Patient Perspectives on Decision Making for Carpal Tunnel Syndrome

Exploring patient perception of decision-making in carpal tunnel release surgery: A systematic review and thematic synthesis of qualitative studies

Background

Carpal tunnel syndrome is a common condition, but some controversies remain regarding diagnostics and the most effective treatments. As a result, patients often experience decisional conflicts, especially when considering carpal tunnel release surgery. Understanding factors that influence decision-making in surgery can help clinicians better grasp patient treatment preferences and priorities, reducing decisional conflicts, and enabling patients to make informed, value-aligned choices through shared decision-making. This qualitative evidence synthesis aims to explore patient perceptions of carpal tunnel release, examine the decision-making factors, and critically appraise and synthesise the existing evidence.

Methods

A systematic search was conducted across four electronic databases (MEDLINE, EMBASE, CINAHL Ultimate, PsycINFO) from inception to August 2023, supplemented by referencing and citation searching to identify eligible qualitative studies. Thematic synthesis was adopted as synthesis methodology, involving a line-by-line coding of the primary study findings, and the development of descriptive and analytical themes. Quality appraisal was conducted using the modified Critical Appraisal Skills Programme checklist, supplemented with the COnsolidated criteria for REporting Qualitative research checklist.

Results

Synthesis of six qualitative studies encompassing 66 participants generated five analytical themes: (1) Journey to normalcy, (2) Patient-centred care, (3) Work and life considerations, (4) Weighing up alternatives, and (5) Shaping the expectations, highlighting the complexity of patient decision-making in carpal tunnel release.

Discussion

In the management of carpal tunnel syndrome, therapists should consider various decision-making factors, prioritising communication and shared decision-making. This, along with personalised interactions, achieves patient-centred care and enhances patient care quality and therapeutic alliance.

Factors Influencing Patient Experience After Cubital Tunnel Syndrome Surgery

PURPOSE

The purpose of this study was to use qualitative methodology to better understand patient experiences after cubital tunnel surgery, with the goal of identifying areas of improvement in delivery of care.

METHODS

Patients who underwent surgery (in situ decompression or anterior transposition) for cubital tunnel syndrome within the last 12 months, which was performed by one of three fellowship-trained hand surgeons, were identified. Participants were invited to an interview regarding "their experiences with ulnar nerve surgery." An interview guide with semistructured, open-ended questions regarding the decision for surgery, treatment goals, and the recovery process was used. Interim data analyses were conducted to assess emerging themes, and interviews were continued until thematic saturation was achieved.

RESULTS

Seventeen participants completed interviews; the mean age of study participants was 57 years, and 71% were women. The mean time between surgery and the interview was 6 months. Participants identified the following two key areas that could improve their surgical experience: (1) the need for detailed preoperative education about the surgery and recovery process, (2) and the importance of discussing treatment goals and expectations. Participants suggested providing both written and online resources to patients, including specific details about incision size and recovery process in education materials, and setting expectations for symptom resolution.

CONCLUSIONS

Although the overall patient experience after cubital tunnel surgery was positive, participants noted that there is a need for providing improved educational resources and counseling before surgery.

CLINICAL RELEVANCE

Addressing education and counseling needs before cubital tunnel surgery will help surgeons to improve delivery of care.

Examining the Public's Most Frequently Asked Questions About Carpal Tunnel Syndrome and Appraising Online Information About Treatment

BACKGROUND

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. Patients often search online for health information regarding common musculoskeletal complaints. Thus, the purpose of this study was to use language processing information from Google to assess the content of CTS frequently asked questions (FAQs) searched online and the transparency and quality of online CTS information.

METHODS

On March 11, 2021, we searched Google for 3 terms "carpal tunnel syndrome treatment," "carpal tunnel syndrome surgical treatment," and "carpal tunnel syndrome non-surgical treatment" until a minimum of 100 FAQs and their answer links were extracted from each search. We used Rothwell classification to categorize the FAQs. The Journal of the American Medical Association's benchmark criteria were used to assess information transparency. Information quality was assessed using the Brief DISCERN tool.

