Feasibility of Quality Measures for the Diagnosis and Treatment of Carpal Tunnel Syndrome


      The American Academy of Orthopaedic Surgeons and the American Society for Surgery of the Hand developed candidate quality measures for potential inclusion in the Merit-Based Incentive Program and National Quality Forum in the hope that hand surgeons could report specialty-specific data. The following measures regarding the management of carpal tunnel syndrome (CTS) were developed using a Delphi consensus process: (1) use of magnetic resonance imaging (MRI) for diagnosis of CTS, (2) use of adjunctive surgical procedures during carpal tunnel release (CTR), and (3) use of formal occupational and/or physical therapy after CTR. This study simulated attempts to identify outlier regions in an insurance claims database, which is an important step in establishing feasibility of these measures.


      Using the Truven Health MarketScan, we identified 643,357 patients who were given a diagnosis of CTS between 2012 and 2014. We reported the percentage of metropolitan statistical areas (MSA) with one or more claims for MRI within 90 days of CTS diagnosis, one or more adjunctive surgical procedures, and one or more formal referrals for physical and/or occupational therapy within 6 weeks of CTR, and we calculated the rate of use for each of these diagnostic or treatment modalities. In addition, we report the precision ratio (signal to noise), SD, and 95% confidence interval.


      A high percentage of patients given a diagnosis of CTS did not have MRI (99%), and the precision ratio was considered high (0.99). Over 30% of all observed MSAs had at least one claim for MRI as a diagnostic modality in CTS. Most patients (98%) did not have adjunctive surgical procedures. For the observed years, over 28% of MSAs had at least one insurance claim for an adjunctive procedure. A total of 86% of patients did not receive formal occupational or physical therapy after CTR. In addition, 92% of MSAs had at least one claim for therapy. The precision ratio was considered high (approximately 0.85).


      There is regional variation in the utilization rate of diagnostic MRI for CTS, adjunctive surgical procedures, and formal referral for physical and occupational therapy. For the proposed quality measures, outlier regions can be detected in insurance claims data.

      Clinical relevance

      Use of MRI in diagnosis, adjunctive surgical procedures, and formal therapy after surgery are feasible quality measures for the Merit-Based Incentive Program and National Quality Forum.

      Key words

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        • Nguyen C.
        • Milstein A.
        • Hernandez-Boussard T.
        • Curtin C.M.
        The effect of moving carpal tunnel releases out of hospitals on reducing United States health care charges.
        J Hand Surg Am. 2015; 40: 1657-1662
        • Kazmers N.H.
        • Presson A.P.
        • Xu Y.
        • Howenstein A.
        • Tyser A.R.
        Cost implications of varying the surgical technique, surgical setting, and anesthesia type for carpal tunnel release surgery.
        J Hand Surg Am. 2018; 43 (971.e1–977.e1)
        • 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.e2–71.e2)
        • Foster B.D.
        • Sivasundaram L.
        • Heckmann N.
        • et al.
        Surgical approach and anesthetic modality for carpal tunnel release: a nationwide database study with health care cost implications.
        Hand (N Y). 2017; 12: 162-167
        • Sears E.D.
        • Swiatek P.R.
        • Chung K.C.
        National utilization patterns of steroid injection and operative intervention for treatment of common hand conditions.
        J Hand Surg Am. 2016; 41 (367.e2–373.e2)
        • Leinberry C.F.
        • Rivlin M.
        • Maltenfort M.
        • et al.
        Treatment of carpal tunnel syndrome by members of the American Society for Surgery of the Hand: a 25-year perspective.
        J Hand Surg Am. 2012; 37 (1997.e3–2003.e3)
        • Hand Surgery Quality Consortium
        Candidate quality measures for hand surgery.
        J Hand Surg Am. 2017; 42 (859.e3–866.e3)
        • Graham B.
        • Peljovich A.E.
        • Afra R.
        • et al.
        The American Academy of Orthopaedic Surgeons Evidence-Based Clinical Practice Guideline on: Management of Carpal Tunnel Syndrome.
        J Bone Joint Surg Am. 2016; 98: 1750-1754
      1. Adams JL. The Reliability of Provider Profiling: A Tutorial. The RAND Corporation: Santa Monica, CA; 2009.

        • Jarvik J.G.
        • Yuen E.
        • Haynor D.R.
        • et al.
        MR nerve imaging in a prospective cohort of patients with suspected carpal tunnel syndrome.
        Neurology. 2002; 58: 1597-1602
        • Leinberry C.F.
        • Hammond III, N.L.
        • Siegfried J.W.
        The role of epineurotomy in the operative treatment of carpal tunnel syndrome.
        J Bone Joint Surg Am. 1997; 79: 555-557
        • Crnkovic T.
        • Bilic R.
        • Trkulja V.
        • Cesarik M.
        • Gotovac N.
        • Kolundzic R.
        The effect of epineurotomy on the median nerve volume after the carpal tunnel release: a prospective randomised double-blind controlled trial.
        Int Orthop. 2012; 36: 1885-1892
        • Mackinnon S.E.
        • McCabe S.
        • Murray J.F.
        • et al.
        Internal neurolysis fails to improve the results of primary carpal tunnel decompression.
        J Hand Surg Am. 1991; 16: 211-218
        • Lowry W.E.J.
        • Follender A.B.
        Interfascicular neurolysis in the severe carpal tunnel syndrome: a prospective, randomized, double-blind, controlled study.
        Clin Orthop Relat Res. 1988; 227: 251-254
        • Shum C.
        • Parisien M.
        • Strauch R.J.
        • Rosenwasser M.P.
        The role of flexor tenosynovectomy in the operative treatment of carpal tunnel syndrome.
        J Bone Joint Surg Am. 2002; 84: 221-225
        • Dias J.J.
        • Bhowal B.
        • Wildin C.J.
        • Thompson J.R.
        Carpal tunnel decompression: is lengthening of the flexor retinaculum better than simple division?.
        J Hand Surg Br. 2004; 29: 271-276
        • Pomerance J.
        • Fine I.
        Outcomes of carpal tunnel surgery with and without supervised postoperative therapy.
        J Hand Surg Am. 2007; 32: 1155-1159
        • Provinciali L.
        • Giattini A.
        • Splendiani G.
        • Logullo F.
        Usefulness of hand rehabilitation after carpal tunnel surgery.
        Muscle Nerve. 2000; 23: 211-216