Creation of a Novel Recuperative Pain Medicine Service to Optimize Postoperative Analgesia and Enhance Patient Satisfaction
Philips BD, Liu SS, Wukovits B, et al.
HSS J. 2009 Sep 17.
Many patients have difficulty with pain control after transition from patient-controlled analgesia modalities to oral analgesics. The creation of a Recuperative Pain Medicine (RPM) service was intended to bridge this gap in pain management at the Hospital for Special Surgery. Specific goals were to improve patient and staff satisfaction with management of postoperative oral analgesics by improving clinical care, administrative policies, and patient and staff education. Primary outcome measures for improved satisfaction were Press Ganey surveys and staff surveys. From inception in Aug 2007 to Dec 2008, RPM has seen 6,305 patients for discharge planning and education and 997 patients for pain management consultation. Administrative and educational accomplishments have included creation of a patient "Helpline" for emergent phone questions regarding postdischarge home pain medications, a policy for prescribing pain medications for home discharge, patient education booklets, a pain management webpage on the Hospital for Special Surgery website, and direct education of staff. Press Ganey measurements of patient satisfaction increased from 87th percentile up to the 99th percentile among peer institutions since the implementation of RPM. Staff satisfaction was 92% positive regarding the RPM service's function and patient management. An RPM appears to be an effective means to optimize postoperative pain management after transition off patient-controlled analgesia devices. Further research is needed to ascertain the exact cost-benefit and potential impact on postoperative quality-of-life measurements.
Documenting and Improving Opioid Treatment: The Prescription Opioid Documentation and Surveillance (PODS) System
Wilsey BL, Fishman SM, Casamalhuapa C, Gupta A.
Pain Med. 2009 Jul 6.
Objective. To demonstrate that a computer-assisted survey instrument offers an efficient means of patient evaluation when initiating opioid therapy.
Design. We report on our experience with the Prescription Opioid Documentation and Surveillance (PODS) System, a medical informatics tool that uses validated questionnaires to collect comprehensive clinical and behavioral information from patients with chronic pain. Setting and Patients. Over a 39-month period, 1,400 patients entered data into PODS using a computer touch screen in a Veterans Administration Pain Clinic. Measures. Indices of pain intensity, function, mental health status, addiction history, and the potential for prescription opioid abuse were formatted for immediate inclusion into the medical record.
Results. The PODS system offers physicians a tool for systematic evaluation prior to prescribing opioids The system generates an opioid agreement between the patient and physician, and provides medicolegal documentation of the patient's condition.
Conclusions. PODS should improve patient care, refine pain control, and reduce the incidence of opioid abuse. Research to determine how PODS affects clinical care is underway. Specially, the effectiveness and efficiency of providing care utilizing PODS will be evaluated in future studies.
Peripheral nerve blocks and trigger point injections in headache management
Ashkenazi A, Blumenfeld A, Napchan U, et al.
Headache. 2010;50(6):943-952.
Interventional procedures such as peripheral nerve blocks (PNBs) and trigger point injections (TPIs) have long been used in the treatment of various headache disorders. There are, however, little data on their efficacy for the treatment of specific headache syndromes. Moreover, there is no widely accepted agreement among headache specialists as to the optimal technique of injection, type, and doses of the local anesthetics used, and injection regimens. The role of corticosteroids in this setting is also debated. We performed a PubMed search of the literature to find studies on PNBs and TPIs for headache treatment. We classified the abstracted studies based on the procedure performed and the treated condition. We found few controlled studies on the efficacy of PNBs for headaches, and virtually none on the use of TPIs for this indication. The most widely examined procedure in this setting was greater occipital nerve block, with the majority of studies being small and non-controlled. The techniques, as well as the type and doses of local anesthetics used for nerve blockade, varied greatly among studies. The specific conditions treated also varied, and included both primary (eg, migraine, cluster headache) and secondary (eg, cervicogenic, posttraumatic) headache disorders. Trigeminal (eg, supraorbital) nerve blocks were used in few studies. Results were generally positive, but should be taken with reservation given the methodological limitations of the available studies. The procedures were generally well tolerated. Evidently, there is a need to perform more rigorous clinical trials to clarify the role of PNBs and TPIs in the management of various headache disorders, and to aim at standardizing the techniques used for the various procedures in this setting.
Adherence to clinical practice guidelines for low back pain in physical therapy: Do patients benefit?
