The impact of the COVID-19 pandemic on patients awaiting spinal cord stimulation surgery in the United Kingdom: a multi-centre patient survey

Development and Feasibility Study of a Triage Tool for Early Referral to Spinal Cord Stimulation for Patients With Chronic Low Back and Leg Pain

BACKGROUND

In recent years, delayed elective care and growing waiting lists increasingly resulted in postponed surgeries for patients with chronic back and leg pain.

OBJECTIVE

To develop, implement, and evaluate the feasibility of a triage tool for patients with chronic back and/or leg pain to identify those eligible for referral to spinal cord stimulation (SCS) consultation.

METHODS

A triage tool was developed, based on Dutch SCS guidelines, literature review and expert panel consultation. The triage process was detected and implemented in collaboration with a multidisciplinary team, prior to first orthopaedic consultation. Feasibility, reliability and predictive accuracy were analysed as part of the evaluation of the triage tool.

RESULTS

The triage indicators included: Pain location (leg/mixed), DN4 > 3, pain duration ≥ 3 months, leg pain ≥ back pain and NPRS leg pain ≥ 5. The triage tool was applied on patients on the orthopaedic waiting list, followed by a full orthopaedic review if they were not excluded. A total of 1025 orthopaedic patients with chronic back and leg pain were assessed with the triage tool. The triage tool was evaluated as feasible (mean System Usability Score 74.2 [SD 11.5]), reliable (inter-rater reliability [Fleiss' Kappa 0.79], intra-rater reliability [Cohen's Kappa 0.89]) and accurate (sensitivity [100%], specificity [98.8%], positive predictive value [40%] and negative predictive value [100%]).

CONCLUSION

Early triage of potential SCS candidates potentially supports rapid and appropriate care allocation, shortens waiting list time and improves clinical outcomes. Future research should explore strategies to optimise the tool's performance in identifying patients most likely to benefit from SCS therapy.

SIGNIFICANCE

A novel triage tool was developed to identify patients with chronic back and leg pain for an early referral to SCS. This tool, evaluated for feasibility, reliability, and predictive accuracy, shows promise in reducing waiting times and improving patient selection. It can be a prelude to the further development of decision support for SCS and an acceleration in the care process for SCS candidates.

Incidence of Infections, Explantations, and Displacements/Mechanical Complications of Spinal Cord Stimulation During the Past Eight Years

OBJECTIVES

The overall awareness and potential of real-world data have drastically increased in the medical field, with potential implications for postmarket medical device surveillance. The goal of this study was to evaluate real-world data on incidence of infections, explantations, and displacements/mechanical complications of spinal cord stimulation (SCS) during the past eight years and to forecast point estimates for the upcoming three years on the basis of the identified patterns.

MATERIALS AND METHODS

Based on electronic health records from 80 healthcare organizations within the TriNetX data base in the USA, data of 11,934 patients who received SCS as treatment for persistent spinal pain syndrome type 2 (PSPS T2) were extracted. Events of interest were explantations and displacements/mechanical complications of both the lead and implanted pulse generator (IPG), in addition to infection rates from 2015 to 2022. Mann-Kendall tests were performed to detect monotonic trends in the time series. Forecasts were conducted for the upcoming three years for every event of interest.

RESULTS

Statistically significant increasing time trends were revealed for the annual incidence of IPG and lead displacements/mechanical complications in patients with PSPS T2 over the past eight years. These time trends were visible in both male and female patients and in smokers and nonsmokers. For annual incidence of explantations and infections, no significant time effect was observed. In 2025, the incidence of displacements/mechanical complications of the lead (3.07%) is predicted to be the highest, followed by explantations of the IPG (2.67%) and lead (2.02%).

CONCLUSIONS

Based on real world data, device explantation was the most frequent event of interest, with negative peaks in the time series in 2016 and 2020, presumably due to the introduction of rechargeable pulse generators and to the COVID-19 pandemic, respectively.

