Sears Erika D, Meerwijk Esther L, Schmidt Eric M, Kerr Eve A, Chung Kevin C, Kamal Robin N, Harris Alex H S
Department of Surgery, Section of Plastic Surgery, Michigan Medicine, Ann Arbor, MI; Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI.
Veterans Affairs Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA.
J Hand Surg Am. 2019 Feb;44(2):85-92.e1. doi: 10.1016/j.jhsa.2018.11.002. Epub 2018 Dec 20.
To evaluate facility-level variation in the use of services for patients with carpal tunnel syndrome (CTS) receiving care in the Veterans Health Administration (VHA).
A national cohort of VHA patients diagnosed with CTS during fiscal year 2013 was divided into nonsurgical and operative treatment groups for comparison. We assessed the use of 5 types of CTS-related services (electrodiagnostic studies [EDS], imaging, steroid injection, oral steroids, and therapeutic modalities) in the prediagnosis and postdiagnosis periods before any operative intervention at the patient and facility levels.
Among 72,599 patients newly diagnosed with CTS, 5,666 (7.8%) received carpal tunnel release within 12 months. The remaining 66,933 (92.2%) were in the nonsurgical group. Therapeutic modalities and EDS were the most commonly employed services after the index diagnosis and had large facility-level variation in use. At the facility level, the use of therapeutic modalities ranged from 0% to 93% in the operative group (mean, 32%) compared with 1% to 67% (mean, 30%) in the nonsurgical group. The use of EDS in the postdiagnosis period ranged from 0% to 100% (mean, 59%) in the operative treatment group and 0% to 55% (mean, 26%) in the nonsurgical group at the facility level.
There is wide facility variation in the use of services for CTS among patients receiving operative and nonsurgical treatment. Care delivered by facilities with the highest and lowest rates of service use may suggest overuse and underuse, respectively, of nonsurgical CTS services and a lack of consideration of individual patient factors in making health care decisions regarding use.
Surgeons must understand the degree of treatment variability for CTS, comprehend the ramifications of large variation in reimbursement and waste in the health care system, and become involved in devising strategies to optimize hand care across all phases of care.
评估退伍军人健康管理局（VHA）中接受治疗的腕管综合征（CTS）患者在医疗机构层面服务使用情况的差异。
将2013财年被诊断为CTS的VHA患者全国队列分为非手术和手术治疗组进行比较。在患者和医疗机构层面，我们评估了在任何手术干预之前的诊断前和诊断后时期内5种与CTS相关服务（电诊断研究[EDS]、影像学检查、类固醇注射、口服类固醇和治疗方式）的使用情况。
在72,599例新诊断为CTS的患者中，5,666例（7.8%）在12个月内接受了腕管松解术。其余66,933例（92.2%）在非手术组。治疗方式和EDS是指标诊断后最常用的服务，且在医疗机构层面的使用差异很大。在医疗机构层面，手术组治疗方式的使用范围为0%至93%（平均32%），而非手术组为1%至67%（平均30%）。诊断后时期手术治疗组EDS的使用范围在医疗机构层面为0%至100%（平均59%），非手术组为0%至55%（平均26%）。
接受手术和非手术治疗的CTS患者在服务使用方面存在广泛的医疗机构差异。服务使用率最高和最低的医疗机构所提供的护理可能分别表明非手术CTS服务的过度使用和使用不足，以及在做出关于服务使用的医疗保健决策时缺乏对个体患者因素的考虑。
外科医生必须了解CTS治疗的变异性程度，理解医疗保健系统中报销和浪费的巨大差异的影响，并参与制定策略以优化整个护理阶段的手部护理。
