The Impact of Pre-Referral Advanced Diagnostic Testing on Wait Time to See a Hand Surgeon for Common Upper Extremity Conditions

Abstract

Purpose

We sought to evaluate the use of pre- and post-referral advanced diagnostic testing among patients with three common hand conditions, rates of subsequent tests, and differences in wait time to see a hand surgeon.

Methods

We analyzed a single academic tertiary care center administrative database of encounters from 2006 – 2015 to identify adult patients who were referred to a hand surgeon for three hand conditions (carpal tunnel syndrome [CTS], soft tissue masses [STM], and joint pain [JP]). We recorded patient characteristics, use and timing of diagnostic tests, and wait time for the initial hand surgeon evaluation.

Results

Among patients who received advanced diagnostic tests prior to the surgeon evaluation, CTS patients had the highest rate of receiving pre-referral advanced testing (53.4%) compared to 10.6% of JP patients and 5.8% of STM patients. CTS patients had the highest rates of repeat testing (19.5%) compared to patients with JP (1.4%) and STM (0%). Across all three conditions, patients who received pre-referral advanced testing waited an additional 19–94 days to see a surgeon compared to patients who received only post-referral testing or no testing.

Conclusions

The use of pre-referral advanced diagnostic tests is associated with an increased time to see a hand surgeon for common hand conditions.

Clinical Relevance Statement

Hand surgeons should play a role in identifying patients who do and do not benefit from advanced testing prior to referral to ensure that tests ordered prior to consultation are useful to both patients and treating surgeons.

INTRODUCTION

Overutilization of diagnostic tests has been a critical issue leading to rapid growth of healthcare costs and increasing burdens on patients.^1–3 The Institute of Medicine (IOM) reported that an estimated 30% of healthcare spending is used on unnecessary services.⁴ Previous studies have shown the use of diagnostic tests to be a common practice among patients with hand conditions who present to hand surgery clinics, with a high proportion of the tests deemed unnecessary or unhelpful.^5–10 Some primary care physicians may feel an obligation to order diagnostic tests to confirm clinical diagnoses and to facilitate referrals to specialists, even if the tests do not necessarily alter the treatment plan or have an impact on patient outcomes.^11–16 Obtaining advanced diagnostic tests prior to a hand surgeon evaluation may unnecessarily delay referral and prolong the time to definitive treatment in patients who receive little or uncertain benefit from testing.

There is concern that many patients may receive advanced testing inappropriately, despite guidelines and appropriateness criteria for use of diagnostic tests relevant to common hand surgery conditions. The 2016 American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines (CPG) for Management and Treatment of Carpal Tunnel Syndrome and the American College of Radiology (ACR) appropriateness criteria provide some guidance on the use of advanced diagnostic tests in patients with common hand and wrist conditions, such as carpal tunnel syndrome (CTS), soft tissue masses (STM) and joint pain (JP).^17,18 However, Hartzell et al. reported 74% of patients presenting to a single hand surgery clinic received pre-referral tests and procedures of any kind, of which 90% of advanced diagnostic tests were deemed unwarranted.⁶ It is common for hand surgeons to request advanced diagnostic tests, such as electrodiagnostic studies, prior to an initial clinic evaluation for carpal tunnel syndrome.¹⁰ Despite current recommendations moving toward more judicious use of advanced tests for patients, the downstream effects of obtaining advanced studies prior to hand surgeon referral and evaluation, and the degree of subsequent use of diagnostic tests in this patient population remain unknown. Furthermore, data are lacking to quantify the impact of advanced testing on delay to hand surgeon evaluation, which could have a profound impact on patients who are sent for testing that has little associated clinical benefit.

