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A 2016 American Academy of Orthopaedic Surgeons (AAOS) clinical practice guideline (CPG) de-emphasized the need for electrodiagnostic studies (EDS) for carpal tunnel syndrome (CTS). We tested the hypothesis that use of EDS decreased after the AAOS CPG.Using a national administrative claims database, we measured the proportion of patients with a diagnosis of CTS who underwent EDS within 1 year after diagnosis between 2011 and 2019. Using an interrupted time series design, we defined 2 time periods (pre-CPG and post-CPG) and compared EDS usage between the periods using segmented regression analysis. We conducted a subgroup analysis of preoperative EDS usage in patients who underwent carpal tunnel release.Of 2,081,829 patients with CTS, 315,449 (15.2%) underwent EDS within 1 year after diagnosis. The segmented regression analysis showed a decrease in the level of EDS usage after publication of the AAOS CPG (-11.50 per 1,000 patients [95% CI, -1.47 to -0.95 per 1,000 patients]); however, the rate of EDS usage increased in the post-CPG period (+1.75 per 1,000 patients per quarter [95% CI, 0.97-2.54 per 1,000 patients per quarter]). Of 473,753 eligible patients who underwent carpal tunnel release, 139,186 (29.4%) underwent EDS within 6 months before surgery. After publication of the AAOS CPG, preoperative EDS usage decreased by -23.57 per 1,000 patients (95% CI, -37.72 to -9.42 per 1,000 patients). However, these decreasing trends in EDS usage predated the 2016 AAOS CPG.The overall and preoperative EDS usage for CTS has been decreasing since at least 2014, predating the 2016 AAOS CPG, reflecting the rapid implementation of evidence into practice. However, EDS usage has increased in the post-CPG period, and a considerable proportion of patients who underwent carpal tunnel release still received EDS.Given its high costs and disputed value, routine EDS usage should be considered for further deimplementation initiatives.

Little is known about patients' postoperative emotional and social functioning and preferences for recovery settings. This qualitative study explores patients' perspectives on factors influencing postoperative recovery, including the proportion of time recovering at home (home time) and unmet information needs.Semistructured interviews were conducted between September and December 2020 with veteran patients aged 65 y or older who underwent surgery at a single hospital. A purposeful sampling strategy was used to identify patients with a broad representation of major operations and various amounts of home time. One-hour interviews were audio-recorded, transcribed verbatim, and anonymized for analysis. A rigorous team-based in-depth thematic analysis was performed. Validation techniques to enhance the quality and credibility of the study included triangulation, independent coding, and search for disconfirming evidence.Twelve patients were interviewed (11 [91.7%] males; mean (standard deviation) age, 72.3 [4.8] y). Five factors that influenced the recovery process emerged: (1) professional support services, (2) informal caregiver support, (3) environment for recovery, (4) individual traits, and (5) physical and functional impairments. The analysis also elucidated four unmet information needs regarding recovery: (1) personalized and detailed information, (2) anticipated recovery time, (3) possible complications, and (4) comprehensive information about discharge location options.The study demonstrated that patients recovering from surgery require wide-ranging levels of support to meet their unique needs and preferences. Patients value easy-to-understand and personalized information about recovery from providers. These findings may be helpful to develop strategies that better support patients in their postoperative recovery and post-acute care transition pathways.

Whether to perform umbilical hernia repair in patients with cirrhosis is a common dilemma for surgeons. We aimed to determine the incidence, morbidity, and mortality associated with emergency and nonemergency umbilical hernia repair in patients with and without cirrhosis, and to explore opportunities for nonemergency repair.Veterans diagnosed with cirrhosis between 2001 and 2014 and a frequency-matched sample of veterans without cirrhosis were followed through September 2017. Veterans Affairs Surgical Quality Improvement Program data provided outcomes and risk factors for mortality after umbilical hernia repair. We performed chart review of a random sample of patients undergoing emergency umbilical hernia repair.Among 119,605 veterans with cirrhosis and 118,125 matched veterans without cirrhosis, the Veterans Affairs Surgical Quality Improvement Program database included 1,475 and 552 open umbilical hernia repairs, respectively. In patients with cirrhosis, 30-day mortality was 1.2% after nonemergency umbilical hernia repair and 12.2% after emergency umbilical hernia repair, contrasting with zero deaths in patients without cirrhosis undergoing these repairs. In patients with cirrhosis but no ascites in the prior month, 30-day mortality after nonemergency umbilical hernia repair was 0.7%, compared to 2.2% in those with ascites. Chart review of patients requiring emergency umbilical hernia repair revealed that elective umbilical hernia repair may have been feasible in 30% of these patients in the prior year; fewer than half of those undergoing emergency umbilical hernia repair had received a general surgery consultation in the prior 2 years.Nonemergency open umbilical hernia repair was associated with relatively low perioperative mortality in patients with cirrhosis and no recent ascites. About 30% of patients undergoing emergency umbilical hernia repair may have been candidates for nonemergency repair in the prior year.

