Patients' satisfaction with cancer pain treatment at adult oncologic centers in Northern Ethiopia; a multi-center cross-sectional study

BACKGROUND

Patient satisfaction is an important indicator of the quality of healthcare. Pain is one of the most common symptoms among cancer patients that needs optimal treatment; rather, it compromises the quality of life of patients.

OBJECTIVE

To assess the levels and associated factors of satisfaction with cancer pain treatment among adult patients at cancer centers found in Northern Ethiopia in 2023.

METHODS

After obtaining ethical approval, a multi-center cross-sectional study was conducted at four cancer care centers in northern Ethiopia. The data were collected using an interviewer-administered structured questionnaire that included the Lubeck Medication Satisfaction Questionnaire (LMSQ). The severity of pain was assessed by a numerical rating scale from 0 to 10 with a pain score of 0 = no pain, 1-3 = mild pain, 4-6 = moderate pain, and 7-10 = severe pain Binary logistic regression analysis was employed, and the strength of association was described in an adjusted odds ratio with a 95% confidence interval.

RESULT

A total of 397 cancer patients participated in this study, with a response rate of 98.3%. We found that 70.3% of patients were satisfied with their cancer pain treatment. Being married (AOR = 5.6, CI = 2.6-12, P < 0.001) and being single (never married) (AOR = 3.5, CI = 1.3-9.7, P = 0.017) as compared to divorced, receiving adequate pain management (AOR = 2.4, CI = 1.1-5.3, P = 0.03) as compared to those who didn't receive it, and having lower pain severity (AOR = 2.6, CI = 1.5-4.8, P < 0.001) as compared to those who had higher level of pain severity were found to be associated with satisfaction with cancer pain treatment.

CONCLUSION

The majority of cancer patients were satisfied with cancer pain treatment. Being married, being single (never married), lower pain severity, and receiving adequate pain management were found to be associated with satisfaction with cancer pain treatment. It would be better to enhance the use of multimodal analgesia in combination with strong opioids to ensure adequate pain management and lower pain severity scores.

Long-Term Satisfaction of Oral Sedation versus Standard-of-Care Intravenous Sedation for Ocular Surgery

Purpose

Long-term patient satisfaction may influence patients' perspectives of the quality of care and their relationship with their providers. This is a follow up to a comparative effectiveness study investigating oral to intravenous sedation (OIV study). The OIV study found that oral sedation was noninferior in patient satisfaction to standard intravenous (IV) sedation for anterior segment and vitreoretinal surgeries. This study aims to determine if patient satisfaction with oral sedation remained noninferior long term.

Patients and Methods

Patients were re-interviewed using the same satisfaction survey given during the OIV study. Statistical analysis involved t-tests for noninferiority of the long-term mean satisfaction score of oral and IV sedation. We also compared the original mean satisfaction score and the follow-up mean satisfaction score for each type of sedation and for both groups combined.

Results

Participants were interviewed at a median of 1225.5 days (range 754-1675 days) from their surgery. The original mean satisfaction score was 5.26 ± 0.79 for the oral treatment group (n = 52) and 5.27 ± 0.64 for the intravenous treatment group (n = 46), demonstrating noninferiority with a difference in mean satisfaction score of 0.015 (p < 0.0001). The follow-up mean satisfaction score was 5.23 ± 0.90 for oral sedation and 5.60 ± 0.61 for IV sedation, with a difference in the mean satisfaction score of 0.371 (p = 0.2071). Satisfaction scores did not differ between the original mean satisfaction score and the follow-up mean satisfaction score for the oral treatment group alone (p = 0.8367), but scores in the intravenous treatment group increased longitudinally (p = 0.0004).

Conclusion

In this study, long-term patient satisfaction with oral sedation was not noninferior to satisfaction with IV sedation, unlike our findings with short-term patient satisfaction in our original study. Patient satisfaction also remained unchanged over time for the oral treatment group, but patients in the intravenous treatment group reported higher long-term satisfaction with their anesthesia experience compared to the immediate post-operative period.

Patient satisfaction and associated factors towards surgical service among patients undergoing surgery at referral hospitals in western Amhara Regional State, Ethiopia

Background

Patient satisfaction is a growing concern in all aspects of healthcare. Assessing patient satisfaction has paramount importance for measuring the level of care provided by a health system. The present study aimed to measure the levels of satisfaction among patients undergoing invasive surgery in the referral hospitals of the Western Amhara Regional State.

Methods

A cross-sectional study design was employed. The data were collected from 422 study participants from February 6 to April 6, 2020. The participants were selected using systematic random sampling technique. Interviewer administered questionnaire and chart review were used for data collection. A binary logistic regression model was used to identify the association between independent variables and patient satisfaction. Level of significance was considered at p value less than 0.05 with 95% confidence level.

Result

Of the total participants, 290 (68.7%, 95% CI: 64.5-73.5) were found to be satisfied with surgical service. Factors such as age >58 years [AOR = 3.80, 95% CI (1.53-9.46)], 47-58 years [AOR = 2.47, 95%CI (1.07-5.71)], those with no formal education [AOR = 2.73, 95% CI (1.18-6.32)], primary school education [AOR = 3.89, 95%CI (1.65-9.17)] and secondary school education [AOR = 3.37, 95%CI (1.38-8.23)], no history of previous surgical admission [AOR = 2.09, 95%CI (1.07-4.08)], length of stay in the hospital <7 days [AOR = 2.13,95%CI(1.21-3.75)] and elective admission for surgery [AOR = 1.75, 95%CI (1.03-2.99)] were significantly associated with patient satisfaction towards surgical service.

Conclusion

The proportion of patient satisfaction towards surgical service was found to be low. Factors including age, educational status, history of previous surgical admission, length of stay in the hospital and elective admission for surgery were associated with patient satisfaction. This suggests that healthcare organizations should focus on providing patients with respectful and compassionate patient care approach while paying close attention to how patients are treated.Moreover, in order to provide patient-focused care, health care providers should strengthen their usage of patient characteristics including age, educational level, and type of surgery while developing patient focused care plan.

Fatal opioid overdoses geospatially cluster with level 1 trauma centers in Ohio

OBJECTIVE

Ohio is consistently ranked as one of the worst states for opioid overdose deaths. Traumatic injury has been linked to opioid overdose deaths, yet the location of trauma centers has not been explored. We examined whether geospatial clustering occurred between county-level opioid overdose deaths (OODs) and trauma center levels.

METHODS

We obtained 2019 county-level data from the Ohio Department of Health for fatal overdoses from prescription opioids. We obtained the total number of opioid doses prescribed in 2019 per county from the Ohio Automated Rx Reporting System and American College of Surgeons designated trauma center locations within Ohio from their website. We used geospatial analysis to assess if clustering occurred between trauma center level and prescription opioid overdose deaths at a county level.

RESULTS

There were 42 trauma centers located within 21 counties: 7 counties had level 1, and 14 counties had only level 2/level 3. There was no difference in rates of opioid doses prescribed per 100,000 people between counties with level 1 trauma centers and only level 2/level 3. However, prescription OODs rates were significantly higher in counties with level 1 trauma centers (37.6 vs 20, P = .02). Geospatial clustering was observed between level 1 trauma centers and prescription opioid overdose deaths at the county level (P < .01).

CONCLUSION

Geospatial clustering exists between prescription OODs and level 1 trauma center locations in Ohio. Improved at-risk patient identification and targeted community outreach represent opportunities for trauma providers to tackle the opioid epidemic.

Periarticular multimodal analgesia in decreasing perioperative pain in tibial plateau fractures: A double blind randomized controlled pilot study

INTRODUCTION

The use of periarticular multimodal analgesia injections is increasing and has become commonplace in some surgeries. However, there is no data on the effectiveness of local periarticular multimodal analgesia for tibial plateau fractures. We hypothesized that closed tibial plateau fracture patients receiving the local multimodal analgesic medications would experience a decrease in VAS pain scores.

