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.
- 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.
- 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.
- 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.