Understanding providers' perspectives using patient-reported outcomes in a pain management setting: a pilot study.

Aim: This pilot study evaluated an electronic patient-reported outcomes collection system in pain management to understand providers' experiences using the data, and how it affects their patient interaction and guides their clinical decision-making. Materials & methods: Using stratified convenience sampling, nine semi-structured interviews were conducted with consented pain physicians. The transcribed, de-identified interviews were coded and analyzed. Results: Although most physicians utilized patient reported outcomes (PROs), one-third reported no significant change in their practice since implementation and 56% stated it does not influence their treatment recommendations. Conclusion: Despite the importance of measuring the impact of chronic pain on quality of life, there are significant limitations to the real-world use of PRO that may limit the patient's assessment and care.

Social determinants of health: modeling and targeting patient propensity to attend pain clinic appointments.

Aim: We sought to investigate the impact of social determinants of health on pain clinic attendance. Materials & methods: Retrospective data were collected from the Pain Center at Montefiore Medical Center from 2016 to 2020 and analyzed with multivariable logistic regression. Results: African-Americans were less likely to attend appointments compared with White patients (odds ratio [OR]: 0.73; 95% CI: 0.70-0.77; p < 0.001). Males had decreased attendance compared with females (OR: 0.89; 95% CI: 0.87-0.92; p < 0.001). Compared with commercial, those with Medicaid (OR: 0.69; 95% CI: 0.66-0.72; p < 0.001) and Medicare (OR: 0.76; 95% CI: 0.73-0.80; p < 0.001) insurance had decreased attendance. Conclusion: Significant disparities exist in pain clinic attendance based upon social determinants of health including race, gender and insurance type.

We aimed to investigate social determinants of health, such as race and type of insurance, and their role in patients' attendance of pain clinic appointments. Data were collected over several years and statistical analysis was performed on over 145,000 patient encounters. It was found that patients with Medicaid and Medicare were less likely to attend appointments compared with patients with commercial insurance. Black or African­American patients were also less likely to attend compared with White patients. Spanish speaking patients were more likely to attend compared with English speaking patients, showing that previous interventions aimed at reducing the language barrier for Spanish speaking patients continue to be successful after many years. Overall, significant disparities exist in pain clinic attendance based upon social determinants of health. Further research is needed to investigate reasons and potential areas of interventions. Patients insured with Medicare and Medicaid may also have greater transportation issues, a potential focus for further studies and targeted interventions.

Medicare Part D Coverage Restrictions and Patient Cost-Sharing for Opioids Commonly Used for Cancer Pain, 2015-2021.

PURPOSE: Nation-wide rapid declines in prescription opioid dispensing gave rise to concerns regarding restricted access to effective pain management for patients with cancer-related pain. One important mechanism for such restrictions could be through more restrictive insurance coverage for opioids. This study aims to assess recent changes in Medicare Part D formulary designs for opioids commonly used for cancer-related pain. METHODS: We used data from the 2015-2021 Medicare Prescription Drug Plan (PDP) Formulary Files to assess formulary changes for six opioid-dose combinations commonly used for cancer-related pain. We estimated % of PDPs adopting prior authorization, quantity limits (and limits adopted), and a higher cost-sharing tier for each opioid-dose combination. We further estimated median and mean out-of-pocket (OOP) costs across all PDPs for a 30-day supply of the drug. Trends in proportions were tested using the Cochrane-Armitage test; trends in continuous measures were tested using the Jonckheere-Terpstra test. RESULTS: Proportion of PDPs adopting prior authorization increased from close to 0% to about 50% for two long-acting opioids (P < .001). Distribution of quantity limits across PDPs shifted over time to being more restrictive for all opioids considered (P < .001). For four of the six opioids, the proportion of PDPs adopting tier 3 or above increased from below or about 50% to well over 70% (P < .001). For the same four opioids, median OOP costs doubled to quadrupled (P < .001). CONCLUSION: Medicare PDP coverage has become increasingly restrictive for opioids commonly used for cancer-related pain, with multifold increases in patient OOP costs over the past 7 years. These changes pose concerns for patients with cancer needing opioid therapies for pain control and call for strategies to effectively exempt cancer-related pain from insurance and pharmacy rules intended to apply to opioids for noncancer chronic pain.

Robust Prescription Monitoring Programs and Abrupt Discontinuation of Long-term Opioid Use.