METHODS

Patients aged between 18 and 79 with an isolated closed tibial plateau fracture (AO 41-B and C) were prospectively enrolled and randomized in a 1:1 double blinded fashion to either a placebo or active medication treatment arm. After ORIF, gel-foam sponges soaked in either multimodal analgesic solution or normal saline. Patients were followed for 24 h post-operatively with Visual Analog pain Scores (VAS). Patients were monitored post-operatively for complications including compartment syndrome, infection, and non-union.

RESULTS

The planned study was terminated prior to completion due to higher than anticipated rates of infection (18%), distributed equally among active (3) and placebo (2) groups, raising concerns that this may have been due to the presence of the delivery device. Twenty-eight patients were enrolled, 15 in the active group and 13 in the placebo group. Patients in the active medication group had significantly decreased pain scores at hours 4 (p = 0.005, 4.2 vs 6.9), 8 (p = 0.05, 5 vs 7), and 12 (p = 0.02, 3.8 vs 6.2). Pain scores at hours 16 (p = 0.10, 4.5 vs 6.5), 20 (p = 0.08, 4.6 vs 6.4), and 24 (p = 0.10, 4.8 vs 6.5) were also decreased but did not reach significance.

DISCUSSION

The use of local multimodal periarticular analgesic for closed tibial plateau fractures appears to be beneficial for short-term pain control post-operatively. Concerns regarding an implantable delivery vehicle leading to infection has warranted a change in method of drug administration. Completion of the full study will permit us to validate or refute these findings.

LEVEL OF EVIDENCE

Therapeutic Level 1.

Patient Demographics Are Associated with Differences in Prehospital Pain Management among Trauma Patients

OBJECTIVE

Disparities have been observed in the treatment of pain in emergency department patients. However, few studies have evaluated such disparities in emergency medical services (EMS). We describe pain medication administration for trauma indications in an urban EMS system and how it varies with patient demographics.

METHODS

We performed a retrospective review of the electronic medical records of adult patients transported for isolated trauma (without accompanying medical complaint) from 1/1/18 to 6/30/2020 by a third service EMS agency in a major United States metropolitan area. We performed descriptive statistics on epidemiology, type of pain medications administered, and pain scores. Kruskall-Wallis and chi-square or Fisher's exact tests were used to compare continuous and categorical variables, respectively. We constructed a logistic regression model to estimate the odds of nontreatment of pain by age, race, sex, transport interval, pain score, and Glasgow Coma Scale (GCS) score for patients with pain scores of at least four on a one to ten scale, the threshold for pain treatment per the EMS protocol.

RESULTS

Of 32,463 EMS patients with traumatic injuries included in the analysis, 40% (12,881/32,463) were African American, 50% (16,284/32,463) were female, the median age was 27 years (IQR 45-64), and the median initial pain score was 5 (IQR 2-8). Fifteen percent (4,989/32,463) received any analgesic. Initial pain scores were significantly higher for African American and female patients. African American patients were less likely to receive analgesia compared to White and Hispanic patients (19% versus 25% and 23%, respectively, p < 0.0001). Adjusting for age, pain score, transport interval, and GCS, African American compared to White, and female compared to male patients were less likely to be treated for pain, OR 1.59 (95% CI 1.47-1.72) and OR 1.20 (95% CI 1.11-1.28), respectively.

CONCLUSION

Among patients with isolated traumatic injuries treated in a single, urban EMS system, African American and female patients were less likely to receive analgesia than White or male patients. Analgesics were given to a small percentage of patients who were eligible for treatment by protocol, and intravenous opioids were used in the vast majority patients who received treatment.

Patient-centered Care and Integrated Practice Units: Embracing the Breast Care Continuum

Patient-centered care is a health care approach optimized for the needs of the patient. As patients have sought more autonomy in recent years, this model has been more frequently adopted. Breast radiologists aspiring to advance patient-centered care should seek greater ownership of the breast diagnostic imaging and intervention workflows, helping their patients navigate the complex breast care landscape with patients' preferences taken into account. Applying this approach to breast radiology will increase patient satisfaction and compliance while also limiting wasted health care dollars, unnecessary diagnostic delays, and overall confusion. Herein, the benefits of patient-centered breast radiology are discussed, and numerous suggestions and case examples are provided to help readers reshape their practice toward the priorities of their patients.

Reliability and Validity of the Adapted Chinese Version of the Satisfaction of Adolescents with Postoperative Pain Management - Idiopathic Scoliosis (SAP-S) Scale

Study Design

A prospective study.

Objective

The aim of this study was to evaluate the internal reliability and structure validity of an adapted simplified Chinese version of the Satisfaction of Adolescents with Postoperative pain management – idiopathic Scoliosis (SAP-S) scale in mainland China.

Summary of Background Data

Pain management is a major issue for adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal fusions. There is a lack of valid scales for evaluating patients’ satisfaction with postoperative pain management. The SAP-S was proven to be a valid and reliable measure in English and French.

Methods

The SAP-S was translated into Chinese according to the internationally recognized guidelines. A total of 95 AIS patients undergoing posterior fusion surgery completed the CSAP-S, along with other self-reported questionnaires, including the 36-Item Short Form Health Survey (SF-36) and Scoliosis Research Society-22 (SRS-22) questionnaires. The internal consistency, test–retest reliability, and construct validity of the CSAP-S were determined.

Results

The SAP-S was successfully translated into Chinese. All patients completed the CSAP-S twice and the other instruments. The CSAP-S had good internal consistency and test–retest reliability with Cronbach’s alpha coefficient measuring 0.895 and intraclass correlation coefficient (ICC) measuring 0.97. Elimination of any one item did not result in a value of Cronbach’s alpha of <0.80. A good construct validity was shown by good correlation with bodily pain (r=0.883, p=0.004) and social functioning (r=0.786, p=0.002) domains of SF-36 and pain (r=0.752, p=0.001) and satisfaction with management (r=0.746, p=0.005) domains of SRS-22.

Conclusion

The CSAP-S demonstrated good internal consistency, reliability, and construct validity, and may be used for the evaluation of AIS patients’ satisfaction with postoperative pain management in mainland China.

Development and Impact of an Institutional Enhanced Recovery Program on Opioid Use, Length of Stay, and Hospital Costs Within an Academic Medical Center: A Cohort Analysis of 7774 Patients

BACKGROUND

Enhanced Recovery (ER) is a change management framework in which a multidisciplinary team of stakeholders utilizes evidence-based medicine to protocolize all aspects of a surgical care to allow more rapid return of function. While service-specific reports of ER adoption are common, institutional-wide adoption is complex, and reports of institution-wide ER adoption are lacking in the United States. We hypothesized that ER principles were generalizable across an institution and could be implemented across a multitude of surgical disciplines with improvements in length of stay, opioid consumption, and cost of care.

METHODS

Following the establishment of a formal institutional ER program, ER was adopted in 9 distinct surgical subspecialties over 5 years at an academic medical center. We compared length of stay, opioid consumption, and total cost of care in all surgical subspecialties as a function of time using a segmented regression/interrupted time series statistical model.

RESULTS

There were 7774 patients among 9 distinct surgical populations including 2155 patients in the pre-ER cohort and 5619 patients in the post-ER cohort. The introduction of an ER protocol was associated with several significant changes: a reduction in length of stay in 5 of 9 specialties; reduction in opioid consumption in 8 specialties; no change or reduction in maximum patient-reported pain scores; and reduction or no change in hospital costs in all specialties. The ER program was associated with an aggregate increase in profit over the study period.

CONCLUSIONS

Institution-wide efforts to adopt ER can generate significant improvements in patient care, opioid consumption, hospital capacity, and profitability within a large academic medical center.

Narcotic Refills and Patient Satisfaction With Pain Control After Total Joint Arthroplasty

BACKGROUND

Patient satisfaction has become an important metric for total joint arthroplasty (TJA) used to reimburse hospitals. Despite ubiquitous narcotic use for post-TJA pain control, there is little understanding regarding patient factors associated with obtaining opioid refills and associations with patient satisfaction.

