Thank you to everyone who participated in the June #JHSJC! We’ll be taking a short break for the summer but will be back in September. See you then!
We looked at two excellent articles from Volume 45, Issue 6 of The Journal of Hand Surgery: The Prognostic Value of Preoperative Patient-Reported Function and Psychological Characteristics on Early Outcomes Following Trapeziectomy With Ligament Reconstruction Tendon Interposition for Treatment of Thumb Carpometacarpal Osteoarthritis and Industry Funding and Self-Declared Conflict of Interest in Hand Surgery Publications.
Feel free to continue the conversation below in the comments! And please check out previous #JHSJC transcripts (please scroll to the bottom of the page).
J Hand Surg Am- ASSH @JHandSurg
Let’s get started!
Articles can be found here jhsfocus.org/jhsjc/
Please tag answers: A1, A2, A3… and use hashtag #JHSJC
New chat format will have numbered questions for each article: Q1, Q2, Q3…
Welcome to #JHSJC with host @BgTalkinman. #OrthoTwitter #MedTwitter
J Hand Surg Am- ASSH @JHandSurg:
Article 1 #JHSJC
Prognostic Value of Preoperative Patient-Reported Function and Psychological Characteristics on Early Outcomes Following Trapeziectomy With Ligament Reconstruction Tendon Interposition for Thumb Carpometacarpal Osteoarthritis.
Brent Graham @BgTalkinman:
Welcome to the June 2020 #JHSJC! Please use the #JHSJC hashtag and any others pertinent to our discussion.
We are trying to organize our discussion around the questions in the notes about the articles Q1,Q2,…but the key is the discussion! #jhsjc
Let’s start with the 1st article on pre-op patient characteristics and early outcomes after #LRTI #jhsjc
#PROMIS Anxiety and Depression didn’t predict early outcome; Q1: Would the findings be likely to change with longer follow-up? #jhsjc
David Ring @DrDavidRing:
Q1: Yes. Figure 1: About a third of the patients are worse at 14 weeks. #jhsjc
Steve Lee @kichmd:
This article confirms the notion that patients do better the worse they start preop #jhsjc
Brent Graham @BgTalkinman to @kichmd:
agreed – and that has been reported with other conditions so that isn’t too surprising #jhsjc
Warren @whammert to @kichmd:
BETTER OR WORSE AT LONG TERM FOLLOW UP #jhsjc
Steve Lee @kichmd to @whammert:
Yes, longer term f/u may show differences for anxiety and depression #jhsjc
David Ring @DrDavidRing:
A1: Good evidence that people need to prepare for a prolonged recovery. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
What do you make of the observation that #PROMIS Anxiety and Depression didn’t predict those early results? #jhsjc
Warren @whammert to @BgTalkinman and @DrDavidRing:
I think PI is more reflective of how they will do #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
A1: What do we make of people that improved in the short window? Meaning/context/placebo effect? #jhsjc
Steve Lee @kichmd:
Also how a surgeon discusses and sets expectations has a huge effect on how a patient does or perceives they do #JHSJC
Brent Graham @BgTalkinman to @kichmd:
Right! Does that suggest that pre-op feelings of anxiety and depression can be positively affected by the surgeons behaviour? #jhsjc
David Ring @DrDavidRing to @BgTalkinman and @kichmd:
Symptoms of depression cannot be expected to improve with surgery pubmed.ncbi.nlm.nih.gov/32097128 #jhsjc
Brent Graham @BgTalkinman to @whammert and @DrDavidRing:
The results showed that was true in the early follow-up. #jhsjc
Steve Lee @kichmd:
perhaps how a surgeon discusses with a patient has the most effect early, but if there is acutal clinical depression and anxiety, this effect dwindles the farther they are from surgery #jhsjc
Steve Lee @kichmd to @DrDavidRing:
Thanks for reference David. 1/8 with depression is a lot! How do we know who has depression (assuming it is not listed in their medical conditions)? #jhsjc
David Ring @DrDavidRing to @kichmd:
Screening questionnaires are one way. But people may not answer honestly. https://pubmed.ncbi.nlm.nih.gov/29419628
Look for the verbal (https://pubmed.ncbi.nlm.nih.gov/22707072) and non-verbal (https://pubmed.ncbi.nlm.nih.gov/29480887)
Christopher J. Dy MD MPH FACS @ChrisDyMD:
Q4: Is that a context-dependent idea that might change from patient-to-patient?
