Variation in Non-operative Treatment Recommendations for Common Upper Extremity Conditions
Lisanne Johanna Henrica Smits, MD2; Suzanne Caroline Wilkens, MD2; David Ring, MD, PhD3; Thierry Guitton, MD PhD4; Neal C. Chen, MD2
1Massachusetts General Hospital, Boston, MA; 2Massachusetts General Hospital/Harvard Medical School, Boston, MA; 3Dell Medical School, Austin, TX; 4University Medical Center Gronigen, Groningen, Netherlands
Introduction: In hand surgery, as in other medical fields, there is known surgeon-to-surgeon variation in recommendations for surgery; variation in recommendations for non-operative treatment of common upper extremity conditions for which surgery is discretionary and preference sensitive remains unclear. We hypothesized that there is no surgeon-to-surgeon variation in non-operative treatment recommendations for common conditions of the upper extremity and measured the influence of reading a short summary of best evidence before making treatment recommendations for carpal tunnel syndrome.
Materials & Methods: One-hundred-eighty-three surgeons were included after completing the following questions for 6 scenarios of upper extremity conditions: (1) Would they recommend rest? (2) Immobilization? (3) Would they allow the patient to return to sport? (4) Work? (5) Will surgery be necessary in more than 10% of the patients with this specific problem? (6) And how many months of non-operative treatment they would provide before offering surgery? For the scenario of carpal tunnel syndrome participants were randomized in two groups, of which one group received a short summary of best evidence before answering the questions. In addition, surgeon characteristics were collected for each participant.
Results: There was notable variation in non-operative treatment recommendations between surgeons and between different upper extremity conditions. Surgeons were more consistent on recommendations for return to work (varying from 91% in the carpal tunnel syndrome scenario to 97% in the trigger finger scenario) than for immobilization (from 3.8% to 80%) and return to sports (48% to 87%). When provided with a short summary of best evidence for the scenario of carpal tunnel syndrome, surgeons thought surgery would be necessary in more than 10% of these patients more often than surgeons who were not provided with this summary.
Conclusions: The notable variation in non-operative treatment recommendations together with similar findings in studies of operative recommendations indicates inordinate influence of surgeon bias in decision-making. To help ensure that decisions are consistent with a patient's values, they might benefit from decision-aids and other measures. The evidence suggesting that reading a short summary of best evidence before recommending treatment for carpal tunnel syndrome suggests that decision-support might also help to limit unwarranted variation.
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