A Qualitative Study of Hospitalists' Perceptions of Patient Satisfaction Metrics on Pain Management

The Effect of Online Prescription Drug Monitoring on Opioid Prescription Habits After Elective Single-level Lumbar Fusion

INTRODUCTION

The United States opioid epidemic is a well-documented crisis stemming from increased prescriptions of narcotics. Online prescription drug monitoring programs (PDMPs) are a potential resource to mitigate narcotic misuse by tracking controlled substance prescriptions. Therefore, the purpose of this study was to evaluate opioid prescription trends after implementation of an online PDMP in patients who underwent single-level lumbar fusion.

METHODS

Patients who underwent a single-level lumbar fusion between August 27, 2017, and August 31, 2020, were identified and placed categorically into one of two cohorts: an "early adoption" cohort, September 1, 2017, to August 31, 2018, and a "late adoption" cohort, September 1, 2019, to August 31, 2020. This allowed for a 1-year washout period after Pennsylvania PDMP implementation on August 26, 2016. Opioid use data were obtained by searching for each patient in the state government's online PDMP and recording data from the year before and the year after the patient's procedure.

RESULTS

No significant difference was observed in preoperative opioid prescriptions between the early and late adoption cohorts. The late adoption group independently predicted decreased postoperative opioid prescriptions (β, 0.78; 95% confidence interval [CI], 0.65 to 0.93; P = 0.007), opioid prescribers (β, 0.81; 95% CI, 0.72 to 0.90; P < 0.001), pharmacies used (β, 0.90; 95% CI, 0.83 to 0.97; P = 0.006), opioid pills (β, 0.61; 95% CI, 0.50 to 0.74; P < 0.001), days of opioid prescription (β, 0.57; 95% CI, 0.45 to 0.72; P < 0.001), and morphine milligram equivalents prescribed (β, 0.53; 95% CI, 0.43 to 0.66; P < 0.001).

CONCLUSIONS

PDMP implementation was associated with decreased postoperative opioid prescription patterns but not preoperative opioid prescribing behaviors.

LEVELS OF EVIDENCE

4.

The effect of patient satisfaction scores on physician clinical decision making: A possible factor driving utilization of opioid prescriptions, magnetic resonance imaging, and interventional spine procedures

Objective

To survey the effect of patient satisfaction scores on pain physicians' medical decision making, with an emphasis on resource utilization.

Design

Email-based Survey.

Methods

Setting & Subjects: A 23-question survey was approved for dissemination to membership of a medical society and emailed to all members. The survey was also available online and via a promoted QR code.

Results

An email with link to the survey was viewed 1,116 times, and clicked on 223 times, with 75 members completing the survey online once the link was clicked. Thirty-three additional physicians directly accessed the survey online and completed it. Seventy-seven percent of physicians reported that patient satisfaction scores were tracked by their institution and were used as a consideration in financial compensation (22%) or performance review (36%). Over half of the physicians surveyed reported feeling that satisfaction scores would decline if they did not order MRI imaging, prescribe opioids or provide work restrictions/disability. Thirty percent reported to have performed a spine injection due to concern about patient satisfaction scores. Twenty-one reported that they had prescribed an opioid medication because of this concern. Lastly 25% and 24% have filled out disability paperwork or provided a disability parking placard respectively.

Conclusions

Over half of physicians surveyed reported having ordered physical therapy, MRIs, opioid medications, spine injections, or provided disability documentation over concern about how providing or not providing such things impacts patient satisfaction scores. This may be an unintended consequence of the current emphasis placed on patient satisfaction scores.

Patient Satisfaction in Academic Pain Management Centers: How Do We Compare?

PURPOSE OF REVIEW

The aim of the study was to investigate patient satisfaction amongst academic pain management centers and associated factors.

RECENT FINDINGS

Approximately 25% of pain management centers perform better than other practices on Press Ganey surveys. The majority of respondents (96%) indicated that pain management practices were uniquely positioned to receive poorer scores on patient satisfaction surveys. The majority of respondents (20/26), who reported a reason, indicated that limiting opioid prescribing led to poor patient satisfaction scores. Eighty-three percent of respondents indicated that they received pressure from administrators to improve patient satisfaction scores. The opioid epidemic in the USA must be addressed in order to diminish the senseless loss of life that is occurring in staggering numbers. The quality of care physicians provide has increasingly been assessed via patient satisfaction surveys. The results of these surveys often are utilized to provide financial incentives to physicians to obtain higher satisfaction scores. In the field of pain management, physicians may experience pressure to prescribe opioids in order to obtain higher patient satisfaction scores.

Observing and Identifying Hospitalist Best Communication Practices in Patient Interactions

This study identifies actual hospitalist best communication practices that optimize patient interactions in a busy hospital context. We observed and rated 36 hospitalists and 206 patient encounters using the Kalamazoo Essential Elements of Communication Checklist-Adapted (KEECC-A). We collected descriptive statistics of checklist scores and thematically analyzed fieldnotes to identify communication patterns. Results show hospitalists score highest and most frequently use three of seven KEECC-A dimensions: builds a relationship, shares information, and gathers information. We first identify exemplar behaviors and then provide statistical comparisons by professional and hospital tenure, gender, and day of rounding observed for these three dimensions. Male hospitalists scored higher than females for shares information and significant differences were found for gender between cross-sex patient-hospitalist interactions. Hospitalists early in their professional and hospital tenure received significantly lower ratings than mid-to-late career hospitalists in the three KEECC dimensions. Hospitalists observed on the first day of rounding received significantly higher ratings than those observed on a middle or last day. We offer interpretations to explain study findings and suggest interventions to help hospitalists with less-than-desirable communication skills.