METHODS

Using our state's mandatory opioid prescription monitoring program, we reviewed preoperative and postoperative narcotic prescriptions filled for 438 consecutive TJA patients. Subjects were divided into 3 groups based on the number of post-TJA narcotic refills obtained (0, 1, or >1), and logistic regression analysis was conducted comparing demographics, surgical factors, and satisfaction with pain control.

RESULTS

One hundred twenty-five patients (25.8%) did not consume preoperative opioids and received no postoperative refills. Total hip arthroplasty (THA) patients (P = .0004), subjects ≥65 years (P = .0057), and Medicare patients (P = .0058) had significantly higher rates of 0 postdischarge refills. THA recipients had 268% increased odds of not receiving a refill narcotic (adjusted odds ratio = 0.373; 95% confidence interval, 0.224- 0.622). Every 100-morphine milligram equivalent (MME) increase in presurgery use led to a 16% increase in odds of needing >1 opioid refill (adjusted odds ratio = 1.161; 95% confidence interval, 1.085-1.242). Subjects who noted higher satisfaction consumed less overall opioids when receiving a refill (436 vs 1119 MMEs, P = .021).

CONCLUSION

Subjects who received fewer narcotic prescriptions and overall MMEs demonstrated higher rates of satisfaction with early pain control. Our results are consistent with other studies in showing that increased preoperative narcotic use portends higher rates of postoperative refills. There appears to be a subset of THA patients >65 years of age who may be candidates for opioid-sparing analgesia.

A Multidisciplinary Approach to Improve Pain Management and Satisfaction in a Trauma Population

An adult trauma center identified pain management as a potential area for improvement. Pain management is at the height of discussion in medical centers across the United States. The Hospital Consumer Assessment of Healthcare Provider and System (HCAHPS) scores relating to pain management were consistently low (<5th percentile). This project was designed to use a collaborative and systematic approach to pain management to improve HCAHPS pain management scores. This is an evaluation of a quality improvement project using a before-and-after design with historical control. Using HCAHPS data to evaluate patients' pain management perceptions, an integrative three-pronged approach was developed and implemented: (1) development of a trauma nurse leadership program, (2) collaboration with pain management providers, and (3) modifications made to the trauma admission order set. Trauma nurse leaders educated patients and families regarding pain management goals and expectations utilizing a standardized script. HCAHPS survey data obtained before and after the intervention showed a significant improvement in patient satisfaction. HCAHPS scores on the three pain questions prior to intervention in Quarters 2 and 3 (Q2-3) 2017 had a mean of less than the 5th percentile. After intervention, HCAHPS scores on the three pain questions improved to a mean of more than the 60th percentile on Q4 2018. Implementation of a pain management strategy involving a three-pronged approach of a dedicated trauma nurse leadership program, collaboration with a pain management team, and evaluation and modification of a trauma admission order set was associated with an improvement in communication about pain with the trauma patients and HCAHPS pain satisfaction scores.

Impact of length of stay on HCAHPS scores following lumbar spine surgery

OBJECTIVE

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys, completed by patients following an inpatient stay, are utilized to assess patient satisfaction and quality of the patient experience. HCAHPS results directly impact hospital and provider reimbursements. While recent work has demonstrated that pre- and postoperative factors can affect HCAHPS results following lumbar spine surgery, little is known about how these results are influenced by hospital length of stay (LOS). Here, the authors examined HCAHPS results in patients with LOSs greater or less than expected following lumbar spine surgery to determine whether LOS influences survey scores after these procedures.

METHODS

The authors conducted a retrospective review of HCAHPS surveys, patient demographics, and outcomes following lumbar spine surgery at a single institution. A total of 391 patients who had undergone lumbar spine surgery and had completed an HCAHPS survey in the period between 2013 and 2015 were included in this analysis. Patients were divided into those with a hospital LOS equal to or less than the expected (LTE-LOS) and those with a hospital LOS longer than expected (GTE-LOS). Expected LOS was based on the University HealthSystem Consortium benchmarks. Nineteen questions from the HCAHPS survey were examined in relation to patient LOS. The primary outcome measure was a comparison of "top-box" ("9-10" or "always or usually") versus "low-box" ("1-8" and "somewhat or never") scores on the HCAHPS questions. Secondary outcomes of interest were whether the comorbid conditions of cancer, chronic renal failure, diabetes, coronary artery disease, hypertension, stroke, or depression occurred differently with respect to LOS. Statistical analysis was performed using Fisher's exact test for the 2 × 2 contingency tables and the chi-square test for categorical variables.

RESULTS

Two hundred fifty-seven patients had an LTE-LOS, whereas 134 patients had a GTE-LOS. The only statistically significant difference in preoperative characteristics between the patient groups was hypertension, which correlated to a shorter LOS. A GTE-LOS was associated with a decreased likelihood of a top-box score for the HCAHPS survey items on doctor listening and pain control.

CONCLUSIONS

Here, the authors report a decreased likelihood of top-box responses for some HCAHPS questions following lumbar spine surgery if LOS is prolonged. This study highlights the need to further examine the factors impacting LOS, identify patients at risk for long hospital stays, and improve mechanisms to increase the quality and efficiency of care delivered to this patient population.

The effect of music on pain and subjective experience in image-guided musculoskeletal corticosteroid injections: a randomized controlled trial

PURPOSE

To investigate the role of music on subjects undergoing routine image-guided musculoskeletal corticosteroid injections and its effect on post-procedure pain and subjective overall experience.

MATERIALS AND METHODS

This prospective study was IRB-approved and HIPAA-compliant. A total of 126 subjects referred for outpatient image-guided musculoskeletal corticosteroid injections were enrolled in the study and randomized into a music offered group ((+)MO) and a no music offered group ((-)MO). (+)MO subjects were given the opportunity to listen to music during their corticosteroid injection. All subjects were then given an anonymous survey on which they recorded their pre-procedural and post-procedural pain on a scale from 0 to 9 and rated their overall experience and how likely they were to recommend our department for musculoskeletal procedures on scales from 1 to 5.

RESULTS

(+)MO subjects had significantly lower post-procedural pain (p = 0.013) and significantly greater decrease in pain (p = 0.031) compared to (-)MO subjects. Among the (+)MO subjects, there was no statistically significant difference in post-procedure pain (p = 0.34) or change in pain (p = 0.62) if music was accepted or declined. However, subjects who listened to music did have lower post-procedural pain compared to those who did not listen to music (p = 0.012), although the differences in the decrease of pain between the two groups did not quite reach statistical significance (p = 0.062).

CONCLUSIONS

Playing music during image-guided musculoskeletal corticosteroid injections may reduce patients' post-procedure pain. Offering patients some measure of control over their procedure may be a factor that contributes to decreased post-procedure pain as well.

Role of Ketamine in Multimodal Analgesia Protocol for Bariatric Surgery

Background and Objectives: Acute postoperative pain is one of the most undesirable experiences for a patient in the postoperative period. Many options are available for the treatment of postoperative pain. One of the methods of multimodal analgesia is a combination of opioids and adjuvant agents, such as ketamine. The aim of this study was to evaluate the effect of a pre-incisional single injection of low-dose ketamine on postoperative pain after remifentanil infusion in patients undergoing laparoscopic gastric bypass or gastric plication surgery. Materials and Methods: The prospective, randomized, double-blinded and placebo-controlled trial took place at the Hospital of the Lithuanian University of Health sciences KaunoKlinikos in 2015-2017. A total of 32 bariatric patients (9 men and 23 women) were randomly assigned to receive a single pre-incisional injection of ketamine (0.15 mg/kg (LBM)) (ketamine, K group) or saline (placebo, S group). Standardized protocol of anesthesia and postoperative pain management was followed for all patients. Postoperative pain intensity, postoperative morphine requirements, incidence of side effects and patients' satisfaction with postoperative analgesia were recorded. Results: Thirty-two patients undergoing bariatric surgery: 18 (56.25%; gastric bypass) and 14 (43.75%; gastric plication) were examined. Both groups did not differ in demographic values, duration of surgery and anesthesia and intraoperative drug consumption. Postoperative pain scores were similar in both groups (p = 0.105-0.941). Morphine consumption was 10.0 (7.0-12.5 mg) in group S and 9.0 (3.0-15.0 mg) in group K (p = 0.022). The incidence of side effects was similar in both groups (p = 0.412). Both groups demonstrated very high satisfaction with postoperative analgesia. Conclusions: Pre-incisional single dose ketamine reduces postoperative opioids consumption, but does not have an effect of postoperative pain intensity and side effects after remifentanil infusions. Very high patient satisfaction is achieved if standard multimodal analgesia protocol with an individual assessment of pain and dosage of medications is followed.

