Abstract
Purpose
The purpose of this paper was to use validated instruments to identify if there is a relationship between preoperative expectations and patient-reported outcomes (PROs) in patients undergoing hand and wrist surgery. We hypothesized that preoperative expectations would be predictive of 2-year PROs in hand and wrist surgery patients.
Methods
In total, 253 patients who underwent hand and wrist surgery were enrolled in a prospective orthopedic registry. The Musculoskeletal Outcomes Data Evaluation and Management System was used to measure preoperative expectations. At both baseline and 2 years after surgery, patients completed multiple questionnaires with multiple PROs, including six domains of the PROs measurement information system (PROMIS) and the Brief Michigan Hand Questionnaire.
Results
Overall, patients undergoing hand and wrist surgery had high expectations. Worse preoperative expectations were significantly associated with smoking, worker’s compensation or other legal claim, a greater number of prior surgeries, and worse baseline PROMIS physical function, fatigue, and anxiety (P < .05). Bivariate analysis indicated that greater preoperative expectations were associated with better 2-year PROMIS physical function, PROMIS pain interference, PROMIS fatigue, PROMIS depression, numeric pain scale, surgical satisfaction questionnaire scores, met expectations, and the Brief Michigan Hand Questionnaire (P < .05). Multivariable analysis controlling for confounding variables revealed that preoperative expectations were not independently predictive of any 2-year PROs.
Conclusions
Patients’ preoperative expectations are associated with, but not independently predictive of, 2-year patient-reported outcomes.
Type/of study/level of evidence
Prognostic IIB.
Key words: Hand surgery, Patient expectations, Patient-reported outcomes, PROMIS
Several studies across many disciplines have demonstrated that better preoperative expectations are associated with better outcomes. Researchers are increasingly categorizing factors that contribute to better expectations, as well as continuously defining the relationship between expectations in outcomes of different populations and procedures.1, 2, 3, 4, 5 This relationship has become increasingly important as surgical outcome measurements have shifted toward patient-reported outcomes (PROs) and surgical satisfaction.6 Studies across multiple surgical specialties have identified the association between preoperative expectations and outcomes.7, 8, 9, 10, 11, 12, 13, 14, 15 However, there is a lack of studies looking into this relationship in patients undergoing hand and wrist surgery.
A previous study has shown that in carpal tunnel surgery, the strongest predictor of satisfaction was symptom relief, but preoperative expectations did not correlate with postoperative disabilities of arm, shoulder, and hand (DASH) scores or patient satisfaction.16 However, this study utilized a small sample size, reported outcomes after only 6 months after surgery, and lacked a validated instrument to measure preoperative expectations. Another study focusing on rheumatoid hand surgery found that better preoperative expectations correlated with better ability to perform activities of daily living. However, there were no statistically significant associations between PRO scores and patients’ preoperative expectations.17 However, this study had similar weaknesses, with a smaller sample size, the lack of validated expectations assessment, and reporting patient outcomes 1 year after surgery. Ultimately, it is unclear if there is an association between preoperative expectations and 2-year outcomes in the hand and wrist surgery population.
The purpose of this study was to evaluate the effect of patients’ preoperative expectations of hand and wrist surgery on self-assessed outcomes 2 years after surgery using validated instruments. We hypothesized that preoperative expectations would be predictive of better 2-year PROs after hand and wrist surgery.
Materials and Methods
After institutional review board approval, a retrospective analysis of prospectively acquired data from our institution’s surgical registry between 2015 and 2018 was conducted for patients undergoing hand and wrist surgery.18 Eligible patients at a single academic institution were approached prior to surgery, and verbal consent was obtained to include their information in the registry. Data were collected using the Research Electronic Data Capture data collection system.19 For our study, the inclusion criteria were patients undergoing hand and wrist surgery who had completed both baseline and 2-year follow-up surveys. Collected data points included self-reported socioeconomic and demographic identifiers such as employment status, alcohol consumption, and income. Electronic medical records were reviewed for relevant medical and operative history.
Patients completed the expectations domain of the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) to measure preoperative expectations. This system consists of six questions evaluating expectations in fields such as “relief from symptoms” and “to prevent future disability.” Each question had five possible answers ranging from a value of 1, “Not at all likely,” to a value of 5, “extremely likely.”20,21 These values were normalized to a 100-point scale where 100 represented the highest preoperative expectations and 0 represented the lowest preoperative expectations.