Factors Influencing Patients' Experiences of Pain Management in the Emergency Department

Background

Despite management of acute pain, concerns regarding pain are still prevalent in the emergency department (ED).

Purpose

This study aimed to explore the factors influencing patients’ pain management in a Jordanian ED.

Method

Fifteen semistructured interviews (N = 15) with purposively selected patients in the ED.

Results

The thematic analysis uncovered two related themes. The first theme described the stage of “being on ED bed” which encapsulates two subthemes: “bad pain means, bad diagnosis” and “smiley faces versus grumpy faces.” The second theme referred to as “being discharged” including two subthemes, namely, “praying for not paying” and “being grateful to God.” The lack of money to pay for pain management was equally as stressful as pain itself. Patients’ narratives suggest that nursing pain management is a critical time, extending beyond medical management to encompass communication and spirituality.

Conclusions

The factors influencing the patients’ experience of pain management extend beyond addressing the source of the pain. Consequently, effective communication coupled with respecting patients’ spirituality and socioeconomic concerns is essential to pain management. To enhance patients’ experience of pain management, the ED system should shift toward a patient-centric model.

Balancing Patient-Centered and Safe Pain Care for Nonsurgical Inpatients: Clinical and Managerial Perspectives

BACKGROUND

Hospitals and clinicians aim to deliver care that is safe. Simultaneously, they are ensuring that care is patient centered, meaning that it is respectful of patients' values, preferences, and experiences. However, little is known about delivering care in cases in which these goals may not align. For example, hospitals and clinicians are facing the daunting challenge of balancing safe and patient-centered pain care for nonsurgical patients, due to lack of comprehensive care guidelines and complexity of this patient population.

METHODS

To gather clinical and managerial perspectives on the importance, feasibility, and strategies used to balance patient-centered care (PCC) and safe pain care for nonsurgical inpatients, the research team conducted in-depth, semistructured interviews with hospitalists, registered nurses, and health care managers from one health care system in the Midwestern United States. We systematically examined transcribed interviews and identified major themes using a thematic analysis approach.

RESULTS

Participants acknowledged the importance of balancing PCC and safe pain care. They envisioned this balance as a continuum, with certain patients for whom it is easier (for example, an opioid-naive patient with a fracture), vs. more difficult (for example, a patient with opioid use disorder). Participants reported several strategies they use to balance PCC and safe pain care, including offering alternatives to opioids, setting realistic pain goals and expectations, and using a team approach.

CONCLUSION

Clinicians and health care managers use various strategies to balance PCC and safe pain care for nonsurgical patients. Future studies should examine the effectiveness of these strategies on patient outcomes.

Not a magic pill: a qualitative exploration of provider perspectives on antibiotic prescribing in the outpatient setting

BACKGROUND

Inappropriate prescribing of antibiotics poses an urgent public health threat. Limited research has examined factors associated with antibiotic prescribing practices in outpatient settings. The goals of this study were to explore elements influencing provider decisions to prescribe antibiotics, identify provider recommendations for interventions to reduce inappropriate antibiotic use, and inform the clinical management of patients in the outpatient environment for infections that do not require antibiotics.

METHODS

This was a qualitative study using semi-structured interviews with key informants. Seventeen outpatient providers (10 medical doctors and 7 advanced care practitioners) within a large healthcare system in Charlotte, North Carolina, participated. Interviews were audio recorded, transcribed, and analyzed for themes.

RESULTS

Primary barriers to reducing inappropriate antibiotic prescribing included patient education and expectations, system-level factors, and time constraints. Providers indicated they would be interested in having system-wide, evidence-based guidelines to inform their prescribing decisions and that they would also be receptive to efforts to improve their awareness of their own prescribing practices. Results further suggested that providers experience a high demand for antibiotic prescriptions; consequently, patient education around appropriate use would be beneficial.

CONCLUSIONS

Findings suggest that antibiotic prescribing in the outpatient setting is influenced by many pressures, including patient demand and patient satisfaction. Training on appropriate antibiotic prescribing, guideline-based decision support, feedback on prescribing practices, and patient education are recommended interventions to improve levels of appropriate prescribing.

How Good Intentions Contributed to Bad Outcomes: The Opioid Crisis

The opioid crisis that exists today developed over the past 30 years. The reasons for this are many. Good intentions to improve pain and suffering led to increased prescribing of opioids, which contributed to misuse of opioids and even death. Following the publication of a short letter to the editor in a major medical journal declaring that those with chronic pain who received opioids rarely became addicted, prescriber attitude toward opioid use changed. Opioids were no longer reserved for treatment of acute pain or terminal pain conditions but now were used to treat any pain condition. Governing agencies began to evaluate doctors and hospitals on their control of patients' pain. Ultimately, reimbursement became tied to patients' perception of pain control. As a result, increasing amounts of opioids were prescribed, which led to dependence. When this occurred, patients sought more in the form of opioid prescriptions from providers or from illegal sources. Illegal, unregulated sources of opioids are now a factor in the increasing death rate from opioid overdoses. Stopping the opioid crisis will require the engagement of all, including health care providers, hospitals, the pharmaceutical industry, and federal and state government agencies.