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

Published:October 30, 2019DOI:


      We sought to evaluate the use of pre- and post-referral advanced diagnostic testing among patients with 3 common hand conditions, rates of subsequent tests, and differences in wait time to see a hand surgeon.


      We analyzed a single academic tertiary care center administrative database of encounters from 2006 to 2015 to identify adult patients who were referred to a hand surgeon for 3 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.


      Among patients who received advanced diagnostic tests before the surgeon evaluation, CTS patients had the highest rate of receiving pre-referral advanced testing (53.4%) compared with JP (10.6% ) and STM patients (5.8%). The CTS patients had the highest rates of repeat testing (19.5%) compared with patients with JP (1.4%) and STM (0%). Across all 3 conditions, patients who received pre-referral advanced testing waited an additional 19 to 94 days to see a surgeon, compared with patients who received only post-referral testing or no testing.


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

      Clinical relevance

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

      Key words

      JHS Podcast

      December 2, 2019

      JHS Podcast Episode 45

      Listen to Dr. Graham interview Dr. Erika Sears regarding her paper, "The Impact of Pre-Referral Advanced Diagnostic Testing on Wait Time to See a Hand Surgeon for Common Upper-Extremity Conditions", which is the lead article for the December 2019 issue of the Journal of Hand Surgery.

      Loading ...
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Hand Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Baker L.
        • Birnbaum H.
        • Geppert J.
        • Mishol D.
        • Moyneur E.
        The relationship between technology availability and health care spending.
        Health Aff (Millwood). 2003; (Suppl Web Exclusives:W3537–W551)
        • Smith-Bindman R.
        • Miglioretti D.L.
        • Johnson E.
        • et al.
        Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, 1996–2010.
        JAMA. 2012; 307: 2400-2409
        • Iglehart J.K.
        Health insurers and medical-imaging policy–a work in progress.
        N Engl J Med. 2009; 360: 1030-1037
      1. Smith M. Saunders R. Stuckhardt L. McGinnis J.M. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Institute of Medicine, Committee on the Learning Health Care System in America, Washington, DC2013
        • Miller B.J.
        • Avedian R.S.
        • Rajani R.
        • et al.
        What is the use of imaging before referral to an orthopaedic oncologist? A prospective, multicenter investigation.
        Clin Orthop Relat Res. 2015; 473: 868-874
        • Hartzell T.L.
        • Shahbazian J.H.
        • Pandey A.
        • et al.
        Does the gatekeeper model work in hand surgery?.
        Plast Reconstr Surg. 2013; 132: 381e-386e
        • Ashwood N.
        • Witt J.D.
        • Hallam P.J.
        • Cobb J.P.
        Analysis of the referral pattern to a supraregional bone and soft tissue tumour service.
        Ann R Coll Surg Engl. 2003; 85: 272-276
        • Nystrom L.M.
        • Reimer N.B.
        • Dean C.W.
        • Bush C.H.
        • Scarborough M.T.
        • Gibbs Jr., C.P.
        Evaluation of imaging utilization prior to referral of musculoskeletal tumors: a prospective study.
        J Bone Joint Surg Am. 2015; 97: 10-15
        • Wilson R.J.
        • Zumsteg J.W.
        • Hartley K.A.
        • et al.
        Overutilization and cost of advanced imaging for long-bone cartilaginous lesions.
        Ann Surg Oncol. 2015; 22: 3466-3473
        • Sears E.D.
        • Lu Y.T.
        • Wood S.M.
        • et al.
        Diagnostic testing requested before surgical evaluation for carpal tunnel syndrome.
        J Hand Surg Am. 2017; 42: 623-629.e621
        • Broder J.
        • Warshauer D.M.
        Increasing utilization of computed tomography in the adult emergency department, 2000–2005.
        Emerg Radiol. 2006; 13: 25-30
        • Kanzaria H.K.
        • Hoffman J.R.
        • Probst M.A.
        • Caloyeras J.P.
        • Berry S.H.
        • Brook R.H.
        Emergency physician perceptions of medically unnecessary advanced diagnostic imaging.
        Acad Emerg Med. 2015; 22: 390-398
        • Korley F.K.
        • Pham J.C.