We aimed to evaluate the use of pre- and post-referral advanced diagnostic testing use across patients with three common hand conditions (CTS, STM, and JP) at a single tertiary hand surgery center to evaluate the prevalence of advanced testing and need for repeat or subsequent testing after a hand surgeon evaluation. Secondarily, we sought to determine the relationship between the use of pre-referral advanced diagnostic tests and the wait time between encounters with the referring provider and hand surgeon. We hypothesized that pre-referral advanced diagnostic testing will substantially increase the wait time to see a hand surgeon and that the need for repeat testing after referral will vary based on the presenting complaint.

MATERIALS AND METHODS

Study Cohort

The study received IRB approval. We conducted a retrospective cohort study using administrative data from 2006 – 2015 from a single academic tertiary care center. The available administrative database included all inpatient and outpatient clinical encounters and associated diagnoses and procedures for each encounter for more than four million unique patients from across the academic tertiary center enterprise. Our study cohort included patients aged 18 years and older, who were referred to a hand surgeon for the three common hand conditions of interest (CTS, STM, and JP) between 1/1/2007 and 9/30/2014. We used International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to identify patients with one of the three hand conditions (Appendix 1) and relevant encounters for the three conditions. For CTS, we identified encounters that included diagnosis codes for either CTS or CTS-related symptoms to ensure that we captured all relevant utilization of CTS-related care prior to a confirmed diagnosis by the hand surgeon. Patients were excluded if they were not observed for at least 12 months before and after the encounter in which they were referred for the hand condition of interest, to ensure established care from an internal provider and have sufficient time to observe the outcomes of interest. The end date of the inclusion and observation periods were chosen given the transition to ICD-10 diagnosis codes on 10/1/2015. Patients were required to have at least one visit with a primary care provider or have been referred from a clinician within the health system to exclude patients referred from outside the health system. Referring providers were included from the following disciplines: Internal Medicine, Family Medicine, Geriatrics, OBGYN, Pediatrics, Medicine/Pediatrics, Endocrinology, Emergency Medicine, and Medical Oncology. During the study period, the institution had between 4 and 8 hand surgeons. We excluded patients who had documentation of additional pathology apart from the hand conditions of interest (e.g. fracture, infection, inflammatory or crystalline arthropathy) or who had history of hand surgery for the three hand conditions prior to the inclusion period.

Study variables

We recorded patient characteristics including age, sex, race/ethnicity and insurance type (private insurance, Medicare, Medicaid, governmental insurance, workers’ compensation, and self-pay). We used Current Procedural Terminology, Fourth Edition (CPT-4) procedure codes to identify use of broad categories of diagnostic tests, including electrodiagnostic studies (EDS), X-ray, ultrasound (US), MRI, CT, arthrography, bone scan, PET/CT scan, and non-invasive vascular studies (Appendix 1). We defined advanced diagnostic studies as the above testing categories excluding plain X-ray. We categorized the timing of advanced diagnostic tests relative to the patient’s initial hand surgery evaluation into the following categories: pre-referral advanced testing only, post-referral advanced testing only, repeat testing, and no testing. We defined the pre-referral testing group as receipt of advanced diagnostic tests prior to any encounter with a hand surgeon. The post-referral testing group was defined as receipt of an advanced diagnostic test within 12 months after the initial hand surgeon evaluation. We defined the repeat testing group as patients receiving both pre-referral and post-referral testing with any type of modality. The pre-referral testing was obtained any time prior to the first encounter with the hand surgeon, but after their initial encounter with the primary care physician for the associated diagnosis of interest. The post-referral testing was obtained between the first encounter with the hand surgeon and surgery if patients received an operation. If the patients did not receive any hand surgery, the follow-up time for post-referral testing was up to one year after the first hand surgery encounter. We recorded wait time for the initial hand surgeon evaluation as the number of days between the last visit with a referring provider and the first encounter with a hand surgeon.

Data analysis

We calculated descriptive statistics to assess the prevalence of pre- and post-referral diagnostic testing use among patients presenting to a hand surgeon for each of the three hand conditions. We calculated the median time between the last clinical encounter with the referring provider and the first hand surgeon evaluation. We evaluated the wait time to see a hand surgeon across clinical diagnoses and compared wait times based on timing of advanced diagnostic testing use (pre-referral, post-referral, repeat testing, and no testing groups). The Kruskal-Wallis equality-of-population rank test was used to identify significant differences between median wait times across sub-groups (significance defined as P < 0.05).

