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CDA 17-169 – HSR&D Study

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CDA 17-169
Assessing Treatment Delay and Resource Use to Improve Value of Pre-Surgical Care
Erika D Sears MD MS
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Funding Period: April 2018 - March 2023

Little attention has been paid to measuring quality and value of care in the period between diagnosis and receipt of a surgical intervention. Treatment for carpal tunnel syndrome (CTS) is an ideal context to develop measurement models of care quality and utilization between primary care and specialty providers, given that approximately 40,000 Veterans per year are newly diagnosed with CTS and often receive care from one or more providers from primary care, occupational therapy, orthopedic surgery, plastic surgery, neurosurgery, physical medicine and rehabilitation, or pain management. Although a variety of nonoperative treatments can be appropriate under certain clinical circumstances, these same treatments can be low value if they lead to delays for patients who would benefit from surgery. The pre-surgical period, during which patients often have multiple touches with the healthcare system, is an important time to identify opportunities to improve coordination and quality of care for Veterans.

The studies proposed for this CDA will facilitate development of innovative strategies to improve coordination, access, and value of care for Veterans with CTS, particularly in the pre-surgical period.
Aim 1: to assess facility-level variation in pre-surgical value for CTS-related care.
Aim 2: to understand factors associated with pre-surgical episode quality and utilization from the patient and provider perspectives.
Aim 3: to design and pilot a multi-disciplinary CTS clinical care pathway to improve pre-surgical episode value.

This research program will assess the quality and utilization of pre-surgical CTS care delivered over time among multiple providers using a model based on the National Quality Forum (NQF) patient-centered episodes of care theoretical construct coupled with Donabedian's structure-process-outcomes framework. In Aim 1, using VHA administrative data, I will construct facility-level measures of pre-surgical episode quality/access (inappropriate delay of surgery) and utilization (number of pre-surgical encounters) and examine the impact of structural and process considerations on facility variation in these performance measures. Structural considerations will focus on care organization that influences timely access to care, including specialist availability, proximity, and use of community care for referrals. Process considerations will focus on the mode of actual healthcare delivery, like use and timing of diagnostic tests, nonoperative treatments, and specialist referrals. In Aim 2, I will conduct semi-structured interviews with patients and providers to understand key factors associated with pre-surgical episode quality and utilization. The interviews will capture organizational factors (referral protocols and mechanisms of provider communication), perspectives, preferences, and care goals of key stakeholders (patients and clinicians) involved in pre-surgical CTS care to determine facilitators and barriers that impact pre-surgical episode value. For Aim 3, I will use findings from Aim 1 and Aim 2 to design and pilot a multidisciplinary CTS clinical care pathway to improve care coordination, prompt access, and appropriate use of resources for Veterans with CTS.

Not yet available.

This series of studies will develop innovative strategies to improve coordination, access and value of care for CTS, particularly in the pre-surgical period. Through future work, I will use the model developed for CTS to examine variation in quality and utilization during pre-surgical care for other conditions, with the goal of optimizing the value of health care services across all treatment phases and maximizing outcomes for Veterans receiving surgical care. This approach will also be beneficial for quality measurement efforts across healthcare settings as the VHA provides more care through the community-based healthcare networks recommended by the Commission on Care.


