Quality of Care for Work-Associated Carpal Tunnel Syndrome

Adherence to Non-operative Clinical Quality Measures in Carpal Tunnel Syndrome

Background: Clinical quality measures exist for non-operative management of carpal tunnel syndrome (CTS). Factors predicting adherence are unclear. Methods: A retrospective cohort study of patients with chronic CTS using MarketScan Research Database (2015-2020) was conducted. Six logistic regression models were designed to study adherence to quality measures within 1 year after diagnosis. Results: Of 782,717 patients identified, 514,073 (65.7%) were female with an average (SD) age of 51.4 (13.4) years. Only 88 patients (0.01%) met all quality measures. Greatest compliance observed with receipt of nerve conduction study (NCS; 283,959 [36.3%]), no prescription of medications (336,297 [43.0%]) and no laser therapy (772,979 [98.8%]); 294,305 patients (37.6%) received hand surgeon referral. Hand surgeon referral predicted higher likelihood of NCS and splinting (OR, 1.83; 95% CI: 1.81-1.84; OR, 2.53; 95% CI: 2.50-2.56) and medication over-prescription (OR, 1.05; 95% CI: 1.00-1.10). Females were more likely to be referred to a hand surgeon and be referred for splinting (OR 1.02; 95% CI: 1.01-1.03; OR 1.19; 95% CI: 1.18-1.21) but less likely to have no prescriptions or avoid laser therapy (OR 0.85, 95% CI: 0.84-0.85; OR 0.82, 95% CI: 0.79-0.86). Medicare recipients adhered less to quality measures compared to patients with fee-for-service insurance. As comorbidities increased, patients were less likely to receive hand surgeon referral and carpal tunnel release. Conclusions: Findings suggest that hand surgery referrals increased adherence to quality measures. Females, Medicare recipients and multimorbid patients should be targeted for improved care. Future quality care efforts should incentivise adherence for Medicare beneficiaries and improve guideline recognition amongst physicians. Level of Evidence: Level III (Therapeutic).

Refining quality measures for electrodiagnostic testing in suspected carpal tunnel syndrome to account for acceptable variations in practice: Expert review process

INTRODUCTION/AIMS

Using a set of process-of-care quality measures for electrodiagnostic testing in suspected carpal tunnel syndrome (CTS), the research team previously documented large variations in electrodiagnostic testing practices and adherence to quality measures. This study sought to enhance the applicability and validity of the quality measures by integrating acceptable variations in testing practices.

METHODS

We recruited 13 expert electrodiagnostic medicine specialists from five specialty societies. The experts iteratively refined five quality measures, and then rated the validity of the refined quality measures (1-9 scale). During this process, the experts reviewed data on adherence to existing quality measures and variations in electrodiagnostic testing practices, and considered recently published quality measures from the American Association of Neuromuscular and Electrodiagnostic Medicine.

RESULTS

Three quality measures (electrodiagnostic testing before surgery for CTS, temperature assessment during electrodiagnostic testing, and electrodiagnostic criteria for severe median neuropathy) underwent few refinements and were rated valid (medians 8-9). Two measures (essential components of electrodiagnosis, criteria for interpreting electrodiagnostic tests as median neuropathy) were judged valid (medians 8) after revisions. For these measures, experts' ratings on the recommended components of sensory or mixed nerve conduction studies varied: agreement among the experts about the use of sensory peak latency was greater than for onset latency or sensory velocity.

DISCUSSION

This study produced quality measures that provide minimum standards for electrodiagnostic testing for suspected CTS that are more comprehensive and nuanced than prior versions. Future work can assess the feasibility, reliability, and validity of these refined measures in diverse physician practices.

The quality of occupational healthcare for carpal tunnel syndrome, healthcare expenditures, and disability outcomes: A prospective observational study

INTRODUCTION/AIMS

In prior work, higher quality care for work-associated carpal tunnel syndrome (CTS) was associated with improved symptoms, functional status, and overall health. We sought to examine whether quality of care is associated with healthcare expenditures or disability.