A Prospective Randomized Trial of an Oral Patient-Controlled Analgesia Device Versus Usual Care Following Total Hip Arthroplasty

BACKGROUND

Multimodal pain management for surgery patients may include the use of a combination of scheduled oral pain medications with as-needed (PRN) oral opioids. Multiple concurrent time demands on nursing staff frequently cause delays in the delivery of oral PRN pain medication compromising pain management.

PURPOSE

Postoperative pain control was compared using a wireless oral patient-controlled analgesia device for the delivery of oxycodone with a control group receiving PRN oxycodone from nursing staff.

METHODS

Thirty patients were prospectively randomized into each of 2 groups after total hip arthroplasty. Patient demographics, pain scores, drug dose data, and physical therapy data were collected from chart reviews. Additional data were obtained from patient and nursing surveys.

RESULTS

Device patients recorded statistically lower pain scores while taking lower doses of oxycodone on postoperative Day 1 as compared with the control group. Patient surveys indicated that those in the device group reported lower pain scores 24 hours prior to discharge, albeit not statistically different from the control group. Men in the device group reported statistically lower pain scores with physical therapy than men in the control group. Findings from the nursing survey indicate that nurses favored the device over nurse-administered PRN.

CONCLUSION

Patients using the wireless patient-controlled analgesia (PCA) (oral) device had less pain at rest and with activity (men) while taking lower doses of oxycodone with each dose. Nursing surveys indicated that nursing staff in this orthopedic postoperative unit found the device easy to use, reliable, and efficient. They also recommended its adoption for those capable of using it.

Ethics of Opioid Prescriber Regulations: Physicians, Patients, and Pain

BACKGROUND

Opioid addiction affects patients of every race, sex, and socioeconomic status. Overprescribing is a known cause of the opioid crisis. Various agencies have implemented requirements and programs to combat practitioner overprescribing; however, there can be adverse ethical consequences when regulations are used to influence physician behavior. We aimed to explore the ethical aspects of some of these interventions.

METHODS

We reviewed various interventions for opioid prescribing through the lens of ethical inquiry. Specifically, we evaluated (1) requirements for educational programs for prescribers and patients, (2) prescription monitoring programs, (3) prescription limits, (4) development of condition-specific pain management guidelines, (5) increased utilization of naloxone, and (6) opioid disposal programs. We also evaluated patient satisfaction survey questions relating to pain.

RESULTS

The present analysis demonstrated that the following regulatory interventions are ethically sound: requirements for educational programs for prescribers and patients, robust prescription monitoring programs that cross state lines, increased prescribing of naloxone for at-risk patients, development of condition-specific pain management guidelines, improvement of opioid disposal programs, and elimination of pain-control questions from patient satisfaction surveys. However, implementation of strict prescribing limits without accommodation for procedure and patient characteristics may have negative ethical consequences.

CONCLUSIONS

Although the importance of addressing the current opioid crisis cannot be understated, as surgeons, we must examine ethical implications of any new regulations that affect musculoskeletal patient care.

Postdischarge Opiate-Prescribing Habits for Primary THA and TKA: A Survey of American Association of Hip and Knee Surgeons Members

Abuse of opiate medications has reached epidemic proportions, and elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) typically require outpatient use of narcotic medications. This survey sought to determine opiate-prescribing habits of members of the American Association of Hip and Knee Surgeons (AAHKS) for patients undergoing primary THA and TKA. An 11-question online survey was developed to evaluate current prescribing habits for opiate and nonopiate medications prescribed after primary THA and TKA. An invitation to complete the survey was e-mailed to 2698 orthopedic surgeons using an AAHKS listserv. Surgeons' demographic information and their prescribing habits of opiate and nonopiate medications postdischarge were recorded. Data were examined using descriptive statistics, chi-square, and multivariate logistic regression. Responses were received from 325 of 2698 (12.1%) AAHKS members. Significant variation in the type of opiate prescribed and the number of pills dispensed was observed. Higher surgical volume and less years in surgical practice were associated with a higher number of opiate pills prescribed after THA and TKA. There were no statistically significant associations between opiates prescribed and use of an ambulatory surgery center or presence of departmental guidelines. Although THA and TKA are relatively standardized procedures performed nationwide, significant variability exists among surgeons regarding postdischarge opiate- and nonopiate-prescribing habits. There is a need for greater standardization to create a unified, evidence-based, and safe regimen for the postoperative period while reducing the opiate burden in the surrounding community. [Orthopedics. 2019; 42(6):361-367.].

The Impact of Patient Interactive Systems on the Management of Pain in an Inpatient Hospital Setting: A Systematic Review

BACKGROUND

While some published literature exists on the use of interactive patient care systems, the effectiveness of these systems on the management of pain is unclear. To fill this gap in knowledge, we aimed to understand the impact and outcomes of pain management patient interactive systems in an inpatient setting.

METHODS

A systematic literature review was conducted across seven databases, and results were independently screened by two researchers. To extract relevant data, critical appraisal forms were developed and each paper was examined by two experts. Information included patient interactive system category, patient population and number of participants/samples, experiment type, and specific outcome measures.

RESULTS

Out of 58 full-text articles assessed for eligibility, 18 were eligible and included in the final qualitative synthesis. Overall, there were two main types of pain management interactive systems within the inpatient setting (standalone systems and integrated platform systems). While systems were diverse especially for integrated platforms, most reported systems were entertainment distraction systems. Reports examined a variety of outcome measures, including changes in patient-reported pain levels, patient engagement, user satisfaction, changes in clinical workflow, and changes in documentation. In the 13 systems measuring pain scores, 12 demonstrated a positive impact on pain level scores.

CONCLUSION

Pain management systems appear to be effective in lowering patient level scores, but research comparing the effectiveness and efficacy of one type of interactive system versus another in the management of pain is needed. While not conclusive, pain management systems integrated with other technology platforms show potentially promising effects with improving patient communication, education, and self-reporting.

Pain Control after Intravitreal Injection Using Topical Nepafenac 0.3% or Pressure Patching: A Randomized, Placebo-Controlled Trial

PURPOSE

Pain after an intravitreal injection (IVI) can last up to 7 days and negatively impacts the patient's experience, potentially reducing treatment compliance. We prospectively evaluated topical nepafenac 0.3% suspension and patching for the reduction of pain after IVI.

DESIGN

Randomized controlled trial.

PARTICIPANTS

Sixty patients receiving an IVI of bevacizumab, aflibercept, or triamcinolone acetonide in 1 eye.

METHODS

Participants were randomized equally to receive either a single drop of nepafenac 0.3%, a pressure patch for 2 hours, or a single drop of preservative-free artificial tears (control group). A single-blinded placebo-controlled design was used to mask the topical treatment used. Pain was assessed using the Numeric Pain Rating Scale that ranged from 0 to 10 (horizontal pain scale). Because pain scores were not normally distributed, statistical analysis was performed using a nonparametric randomization-based analysis of covariance.

MAIN OUTCOME MEASURE

Pain scores.

RESULTS

Fifty-six and 53 patients of the 60 patients enrolled completed the 6- and 24-hour follow-ups, respectively. Numeric Pain Rating Scale scores at 6 and 24 hours after IVI were lower in the nepafenac group (0.8±0.3 and 0.1±0.1, respectively; n = 18) and the patching group (1.3±0.4 and 0.4±0.2, respectively; n = 19) compared with the control group (2.5±0.6 and 0.9±0.4, respectively; n = 19). After controlling for age, gender, number of prior injections, and physician administering the injection, patients in the nepafenac group reported significantly lower pain scores than those in the control group at 6 hours (1.3±0.6 less; P = 0.047) and 24 hours (0.7±0.3 less; P = 0.047). Although the patching group reported lower pain scores than the control group, this was not statistically significant (6 hours, P = 0.24; 24 hours, P = 0.29).