Rutten GM, Degen S, Hendriks EJ, et al.
Phys Ther. 2010 May 20.
Background Various guidelines for the management of low back pain have been developed to enhance the effectiveness and efficiency of care. Evidence that guideline-adherent care results in better health outcomes, however, is not conclusive. Objective The main objective of this study was to assess whether a higher percentage of adherence to the Dutch physical and manual therapy guidelines for low back pain is related to improved outcomes. The study further explored whether this relationship differs for the individual steps of the process of care and for distinct subgroups of patients. Design This was an observational prospective cohort study (2005-2006) in the Netherlands that included a sample of 61 private practice therapists and 145 patients. METHODS:/b> Therapists recorded the process of care and the number of treatment sessions in Web-based patient files. Guideline adherence was assessed using quality indicators. Physical functioning was measured by the Dutch version of the Quebec Back Pain and Disability Scale, and average pain was measured with a visual analog scale. Relationships between the percentage of guideline adherence and outcomes of care were evaluated with regression analyses. RESULTS: /b> Higher percentages of adherence were associated with fewer functional limitations (beta=-0.21, P=.023) and fewer treatment sessions (beta=-0.27, P=.005). Limitations The relatively small self-selected sample might limit external validity, but it is not expected that the small sample greatly influenced the internal validity of the study. Larger samples are required to enable adequate subgroup analyses. CONCLUSIONS:/b> The results indicate that higher percentages of guideline adherence are related to better improvement of physical functioning and to a lower utilization of care. A proper assessment of the relationship between the process of physical therapy care and outcomes may require a comprehensive set of process indicators to measure guideline adherence.
Interventional therapies for the management of cancer pain.
Brogan S, Junkins S.
J Support Oncol. 2010;8(2):52-59.
Timely interventional cancer pain therapies complement conventional pain management by reducing the need for high-dose opioid therapy and its associated toxicity. All patients with upper abdominal visceral pain should be considered for celiac plexus neurolysis soon after diagnosis. Intrathecal therapy should be considered in any patient with moderate-to-severe pain despite a reasonable therapeutic trial of opioid pharmacotherapy or in any patient intolerant of opioid therapy. Specific interventions for vertebral metastases and other sites of metastatic bone pain, including vertebroplasty, kyphoplasty, and image-guided tumor ablation, should be understood and considered. A collaborative model of care, including pain medicine specialists with expertise in interventional therapies, should be standard in all oncologic practices in order to optimize outcomes for patients with cancer throughout the course of their treatment.
Opioids for chronic noncancer pain: a new Canadian practice guideline.
Furlan AD, Reardon R, Weppler C.
CMAJ. 2010;182(9):923-930.
The impact of chronic pain on the health of black and white men.
Green CR, Hart-Johnson T.
J Natl Med Assoc. 2010;102(4):321-331.
Persistent pain, disability, and depression are hallmarks for chronic pain. While disparities based upon race, gender, and class are documented, little is known about pain disparities in minority men. This investigation examines black (6.2%) and white (93.8%) men (N = 1650) presenting for initial assessment at a tertiary care pain center. Racial comparisons utilized analysis of variance; all variables of interest were then placed in a theoretical model using path analysis. The model included race, age, education, neighborhood income, marital status, litigation, substance use, and high blood pressure as predictors and pain, depression, affective distress, posttraumatic stress disorder (PTSD), and disability as outcomes. Black race was associated with lower neighborhood income, education and marriage rates, and higher rates of litigation and high blood pressure. Black men also had higher pain (affective and miscellaneous), disability, and depression. Path analysis found black race was a direct predictor of greater pain, and through pain, was an indirect predictor of depression, affective distress, PTSD, and disability. Path analysis confirmed the complexity of relationships and supported using techniques to understand these relationships. Our data highlight disparities in the pain experience for black men. They also elucidate potential mechanisms through which disparities work in vulnerable and understudied populations.
Consensus guidelines for the selection and implantation of patients with noncancer pain for intrathecal drug delivery.
Deer TR, Smith HS, Cousins M, et al.
Pain Physician. 2010 May-Jun;13(3):E175-213.