INTRODUCTION: This study assesses the associations between the recent implementation of robust features of state Prescription Drug Monitoring Programs and the abrupt discontinuation of long-term opioid therapies. METHODS: Data were from a national commercial insurance database and included privately insured adults aged 18-64 years and Medicare Advantage enrollees aged ≥65 years who initiated a long-term opioid therapy episode between Quarter 2 of 2011 and Quarter 2 of 2017. State Prescription Drug Monitoring Programs were characterized as nonrobust, robust, and strongly robust. Abrupt discontinuation was measured on the basis of high daily morphine milligram equivalents over the last 30 days of a long-term opioid therapy episode or no sign of tapering before discontinuation. Difference-in-differences models were estimated in 2019‒2020 to assess the association between robust Prescription Drug Monitoring Programs and abrupt discontinuation. RESULTS: Among nonelderly privately insured adults, robust Prescription Drug Monitoring Programs were associated with an increase from 14.8% to 15.4% (4% relative increase, p=0.02) in the rate of ending long-term opioid therapy with ≥60 daily morphine milligram equivalents. For older Medicare Advantage enrollees, strongly robust Prescription Drug Monitoring Programs were associated with a reduction from 4.8% to 4.3% (10.4%, p=0.01) and from 3.0% to 2.4% (17.3%, p=0.001) in the rate of ending long-term opioid therapy with ≥90 and 120 daily morphine milligram equivalents, respectively. Prescription Drug Monitoring Programs robustness was not associated with clinically meaningful changes in the rate of discontinuing long-term opioid therapy without tapering. CONCLUSIONS: Discontinuation without tapering was the norm for long-term opioid therapies in the samples throughout the study years. Findings do not support the notion that policies aimed at enhancing Prescription Drug Monitoring Program use were associated with substantial increases in abrupt long-term opioid therapy discontinuation.

The effect of obesity on pain severity and pain interference.

Aim: Obesity is one of the most prevalent comorbidities associated with chronic pain, which can severely interfere with daily living and increase utilization of clinical resources. We hypothesized that a higher level of obesity, measured by BMI, would be associated with increased pain severity (intensity) and interference (pain related disability). Materials & methods: Participant data was pulled from a multisite chronic pain outpatient database and categorized based on BMI. Results: A total of 2509 patients were included in the study. We found significant differences between BMI groups for all pain severity scores (worst, least, average, current) and total pain interference score. Obese patients had significantly higher scores than normal weight patients. Conclusion: We found obesity to be associated with increased pain severity and pain interference.

Black Race as a Social Determinant of Health and Outcomes After Lumbar Spinal Fusion Surgery: A Multistate Analysis, 2007 to 2014.

STUDY DESIGN: A retrospective analysis of patient hospitalization and discharge records. OBJECTIVE: To examine the association between race and inpatient postoperative complications following lumbar spinal fusion surgery. SUMMARY OF BACKGROUND DATA: Racial disparities in healthcare have been demonstrated across a range of surgical procedures. Previous research has identified race as a social determinant of health that impacts outcomes after lumbar spinal fusion surgery. However, these studies are limited in that they are outdated, contain data from a single institution, analyze small limited samples, and report limited outcomes. Our study aims to expand and update the literature examining the association between race and inpatient postoperative complications following lumbar spine surgery. METHODS: We analyzed 267,976 patient discharge records for inpatient lumbar spine surgery using data from the Healthcare Cost and Utilization Project's State Inpatient Databases for California, Florida, New York, Maryland, and Kentucky from 2007 through 2014. We used unadjusted bivariate analysis, adjusted multivariable, and stratified analysis to compare patient demographics, present-on-admission comorbidities, hospital characteristics, and complications by categories of race/ethnicity. RESULTS: Black patients were 8% and 14% more likely than white patients to experience spine surgery specific complications (adjusted odds ratios [aOR]: 1.08, 95% confidence interval [CI]: 1.03-1.13) and general postoperative complications (aOR: 1.14, 95% CI: 1.07-1.20), respectively. Black patients, compared with white patients, also had increased adjusted odds of 30-day readmissions (aOR: 1.13, 95% CI: 1.07-1.20), 90-day readmissions (aOR: 1.07, 95% CI: 1.02-1.13), longer length of stay (LOS) (adjusted Incidence Rate Ratio: 1.15, 95% CI: 1.14-1.16), and higher total charges (adjusted Incidence Rate Ratio: 1.08, 95% CI: 1.07-1.09). CONCLUSION: Our findings demonstrate that black patients, as compared with white patients, are more likely to have postoperative complications, longer postoperative lengths of stay, higher total hospital charges, and increased odds of 30- and 90-day readmissions following lumbar spinal fusion surgery. LEVEL OF EVIDENCE: 4.

