#JHSJC

January #JHSJC Transcript

Happy New Year! We kicked off 2023 by discussing two leading articles from Volume 48, Issue 1 of JHS:

  1. Electrodiagnostic Predictors of Outcomes After In Situ Decompression of the Ulnar Nerve (https://www.jhandsurg.org/article/S0363-5023(22)00609-8/fulltext)
  2. A Systematic Review of Satisfaction Measures in Hand and Wrist Surgery (https://www.jhandsurg.org/article/S0363-5023(22)00614-1/fulltext)

As always, we thank everyone for their participation! We hope you’ll plan on joining us next month. To do so, you can find the instructions for using the TwChat platform here.

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:
January’s #JHSJC is happening NOW! Let’s get the discussion going. #JHS #HandSurgery #outcomes #UlnarNerveDecompression #hand #WristSurgery #satisfaction

Brent Graham @BgTalkinman:
Happy New Year all! Welcome to the January session! #jhsjc

Brent Graham @BgTalkinman:
Let’s start with the paper by Florczynski et al. #jhsjc
The objective of this study was to determine if there are any electrophysiologic parameters that predict outcome after in situ cubital tunnel release. #jhsjc

RyanC @RPCalfeeSTL:
Interesting study and always remarkably humbling trying to predict outcomes #jhsjc

Brent Graham @BgTalkinman to @RPCalfeeSTL:
Agreed!! #jhsjc

Brent Graham @BgTalkinman:
The pts underwent a series of electrodiagnostic tests pre-operatively and then at 6 weeks, 3 months, 6 months, and 12 months following an in situ ulnar nerve decompression. #jhsjc
Decreased compound motor action potential (CMAP) amplitude predicted slower recovery but no other parameters were associated with either the 12-month impairment measures or the patient-reported outcomes. #jhsjc

RyanC @RPCalfeeSTL:
Personally, I haven’t paid as much attention to CMAP values but will have to watch going forward #jhsjc

Brent Graham @BgTalkinman:
There was a moderate attrition from the orig cohort over the course of the 12-month follow-up: 30 patients had PROMs documented, and 26 had clinical outcomes at 12 months of follow-up. Is that loss to follow-up important conclusions, or are the conclusions valid anyway? #jhsjc

RyanC @RPCalfeeSTL to @BgTalkinman:
Certainly loss to follow up and missing data always create uncertainty in any study #jhsjc

Brent Graham @BgTalkinman:
It wasn’t studied in this investigation, but is it likely that CMAP would better predict the trajectory of recovery than the clinical evaluation? #jhsjc

RyanC @RPCalfeeSTL to @BgTalkinman:
I’m not sure but certainly interested in others’ thoughts #jhsjc

Brent Graham @BgTalkinman:
I will answer my own question! I would say while recovery trajectory is sometimes important, the cost, discomfort and other issues wouldn’t be enough to justify getting routine investigations like those. #jhsjc
The authors state that PROMs plateau after about 3 months. If there is little or no impact of surgical treatment on patient-reported outcomes after 3 months, is there value in predicting a slower trend of improvement in the impairment measures out to 12 months? #jhsjc

RyanC @RPCalfeeSTL to @BgTalkinman:
If PRO’s plateau at 3months then no need to follow longer unless PRO’s not capturing some elements of improvement ongoing. #jhsjc

Avi Giladi @theaviram to @RPCalfeeSTL:
Some of the earlier studies from the first SUN study showed strength recovery took up to a year #jhsjc

Brent Graham @BgTalkinman to @theaviram:
Correct – those are the results I’m referring to. #jhsjc

Brent Graham @BgTalkinman to @RPCalfeeSTL:
They cite their earlier work that evidently shows continuing sensory and motor improvement out to 12 months, but I would agree that those don’t matter as much as the PROMs. #jhsjc

RyanC @RPCalfeeSTL to @theaviram:
Clinically I do think recovery from cubital takes longer and tell patients we will watch and see for a year #jhsjc

Avi Giladi @theaviram to @BgTalkinman:
agree PRO matter “more” — but individual PRO can be relative. the patient at 12 months might re-rate their 3 month lower once they hit “real” final result #jhsjc

Brent Graham @BgTalkinman to @theaviram:
That is a very interesting point. Do you mean the the earlier PROM results might “re-calibrate” after longer follow-up? #jhsjc
That’s an idea I would be interested in seeing studied more – changes in PROMs over time following an intervention. #jhsjc

Avi Giladi @theaviram to @BgTalkinman:
Yes exactly. when patients trend out over 1-2 years we see many PRO scores go down. a very under-discussed but real issue #jhsjc

Brent Graham @BgTalkinman to @theaviram:
I hope to hear more about that! #jhsjc

Brent Graham @BgTalkinman to @RPCalfeeSTL and @theaviram:
Is that justification for obtaining electrodiagnostic studies – ie for identifying prognosis? #jhsjc

RyanC @RPCalfeeSTL to @BgTalkinman:
tough call. Lots of debate about ncv/emg’s and need for them. I do like them adding data to sometimes challenging exams and to help with counseling but clearly not perfect #jhsjc

Brent Graham @BgTalkinman to @RPCalfeeSTL:
It’s been my longstanding contention that EDS are useful in situations of uncertainty. #jhsjc

Avi Giladi @theaviram to @BgTalkinman:
I would love it if they did give prognostic information. that would be very helpful especially in those with signs of weakness #jhsjc

Brent Graham to @BgTalkinman:
Let’s talk about the other paper, a systematic review oi the topic of measurement of patient satisfaction. https://jhandsurg.org/article/S0363-5023(22)00614-1/fulltext; podcast: https://jhandsurg.org/audio-do/jhs-podcast-episode-82 #jhsjc