CONCLUSIONS

Nepafenac 0.3% was effective as a single drop in reducing pain at 6 and 24 hours after IVI compared with placebo. Limited patching was associated with lower pain scores than placebo, but the difference was not statistically significant. Additional studies are needed to determine the most effective method to maximize the patient's experience after an IVI without sacrificing outcomes.

Bundling Interventions to Enhance Pain Care Quality (BITE Pain) in Medical Surgical Patients

Background: Inadequate pain management and undertreatment remain a serious clinical issue among hospitalized adults, contributing to chronic pain syndromes and opioid dependency. Implementation of individual pain care interventions has been insufficient to improve pain care quality. The purpose of this interprofessional, patient-centered project was to implement a 6-component bundle of evidence-based pain management strategies to improve patients' perception of pain care quality and 24-hour pain experience outcomes. Methods: A quasi-experimental design was used to test the effect of a bundled pain management intervention on 3 medical surgical units. Baseline outcomes using the Pain Care Quality-Interdisciplinary (PainCQ-I^©) and Pain Care Quality-Nursing (PainCQ-N^©) surveys were measured monthly for 4 months preintervention and 30 months postintervention. Results: A convenience sample of 846 patients was analyzed. The effect of the intervention on pain outcomes could not be tested because unit-based adherence did not meet the goal of 80%. A subsample of 70.2% (594/846) of participants was sufficient to complete a 3-group analysis of preintervention and postintervention participants with confirmed intervention adherence. Participants in the postintervention group who received all 6 components (n=65) had significantly higher odds of higher PainCQ^© scores than those in the preintervention group (n=141) (PainCQ-I^©: odds ratio [OR] 2.61, 95% confidence interval [CI] 1.54-4.42; PainCQ-N^©: OR 3.82, 95% CI 2.06-7.09) or those in the postintervention group receiving ≤5 components (n=388) (PainCQ-I^©: OR 2.52, 95% CI 1.57-4.03; PainCQ-N^©: OR 3.84, 95% CI 2.17-6.80). Conclusion: Medical surgical patients participating in this study who received the bundled 6-component intervention reported significantly higher levels of perceived pain care quality, suggesting that a bundled approach may be more beneficial than unstandardized strategies.

Optimizing the Patient Experience during Breast Biopsy

For years, breast imaging has been the model in radiology for patient communication, and more recently, it has been a leader in the growing patient- and family-centered approach to care. To maintain high levels of patient satisfaction during image-guided core-needle breast biopsies, the radiologist should understand patient perspectives so that interventions can be developed to manage patient concerns. This article reviews patient perspectives before, during, and after imaging-guided breast biopsies, and it describes strategies to help optimize the experiences of patients as they navigate the process.

Addressing the Opioid Crisis One Surgical Patient at a Time: Outcomes of a Novel Perioperative Pain Program

Opioid prescriptions in the surgical setting have been implicated as contributors to the opioid epidemic. The authors hypothesized that a multidisciplinary approach to perioperative pain management for patients on chronic opioid therapy could decrease postoperative opioid requirements while reducing postoperative pain scores and improving functional outcomes. Therefore, a Perioperative Pain Program (PPP) for chronic opioid users was implemented. This study presents outcomes from the first 9 months of the PPP. Sixty-one patients met the inclusion criteria. Opioid consumption in morphine milligram equivalent (MME) was calculated and physical and health status of patients was assessed with the Brief Pain Inventory, Short-Form McGill Pain Questionnaire, and Short Form-12. Preliminary results showed significant reduction in MME, improved pain scores, and improved function for surgical patients on chronic opioids. PPP effectively reduced opioid usage without negatively influencing patient-reported outcomes, such as physical pain score assessment and health-related quality of life.

Pain process of patients with cardiac surgery-Semantic annotation of electronic patient record data

AIMS AND OBJECTIVES

To describe and compare the pain process of the patients' with cardiac surgery through nurses' and physicians' documentations in the electronic patient records.

BACKGROUND

Postoperative pain assessment and management should be documented regularly, to ensure optimal pain care process for patients. Despite availability of evidence-based guidelines, pain assessment and documentation remain inadequate.

DESIGN

A retrospective patients' record review.

METHODS

The original data consisted of the electronic patient records of 26,922 patients with a diagnosed heart disease. A total of 1,818 care episodes of patients with cardiac surgery were selected from the data. We used random sampling to obtain 280 care episodes for annotation. These 280 care episodes contained 2,156 physician reports and 1,327 days of nursing notes. We developed an annotation manual and schema, and then, we manually conducted semantic annotation on care episodes, using the Brat annotation tool. We analysed the annotation units using thematic analysis. Consolidated criteria for reporting qualitative research guideline was followed in reporting where appropriate in this study design.

RESULTS

We discovered expressions of six different aspects of pain process: (a) cause, (b) situation, (c) features, (d) consequences, (e) actions and (f) outcomes. We determined that five of the aspects existed chronologically. However, the features of pain were simultaneously existing. They indicated the location, quality, intensity, and temporality of the pain and they were present in every phase of the patient's pain process. Cardiac and postoperative pain documentations differed from each other in used expressions and in the quantity and quality of descriptions.

CONCLUSION

We could construct a comprehensive pain process of the patients with cardiac surgery from several electronic patient records. The challenge remains how to support systematic documentation in each patient.

RELEVANCE TO CLINICAL PRACTICE

The study provides knowledge and guidance of pain process aspects that can be used to achieve an effective pain assessment and more comprehensive documentation.

Analgesic efficacy of modified pectoral block plus serratus plane block in breast augmentation surgery: A randomised, controlled, triple-blind clinical trial

INTRODUCTION

Prosthetic breast surgery is a very common plastic surgery procedure, but its postoperative analgesic management is a challenge for the surgical team. The purpose of the present study is to validate the analgesic efficacy of pectoral block and serratus plane block in retropectoral mammoplasty.

PATIENTS AND METHODS

A randomised, controlled, triple-blind, clinical trial was designed, and included 30 patients undergoing retropectoral augmentation mammoplasty. All of them had a modified PECII block and a serratus plane block with a total volume of 40ml per breast. In 15 of them bupivacaine 0.25% (GPEC) was injected and in the other 15 patients saline was used (GC). Standardised management of anaesthesia and postoperative analgesia was performed. Intra-operative haemodynamic parameters required for postoperative analgesia, and a numeric verbal scale on arrival in the recovery unit were measured and at 3, 6, and 24h. The quality perceived by patients and surgeons was also measured.

RESULTS

Post-operative pain was significantly better in GPEC (5.3±2.3 vs. 2.9±2.7; P=.018). No significant differences were observed at 3, 6, and 24h. The surgeons rated the anaesthetic-analgesic quality as very good in 80% of the cases in GPEC versus 33% in CG (P=.01).

CONCLUSIONS

The use of these blocks is a good perioperative analgesic strategy in the multimodal management of retropectoral augmentation mammoplasty.

Quality Improvement Initiative to Improve Postoperative Pain with a Clinical Pathway and Nursing Education Program

BACKGROUND AND AIMS

We created a multicomponent intervention to improve pain management in the immediate postoperative period with the goal of improving the quality of patient recovery.

DESIGN

A multicomponent intervention to improve pain management in the immediate postoperative period with the goal of improving the quality of patient recovery.

SETTINGS

Pain management education of postanesthesia recovery room nurses through a practical intervention has the potential to improve patient pain experience, especially in those with a history of opioid tolerance.

PARTICIPANTS/SUBJECTS

Postanesthesia recovery nurses/postanesthesia patients.

METHODS

The intervention included two components: a clinical pain pathway on multimodal analgesia for both opioid-naïve and opioid-tolerant patients undergoing surgery and an educational program on pain management for frontline clinical nurses in the postanesthesia care unit (PACU). We measured the intervention's impact on time to pain relief, PACU length of stay, and patient satisfaction with pain management, as measured by self-report.

