Quality measures for the diagnosis and non-operative management of carpal tunnel syndrome in occupational settings

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.

Facing symptoms and limitations: a qualitative study of women with carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome (CTS) is a neuropathic pain condition characterised by pain, paresthesia, loss of strength and disability.

OBJECTIVE

To explore the experiences of women with CTS regarding the management of symptoms and limitations.

METHODS

A qualitative phenomenological study was conducted. Women with a clinical and electromyographic diagnosis of CTS recruited from the Neurology Department of a Public Hospital were included. Purposeful sampling was performed. Data were collected using in-depth interviews and researchers' field notes. Analysis proposed by Giorgi was used.

RESULTS

A total of 18 women with CTS were included. Two themes emerged: a) Living with CTS symptoms and limitations: describing the symptoms experienced, triggers of their symptoms and how they define CTS. Also, describing the difficulties that they experience on a daily basis, at home when handling tools, communicating, driving, and at work; and b) developing daily strategies for managing limitations: developing potential daily strategies to overcome daily limitations and/or compensate for them, and seeking professional help.

CONCLUSIONS AND SIGNIFICANCE

Current results provide insight on how symptoms and daily limitations are experienced by a group of women with CTS. These findings could help occupational therapists to understand the day-to-day difficulties and the reasons for developing certain strategies.

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.

Reliability and validity of Duruoz Hand Index in carpal tunnel syndrome

Objectives

The aim of this study is to investigate the reliability and validity of Duruoz Hand Index (DHI) in patients with carpal tunnel syndrome (CTS).

Patients and methods

A total of 55 patients (50 females, 5 males; mean age 51.0±10.2 years: range, 30 to 73 years) aged ≥18 years who were admitted to the outpatient clinic of a rehabilitation hospital between December 2010 and December 2012 with the diagnosis of CTS both clinically and electrophysiologically were included in this study. All patients completed DHI at baseline and repeated after a week interval. The Boston Questionnaire (BQ) and Health Assessment Questionnaire Disability Index (HAQ-DI) were filled out at baseline. And the internal consistency reliability was tested using the Cronbach's alpha. For the test-retest reliability, intraclass correlation coefficients (ICC) were calculated. The correlations between the DHI and both BQ and HAQ-DI were investigated for the construct validity.

Results

Of the patients, 41 (74.5%) were housewives. Carpal tunnel syndrome was bilateral in 29 patients (52.7%). The Mean Body Mass Index was 31.2±5.5 kg/m2. The mean symptom duration was 22.8±23.7 months. The mean DHI scores for the first and second evaluations were 23.25±20.64 and 20.45±20.07, respectively. The mean BQ symptom severity and functional status scores were 2.87±0.80 and 2.72±1.03, respectively. The mean HAQ-DI score was 0.91±0.66. The Cronbach's alpha was 0.97 indicating excellent internal consistency reliability. There was a statistically significant correlation between the two measurements of DHI. The ICC value for total score was 0.88 indicating good reliability. There was a statistically significantly positive correlation between the DHI and BQ (r=0.638, p<0.001). Also, DHI was significantly correlated with the HAQ-DI (0.613, p<0.001).

Conclusion

Our study results suggest that DHI is a reliable and valid test which can be used for evaluating hand functions in CTS patients.

What Types of Treatment Are Provided for Patients With Carpal Tunnel Syndrome? A Retrospective Analysis of Commercial Insurance

BACKGROUND

Treatment of carpal tunnel syndrome (CTS) in commercially insured patients across the spectrum of provider types rarely has been described.

OBJECTIVE

To describe patterns of types of treatment for patients with CTS using a large commercial insurance database.

DESIGN

Retrospective cohort descriptive study.

SETTING

Administrative health data from the Clinformatics Data Mart (OptumInsight, Eden Prairie, MN).

PATIENTS

Adults with a primary diagnosis of CTS seen from between January 2010 to December 2012 who had a total of 48 months of continuous data (12 months before diagnosis and 36 months after diagnosis) (n = 24,931).

OUTCOMES

Frequency of types of treatment (heat, manual therapy, positioning, steroids, stretching, surgery) by number of treatments, number of visits, provider type, and characteristics.

RESULTS

Fifty-four percent of patients received no reported treatment, and 50.4% had no additional visits. Surgery (42.5%) and positioning (39.8%) were the most frequent single treatments. Patients who were seen by orthopedist for their first visit more frequently received some treatment (75.1%) and at least 1 additional visit (74.1%) compared with those seen by general practitioners (59.5%, 57.5%, respectively) or other providers (65.4%, 68.4, respectively). Orthopedists more frequently prescribed positioning devices (26.8%) and surgery (36.8%) than general practitioners (18.8%, 14.1%, respectively) or other providers (15.7%, 19.7%, respectively). Older adults more frequently had CTS surgery, as did people who lived in the Midwest. Overall, only 24% of patients with CTS had surgery.

