ABSTRACT
BACKGROUND: Most managed care plans use a physician "gatekeeper" to control referrals to hand surgeons. The appropriateness of this model for upper extremity complaints has never been challenged. The purpose of this study was to evaluate the prior management of patients with elective hand disorders who present to a hand surgery clinic. METHODS: All patients presenting to a tertiary, academic medical center for a new-patient hand surgery evaluation from February 3, 2011, to June 15, 2011, were prospectively enrolled. Patients were evaluated for prior provider, diagnosis, treatment, and complications. Actual diagnosis, recommended workup, and appropriate treatment were determined independently by two experienced hand examiners. Traumatic injuries and surgeon disagreements in diagnosis and treatment were excluded, leaving 125 patients. RESULTS: Ninety-eight percent of patients had been evaluated by a primary care provider. Overall, the correct diagnosis was established 34 percent of the time. Nerve compression syndromes were diagnosed with the greatest accuracy (64 percent), whereas stenosing tenosynovitis was diagnosed correctly only 15 percent of the time. Before presentation, 74 percent of patients had undergone a study or intervention. On review, 70 percent of studies/interventions were deemed unnecessary. Advanced imaging was unwarranted in 90 percent of patients who received it. Seventeen percent of patients experienced a complication. Most (67 percent) were caused by a delay in diagnosis, whereas 33 percent resulted from an intervention. CONCLUSIONS: Health care providers less familiar with an examination of the hand often misdiagnose and mistreat common problems. A referral system may not be the most efficient means of delivering care to patients with elective hand maladies.
Subject(s)
Delayed Diagnosis/statistics & numerical data , Diagnostic Errors/statistics & numerical data , Hand/surgery , Primary Health Care , Referral and Consultation , Unnecessary Procedures/statistics & numerical data , Dupuytren Contracture/complications , Dupuytren Contracture/diagnosis , Dupuytren Contracture/therapy , Hand/diagnostic imaging , Humans , Nebraska , Nerve Compression Syndromes/complications , Nerve Compression Syndromes/diagnosis , Nerve Compression Syndromes/therapy , Osteoarthritis/complications , Osteoarthritis/diagnosis , Osteoarthritis/therapy , Primary Health Care/statistics & numerical data , Prospective Studies , Radiography , Referral and Consultation/statistics & numerical data , Tenosynovitis/complications , Tenosynovitis/diagnosis , Tenosynovitis/therapyABSTRACT
PURPOSE: The purpose of the study was to assess how context influences range of motion measurements in hand surgery. METHODS: One hundred seventy-five consecutive patients presenting to a hand surgery clinic were evaluated over 7 sessions. Passive and active motion were measured with a goniometer and by visual estimation. The affected joint was measured by 3 different examiners-one hand surgeon and 2 research assistants (RAs). Measurements by the RAs were performed under the pretense of imaginary project titles and purposes. RESULTS: Range of motion measurements were easily influenced. As the invented project's purpose became more specific and dependent on physician intervention, the bias became more pronounced. Measurements performed under construed project titles that promoted surgical intervention garnered outcomes that supported surgery (P < 0.01). Conversely, when the manufactured study's intent was to find support in conservative treatment, this outcome could also be generated (P < 0.01). DISCUSSION: Range of motion measurements can easily be influenced by the context of the study, even in seemingly blinded examiners. Reliable range of motion measurements can only be made when the examiner has no knowledge of the study's intent.