Q3: What should be considered more important: improvement of a certain extent or to a certain level on a reliable, valid outcome measure?
Article 1 #JHSJC
Brent Graham @BgTalkinman:
this is the link to my interview with the authors. #jhsjc
https://www.jhandsurg.org/pb/assets/raw/Health%20Advance/journals/yjhsu/June_2020.mp3
David Ring @DrDavidRing to @ChrisDyMD:
You’re jumping ahead!…A3: Better to use post-op scores than change scores for many reasons. #jhsjc
Warren @whammert to @ChrisDyMD:
PROMIS not perfect for individual outcomes, but I look at level of improvement rather than certain level #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing and @kichmd:
Q2 agreed, so why didn’t depression seem to predict a worse early result the way it has for other conditions? #jhsjc
David Ring @DrDavidRing to @BgTalkinman and @kichmd:
A2:Table 4 shows the correlation of mental with physical health. Raises concerns about co-linearity #jhsjc
Brent Graham @BgTalkinman to @whammert and @ChrisDyMD:
A3: I would say that for aggregate results, level matters, for an individual, extent of improvement. #jhsjc
David Ring @DrDavidRing:
A2: Pre-operative DASH is directly mathematically related to the change score (post-pre op DASH). Definition of collinearity #jhsjc
David Ring @DrDavidRing to @BgTalkinman, @whammert, and @ChrisDyMD:
A2: From a DASH of 80 to 60, you have achieved MCID. From 30 to 20 you have not. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
A2: Agreed. There is more room for improvement if there is a high DASH to begin with. Is that what you mean? #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
Yes. Change scores are misleading for many reason, but that is the main one. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing, @whammert, and @ChrisDyMD:
A2: That is very important. Should intervention be reserved for those with high DASH only? #jhsjc
Brent Graham @BgTalkinman:
Back to Q2: What are reasons for the discrepancy btwn these findings and those previously reported in other conditions such as CTS? #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
Colinearity. Re-analyze the data without pre-operative DASH, and use of final DASH not change score: things will change #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
Would you expect to see an association with the #PROMIS Anxiety and Depression scores then? #jhsjc
David Ring @DrDavidRing to @BgTalkinman, @whammert, and @ChrisDyMD:
High DASH correlates best with mental and social health, so the answer is no. #JHSJC
Treat ALL the opportunities for improved health. Don’t do surgery and then figure it out later
David Ring @DrDavidRing to @BgTalkinman:
Yes. #jhsjc
The correlations show it. So when it disappears in multivariable analyses. Think: co-linearity. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
I will have to think about that …deeply! #jhsjc
Robert Foster MD @RobertFosterMD1:
So clinic patients might be told “No rush to surgery- it may help no matter how far progressed disease/symptoms?” #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
Are you saying that the variance explained by the pre-op DASH takes up that possibly attributable to the psych factors? #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
Yes. The definition of co-linearity. Classic statistician error. #jhsjc
They think they are accounting for confounding, but humans are not that simple #jhsjc
Pre-op DASH correlates with mental health. And change scores is constrained by pre-op DASH. Inseparable #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
The same variance would be explained by #PROMIS Anxiety and Depression would eliminate pre-op DASH as a predictor? #jhsjc
I agree with that! But collinearity may also be too simple an explanation as well. #jhsjc
Brent Graham @BgTalkinman:
This is a discussion that should continue but let’s move on to the other article about financial COI and hand surgery publications. #jhsjc
J Hand Surg Am- ASSH @JHandSurg:
Article 2 #JHSJC:
Industry Funding and Self-Declared Conflict of Interest in Hand Surgery Publications.