Excess weight has the potential to carry a substantial physical and emotional burden. A better understanding of perceived consequences of excess weight may facilitate the development of patient-centered programs and interventions to promote weight management efforts in persons with spinal cord injury (SCI). The study objective was to describe consequences of excess weight from the personal perspectives of individuals with SCI.Descriptive qualitative design using in-depth semi-structured interviews and thematic analysis.Veterans Health Administration (VHA) SCI System of Care.Individuals with SCI (n-33).Key themes from thematic analysis.Participants were male (61%), ranged from 29 to 84 years of age, and about half had tetraplegia (55%). Five themes were identified that demonstrate negative consequences of excess weight experienced by individuals with SCI, including: (1) physical health conditions (including chronic conditions and SCI secondary conditions), (2) physical symptoms (such as pain, discomfort, and fatigue), (3) movement challenges, (4) appearance-related concerns, and (5) emotional impacts.Carrying excess weight is concerning to individuals with SCI and in terms of consequences such onset or exacerbation of chronic conditions, SCI secondary conditions, physical symptoms

Hydroxyapatite (HA) coatings were introduced to improve uncemented implant osteointegration and to prevent loosening and osteolysis. However, data regarding these implants have been inconsistent. We studied the effect of HA coating of femoral stems and acetabular cups on component revision after primary total hip arthroplasty (THA) in the veteran population.We identified patients who underwent uncemented primary THA at any Veterans Health Administration (VHA) hospital from 2000 to 2017 and who had implants that were available as either HA-coated or non-HA-coated models. The endpoint was removal of the component of interest for any reason. For each individual stem and shell, unadjusted and adjusted (for age and body mass index) Cox proportional hazards models were used to estimate hazard ratios for the risk of explantation between HA-coated and non-HA-coated implants of the same type.A total of 262 HA-coated cups, 4580 non-HA-coated cups, 4767 HA-coated stems, and 9397 non-HA-coated stems were available for analysis. The mean follow-up time was 9.01 years (43,627 total implant-years) for cups and 7.13 years (101,004 total implant-years) for stems. One of the two shells reviewed had significantly lower survivorship and an elevated hazard ratio for explantation with HA coating. Among the five implant pairs of stems, and the other shell, implant survival and hazard ratios for explantation were not affected by HA coating.HA coating did not improve THA implant survival in our veteran population. Although HA-coated versions of hip implants tend to be more costly than their noncoated counterparts, these results do not support their general use.

Direct data abstraction from a patient's chart by experienced medical professional data abstractors has been the historical gold standard for quality and accuracy in clinical medical research. The limiting challenge to population-wide studies for quality and public health purposes is the high personnel costs associated with very large-scale efforts of this type. Two historically related programs that are at least partially able to successfully circumvent this problem and provide high-quality data relating to surgical procedures and the early postoperative period are reviewed in this article. Both utilize similar data abstraction efforts by specially trained and qualified medical abstractors of a sample subset of the total procedures performed at participating hospitals.The Veterans Affairs Surgical Quality Improvement Program (VASQIP), detailed by Nicholas J. Giori, MD, PhD, in the first section of this article, makes use of trained abstractors and has undergone recent additions and updates, including the development of an associated total hip registry for the VA system. The data elements and data integrity provided by both of these programs establish important benchmarks for other "big data" efforts, which often attempt to use alternative less-expensive methods of data collection in order to achieve more widespread or even nationwide data collection.In the second section, Elizabeth B. Habermann, PhD, MPH, provides a detailed review of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), the data elements collected, and examples of the range of quality improvement and outcomes studies in orthopaedic surgery that it has made possible, along with information on data that have not been collected and the resulting limitations. The ACS NSQIP was actually modeled after the very similar earlier effort started by the United States Department of Veterans Affairs (VA).