Patients completed PRO measurement information system (PROMIS) computer-adaptive testing in six domains: (1) physical function (PF), (2) pain interference (PI), (3) fatigue, (4) social satisfaction (SS), (5) anxiety, and (6) depression.22 In addition, patients completed the Brief Michigan Hand Questionnaire (BMHQ), Tegner Activity Scale, numeric pain scale (NPS) for both the surgical site and whole body, and the Marx activity rating scale (MARS) for the upper extremity.23, 24, 25, 26 At the 2-year time point, patients were asked to repeat these same questionnaires, with the addition of the surgical satisfaction questionnaire-8 and MODEMS Met Expectations domain.21,27
Continuous data were reported as means and standard deviations. A goodness-of-fit test was run for all continuous variables, which found that a minority demonstrated a normal distribution, justifying nonparametric testing. Categorical variables were reported as frequencies and percentages. Wilcoxon ranked sum and/or Kruskal-Wallis tests were used to analyze the relationship between categorical variables and preoperative expectations. Post-hoc Wilcoxon analysis was performed for categorical variables with greater than two subgroups. Analysis of the relationship between continuous variables and preoperative expectations was performed via Spearman correlation coefficient (rs). The minimal clinically important difference (MCID) for each PRO was calculated as one-half the standard deviation of baseline distributions.
Backward stepwise maximum-validation multivariable linear regression models for each outcome parameter were performed incorporating all variables associated with preoperative expectations on bivariate analysis (P < .05). In addition to MODEMS preoperative expectations, variables included smoking status, worker’s compensation, legal claim, prior operative site surgery, number of previous orthopedic surgeries, baseline PROMIS PF, PROMIS fatigue, and PROMIS anxiety. Statistical software JMP Pro version 13 was used for all analysis (JMP, Version 13, SAS Institute Inc). All P values were two-tailed, and P < .05 was used as a threshold for significance.
Results
Of the total 361 patients who completed baseline, 253 (70.1%) completed a 2-year follow-up. Overall, patients had high preoperative expectations, with a mean and median of 85.5 and 95, respectively. Table 1 demonstrates the overall and individual expectation scores for each question; 80% or more of patients answered “very likely” or “extremely likely” for improvement for each question. Highest expectations were seen in “To exercise and do recreational activities” (mean of 87.2 ± 20.2 points), whereas “to sleep more comfortably” reported the lowest expectations (mean of 83.3 ± 24.9 points).
Table 1.
Quantified Expectations of Hand Surgery Patients
| What Results Do You Expect From Your Treatment? | No. (%) of Patients Reporting Level of Expectation |
Mean Score∗(±SD) | ||||
|---|---|---|---|---|---|---|
| Not at All Likely (1) | Slightly Likely (2) | Somewhat Likely (3) | Very Likely (4) | Extremely Likely (5) | ||
| 1. Relief from symptoms (pain, stiffness, swelling, numbness, weakness, instability) | 2 (0.9%) | 6 (2.6%) | 17 (7.3%) | 67 (28.6%) | 142 (60.7%) | 86.4 (±20.2) |
| 2. To do more everyday household or yard activities | 2 (0.9%) | 10 (4.4%) | 19 (8.3%) | 65 (28.4%) | 133 (58.1%) | 84.6 (±22.0) |
| 3. To sleep more comfortably | 6 (2.8%) | 8 (3.7%) | 22 (10.3%) | 51 (23.8%) | 127 (59.3%) | 83.3 (±24.9) |
| 4. To go back to my usual job | 6 (3.0%) | 3 (1.5%) | 15 (7.4%) | 45 (22.3%) | 133 (65.8 %) | 86.6 (±23.0) |
| 5. To exercise and do recreational activities | 2 (0.9%) | 5 (2.2%) | 19 (8.3%) | 56 (24.5%) | 147 (64.2%) | 87.2 (±20.2) |
| 6. To prevent future disability | 4 (1.8%) | 6 (2.8%) | 22 (10.1%) | 53 (24.3%) | 133 (61.0%) | 85.0 (±22.8) |
| Overall mean expectations | 85.5 (±18.3) | |||||
The mean expectations score was converted to 0–100 continuous scale.