RESULTS

The study cohort included 1,342 patients with CTS, 1,156 patients with STM, and 1,572 patients with JP who were internally referred to see a hand surgeon at the academic tertiary care center between 1/1/2006 and 9/30/2015. Demographic and insurance characteristics for the study cohort are outlined in Table 1. Of patients who saw a hand surgeon for the three hand conditions, 88.3% of JP patients received pre-referral testing of any type compared to 57.2% of CTS patients and 8.8% of STM patients. Among patients who received advanced diagnostic tests (excluding X-ray) prior to the hand surgeon evaluation, CTS patients had the highest rate of receiving pre-referral advanced testing (53.4%) compared to 10.6% of JP patients and 5.8% of STM patients. Among patients who received pre-referral tests, CTS patients had the highest rate of receiving repeat testing after hand surgeon evaluation (19.5%), whereas patients with JP rarely had repeat testing (1.4%) and no STM patients had repeat testing after hand surgeon evaluation. Of 717 CTS patients who received pre-referral advanced studies, 13.5% (97 of 717) underwent repeat advanced testing, most of which was repeat EDS (n = 92 patients) (Table 2).

Table 1.

Patient Characteristics

	Carpal Tunnel Syndrome	Soft Tissue Masses	Joint Pain
	N (%)	N (%)	N (%)
Entire Cohort	1,342	1,156	1,572
Sex
Male	417 (31.1)	571 (49.4)	617 (39.3)
Female	925 (68.9)	585 (50.6)	955 (60.8)
Race
Caucasian	1,154 (86)	915 (79.2)	1,298 (82.6)
African American	108 (8.1)	118 (10.2)	134 (8.5)
Asian	28 (2.1)	58 (5.0)	75 (4.8)
American Indian	5 (0.4)	2 (0.2)	6 (0.4)
Unspecified	47 (3.5)	63 (5.5)	59 (3.8)
Ethnicity
Non-Hispanic Latino	753 (56.1)	331 (28.6)	1,316 (83.7)
Hispanic Latino	16 (1.2)	10 (0.9)	33 (2.1)
Unspecified	573 (42.7)	815 (70.5)	223 (14.2)
Age
18–34	145 (10.8)	262 (22.7)	306 (19.5)
35–44	227 (16.9)	224 (19.4	296 (18.8)
45–54	391 (29.1)	269 (23.3)	410 (26.1)
55–64	308 (23.0)	207 (17.9)	350 (22.3)
≥65	271 (20.2)	194 (16.8)	210 (16.4)
Insurance Type
Private Insurance	887 (66.1)	866 (74.9)	1,168 (74.3)
Medicare	249 (18.6)	165 (14.3)	200 (12.7)
Medicaid	105 (7.8)	65 (5.6)	90 (5.7)
Governmental Insurance	49 (3.7)	23 (2.0)	58 (3.7)
Workers’ Compensation	15 (1.1)	8 (0.7)	23 (1.5)
Self-Pay	11 (0.8)	13 (1.1)	14 (0.9)
Unspecified	16 (1.2)	16 (1.4)	19 (1.2)

Table 2.