        • Kirsch T.D.
        Use of advanced radiology during visits to US emergency departments for injury-related conditions, 1998–2007.
        JAMA. 2010; 304: 1465-1471
        • Pines J.M.
        Trends in the rates of radiography use and important diagnoses in emergency department patients with abdominal pain.
        Med Care. 2009; 47: 782-786
        • Goldstone A.
        • Bushnell A.
        Does diagnosis change as a result of repeat renal colic computed tomography scan in patients with a history of kidney stones?.
        Am J Emerg Med. 2010; 28: 291-295
        • Westphalen A.C.
        • Hsia R.Y.
        • Maselli J.H.
        • Wang R.
        • Gonzales R.
        Radiological imaging of patients with suspected urinary tract stones: national trends, diagnoses, and predictors.
        Acad Emerg Med. 2011; 18: 699-707
        • American Academy of Orthopaedic Surgeons
        Management of Carpal Tunnel Syndrome Evidenced-Based Clinical Practice Guideline.
        (Available at:)
        Date accessed: August 23, 2018
        • American College of Radiology
        ACR Appropriateness Criteria.
        (Available at:)
        • Bernstein J.
        • Roberts F.O.
        • Wiesel B.B.
        • Ahn J.
        Preoperative testing for hip fracture patients delays surgery, prolongs hospital stays, and rarely dictates care.
        J Orthop Trauma. 2016; 30: 78-80
        • Kocher K.E.
        • Meurer W.J.
        • Desmond J.S.
        • Nallamothu B.K.
        Effect of testing and treatment on emergency department length of stay using a national database.
        Acad Emerg Med. 2012; 19: 525-534
        • Scher D.L.
        • Boyer M.I.
        • Hammert W.C.
        • Wolf J.M.
        Evaluation of knowledge of common hand surgery problems in internal medicine and emergency medicine residents.
        Orthopedics. 2011; 34: e279-e281
        • Queally J.M.
        • Kiely P.D.
        • Shelly M.J.
        • O’Daly B.J.
        • O’Byrne J.M.
        • Masterson E.L.
        Deficiencies in the education of musculoskeletal medicine in Ireland.
        Ir J Med Sci. 2008; 177: 99-105
        • Freedman K.B.
        • Bernstein J.
        The adequacy of medical school education in musculoskeletal medicine.
        J Bone Joint Surg Am. 1998; 80: 1421-1427
        • Freedman K.B.
        • Bernstein J.
        Educational deficiencies in musculoskeletal medicine.
        J Bone Joint Surg Am. 2002; 84: 604-608
        • Matzkin E.
        • Smith E.L.
        • Freccero D.
        • Richardson A.B.
        Adequacy of education in musculoskeletal medicine.
        J Bone Joint Surg Am. 2005; 87: 310-314
        • Fowler J.R.
        • Cipolli W.
        • Hanson T.
        A comparison of three diagnostic tests for carpal tunnel syndrome using latent class analysis.
        J Bone Joint Surg Am. 2015; 97: 1958-1961
        • Deniz F.E.
        • Oksuz E.
        • Sarikaya B.
        • et al.
        Comparison of the diagnostic utility of electromyography, ultrasonography, computed tomography, and magnetic resonance imaging in idiopathic carpal tunnel syndrome determined by clinical findings.
        Neurosurgery. 2012; 70: 610-616
        • Geyman J.P.
        • Gordon M.J.
        Orthopedic problems in family practice: incidence, distribution, and curricular implications.
        J Fam Pract. 1979; 8: 759-765
        • Kahl L.E.
        Musculoskeletal problems in the family practice setting: guidelines for curriculum design.
        J Rheumatol. 1987; 14: 811-814
        • Marsland D.W.
        • Wood M.
        • Mayo F.
        Content of family practice. Part I: rank order of diagnoses by frequency. Part II: diagnoses by disease category and age/sex distribution.
        J Fam Pract. 1976; 3: 37-68
        • Mulhall K.J.
        • Masterson E.
        Relating undergraduate musculoskeletal medicine curricula to the needs of modern practice.
        Ir J Med Sci. 2005; 174: 46-51
        • Lynch J.R.
        • Gardner G.C.
        • Parsons R.R.
        Musculoskeletal workload versus musculoskeletal clinical confidence among primary care physicians in rural practice.
        Am J Orthop (Belle Mead NJ). 2005; 34: 487-491
        • Munns J.J.
        • Awan H.M.
        Trends in carpal tunnel surgery: an online survey of members of the American Society for Surgery of the Hand.
        J Hand Surg Am. 2015; 40: 767-771.e2