The average scores of PROMIS PF, PROMIS PI, PROMIS fatigue, PROMIS SS, PROMIS anxiety, Tegner, NPS op site, and BMHQ improved significantly from baseline at 2 years following surgery (P < .001). No significant postoperative improvement was observed for PROMIS depression or MARS.
Higher expectations were observed in patients who were nonsmokers or had quit smoking (P = .022). Additionally, patients without a worker’s compensation claim (P = .025) or legal claim (P < .001) had significantly greater preoperative expectations (Table 2).
Table 2.
Relationship Between Categorical Variables and Overall Expectation Score
| N | Overall Preoperative Expectations |
|||
|---|---|---|---|---|
| Mean | SD | P Value | ||
| Gender | ||||
| Female | 127 | 85.5 | ±19.4 | .51 |
| Male | 108 | 85.5 | ±17.1 | |
| Race | ||||
| Asian | 10 | 77.9 | ±29.5 | .73 |
| Black | 79 | 84.0 | ±19.7 | |
| Other | 8 | 91.7 | ±12.4 | |
| White | 133 | 86.4 | ±16.9 | |
| Ethnicity | ||||
| Not Hispanic or Latino | 223 | 85.4 | ±18.5 | .99 |
| Hispanic or Latino | 12 | 87.2 | ±13.9 | |
| Education level | ||||
| College graduate | 101 | 87.8 | ±17.6 | .09 |
| Completed high school | 117 | 82.9 | ±19.0 | |
| Some high school or below | 14 | 87.7 | ±16.1 | |
| Employment status | ||||
| Currently employed | 150 | 86.7 | ±17.4 | .36 |
| Not currently employed | 57 | 82.1 | ±20.8 | |
| Student | 25 | 86.0 | ±16.4 | |
| Income | ||||
| <$70,000 | 110 | 85.7 | ±16.4 | .25 |
| >$70,000 | 95 | 86.9 | ±19.8 | |
| Marital status | ||||
| Single | 120 | 85.3 | ±18.8 | .91 |
| Married or domestic partnership | 111 | 85.9 | ±17.8 | |
| Smoking | ||||
| Currently smokes | 34 | 76.4 | ±23.2 | .022∗ |
| Never smoked | 141 | 86.6 | ±17.2 | |
| Quit Smoking | 57 | 88.3 | ±15.9 | |
| Alcohol | ||||
| Greater than four time a month | 46 | 87.7 | ±16.2 | .09 |
| Four times a month or fewer | 116 | 87.0 | ±18.1 | |
| Never | 69 | 81.3 | ±19.4 | |
| Recreational drug use | ||||
| No | 219 | 86.4 | ±17.6 | .12 |
| Yes | 12 | 75.0 | ±24.7 | |
| Preoperative narcotic use | ||||
| No | 160 | 86.4 | ±17.8 | .14 |
| Yes | 72 | 83.1 | ±19.7 | |
| ASA score | ||||
| I | 65 | 87.0 | ±14.2 | .86 |
| II | 129 | 83.6 | ±20.4 | |
| III | 22 | 84.5 | ±19.8 | |
| Depression or anxiety | ||||
| No | 202 | 85.9 | ±17.2 | .86 |
| Yes | 33 | 82.7 | ±24.3 | |
| Prior surgery on hand | ||||
| No | 191 | 86.2 | ±18.2 | .06 |
| Yes | 42 | 82.1 | ±19.0 | |
| Injury prior to surgery | ||||
| No | 105 | 85.8 | ±20.1 | .56 |
| Yes | 119 | 86.2 | ±16.4 | |
| Workers compensation | ||||
| No | 221 | 83.3 | ±18.0 | .025∗ |
| Yes | 7 | 75.4 | ±11.9 | |
| Legal claim | ||||
| No | 212 | 87.0 | ±17.7 | <.001∗ |
| Yes | 16 | 73.1 | ±16.5 | |
Education level, never and quitting smoking, drinking alcohol, no prior surgery on hand, no worker’s compensation, and no legal claim were associated with higher mean preoperative expectation scores.
ASA, American Society of Anesthesiologists.
Statistically significant correlation (P < .05).
Bivariate analysis of continuous variables revealed that fewer previous hand or wrist surgeries (P = .043), and fewer prior orthopedic surgeries (P = .048) were both associated with higher preoperative expectations. Analysis also found that better preoperative PROMIS PF (P = .038), lower PROMIS fatigue (P = .048), and lower PROMIS anxiety (P = .048) were also associated with higher preoperative expectation scores (Table 3).