METHODS

Among 343 adults with workers' compensation claims for CTS, we created patient-level aggregate quality scores for underuse (not receiving highly beneficial care) and overuse (receiving care for which risks exceed benefits). We assessed whether each aggregate quality score (0%-100%, 100% = better care) was associated with healthcare expenditures (18-mo expenditures, any anticipated need for future expenditures) or disability (days on temporary disability, permanent impairment rating at 18 mo).

RESULTS

Mean aggregate quality scores were 77.8% (standard deviation [SD] 16.5%) for underuse and 89.2% (SD 11.0%) for overuse. An underuse score of 100% was associated with higher risk-adjusted 18-mo expenditures ($3672; 95% confidence interval [CI] $324 to $7021) but not with future expenditures (-0.07 percentage points; 95% CI -0.48 to 0.34), relative to a score of 0%. An overuse score of 100% was associated with lower 18-mo expenditures (-$4549, 95% CI -$8792 to -$306) and a modestly lower likelihood of future expenditures (-0.62 percentage points, 95% CI -1.23 to -0.02). Quality of care was not associated with disability.

DISCUSSION

Improving quality of care could increase or lower short-term healthcare expenditures, depending on how often care is currently underused or overused. Future research is needed on quality of care in varied workers' compensation contexts, as well as effective and economical strategies for improving quality.

Carpal Tunnel Syndrome: A National Survey to Monitor Knowledge and Operating Methods

The aim of this article was to investigate the knowledge, management, and clinical practice of Italian physiotherapists concerning patients with carpal tunnel syndrome (CTS). A national cross-sectional survey consisted of 24 questions was administered from December 2019 until February 2020. A Chi-squared independence test was run to study any difference between subgroups of the sample and responses to the questionnaire. Five hundred and eight respondents completed the survey. Most respondents (n = 225/508; 44.3%) are under 29 years old, female (n = 256/508; 50.4%) and have been working as physiotherapists for less than 5 years (n = 213/508; 41.9%). Most of respondents correctly knows about the cause (n = 455/508, 89.6%), main signs and symptoms of CTS (n = 415/508, 81.70%) and administer education, manual therapy, myofascial techniques and therapeutic exercises (n = 457/508, 89.88%). Three hundred and sixty-four (71.68%) respondents were aware of the influence of psychosocial factors on the patient’s outcomes. The survey showed greater adherence to evidences by physiotherapists holding a master’s degree. The results are mostly comparable with other surveys structured all over the world on the same topic. Italian physiotherapists management of the CTS was not always in line with current evidence. Interventions such as education, manual therapy, therapeutic exercise, nerve and tendon glide techniques are widely used, while the orthotic is only offered by half of the sample.

The quality of electrodiagnostic tests for carpal tunnel syndrome: Implications for surgery, outcomes, and expenditures

INTRODUCTION

The quality of electrodiagnostic tests may influence treatment decisions, particularly regarding surgery, affecting health outcomes and health-care expenditures.

METHODS

We evaluated test quality among 338 adults with workers' compensation claims for carpal tunnel syndrome. Using simulations, we examined how it influences the appropriateness of surgery. Using regression, we evaluated associations with symptoms and functional limitations (Boston Carpal Tunnel Questionnaire), overall health (12-item Short Form Health Survey version 2), actual receipt of surgery, and expenditures.

RESULTS

In simulations, suboptimal quality tests rendered surgery inappropriate for 99 of 309 patients (+32 percentage points). In regression analyses, patients with the highest quality tests had larger declines in symptoms (-0.50 point; 95% confidence interval [CI], -0.89 to -0.12) and functional impairment (-0.42 point; 95% CI, -0.78 to -0.06) than patients with the lowest quality tests. Test quality was not associated with overall health, actual receipt of surgery, or expenditures.

DISCUSSION

Test quality is pivotal to determining surgical appropriateness and associated with meaningful differences in symptoms and function.

Quality of electrodiagnostic testing for carpal tunnel syndrome: adherence to quality measures

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.

Quality of care and patient-reported outcomes in carpal tunnel syndrome: A prospective observational study

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.