Variation in CCG policies for the treatment of carpal tunnel syndrome

Ryan, Daniel; Shaw, Abigail; Graham, Stuart I.; Mason, W

doi:10.1308/rcsbull.2017.28

Cited by 17 publications

(13 citation statements)

References 28 publications

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“…Despite local clinical commissioning policies that advocate conservative treatment first, the proportion of participants having a steroid injection in the first 6 months was only 9%, which is in contrast to 52% proceeding directly to surgery. This may be due, in part, to some patients having had symptoms for some time or having receiving a steroid injection prior to referral for NCS and enrolment in our study.…”

Section: Discussionmentioning

confidence: 94%

“…13 Some healthcare systems use restrictive policies in which surgery is offered only in cases in which symptoms persist for more than 3 months after initial conservative therapy or in which the patient suffers from significant functional impairment or has a neurological deficit. 14 Several studies have explored a range of prognostic factors for outcome from surgical and conservative treatments. [15][16][17][18] However, these studies were limited by small sample sizes, a poor ratio of events to number of factors being studied resulting in overfitting, a restricted range of variables, or the use of univariable analysis rather than multivariable models or were retrospective.…”

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confidence: 99%

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Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): A prospective multicenter cohort study

et al. 2019

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Introduction Studies of prognosis for surgery and corticosteroid injection for carpal tunnel syndrome (CTS) have considered only a limited range of explanatory variables for outcome. Methods Data were prospectively collected on patient‐reported symptoms, physical and psychological functioning, comorbidity, and quality of life at baseline and every 6 months for up to 2 years. Outcomes were patient‐rated change over a 6‐month period and symptom‐severity score at 18 months. Results In total, 754 patients with CTS completed baseline questionnaires, and 626 (83%) completed follow‐up to 18 months. Multivariable modeling identified, independent of symptom severity at outset, higher health utility, fewer comorbidities, and lower anxiety as significant predictors of better outcome from surgery. In patients treated by steroid injection, independent of symptom severity at outset, shorter duration of symptoms and having no prior injection were significant predictors of better outcome. Discussion These multivariable models of outcome may inform shared decision making about treatment for CTS. Muscle Nerve, 2019

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Section: Discussionmentioning

confidence: 94%

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confidence: 99%

Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): A prospective multicenter cohort study

et al. 2019

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“… 27 In the UK, CTR has been labeled by some Clinical Commissioning Groups (member organizations who determine how National Health Service (NHS) funds are spent in a particular locality) as a “procedure of limited clinical value” leading to variable patient access to the procedure. 28 The Royal College of Surgeons expressed their concern on the potential impact on patient health and well-being. 29…”

Section: Introductionmentioning

confidence: 99%

Predicting surgical intervention in patients presenting with carpal tunnel syndrome in primary care

Burton¹,

Chesterton²,

Chen³

et al. 2018

CLEP

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PurposeCarpal tunnel syndrome (CTS) is a symptomatic compression neuropathy of the median nerve. This study investigated the value of candidate prognostic factors (PFs) in predicting carpal tunnel release surgery.Patients and methodsThis is a retrospective cohort study set in the Clinical Practice Research Datalink. Patients ≥18 years presenting with an incident episode of CTS were identified between 1989 and 2013. Candidate PF’s defined in coded electronic patient records were identified following literature review and consultation with clinicians. Time to first carpal tunnel release surgery was the primary end point. A manual backward stepwise selection procedure was used to obtain an optimal prediction model, which included all the significant PFs.ResultsIn total, 91,412 patients were included in the cohort. The following PFs were included in an optimal model (C-statistic: 0.588 [95% CI 0.584–0.592]) for predicting surgical intervention: geographical region; deprivation status; age hazard ratio (HR 1.02 per year, 95% CI 1.01–1.02); obesity (HR 1.23, 95% CI 1.19–1.27); alcohol drinker (HR 1.05, 95% CI 1.00–1.10); smoker (HR 1.06, 95% 1.03–1.10); inflammatory condition (HR 1.13, 95% CI 0.98–1.29); neck condition (HR 1.13, 95% CI 1.03–1.23); and multisite pain (HR 1.10, 95% CI 1.05–1.15). Although not included in the multivariable model, pregnancy (if gender female) within 1 year of the index consultation, reduced the risk of surgery (HR 0.24, 95% CI 0.21–0.28).ConclusionThis study shows that patients who are older and who have comorbidities including other pain conditions are more likely to have surgery, whereas patients presenting with CTS during or within a year of pregnancy are less likely to have surgery. This information can help to inform clinicians and patients about the likely outcome of treatment and to be aware of which patients may be less responsive to primary care interventions.

