Overuse of healthcare resources is burdensome on society. Prior research has demonstrated that many patients with traumatic musculoskeletal injuries continue to seek care long after appropriate healing is well established, suggesting an overuse of services. However, few studies have examined the factors—including patient-reported outcomes—associated with an increased number of clinic visits for traumatic hand and wrist conditions.
(1) After accounting for surgical treatment, surgeon, and demographic factors, is a patient’s PROMIS Pain Interference score associated with the total number of office visits? (2) Is PROMIS Depression, combination of PROMIS Depression and Pain Interference, or Physical Function scores associated with the number of office visits?
Between June 2015 and May 2018, 1098 patients presenting for a new patient visit at a single, urban academic medical center for distal radius fracture, wrist or hand sprain, tendon rupture, traumatic finger amputation, or scaphoid fracture were identified. Of those, 823 (75%) patients completed all PROMIS domains and presented before the trailing period and thus were included in this retrospective study. We recorded a number of variables including: Total number of office visits, age, sex, race, marital status, diagnosis, provider, and operative or nonoperative treatment. Multivariable Poisson regression analysis was conducted to determine whether Patient-Reported Outcomes Measurement Information System Pain Interference (PROMIS PI), Physical Function (PROMIS PF), and Depression scores measured at the first visit were associated with the total number of office visits, after accounting for the other factors we measured.
Higher PROMIS PI scores were associated with greater number of clinic visits (0.0077; 95% CI, 0.0018–0.014; p = 0.010). Although PROMIS Depression scores were not associated with the number of office visits (0.0042; 95% CI, -0.0099 to 0.0094; p = 0.112), higher PROMIS PF scores were associated with fewer office visits when accounting for confounding variables (-0.0077; 95% CI, -0.0012 to -0.0029; p = 0.001). Additionally, across all individual PROMIS models, there was an association between the variables “operative treatment” (PI: 0.85; 95% CI, 0.72–0.98; p < 0.001; Depression: 0.87; 95% CI, 0.74–1.0; p < 0.001; PF: 0.85; 95% CI, 0.72–0.99; p < 0.001) and “traumatic finger amputation” (PI: 0.22; 95% CI, 0.016–0.42; p = 0.034; Depression: 0.2; 95% CI, 0.086–0.47; p = 0.005; PF: 0.21; 95% CI, 0.014–0.41; p = 0.036) with an increased total number of office visits. Provider team 5 (PI: -0.62; 95% CI, -0.98 to -0.27; p = 0.001; Depression: -0.61; 95% CI, -0.96 to -0.26; p = 0.001; PF: -0.60; 95% CI, -0.96 to -0.25; p = 0.001) was associated with fewer office visits. In both the PROMIS Depression and PROMIS PF regression models, increasing age (Depression: -0.0048; 95% CI, -0.0088 to -0.00081; p = 0.018; PF: -0.0045; 95% CI, -0.0085 to -0.0006; p = 0.024) was also associated with fewer total number of office visits.
This study helps surgeons understand that patients who present at their initial office visit for traumatic hand and wrist conditions displaying worse pain coping strategies and decreased physical function will have more office visits. We recommend that surgeons engage in a comprehensive care approach that is empathetic, fosters effective pain coping strategies (and so might decrease PROMIS PI scores), and educates patients about expectations by providing educational materials and/or including other health professionals (such as, social work, physical therapy, mental health professional) as needed. This may decrease healthcare use in patients with traumatic hand and wrist conditions.
Level IV, prognostic study.
D. N. Bernstein, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA
T. J. Crijns, D. Ring, Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
B. Mahmood, W. C. Hammert, Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
W C. Hammert, University of Rochester Medical Center, Department of Orthopaedics and Rehabilitation, 601 Elmwood Ave, Box 665, Rochester, NY 14642 USA, Email: Warren_Hammert@urmc.rochester.edu
One of the authors certifies that he (DNB) has received grants from Alpha Omega Alpha (AOA), outside the submitted work.
One of the authors certifies that he (DR), or a member of his immediate family, has received royalties for elbow plates in an amount of less than USD 10,000 per year from Wright Medical (Memphis, TN, USA); royalties for an internal joint stabilizer elbow in the amount of USD 10,000 to 100,000 per year from Skeletal Dynamics, Miami, FL, USA); is a Deputy Editor for Hand and Wrist, Journal of Orthopaedic Trauma, and Clinical Orthopaedics and Related Research® and has received or may receive payments or benefits in the amount of USD less than 10,000 per year; has received honoraria from various hospitals and universities.
One of the authors certifies that he (WCH) has received payments in the amount of USD 10,000 to USD 100,000 as editor of Hand-e, Editor (American Society for Surgery of the Hand (Chicago, IL, USA).
Each of the remaining authors (TJC, BM) certify that neither he, nor any member of his immediate family, have funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.
Each author certifies that the appropriate institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.
The work was performed at the Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York.
Received October 14, 2018
Accepted March 05, 2019
Online date: April 27, 2019