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Development of a Brief, 12-Item Version of the Michigan Hand Questionnaire

Waljee, Jennifer F. M.D., M.P.H., M.S.; Kim, H. Myra Sc.D.; Burns, Patricia B. M.P.H.; Chung, Kevin C. M.D., M.S.

Plastic & Reconstructive Surgery: July 2011 - Volume 128 - Issue 1 - pp 208-220
doi: 10.1097/PRS.0b013e318218fc51
Hand/Peripheral Nerve: Outcomes Articles

Background: The Michigan Hand Questionnaire is one of the most widely used hand-specific surveys that measure health status relevant to patients with acute and chronic hand disorders. However, item redundancy exists in the original version, and an abbreviated survey could minimize responder burden and offer broader applicability.

Methods: Patients (n = 422) with four specific hand conditions—rheumatoid arthritis (n = 162), thumb carpometacarpal osteoarthritis (n = 31), carpal tunnel syndrome (n = 97), and distal radius fracture (n = 132)—completed the Michigan Hand Questionnaire at two time points. Correlation analysis identified two items from each of six domains (i.e., function, activities of daily living, work, pain, aesthetics, and satisfaction). The Brief Michigan Hand Questionnaire score was calculated as the sum of the responses to the 12 items. Psychometric analysis was performed to describe the reliability, validity, and responsiveness of the Brief Michigan Hand Questionnaire.

Results: The Brief Michigan Hand Questionnaire includes 12 items that were highly correlated with the summary Michigan Hand Questionnaire score (r = 0.99, p < 0.001). The Brief Michigan Hand Questionnaire scores were highly correlated between the two time periods (r = 0.78, p < 0.001) and by disease type. Responsiveness of the Brief Michigan Hand Questionnaire was high for all diseases and similar to that of the original Michigan Hand Questionnaire.

Conclusions: The 12-item Brief Michigan Hand Questionnaire is an efficient and versatile outcomes instrument specific to hand disability that retains the psychometric properties of the original Michigan Hand Questionnaire. The Brief Michigan Hand Questionnaire is an important tool with which to measure patient outcomes and the quality of care in hand surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, I.

Figure. No caption a...

Ann Arbor, Mich.

From the Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; the Center for Statistical Consultation and Research, University of Michigan; and the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical Center.

Received for publication July 1, 2010; accepted January 3, 2011.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal's Web site (www.PRSJournal.com).

Kevin C. Chung, M.D., M.S., Section of Plastic Surgery, University of Michigan Health System, 2130 Taubman Center, SPC 5340, 1500 East Medical Center Drive, Ann Arbor, Mich. 48109-5340, kecchung@umich.edu

In the United States, health care quality is variable, difficult to measure, and not well correlated with health care expenditure. In response, health services research has focused on identifying ways of measuring health care quality efficiently and accurately.1 Efforts to measure health care quality range widely, from examining 30-day mortality or hospital readmission rates, to implementing recertification standards for physicians in practice. Hand disability presents a unique challenge for health services researchers in that traditional indicators, such as mortality or perioperative processes of care, are not sensitive enough to distinguish variations in patient outcomes.2 However, hand function has a profound effect on a patient's quality of life. Therefore, measures of patient satisfaction and disability are essential quality indicators for clinicians, researchers, and health care policy makers interested in the quality of care of upper extremity disability.

Over 25 years ago, the Socioeconomic Committee of the American Society for Surgery of the Hand advocated the development of a comprehensive instrument through rigorous methodology to measure patient outcomes following hand surgery.3 In 1998, the Michigan Hand Outcomes Questionnaire was introduced as a hand-specific outcomes instrument that can effectively measure aspects of health status that are relevant to patients with acute and chronic hand disorders.4 Today, the Michigan Hand Questionnaire is a widely used, self-administered instrument for measuring upper extremity disability and patient outcomes across a broad range of hand-related diseases. The Michigan Hand Questionnaire has been translated into eight different languages and used worldwide for a range of acute and chronic hand conditions, including, trauma, nerve compression syndromes, arthritis, and inflammatory conditions.5–19 The Michigan Hand Questionnaire comprehensively gathers information on hand function, the ability to complete daily and occupational activities, patient satisfaction, pain, and aesthetic hand appearance. It is the only questionnaire currently in use that adjusts for hand dominance, and can distinguish the differences in disability between both hands.20