Sociodemographic Characteristics Predict Readmission Rates After Lumbar Spinal Fusion Surgery.

OBJECTIVE: To evaluate the impact of social determinants of health (race/ethnicity, household income, insurance) and hospital surgical volume on 30- and 90-day readmissions after lumbar spinal fusion surgery. METHODS: A retrospective review of the State Inpatient Databases (SID) Healthcare Cost and Utilization Project (HCUP) included all patients age ≥18 years who underwent an index lumbar spinal fusion procedure and met inclusion criteria in California (2007-2011), Maryland (2012-2014), Florida, and New York (2007-2014). Primary outcomes were unadjusted rates and adjusted odds of readmission at 30 and 90 days postoperatively. RESULTS: After assessing for exclusion criteria, 267,976 patients were included in analyses. The overall 30-day readmission rate was 7.5%, and the 90-day readmission rate was 11.6%. Black patients (odds ratio [OR] = 1.12, 95% confidence interval [CI] = 1.06-1.19) and patients with nonprivate insurance (Medicare OR = 1.44, 95% CI = 1.37-1.51; Medicaid OR = 1.46, 95% CI = 1.36-1.56; or uninsured OR = 1.16, 95% CI = 1.00-1.35) had higher odds of 30-day readmission, with comparable effects at 90 days. The three highest quartiles of hospital lumbar spine surgical volume had decreased odds for 30- and 90-day readmission when compared with the lowest quartile. Median income had no effect on readmission rates, save for the top quartile having lower odds of 90-day readmission than the bottom quartile. CONCLUSIONS: Sociodemographic disparities in primary insurance payer, race/ethnicity, and hospital surgical volume affect lumbar spinal fusion surgery readmission rates. Public health interventions may improve readmissions and clinical outcomes and reduce health care costs.

First Opioid Prescription and Subsequent High-Risk Opioid Use: a National Study of Privately Insured and Medicare Advantage Adults.

BACKGROUND: National guidelines make recommendations regarding the initial opioid prescriptions, but most of the supporting evidence is from the initial episode of care, not the first prescription. OBJECTIVE: To examine associations between features of the first opioid prescription and high-risk opioid use in the 18 months following the first prescription. DESIGN: Retrospective cohort study using data from a large commercial insurance claims database for 2011-2014 to identify individuals with no recent use of opioids and follow them for 18 months after the first opioid prescription. PARTICIPANTS: Privately insured patients aged 18-64 and Medicare Advantage patients aged 65 or older who filled a first opioid prescription between 07/01/2011 and 06/30/2013. MAIN OUTCOMES AND MEASURES: High-risk opioid use was measured by having (1) opioid prescriptions overlapping for 7 days or more, (2) opioid and benzodiazepine prescriptions overlapping for 7 days or more, (3) three or more prescribers of opioids, and (4) a daily dosage exceeding 120 morphine milligram equivalents, in each of the six quarters following the first prescription. KEY RESULTS: All three features of the first prescription were strongly associated with high-risk use. For example, among privately insured patients, receiving a long- (vs. short-) acting first opioid was associated with a 16.9-percentage-point increase (95% CI, 14.3-19.5), a daily MME of 50 or more (vs. less than 30) was associated with a 12.5-percentage-point increase (95% CI, 12.1-12.9), and a supply exceeding 7 days (vs. 3 or fewer days) was associated with a 4.8-percentage-point increase (95% CI, 4.5-5.2), in the probability of having a daily dosage of 120 MMEs or more in the long term, compared to a sample mean of 4.2%. Results for the Medicare Advantage patients were similar. CONCLUSIONS: Long-acting formulation, high daily dosage, and longer duration of the first opioid prescription were each associated with increased high-risk use of opioids in the long term.

Patient-Reported Outcomes and Opioid Use in Outpatients With Chronic Pain.

