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Zhuang T, Shapiro LM, Schultz EA, Truong NM, Harris AHS, Kamal RN. Has the Use of Electrodiagnostic Studies for Carpal Tunnel Syndrome Changed After the 2016 American Academy of Orthopaedic Surgeons Clinical Practice Guideline? J Hand Surg Am 2023; 48:19-27. [PMID: 36460552 DOI: 10.1016/j.jhsa.2022.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 09/08/2022] [Accepted: 09/21/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE A 2016 American Academy of Orthopaedic Surgeons (AAOS) clinical practice guideline (CPG) de-emphasized the need for electrodiagnostic studies (EDS) for carpal tunnel syndrome (CTS). We tested the hypothesis that use of EDS decreased after the AAOS CPG. METHODS Using a national administrative claims database, we measured the proportion of patients with a diagnosis of CTS who underwent EDS within 1 year after diagnosis between 2011 and 2019. Using an interrupted time series design, we defined 2 time periods (pre-CPG and post-CPG) and compared EDS usage between the periods using segmented regression analysis. We conducted a subgroup analysis of preoperative EDS usage in patients who underwent carpal tunnel release. RESULTS Of 2,081,829 patients with CTS, 315,449 (15.2%) underwent EDS within 1 year after diagnosis. The segmented regression analysis showed a decrease in the level of EDS usage after publication of the AAOS CPG (-11.50 per 1,000 patients [95% CI, -1.47 to -0.95 per 1,000 patients]); however, the rate of EDS usage increased in the post-CPG period (+1.75 per 1,000 patients per quarter [95% CI, 0.97-2.54 per 1,000 patients per quarter]). Of 473,753 eligible patients who underwent carpal tunnel release, 139,186 (29.4%) underwent EDS within 6 months before surgery. After publication of the AAOS CPG, preoperative EDS usage decreased by -23.57 per 1,000 patients (95% CI, -37.72 to -9.42 per 1,000 patients). However, these decreasing trends in EDS usage predated the 2016 AAOS CPG. CONCLUSIONS The overall and preoperative EDS usage for CTS has been decreasing since at least 2014, predating the 2016 AAOS CPG, reflecting the rapid implementation of evidence into practice. However, EDS usage has increased in the post-CPG period, and a considerable proportion of patients who underwent carpal tunnel release still received EDS. CLINICAL RELEVANCE Given its high costs and disputed value, routine EDS usage should be considered for further deimplementation initiatives.
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Affiliation(s)
- Thompson Zhuang
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Lauren M Shapiro
- Department of Orthopaedic Surgery, University of California at San Francisco, San Francisco, CA
| | - Emily A Schultz
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Nicole M Truong
- Department of Orthopaedic Surgery, University of California at San Francisco, San Francisco, CA
| | - Alex H S Harris
- Department of Surgery, Stanford University, Redwood City, CA
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA.
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Harris AHS, Ding Q, Trickey AW, Finlay AK, Schmidt EM, Curtin CM, Sears ED, Yoshida R, Lashgari D, Nuckols TK, Kamal RN. Do Proposed Quality Measures for Carpal Tunnel Release Reveal Important Quality Gaps and Are They Reliable? Clin Orthop Relat Res 2022; 480:1743-1750. [PMID: 35274625 PMCID: PMC9384918 DOI: 10.1097/corr.0000000000002175] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 02/22/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The American Academy of Orthopaedic Surgeons recently proposed quality measures for the initial surgical treatment of carpal tunnel syndrome (CTS). One measure addressed avoidance of adjunctive surgical procedures during carpal tunnel release; and a second measure addressed avoidance of routine use of clinic-based occupational and/or physical therapy (OT/PT) after carpal tunnel release. However, for quality measures to serve their intended purposes, they must be tested in real-world data to establish that gaps in quality exist and that the measures yield reliable performance information. QUESTIONS/PURPOSES (1) Is there an important quality gap in clinical practice for avoidance of adjunctive surgical procedures during carpal tunnel release? (2) Is there an important quality gap in avoiding routine use of clinic-based occupational and/or physical therapy after carpal tunnel release? (3) Do these two quality measures have adequate beta-binomial signal-to-noise ratio (SNR) and split-sample reliability (SSR)? METHODS This retrospective comparative study used a large national private insurance claims database, the 2018 Optum Clinformatics® Data Mart. Ideally, healthcare quality measures are tested within data reflective of the providers and payors to which the measures will be applied. We previously tested these measures in a large public healthcare system and a single academic medical center. In this study, we sought to test the measures in the broader context of patients and providers using private insurance. For both measures, we included the first carpal tunnel release from 28,083 patients performed by one of 7236 surgeons, irrespective of surgical specialty (including, orthopaedic, plastic, neuro-, and general surgery). To calculate surgeon-level descriptive and reliability statistics, analyses were focused on the 66% (18,622 of 28,083) of patients who received their procedure from one of the 24% (1740 of 7236) of surgeons with at least five carpal tunnel releases in the database. No other inclusion/exclusion criteria were applied. To determine whether the measures reveal important gaps in treatment quality (avoidance of adjunctive procedures and routine therapy), we calculated descriptive statistics (median and interquartile range) of the performance distribution stratified by surgeon-level annual volume of carpal tunnel releases in the database (5+, 10+, 15+, 20+, 25+, and 30+). Like the Centers for Medicare & Medicaid Services (CMS), we considered a measure "topped out" if median performance was greater than 95%, meaning the opportunity for further quality improvement is low. We calculated the surgeon-level beta-binomial SNR and SSR for each measure, each stratified by the number of carpal tunnel releases performed by each surgeon in the database. These are standard measures of reliability in health care quality measurement science. The SNR quantifies the proportion of variance that is between rather than within surgeons, and the SSR is the correlation of