The Michigan Hand Questionnaire was developed based on strict psychometric testing and has been validated extensively in field studies in the United States and around the world. In its current form, the Michigan Hand Questionnaire includes 37 items, and takes approximately 15 minutes to complete. Although it has been widely used for a variety of hand conditions, previous reliability studies have demonstrated redundancy in the items included in the original survey, which limits its application for larger studies.4,21 Studies of reliability measures, such as Cronbach α values, have demonstrated that higher Cronbach α values (>0.9) indicate item redundancy and multiple dimensions in a given scale rather than the true reliability of a scale, and should be avoided.22,23 A shortened version of the Michigan Hand Questionnaire is a more attractive research instrument for population studies because it is more time-efficient, reduces responder burden, and can therefore minimize missing data. Previous research has demonstrated that longer surveys yield lower response rates and poorer data quality or incomplete data.24,25 Although there is no defined optimal number of survey items, longer surveys clearly increase responder burden and the cost of survey production, distribution, and coding.24,26–28

Shortening a survey while retaining its reliability, validity, and sensitivity is challenging. Shortened versions of the Medical Outcomes Study 36-Item Short-Form Health Survey and Disabilities of the Arm, Shoulder and Hand questionnaire have been developed and tested.24,29,30 Using the experience from these shortened questionnaires, we created an abbreviated version of the Michigan Hand Questionnaire based on rigorous methodology to preserve the essential properties of the original instrument. To develop a brief version of the Michigan Hand Questionnaire, we used data gathered prospectively from patients with four distinct hand conditions: distal radius fractures, carpal tunnel syndrome, rheumatoid arthritis, and thumb carpometacarpal arthritis. We hypothesize that the shortened version of the Michigan Hand Questionnaire will be as valid and reliable as the original version and yet more practical for studying health care quality in multicenter or nationwide studies.

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PATIENTS AND METHODS

Study Sample

We gathered data prospectively from 422 patients with four specific hand conditions: rheumatoid arthritis, thumb carpometacarpal osteoarthritis, carpal tunnel syndrome, and distal radius fracture. With the exception of patients with distal radius fractures, patients for the elective procedures were evaluated preoperatively and at a designated time period postoperatively.

In this data set, 162 patients with rheumatoid arthritis were included in a larger, prospective study supported by the National Institutes of Health regarding the use of silicone metacarpophalangeal arthroplasty for joint deformities caused by rheumatoid arthritis. The details of this study and the data collection have been described elsewhere.31,32 Rheumatoid arthritis patients completed the Michigan Hand Questionnaire at the time of enrollment and at 6-month follow-up. In addition, 97 patients treated at the University of Michigan for carpal tunnel syndrome completed the Michigan Hand Questionnaire as part of a study designed to evaluate the complications associated with minimal-incision carpal tunnel release. Patients were included in the study based on a diagnosis of carpal tunnel syndrome from clinical presentation (history of hand dysesthesia along the distribution of the median nerve and a positive Phalen flexion test finding and/or a positive Tinel sign) and electrodiagnostic study confirmation of carpal tunnel syndrome. Patients completed the Michigan Hand Questionnaire before carpal tunnel release and at 6 months postoperatively.18,33 Data were also collected from 132 distal radius fracture patients who underwent operative fixation using the volar locking plating system. As it was not possible to survey patients before their injury, responses taken at 3 months after surgery were used as the baseline, and responses taken at 6 months after surgery were used as the follow-up.34 Finally, 31 patients with thumb carpometacarpal arthritis completed the Michigan Hand Questionnaire as part of a larger study to determine patient outcomes following trapeziectomy and modified abductor pollicis longus suspension arthroplasty.12 Patients completed the Michigan Hand Questionnaire at their preoperative clinic visit and again at 3 months postoperatively. All study protocols were approved by the institutional review boards at the University of Michigan.

In addition, the distal radius fracture, rheumatoid arthritis, and thumb carpometacarpal arthritis patients were assessed at baseline and at each clinic visit with objective measures of functioning, specifically, grip strength (in kilograms), key or lateral pinch strength (in kilograms), and Jebsen-Taylor test score.35 The Jebsen-Taylor test is a battery of tasks for which the subject's speed of completion is calculated, and consists of the following components: (1) writing a short sentence; (2) turning over 3 × 5-inch cards; (3) picking up small objects and placing them in a container; (4) stacking checkers; (5) simulated eating; (6) moving large, empty cans; and (7) moving large, weighted cans. The time required in seconds to complete each task was recorded for subjects' dominant and nondominant hands. A subset of patients completed the Arthritis Impact Measurement Scales 2 questionnaire, a 45-item, self-administered outcomes tool designed to assess health status in patients with inflammatory arthritis and osteoarthritis.36 The Arthritis Impact Measurement Scales 2 questionnaire is designed to provide a global, self-reported assessment of patient health status, and yields information in four domains including physical functioning, affect, symptom, and social interaction. Scores range from 1 to 10, with lower scores reflecting better health.