Warren @whammert to @BgTalkinman:
Not always clear to authors what a COI is, so hard to understand if intentionally not reporting or don’t understand #jhsjc
J Hand Surg Am- ASSH @JHandSurg:
Points for discussion
#JHSJC Article 1: Industry Funding and Self-Declared Conflict of Interest in Hand Surgery Publications
Brent Graham @BgTalkinman:
Q1: Is the OPD a reasonable reference standard for this purpose? More than 50% of JHS submissions are from outside North America. #jhsjc
Warren @whammert to @JHandSurg:
Funding is only one type of COI, so not by itself #jhsjc
Brent Graham @BgTalkinman to @whammert:
I think that is clear. There is an incentive for industry to report small amounts i.e. small social events #jhsjc
That explains the small sums: median $118 #jhsjc
Steve Lee @kichmd:
Some of the disparity may be that relationships change from the time a manuscript is submitted and then finally in print #jhsjc
Brent Graham @BgTalkinman to @kichmd:
That is possible. #jhsjc
Warren @whammert to @kichmd:
or author/ presenters perception of COI. Company support, even if for a different product is still COI by definition #jhsjc
Steve Lee @kichmd:
I agree small social events are often forgotten by surgeons and not listed #JHSJC
Brent Graham @BgTalkinman to @kichmd:
To me that isn’t the important issue because some of the sums are pretty large. Senior people received a median of $3000. #jhsjc
Brent Graham @BgTalkinman to @whammert:
For this study underreporting related to the published article was only found in 14%. #jhsjc
Warren @whammert to @BgTalkinman and @kichmd:
bigger issue for spine, joint, trauma than hand surgeons #jhsjc
Warren @whammert to @BgTalkinman and @kichmd:
but still should be reported regardless #jhsjc
Steve Lee @kichmd:
People receiving large sums should certainly report these. #jhsjc
Brent Graham @BgTalkinman to @whammert and @kichmd:
That is unquestionably true and of course that relates to the devices themselves. #jhsjc
Brent Graham @BgTalkinman to @whammert and @kichmd:
Q2: What is a practical level at which payments should be reported – any payment at all or a certain minimum? #jhsjc
Warren @whammert to @BgTalkinman and @kichmd:
any line you draw is arbitrary, so I would say any amount and let reader decide if important #jhsjc
Nina Suh @NinaSuh9:
Q2-i would believe all should be reported to be fully transparent #jhsjc
Although I appreciate that small sums may inadvertedly be missed by authors #jhsjc
Brent Graham @BgTalkinman to @whammert, @kichmd, and @NinaSuh9:
We have not asked for specific amounts bc that has been thought to be too intrusive. Is that wrong? #jhsjc
Warren @whammert to @BgTalkinman and @kichmd:
but there is some level where the surgeon likely doesn’t know – received a drink and company reports #jhsjc
Warren @whammert to @BgTalkinman and 2 others:
I would think have range – < 500, 500-2500, >2500 or similar #jhsjc
Nina Suh @NinaSuh9:
I don’t thinking asking for amounts is intrusive. #jhsjc
Brent Graham @BgTalkinman to @NinaSuh9:
I will assume that authors won’t be biased if they have received $100 whether or not they know. It’s the larger sums. #jhsjc
Megan Conti Mica, MD @MeganContiMica to @BgTalkinman and 2 others:
Any relationship no matter how small is still a relationship #jhsjc
Brent Graham @BgTalkinman to @NinaSuh9:
I think a lot of people would consider that an invasion of privacy. Comments from others? #jhsjc
Brent Graham @BgTalkinman to @whammert, @kichmd, and @NinaSuh9:
Times have changed. When I was at JBJS, sums less than $10000 didn’t have to be reported at all. #jhsjc
Warren @whammert to @BgTalkinman and @NinaSuh9:
If they are reporting on something they have an interest in, they are obliged to disclose #jhsjc
Nina Suh @NinaSuh9:
I assume cumulative amounts are what we are discussing but ranges seem reasonable. #jhsjc
Steve Lee @kichmd:
I agree to report all. #jhsjc
Brent Graham @BgTalkinman to @kichmd:
Do you check the OPD before filling out your COI form with a submission? That is where a lot of the discrepancies are. #jhsjc
Steve Lee @kichmd:
I think reporting ranges is reasonable #jhsjc
Brent Graham @BgTalkinman to @whammert and @NinaSuh9:
I think our authors do and that is what the study seems to show but we do not ask the sum received. Should we? #jhsjc
Brent Graham @BgTalkinman:
Q3: Should a journal require disclosure of the amounts of all payments – or is that too intrusive? #jhsjc
Warren @whammert to @BgTalkinman:
I am less worried about intrusion than something reasonable they recall – JBJS 10K is a lot, but 100 can be overlooked #jhsjc
Brent Graham @BgTalkinman to @whammert and @kichmd:
And there is a tax incentive for them to do that. It suggests that the OPD is a biased standard. #jhsjc
Nina Suh @NinaSuh9:
I don’t think asking for ranges are too intrusive. #jhsjc
Warren @whammert to @BgTalkinman and @kichmd:
OPD only picks ups payments – not ownership, stocks, … (I think) #jhsjc
Brent Graham @BgTalkinman to @whammert:
JBJSA long ago changed that policy; they now require disclosure of any benefit; I don’t think they ask for a specific sum #jhsjc
Brent Graham @BgTalkinman to @whammert and @kichmd:
I think that is true. #jhsjc
Warren @whammert to @BgTalkinman and @kichmd:
So I would say OPD is not the standard. Although I don’t know what is #jhsjc
Steve Lee @kichmd:
I think reporting a range per company per year is reasonable. It will really make people think about how much they are getting and for what #jhsjc
Brent Graham @BgTalkinman to @kichmd:
Agreed. Should those sums be published with a paper an author publishes in JHS? #jhsjc
Brent Graham @BgTalkinman to @whammert and @kichmd:
I’m pretty sure most of our authors are very honest #jhsjc
Warren @whammert to @BgTalkinman and @kichmd:
I think it is usually a lack of understanding about the process and not intentiallally being dishonest #jhsjc
Steve Lee @kichmd:
Maybe a link to the ASSH website where disclosures and amounts are kept up to date #jhsjc
Brent Graham @BgTalkinman to @kichmd:
That is an interesting idea. What we are aiming for is transparency #jhsjc
Steve Lee @kichmd:
This would then apply to all disclosures for meeting presentations too #jhsjc
Brent Graham @BgTalkinman to @kichmd:
Agreed! That is an idea with merit. #jhsjc
Warren @whammert to @kichmd:
Meetings are a bit different as they are governed by ACCME guidelines/ CME requirements (assuming CME meeting) #jhsjc
Brent Graham @BgTalkinman:
Overall, JHS came out looking pretty good in this study but we can always do better #jhsjc
Brent Graham @BgTalkinman to @whammert and @kichmd:
They must still have rules about COI – maybe ones that are even more stringent. #jhsjc
Warren @whammert to @BgTalkinman and @kichmd:
yes – discrepancy between program and slide can get the CME provider in trouble #jhsjc
Brent Graham @BgTalkinman:
We are at the end of our hour. Thanks to all for another great discussion! We will be on a summer hiatus and return on September 9. #jhsjc
Have great summer! #OrthoTwitter #MedTwitter #HandSurgery #JHSJC
Steve Lee @kichmd:
Thank you Brent and all! Have great summers! #jhsjc
J Hand Surg Am- ASSH @JHandSurg
Please be sure to review transcripts of the discussion at jhsfocus.org/jhsjc
Thank you for a great discussion.