RESULTS

Patient PACU surveys indicated a decrease in the percent of patients with opioid tolerance who required more than 60 minutes to achieve adequate pain relief (from 32.7% preintervention to 21.3% postintervention). Additionally, after the intervention, the average time from a patient's PACU arrival to his or her discharge criteria being met decreased by 53 minutes and PACU stay prolongation as a result of uncontrolled pain for opioid-tolerant patients decreased from 45.2% to 25.7%. The sample size was underpowered to perform statistical analysis of this improvement.

CONCLUSIONS

After the combined intervention of a clinical pain pathway and interactive teaching workshop, we noted shortened PACU length of stay, reduced time to reach pain control, and improved overall patient satisfaction. Although we could not determine statistical significance, our findings suggest improved management of acute postoperative pain, especially for patients who are opioid tolerant. Because of the paucity of data, we were not able to conduct the analysis needed to evaluate quality improvement projects, as per SQUIRE 2.0. could be adopted by any institution.

Inpatient Pain Medication Administration: Understanding the Process and Its Delays

BACKGROUND

A patient's impression of quality of care is strongly influenced by pain management.

MATERIALS AND METHODS

We sought to understand the process of pro re nata (PRN) pain medication administration through direct observation and use of timestamped data from the electronic medical record (EMR). The total time from nurse notification to administration was compared between PRN narcotics, non-narcotic pain, and nonpain medications.

RESULTS

We noted two pathways: patient-initiated requests and nurses preemptively asking about pain. We observed 44 instances of PRN medication administration (33 narcotics, 5 non-narcotics, 6 nonpain). Patients waited a median of 14.5 min for all PRN medications, interquartile range 6.5, 36. There was no significant difference in times for the patient-initiated pathway (n = 39, median 15 min, [7, 40]) compared to preemptive rounding (n = 5, 10 min [5, 30]), P = 0.88. Narcotics (median 14 min, [5, 30]) did not take longer than non-narcotic (11, [10, 88]) or nonpain medications (19.5, [11, 40]), P = 0.75. Electronic medical record data included only the time from medication retrieval to administration, which took approximately 5 min for all medications.

CONCLUSIONS

Medication administration is complex, comprising multiple vital steps. The findings of this study suggest opportunities for process improvement that may enhance the experience and overall satisfaction of the surgical patient.

Current pain prescribing habits for common shoulder operations: a survey of the American Shoulder and Elbow Surgeons membership

BACKGROUND

Orthopedic surgeons are among the highest prescribers of narcotic pills, and no guidelines currently exist for appropriate management of postoperative pain within this field. The purpose of this study was to gain understanding of the current pain management strategies used perioperatively and postoperatively among orthopedic shoulder surgeons.

METHODS

Members of the American Shoulder and Elbow Surgeons were e-mailed an online survey regarding methods for managing pain in the perioperative and postoperative setting for total shoulder arthroplasty, labral and capsular stabilization procedures, and rotator cuff repair. Postoperative narcotic prescribing amounts were converted into oral morphine equivalents.

RESULTS

The survey response rate was 25.8% (170/658), with >90% of surgeons reporting use of a standard pain management regimen in the perioperative and postoperative periods. A regional nerve block was used on the operative day by >80% of surgeons for all 3 procedures. Short-acting narcotics are prescribed for postoperative pain control by >85% of surgeons, with long-acting narcotics provided by <14%. More than 400 oral morphine equivalents of short-acting narcotic are prescribed by shoulder surgeons. Referral to a pain specialist or primary care physician is made after 12 weeks by 92.3% of surgeons if patients continue to require narcotic painkillers.

CONCLUSION

The majority of shoulder surgeons use a standard pain management protocol in perioperative and postoperative settings. Regimens frequently include a regional nerve block, nonsteroidal anti-inflammatory drugs, and short-acting oral narcotics. Findings from this study provide guidelines on standard pain management strategies for common shoulder operations based on expert opinion.

An Innovative Perioperative Pain Program for Chronic Opioid Users: An Academic Medical Center’s Response to the Opioid Crisis

Increased utilization of prescription opioids for pain management has led to a nationwide public health crisis with alarming rates of addiction and opioid-related deaths. In the surgical setting, opioid prescriptions have been implicated as a contributing factor to the opioid epidemic. The authors developed an innovative model to address aspects of pain management and opioid utilization during preoperative evaluation, acute surgical hospitalization, and postoperative follow-up for chronic opioid users. This program involves multidisciplinary teams that include acute and chronic pain specialists, psychiatrists, integrative medicine specialists, and physical medicine and rehabilitation services. It also features a novel infrastructure for triage and pain management education and treatment. Individualized patient plans are devised that can include preoperative opioid weaning, regional anesthesia that minimizes opioid use, and multimodal techniques for surgical pain treatment. Multidisciplinary programs such as this have the potential to both improve perioperative pain control and prevent escalation of opioid use among chronic opioid users.

Key drivers of patient satisfaction in lumbar spine surgery

OBJECTIVE The Patient Experience of Care, composed of 9 dimensions derived from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, is being used by the Centers for Medicare & Medicaid Services to adjust hospital reimbursement. Currently, there are minimal data on how scores on the constituent HCAHPS items impact the global dimension of satisfaction, the Overall Hospital Rating (OHR). The purpose of this study was to determine the key drivers of overall patient satisfaction in the setting of inpatient lumbar spine surgery. METHODS Demographic and preoperative patient characteristics were obtained. Patients selecting a top-box score for OHR (a 9 or 10 of 10) were considered to be satisfied with their hospital experience. A baseline multivariable logistic regression model was then developed to analyze the association between patient characteristics and top-box OHR. Then, multivariable logistic regression models adjusting for patient-level covariates were used to determine the association between individual components of the HCAHPS survey and a top-box OHR. RESULTS A total of 453 patients undergoing lumbar spine surgery were included, 80.1% of whom selected a top-box OHR. Diminishing overall health status (OR 0.63, 95% CI 0.43-0.91) was negatively associated with top-box OHR. After adjusting for potential confounders, the survey items that were associated with the greatest increased odds of selecting a top-box OHR were: staff always did everything they could to help with pain (OR 12.5, 95% CI 6.6-23.7), and nurses were always respectful (OR 11.0, 95% CI 5.3-22.6). CONCLUSIONS Patient experience of care is increasingly being used to determine hospital and physician reimbursement. The present study analyzed the key drivers of patient experience among patients undergoing lumbar spine surgery and found several important associations. Patient overall health status was associated with top-box OHR. After adjusting for potential confounders, staff always doing everything they could to help with pain and nurses always being respectful were the strongest predictors of overall satisfaction in this population. These findings highlight opportunities for quality improvement efforts in the spine care setting.

Pain Management After Outpatient Foot and Ankle Surgery

BACKGROUND

The number of opioids prescribed and used has increased precipitously over the past 2 decades for a number of reasons and has led to increases in long-term dependency, opioid-related deaths, and diversion. Most studies examining the role of prescribing habits have investigated nonoperative providers, although there is some literature describing perioperative opioid prescription and use. There are no studies looking at the number of pills consumed after outpatient foot and ankle surgeries, nor are there guidelines for how many pills providers should prescribe. The purpose of this study was to quantify the number of narcotic pills taken by opioid-naïve patients undergoing outpatient foot and ankle surgeries with regional anesthesia.

METHODS

Eighty-four patients underwent outpatient foot and ankle surgeries under spinal blockade and long-acting popliteal blocks. Patients were given 40 or 60 narcotic pills, a 3-day supply of ibuprofen, deep vein thrombosis prophylaxis, and antiemetics. Patients received surveys at postoperative day (POD) 3, 7, 14, and 56 documenting if they were still taking narcotics, the quantity of pills consumed, whether refills were obtained, their pain level, and their reason for stopping opioids.

RESULTS

Patients consumed a mean of 22.5 pills, with a 95% confidence interval from 18 to 27 pills. Numerical Rating Scale pain scores started at 4 on POD 3 and decreased to 1.8 by POD 56. The percentage of patients still taking narcotics decreased from 55% on POD 3 to 2.8% by POD 56. Five new prescriptions were given during the study, with 3 being due to side effects from the original medication.

