Pearls: Effective Communication Strategies for the Biopsychosocial Paradigm of Musculoskeletal Medicine

Approach to Tendinopathies of the Upper Limb: What Works

Tendinopathies are some of the most common diagnoses treated by hand surgeons. Diagnoses such as trigger digit, de Quervain tenosynovitis, extensor carpi ulnaris tendinitis, and epicondylitis often resolve with nonoperative treatment and/or a single ambulatory procedure. When symptoms persist or worsen after surgery, patients are disappointed and treatment can be challenging. This article reviews practical points in evaluation of such cases, and surgical options that work in revision scenarios.

Mental Health Among People Presenting for Care of Physical Symptoms: The Factors Associated with Suicidality and Symptoms of Depression and Anxiety are Similar Across Specialties

Background

To identify differences in thoughts of suicide and symptoms of depression and anxiety by specialty among people presenting for care of physical symptoms, we analyzed data from routine mental health measurement in a small multispecialty practice and asked: 1. Are there any differences in suicidality (analyzed as an answer of 1 or greater or 2 or greater on the Patient Health Questionnaire [PHQ] question 9) in non-specialty and various types of specialty care? 2. Are there any factors-including specialty-associated with symptoms of depression (mean PHQ score), PHQ thresholds (greater than 0, 3 or greater, 10 or greater), Generalized Anxiety Disorder instrument [GAD] score of 3 or greater, and either GAD score 3 or greater or PHQ score 3 or greater? and 3. What factors are associated with referral to a social worker?

Methods

As part of routine specialty and non-specialty care, 13,211 adult patients completed a measure of symptoms of depression (PHQ) that included a question about suicidality and a measure of symptoms of anxiety (GAD). Factors associated with suicidality and symptoms of depression and anxiety at various thresholds, and visit with a social worker, were sought in multivariable models.

Results

Accounting for potential confounding in multivariable analyses, a score higher than 0 on the suicidality question (present in 18% of people) was associated with men, younger age, English-speakers, and neurodegenerative specialty care. Symptoms of depression on their continuum and using various thresholds (28% of people had a PHQ score greater than 2) were associated with non-Spanish-speakers, younger age, women, and county insurance or Medicaid insurance. Care from the social worker was associated with PHQ score of 3 or greater and having any suicidal thoughts (score of 1 or greater on question 9) but was less common with Medicare or Commercial Insurance and less common in the unit treating cognitive decline.

Conclusion

The notable prevalence of symptoms of depression and suicidality among people presenting for care of physical symptoms across specialties and the relatively similar factors associated with suicidality, symptoms of depression, and symptoms of anxiety at various thresholds suggests that both non-specialty and specialty clinicians can be vigilant for opportunities for improved mental health. Increased recognition that people seeking care for physical symptoms often have mental health priorities has the potential to improve comprehensive care strategies, alleviate distress, and reduce suicide.

Preoperative Patient-Reported Data Indicate the Risk of Prolonged Opioid Use After Hand and Upper Extremity Surgeries

PURPOSE

Opioids play an important role in pain management after surgery but also increase the risk of prolonged opioid use in patients. The identification of patients who are more likely to use opioids after intended short-term treatment is critical for employing alternative management approaches or targeted interventions for the prevention of opioid-related problems. We used patient-reported data (PRD) and electronic health record information to identify factors predictive of prolonged opioid use after surgery.

METHODS

We used our institutional registry containing data on all patients who underwent elective upper extremity surgeries. We evaluated factors associated with prolonged opioid use in the cohort from the year 2018 to 2019. We then validated our results using the 2020 cohort. The predictive variables included preoperative PRD and electronic health record data. Opioid use was determined based on patient reports and/or filled opioid prescriptions 3 months after surgery. We conducted bivariate regression, followed by multivariable regression analyses, and model validation using area under the receiver operating curve.

RESULTS

We included 2,114 patients. In our final model on the 2018-2019 electronic health records and PRD data (n = 1,589), including numerous patient-reported outcome questionnaire scores, patients who were underweight and had undergone trauma-related surgery had higher odds of being on opioids at 3 months. Additionally, each 5-unit decrease in the preoperative Patient-Reported Outcomes Measurement Information System Global Physical Health score was associated with a 30% increased odds of being on opioids at 3 months. The area under the receiver operating curve of our model was 70.4%. On validation using data from the 2020 cohort, the area under the receiver operating curve was 60.3%. The Hosmer-Lemeshow test indicated a good fit.

CONCLUSIONS

We found that preoperative questionnaire scores were associated with prolonged postoperative opioid use, independent of other variables. Furthermore, PRD may provide unique patient-level insights, alongside other factors, to improve our understanding of postsurgical pain management.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.