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“…There has been much debate over the value of NCS in the diagnosis of CTS, 1 22–24 and in the UK not all patients have NCS. 7 Several studies have examined the association of self-reported symptoms and function with objective severity from electrodiagnostic findings. Most have used simple correlations with the exception of Chan et al .…”

Section: Discussionmentioning

confidence: 99%

“…A recent review of policies from 175 CCGs in England highlighted that these were highly variable in terms of criteria for defining severity, the necessity for nerve conduction studies (NCS) and duration of non-operative treatment before referral for surgery is allowed. 7 Controversy continues over the best management of CTS at different stages. More recent research on CTS has highlighted the role of psychological factors such as anxiety, depression and patient’s health beliefs in how patients perceive their symptoms, their impact on function and the outcome from treatment.…”

Section: Introductionmentioning

confidence: 99%

Association of psychological distress, quality of life and costs with carpal tunnel syndrome severity: a cross-sectional analysis of the PALMS cohort

et al. 2017

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ObjectivesThe Prediciting factors for response to treatment in carpal tunnel syndrome (PALMS) study is designed to identify prognostic factors for outcome from corticosteroid injection and surgical decompression for carpal tunnel syndrome (CTS) and predictors of cost over 2 years. The aim of this paper is to explore the cross-sectional association of baseline patient-reported and clinical severity with anxiety, depression, health-related quality of life and costs of CTS in patients referred to secondary care.MethodsProspective, multicentre cohort study initiated in 2013. We collected baseline data on patient-reported symptom severity (CTS-6), psychological status (Hospital Anxiety and Depression Scale), hand function (Michigan Hand Questionnaire) comorbidities, EQ-5D-3L (3-level version of EuroQol-5 dimension) and sociodemographic variables. Nerve conduction tests classified patients into five severity grades (mild to very severe). Data were analysed using a general linear model.Results753 patients with CTS provided complete baseline data. Multivariable linear regression adjusting for age, sex, ethnicity, duration of CTS, smoking status, alcohol consumption, employment status, body mass index and comorbidities showed a highly statistically significant relationship between CTS-6 and anxiety, depression and the EQ-5D (p<0.0001 in each case). Likewise, a significant relationship was observed between electrodiagnostic severity and anxiety (p=0.027) but not with depression (p=0.986) or the EQ-5D (p=0.257). National Health Service (NHS) and societal costs in the 3 months prior to enrolment were significantly associated with self-reported severity (p<0.0001) but not with electrodiagnostic severity.ConclusionsPatient-reported symptom severity in CTS is significantly and positively associated with anxiety, depression, health-related quality of life, and NHS and societal costs even when adjusting for age, gender, body mass index, comorbidities, smoking, drinking and occupational status. In contrast, there is little or no evidence of any relationship with objectively derived CTS severity. Future research is needed to understand the impact of approaches and treatments that address psychosocial stressors as well as biomedical factors on relief of symptoms from carpal tunnel syndrome.

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Variation in CCG policies for the treatment of carpal tunnel syndrome

Abstract: Are CTS patients receiving equal standards of care across the country?

Cited by 17 publications

References 28 publications

Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): A prospective multicenter cohort study

Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): A prospective multicenter cohort study

Predicting surgical intervention in patients presenting with carpal tunnel syndrome in primary care

Association of psychological distress, quality of life and costs with carpal tunnel syndrome severity: a cross-sectional analysis of the PALMS cohort

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