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Michigan Hand Questionnaire

All subjects completed the original, 37-item version of the Michigan Hand Questionnaire (See Document, Supplemental Digital Content 1, which presents the Michigan Hand Outcomes Questionnaire, with permission from the Regents of the University of Michigan, http://links.lww.com/PRS/A349). Each item on the Michigan Hand Questionnaire allows the subject to respond to the question along a Likert-like scale ranging from 1 to 5. Responses are then summed to yield a domain score for each of the six domains, and respondents must respond to 50 percent or more of the items within the scale for their responses to be considered as sufficient to generate a domain score. Each domain scores are transformed to range from 0 to 100, and higher scores indicate better performance for all scales, with the exception of the pain scale. The Michigan Hand Questionnaire also yields a summary score, which is calculated by averaging the scores for each domain, after reversing the pain score.

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Item Reduction

Item reduction was performed using a concept-retention technique to identify those items of the original Michigan Hand Questionnaire that would be retained in the brief version.29 Briefly, this technique allows the selection of items based on their clinical relevance rather than on statistical testing alone. This technique is ideal in that it allows investigators to retain those items that were clinically relevant, regardless of their statistical value. For example, with the pain scale, both “Describe the pain in your hand(s)/wrist(s)” and “How often did the pain in your hand(s)/wrists(s) make you unhappy?” had similar correlation coefficients at 0.18. However, all authors reviewed these items to choose the most clinically relevant item, which was included in the final instrument. Twelve items were selected, with two items chosen from each scale. This allows for each scale from the original survey to be represented in the brief version. The two items from each scale that were most correlated with the original Michigan Hand Questionnaire score were retained. Items were selected from each domain by the authors with the goal of retaining all of the concepts of the original framework of the Michigan Hand Questionnaire (Fig. 1). We then confirmed those items that were retained by determining the correlation of each item of the Michigan Hand Questionnaire with the summary Michigan Hand Questionnaire score using correlation analysis. Because the original Michigan Hand Questionnaire requires subjects to respond to items separately for the right and left hands, except for items in work domain, responses of the two hands were averaged for each item before item reduction for all patients except those with distal radius fractures. The design of the Brief Michigan Hand Questionnaire will not distinguish between laterality of hand symptoms so that the Brief Michigan Hand Questionnaire will be as economical as possible in content and response time.

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Michigan Hand Questionnaire and Brief Michigan Hand Questionnaire Scoring Algorithm

We generated a summary score from the items in the Brief Michigan Hand Questionnaire by averaging the responses of the final 12 items. The minimum possible raw summary score for the Brief Michigan Hand Questionnaire score is 1 and the maximum score is 5. The Brief Michigan Hand Questionnaire score was normalized to a scale of 0 to 100, which is similar to the original Michigan Hand Questionnaire. Summary scores were not calculated if any of the items along the Brief Michigan Hand Questionnaire were missing. The brevity of the Brief Michigan Hand Questionnaire requires complete response to all 12 items. Therefore, Brief Michigan Hand Questionnaire scores were not calculated if any data were missing in the included items. For the full Michigan Hand Questionnaire, scores were only calculated if at least three of the six scales were complete. For the function, activities of daily living for individual hands, pain, and aesthetic scales, respondents must have had no more than two missing values for scores for these scales to be calculated. The satisfaction and activities of daily living using both hands scales required three or fewer items missing. See Document, Supplemental Digital Content 2, which presents the final survey and scoring algorithm, with permission from the Regents of the University of Michigan, http://links.lww.com/PRS/A350.

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Psychometric Testing of the Brief-Michigan Hand Questionnaire

Reliability of the Brief Michigan Hand Questionnaire

Reliability is the ability of a survey instrument to precisely measure a concept.37 We measured the reliability of the Brief Michigan Hand Questionnaire among rheumatoid arthritis patients who did not undergo silicone metacarpophalangeal arthroplasty because their responses would be expected to remain similar over a relatively short period. The Brief Michigan Hand Questionnaire summary score and the original Michigan Hand Questionnaire summary score were compared between baseline and 6-month follow-up time points. The degree of correlation between the measurements of the two time points was obtained using Spearman's correlation coefficient. Paired t tests were used to determine the average difference in the summary score between these two time points. A mean difference of 0 indicates perfect test-retest reliability.