Pre- and Post-referral Diagnostic Testing Use in Patients Evaluated by a Hand Surgeon for Three Conditions

	Carpal Tunnel Syndrome				Soft Tissue Masses				Joint Pain
	N (%)				N (%)				N (%)
Entire Cohort	1,342				1,156				1,572
	Any Study*		Advanced Studies**		Any Study*		Advanced Studies**		Any Study*		Advanced Studies**
# with Pre-referral Testing	768	(57.2)	717	(53.4)	102	(8.8)	67	(5.8)	1,388	(88.3)	169	(10.8)
Any Repeat Testing	150	(19.5)	97	(13.5)	0	(0)	0	(0)	22	(1.6)	2	(1.2)
Repeat EDS	122	(15.9)	92	(12.8)	–	–	–	–	–	–	–	–
Repeat Studies Excluding	40	(5.2)	35	(4.9)	–	–	–	–	–	–	–	–
EDS
# with Post-referral Testing Only	259	(19.3)	284	(21.2)	6	(0.5)	6	(0.5)	0	(0)	8	(0.5)
# without Pre- or Post-referral Testing	315	(23.5)	341	(25.4)	1,048	(90.7)	1,083	(93.7)	184	(11.7)	1,395	(88.7)

^*Any study includes electrodiagnostic studies (EDS), X-ray, ultrasound, MRI, CT, arthrography, bone scan, PET/CT scan, and non-invasive vascular studies

^**Advanced studies exclude X-ray

For patients with CTS, EDS was the most common pre-referral test (53.3%) followed by X-ray (8.4%), US (0.9%), and MRI (0.2%). US was the most common test obtained in patients with STM in 4%, followed by X-ray in 3.5%, and MRI in 2.2% of patients. For patients with JP, 86.7% received X-ray and 8% received MRI in the pre-referral period (Table 3).

Table 3.

Type of Pre-referral Diagnostic Testing Received by Patients Presenting to a Hand Surgeon

	Carpal Tunnel Syndrome		Soft Tissue Masses		Joint Pain
	N (%)		N (%		N (%)
Entire Cohort	1,342		1,156		1,572
EDS	705	(53.3)	–	–	–	–
X-ray	112	(8.4)	40	(3.5)	1,368	(86.7)
US	12	(0.9)	46	(4.0)	27	(1.7)
MRI	3	(0.2)	25	(2.2)	126	(8.0)
CT	0	(0)	0	(0)	15	(1.0)
Arthrography	0	(0)	0	(0)	26	(1.7)
Bone Scan	0	(0)	2	(0.2)	1	(0.1)
PET/CT Scan	0	(0)	2	(0.2)	0	(0)
Noninvasive Vascular Studies	0	(0)	0	(0)	3	(0.2)

EDS: electrodiagnostic studies; US: ultrasound

Patients who received pre-referral advanced diagnostic testing (excluding X-ray) had the longest wait times to see a hand surgeon across the three conditions, compared to patients having post-referral testing or no testing (Table 4). CTS patients in the advanced pre-referral testing only group had a median wait time of 182 days (IQR 61–685) to see a hand surgeon compared to 88 days (IQR 30–446) for patients who did not receive any testing and 111 days (IQR 38–480) for patients who received testing after hand surgeon referral (p<0.05). Among STM patients who received pre-referral advanced diagnostic testing, patients waited an additional 31 days to see a hand surgeon compared to patients who did not receive any testing and an additional 26 days compared to patients who received post-referral testing only, although this difference was not statistically significant and there was likely insufficient power to detect a significant difference based on the distribution of the median time to see a surgeon within this diagnosis group. The median time to see a hand surgeon in patients with JP who received only pre-referral advanced testing was increased by 46 days compared to patients received testing after the hand surgeon evaluation and was increased by 19 days compared to patients who did not receive any testing (p<0.05). Across the three diagnoses, patients who received pre-referral advanced testing had an increase in wait time to see a hand surgeon by 19–94 days (corresponding to an increased wait time of 25 – 107%) compared to patients who received no advanced testing (Table 4).

Table 4.