CONCLUSIONS

Patients receiving regional anesthesia for outpatient foot and ankle surgeries reported progressively lower pain scores with low narcotic use up to 56 days postoperatively. We suggest that providers consider prescribing 30 pills as the benchmark for this patient population.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Tobacco use predicts a more difficult episode of care after anatomic total shoulder arthroplasty

BACKGROUND

In the current health care environment, it is becoming increasingly important to recognize risks factors that may affect a patient's postoperative outcome. To determine the potential impact of tobacco as a risk factor, we evaluated postoperative pain, narcotic use, length of stay, reoperations, and complications in the global 90-day episode of care for patients undergoing anatomic total shoulder arthroplasty (TSA) who were current tobacco users, former users, or nonusers.

METHODS

Database search identified 163 patients with primary anatomic TSA done for glenohumeral arthritis; these were divided into 3 groups: current tobacco users (28), nonusers (88), and former users (47). All surgeries were done with the same technique and implants.

RESULTS

Patients in the current tobacco use group had significantly higher visual analog scale scores preoperatively and at 12 weeks postoperatively than nonusers and former users. Mean improvement in visual analog scale scores was significantly less in current tobacco users. Cumulative oral morphine equivalent use at 12 weeks was significantly higher in current tobacco users than in nonusers and former users. The average oral morphine equivalent per day was also significantly higher in the current tobacco users than in nonusers and former users. There were no significant differences in length of stay or complications.

CONCLUSIONS

Although length of stay, complication rates, hospital readmissions, and reoperation rates were not significantly different, tobacco users reported increased postoperative pain and narcotic use in the global period after TSA. Former tobacco users were found to have a postoperative course similar to that of nonusers, suggesting that discontinuation of tobacco use can improve a patient's episode of care performance after TSA.

Hospital consumer assessment of healthcare providers and systems scores relating to pain following the incorporation of clinical pharmacists into patient education prior to joint replacement surgery

Background:

Pharmacist involvement has been shown to improve various aspects of patient care. Patients undergoing knee and hip replacement surgery generally experience post-operative pain and discomfort. Pain control can impact patient satisfaction, as reported by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

Objective:

The current pilot study aims to measure the potential impact that incorporating pharmacists into preoperative patient education programs has on the response to select HCAHPS questions.

Methods:

Patient responses to two select HCAHPS questions related to pain were recorded for a year prior to pharmacist involvement in a comprehensive preoperative patient education program (2012) and a year after pharmacists became actively involved (2013).

Results:

In all reporting surgical patients, there was a modest 3.68% improvement in mean scores reflecting patient’s feelings that hospital staff did “everything they could” to attend to their pain (mean₂₀₁₂=3.66, SD=0.63 versus mean₂₀₁₃=3.80, SD=0.43, p=0.018, Mann-Whitney U test). There was a non-significant 2.98% improvement in scores reflecting the level that pain was “well controlled” (mean₂₀₁₂=3.54, SD=0.651 versus mean₂₀₁₃=3.65, SD=0.554, p=0.069, Mann-Whitney U test) in surgical patients.

Conclusion:

The results suggest comprehensive pharmacist involvement in patient education prior to joint replacement surgery may impact HCAHPS scores related to pain control. While the observed potential improvements were modest, the current results justify larger, multi-institution prospective studies to better elucidate the impact pharmacists can have on pain management in patients undergoing joint replacement.

Characterizing the pain score trajectories of hospitalized adult medical and surgical patients: a retrospective cohort study

Pain care for hospitalized patients is often suboptimal. Representing pain scores as a graphical trajectory may provide insights into the understanding and treatment of pain. We describe a 1-year, retrospective, observational study to characterize pain trajectories of hospitalized adults during the first 48 hours after admission at an urban academic medical center. Using a subgroup of patients who presented with significant pain (pain score >4; n = 7762 encounters), we characterized pain trajectories and measured area under the curve, slope of the trajectory for the first 2 hours after admission, and pain intensity at plateau. We used mixed-effects regression to assess the association between pain score and sociodemographics (age, race, and gender), pain medication orders (opioids, nonopioids, and no medications), and medical service (obstetrics, psychiatry, surgery, sickle cell, intensive care unit, and medicine). K-means clustering was used to identify patient subgroups with similar trajectories. Trajectories showed differences based on race, gender, service, and initial pain score. Patients presumed to have dissimilar pain experiences (eg, sickle vs obstetrical) had markedly different pain trajectories. Patients with higher initial pain had a more rapid reduction during their first 2 hours of treatment. Pain reduction achieved in the 48 hours after admission was approximately 50% of the initial pain, regardless of the initial pain. Most patients' pain failed to fully resolve, plateauing at a pain score of 4 or greater. Visualizing pain scores as graphical trajectories illustrates the dynamic variability in pain, highlighting pain responses over a period of observation, and may yield new insights for quality improvement and research.

Postoperative Visual Analog Pain Scores and Overall Anesthesia Patient Satisfaction

Patient satisfaction is evolving into an important measure of high-quality health care and anesthesia care is no exception. Pain management is an integral part of anesthesia care and must be assessed to determine patient satisfaction; therefore, it is a measure for quality of care. One issue is how patients reflect individual experiences into their overall anesthesia experience. There is a need to identify how postoperative pain scores correlate with anesthesia patient satisfaction survey results. Postoperative pain is not a dominant measure in determining anesthesia patient satisfaction.

Using Quality Improvement Methods to Improve Patient Experience

Patient experience is an important component of the overall medical encounter. This paper explores how patient experience is measured and its role in radiology, including its impact on clinical outcomes and reimbursement. Although typically applied to safety and clinical outcomes, quality improvement methodology can also be used to drive improvement efforts centered on patient experience. Applying an established framework for patient-centered care to radiology, this paper provides a number of examples of projects that are likely to yield significant improvement in patient satisfaction measures.

Does Acupressure Hit the Mark? A Three-Arm Randomized Placebo-Controlled Trial of Acupressure for Pain and Anxiety Relief in Athletes With Acute Musculoskeletal Sports Injuries

OBJECTIVES

Injuries are a common consequence of sports and recreational activity. The optimal management of symptoms is a crucial element of sports injury management. Acupressure has previously been shown to effectively decrease symptoms of musculoskeletal injury, thus may be considered a potentially useful intervention in the management of sport-related injuries. Therefore, this study was conducted to examine the effectiveness of acupressure in decreasing pain and anxiety in acutely injured athletes.

DESIGN

A prospective 3-arm randomized placebo-controlled trial.

SETTING

A sports injury clinic, Dunedin, New Zealand.

PATIENTS

Seventy-nine athletes who sustained a sport-related musculoskeletal injury on the day.

INTERVENTION

Three minutes of either acupressure, sham acupressure, or no acupressure.

MAIN OUTCOME MEASURES

The primary outcomes of pain and anxiety intensity were measured before and immediately after the intervention on a 100-mm visual analog scale (VAS). Pain and anxiety relief, satisfaction with treatment, willingness to repeat a similar treatment, and belief in the effect of acupressure were secondary outcomes measured on Likert scales after the intervention.

RESULTS

The acupressure group reported 11 mm less pain (95% CI: 5-17) on average than the sham acupressure group, and 9 mm less (95% CI: 3-16) than the control group as a result of the intervention (P < 0.05). There was no difference between groups in: anxiety levels, or in any of the secondary outcome measures.

CONCLUSIONS

Three minutes of acupressure was effective in decreasing pain intensity in athletes who sustained an acute musculoskeletal sports injury when measured on the VAS, but did not change anxiety levels.

Non-opioid pain management in benign minimally invasive hysterectomy: A systematic review

BACKGROUND

Less postoperative pain typically is associated with a minimally invasive hysterectomy compared with a laparotomy approach; however, poor pain control can still be an issue. Multiple guidelines exist for managing postoperative pain, yet most are not specialty-specific and are based on procedures that bear little relevance to a minimally invasive hysterectomy.