RESULTS

Our Google search returned 124 unique FAQs. Fifty-six (45.2%) were value based and most were related to the evaluation of treatment options (45/56, 80.4%). The most common source type was medical practices (26.6%). Nearly half of the answer sources (45.9%) were found to be lacking in transparency. One-way analysis of variance revealed a significant difference in mean Brief DISCERN scores among the 5 source types, F(4, 119) = 5.93, P = .0002, with medical practices averaging the worst score (13.73/30).

CONCLUSIONS

Patients are most commonly searching Google to gain information regarding CTS treatment options. Online sources such as medical practices should use widely accepted rubrics for ensuring transparency and quality prior to publishing CTS information.

Carpal Tunnel Syndrome: As Seen from the Perspective of the Patient

Carpal tunnel syndrome (CTS) is the most common nerve compression syndrome in the upper extremity and is one of the most common problems treated by hand surgeons. Despite its ubiquity-or perhaps because of it-there is a lack of unanimity regarding how best to treat CTS and what the options for treatment are. This study aimed to explore what patients find important when deciding on treatment of CTS in an effort to improve the physician-patient shared decision-making process.

Methods

An online crowdsourcing platform was used to recruit participants for this study. Study participants were first led through a clinical scenario in which the symptoms of CTS were explained. They were then asked a series of questions regarding what was important to them when deciding upon treatment. A Likert scale was used for responses.

Results

In total, 268 participant responses were included in the study. A majority of patients responded that all surveyed factors were either very important or important when considering treatment. The risk of surgery was most important, whereas postoperative pain was least important. The risk of surgery was significantly more important to patients than postoperative pain and time out of work. The cost of surgery was significantly more important to patients than postoperative pain.

Conclusions

Given the lack of consensus regarding an algorithm for the treatment of CTS, the patient's preference is increasingly important when formulating a treatment plan. The results of this study may better help physicians frame the discussion of treatment options for CTS with their patients.

Patients who have undergone total shoulder arthroplasty prefer greater surgeon involvement in shared decision making

BACKGROUND

There has been a shift in medical decision making from a paternalist model to a shared decision-making (SDM) approach, described as a patient-physician relationship where both parties collaborate to arrive on an evidence-based treatment regimen that best suits the patient's needs and values. However, there is a scarcity in evidence regarding SDM in shoulder arthroplasty. The purpose of this study was to evaluate overall patient preference for SDM and determine demographic and socioeconomic factors related to SDM preference in those undergoing shoulder arthroplasty.

METHODS

Patients aged 40-89 years who had undergone a total shoulder arthroplasty were enrolled. Two-part questionnaires were administered collecting patient demographic information and SDM subscale scores postoperatively. Bivariate and multivariate regression models were used to determine factors associated with SDM Total and subscale scores.

RESULTS

A total of 125 patients (53 male; mean age, 69.5 ± 10.4 years) who had undergone primary total shoulder arthroplasty were included. The mean Total SDM score was -2.24 ± 1.9 and the Preoperative, Operative, and Postoperative SDM subscale scores were -1.54 ± 2.0, -2.59 ± 2.2, and -2.48 ± 2.1, respectively, indicating a preference for SDM in the Preoperative subscale and surgeon-driven decision making in the total score and other 2 subscales. Multivariate regression models demonstrated a preference for surgeon decision making at both the 4-12-week postoperative period for the Preoperative subscale (odds ratio [OR] -1.03, 95% CI -2.0, -0.1, P = .039) and the 2-4-week postoperative period for the Operative subscale (OR -1.74, 95% CI -3.4, -0.1, P = .038) when compared to patients at the 2-week postoperative period. No other variables were significantly associated with any of the SDM subscale scores or Total SDM score.

CONCLUSION

Patients reported a more passive role in the decision-making process with an overall preference for a surgeon-led approach in primary total shoulder arthroplasty. Patients preferred a shared decision-making approach in regard to preoperative considerations but indicated a significant preference for surgeon-led decision making regarding day of surgery decisions. There were no correlations between SDM scores and age, sex, race, income, education level, insurance type, or treating surgeon. Overall, patients demonstrated a predilection for an SDM approach for preoperative considerations, contrary to those decisions associated with the day of surgery and postoperative care.