Wait Time^* to Hand Surgery Evaluation Based onTiming of Advanced Diagnostic Tests^** Across Three Conditions

	Carpal Tunnel Syndrome				Soft Tissue Masses				Joint Pain
	N (%)		Median (IQR), days		N (%)		Median (IQR), days		N (%)		Median (IQR), days
Entire Cohort	1,342		133	(49–607)	1,156		54	(21–175)	1,572		77	(27–517)
Pre-referral Testing Only	620	(46.2)	182	(61–685)	67	(5.8)	83	(33–195)	167	(10.6)	94	(41–575)
Pre-+Post-referral Testing	97	(7.2)	238	(70–989)	0	(0)	–	–	2	(0.1)	29	(16–41)
Post-referral Testing Only	284	(21.2)	111	(38–480)	6	(0.5)	57	(43–1571)	8	(0.5)	48	(18–73)
No Pre- and Post-referral Testing	341	(25.4)	88	(30–395)	1,083	(93.7)	52	(21–174)	1,395	(88.7)	75	(24–523)
***P Value			<0.001				0.16				0.011

^*Wait time defined as number of days between last referring provider evaluation and first hand surgery encounter

^**Advanced diagnostic test includes electrodiagnostic studies (EDS), arthrography, CT, MRI, ultrasound (US), non-invasive vascular studies, bone scan, and PET/CT scan(X-ray excluded)

^***Statistical testing for differences in median time to hand surgery evaluation between timing groups for each condition based on Kruskal-Wallis equality-of-population rank test.

DISCUSSION

In this study, we found that patients with CTS had the highest rates of advanced diagnostic test utilization prior to hand surgeon referral and had the highest rates of repeat testing, receiving advanced tests both before and after referral to a hand surgeon, compared to patients with JP and STM. Across all three conditions, patients who received pre-referral advanced testing had an increased time in referral to see a hand surgeon by 19–94 additional days compared to patients who receive only post-referral testing or no testing. Avoiding unnecessary use of diagnostic tests ordered prior to a hand surgeon evaluation could substantially reduce a patient’s wait time to see a hand surgeon, which would have the greatest impact for patients who receive tests that do not affect treatment decisions. Minimizing noncritical tests could reduce delays in receiving definitive treatment and minimize the time that patients experience symptoms.

Advanced testing has been reported at high rates among patients with upper extremity and musculoskeletal conditions.^6–9 A study evaluating patients with musculoskeletal neoplasms showed that 32.4% of patients received inappropriate advanced imaging prior to referral.⁸ Hartzell et al. found that among patients who presented for hand surgery evaluation at a tertiary academic medical center, 74% of patients with six common hand conditions underwent a prior study or intervention, of which 90% of advanced studies were deemed unnecessary.⁶ Our findings suggest that over 50% of CTS patients presenting to hand clinics received pre-referral advanced testing, most of which included electrodiagnostic studies, and 14% of those patients received additional testing after their surgery evaluation. However, our study in general found a lower rate of pre-referral diagnostic testing among the other two hand conditions compared to the findings published in other studies across all hand conditions. Although the appropriateness of diagnostic testing was not evaluated in the present study, our results suggested a majority of CTS patients received pre-referral testing, and a substantial rate of repeat testing occurred, resulting in an increased wait time and potential treatment delay if some of these patients could be diagnosed with CTS clinically.

Our findings are supported by other studies which demonstrate that advanced testing leads to prolonged time to surgical specialty care.^7,19,20 Although our study is focused on upper extremity care, there is a similar trend in delay to surgical care in previous studies of musculoskeletal conditions beyond the upper extremity. Bernstein et al. found that hip fracture patients with additional preoperative testing beyond basic laboratory tests had a greater time-to-surgery and length of stay compared to patients with no testing.¹⁹ Ashwood et al. found a delay in referral to specialists among patients with soft tissue and bone tumors who received complex imaging studies; however, most of the studies had to be repeated for accurate staging after referrals.⁷ To our knowledge, no studies have quantified the relationship between receipt of advanced diagnostic testing on timing of care delivery for patients with common hand conditions. Our study showed the timing of advanced testing may have an impact on the efficiency of care among patients whose diagnosis depends on physical exam findings and standard X-rays, which is typically the case with the three common hand conditions included in this study.

