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Malik AT, Lin JS, Jain S, Awan H, Khan SN, Goyal KS. Interspecialty Variation in Perioperative Health Care Resource Usage for Carpal Tunnel Release. Hand (N Y) 2024:15589447241233710. [PMID: 38420784 DOI: 10.1177/15589447241233710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND We investigated whether any interspecialty variation exists, regarding perioperative health care resource usage, in carpal tunnel releases (CTRs). METHODS The 2010 to 2021 PearlDiver Mariner Database, an all-payer claims database, was queried to identify patients undergoing primary CTRs. Physician specialty IDs were used to identify the specialty of the surgeon-orthopedic versus plastic versus general surgery versus neurosurgery. Multivariate logistic regression analysis was used to identify whether there was any interspecialty variation between the use of health care resources. RESULTS A total of 908 671 patients undergoing CTRs were included, of which 556 339 (61.2%) were by orthopedic surgeons, 297 047 (32.7%) by plastic surgeons, 44 118 (4.9%) by neurosurgeons, and 11 257 (1.2%) by general surgeons. In comparison with orthopedic surgeons, patients treated by plastic surgeons were less likely to have received opioids, nonsteroidal anti-inflammatory drugs, oral steroids, and preoperative antibiotic prophylaxis but were more likely to have received steroid injections and electrodiagnostic studies (EDSs) preoperatively. Patients treated by neurosurgeons were more likely to have received preoperative opioids, gabapentin, oral steroids, preoperative antibiotic prophylaxis, EDSs, and formal preoperative physical/occupational therapy and less likely to have received steroid injections. Patients treated by general surgeons were less likely to receive oral steroids, steroid injections, EDSs, preoperative formal physical therapy, and preoperative antibiotic prophylaxis, but were more likely to be prescribed gabapentin. CONCLUSIONS There exists significant variation in perioperative health care resource usage for CTRs between specialties. Understanding reasons behind such variation would be paramount in minimizing differences in how care is practiced for elective hand procedures.
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Affiliation(s)
| | - James S Lin
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sonu Jain
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Hisham Awan
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Safdar N Khan
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kanu S Goyal
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Dahlin LB, Perez R, Nyman E, Zimmerman M, Merlo J. Overuse of the psychoactive analgesics' opioids and gabapentinoid drugs in patients having surgery for nerve entrapment disorders. Sci Rep 2023; 13:16248. [PMID: 37758760 PMCID: PMC10533484 DOI: 10.1038/s41598-023-43253-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 09/21/2023] [Indexed: 09/29/2023] Open
Abstract
Knowledge about risks for overuse of psychoactive analgesics in patients having primary surgery for carpal tunnel syndrome (CTS) or ulnar nerve entrapment (UNE), or both, is limited. We investigated if patients with those nerve entrapment disorders have a higher risk of overuse of psychoactive analgesics (i.e., opioids and gabapentinoid drugs) before, after, and both before and after surgery than observed in the general population after accounting for demographical and socioeconomic factors. Using a large record linkage database, we analysed 5,966,444 individuals (25-80 years), residing in Sweden December 31st, 2010-2014, of which 31,380 underwent surgery 2011-2013 for CTS, UNE, or both, applying logistic regression to estimate relative risk (RR) and 95% confidence interval (CI). Overall, overuse of the psychoactive analgesics was low in the general population. Compared to those individuals, unadjusted RR (95% CI) of overuse ranged in patients between 2.77 (2.57-3.00) with CTS after surgery and 6.21 (4.27-9.02) with both UNE and CTS after surgery. These risks were only slightly reduced after adjustment for demographical and socioeconomic factors. Patients undergoing surgery for CTS, UNE, or both, have a high risk of overuse of psychoactive analgesics before, after, and both before and after surgery.
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Affiliation(s)
- Lars B Dahlin
- Department of Translational Medicine - Hand Surgery, Skåne University Hospital, Lund University, Jan Waldenströms g 5, 20502, Malmö, Sweden.
