAND Corporation in Santa Monica, CA.
| | - Michael Dworsky
- Associate Economist for the RAND Corporation in Santa Monica, CA.
| | - Seth Seabury
- Associate Professor of Research in Emergency Medicine at the Keck School of Medicine at the University of Southern California in Los Angeles.
| | - Teryl Nuckols
- Health Services Researcher for the RAND Corporation in Santa Monica and the Director of the Division of Internal Medicine at Cedars-Sinai Medical Center in Los Angeles, CA.
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Kamal RN, Ring D, Akelman E, Yao J, Ruch DS, Richard M, Ladd A, Got C, Blazar P, Kakar S. Quality Measures in Upper Limb Surgery. J Bone Joint Surg Am 2016; 98:505-10. [PMID: 26984919 DOI: 10.2106/jbjs.15.00651] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Quality measures are now commonplace and are increasingly tied to financial incentives. We reviewed the existing quality measures that address the upper limb and tested the null hypothesis that structure (capacity to deliver care), process (appropriate care), and outcome (the result of care) measures are equally represented. METHODS We systematically reviewed MEDLINE/PubMed, Embase, Google Scholar, the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines, the National Quality Forum, the Agency for Healthcare Research and Quality, and the Physician Quality Reporting System for quality measures addressing upper limb surgery. Measures were characterized as structure, process, or outcome measures and were categorized according to their developer and their National Strategy for Quality Improvement in Health Care (National Quality Strategy) priority as articulated by the U.S. Department of Health & Human Services. RESULTS We identified 134 quality measures addressing the upper limb: 131 (98%) process and three (2%) outcome measures. The majority of the process measures address the National Quality Strategy priority of effective clinical care (90%), with the remainder addressing communication and care coordination (5%), person and caregiver-centered experience and outcomes (4%), and community/population health (1%). CONCLUSIONS Our review identified opportunities to develop more measures in the structure and outcome domains as well as measures addressing patient and family engagement, public health, safety, care coordination, and efficient use of resources. The most common existing measures-process measures addressing care-might not be the best measures of upper limb surgery quality given the relative lack of evidence for their use in care improvement.
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Affiliation(s)
- Robin N Kamal
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - David Ring
- Department of Orthopaedic Surgery, Massachusetts General Hospital/Harvard University, Boston, Massachusetts
| | - Edward Akelman
- Department of Orthopaedic Surgery, Rhode Island Hospital/Brown University, Providence, Rhode Island
| | - Jeffrey Yao
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - David S Ruch
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Marc Richard
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Amy Ladd
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Christopher Got
- Department of Orthopaedic Surgery, Rhode Island Hospital/Brown University, Providence, Rhode Island
| | - Philip Blazar
- Department of Orthopaedic Surgery, Brigham and Women's Hospital/Harvard University, Boston, Massachusetts
| | - Sanjeev Kakar
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Noszczyk BH, Nowak M, Krześniak N. Use of the Accordion Severity Grading System for negative outcomes of carpal tunnel syndrome. J Plast Reconstr Aesthet Surg 2013; 66:1123-30. [PMID: 23668952 DOI: 10.1016/j.bjps.2013.04.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2012] [Revised: 03/10/2013] [Accepted: 04/06/2013] [Indexed: 12/31/2022]
Abstract
A universal classification of the negative outcomes of carpal tunnel release surgery does not, as yet, exist. In order to avoid the use of arbitrary factors we have applied the Accordion Severity Grading System, which uses rigorously defined qualitative terms to classify complications. It also provides a uniform manner for grading the severity of complications, enabling outcome comparisons between centres. We analysed the negative outcomes of 500 device-assisted carpal tunnel releases performed over a 2-year period in the author's department. In order to establish a standardised list of complications we used the terms employed within the guidelines of the American Academy of Orthopaedic Surgeons. Most of these terms were subsequently defined using the data variables and definitions taken from the American College of Surgeons National Surgical Quality Improvement Program or the Medical Subject Headings of the National Library of Medicine. We also adopted the quantitative severity weighting, as proposed by the Accordion system, in order to determine the postoperative morbidity index for our assisted carpal tunnel releases. The most common complications were pain and reversible damage to peripheral nerves. Other common negative events, other than complications, included hand weakness, which we classified as a sequela of the procedure, and incomplete retinaculum release, which we classified as failure to cure. The overall postoperative morbidity index for complications was 0.014. Although the Accordion system was developed for more complex procedures, it may also be adopted for carpal tunnel release surgery where it provides an objective and universal method for the classification of complications.
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Affiliation(s)
- B H Noszczyk
- Department of Plastic Surgery, Medical Centre for Postgraduate Education, Warsaw, Poland.
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