RESUMO
BACKGROUND: Traditional pain management after total knee arthroplasty (TKA) relies heavily on opioids. Although there is evidence that in-hospital multimodal pain management (MMPM) is more effective than opioid-only (OO) analgesia, there has been little focus on postdischarge pain management. The hypothesis of this study was that MMPM after TKA would reduce pain scores and opioid consumption in the 30-day period after hospital discharge. METHODS: This is a prospective, 2-group, comparative study with a provider cross-over design comparing a 30-day OO prn regimen with a MMPM regimen and opioid medications prn. The primary outcome measure was visual analog scale pain score and opioid-related side effects. Secondary outcome measures included morphine milligram equivalents consumed, failure of the protocol, and opioid refills. RESULTS: There were 216 patients included in the trial, with final data available for 143. There was no clinically meaningful difference in visual analog scale score between the 2 groups at any time. Average opioid consumption at 30 days was 582.5 and 386.4 morphine milligram equivalents for the OO and MMPM cohorts, respectively (P = .0006). Average number of opioid pills consumed at 30 days was 91.8 and 60.4 for OO and MMPM cohorts, respectively (P = .0004). CONCLUSION: A 30-day postdischarge multimodal pain regimen reduced opioid use after TKA while maintaining a similar level of pain control as the OO regimen. OO regimens are at an increased risk of needing additional medications to control pain. LEVEL OF EVIDENCE: Level II. REGISTRY NAME: www.clinicaltrials.gov. TRIAL NUMBER: NCT04003350.
Assuntos
Analgésicos Opioides , Artroplastia do Joelho , Assistência ao Convalescente , Artroplastia do Joelho/efeitos adversos , Humanos , Manejo da Dor , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/epidemiologia , Dor Pós-Operatória/etiologia , Alta do Paciente , Estudos ProspectivosRESUMO
BACKGROUND: The Comprehensive Care for Joint Replacement model is the newest iteration of the bundled payment methodology introduced by the Centers for Medicare and Medicaid Services. Comprehensive Care for Joint Replacement model, while incentivizing providers to deliver care at a lower cost, does not incorporate any patient-level risk stratification. Our study evaluated the impact of specific medical co-morbidities on the cost of care in total joint arthroplasty (TJA) patients. METHODS: A retrospective study was conducted on 1258 Medicare patients who underwent primary elective TJA between January 2015 and July 2016 at a single institution. There were 488 males, 552 hips, and the mean age was 71 years. Cost data were obtained from the Centers for Medicare and Medicaid Services. Co-morbidity information was obtained from a manual review of patient records. Fourteen co-morbidities were included in our final multiple linear regression models. RESULTS: The regression models significantly predicted cost variation (P < .001). For index hospital costs, a history of cardiac arrhythmias (P < .001), valvular heart disease (P = .014), and anemia (P = .020) significantly increased costs. For post-acute care costs, a history of neurological conditions like Parkinson's disease or seizures (P < .001), malignancy (P = .001), hypertension (P = .012), depression (P = .014), and hypothyroidism (P = .044) were associated with increases in cost. Similarly, for total episode cost, a history of neurological conditions (P < .001), hypertension (P = .012), malignancy (P = .023), and diabetes (P = .029) were predictors for increased costs. CONCLUSION: The cost of care in primary elective TJA increases with greater patient co-morbidity. Our data provide insight into the relative impact of specific medical conditions on cost of care and may be used in risk stratification in future reimbursement methodologies.
Assuntos
Artroplastia de Quadril/economia , Artroplastia do Joelho/economia , Custos Hospitalares/estatística & dados numéricos , Osteoartrite/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Centers for Medicare and Medicaid Services, U.S. , Comorbidade , Procedimentos Cirúrgicos Eletivos/economia , Feminino , Hospitais , Humanos , Masculino , Medicare/economia , Pessoa de Meia-Idade , Osteoartrite/economia , Osteoartrite/epidemiologia , Osteoartrite/cirurgia , Pacotes de Assistência ao Paciente/economia , Estudos Retrospectivos , Cuidados Semi-Intensivos , Estados UnidosRESUMO
STUDY DESIGN: Retrospective cohort. OBJECTIVE: Determine the effect of duration of symptoms (DOS) on health-related quality of life (HRQOL) outcomes for patients with cervical radiculopathy. SUMMARY OF BACKGROUND DATA: The effect of DOS has not been extensively evaluated for cervical radiculopathy. METHODS: A retrospective analysis of patients who underwent an anterior cervical decompression and fusion for radiculopathy was performed. Patients were grouped based on DOS of less than 6 months, 6 months to 2 years, and more than 2 years and HRQOL outcomes were evaluated. RESULTS: A total of 216 patients were included with a mean follow-up of 16.0 months. There were 86, 61, and 69 patients with symptoms for less than 6 months, 6 months to 2 years, and more than 2 years, respectively. No difference in the absolute postoperative score of the patient reported outcomes was identified between the cohorts. However, in the multivariate analysis, radiculopathy for more than 2 years predicted lower postoperative Short Form-12 Physical Component Score (Pâ=â0.037) and Short Form-12 Mental Component Score (Pâ=â0.029), and higher postoperative Neck Disability Index (Pâ=â0.003), neck pain (Pâ=â0.001), and arm pain (Pâ=â0.004) than radiculopathy for less than 6 months. Furthermore, the recovery ratios for patients with symptoms for less than 6 months demonstrated a greater improvement in NDI, neck pain, and arm pain than for 6 months to 2 years (Pâ=â0.041; 0.005; 0.044) and more than 2 years (Pâ=â0.016; 0.014; 0.002), respectively. CONCLUSION: Patients benefit from spine surgery for cervical radiculopathy at all time points, and the absolute postoperative score for the patient reported outcomes did not vary based on the duration of symptoms; however, the regression analysis clearly identified symptoms for more than 2 years as a predictor of worse outcomes, and the recovery ratio was statistically significantly improved in patients who underwent surgery within 6 months of the onset of symptoms. LEVEL OF EVIDENCE: 3.
Assuntos
Vértebras Cervicais/cirurgia , Descompressão Cirúrgica , Radiculopatia , Fusão Vertebral , Descompressão Cirúrgica/efeitos adversos , Descompressão Cirúrgica/estatística & dados numéricos , Humanos , Medidas de Resultados Relatados pelo Paciente , Qualidade de Vida , Radiculopatia/epidemiologia , Radiculopatia/cirurgia , Estudos Retrospectivos , Fusão Vertebral/efeitos adversos , Fusão Vertebral/estatística & dados numéricos , Resultado do TratamentoRESUMO
Health care increasingly collects patient-reported outcomes (PROs) via web-based platforms. The purpose of this study was to evaluate how patient age influences portal engagement. Patients undergoing elective surgery at a single multispecialty orthopedic practice from September 2014 to February 2017 had access to an online portal to complete PROs, message the clinic, and view physical therapy instructions. A mobile app was optionally available. Age, sex, log-in frequency, PRO completion rates, and number of messages sent were reviewed retrospectively. Message frequency, log-in rates, and PRO compliance were highest for patients aged 41 to 50, 51 to 60, and 61 to 70, respectively. Mobile app use decreased with age ( P = .002); yet, at all ages, the mobile app group was more engaged. In particular, for patients aged 18 to 30 years, log-in frequency increased 2.5-fold and PRO compliance improved 44% ( P < .001) in the mobile app group. This study demonstrates that portal interaction varies by age and that data capture is highest in patients who choose the mobile app.