Geographic and doctor-to-doctor variations in care are a focus of quality and safety efforts in medicine. A recent study addressed factors associated with variation in the rate of operative treatment of de Quervain tendinopathy (1). A better understanding of the variation in surgery rate for common, benign hand illnesses, such as de Quervain tendinopathy, is a first step in developing interventions to improve the value of hand surgery. 

We found that clinicians have substantial influence on treatment of de Quervain tendinopathy (1). For example, patients who had a corticosteroid injection were more likely to have surgery, possibly because providers who offer injection are also more likely to offer surgery. Or it might be that a subset of patients prefer to intervene and if injections don’t work, they and their providers will decide to progress to surgery. An important alternative explanation is that the steroid injection might medicalize the problem. In other words, while evidence suggests that de Quervain tendinopathy is a self-limited condition, giving a patient an injection might reinforce a false belief that the problem will not resolve without intervention. When the injection doesn’t resolve the problem, patients with this mindset will be more likely to proceed to the next step of surgery.

From another study that investigated the factors associated with variation in the rate of surgery for enthesopathy of the extensor carpi radialis brevis, it seems likely that an emphasis on the preferences and values of the patient rather than the surgeon would decrease the variation in surgery rates (2). Corticosteroid injection delayed the time to surgery but was ultimately associated with a higher rate of surgery.

There is also controversy regarding the value of repair of the distal radioulnar ligaments and articular disc. Given that an acute tear of the distal radioulnar ligament associated with a displaced distal radius fracture uncommonly benefits from repair, the role of repair in other settings is uncertain (3). We found that the rate of radioulnar ligament and articular disc repair varies substantially from surgeon-to-surgeon. The observation that repair is more likely to happen when patients perceive themselves as injured may be an example of how cognitive bias (considering pain as injury) can affect how patients and surgeons consider treatment options. 

When we studied factors associated with increased costs and surgery in the first year after diagnosis of osteoarthritis in the hand (4), we found wide variation in the use of medical services and associated costs between clinicians. Younger patients, men, and people that saw more than one clinician incurred higher costs and were more likely to request surgery. 

To ensure that a choice for surgery is not based on cognitive biases of the surgeon or patient, we suggest studying the effect of tools that provide simple, balanced, dispassionate, and empowering information that can limit surgeon-to-surgeon variation by addressing cognitive bias. The use of decision aids and other methods that help involve the patient in decision-making merit investigation as interventions to help reduce these variations in care.

Our research on variations in care is focusing on several areas:

1. We are studying methods for optimizing the influence of patient values on decision-making by addressing cognitive error and bias.
2. We are evaluating the use of decision aids for discretionary hand surgery.

References

1. Kachooei AR, Nota SP, Menendez ME, Dyer GS, Ring D. Factors Associated with Operative Treatment of De Quervain Tendinopathy. Arch Bone Jt Surg. 2015 Jul;3(3):198-203. PubMed PMID: 26213704; PubMed Central PMCID: PMC4507074.
2. Kachooei AR, Talaei-Khoei M, Faghfouri A, Ring D. Factors associated with operative treatment of enthesopathy of the extensor carpi radialis brevis origin. J Shoulder Elbow Surg. 2016 Apr;25(4):666-70. doi: 10.1016/j.jse.2015.12.019. PubMed PMID: 26995457.
3. Kootstra TJM, van Leeuwen WF, Chen N, Ring D. Variation in Repair of the Triangular Fibrocartilage Complex. J Wrist Surg. 2018 Jul;7(3):243-246. doi: 10.1055/s-0038-1625953. Epub 2018 Jan 30. PubMed PMID: 29922502; PubMed Central PMCID: PMC6005778.
4. Becker SJ, Teunis T, Blauth J, Kortlever JT, Dyer GS, Ring D. Medical services and associated costs vary widely among surgeons treating patients with hand osteoarthritis. Clin Orthop Relat Res. 2015 Mar;473(3):1111-7. doi: 10.1007/s11999-014-3912-3. Epub 2014 Aug 30. PubMed PMID: 25171936; PubMed Central PMCID: PMC4317453.