Task-Specific Patient Preferences for Shared Decision-Making in Hand Surgery

BACKGROUND

Shared decision-making for surgery can increase patient engagement, satisfaction, and clinical outcomes. However, the level of involvement that patients desire at each step of the decision-making process is unknown.

METHODS

The authors surveyed patients at an academic hand surgery clinic to examine the preferred role in decision-making using validated questionnaires (i.e., Control Preference Scale, Problem-Solving Decision-Making Scale, and General Self-Efficacy Scale). The Control Preference Scale assesses general treatment preferences, whereas the Problem-Solving Decision-Making Scale distinguishes between problem-solving tasks (e.g., making diagnoses, calculating risks/benefits) and decision-making tasks. Patients' self-beliefs and perceived ability to handle difficult situations were assessed with the General Self-Efficacy Scale. The authors used linear regression models and ordinal logistic regression to examine the relationship between self-efficacy and patients' preferred role in treatment decision-making.

RESULTS

Patients overall preferred an equal share of decision-making responsibility with the surgeon (mean Control Preference Scale score, 3.3 ± 0.7). Specifically, for problem-solving tasks, however, 81 percent of patients wanted to "hand over" the responsibility and 19 percent preferred shared decision-making. In contrast, for decision-making tasks, 54 percent of patients preferred shared decision-making. Each point increase in General Self-Efficacy Scale score correlated with 12 percent greater odds of preferring to retain the responsibility (OR, 1.12; 95 percent CI, 1.05 to 1.21; p = 0.001). However, self-efficacy did not show a significant effect for problem-solving tasks.

CONCLUSIONS

The authors found that patients prefer surgeons to provide expert knowledge for problem-solving tasks but desire equal share of responsibility in decision-making tasks. The authors' findings support the current shift away from the paternalistic model of surgical decision-making, and provide an effective strategy to tailor shared decision-making to align care delivery with patient preferences.

The Ability of Upper Extremity Surgeons to Assess Patient's Functional Status

PURPOSE

To compare surgeon and patient assessment of upper extremity functional status at the time of initial consultation. We hypothesized that surgeons and patients demonstrate low levels of agreement with respect to assessing pain scores, functional status, and self-efficacy.

METHODS

One hundred forty-three consecutive new patients were evaluated by 1 of 5 fellowship-trained upper extremity surgeons. Patients completed a Numeric Pain Rating Scale as well as the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE), Pain Interference (PI), and Self-Efficacy (SE) instruments. Surgeons provided their own estimates of patient function on each questionnaire at the conclusion of the visit and were blinded to the results of the patient-reported outcome measures (PROMs) for the duration of the study. Estimation errors, which represent the absolute value of the difference between the patient's actual score and the surgeon's estimated score on each questionnaire, were calculated for each questionnaire.

RESULTS

As a group, surgeons assumed that the PROMIS UE and SE scores were higher than the patients' actual scores and assumed that patients had lower PROMIS PI scores than were actually reported. Mean estimation errors for all PROMIS instruments were greater than 10 points and larger than the SD for these instruments in the general population.

CONCLUSIONS

Upper extremity surgeons demonstrate difficulty assessing their patient's self-reported functional status, pain interference, and level of self-efficacy during initial consultations.

CLINICAL RELEVANCE

Although formalized PROMs are infrequently administered in orthopedic clinics, increased utilization of these questionnaires would allow for a more accurate baseline functional assessment. When evaluating new patients in the outpatient clinic, surgeons should recognize the potential limitations of their assessments of patient-reported function.

The Critical Portions of Carpal Tunnel Surgery: A Comparison Between Opinions of Surgeons and the General Public

PURPOSE

Attending surgeons must participate in critical and key portions of procedures and otherwise be immediately available. However, surgeon-defined standards of the critical and key portions of surgery have been questioned, potentially affecting trainee graduated responsibility. This study compares the opinions of surgeons and the general public regarding what constitutes the critical portions of carpal tunnel release (CTR).

METHODS

A survey was devised inquiring about the appropriateness of surgical trainee execution of each step of CTR. Surgeons who perform CTR were queried (n = 112) and 32 (29%) responded. The survey was modified to compare responses from a sample of 184 nonmedical respondents (NMRs). The NMRs were excluded if they indicated having a career in health care.