- Department of Hand Surgery, Skåne University Hospital, 20502, Malmö, Sweden.
- Department of Biomedical and Clinical Sciences, Linköping University, 58183, Linköping, Sweden.
| | - Raquel Perez
- Department of Translational Medicine - Hand Surgery, Skåne University Hospital, Lund University, Jan Waldenströms g 5, 20502, Malmö, Sweden
- Unit for Social Epidemiology, Department of Clinical Sciences (Malmö), Faculty of Medicine, Lund University, 20502, Malmö, Sweden
| | - Erika Nyman
- Department of Biomedical and Clinical Sciences, Linköping University, 58183, Linköping, Sweden
- Department of Hand Surgery, Plastic Surgery and Burns, Linköping University Hospital, 58183, Linköping, Sweden
| | - Malin Zimmerman
- Department of Translational Medicine - Hand Surgery, Skåne University Hospital, Lund University, Jan Waldenströms g 5, 20502, Malmö, Sweden
- Department of Hand Surgery, Skåne University Hospital, 20502, Malmö, Sweden
- Department of Orthopedics, Helsingborg Hospital, Helsingborg, Sweden
| | - Juan Merlo
- Unit for Social Epidemiology, Department of Clinical Sciences (Malmö), Faculty of Medicine, Lund University, 20502, Malmö, Sweden
- Center for Primary Health Research, Region Skåne, 20502, Malmö, Sweden
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Bongiovanni T, Gan S, Finlayson E, Ross JS, Harrison JD, Boscardin WJ, Steinman MA. Trends in the Use of Gabapentinoids and Opioids in the Postoperative Period Among Older Adults. JAMA Netw Open 2023; 6:e2318626. [PMID: 37326989 PMCID: PMC10276300 DOI: 10.1001/jamanetworkopen.2023.18626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 05/02/2023] [Indexed: 06/17/2023] Open
Abstract
Importance In response to the opioid epidemic, recommendations from some pain societies have encouraged surgeons to embrace multimodal pain regimens with the intent of reducing opioid use in the postoperative period, including by prescribing gabapentinoids. Objective To describe trends in postoperative prescribing of both gabapentinoids and opioids after a variety of surgical procedures by examining nationally representative Medicare data and further understand variation by procedure. Design, Setting, and Participants This serial cross-sectional study of gabapentinoid prescribing from January 1, 2013, through December 31, 2018, used a 20% US Medicare sample. Gabapentinoid-naive patients 66 years or older undergoing 1 of 14 common noncataract surgical procedures performed in older adults were included. Data were analyzed from April 2022 to April 2023. Exposure One of 14 common surgical procedures in older adults. Main Outcomes and Measures Rate of postoperative prescribing of gabapentinoids and opioids, defined as a prescription filled between 7 days before the procedure and 7 days after discharge from surgery. Additionally, concomitant prescribing of gabapentinoids and opioids in the postoperative period was assessed. Results The total study cohort included 494 922 patients with a mean (SD) age of 73.7 (5.9) years, 53.9% of whom were women and 86.0% of whom were White. A total of 18 095 patients (3.7%) received a new gabapentinoid prescription in the postoperative period. Of those receiving a new gabapentinoid prescription, 10 956 (60.5%) were women and 15 529 (85.8%) were White. After adjusting for age, sex, race and ethnicity, and procedure type in each year, the rate of new postoperative gabapentinoid prescribing increased from 2.3% (95% CI, 2.2%-2.4%) in 2014 to 5.2% (95% CI, 5.0%-5.4%) in 2018 (P < .001). While there was variation between procedure types, almost all procedures saw an increase in both gabapentinoid and opioid prescribing. In this same period, opioid prescribing increased from 56% (95% CI, 55%-56%) to 59% (95% CI, 58%-60%) (P < .001). Concomitant prescribing also increased from 1.6% (95% CI, 1.5%-1.7%) in 2014 to 4.1% (95% CI, 4.0%-4.3%) in 2018 (P < .001). Conclusions and Relevance The findings of this cross-sectional study of Medicare beneficiaries suggest that new postoperative gabapentinoid prescribing increased without a subsequent downward trend in the proportion of patients receiving postoperative opioids and a near tripling of concurrent prescribing. Closer attention needs to be paid to postoperative prescribing for older adults, especially when using multiple types of medications, which can have adverse drug events.