Social support and mental well-being among people with and without chronic illness during the Covid-19 pandemic: evidence from the longitudinal UCL covid survey

PURPOSE

An immediate research priority recovering from the COVID-19 pandemic is well-being among some of our most vulnerable-people with chronic illness. We studied how mental health changed among people with and without chronic illness throughout the pandemic and the mediating role of social support.

METHODS

We used the 3-waves of COVID-19 survey within the Millennium Cohort Study (MCS, age 19, N = 5522) and MCS Parent (MCSP, age > > 19, N = 7479) samples, with additional pre-pandemic measures of some outcomes and exposure. Using Structural Equation Panel Models with Full Information Maximum Likelihood estimation to address missing data, we studied differences between respondents with a chronic illness and without, regarding depressive symptoms and mental well-being, with social provision, social support, and loneliness as potential mediators.

RESULTS

Mental well-being (SWEMWBS) and psychological distress (Kessler-6) worsened significantly during the pandemic relative to baseline for people with and without chronic illness, while the latter group had substantially better well-being at all waves and the baseline regarding both outcomes. When the lockdown was lifted during wave-2, mental well-being temporarily rebounded, and distress waned among people without chronic illness but continued to worsen among people with chronic illness. Social support partially mediated the link between chronic illness and mental well-being.

CONCLUSIONS

The large mental well-being gap between people with and without chronic illness persisted during the pandemic. However, social support and provision can partially narrow this gap, hence should be employed in future pandemic management.

The Diagnostic Odyssey of Patients with Chronic Neuropathic Pain-Expert Opinion of Greek Pain Specialists

The diagnosis of chronic neuropathic pain requires a laborious process and can be a very long journey for the patients, one that can be characterized as an "odyssey." Our aim was to describe the "diagnostic odyssey" associated with chronic neuropathic pain in the Greek context. Specialized clinicians working at dedicated chronic pain and palliative care centers were asked to participate in a survey regarding the diagnostic process in Greece. In total, 44 respondents provided information on the organization of their centers, the diagnostic process, and the perceived obstacles involved in the diagnosis of chronic neuropathic pain. Most respondents reported that their centers were not fully or efficiently organized and believed that additional specialized healthcare personnel should be employed. Raising public awareness about the existence of such centers was also considered key. The two main obstacles in reaching a diagnosis were the difficulty non-experts had in recognizing chronic neuropathic pain and the lack of acknowledgement that chronic neuropathic pain is a condition that needs to be addressed. When considering these responses in light of the extended socioeconomic burden associated with chronic neuropathic pain, efforts should be made to limit the "diagnostic odyssey" of chronic neuropathic pain in Greece. The aim of this study is to explore the experience of patients with chronic neuropathic pain in Greece from the viewpoint of pain specialists. A better organization of pain and palliative care centers, facilitation of communication with previously treating clinicians, increased personnel, utilization of a chronic pain registry, and guidelines development can aid in this venture. Keypoints: The diagnosis of chronic neuropathic pain in Greece is a laborious and time-consuming process that needs to be refined; Greek clinicians believe that their centers were not fully or efficiently organized and think that additional specialized healthcare personnel should be employed; Patient comorbidities and retards in visiting a clinic at the onset of symptoms delay the diagnosis of neuropathic pain and may complicate subsequent care; The diagnostic delay has been reported as three years between the onset of symptoms and seeking general medical help and another nine years before a referral to a pain specialist; Neuropathic pain is associated with patient distress and socioeconomic burdens, and diagnostic delays prolong the condition, may allow it to worsen, and utilize valuable healthcare resources without providing effective solutions.

Impact of the COVID-19 Pandemic and Lockdown on Non-COVID Neurosurgical Patients: Lessons Learned

Objective The COVID-19 pandemic has challenged the basic functioning of the health care system. There has been an adverse impact on non-COVID-19 patients due to a shift in healthcare delivery, which is underreported. This study aims to explore the impact of the pandemic on various aspects of non-COVID neurosurgical patients.