RESULTS

Of the surgeon respondents, 94% (n = 30) had completed hand fellowship training, 53% (n = 17) declared themselves academic or affiliated with academia, and 53% (n = 17) utilized concurrent operating rooms. The NMR average age was 35.3 ± 10.3 years, 40% were female (n = 73), and they represented various regions of the United States including an assortment of socioeconomic and ethnic groups. Surgeons demonstrated significantly more hesitation with trainees performing surgical steps. Academic surgeons were significantly more comfortable having trainees performing surgical steps than nonacademic surgeons. Critical portions of CTR as agreed upon by surgeons and NMRs included incision, dissection, transverse carpal ligament division, and inspection of the median nerve for injury/complete release.

CONCLUSIONS

Surgeons are significantly less comfortable with trainee performance of CTR steps than the general public. Surgeons who regularly work with trainees are more accepting of trainee involvement than those who do not.

CLINICAL RELEVANCE

Understanding the opinions of surgeons as well as NMRs with respect to surgical trainee participation in the operating room is important to optimize the informed consent process as well as influence hospital policies that affect graduated surgical trainee autonomy.

Which Decisions For Management of Carpal Tunnel Syndrome and Distal Radius Fractures Should Be Shared?

PURPOSE

To evaluate, from the surgeon's perspective, the importance, feasibility, and appropriateness of sharing decisions during an episode of care of carpal tunnel syndrome (CTS) or distal radius fracture in patients aged greater than 65 years.

METHODS

A consortium of 9 fellowship-trained hand/upper-limb surgeons used the RAND Corporation/University of California Los Angeles Delphi Appropriateness method to evaluate the importance, feasibility, and appropriateness of sharing 27 decisions for CTS and 28 decisions for distal radius fractures in patients aged greater than 65 years. Panelists rated each measure on a scale of 1 (definitely not important/feasible/appropriate) to 9 (definitely important/feasible/appropriate) in 2 voting rounds with an intervening face-to-face discussion. Panelist agreement and disagreement were assessed using predetermined criteria.

RESULTS

Panelists achieved agreement on 16 decisions (29%) as important, 43 (78%) as feasible, and 17 (31%) as appropriate for sharing with patients. Twelve decisions met all 3 of these criteria and were therefore considered important, feasible, and appropriate to share with patients. Examples in CTS included decisions to perform extra confirmatory diagnostic testing, to have surgery, and to perform a steroid injection into the carpal tunnel. Examples in distal radius fracture management included the decision to have surgery, type of pain medication prescribed after surgery, and whether to remove the implant. The remaining 43 decisions did not reach consensus on the importance, feasibility, and appropriateness of sharing with patients.

CONCLUSIONS

Using a validated consensus-building approach, we identified 12 decisions made during an episode of care for CTS or distal radius fracture that were important, feasible, and appropriate to share with patients from the surgeon's perspective. These decisions merit inclusion in shared decision-making models (eg, preoperative patient preference elicitation tools or decision aids) to align patient preferences with care decisions.

CLINICAL RELEVANCE

Understanding which aspects of care are important, feasible, and appropriate to share with patients may improve patient-centered care by aligning patient preferences with care decisions.

The Association Between Patient-Reported Outcome Measurement Scores and Preference for Specific Interventions

To determine whether greater patient-reported symptom intensity and functional limitation influence expressed preferences for discretionary diagnostic and treatment interventions, we studied the association of patient factors and several Patient Reported Outcome Measure (PROM) scores with patient preferences for diagnostic and treatment interventions before and after the visit, a cross-sectional cohort study. One hundred and forty-three adult patients who completed several PROMs were asked their preferences for diagnostic and treatment interventions before and after a visit with an orthopedic surgeon. Patients with better physical function had fewer preferences for specific diagnostic interventions after the visit (P = .02), but PROM scores had no association with preferences for treatment interventions before or after the visit. A greater percentage of patients expressed the preference for no diagnostic or treatment intervention after the visit with a physician than before (diagnostic intervention; 2.1% before vs 30% after the visit; P ≤ .001 and treatment intervention; 2.1% before vs 17% after the visit; P ≤ .001). This study suggests that physician expertise may be more reassuring to people with more adaptive mind sets.