Evaluation of PROMIS' Ability to Detect Immediate Postoperative Symptom Improvement Following Carpal Tunnel Release

Association of Patient-Reported Outcomes Measurement Information System Measures With Injection and Surgical Treatment Response in Patients With De Quervain Tenosynovitis

PURPOSE

Treatment of de Quervain tenosynovitis is largely empiric. Patient-Reported Outcomes Management Information System (PROMIS) scores at the time of diagnosis might provide insights into the probability of success of nonsurgical management and predict the necessity for surgical treatment. We aimed to identify which, if any, of the PROMIS metrics may be used to identify patients who will opt for surgery or be managed with injection alone.

METHODS

Patients presenting to a tertiary academic medical center from 2014 to 2019, with a sole diagnosis of de Quervain tenosynovitis, were identified and separated by initial and most invasive treatment of either injection or surgery. These groups were then dichotomized using cut points of more than one SD from the mean on the PROMIS physical function and pain interference scales, and a logistic regression model was used to determine the odds ratio of surgical intervention.

RESULTS

Patients who had low physical function or high pain interference had significantly increased odds of ultimately undergoing surgery. Age ranging from 40 to 60 years and female sex were also associated with increased odds of undergoing surgery.

CONCLUSIONS

Patients who scored lower than 40 for physical function or higher than 60 for pain interference had significantly increased odds of eventually undergoing surgical release for de Quervain tenosynovitis. PROMIS scores may identify patients who are likely to fail steroid injections as a sole nonsurgical intervention and inform an individualized discussion about surgical management of this condition.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Older Patients Demonstrate PROMIS Outcomes Comparable to Younger Cohorts After Carpal Tunnel Release

BACKGROUND

The utility of Patient-Reported Outcomes Measurement Information System (PROMIS) in monitoring clinical progress after carpal tunnel release (CTR) in patients of different ages remains unknown. We sought to evaluate early PROMIS scores in elderly patients (ie, those aged ≥65 years) after CTR and compare those with all younger patients after CTR.

METHODS

Patients presenting to a single academic medical center for CTR between September 2018 and January 2020 completed PROMIS physical function (PF), pain interference (PI), and upper extremity (UE) computer adaptive tests and answered a single 5-point Likert-scale question evaluating subjective changes in their condition following CTR. Patients were divided into 3 age groups, and preoperative and postoperative PROMIS scores were compared.

RESULTS

In all, 214 patients fit inclusion criteria: 86 aged 18-54 years, 71 aged 55-64 years, and 57 aged ≥65 years. Subjective improvement was reported in 70.9% (n = 61), 84.5% (n = 60), and 71.9% (n = 41) of patients aged ≤54, 55-64, and ≥65 years, respectively. Patients aged ≤54 years showed significantly worse UE scores (P = .02), whereas those aged 55-64 years demonstrated significant worsening in all 3 PROMIS domains (P < .01). Patients aged ≥65 years who reported subjective improvement after CTR demonstrated significant improvement in PI scores (P = .03), whereas significant worsening of all PROMIS scores was observed in the subset of patients aged 55-64 years who reported subjective improvement (P < .01, .04, and .04 for PF, PI, and UE, respectively).

CONCLUSIONS

Younger patients showed worsening in PROMIS scores after CTR, whereas elderly patients did not show similar magnitude reductions in PROMIS scores. Moreover, the subset of elderly patients endorsing subjective improvement after CTR had reduced PI scores, consistent with less postoperative pain limitations.

What are the Minimum Clinically Important Difference Values for the PROMIS and QuickDASH After Carpal Tunnel Release? A Prospective Cohort Study

BACKGROUND

To better define the clinical significance of patient-reported outcomes, the concept of a minimum clinically important difference (MCID) exists. The MCID is the minimum change that a patient will perceive as meaningful. Prior attempts to determine the MCID after carpal tunnel release are limited by methodologic concerns, including the lack of a true anchor-based MCID calculation.

QUESTIONS/PURPOSES

To address previous methodologic concerns in existing studies, as well as establish a clinically useful value for clinicians, we asked: What are the MCID values for the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE), PROMIS Pain Interference (PI), and the QuickDASH after carpal tunnel release?