Methods This descriptive cross-sectional study was conducted with a structured questionnaire to assess the physical, economic, and psychological impacts of the COVID-19 pandemic and lockdown measures on neurosurgical patients presenting to our hospital after a nationwide lockdown.

Results Among 203 patients, non-neurotrauma and neurotrauma cases were 175 (86%) and 28 (16%), respectively. Among non-neurotrauma patients, 130 (64%) patients had cranial pathology. All 56 (27.6%) preoperative patients experienced rescheduling of surgery. Among 52 postsurgical patients, 47 (90%) had their adjuvant therapy delayed. Forty patients experienced deterioration in their neurological symptoms. Seventy-six (37%) patients sought medical attention from private hospitals. A severe contraction of income (≥ 25% of the income before lockdown) was experienced by families of 29 (14.3%) patients. Severe and very severe stress have been experienced by 24 (11.8%) and 14 (6.9%) patients, respectively. Severe and very severe anxiety was experienced by 32 (15.8%) and 9 (4.4%) patients.

Conclusion The COVID-19 pandemic and nationwide lockdown had a tremendous impact on the physical, social, and psychological well-being of patients with non-COVID illnesses. We are yet to face the long-term implications of the delay due to this pandemic in scheduled surgical and adjuvant treatments of non-COVID neurosurgical patients.

Recent Trends in Medicare Utilization and Reimbursement for Spinal Cord Stimulators: 2000-2019

OBJECTIVE

Spinal cord stimulators (SCS) allow spine surgeons to provide relief for patients who suffer from chronic pain due to several disorders, such as failed back surgery syndrome, complex regional pain syndrome, and neuropathy. Despite this, there remains a paucity of data regarding the utilization and reimbursement of SCS. Therefore, the purpose of this study is to evaluate the monetary and procedural trends of spinal cord stimulators among the Medicare database from 2000 to 2019.

METHODS

Medicare Part B National Summary Data files, which are publicly available, were used. These files contain data from the years 2000-2019 on all services billed to Medicare within that time frame. Each service is given a Current Procedural Terminology (CPT) code and the number of times that service was performed, as well as the total physician Medicare charges and reimbursements for each service annually are included in that data set. The CPT codes for percutaneous and open placement of spinal cord stimulators were identified: 63650 and 63655, respectively. The total allowed services allowed charges and actual payments were isolated from the data set for each year for each CPT code. The total allowed charges and actual payments for the year were then divided by the total allowed services to find and trend the allowed charges and actual payment for each individual service performed for both percutaneous and open placement of spinal cord stimulators.

RESULTS

There were 992,372 Medicare-approved total percutaneous spinal cord stimulator operations and 99,736 Medicare-approved total open spinal cord stimulator operations from 2000 to 2019. Medicare paid $1.02 billion (2019 U.S. dollars) in reimbursement to physicians for percutaneous spinal cord stimulator operations and nearly $145 million (2019 U.S. dollars) in reimbursement to physicians for open spinal cord stimulator operations. From the years 2000 to 2019, there was an average 21.9% increase annually in Medicare-approved percutaneous spinal stimulator placement operations and a 18.4% increase annually in Medicare-approved open spinal stimulator placement operations. During this time, there was also an average 8.7% increase annually in Medicare reimbursement per each percutaneous spinal stimulator placement operation and a 9.1% increase annually in Medicare reimbursement per each open spinal stimulator placement operation.

CONCLUSIONS

The results of this study show that the number of percutaneous and open procedures have steadily increased from 2000 to 2019. Reimbursement per procedure has also increased steadily over this time. Identifying these trends is important to promote research into costs of these surgeries and ensure adequate resource allocation.

