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.
Clin Orthop Relat Res. 2019 Oct;477(10):2345-2355. doi: 10.1097/CORR.0000000000000742.
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.
QUESTIONS/PURPOSES: (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.
过度使用医疗资源给社会带来了负担。先前的研究表明，许多创伤性肌肉骨骼损伤患者在适当的愈合后仍继续寻求治疗，这表明服务过度。然而，很少有研究检查与创伤性手和腕部疾病就诊次数增加相关的因素，包括患者报告的结果。
问题/目的：（1）在考虑手术治疗、外科医生和人口统计学因素后，患者的 PROMIS 疼痛干扰评分是否与就诊次数有关？（2）PROMIS 抑郁、PROMIS 抑郁和疼痛干扰的组合，或身体功能评分是否与就诊次数有关？
在 2015 年 6 月至 2018 年 5 月期间，在一家城市学术医疗中心，对 1098 名因桡骨远端骨折、手腕或手部扭伤、肌腱断裂、创伤性手指截肢或舟状骨骨折而新就诊的患者进行了研究。其中，823 名（75%）患者完成了所有 PROMIS 领域的评估，并在随访期之前就诊，因此被纳入本回顾性研究。我们记录了一系列变量，包括就诊次数、年龄、性别、种族、婚姻状况、诊断、提供者、手术或非手术治疗。多变量泊松回归分析用于确定患者报告的结局测量信息系统疼痛干扰（PROMIS PI）、身体功能（PROMIS PF）和抑郁评分是否与就诊次数有关，这些评分是在第一次就诊时测量的，在考虑到我们测量的其他因素后。
较高的 PROMIS PI 评分与就诊次数较多有关（0.0077；95%CI，0.0018-0.014；p=0.010）。尽管 PROMIS 抑郁评分与就诊次数无关（0.0042；95%CI，-0.0099 至 0.0094；p=0.112），但在考虑混杂因素后，较高的 PROMIS PF 评分与就诊次数减少有关（-0.0077；95%CI，-0.0012 至-0.0029；p=0.001）。此外，在所有单独的 PROMIS 模型中，变量“手术治疗”（PI：0.85；95%CI，0.72-0.98；p<0.001；抑郁：0.87；95%CI，0.74-1.0；p<0.001；PF：0.85；95%CI，0.72-0.99；p<0.001）和“创伤性手指截肢”（PI：0.22；95%CI，0.016-0.42；p=0.034；抑郁：0.2；95%CI，0.086-0.47；p=0.005；PF：0.21；95%CI，0.014-0.41；p=0.036）与就诊次数的增加有关。团队 5 提供者（PI：-0.62；95%CI，-0.98 至-0.27；p=0.001；抑郁：-0.61；95%CI，-0.96 至-0.26；p=0.001；PF：-0.60；95%CI，-0.96 至-0.25；p=0.001）与就诊次数减少有关。在 PROMIS 抑郁和 PROMIS PF 回归模型中，年龄增加（抑郁：-0.0048；95%CI，-0.0088 至-0.00081；p=0.018；PF：-0.0045；95%CI，-0.0085 至-0.0006；p=0.024）也与就诊次数减少有关。
这项研究有助于外科医生了解到，在初次就诊时表现出更严重的疼痛应对策略和身体功能下降的创伤性手部和腕部疾病患者，就诊次数会更多。我们建议外科医生采用全面的护理方法，这种方法富有同情心，促进有效的疼痛应对策略（因此可能会降低 PROMIS PI 评分），并通过提供教育材料和/或根据需要包括其他健康专业人员（如社会工作者、物理治疗师、心理健康专业人员）来教育患者，以了解预期。这可能会减少创伤性手部和腕部疾病患者的医疗保健使用。
IV 级，预后研究。