METHODS

We conducted a prospective cohort study at an urban, Midwest, multihospital, academic health system. One hundred forty-seven adult patients undergoing unilateral carpal tunnel release between September 2020 and February 2022 were identified. PROMIS UE, PI, and QuickDASH scores were collected preoperatively and 3 months postoperatively. We also collected responses to an anchor-based question: "Since your treatment, how would you rate your overall function?" (much worse, worse, slightly worse, no change, slightly improved, improved, or much improved). Patients who did not respond to the 3-month postoperative surveys were excluded. A total of 122 patients were included in the final analysis (83% response proportion [122 of 147]). The mean age was 57 years (range 23 to 87 years), and 68% were women. The MCID was calculated using both anchor-based and distribution-based methods. Although anchor-based calculations are generally considered more clinically relevant because they consider patients' perceptions of improvement, an estimation of the minimum detectable change (which represents measurement error) relies on a distribution-based calculation. We determined a range of MCID values to propose a final MCID value for all three instruments. A negative MCID value for the PROMIS PI instrument represents a decrease in pain, whereas a positive value for the PROMIS UE instrument represents an improvement in function. A negative value for the QuickDASH instrument represents an increase in function.

RESULTS

The final proposed MCID values were 6.2 (interquartile range [IQR] 5.4 to 9.0) for the PROMIS UE, -7.8 (IQR -6.1 to -8.5) for the PROMIS PI, and -18.2 (IQR -13.3 to -34.1) for the QuickDASH.

CONCLUSION

We recommend that clinicians use the following values as the MCID after carpal tunnel release: 6 for the UE, -8 for the PI, and -18 for the QuickDASH. Surgeons may find these values useful when counseling patients postoperatively regarding improvement. Future studies could examine whether a single MCID (or small range) for PROMIS instruments is applicable to a variety of conditions and interventions.

LEVEL OF EVIDENCE

Level II, therapeutic study.

The Effect of Socioeconomic Disparity on Improvement in QuickDASH at 3 Months after Carpal Tunnel Release

The primary objective of this study was to determine the association between socioeconomic disparity and improvement in QuickDASH score 3 months after carpal tunnel release (CTR). The secondary objectives of this study were to determine the association between socioeconomic disparity and baseline preoperative QuickDASH score and 3 months postoperative QuickDASH score after CTR.

Methods

A single-institutional, prospective, longitudinal study was performed of 85 patients who underwent isolated, unilateral CTR for idiopathic carpal tunnel syndrome. Sixty-three patients (74%) who completed patient-reported outcome measures at 3 months after surgery comprised our study cohort. Socioeconomic disparity was assessed using the zip code level Distressed Communities Index (DCI) and the neighborhood level Area Deprivation Index. The outcome variables were the improvement in the QuickDASH score, 3 months postoperative QuickDASH score, and the preoperative QuickDASH score. Associations between continuous variables were assessed using simple linear regression.

Results

The mean DCI of the study cohort was in the 23rd national percentile, and the mean Area Deprivation Index was in the 15th national percentile. The mean preoperative QuickDASH of the study cohort was 49.3. The mean 3 months postoperative QuickDASH of the study cohort was 29.8. The mean improvement in QuickDASH at 3 months after surgery was 19.5, which was statistically significant and clinically meaningful. Area Deprivation Index and DCI were not associated with improvement in QuickDASH score or 3 months postoperative QuickDASH score. Higher DCI was associated with poorer baseline preoperative QuickDASH score.

Conclusion

Patients of various socioeconomic backgrounds can expect similar short-term improvements in symptoms and function after CTR.

The Responsiveness of the Patient-Reported Outcomes Measurement Information System Upper Extremity and Physical Function in Patients With Cubital Tunnel Syndrome

PURPOSE

The Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) and PROMIS Physical Function (PF) are increasingly referenced patient-reported outcomes. To interpret treatment effects with these patient-reported outcomes, investigators must understand magnitudes of change that represent clinically relevant improvement. This study assessed the responsiveness of PROMIS UE and PF in patients with cubital tunnel syndrome.

METHODS

A retrospective analysis of PROMIS UE and PROMIS PF computer adaptive test scores was performed for patients treated nonoperatively for cubital tunnel syndrome over 3 years at a tertiary institution. The Patient-Reported Outcomes Measurement Information System UE and PROMIS PF outcome scores were collected at initial and return clinic visits. At follow-up appointments, patients completed clinical anchor questions evaluating their degree of interval clinical improvement. Anchor questions allowed categorization of patients into groups that had experienced "no change," "minimal change," and "much change." Minimal clinically important difference (MCID) values were calculated for the PROMIS assessments with anchor-based and distribution-based methods.