Table 3.
Association Between Continuous Variables and Expectation Scores
| Mean (±SD) | Median | Spearman’s (rs) Correlation Coefficient | P Value | |
|---|---|---|---|---|
| Age (y) | 50.4 (±16.2) | 52.0 | 0.03 | .64 |
| BMI (kg/m2) | 30.2 (±7.9) | 28.8 | −0.02 | .82 |
| CCI | 1.7 (±1.8) | 1 | 0.09 | .17 |
| No. of all prior surgeries | 3.7 (±4.8) | 3.0 | −0.11 | .09 |
| No. of prior hand surgeries | 0.3 (±0.9) | 0 | −0.13 | .043∗ |
| No. of prior orthopedic surgeries | 1.5 (±2.0) | 1.0 | −0.13 | .048∗ |
| PROMIS physical function | 46.1 (±9.4) | 46.6 | 0.14 | .038∗ |
| PROMIS social satisfaction | 44.5 (±9.8) | 43.4 | 0.10 | .11 |
| PROMIS pain interference | 59.1 (±7.3) | 58.7 | −0.09 | .18 |
| PROMIS fatigue | 50.7 (±9.6) | 50.7 | −0.13 | .047∗ |
| PROMIS anxiety | 53.0 (±9.0) | 52.9 | −0.13 | .048∗ |
| PROMIS depression | 47.9 (±9.1) | 48.1 | −0.11 | .10 |
| TAS (preop) | 2.6 (±2.1) | 2.0 | 0.06 | .37 |
| Numeric pain (Op site) | 4.7 (±2.9) | 5.0 | −0.03 | .71 |
| Numeric pain (whole body) | 1.5 (±2.3) | 0 | −0.13 | .05 |
| MARS upper | 48.8 (±28.8) | 50.0 | 0.10 | .16 |
| BMHQ | 49.4 (±19.9) | 50.0 | 0.10 | 0.15 |
Number of all prior surgeries, number of prior hand surgeries, number of prior orthopedic surgeries. PROMIS physical function, PROMIS fatigue, and numeric pain (whole body) were associated with higher preoperative mean expectations.
BMI, body mass index; CCI, Charlson Comorbidity Index; TAS, Tegner activity scale.
Statistically significant correlation (P < .05).
The top five most common current procedural terminology (CPT) codes for our cohort of patients and the mean expectations for each procedure are shown in Table 4. We found no significant relationship between CPT codes and expectation scores.
Table 4.
Mean Expectations for the Top 5 CPT Codes∗
| CPT | Procedure | N | Mean Expectations (±SD) |
|---|---|---|---|
| 64721 | Neuroplasty and/or transposition; median nerve at carpal tunnel | 51 | 88.3 (±16.7) |
| 26055 | Tendon sheath incision (eg, for trigger finger) | 29 | 84.1 (±17.4) |
| 25609 | Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of three or more fragments | 13 | 92.0 (±15.6) |
| 25607 | Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixation | 11 | 88.6 (±12.9) |
| 25447 | Arthroplasty, interposition, intercarpal, or carpometacarpal joints | 9 | 93.4 (±10.6) |
CPT, current procedural terminology.
There was no statistically significant difference (P > .05) in mean preoperative expectations scores among the top five CPT codes.
Bivariate analysis (Table 5) of 2-year outcome scores revealed that higher preoperative expectations were associated with better scores on PROMIS PF (P = .006), PROMIS PI (P < .001), PROMIS fatigue (P = .013), PROMIS depression (P = .042), NPS op site (P < .001), NPS whole body (P = .04), surgical satisfaction questionnaire-8 (P = .002), MODEMS met expectations (P < .001), and BMHQ (P = .003). Bivariate analysis of MCID in all PROs found that achieving MCID in PROMIS PI was associated with higher preoperative expectations (P < .001, Table 6).
Table 5.