Journal Articles

  1. Billig JI, Chen JS, Lu YT, Chung KC, Sears ED. The Economic Burden of Out-of-Pocket Expenses for Plastic Surgery Procedures. Plastic and reconstructive surgery. 2020 Jun 1; 145(6):1541-1551.
  2. Billig JI, Sears ED, Gunaseelan V, Santosa KB, Iwashyna TJ, Englesbe MJ, Brummett CM, Waljee JF. Inappropriate Preoperative Gabapentinoid Use Among Patients With Carpal Tunnel Syndrome. The Journal of hand surgery. 2020 May 30.
  3. Morrell NT, Sears ED, Desai MJ, Forseth MJ, McClelland WB, Chang J, Kakar S. A Survey of Burnout Among Members of the American Society for Surgery of the Hand. The Journal of hand surgery. 2020 Jul 1; 45(7):573-581.e16.
  4. Santosa KB, Keane AM, Keller M, Olsen MA, Sears ED, Snyder-Warwick AK. Inpatient Versus Outpatient Management of Negative Pressure Wound Therapy in Pediatric Patients. The Journal of surgical research. 2020 May 22; 254:197-205.
  5. Billig JI, Sears ED. The Compounding Access Problem for Surgical Care: Innovations in the Post-COVID Era. Annals of surgery. 2020 May 20.
  6. Ding Q, Trickey AW, Mudumbai S, Kamal RN, Sears ED, Harris AHS. Prevalence and Factors Associated With Low-Value Preoperative Testing for Patients Undergoing Carpal Tunnel Release at an Academic Medical Center. Hand (New York, N.Y.). 2020 Feb 26; 1558944720906498.
  7. Billig JI, Lu YT, Kelley BP, Chung KC, Sears ED. Out-of-Pocket Spending for Thumb Carpometacarpal Arthritis: Capitation Matters. Hand (New York, N.Y.). 2020 Feb 23; 1558944720906503.
  8. Mudumbai SC, Pershing S, Bowe T, Kamal RN, Sears ED, Finlay AK, Eisenberg D, Hawn MT, Weng Y, Trickey AW, Mariano ER, Harris AHS. Development and validation of a predictive model for American Society of Anesthesiologists Physical Status. BMC health services research. 2019 Nov 21; 19(1):859.
  9. Lu YT, Haase SC, Chung TT, Chung KC, Sears ED. The Impact of Pre-Referral Advanced Diagnostic Testing on Wait Time to See a Hand Surgeon for Common Upper-Extremity Conditions. The Journal of hand surgery. 2019 Dec 1; 44(12):1013-1020.e2.
  10. Billig JI, Sears ED, Travis BN, Waljee JF. Patient-Reported Outcomes: Understanding Surgical Efficacy and Quality from the Patient's Perspective. Annals of Surgical Oncology. 2020 Jan 1; 27(1):56-64.
  11. Harris AHS, Meerwijk EL, Kamal RN, Sears ED, Hawn M, Eisenberg D, Finlay AK, Hagedorn H, Mudumbai S. Variability and Costs of Low-Value Preoperative Testing for Carpal Tunnel Release Surgery. Anesthesia and analgesia. 2019 Sep 1; 129(3):804-811.
  12. Chung KC, Malay S, Shauver MJ, Wrist and Radius Injury Surgical Trial Group. The Relationship between Hand Therapy and Long-Term Outcomes after Distal Radius Fracture in Older Adults: Evidence from the Randomized Wrist and Radius Injury Surgical Trial. Plastic and reconstructive surgery. 2019 Aug 1; 144(2):230e-237e.
  13. Chung KC, Kim HM, Malay S, Shauver MJ, WRIST Group. Predicting Outcomes After Distal Radius Fracture: A 24-Center International Clinical Trial of Older Adults. The Journal of hand surgery. 2019 Sep 1; 44(9):762-771.
  14. Santosa KB, Larson EL, Vannucci B, Lapidus JB, Gast KM, Sears ED, Waljee JF, Suiter AM, Sarli CC, Mackinnon SE, Snyder-Warwick AK. Gender Imbalance at Academic Plastic Surgery Meetings. Plastic and reconstructive surgery. 2019 Jun 1; 143(6):1798-1806.
  15. Sears ED, Lu YT, Chung TT, Momoh AO, Chung KC. Pathology Evaluation of Reduction Mammaplasty Specimens and Subsequent Diagnosis of Malignant Breast Disease: A Claims-Based Analysis. World Journal of Surgery. 2019 Jun 1; 43(6):1546-1553.
  16. Sears ED, Hayward RA, Kerr EA. The presurgical episode: an untapped opportunity to improve value. The American journal of managed care. 2019 May 1; 25(5):219-220.
  17. Sears ED, Lu YT, Swiatek PR, Chung TT, Kerr EA, Chung KC. Use of Preoperative Mammography During Evaluation for Nononcologic Breast Reduction Surgery. JAMA surgery. 2019 Apr 1; 154(4):356-358.
  18. Harris AHS, Meerwijk EL, Kamal RN, Sears ED, Hawn M, Eisenberg D, Finlay AK, Hagedorn H, Marshall N, Mudumbai SC. Variation in Surgeons' Requests for General Anesthesia When Scheduling Carpal Tunnel Release. Hand (New York, N.Y.). 2019 Feb 21; 1558944719828006.
  19. Sears ED, Meerwijk EL, Schmidt EM, Kerr EA, Chung KC, Kamal RN, Harris AHS. Variation in Nonsurgical Services for Carpal Tunnel Syndrome Across a Large Integrated Health Care System. The Journal of hand surgery. 2019 Feb 1; 44(2):85-92.e1.
  20. Kelley BP, Chung KC, Chung TT, Bennett KG, Sacks G, Sears ED, Waljee JF. Postoperative Ketorolac in Breast and Body Contouring Procedures: A Nationwide Claims Analysis. Plastic and reconstructive surgery. 2018 Oct 1; 142(4):472e-480e.

DRA: Health Systems
DRE: none
Keywords: none
MeSH Terms: none

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