The Weill Cornell Medical College Pain Registry database contains patient characteristics, treatments, and outcomes for a prospective cohort of 1,159 chronic pain patients who were seen at the Weill Cornell Medical College Pain Medicine outpatient clinic from July 8, 2011 to December 10, 2014. Patients aged 45 to 64 years comprised 43% followed by age ≥ 65 years at 37%. Fifty-eight percent were female. Average pain intensity (Brief Pain Inventory) was reported as mild by 22.3% of patients, moderate by 34.7%, and severe by 43.0%. For each pain intensity category, patient's report of average percent pain relief and health state (EuroQOL 5 Dimensions) was inversely related to average pain intensity category, whereas measures of pain interference, number of worst pain locations, and physical and psychological distress were directly related to pain intensity category. Seventy-seven percent of patients received an opioid at 1 or more clinic encounters. Median daily opioid dose in morphine equivalents was 55 with a range from 2 to 1,145 morphine equivalents. Regression analysis revealed that being male was associated with greater likelihood of an opioid ordered and higher average dosage than being female. The registry can identify patient characteristics and treatments that provide new insights into chronic pain management. PERSPECTIVE: This article describes results of analyses of patient-reported outcomes and patient-related electronic health record data collected under standard of care from a prospective cohort of chronic pain outpatients at a New York City pain management clinic. The registry provides an opportunity to learn how to improve individualized chronic pain management.

Pain Assessment, Management, and Control Among Patients 65 Years or Older Receiving Hospice Care in the U.S.

CONTEXT: Knowledge is limited regarding pain assessment and management practices, as well as pain-related outcomes in hospice care. OBJECTIVES: To generate national estimates of pain assessment and management practices and outcomes of pain control among patients 65 years or older receiving hospice care in the U.S. and identify hospice discharge and agency characteristics predicting study outcomes. METHODS: The 2007 National Home Health and Hospice Care Survey was analyzed. Multivariate logistic regressions were estimated to identify discharge and agency characteristics predicting guideline-concordant pain assessment and management practices and pain control outcomes. RESULTS: A high percentage of discharges had pain assessment at admission (97%) and before discharge (93%); use of valid pain rating scales was relatively low (69% and 54% for first and last assessments, respectively). Almost 95% of patients received pain medication, but only 42% received nonpharmacologic therapies. About 70% of patients assessed with a valid pain scale saw improvement in the level of pain or remained free of pain from admission to discharge. Non-Hispanic blacks were less likely to have pain assessments, and Hispanics were less likely to receive opioid analgesics or to have pain-free status at discharge, compared with non-Hispanic whites. Patients receiving care from for-profit (vs. nonprofit) agencies were more likely to receive pain assessment with a valid scale before discharge but less likely to experience pain control or improvement. CONCLUSION: Greater use of valid pain assessment scales and nonpharmacologic therapies constitutes areas for improvement in hospice care. Targeted interventions are needed to address disparities in pain care by patient race and/or ethnicity and agency ownership status.

Using Chronic Pain Outcomes Data to Improve Outcomes.

Standardization of care that is derived from analysis of outcomes data can lead to improvements in quality and efficiency of care. The outcomes data should be validated, standardized, and integrated into ongoing patient care with minimal burden on the patient and health care team. This article describes the organization and workflow of a chronic pain clinic registry designed to collect and analyze patient data for quality improvement and dissemination. Future efforts in using mobile technology and integrating patient-reported outcome data in the electronic health records have the potential to offer new and improved models of comprehensive pain management.

Usefulness of the opioid risk tool to predict aberrant drug-related behavior in patients receiving opioids for the treatment of chronic pain.

OBJECTIVE: The purpose of this study was to determine if the opioid risk tool (ORT) was clinically useful in guiding physician decision making during chronic opioid therapy and to determine whether there were differences between the patient-completed and physician-completed ORT. DESIGN: Retrospective review of prospectively collected data. SETTING: A single-center tertiary care outpatient pain management center. PATIENTS, PARTICIPANTS: One-hundred twenty-five patients who received chronic opioids as part of their pain therapy. INTERVENTIONS: Patients receiving care were asked to complete the ORT as part of their initial evaluation. In addition, as part of this study, a pain physician reviewed the information available at the time of the initial evaluation and completed the ORT. Medical records were reviewed for evidence of moderate-to-severe aberrant drug-related behavior (ADRB), according to specified criteria. MAIN OUTCOME MEASURES: Patient-completed and physician-completed ORT and presence or absence of moderate to severe ADRB. RESULTS: Of the 125 patients included in this study, physician-completed ORT was available for 125 patients, and a patient-completed ORT was available on 87 of these patients. There was good correlation between the patient-completed and physician-completed ORT (correlation coefficient = 0.61). There were 112 observations of ADRB in 53 of 125 patients (42.4 percent) during the observation period of an average of 7.8 months (range 2-17 months). Of these 53 patients, 32 (60.4 percent) were identified by urine drug screen (UDS) alone, 7 (13.2 percent) were identified by physician observation alone, and 14 (26.4 percent) were identified by both UDS and physician observation. Based on the physician-completed ORT, 41 of 106 (38.7 percent) low risk patients had ADRB, compared to 8 of 14 (57.1 percent) moderate risk, and 4 of 5 (80 percent) high risk patients. CONCLUSIONS: Neither the patient-completed nor the physician-completed ORT was strongly predictive of moderate-to-severe ADRB in patients receiving chronic opioid therapy for the treatment of noncancer pain in our pain center.