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Affiliation(s)
- Tasce Bongiovanni
- Department of Surgery, University of California, San Francisco, School of Medicine
| | - Siqi Gan
- Division of Geriatrics, University of California, San Francisco, School of Medicine
- Northern California Institute for Research and Education, San Francisco
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, School of Medicine
| | - Joseph S. Ross
- Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut
| | - James D. Harrison
- Division of Hospital Medicine, University of California, San Francisco, School of Medicine
| | - W. John Boscardin
- Department of Medicine, University of California, San Francisco, School of Medicine
- Department of Epidemiology and Biostatistics, University of California, San Francisco, School of Medicine
| | - Michael A. Steinman
- Division of Geriatrics, University of California, San Francisco, School of Medicine
- San Francisco Veterans Affairs Medical Center, San Francisco, California
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Ghițan AF, Gheorman V, Pîrvu D, Gheorman V, Udriștoiu I, Ciurea ME. A Review of Psychological Outcomes in Patients with Complex Hand Trauma: A Multidisciplinary Approach. CURRENT HEALTH SCIENCES JOURNAL 2023; 49:143-150. [PMID: 37779837 PMCID: PMC10541061 DOI: 10.12865/chsj.49.02.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 05/21/2023] [Indexed: 10/03/2023]
Abstract
This systematic review aimed to assess the psychological outcomes in patients with complex hand trauma and explore the importance of a multidisciplinary approach in addressing both physical and mental health needs. The study employed a rigorous methodology, including a comprehensive search of relevant databases, strict inclusion and exclusion criteria, and data synthesis from the included studies. The results demonstrated the significant negative psychological impact of complex hand trauma on patients' overall health and quality of life. This trauma affected patients emotionally, psychologically, and physically, highlighting the essential role of hand function in performing daily activities. The findings emphasize the need for continued research aimed at identifying effective psychological interventions to support the rehabilitation of patients with complex hand trauma. Providing these patients with multidisciplinary care, addressing both the physical and mental health components of recovery, can result in a more favorable long-term outcome.
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Affiliation(s)
| | - Veronica Gheorman
- Department of Cardiology, University of Medicine and Pharmacy of Craiova, Romania
| | - Daniel Pîrvu
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, Romania
| | - Victor Gheorman
- Department of Psychiatry, University of Medicine and Pharmacy of Craiova, Romania
| | - Ion Udriștoiu
- Department of Psychiatry, University of Medicine and Pharmacy of Craiova, Romania
| | - Marius Eugen Ciurea
- Department of Plastic Surgery, University of Medicine and Pharmacy of Craiova, Romania
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Billig JI, Gunaseelan V, Yazdanfar M, Sears ED, Iwashyna TJ, Chang T, Waljee JF. Gabapentinoid Prescribing for Carpal Tunnel Syndrome. Hand (N Y) 2023; 18:106S-113S. [PMID: 35225033 PMCID: PMC9896291 DOI: 10.1177/15589447211063544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Gabapentinoids, including gabapentin and pregabalin, are commonly prescribed for neuropathic pain, but robust evidence recommends against using gabapentinoids for the treatment of carpal tunnel syndrome (CTS). We aimed to quantify national prescribing patterns of gabapentinoids for CTS. METHODS We performed a retrospective population-based cohort study using claims data of gabapentinoid-naïve patients with a new diagnosis of CTS (2009-2016). Our primary outcome was a new gabapentinoid fill for CTS. We assessed temporal trends and characteristics associated with a gabapentinoid fill. Multivariable logistic regression was used to evaluate the association between patient-level factors and a new gabapentinoid fill for CTS. RESULTS Of the 248 324 previously gabapentinoid-naïve patients with CTS, 9589 patients (4%) filled a gabapentinoid prescription. Sixty-one percent were prescribed by primary care providers or medical subspecialists. Patients with a history of neck pain (odds ratio [OR]: 1.31, 95% confidence interval [CI], 1.25-1.38), back pain (OR: 1.25, 95% CI, 1.20-1.31), arthritis (OR: 1.25, 95% CI, 1.18-1.31), and other pain conditions (OR: 1.26, 95% CI, 1.20-1.31) were associated with an increased odds of a new gabapentinoid fill. In addition, patients with a history of alcohol or substance use disorder were significantly associated with a new gabapentinoid prescription fill (OR: 1.33, 95% CI, 1.20-1.47). CONCLUSIONS Despite evidence recommending against the use of gabapentinoids for CTS, gabapentinoids were frequently initiated among those with higher risk for misuse, including substance use disorders. Given the effectiveness of bracing or surgery for CTS and the risks associated with gabapentinoids, efforts aimed at disseminating evidence-based treatment for CTS are critical to minimize the harms of gabapentinoid misuse.