Association Between Preoperative Expectations and 2-Year Patient-Reported Outcomes
| Outcome Measurements (2Y Follow-Up) | Spearman’s (rs) Correlation Coefficient | P Value |
|---|---|---|
| PROMIS PF | 0.18 | .006∗ |
| PROMIS PI | −0.22 | < .001∗ |
| PROMIS fatigue | −0.17 | .013∗ |
| PROMIS SS | 0.08 | .23 |
| PROMIS anxiety | −0.07 | .29 |
| PROMIS depression | −0.14 | .042∗ |
| TAS (preop) | 0.03 | .64 |
| TAS (postop) | 0.13 | .07 |
| NPS (op. Site) | −0.25 | < .001∗ |
| NPS (whole body) | −0.14 | .04∗ |
| SSQ8 | 0.22 | .002∗ |
| MODEMS met expectations | 0.25 | < .001∗ |
| MARS upper | 0.004 | .95 |
| BMHQ | 0.21 | .003∗ |
Preoperative expectations were associated with PROMIS PF, PROMIS PI, PROMIS fatigue, PROMIS depression, NPS (op site), NPS (Whole body), SSQ8, MODEMS, and MHQA.
SS, social satisfaction; TAS, Tegner activity scale.
Statistically significant correlation (P < .05).
Table 6.
Preoperative Expectations by Achievement of the Minimal Clinically Important Difference
| Outcome Measurements | Preoperative Expectations |
P Value | |
|---|---|---|---|
| MCID (Yes) |
MCID (No) |
||
| Mean (SD) | |||
| PROMIS PF | 87.8 (16.2) | 83.2 (20.0) | .06 |
| PROMIS PI | 87.1 (18.8) | 82.1 (17.1) | .009∗ |
| PROMIS fatigue | 86.2 (17.4) | 83.6 (19.7) | .44 |
| PROMIS SS | 85.8 (17.7) | 85.4 (18.4) | .96 |
| PROMIS anxiety | 86.0 (18.2) | 85.4 (17.7) | .88 |
| PROMIS depression | 86.5 (19.6) | 85.5 (17.2) | .47 |
| TAS | 89.5 (13.2) | 85.3 (19.1) | .22 |
| NPS op. site | 87.6 (16.4) | 82.8 (19.4) | .08 |
| NPS body | 85.9 (17.0) | 86.0 (17.8) | .67 |
| MARS UE | 86.5 (18.2) | 87.1 (16.2) | .95 |
| BMHQ | 88.5 (15.6) | 84.1 (15.2) | .08 |
MARS UE, Marx activity rating scale upper extremity; MCID, minimal clinically important difference; NPS, numerical pain scale; PF, physical function; PI, pain interference; SS, Social Satisfaction; TAS, Tegner activity scale.
Statistically significant correlation (P < .05).
Multivariable analysis to control for confounding variables revealed that higher preoperative expectations were not independently associated (P > .05) with any 2-year PROs (R2, PROMIS PF: 0.28; PROMIS PI: 0.18; PROMIS fatigue: 0.32; PROMIS SS: 0.15; PROMIS anxiety: 0.22; PROMIS depression: 0.25; Tegner Activity Scale: 0.15; NPS op site: 0.16; NPS body: 0.12; SSQ-8: 0.12; MODEMS met expectations: 0.24; MARS: 0.14; BMHQ: 0.24).
Discussion
The findings from this study largely do not support our hypothesis that preoperative expectations would be predictive of 2-year PROs after hand and wrist surgery. Although significant associations between better preoperative expectations and better 2-year PROs were observed, expectations were not an independent predictor of any 2-year PRO in the current study. These findings suggest that associations exist between expectations and 2-year PROs, but these relationships are not representative of causality and may be influenced by other factors.
There are prior studies that have shown similar relationships between expectations and outcomes in hand surgery patients. Kadzielski et al16 found that preoperative expectations did not correlate with patient satisfaction or postoperative DASH scores. A second study found that patient satisfaction correlated with met expectations, but not with previsit expectations.17 Our study somewhat aligns with these findings, showing that preoperative expectations are not independently predictive of 2-year outcomes when controlling for potential confounding variables. However, the current study identified associations between preoperative expectations and function, pain, and satisfaction. The previously cited studies were limited due to their small sample sizes and lack of a validated measurement instrument to measure preoperative expectations. In this study, the validated MODEMS preoperative expectations domain was used to document the expectations of hand and wrist surgery patients.28 Notably, the sample size in the current study is also limited, which may in part explain the replication of findings of these previous studies.