Can assessing chronic pain outcomes data improve outcomes?

OBJECTIVE: This manuscript reviews how patient-reported outcomes data can be used to guide efforts to improve patient outcomes. DESIGN: Review Manuscript. SETTING: The clinical management of chronic, non-cancer pain. SUBJECTS: Adult patients receiving treatment for chronic, non-cancer pain. RESULTS: While there have been great advances in the science of pain and various therapeutic medications and interventions, patient outcomes are variable. This manuscript reviews how outcomes data can be used to guide efforts to improve patient outcomes. CONCLUSIONS: Patient outcomes can be improved with standardization of the process of patient care, as well as through other quality improvement efforts. The cornerstone to any effort to improve patient outcomes starts with the integration of valid outcomes data collection into ongoing patient care. Outcome measurement tools should provide information on several key domains, yet the process of data collection should not pose a significant burden on either the patient or health care team. Efforts to improve patient outcomes are ongoing, and should be a high priority for every health care team.

Abscess after a laparoscopic appendectomy presenting as low back pain in a professional athlete.

A professional baseball player presented to the orthopaedic clinic for a preseason assessment because of continued lumbar spine and flank pain. He had a laparoscopic appendectomy for a perforated appendix 8 months before his presentation. He was able to finish the previous season with only mild limitation. He presented with back pain that limited his activity. His examination was nonlocalizing, but subsequent computed tomography revealed a hepatic abscess. The abscess was drained; he was treated with intravenous antibiotics; and his symptoms resolved.

Horizontal maxillary osteotomy with interpositional fibula flap.

Horizontal maxillary osteotomy with an interpositional fibula flap for maxillary deficiency offers several advantages over conventional techniques for maxillary reconstruction. Maxillary deficiencies in all 3 planes, vertical, anterior-posterior, and transverse, can be corrected with a long-term stable construct while simultaneously restoring bony and soft tissue deficiencies. We conducted a retrospective review of patients with maxillary hypoplasia who underwent Horizontal maxillary osteotomy with interpositional osteoseptocutaneous fibula flaps. Compared with nonvascularized bone grafts, vascularized bone flaps undergo less resorption and can be used in poorly vascularized, mechanically unstable, irradiated, or scarred wound beds.

Kullback-Leibler clustering of continuous wavelet transform measures of heart rate variability.

Power spectral analysis of beat-to-beat heart rate variability (HRV) has provided a useful means of understanding the interplay between autonomic and cardiovascular functionality. Despite their utility, commonly employed frequency-domain techniques are limited in their prerequisite for stationary signals and their inability to account for temporal changes in the power spectral and/or frequency properties of signals. The purpose of this study is to develop an algorithm that utilizes continuous wavelet transform (CWT) parameters as inputs to a Kohonen self-organizing map (SOM), providing a method of clustering subjects with similar wavelet transform signatures. Continuous interbeat-intervals were recorded (Portapres monitor at 200 Hz) during a perception of affect test in 79 African-American volunteers (ages 21-83), where after a 5-min baseline, participants evaluated emotional expressions in sentences and pictures of faces, followed by a 5-min recovery. Individual HRV biosignals from each session were pre-processed (artifact replacement and signal resampling at 2 Hz) and a CWT was applied (db9 wavelet basis function over 32 scales). Standard deviations of resulting wavelet coefficients at each scale were calculated, normalized, and used as inputs into a SOM with Kullback-Leibler divergence as the dissimilarity measure used for clustering. Differences in subject demographics between two final clusters were assessed via two-independent-groups t-tests or chi-square or Fisher's exact tests of contingency tables. Significant differences were found for age, initial systolic blood pressure, smoking status, and mean s.d. of coefficients in the high frequency band (0.15-0.4 Hz). These findings may have clinical significance and the developed algorithm provides an alternative means of analyzing HRV data originating from populations with complex covariates.