Impact on neurosurgical management in a Level 1 trauma center post COVID-19 shelter-in-place restrictions

The stringent restrictions from shelter-in-place (SIP) policies placed on hospital operations during the COVID-19 pandemic led to a sharp decrease in planned surgical procedures. This study quantifies the surgical rebound experienced across a neurosurgical service post SIP restrictions in order to guide future hospital programs with resource management. We conducted a retrospective review of all neurosurgical procedures at a public Level 1 trauma center between February 15th to August 30th for the years spanning 2018-2020. We categorized patient procedures into four comparative one-month periods: pre-SIP; SIP; post-SIP; and late recovery. Patient procedures were designated as either cranial; spinal; and other; as well as Elective or Add-on (Urgent/Emergent). Categorical variables were analyzed using χ2 tests and Fisher's exact tests. A total of 347 cases were reviewed across the four comparative periods and three years studied; with 174 and 152 spinal and cranial procedures; respectively. There was a proportional increase; relative to historical controls; in total spinal procedures (p-value < 0.001) and elective spinal procedures (p-value < 0.001) in the 2020 SIP to Post-SIP. The doubling of elective spinal cases in the Post-SIP period returned to historical baseline levels in three months after SIP restrictions were lifted. Total cranial procedures were proportionally increased during the SIP period relative to historical controls (p-value = 0.005). We provide a census on the post-pandemic neurosurgical operative demands at a major public Level 1 trauma hospital, which can potentially be applied for resource allocations in other disaster scenarios.

Lessons from the COVID-19 pandemic to improve the health and social care and wellbeing of minoritised ethnic groups with chronic conditions or impairments: protocol for the mixed methods intersectional asset-based study CICADA (Preprint)

Background

The COVID-19 pandemic has inequitably impacted the experiences of people living with ill health/impairments or from minoritized ethnic groups across all areas of life. Given possible parallels in inequities for disabled people and people from minoritized ethnic backgrounds, their existence before the pandemic and increase since, and the discriminations that each group faces, our interest is in understanding the interplay between being disabled AND being from a minoritized ethnic group.

Objective

The overarching aim of the Coronavirus Chronic Conditions and Disabilities Awareness (CICADA) project, building on this understanding, is to improve pandemic and longer-term support networks, and access to and experiences of care, services, and resources for these underserved groups, both during the pandemic and longer term, thereby reducing inequities and enhancing social, health, and well-being outcomes.

Methods

This mixed methods study involves three “sweeps” of a new UK survey; secondary analyses of existing cohort and panel surveys; a rapid scoping review; a more granular review; and qualitative insights from over 200 semistructured interviews, including social network/map/photo elicitation methods and two subsequent sets of remote participatory research workshops. Separate stakeholder cocreation meetings, running throughout the study, will develop analyses and outputs. Our longitudinal study design enables the exploration of significant relationships between variables in the survey data collected and to the assessment of changes in variables over time, including consideration of varying pandemic contexts. The qualitative data will provide more granular detail. We will take a strengths and assets–based approach, underpinned by the social model of disability and by intersectional considerations to challenge discrimination. Our exploration of the social determinants of health and well-being is framed by the social ecological model.

Results

The CICADA project was funded by the Health and Social Care Delivery Research (HSDR) Programme of the United Kingdom (UK) National Institute for Health and Care Research (NIHR) in March 2021 and began in May 2021. Further work within the project (84 interviews) was commissioned in March 2022, a substudy focusing on mental health, specifically in Northeast England, Greater Manchester, and the Northwest Coast of the United Kingdom. Data collection began in August 2021, with the last participants due to be recruited in September 2022. As of January 2022, 5792 survey respondents and 227 interviewees had provided data. From April 2022, the time of article submission, we will recruit participants for the substudy and wave 2 of the surveys and qualitative work. We expect results to be published by winter 2022.

Conclusions

In studying the experiences of disabled people with impairments and those living with chronic conditions who come from certain minoritized ethnic groups, we are aiming for transformative research to improve their health and well-being.

International Registered Report Identifier (IRRID)

DERR1-10.2196/38361