Lisa R. Witkin

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.

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.

Integrating outcome data collection into the care of the patient with pain

Individuals who suffer from chronic pain are all too aware of the toll pain takes on many aspects of their lives. In addition to suffering, chronic pain can impact every life dimension, including physical and mental wellbeing. Moreover, the impact extends beyond the individual, involving family and society as a whole due to major disruptions of the family function to the burden of lost work and the cost of ongoing healthcare. Many patients continue to suffer from poorly controlled pain for a variety of reasons. Contributing factors include lack of access to qualified clinicians, lack of response to available therapy, and variability in the quality of care provided. Variability in care can exist throughout the care process, including evaluation and diagnosis, selection of treatments, implementation of therapies, and monitoring the effectiveness or complications throughout treatment. While evidence-based guidelines exist to guide clinical decision-making for selected patient populations, these guidelines are integrated into patient care at a very slow rate, if at all. Ultimately, patient outcomes vary between different providers as well as in different care settings. Therefore, it follows that many potential opportunities exist to improve the care provided to patients with pain. Ongoing treatment should be guided by the patient’s response to therapy, yet the patient’s outcomes are often not objectively measured and documented as part of ongoing care. There are several outcome domains that should be assessed using valid measures, including patient-reported pain intensity, physical and mental functioning, pain interference with mood, sleep and physical function, and patient satisfaction with care. Of course, adverse effects of treatment, as well as the treatment provided, should also be properly documented. Outcome measurement tools can broadly be described as generic measures of health or disease-specific measures of health. Generic measures of health are intended to track health outcomes in large patient populations over time, rather than to track health outcomes in individual patients with specific disorders. The SF12 and SF-36 [4] are two commonly used generic measures of health. A disease-specific measure of health, by contrast, is intended to assess health outcomes in patients suffering from a specific disease or condition, such as chronic pain. Disease-specific measures of health may allow for documentation of an individual patient’s health status over time. An example of a disease-specific measure of health for chronic pain is the Treatment Outcomes in Pain Survey (TOPS). While this outcomes tool provides important information regarding the health status of patients with chronic pain [2,3,5], the TOPS can take up to 30 minutes for the patient

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.

Acute Pain Management/Regional Anesthesia

Effective and efficient acute pain management strategies have the potential to improve medical outcomes, enhance patient satisfaction, and reduce costs. Pain management records are having an increasing influence on patient choice of health care providers and will affect future financial reimbursement. Dedicated acute pain and regional anesthesia services are invaluable in improving acute pain management. In addition, nonpharmacologic and alternative therapies, as well as information technology, should be viewed as complimentary to traditional pharmacologic treatments commonly used in the management of acute pain. The use of innovative technologies to improve acute pain management may be worthwhile for health care institutions.

Lateral Femoral Cutaneous Nerve Entrapment

The lateral femoral cutaneous nerve (LFCN) is a sensory nerve innervating the anterolateral thigh. It is susceptible to entrapment along its course, usually at its exit from the pelvis under the inguinal ligament. The typical presentation of LFCN neuropathy is pain, paresthesia or dysesthesia, and numbness over the anterolateral thigh. Meralgia paresthetica is the name of this clinical syndrome. However, due to the great variation of LFCN distribution, the clinical presentation may be atypical; other causes such as lumbar radiculopathy need to be ruled out. The management of LFCN neuropathy includes treating underlying conditions and providing symptomatic relief with steroid nerve blocks.

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.