The role of uncertainty in clinical decision-making likely has an impact on physician practice variation, and the desire to minimize and eliminate any diagnostic uncertainty is probably a contributor to the perceived need to obtain confirmatory diagnostic tests. Studies have demonstrated that medical education of non-specialists is lacking in musculoskeletal medicine,^21–25 which may be the reason that some referring providers order pre-referral diagnostic tests. Furthermore, hand surgeons may request tests to be performed before seeing patients, particularly with CTS,¹⁰ whereas primary care providers may have difficulty in knowing the individual preferences of surgeons they are referring to and the utility of tests in ultimate treatment decisions for patients. If EDS is used as a screening tool for referral to a hand surgeon, there is potential for patients with false negative studies to be inappropriately delayed or refused a consultation. Studies have shown that based on the sensitivity and specificity of EDS, the test should not be used as a confirmatory test given the potential for false negative results, and that EDS did not out-perform diagnosis using a clinical questionnaire (CTS-6).^26,27 Since musculoskeletal conditions are the second most common reason for visiting primary care physicians,^22,28–32 it is essential for referring providers and hand surgeons to work together to make sure that tests are useful to both surgeons and patients. The first critical step is to recognize those patients who do not need tests prior to a surgeon evaluation, given the associated delays in referral. Second, hand surgeons can provide guidance to referring providers to identify patients who would benefit from pre-referral testing. Surgeons should be involved in systems-level reforms to better identify patients who do and do not need testing prior to their evaluation to minimize delays in referral and reduce the need for repeat testing.

Our study has several limitations. The cohort was from a single institution, which is not necessarily representative of all practices. However, the rate of pre-referral advanced testing in CTS patients in this cohort was similar to that reported in other studies.^10,33 Although we hypothesized that use of advanced tests prior to hand surgeon referral is partly attributable to habits of referring providers and partly attributable to requests from surgeons, an understanding of the rationale and facilitators of this practice is outside the scope of this study. It is possible that providers or clerical staff may request a test before scheduling an appointment with a surgeon, which has been demonstrated to be a common practice in prior research,¹⁰ but the surgeon-level variation and motivation of this potential requirement was not assessed in this study. In addition, we do not know the rationale for repeat testing after patients are seen by a hand surgeon and whether the subgroups of patients who received pre- or post-referral testing differ based on characteristics of the surgeons or referring providers. Future studies are warranted to investigate this decision-making process to better understand appropriateness of testing and impact on efficiency of care. Lastly, this study is unable to determine causality between testing and prolonged care to hand surgery evaluation owing to the nature of administrative data and the retrospective study design. Some factors such as scheduling constraints for specific surgeons could not be measured in the administrative data; however, we have excluded patients referred from outside the health system to minimize some degree of confounding based on differences in systems-based constraints. Despite these limitations, this study found that advanced testing use prior to hand surgery evaluation is commonly associated with a substantially increased wait time to surgeon evaluation, and is associated with some degree of repeat testing, particularly in patients with CTS.

Despite the study limitations, this study demonstrated the magnitude of increased wait time to surgeon evaluation and repeat testing associated with use of advanced diagnostic testing in the pre-referral period. The results suggest that use of pre-referral advanced diagnostic testing is associated with prolonged time to see hand surgeons for common hand conditions. These findings give referring providers and hand surgeons a better understanding of the magnitude of potential delay associated with advanced testing use, particularly if there is a question of whether a test will have an impact on decision-making and treatment for patients. For this reason, among others, it is necessary for clinicians to adhere to appropriateness criteria for advanced testing. Going forward, it is imperative for healthcare providers and organizations to develop strategies to more actively identify patients who would most benefit from the testing early and be aware of the need to identify patients who would not benefit from testing to avoid evaluation and treatment delay in these patients. Hand surgeons should play a role in better defining clinical indications for advanced testing and communicating with referring providers to ensure that tests ordered prior to consultation are beneficial to both patients and treating surgeons.