CONCLUSIONS

For more than one-half of patients with CTS no treatment was provided after an initial visit. Surgery rates were much lower than what has previously been reported in the literature. Generally, patients with CTS receive treatments that are supported by current treatment guidelines.

LEVEL OF EVIDENCE

NA.

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.

Quality of Care for Work-Associated Carpal Tunnel Syndrome

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.

Assessing the Value of High-Quality Care for Work-Associated Carpal Tunnel Syndrome in a Large Integrated Health Care System: Study Design

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.

Symptom severity and conservative treatment for carpal tunnel syndrome in association with eventual carpal tunnel release

PURPOSE

To study the relationship between the severity of carpal tunnel syndrome (CTS) symptoms and surgery for CTS and the relationship between conservative treatments and surgery for CTS.

METHODS

A secondary analysis of baseline to 6-month data from a randomized controlled trial, which examined the effectiveness of orthosis/stretch combinations on the symptoms of CTS, was conducted for a total of 96 participants with CTS. Participants completed the Carpal Tunnel Questionnaire and posttreatment surveys. Statistical analyses included exploration of correlates of progression to surgery for CTS and logistical regression to examine the association between conservative treatments and CTS symptoms and progression to surgery for CTS.

RESULTS

Twenty-one participants received surgery for their CTS, and 31 participants received 1 or more conservative treatments. Severity of baseline CTS symptoms and additional treatments were indicators of progression to surgery. The randomized controlled trial intervention was inversely associated with progression to surgery.

CONCLUSIONS

CTS that does not respond to an initial course of conservative treatment may not improve with additional treatments. More than half of the participants who received additional conservative treatment still progressed to surgery. Current intervention guidelines for CTS provide limited guidance as to the best methods to efficiently treat CTS.

CLINICAL RELEVANCE

CTS is a costly and high-burden disorder, resulting in reduced quality of life. Research should examine when and for whom conservative care is an effective choice and the association between conservative care and the eventual need for CTS surgery.

Investigating the Effectiveness of Full-Time Wrist Splinting and Education in the Treatment of Carpal Tunnel Syndrome: A Randomized Controlled Trial

This study investigated the effects of wearing a wrist support splint for 8 wk and receiving a formal education program on patients with carpal tunnel syndrome (CTS), as well as factors associated with patients’ desire to seek surgical intervention. Participants were recruited from a hospital surgical wait list and randomly assigned to an intervention group (n = 30) or a control group (n = 24). Significant improvements in measures of symptom severity and functional status over the duration of the study appeared in the intervention group but not in the control group. Logistic regression for the intervention group showed that symptom severity (odds ratio [OR] = 1.53, 95% confidence interval [CI] [1.20–1.93]), functional deficits (OR = 1.31, 95% CI [1.08–1.57]), pain score (OR = 1.25, 95% CI [1.11–1.61]), and symptom duration (OR = 1.11, 95% CI [1.01–1.24]) were positively associated with the desire to seek surgical intervention. This conservative CTS treatment program conducted by occupational therapists can improve symptoms and hand function in CTS patients.

Clinical quality measures for intraoperative and perioperative management in carpal tunnel surgery

BACKGROUND

Previous research documents suboptimal preoperative or postoperative care for patients undergoing surgery. However, few existing quality measures directly address the fundamental element of surgical care: intra-operative care processes. This study sought to develop quality measures for intraoperative, preoperative, and postoperative care for carpal tunnel surgery, a common operation in the USA.

METHODS

We applied a variation of the well-established RAND/UCLA Appropriateness Method. Adherence to measures developed using this method has been associated with improved patient outcomes in several studies. Hand surgeons and quality measurement experts developed draft measures using guidelines and literature. Subsequently, in a two-round modified-Delphi process, a multidisciplinary panel of 11 national experts in carpal tunnel syndrome (including six surgeons) reviewed structured summaries of the evidence and rated the measures for validity (association with improved patient outcomes) and feasibility (ability to be assessed using medical records).

RESULTS

Of 25 draft measures, panelists judged 22 (88%) to be valid and feasible. Nine intraoperative measures addressed the location and extent of surgical dissection, release after wrist trauma, endoscopic release, and four procedures sometimes performed during carpal tunnel surgery. Eleven measures covered preoperative and postoperative evaluation and management.

CONCLUSIONS

We have developed several measures that experts, including surgeons, believe to reflect the quality of care processes occurring during carpal tunnel surgery and be assessable using medical records. Although quality measures like these cannot assess a surgeon's skill in handling the instruments, they can assess many important aspects of intraoperative care. Intraoperative measures should be developed for other procedures.