As an additional measure of reliability, we calculated the values of the intraclass correlation coefficient, which is an additional measure of agreement of estimates between paired data. The ideal values for the intraclass correlation coefficient should range between 1 (perfect correlation) and −1/(k − 1) (low correlation), where k is the number of subjects.38

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Validity of the Brief Michigan Hand Questionnaire

Validity is defined as the ability of a survey instrument to accurately measure a concept of interest. Important types of validity to consider in survey development include content validity, criterion validity, and construct validity. Content validity refers to the extent to which the instrument appears capable of measuring the desired outcome. The original Michigan Hand Questionnaire was developed with strict attention to psychometric principles; it has been validated in a variety of acute and chronic hand conditions and translated into several languages. Therefore, we would expect that the Brief Michigan Hand Questionnaire would also have similar content validity.12,14,15,39,40 Criterion validity describes the extent to which a survey instrument compares with the accepted reference standard. Currently, there is no established standard by which health outcomes related to hand dysfunction across a wide range of acute and chronic hand conditions can be measured. Therefore, we rely on construct validity to ensure that the Brief Michigan Hand Questionnaire accurately measures hand disability and function. Construct validity describes the extent to which survey responses or scores correspond to expected values. If the Brief Michigan Hand Questionnaire is valid, we hypothesize that the Brief Michigan Hand Questionnaire scores and the original Michigan Hand Questionnaire scores should be similar within disease groups. To analyze this, we used multiple linear regression to compare the mean Brief Michigan Hand Questionnaire scores, adjusted for clinical and demographic characteristics, by disease type. Furthermore, we compared the brief and full Michigan Hand Questionnaire scores with objective measures of hand function (e.g., grip and pinch strength, and Jebsen-Taylor test score) and subjective measures of hand function (e.g., Arthritis Impact Measurement Scales 2 questionnaire scores) as an additional measure of validity.

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Responsiveness of the Brief-Michigan Hand Questionnaire

Responsiveness is the ability of a survey instrument to detect changes in an outcome of interest over time.41 To determine the responsiveness of the Brief Michigan Hand Questionnaire, we compared the summary Brief Michigan Hand Questionnaire score at baseline and at follow-up after a surgical intervention for each of the disease groups using paired t tests. To compare the change in Brief Michigan Hand Questionnaire scores over time in a standardized fashion, we calculated the standardized response mean, calculated as the change in mean follow-up time from baseline divided by the standard deviation of the change scores, for each disease type. We expect that a sensitive survey instrument should have a correspondingly high standardized response mean.42 Using the Cohen effect size definition, we can interpret a standardized response mean of 0.2 as a small effect size, 0.5 as a medium effect size, and 0.8 as a large effect size.43 As an additional point of comparison, the responsiveness of the Brief Michigan Hand Questionnaire was compared with that of the original Michigan Hand Questionnaire regarding grip strength, key pinch strength, and Jebsen-Taylor test for those patients who completed these measures.

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Statistical Analysis

Descriptive statistics were used to describe the characteristics of the study sample. Linear regression was used to identify the survey items to be retained in the final version of the Brief Michigan Hand Questionnaire and to describe the correlation of these items to the summary score of the original Michigan Hand Questionnaire. Reliability testing was performed using Spearman correlation coefficients and paired t tests as described above. Validity testing was performed by using linear regression to determine the Brief Michigan Hand Questionnaire summary score for each disease type, adjusted for age, sex, and education level. Responsiveness of the Brief Michigan Hand Questionnaire was determined using paired t tests and calculating the standardized response mean as described above. Multivariate linear regression was used to generate standardized response mean measures controlling for disease type. Statistical significance was set at an α level of 0.05. All analyses were conducted using Stata 10.1. (StataCorp, College Station, Texas).

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RESULTS

The demographic characteristics of the study sample are detailed in Table 1. This study sample consisted of 422 patients, 132 of whom had suffered distal radius fractures, 97 of whom had carpal tunnel syndrome, 162 of whom had rheumatoid arthritis, and 31 of whom had thumb carpometacarpal arthritis. The average age of the patient sample was approximately 55 years, and 69.7 percent were women. Approximately 33 percent had a college education or higher.