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Affiliation(s)
| | | | | | - Erika D. Sears
- University of Michigan, Ann Arbor,
USA
- VA Ann Arbor Healthcare System, MI,
USA
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Abstract
Recovery from injury involves painful movement and activity, painful stretches and muscle strengthening, and adjustment to permanent impairment. Recovery is facilitated by embracing the concept that painful movement can be healthy, which is easier when one has more hope, less worry, and greater social supports and security. Evolution of one's identity to match the new physical status is a hallmark of a healthy outcome and is largely determined by mental and social health factors. When infection, loss of alignment or fixation, and nerve issues or compartment syndrome are unlikely, greater discomfort and incapability that usual for a given pathology or stage of recovery signal opportunities for improved mental and social health. Surgeons may be the clinicians most qualified to make this discernment. A surgeon who has gained a patient's trust can start to noticed despair, worry, and unhelpful thinking such as fear of painful movement. Reorienting people to greater hope and security and a healthier interpretation of the pains associated with the body's recovery can be initiated by the surgeon and facilitated by social workers, psychologist, and physical, occupational and hand therapists trained in treatments that combine mental and physical therapies.
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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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Nonsurgical Treatment of Carpal Tunnel Syndrome: A Survey of Hand Surgeons. Plast Reconstr Surg Glob Open 2022; 10:e4189. [PMID: 35450266 PMCID: PMC9015205 DOI: 10.1097/gox.0000000000004189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/14/2022] [Indexed: 11/26/2022]
Abstract
Background The nonsurgical treatment of carpal tunnel syndrome (CTS) consists of multiple modalities: splinting, corticosteroid injections, hand therapy, and oral medications. However, data supporting the effectiveness of these different modalities are varied, thus creating controversy regarding the optimal nonsurgical treatment. It is unknown how current hand surgeons utilize nonsurgical treatments for CTS. Methods An anonymous web-based survey was sent to 3289 members of the American Society for Surgery of the Hand to assess nonsurgical treatment patterns for CTS. We pretested the survey using expert survey and content review and cognitively tested the survey for readability and understandability. Results We analyzed surveys from 770 hand surgeons. Of the respondents, 41.2% of respondents recommend steroid injections for the treatment of CTS, 81.3% of respondents do not believe that oral steroids are beneficial for the treatment of CTS, and 3.6% of respondents typically prescribe gabapentinoids for the treatment of CTS. In total, 561 (72.9%) respondents always, usually, or sometimes encounter patients with more than two steroid injections for CTS before hand surgeon evaluation. Conclusions There is variation in the use of nonsurgical modalities for the treatment of CTS among American Society for Surgery of the Hand members. However, patients do not obtain long-term benefit from multiple steroid injections and gabapentinoids for the treatment of CTS, highlighting the importance of dissemination of evidence-based nonsurgical management of CTS. Collectively, these findings underscore the importance of providing clear guidelines as to which patients benefit most from nonsurgical treatments.
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