Successful recovery after surgery is complex and highly individual. Rural patients encounter greater barriers to successful surgical recovery than urban patients due to varying healthcare and community factors. Although studies have previously examined the recovery process, rural patients' experiences with recovery have not been well-studied. The rural socioecological context can provide insights into potential barriers or facilitators to rural patient recovery after surgery.We conducted semi-structured qualitative interviews with a purposeful sample of 30 adult general surgery patients from rural areas in the Mountain West region of the United States. We used the socioecological framework to analyze their responses. Interviews focused on rural participants' experiences accessing healthcare and the impact of family and community support during postoperative recovery. Interviews were transcribed verbatim and coded using content and thematic analysis.All participants commented on the quality of their rural healthcare systems and its influence on postoperative care. Some enjoyed the trust developed through long-standing relationships with providers in their communities. However, participants described community providers' lack of money, equipment, and/or knowledge as barriers to care. Following surgery, participants recognized that there are advantages and disadvantages to receiving family and community support. Some participants worried about being stigmatized or judged by their community.Future interventions aimed at improving access to and recovery from surgery for rural patients should take into account the unique perspectives of rural patients. Addressing the socioecological factors surrounding rural surgery patients, such as healthcare, family, and community resources, will be key to improving postoperative recovery.

PURPOSE: Pancreatic adenocarcinoma (PDAC) remains a highly lethal disease. Surgery represents the only opportunity for cure, but is accompanied by high rates of morbidity. Understanding patients’ lived experiences after surgical resection of PDAC is critical to knowing whether the decision to undergo surgery was worth it for these patients.METHODS: We performed a convergent, mixed-methods study with patients who underwent resection of PDAC between 01/01/2019-08/01/2020. Quantitative data (medical record review and 3 questionnaires) were analyzed using descriptive statistics. Qualitative data (semi-structured interviews) were analyzed using the constant comparative method. Data were then compared for congruence.RESULTS: 18/22 eligible participants completed interviews and 11 completed questionnaires. Data collection occurred at a median of 14.2 months (IQR 11.6-16.3) from surgery. We identified 4 main themes. First, persistent negative symptoms were common for patients, but patients adapt to these and are satisfied with their “new normal.” Second, patients have varied and continually evolving mindsets throughout their cancer journey. Third, despite decreased quality-of-life, patients have a high degree of satisfaction with their decision to pursue surgery. Finally, patients were okay with a passive role in decision-making around surgery. Despite variable involvement in decision-making and outcomes, no participants reported regret over the decision to pursue surgery. CONCLUSION: This nuanced account of patients’ lived experiences following surgery for PDAC allows for an improved understanding of the impact of pancreatic resection on patients. Surgeons can use this data to improve preoperative counselling for patients with PDAC and help guide them to making the correct decisions about surgery.

There are growing concerns that Veterans' increased use of Veterans Health Administration (VA)-purchased care in the community may lead to lower quality of care.We compared rates of hospital readmissions following elective total knee arthroplasties (TKAs) that were either performed in VA or purchased by VA through community care (CC) at both the national and facility levels.Three-year cohort study using VA and CC administrative data from the VA's Corporate Data Warehouse (October 1, 2016-September 30, 2019). We obtained Medicare data to capture readmissions that were paid by Medicare. We used the Centers for Medicare and Medicaid Services (CMS) methods to identify unplanned, 30-day, all-cause readmissions. A secondary outcome, TKA-related readmissions, identified readmissions resulting from complications of the index surgery. We ran mixed-effects logistic regression models to compare the risk-adjusted odds of all-cause and TKA-related readmissions between TKAs performed in VA versus CC, adjusting for patients' sociodemographic and clinical characteristics.Nationally, the odds of experiencing an all-cause or TKA-related readmission were significantly lower for TKAs performed in VA versus CC (eg, the odds of experiencing an all-cause readmission in VA were 35% of those in CC. At the facility level, most VA facilities performed similarly to their corresponding CC providers, although there were 3 VA facilities that performed worse than their corresponding CC providers.Given VA's history in providing high-quality surgical care to Veterans, it is important to closely monitor and track whether the shift to CC for surgical care will impact quality in both settings over time.