The results of the item reduction of the Michigan Hand Questionnaire are described in Table 2. In all of the domains except for satisfaction, the two survey items for each domain that were most strongly associated with the summary Michigan Hand Questionnaire score were retained in the final version of the Brief Michigan Hand Questionnaire, for a total of 12 items. Within the function domain, the following two items “Overall, how well did your hand work?” (R2 = 0.41) and “How was the sensation in your hand?” (R2 = 0.21) were most correlated with the summary Michigan Hand Questionnaire, and were retained in the Brief Michigan Hand Questionnaire survey. Within the activities of daily living domain, two items—“How difficult was it for you to hold a frying pan?” (R2 = 0.16) and “How difficult was it for you to button a shirt/blouse?” (R2 = 0.17)—were most strongly correlated with the summary Michigan Hand Questionnaire score, and were retained in the Brief Michigan Hand Questionnaire. The items within the work domain that were most strongly correlated with the summary Michigan Hand Questionnaire score included “How often were you unable to do your work in the last week because of your hands/wrists?” (R2 = 0.25) and “How often did you take longer to do tasks in your work because of problems with your hands/wrists?” (R2 = 0.34). The items within the pain domain that were selected for the Brief Michigan Hand Questionnaire included “Describe the pain in your hands/wrists” (R2 = 0.18) and “How often did the pain in your hands/wrists interfere with your daily activities?” (R2 = 0.39). Within the aesthetic domain, two items—“I am satisfied with the look of my hands” (R2 = 0.33) and “The appearance of my hand interferes with my normal daily activities” (R2=0.32)—were most strongly correlated with the summary Michigan Hand Questionnaire score, and were retained in the Brief Michigan Hand Questionnaire. Finally, the two items related to satisfaction that were retained included “Satisfaction with the motion of your fingers” (R2 = 0.14) and “Satisfaction with the motion of your wrist” (R2 = 0.19). These items were selected for inclusion in the Brief Michigan Hand Questionnaire over others with higher correlation coefficients because these items contained concepts that were not represented in other portions of the survey. After these 12 items were selected for inclusion in the final Brief Michigan Hand Questionnaire survey, regression analysis revealed that these survey items explained 97.8 percent of the variance of the original summary Michigan Hand Questionnaire scores.

Table 3 details the reliability of the Brief Michigan Hand Questionnaire. The reliability of the Brief Michigan Hand Questionnaire was examined by measuring the test-retest correlation over a 6-month period among a subset of 68 rheumatoid arthritis patients who did not undergo surgical intervention and had both baseline and 6-month measurements available. The correlation and intraclass correlation coefficient values between the Brief Michigan Hand Questionnaire scores between each time period was high (r = 0.78, r I = 0.91), and the mean difference between the two scores was not statistically significant (0.22, p = 0.87). Similar findings were noted for the original Michigan Hand Questionnaire scores. This indicates excellent test-retest reliability of the Brief Michigan Hand Questionnaire in this subset of patients.

Figure 2 shows the adjusted means of the Brief Michigan Hand Questionnaire summary score and the original Michigan Hand Questionnaire summary score, stratified by disease type and adjusted for age, sex, and education. We hypothesize that the relative hand health status by the different disease types shown using the original Michigan Hand Questionnaire will also be shown using the Brief Michigan Hand Questionnaire scores. We observed that patients with distal radius fracture had the highest summary Michigan Hand Questionnaire scores (77.8 ± 1.60) and patients with rheumatoid arthritis had the lowest summary Michigan Hand Questionnaire scores (51.7 ± 1.38). Similarly, patients with distal radius fracture had the highest Brief Michigan Hand Questionnaire scores (77.8 ± 1.42) and patients with rheumatoid arthritis had the lowest Brief Michigan Hand Questionnaire scores (47.6 ± 1.34). Of note, distal radius fracture patients were surveyed postoperatively and had significantly better hand outcomes than each of the other three conditions.

Table 4 details the responsiveness of the Brief Michigan Hand Questionnaire to clinical change among patients who underwent surgical intervention by disease type. Overall, the responsiveness of the Brief Michigan Hand Questionnaire was high for all disease types, even in the distal radius fracture patients whose measurements reflect the improvements between 3 and 6 months after use of the volar locking plating system, and were similar to that of the original Michigan Hand Questionnaire. Responsiveness was highest among rheumatoid arthritis patients who had undergone silicone metacarpophalangeal arthroplasty, and was similar for the Brief Michigan Hand Questionnaire (standardized response mean, 1.28) and the original Michigan Hand Questionnaire (standardized response mean, 1.36).