OBJECTIVE

The purpose of this study was to determine whether there is enough quality evidence within the benign gynecology literature to make non-opioid pain control recommendations for women who undergo a benign minimally invasive hysterectomy.

STUDY APPRAISAL AND SYNTHESIS METHODS

We queried PubMed, ClinicalTrials.gov, and Cochrane databases using MeSH terms: "postoperative pain," "perioperative pain," "postoperative analgesia," "pain management," "pain control," "minimally invasive gynecologic surgery," and "hysterectomy." A manual examination of references from identified studies was also performed. All PubMed published studies that involved minimally invasive hysterectomies through November 9, 2016, were included. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were restricted to benign minimally invasive hysterectomies evaluating non-opioid pharmacologic therapies. Primary outcomes included amount of postoperative analgesics consumed and postoperative pain scores. Two reviewers independently completed an in-depth evaluation of each study for characteristics and results using an established database, according to inclusion/exclusion criteria. A risk assessment was performed, and a quality rating was assigned with the use of the Cochrane Collaboration's Grades of Recommendation, Assessment, Development and Evaluation approach.

RESULTS

Initially 1155 studies were identified, and 24 studies met all inclusion criteria. Based on limited data of varying quality, intravenous acetaminophen, anticonvulsants and dexamethasone demonstrate opioid-sparing benefits; ketorolac shows mixed results in laparoscopic hysterectomies. Paracervical blocks provide pain-reducing benefits in vaginal hysterectomies.

CONCLUSIONS

Convincing conclusions are difficult to draw because of the heterogeneous and contradictory nature of the literature. There is a clear need for more high-quality research that will evaluate each medication type for posthysterectomy pain control.

Naloxone Triggering the RRT: A Human Antidote?

OBJECTIVES

At our institution, we observed an increase in opioid-related adverse events after instituting a new pain treatment protocol. To prevent this, we programmed the Omnicell drug dispensing system to page the RRT whenever naloxone was withdrawn on the general wards.

METHODS

Retrospective review of a prospectively collected database with a before and after design.

RESULTS

When comparing the two 12-month periods, there was a decrease in monthly opioid-related cardiac arrests from 0.75 to 0.25 per month (difference = 0.5; 95% CI, 0.04-0.96, P = 0.03) and a nearly significant decrease in code deaths from 0.25 to 0 per month (difference = -0.25; 95% CI, -0.02-0.52, P = 0.07) without a significant decrease in pain satisfaction scores (difference = -2.3; 95% CI, -4.4 to 9.0, P = 0.48) over the study period. There were also decreased RRT interventions from 7.3 to 5.6 per month (difference = -1.7; 95% CI, -0.31 to -3.03, P = 0.02) and decreased inpatient transfers from 2.9 to 1.8 transfers per month (difference = -1.2; 95% CI, -0.38 to -1.96, P = 0.005). When adjusting for inpatient admissions and inpatient days, there was a decrease in opioid-related cardiac arrests from 2.9 to 0.1 per 10,000 admissions (difference = -2.0; 95% CI, -0.2 to -3.8, P = 0.03) and a decrease in cardiac arrests from 0.5 to 0.2 per 10,000 patients (difference = -0.34; 95% CI, -.02 to -0.65, P = 0.04).

CONCLUSION

Naloxone-triggered activation of the RRT resulted in reduced opioid-related inpatient cardiac arrests without adversely affecting pain satisfaction scores.

Cancer pain: a review of epidemiology, clinical quality and value impact

Cancer-related pain, reported by more than 70% of patients, is one of the most common and troublesome symptoms affecting patients with cancer. Despite the availability of effective treatments, cancer-related pain may be inadequately controlled in up to 50% of patients. With the growing focus on ‘value’ (healthcare outcomes achieved per dollar spent) in healthcare, the management of cancer-related pain has assumed novel significance in recent years. Data from initiatives that assess the quality of pain management in clinical practice have shown that effective management of cancer-related pain improves patient-perceived value of cancer treatment. As a result, assessment and effective management of cancer-related pain are now recognized as important measures of value in cancer care.

Unused Opioid Pills After Outpatient Shoulder Surgeries Given Current Perioperative Prescribing Habits

BACKGROUND

In the past 16 years, the number of prescription opioids sold in the United States, as well as deaths from prescription opioids, has nearly quadrupled. However, the overall amount of pain reported by patients has not changed significantly. Specific information about opioid prescriptions in the perioperative period is lacking. Of the studies that have been published, investigators have shown that the majority of patients have unused postoperative opioid pills. Moreover, patients appear to lack information about disposal of unused opioid pills.

PURPOSE

To compare the number of pills prescribed versus the numbers left unused after outpatient shoulder surgeries at an orthopaedic surgery institution.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

In this prospective, observational study, 100 patients (age >18 years) undergoing outpatient shoulder surgery (rotator cuff repair, labral repair, stabilization/Bankart repair, debridement) were enrolled. Follow-ups were conducted via surveys on postoperative days (PODs) 7, 14, 28, and 90. The primary outcome was the number of unused pills from the originally prescribed medication.

RESULTS

For all procedure types, the median (Q1, Q3) number of prescribed pills was 60 (40, 80). On POD 90, patients reported a median (Q1, Q3) of 13 (0, 32) unused pills; patients who underwent rotator cuff repairs had the lowest number of pills remaining (median [Q1, Q3], 0 [0, 16]), whereas patients who had stabilization/Bankart repairs had the highest number of unused pills (median [Q1, Q3], 37 [29, 50]). Patient satisfaction with pain management ranged from an average of 70% to 90%. Only 25 patients received instructions or education about opioid disposal.

CONCLUSION

Most outpatient shoulder surgery patients who underwent certain operations were prescribed more opioid analgesics than they consumed. Patient education regarding the disposal of opioids was lacking.

Advice to Quit Smoking and Ratings of Health Care among Medicare Beneficiaries Aged 65

OBJECTIVE

To examine the relationship between physician advice to quit smoking and patient care experiences.

DATA SOURCE

The 2012 Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) surveys.

STUDY DESIGN

Fixed-effects linear regression models were used to analyze cross-sectional survey data, which included a nationally representative sample of 26,432 smokers aged 65+.

PRINCIPAL FINDINGS

Eleven of 12 patient experience measures were significantly more positive among smokers who were always advised to quit smoking than those advised to quit less frequently. There was an attenuated but still significant and positive association of advice to quit smoking with both physician rating and physician communication, after controlling for other measures of care experiences.

CONCLUSIONS

Physician-provided cessation advice was associated with more positive patient assessments of their physicians.

Validation of the scale on Satisfaction of Adolescents with Postoperative pain management - idiopathic Scoliosis (SAP-S)

Background

Spinal fusion is a common orthopedic surgery in children and adolescents and is associated with high pain levels postoperatively. If the pain is not well managed, negative outcomes may ensue. To our knowledge, there is no measure in English that assesses patient’s satisfaction with postoperative pain management following idiopathic scoliosis surgery. The aim of the present study was to assess the psychometric properties of the satisfaction subscale of the English version of the Satisfaction of Adolescents with Postoperative pain management – idiopathic Scoliosis (SAP-S) scale.

Methods

Eighty-two participants aged 10–18 years, who had undergone spinal fusion surgery, fully completed the SAP-S scale at 10–14 days postdischarge. Construct validity was assessed through a principal component analysis using varimax rotation.

Results

Principal component analysis indicated a three-factor structure of the 13-item satisfaction subscale of the SAP-S scale. Factors referred to satisfaction regarding current medication received (Factor 1), actions taken by nurses and doctors to manage pain (Factor 2) and information received after surgery (Factor 3). Cronbach’s alpha was 0.91, showing very good internal consistency. Data on satisfaction and clinical outcomes were also reported.

Conclusion

The SAP-S is a valid and reliable measure of satisfaction with postoperative pain management that can be used in both research and clinical settings to improve pain management practices. Although it was developed and validated with adolescents who had undergone spinal fusion surgery, it can be used, with further validation, to assess adolescents’ satisfaction with pain management in other postoperative contexts.