Intrathecal therapy offers an invasive alternative for the long-term management of select patients with intractable pain associated with various disease states, including those of noncancer origin. It is commonly accepted that proper patient selection is essential to optimizing treatment outcomes, yet the practice of candidate selection for device implantation varies widely. A multifaceted approach--with consideration of preexisting medical comorbidities; psychological status; associated social, technical, and economic issues; and response to intrathecal trialing--enables practitioners to fully evaluate the appropriateness of implanting a patient with an intrathecal drug delivery system. Yet, to date no standard set of guidelines have been developed to aid practitioners in navigating this evaluation process. Using experience- and knowledge-based expert opinion to systematically evaluate the available evidence, this article provides consensus guidelines aimed at optimizing the selection of patients with noncancer pain for intrathecal therapy. In conclusion, complete assessment of a patient's physical, psychological, and social characteristics, can guide practitioners in determining the appropriateness of initiating intrathecal therapy. These consensus guidelines are intended to assist with weighing this risk/benefit ratio of intrathecal therapy, thereby minimizing the potential for treatment failure, unacceptable adverse effects, and excess mortality.
The pain imaging revolution: advancing pain into the 21st century.
Borsook D, Sava S, Becerra L.
Neuroscientist. 2010 Apr;16(2):171-85.
The great advances in brain imaging techniques over the last few decades have determined a shift in our understanding of chronic pain conditions and opened the door for new opportunities to develop better diagnoses and perhaps better drug treatments. Neuroimaging has helped shape the concept of chronic pain from a disease affecting mainly the somatosensory system, to a condition in which emotional, cognitive, and modulatory areas of the brain are affected, in addition to degenerative processes. All these contribute to the development and maintenance of pain symptoms and comorbid features, including alterations in anxiety, depression, and cognitive processes. In this article the authors review the current understanding of the brain changes in chronic pain and the developments made possible by the use of various brain imaging techniques. They also discuss the possible applications of brain imaging to developing a "pain phenotype" that could aid in diagnostic and treatment choices of chronic pain conditions.
Minimum Acceptable Outcomes After Lumbar Spinal Fusion.
Carragee EJ, Cheng I.
Spine J. 2010 Apr;10(4):313-20.
BACKGROUND CONTEXT: Defining success after spinal surgery remains problematic. The minimal clinically important difference (MCID) in pain or functional outcomes is a common metric often calculated independent of perceived risk and morbidity, which is an important consideration in large procedures such as spinal fusion and instrumentation. PURPOSE: The purpose of this study was to describe a method of assessing treatment success based on prospective, patient-reported "minimum acceptable" outcome for which they would undergo a procedure. These goals can then be compared at follow-up to gauge how frequently patient goals are met and determine correlation with patient satisfaction. STUDY DESIGN: This is a clinical descriptive study of the patient-reported minimum acceptable outcomes for spinal fusion surgery. OUTCOME MEASURES: Minimum acceptable outcomes were determined by patients on preoperatively administered standard questionnaires regarding ultimate pain intensity, functional outcome (Oswestry Disability Index [ODI]), medication usage, and work status. Satisfaction with outcomes was assessed at 2-year follow-up. METHODS: One hundred sixty-five consecutive patients undergoing lumbar fusion for either isthmic spondylolisthesis or disc degeneration were asked to preoperatively define on standard questionnaires their minimum acceptable outcomes after surgery. Two-year outcomes and satisfaction were subsequently reported and compared with the preoperatively determined minimum acceptable outcomes. RESULTS: Both the spondylolisthesis and the degenerative disc disease (DDD) groups reported that a high degree of improvement was the minimum acceptable threshold for considering spinal fusion. A large majority indicated that the minimum acceptable outcomes included at least a decrease in pain intensity to 3/10 or less, an improvement in ODI of 20 or more, discontinuing opioid medications, and return to some occupational activity. Achieving the minimum acceptable outcome was strongly associated with satisfaction at 2 years after surgery. Patients with compensation claims, psychological distress, and other psychosocial stressors were more likely to report satisfaction in the absence of achieving their minimum acceptable outcome. CONCLUSIONS: Patients with spondylolisthesis and DDD both have relatively high minimum acceptable outcomes for spinal fusion. In these cohorts, few subjects considered more commonly proposed MCIDs for pain and function as an acceptable outcome and report that they would not have surgery if they did not expect to achieve more than those marginal improvements. Although there was good concordance between achieving the minimum acceptable outcomes and ultimate satisfaction, patients with significant psychosocial factors (compensation claims, psychological distress, and others) are less likely to associate satisfaction with outcomes with actually achieving these improvements.
|
Association Links
|
e-Newsletter
|