Table 5 compares the changes in scores between the two time points and the responsiveness to clinical change for the Brief Michigan Hand Questionnaire, the original Michigan Hand Questionnaire, grip and pinch strength, and Jebsen-Taylor test score. All analyses were adjusted for disease type, and carpal tunnel syndrome patients were omitted from this portion of the analysis because they did not complete these parameters. Responsiveness to clinical change was highest for the Brief Michigan Hand Questionnaire (standardized response mean, 4.15), followed by the original Michigan Hand Questionnaire (standardized response mean, 3.30), Jebsen-Taylor test score (standardized response mean, 1.26), and pinch strength (standardized response mean, 1.60). Responsiveness was lowest for grip strength (standardized response mean, 0.36).

Figure 3 describes the correlation between the Brief Michigan Hand Questionnaire and objective measures of hand function, specifically, grip and pinch strength, and Jebsen-Taylor test score. The Brief Michigan Hand Questionnaire was moderately correlated with each of these measures, after adjusting for disease type, age, sex, and education level. The correlation values were highest for grip strength (r = 0.38), followed by pinch strength (r = 0.35) and Jebsen-Taylor test (r = 0.35). Similar trends were identified in the correlation of the full Michigan Hand Questionnaire with these parameters.

Figure 4 describes the correlation between the Brief Michigan Hand Questionnaire and patient-reported hand function in a subset of the patient sample. Rheumatoid arthritis patients completed the Arthritis Impact Measurement Scales 2 questionnaire survey, and responses to each domain were compared with the Brief Michigan Hand Questionnaire score, after controlling for age, sex, and education level. The Brief Michigan Hand Questionnaire score was most highly correlated with function (r = 0.68) and least correlated with social interaction (r = 0.15). Brief Michigan Hand Questionnaire score was moderately correlated with affect (r = 0.36) and disease symptoms (r = 0.53). Similar trends were identified in the correlation of the full Michigan Hand Questionnaire with each of these domains.

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DISCUSSION

Health services research relies on the ability to accurately and reliably measure patient outcomes to describe variations in health care quality. To describe patient outcomes related to upper extremity disability and surgery, surgeons rely on patient-reported data regarding hand function, pain, and satisfaction that cannot be captured by objective testing.44 The Michigan Hand Questionnaire is popular because it comprehensively measures multiple aspects of hand disability and adjusts for hand dominance and injury. It includes measures of satisfaction and aesthetic appearances, which are important for patients with chronic and deforming hand conditions such as osteoarthritis and rheumatoid arthritis.29,45–48 In this study, we have created a shortened, 12-item version of the original Michigan Hand Questionnaire by eliminating certain items and selecting those items with the greatest correlation with the original Michigan Hand Questionnaire. The Brief Michigan Hand Questionnaire was reliable on repeated testing, well correlated with the original version, and can detect clinical change among patients who undergo surgery. It was correlated with objective measures of hand function, including Jebsen-Taylor test score and pinch strength, and subjective measures of hand function, including domains of the Arthritis Impact Measurement Scales 2 instrument.

Previous research has demonstrated that longer surveys are associated with lower response rates.49 For example, Jepson et al. conducted a study of physicians to determine the response rate with varying of lengths of surveys. In this study, response rates declined sharply with increasing length.50 However, reducing the number of survey items can also lead to reduction in the comprehensiveness and precision of the data that can be collected.51 The decisions regarding these tradeoffs must be weighed against the benefit of a shorter survey and the ultimate purpose of the instrument. Often, scales that were previously present in the original instrument are unable to be maintained in the shorter instrument. Furthermore, homogeneity of items in measuring a distinct concept is traded for heterogeneity of items, to capture data. For example, when shortening the Short Form-36 down to abbreviated versions such as the Short Form-12 and the Short Form-8, representative items from scales were able to be maintained.24,25 However, the selected items were heterogeneous and unique but had a reliable variance and were able to predict the outcome of interest. Therefore, the concepts measured by shorter surveys are assessed with less precision and greater variance. Regardless, these differences in precision are not likely to be detrimental when used in large studies with more than 500 subjects, as confidence intervals of estimates are related primarily to sample size. Therefore, it is important to take into account the purpose of the instrument and the scale of the study when developing and implementing shorter survey instruments to account for these tradeoffs.25,52