RyanC @RPCalfeeSTL to @BgTalkinman:
one of your favorite topics as a more complex thing than at first glance #jhsjc

Brent Graham @BgTalkinman to @RPCalfeeSTL:
Yes! We don’t feature many systematic reviews but this one points out a very important problem, the lack of rigor in the way this important construct is measured. #jhsjc

Brent Graham to @BgTalkinman:
There were 2 main findings: nothing has changed in the way satisfaction is being measured over the last 20 years; most of the approaches to measurement seem to have substantial ceiling effects. #jhsjc

Dafang Zhang @DafangZhang to @BgTalkinman:
I love how the authors highlighted the difference between saturation with outcomes of treatment and with the patient experience. So much is often lumped into “satisfaction” in research #jhsjc

RyanC @RPCalfeeSTL to @BgTalkinman:
I’m sure others have experiences with patients happy/unhappy based on parts of process of care vs actual outcome of treatment. Can catch me off guard at times. #jhsjc

Brent Graham @BgTalkinman to @RPCalfeeSTL:
This is a key distinction that many authors fail to identify. #jhsjc

Brent Graham @BgTalkinman to @DafangZhang:
This came up during the review too. Is it saturation or is it possible that patients actually are generally pretty satisfied? #jhsjc

Dafang Zhang @DafangZhang to @BgTalkinman:
My typo from earlier, but great question.. I do believe patients are very satisfied in general. Maybe high satisfaction reflects reality, but we’ve not tried to make measurements close to this ceiling #jhsjc

Brent Graham @BgTalkinman:
The authors specifically excluded studies that used MHQ satisfaction scales because they felt that the MHQ measured constructs that were covered by other patient-reported outcomes. Was that a valid strategy? #jhsjc
The longstanding policy of JHS has been to disallow any reports of satisfaction that are not measured using a scale of known validity and reliability. Until recently, the MHQ is the only scale that has met that criterion. #jhsjc

Avi Giladi @theaviram to @BgTalkinman:
it’s like the 1 star yelp review at a good restaurant because the power went out for 5 minutes during the meal. satisfaction/ratings are as fallible as humans are. #jhsjc

RyanC @RPCalfeeSTL to @theaviram:
true #jhsjc

RyanC @RPCalfeeSTLto @BgTalkinman and @DafangZhang:
I think that most hand surgery patients are actually pretty happy with both care delivered and objective outcomes #jhsjc

Avi Giladi @theaviram to @RPCalfeeSTL:
agreed. most are happy overall. but even in one clinic visit they will report differently to the PA/fellow than they do to me. It’s such a difficult metric to obtain let alone understand #jhsjc

Brent Graham @BgTalkinman to @theaviram:
Ha! We need the same rigour to measuring this as we have now accepted as fundamental for measuring other patient reported outcomes. #jhsjc

David Ring @DrDavidRing:
Is there another measure in research that we would consider useful if it didn’t have good variation is scores? I think we can always do better. #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
I wholeheartedly agree! What I hope this paper achieves is bringing greater awareness of this issue. We can argue if there are ceiling effects or not but we won’t know until we have reliable, valid scales #jhsjc

Avi Giladi @theaviram to @DrDavidRing:
It seems many have moved to the “would you recommend this treatment to a loved one” as the satisfaction question of greatest importance/impact. But I am not sure how substantiated that is #jhsjc

Dafang Zhang @DafangZhang to @theaviram and @DrDavidRing:
When designing PREM, should we separate satisfaction with outcome versus experience? Since they can be very independent? #jhsjc

David Ring @DrDavidRing to @DafangZhang:
Satisfaction with capability and comfort = PROM Satisfaction wtih communication, empathy, trust, involvement in decisions etc. = PREM. #jhsjc

Avi Giladi @theaviram to @DafangZhang:
absolutely. theyre often not even related! #jhsjc

David Ring @DrDavidRing to @theaviram:
You’ll get mostly yes’s to that question, meaning you can’t learn how to improve. Ask even the most satisfied patient and they will have a useful tip for us. #jhsjc

Avi Giladi @theaviram to @DrDavidRing:
fair. then perhaps comes the challenge of how to collect the open-ended responses that we likely need most #jhsjc

Brent Graham @BgTalkinman to @theaviram:
My understanding is that it’s an approach that has been validated in the primary care literature. #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
How do we get more headroom for this construct? #jhsjc

David Ring @DrDavidRing to @theaviram:
How about just asking patient how we can improve and then developing scores from their language while also collecting themes? Like this: https://pubmed.ncbi.nlm.nih.gov/35383720/ #jhsjc

Brent Graham @BgTalkinman to @theaviram and @DrDavidRing:
I agree that the details of how this can be measured matter. #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
One idea is analyzing verbatim patient comments. Another is adjusting for things like social desirability bias. Like this: https://pubmed.ncbi.nlm.nih.gov/35155757/. I’m sure we can come up with other ideas. #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
Sure! But to be practical any scale, no matter the basis, has to be reliable and valid. #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
100%. I think those are relatively easy to achieve. Work to be done! #jhsjc

Avi Giladi @theaviram to @DrDavidRing:
yes it would need to not be writing-based, so NLP of transcribed text from verbal responses could certainly have merit. But validating the analyses/process still requires (a) reliable measure(s) #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
Hopefully that is true! As I said the true importance of this paper might be in raising awareness of this problem just like this discussion is doing among all of you very smart people! #jhsjc

Brent Graham @BgTalkinman to @theaviram and @DrDavidRing:
These are all great ideas that merit some thoughtful investigation. #jhsjc

Brent Graham @BgTalkinman:
I will be anxiously waiting to see these submissions to @JHandSurg! Thanks to all for your ideas and insights! We return here February 14, same time. #jhsjc

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