Impact of rescheduling hydrocodone-combination products in an urban Texas county healthcare system.

OBJECTIVE: The objective of this study was to examine the rescheduling of hydrocodone-combination products (HCPs) and associated changes in prescriber patterns in an urban county healthcare system in Texas. METHODS: Pharmacy data were obtained electronically for tramadol, hydrocodone-acetaminophen, and acetaminophen-codeine from 180 days before and after the schedule change on October 6, 2014. x2 and t tests were used to calculate the significance of changes between the medications over the studied time. RESULTS: Hydrocodone-acetaminophen saw a decline in dispense events and pills dispensed of 80.2 and 67.9 percent, respectively, in the immediate 30-day period following the scheduling change with a total decrease of 80.8 and 67.5 percent, respectively, in the 180-day period. Acetaminophen-codeine dispense events and total pills dispensed increased by 302.3 and 288.9 percent, respectively, in the immediate 30-day period while 180-day results experienced an increase of 215.1 and 209.8 percent, respectively. There were no major changes with tramadol. Additionally, an increase of 69.5 percent in pills per dispense event of hydroco-done-acetaminophen was noted in the 180-day period following the schedule change. CONCLUSION: The scheduling change of HCPs is associated with an immediate decrease in hydrocodone-acetaminophen use at our institution while a simultaneous rise in acetaminophen-codeine products was observed.

A novel interdisciplinary analgesic program reduces pain and improves function in older adults after orthopedic surgery.

OBJECTIVES: To examine the effect of a multicomponent intervention on pain and function after orthopedic surgery. DESIGN: Controlled prospective propensity score-matched clinical trial. SETTING: New York City acute rehabilitation hospital. PARTICIPANTS: Two hundred forty-nine patients admitted to rehabilitation after hip fracture repair (n=51) or hip (n=64) or knee (n=134) arthroplasty. INTERVENTION: Pain assessment at rest and with physical therapy (PT) by staff using numeric rating scales (1 to 5). Physician protocols for standing analgesia and preemptive analgesia before PT were implemented on the intervention unit. Control unit patients received usual care. MEASUREMENTS: Pain, analgesic prescribing, gait speed, transfer time, and percentage of PT sessions completed during admission. Pain and difficulty walking at 6, 12, 18, and 24 weeks after discharge. RESULTS: In multivariable analyses intervention patients were significantly more likely than controls to report no or mild pain at rest (66% vs 49%, P=.004) and with PT (52% vs 38%, P=.02) on average for the first 7 days of rehabilitation, had faster 8-foot-walk times on Days 4 (9.3 seconds vs 13.2 seconds, P=.02) and 7 (6.9 vs 9.2 seconds, P=.02), received more analgesia (23.6 vs 15.6 mg of morphine sulfate equivalents per day, P<.001), were more likely to receive standing orders for analgesia (98% vs 48%, P<.001), and had significantly shorter lengths of stay (10.1 vs 11.3 days, P=.005). At 6 months, intervention patients were less likely than controls to report moderate to severe pain with walking (4% vs 15%, P=.02) and that pain did not interfere with walking (7% vs 18%, P=.004) and were less likely to be taking analgesics (35% vs 51%, P=.03). CONCLUSION: The intervention improved postoperative pain, reduced chronic pain, and improved function.

The effect of a web-based, patient-directed intervention on knowledge, discussion, and completion of a health care proxy.

OBJECTIVES: To examine the effect of patient-directed electronic messages on health care proxy (HCP) use. DESIGN: Randomized control trial using an electronic message intervention to encourage patients to complete an HCP document. SETTING: General medical practice at a large tertiary care teaching institution. PARTICIPANTS: Nine hundred twelve patients aged older than 50. MEASUREMENTS: We reviewed online medical records (OMRs) to assess for discussion and documentation of HCPs and to collect information on patient characteristics. We surveyed participants to determine knowledge, discussion, and completion of HCPs. RESULTS: Four hundred thirty participants were randomized to the intervention group and 482 to the control group. Only 1 HCP discussion (intervention group) and only 10 new HCPs (4 in intervention group versus 6 in control group, p = 0.649) were documented in the OMR. Among the 444 survey responders, 205 (46%) reported having an HCP, but only 74 (36%) of these had discussed the HCP with their doctors and only 9 (4%) had a documented HCP in the OMR. Patients in the intervention group were more likely to report knowledge of HCPs (adjusted risk ratio [RR] 1.07; 95% confidence interval [CI], 1.01-1.14) and having a plan to complete one in the future (adjusted RR 1.19; 95% CI, 1.05-1.36). CONCLUSION: This patient-directed intervention did not increase patient completion of an HCP but was associated with greater knowledge of an HCP and planning to complete one.

Pain and ethnicity in the United States: A systematic review.

BACKGROUND: Evidence suggests that racial and ethnic disparities exist in access to effective pain treatment. PURPOSE: To review evidence of these disparities and provide recommendations for care and further research. DESIGN: Systematic review. METHODS: We conducted a MEDLINE search using the MeSH terms of ethnic groups, minority groups, pain, analgesia, and analgesics. We included studies describing current practice patterns, utilization of available treatments, treatment outcomes, and patient and provider knowledge, attitudes, and behaviors. RESULTS: Our search identified 35 journal articles describing the effect of patient race and ethnicity on pain assessment and management. Three studies on pain assessment revealed that minority patients are more likely to have their pain underestimated by providers and less likely to have pain scores documented in the medical record compared to whites. Eleven of 17 studies found that African Americans and Hispanics are less likely to receive opioid analgesics and more likely to have their pain untreated compared to white patients. Three studies revealed that minority patients are more likely to have negative pain management index (PMI) scores-undertreated pain-compared to whites. Patient-related, provider-related, and pharmacy-related barriers to effective pain management were identified. CONCLUSION: The majority of studies reveal racial and ethnic disparities in access to effective pain treatment akin to disparities found in other medical services. Quality improvement initiatives that improve treatment of pain for all patients according to established guidelines should decrease disparities by race or ethnicity. Educational interventions should aim to improve patient-provider communication regarding pain and its treatment and should provide support around substance abuse issues. Further research is needed to examine pain treatment outcomes and to determine whether health care system factors lead to these disparities.

Hospitalization of hospice patients with cancer.

OBJECTIVES: To identify factors associated with hospitalization of elderly hospice patients with cancer and to describe their hospital experiences. DESIGN: Retrospective analysis of the last year of life. SETTING: Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. PARTICIPANTS: Medicare beneficiaries dying of lung or colorectal cancer between 1988 and 1998 who enrolled in hospice. MEASUREMENTS: Hospitalization after hospice entry. For hospitalized patients, we describe admission diagnoses, aggressiveness of care, and in-hospital death. RESULTS: Of the 23608 patients, 1423 (6.0%) were hospitalized after hospice enrollment. Hospitalization declined over time by 7.0% per year of hospice enrollment. Factors associated with higher hospitalization rates were younger age, male gender, black race/ethnicity, local cancer stage at diagnosis, and hospice enrollment within 4 months of cancer diagnosis. The most common reasons for hospital admission were lung cancer, metastatic disease, bone fracture, pneumonia, and volume depletion. Of the 1423 patients hospitalized, 34.6% received aggressive care and 35.8% died in the hospital. CONCLUSION: The rates of hospitalization for elderly hospice patients with lung or colorectal cancer appear to be declining. However, patients who are hospitalized undergo aggressive care and often die in the hospital rather than at home. This aggressive care may be consistent with changes in patients' care preferences, but could also reflect the current culture of acute care hospitals, which focuses on curative treatment and is ill-equipped to provide palliative care.