RESULTS

A total of 304 patients with PROMIS PF scores and 111 with PROMIS UE scores were analyzed. The MCID for the PROMIS UE was 3.1 (95% confidence interval, 1.4-4.8) using the anchor-based method and 3.7 (95% confidence interval, 2.9-4.4) using the distribution-based method. These point estimates exceeded the minimal detectable change of 2.3. The MCID for the PROMIS PF was unable to be determined in this patient sample because patients reporting mild change did not have score changes exceeding measurement error.

CONCLUSIONS

The PROMIS UE v2.0 computer adaptive test detected minimal change in patients managed nonoperatively for cubital tunnel syndrome with an estimated MCID range of 3.1-3.7. While PROMIS PF has demonstrated acceptable performance in patients with a variety of upper extremity conditions, for cubital tunnel syndrome, it was less able to detect subtle change. PROMIS UE appears more responsive to subtle changes in cubital tunnel syndrome symptoms.

CLINICAL RELEVANCE

Patient-reported outcomes may have varied responsiveness depending on the condition studied.

Boston Carpal Tunnel Questionnaire Scores Alone Do Not Predict Surgical Intervention for Patients With Carpal Tunnel Syndrome

BACKGROUND

With the expanded indications for telemedicine, there is increased utility for screening methods to determine which patients are likely to progress to surgical intervention, requiring in-person visits. Patient-rated tools such as the Boston Carpal Tunnel Questionnaire (BCTQ) may be one such tool for screening patients with carpal tunnel syndrome (CTS). The aim of the study was to evaluate whether BCTQ scores were predictive of offering conservative treatment or surgical intervention for CTS.

METHODS

Patients diagnosed with CTS from January 2017 to February 2020 completed BCTQ questionnaires prior to in-person office visits. Demographics, comorbidities, and highest level of intervention recommended were recorded for each patient as conservative, injection, or surgery. Pearson χ2 and independent-samples t tests were conducted to determine whether BCTQ symptom severity and functional scores were associated with intervention type.

RESULTS

A total of 200 patients with CTS were included. Of these, 103 were recommended conservative or injection treatment and 97 were recommended surgery. There were no differences in comorbidities between groups, including other upper extremity pathology (P = .57), previous upper extremity surgery (P = .32), hypertension (P = .17), hypothyroidism (P = .15), rheumatoid arthritis (P = .34), and diabetes (P = .30). Between these groups, there were no differences in BCTQ symptom severity score (symptom severity scale [SSS]; P = .16) or BCTQ functional severity score (functional severity scale [FSS]; P = .96).

CONCLUSIONS

There is no correlation between comorbidities and BCTQ SSS or FSS score, and offering surgery for CTS. In an era of minimizing non-essential health care visits, the BCTQ is insufficient in screening patients as potential surgical candidates.

Evaluation of PROMIS Scores 6 Weeks after Conservative Management of Carpometacarpal Thumb Arthritis

Patient-reported outcome measures are being increasingly emphasized to assign value to care‚ given the current trend toward pay-for-performance healthcare. We sought to determine if the Patient-reported Outcomes Measurement Information System (PROMIS), a general questionnaire, is sensitive enough to detect improvement after corticosteroid injection or splinting/hand therapy for thumb carpometacarpal (CMC) arthritis.

Bringing Patient-Reported Outcome Measures (PROMs) Into Practice: A Review of the Latest Developments in PROM Use in the Evaluation and Treatment of Carpal Tunnel Syndrome

As health care systems globally shift toward optimizing value, defined as health outcomes achieved per dollar spent across a full cycle of care, there has been increasing focus on using patient-reported outcome measures (PROMs) to gauge success. Patient-reported outcome measures are validated questionnaires that allow patients to share their health status across several domains (eg, pain or physical function). This trend has been particularly notable in hand surgery, with PROM use investigated for many common hand conditions, including carpal tunnel syndrome, Dupuytren contracture, trigger finger, osteoarthritis, and wrist ganglion. The purpose of this article is to review recent developments in the use of PROM instruments, including the Boston Carpal Tunnel Questionnaire; Michigan Hand Outcomes Questionnaire; Disabilities of the Arm, Shoulder, and Hand; and Patient-Reported Outcomes Measurement Information System, for the evaluation and treatment of patients with carpal tunnel syndrome. The considerable progress in establishing PROMs for use in carpal tunnel syndrome is reviewed, and future improvements are proposed to standardize PROM use and bring PROMs into day-to-day clinical practice for individualized patient treatment decision-making and counseling.

Developing Machine Learning Algorithms to Support Patient-centered, Value-based Carpal Tunnel Decompression Surgery

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