performance scores when each surgeons' patients are split into two random samples and then corrected for sample size. RESULTS We found that 2% (308 of 18,622) of carpal tunnel releases involved an adjunctive procedure. The results showed that avoidance of adjunctive surgical procedures during carpal tunnel release had a median (IQR) performance of 100% (100% to 100%) at all case volumes. Only 8% (144 of 1740) of surgeons with at least five cases in the database had less than 100% performance, and only 5% (84 of 1740) had less than 90% performance. This means adjunctive procedures were rarely performed and an important quality gap does not exist based on the CMS criterion. Regarding the avoidance of routine therapy, there was a larger quality gap: For surgeons with at least five cases in the database, median performance was 89% (75% to 100%), and 25% (435 of 1740) of these surgeons had less than 75% performance. This signifies that the measure is not topped out and may reveal an important quality gap. Most patients receiving clinic-based OT/PT had only one visit in the 6 weeks after surgery. Median (IQR) SNRs of the first measure, which addressed avoidance of adjunctive surgical procedures, and the second measure, which addresses avoidance of routine use clinic-based OT/PT, were 1.00 (1.00 to 1.00) and 0.86 (0.67 to 1.00), respectively. The SSR for these measures were 0.87 (95% CI 0.85 to 0.88) and 0.75 (95% CI 0.73 to 0.77), respectively. All of these reliability statistics exceed National Quality Forum's emerging minimum standard of 0.60. CONCLUSION The first measure, the avoidance of adjunctive surgical procedures during carpal tunnel release, lacked an important quality gap suggesting it is unlikely to be useful in driving improvements. The second measure, avoidance of routine use of clinic-based OT/PT, revealed a larger quality gap and had very good reliability, suggesting it may be useful for quality monitoring and improvement purposes. CLINICAL RELEVANCE As healthcare systems and payors use the second measure, avoidance of routine use of clinic-based OT/PT, to encourage adherence to clinical practice guidelines (such as provider profiling, public reporting, and payment policies), it will be critically important to consider what proportion of patients receiving OT/PT should be considered routine practice and therefore inconsistent with guidelines. The value or potential harm of this measure depends on this judgement.
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Affiliation(s)
- Alex H. S. Harris
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford, CA, USA
| | - Qian Ding
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford, CA, USA
| | - Amber W. Trickey
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford, CA, USA
| | - Andrea K. Finlay
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Eric M. Schmidt
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Catherine M. Curtin
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford, CA, USA
| | - Erika D. Sears
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Michigan Medicine Department of Surgery, Ann Arbor, MI, USA
| | - Ryu Yoshida
- Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Donna Lashgari
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford, CA, USA
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Michigan Medicine Department of Surgery, Ann Arbor, MI, USA
- Cedars Sinai Medical Center, Los Angeles, CA, USA
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Robin N. Kamal
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
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Greenfield PT, Spencer CC, Dawes A, Wagner ER, Gottschalk MB, Daly CA. The Preoperative Cost of Carpal Tunnel Syndrome. J Hand Surg Am 2022; 47:752-761.e1. [PMID: 34509312 DOI: 10.1016/j.jhsa.2021.07.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 05/12/2021] [Accepted: 07/21/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Carpal tunnel syndrome is a common condition, with well-defined diagnostic and treatment guidelines. Despite these guidelines, continued variation in care exists, with providers variably using diagnostic tests and nonsurgical treatment modalities prior to surgery. The purpose of this study was to evaluate the variation and cost associated with the diagnosis and nonsurgical treatment of patients prior to undergoing carpal tunnel release. METHODS We queried the Truven MarketScan database to identify patients who underwent carpal tunnel release from 2010 to 2017. Patients were identified using common current procedural terminology codes and included if they were enrolled in the database for a minimum of 12 months prior to surgery to allow all preoperative data to be captured. All associated current procedural terminology codes during the 1-year preoperative period were refined to codes related to median neuropathy and categorized as office visits, diagnostic imaging (x-ray, ultrasound, and magnetic resonance imaging), electrodiagnostic testing, injections, occupational or physical therapy, durable medical equipment, and preoperative laboratory tests. RESULTS In total, 378,381 patients were included in the study. A per-patient average cost of $858.74 was spent on preoperative workup and nonsurgical treatment. Electrodiagnostic testing represented 44.6% of the cost, and office visits represented 31.9%. Regarding nonsurgical treatment, 16.1% of the patients received an injection during the 1-year preoperative period, 26.8% received a medical brace, and 6.6% used physical therapy. When analyzed based on age group, the per-patient average cost for patients aged 70 years or older was significantly less than those younger than 70 years ($723.92 vs $878.76). CONCLUSIONS Despite robust clinical practice guidelines and high volumes, significant variation in presurgical care exists. These data are useful to begin to critically analyze the causes of variation in the diagnosis and treatment of carpal tunnel syndrome and move toward a more effective, efficient, and informed treatment strategy. TYPE OF STUDY/LEVEL OF EVIDENCE Economic/decision analysis II.
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Affiliation(s)
| | - Corey C Spencer
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA
| | - Alexander Dawes
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA
| | - Eric R Wagner
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA
| | | | - Charles A Daly
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA.
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