Objective: Interventions aimed at limiting opioid use are widespread. These are most often targeted toward prescribers or health systems. Patients’ perspectives are too often absent during the creation of such interventions. This qualitative study aims to understand patient experiences with education about perioperative pain control, from preoperative expectation-setting to post-operative pain control strategies and ultimately opioid disposal.Design: We performed semistructured interviews focused on patient experiences in the perioperative period. Content from interview transcripts was analyzed using a constant comparative method.Setting: All participants underwent surgery at a single, academic tertiary-care center.Participants: Adult patients who had a general surgery operation in the prior 60 days.Outcome measure: Key themes from interviews about perioperative pain management, specifically related to preoperative expectation-setting and post-operative education.Results: Patients identified gaps in communication and education in three main areas: preoperative expectation setting of post-operative pain; post-operative pain control strategies, including use of opioid medications; and the importance of appropriate opioid disposal. Failure to set expectations led to either significant patient anxiety preoperatively or poor preparation for home discharge. Poor education on pain control strategies led to misinformation on when and how to use opioids. Lack of education on opioid disposal led to most participants failing to properly dispose of leftover medication.Conclusions: Gaps in education surrounding post-operative pain and opioid use can lead to patient anxiety, inappropriate use of opioids, and poor disposal rates of leftover medications. Future interventions aimed at patient education to improve pain management and opioid stewardship should be created with an understanding of patient experiences and perceptions.

Transgender persons are vulnerable to under-receipt of recommended health care due to chronic exposure to systemic stressors (e.g., discriminatory laws and health system practices). Scant information exists on receipt of alcohol-related care for transgender populations, and whether structural interventions to reduce transgender discrimination in health care improve receipt of recommended treatment. This study evaluated the effect of the Veteran Health Administration (VA) Transgender Healthcare Directive-a national policy to reduce structural discrimination-on receipt of evidence-based alcohol-related care for transgender VA patients with unhealthy alcohol use.The study used an interrupted time series with control design to compare monthly receipt of alcohol-related care among transgender patients with unhealthy alcohol use (Alcohol Use Disorders Identification Test Consumption ≥5) documented in their electronic health record before (10/1/2009-5/31/2011) and after (7/1/2011-7/31/2017) implementation of VA's Transgender Healthcare Directive. A propensity-score matched sample of non-transgender patients with unhealthy alcohol use served as a comparison group to control for concurrent secular trends. Mixed effects segmented logistic regression models estimated changes in level and slope (i.e., rate of change) in receipt of any evidence-based alcohol-related care, including brief intervention, specialty addictions treatment, and alcohol use disorder medications.The matched sample (mean age = 47.5 [SD = 15.0]; 75% non-Hispanic White race/ethnicity) included 2074 positive alcohol screens completed by 1377 transgender patients and 6,l99 positive alcohol screens completed by 6185 non-transgender patients. Receipt of alcohol-related care increased for transgender patients from 78.5% (95% CI: 71.3%-85.6%) at the start of study to 83.0% (75.9%-90.1%) immediately before the directive and decreased slightly from 81.6% (77.4%-85.9%) immediately after the directive to 80.1% (76.8-85.4) at the end of the study. Changes in level and slope comparing periods before and after the directive were not statistically significant, nor were they statistically significantly different from the matched sample of non-transgender patients.Health systems must urgently employ and evaluate policies to address structural stigma that produces and reproduces disparities in health and health care. Although VA's directive was not associated with increased receipt of alcohol-related care, that receipt of alcohol-related care among transgender patients is comparable to non-transgender patients is promising.

Despite the growing attention to evaluating care from the patient perspective, the most common definitions and measurements of quality are currently defined by physicians and health systems. Studies have demonstrated how a lack of patient input can lead to discrepancies between patients' and physicians' assessments of quality and, subsequently, worse patient outcomes. Although quality measures are increasingly used in hand surgery, insufficient work has examined whether these quality measures align with what matters to patients. We completed a qualitative study to assess how patients define high-quality care through the pre-, peri-, and postoperative phases of care in hand surgery.Based on our prior work, we created an open-ended interview guide and conducted semistructured interviews with 43 hand surgery patients at 5 tertiary-care institutions during various phases of care. We completed a thematic analysis to generate subcodes and open codes, to identify themes in high-quality care from the patient perspective.Patients defined high-quality care as a process of (1) setting and meeting clear expectations; (2) achieving functional goals after surgery; and (3) feeling comfortable with and cared for by the care team. We identified the following 4 patient-centered themes that contributed to high-quality care: (1) communication between the patient and care team through all phases of care; (2) efficient and accurate diagnosis and treatment; (3) satisfactory treatment outcomes and postsurgical experience; and (4) acceptable systemic aspects of care.Efforts to improve health care delivery should include areas of care that are important to patients. Our results suggest that measuring aspects of care that often go without assessments, such as communication, can maximize care quality as defined by patients.The themes identified in this study can inform efforts towards patient-centered quality measure development.