In a randomized control trial, patients who received metacarpophalangeal joint arthroplasty for rheumatoid arthritis had high expectations, and these expectations correlated with satisfaction.29 Although our findings differ, this study may not be generalizable, as there was a small sample size of only 33 patients who underwent a single type of hand procedure without a validated satisfaction measurement instrument and a shorter follow-up of 1 year. The current study included a much greater number of patients and a broadened population encompassing all hand and wrist surgery patients with validated instruments at longer follow-up periods. Ultimately, different populations and measurement domains may be contributory to the variability among existing studies and our findings. Our study also includes frequently underrepresented populations in research. Inclusion of underrepresented minorities increases the generalizability of our research findings and the accuracy of ethnicity-specific subgroup analysis.30
The relationship between expectations and outcomes has been documented in various surgical populations, particularly those undergoing shoulder surgery. Henn et al31 analyzed the relationship between preoperative expectations and the outcome of rotator cuff repairs. Multivariable analysis showed that greater preoperative expectations were independently predictive of better 1-year postoperative scores and improvement in the simple shoulder test, DASH questionnaire, visual analog scores (VAS) for shoulder pain, function, and quality of life, and the short form-36. Similarly, a study examining patients undergoing total shoulder arthroplasty found that preoperative expectations were significantly associated with American Shoulder and Elbow Surgeons, shoulder activity scale, and short form-36 2 years after surgery.32 Additionally, Rauck et al found no association between the number of high preoperative expectations and better outcomes, but patients with greater expectations to relieve nighttime pain had significantly greater American Shoulder and Elbow Surgeons and VAS scores and improvement in VAS, and patients with greater expectations for improvement in the ability to participate in nonoverhead sports had significant improvement in shoulder activity scale scores.33
These findings align with the associations between preoperative expectations and 2-year outcomes scores demonstrated by the bivariate analysis in our study.1, 2, 3,30,31 Specifically, the current study found that higher preoperative expectations were associated with achieving MCID in PROMIS PI, which affirms that expectations may be particularly valuable when considering improvement in postoperative pain in hand wrist surgery. Additionally, preoperative expectations were associated with baseline PROMIS anxiety and 2-year PROMIS depression. To our knowledge, mental health outcomes after hand and wrist surgery have not been well-studied, making this area worthy of focus in future research. Variables such as smoking and previous hand or wrist surgery may have a confounding effect on this relationship in hand and wrist surgery patients. Further studies may be warranted to identify why, despite similar models and analysis, the data from previous studies in other surgical populations were not generalizable to the hand and wrist surgery patient population, given our findings.
Although this study has important findings, there are a few limitations. First, ceiling effects may be observed for the MODEMS expectations measurements. Most of our population answered either “very likely” or “extremely likely” for all six of the domains of the expectation questionnaire. More possible answers may have led to a stratification of responses rather than the right-skewed preoperative expectations distribution in this study. A second weakness is the use of surveys to collect patient information, and the possibility of loss of follow-up and nonresponse. Although we had a 70.1% 2-year follow-up, our study group may have selection bias due to our inclusion criteria. Additionally, inclusion of many different procedures in a single cohort reduces the generalizability of these findings to procedure-specific cohorts. A final weakness of this paper was that it examined PROs at only two time points. The effect of expectations on postoperative outcomes may change over time and requires further investigation at a variety of different time points. Overall, this study’s findings suggest that patients expecting to do well after hand surgery will have better PROs at 2 years after surgery.
Conflicts of Interest
No benefits in any form have been received or will be received related directly to this article.
Acknowledgments
The authors would like to thank J. Kathleen Tracy, PhD; Ali Aneizi, MD; Andrew G. Dubina, MD; Julio J. Jauregui, MD; Vidushan Nadarajah, MD; Patrick M.J. Sajak: Joshua M. Abzug, MD; Ngozi M. Akabudike, MD; Craig H. Bennett, MD; W. Andrew Eglseder, MD; Mohit N. Gilotra, MD; S. Ashfaq Hasan, MD; Jonathan D. Packer, MD; Ebrahim Paryavi, MD; Cameran I. Burt, Shaun H. Medina; Keyan Shasti; Dominic J. Ventimiglia; Alexander J. Wahl; and Michael P. Smuda for their assistance with data collection.
Footnotes
This work was supported by a grant from The James Lawrence Kernan Hospital Endowment Fund, Incorporated (BL1941007WS).
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