Scientific investigation relies on the ability to accurately and efficiently measure phenomena in a given population. An ideal measure should measure concepts consistently with as few items as possible. Achieving this ideal is challenging in areas where concepts such as pain and satisfaction are ambiguous and dynamic. To create a new version of the Michigan Hand Questionnaire, we chose to use the concept-retention technique to identify two items most highly correlated with the original Michigan Hand Questionnaire score to include in the final version. This approach has been used successfully for item reduction of other instruments, such as the Disabilities of the Arm, Shoulder and Hand instrument.29 This methodology has been criticized previously in that it is more subjective compared with other psychometric approaches, such as the Rasch or equidiscriminative techniques. Input from clinicians and patients in survey development can potentially lead to more heterogeneous scales in survey development. However, clinician input is often correlated with greater validity and is not limited by specific mathematical or statistical parameters, such as item difficulty, which may exclude important items that are clinically relevant.53,54

Although the original Michigan Hand Questionnaire remains a robust tool for comprehensive analysis, the Brief Michigan Hand Questionnaire will be an important adjunct to the original instrument for collecting data on a large scale. The responsiveness of the Brief Michigan Hand Questionnaire in this analysis indicates that it will detect clinical change with sensitivity similar to that of the full Michigan Hand Questionnaire. For example, for studies with smaller sample size, the comprehensive questions in the six scales of the original Michigan Hand Questionnaire can minimize “noise” inherent in blunter survey instruments. Conversely, in larger studies, the Brief Michigan Hand Questionnaire is ideal for reducing responder burden and maximizing response rates. This shortened instrument will allow the domains of the Michigan Hand Questionnaire to be applied more efficiently and with greater versatility across a broad range of hand diseases. The Brief Michigan Hand Questionnaire will likely excel as a screening tool or for capturing a cross-sectional snapshot of patient outcomes in larger scale audits of practice outcomes. Surgeons could use the Brief Michigan Hand Questionnaire to document their practice outcomes and follow these longitudinally as a way of comparing care against normative values and identifying areas for attention or improvement. The Brief Michigan Hand Questionnaire will offer greater efficiency than the original Michigan Hand Questionnaire for this purpose by reducing responder burden and eliminating the need for complicated scoring algorithms.

This study has several notable limitations. First, the Brief Michigan Hand Questionnaire was developed in a group of patients with four specific hand diseases, and its applicability for other conditions requires testing in large field studies. However, the diseases included in this prospective data set represent both acute and chronic disorders, and include patients with degenerative, inflammatory, and nerve compression syndromes. In addition, we performed validity testing by comparing our abbreviated instrument against the original instrument. However, there is no existing criterion standard survey instrument for hand disability for comparison. Objective measures such as grip and pinch strength may not correlate with other important aspects of hand dysfunction, such as aesthetic deformity.20,55–57 Furthermore, the shortened version of this instrument does not account for laterality and does not retain the detail of the six domains of the original version. Finally, our analysis was conducted retrospectively on a subset of patients in our data set. This work captures our experience in the initial development of the Brief Michigan Hand Questionnaire and details our efforts to perform item reduction of the Michigan Hand Questionnaire and define psychometric properties of the resulting instrument. Rigorous survey development and item reduction demands a sequential process, including systematic review of existing knowledge, qualitative and quantitative preliminary testing, and eventual expansion to larger multicenter studies for survey refinement. The Brief Michigan Hand Questionnaire will be further refined through a larger, prospective study to describe the logistics of surgery administration and applicability to other conditions.

The brief, 12-item version of the Michigan Hand Questionnaire has the potential for many applications for surgeons in practice, researchers, and policy makers interested in improving the delivery of care to patients with hand disability. This shortened version has psychometric properties similar to those of the original Michigan Hand Questionnaire, and demonstrates excellent reliability and validity across a variety of acute and chronic hand conditions. The Brief Michigan Hand Questionnaire will be an essential tool for measuring the quality of care and influencing practice patterns to optimize the practice of hand surgery.

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ACKNOWLEDGMENTS

This work was supported in part by National Institute of Arthritis and Musculoskeletal and Skin Diseases grant R01 AR047328 and Midcareer Investigator Award in Patient-Oriented Research grant K24 AR053120 (to K.C.C.).

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