Using Interviews to Understand Patients’ Post-operative Pain Management Educational Needs Before and After Elective Total Joint Replacement Surgery

Objective: To better understand the education needs of patients electing to have TJR in managing their pain in the post-operative period after discharge from the hospital. Methods: An exploratory, descriptive, qualitative design. Convenience sample of people who reported that they had not received information about pain management prior to TJR surgery were recruited from 9 surgeon practices in 8 states to participate in telephone interviews, utilizing open-ended questions. Questions included: recollection of pre-op class attended and content; experiences with surgical pain after surgery and how it was managed; experiences with pain medicine; experience using non-medicine related pain reduction methods; suggestions for delivery of pain management information. Interviews were recorded and transcribed. Data were categorized using content analysis techniques. Results: Seventeen patients were interviewed. Although all remembered attending a pre-operative class prior to their joint replacement surgery, none remembered receiving information during that class about managing pain once they were discharged. All had been prescribed an opioid for pain management post-operatively; however no patients reported receiving any information regarding use of the medication other than the information on the pill bottle. Many had concerns regarding the use of opioids to control their pain, including side effects, such as constipation and the risk of addiction. The most common non-medicine method used to manage pain was the use of ice. Participants believed that information about pain management, including both non-medicine approaches and instructions for taking opioids would be helpful and should be delivered at multiple time points, including pre-operatively, at discharge, and within the first few days after discharge. Conclusion: With trends toward shorter hospital stays, home based pain management is a priority. Understanding the pain management education needs of patients considering elective TJR could inform interventions for this population as well as provide insight into the needs of other patients undergoing surgery

Obesity Prevalence, Weight-Related Beliefs and Behaviors among Low-Income Ethnically Diverse National Job Corps Students

The obesity rates of Job Corps students, a predominantly ethnic minority and low income group of youth, are unknown. The purpose of this project was to examine obesity rates among these youth as well as their weight-related perceptions and behavior. First, medical charts (N=641) of all Job Corps students (ages 16-25) who were enrolled in the program in the past year were examined for height and weight. In the second phase of the study, 344 Job Corp students were recruited and information on weight perceptions, knowledge of obesity consequences, and weight loss behavior were examined. Almost half of the participants were overweight or obese. Overweight males were less likely to perceive themselves as being overweight than females. The majority of participants were aware of obesity-related health consequences but of those with past weight loss attempts, only 13% reported using both exercise and diet. High levels of overweight and obesity among Job Corps students are likely to impact employment and career goals. Evidence-based obesity interventions for Job Corps students are needed

Effective Pain Information Pre-operatively is Associated with Improved Functional Gain after Total Joint Replacement

Objective: We evaluated receipt of pre-operative pain management education in a national prospective cohort on post-operative pain and function. Methods: Preoperative, 2 week and 6 month postoperative data from a nationally representative cohort of 1404 primary unilateral TJR patients with a date of surgery between May 2011 and December 2014. Data included demographics, comorbid conditions, operative joint pain severity (HOOS/KOOS), musculoskeletal disease burden, physical function (SF36 PCS), and mental health (SF36 MCS). At 2 weeks post-op, patients were asked if they had received information prior to surgery about pain management options and if so, how helpful the information was. Additionally, patients were asked about use of non-medication methods to relieve operative joint pain. Descriptive statistics were performed. Results: One third reported not receiving information about pain management; an additional 11% did not find it helpful. There were no differences pre-operatively in demographics, comorbid conditions, operative joint pain severity, musculoskeletal disease burden, SF36 PCS and MCS between those who received information and those who did not. Patients who received information about pain management options were more likely to use non-medication methods to relieve operative joint pain (p\u3c 0.000). They reported less current pain (p = 0.02) and maximum pain (p = 0.03) in their operative joint at 2 weeks post-op. At 6 months post-op, patients who reported not receiving information about pain management had statistically lower physical function scores that those receiving information (p = 0.04). There was no difference in HOOS/KOOS pain scores 6 months post-op. Conclusion: More than 40% of TJR patients in this study reported that they did not receive or received unhelpful information regarding post-op pain management options, highlighting a need for more consistent patient education. In this study, the lack of pain management information appears to negatively impact 6 month post-operative function

Direct-to-Patient PRO Collection to Support Quality Improvement in TJR

Introduction: Patient-reported outcomes (PROs) are widely used in orthopedic clinical research to evaluate quality of care. However, it is difficult to capture complete post-operative PRO data through surgeon office visits. The UK and Sweden collect post-TJR PRO measures directly from patients in their homes. We compared two US post-operative PRO collection processes- PROs in clinic at scheduled office visits and direct-to-patient collection, to evaluate timing and completeness of both approaches. Methods: At a large TJR center that has collected PROs at office visits routinely for years, post-TJR patients complete a PRO survey on a computer at follow-up clinic visits. In contrast, the national FORCE-TJR cohort manages post-operative PRO surveys across dozens of offices by sending PROs to patients directly via web-based questionnaires or scannable paper forms. We calculated post-operative PRO response rates and timing from these two approaches and compared patient physical outcomes between them. Results: In the clinic, 892 patients had TJR surgery during the study period. Of these, 392 (44%) completed post-operative surveys; 115 (29%) between 5 months and 7 months after surgery, and 85 (22%) after 7 months. Direct to patient PRO surveys were centrally distributed in month 5 after surgery. Of 11,702 TJR patients, 8283 (71%) completed the PRO survey within 5 to 9 months post-op. Of these, 90% were returned between 5 and 7 months. SF36 PCS scores were comparable between these two approaches. Discussion: While PRO collection at the office visit can support individual patient care decisions, patients return to the surgeon office at varied time points after TJR based on their recovery progress and convenience. Direct to patient PRO collection with appropriate retention processes can lead to uniform data timing and optimal completeness. Quality monitoring programs will benefit from consistent data across providers and should consider these factors in designing PRO procedures

Translating Comparative TJR Outcomes for Performance Improvement to Guide Surgical Quality Improvement

Background/Purpose: With the CMS decision to publicly report hospital-specific post-operative total joint replacement (TJR) complications and readmissions, orthopedic surgeons need new sources of post-operative outcome data to monitor and improve post-hospital care. The AHRQ funded research program, Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR), developed methods to capture longitudinal patient-reported outcomes (PROs) and comprehensive post-TJR medical and surgical events, and established a web reporting system to return comparative outcome reports to participating surgeons and hospitals in order to monitor and improve quality and outcomes. Methods: This national cohort/registry captures post-TJR measures directly from patients in their homes to assure uniform time, completion, and consistency for data comparisons across hospitals. Quarterly updated web reports deliver hospital- and surgeon-specific TJR outcomes compared with those of their peers and risk-adjusted national benchmarks on PROs as well as on post-operative event rates. Results: Our national cohort enrolled 25,000 patients from 150 diverse orthopedists in 22 US states with varied hospital and surgeon practices. The secure, HIPAA compliant website was established that presents summary and risk-adjusted comparative statistics for primary TJR for all enrolled patients. The website provides a downloadable and printable report and an Executive Summary of key pre-operative patient risk factors, post-operative events, and post-operative PROs enabling the providers to compare their outcomes to the other participating sites. Individual patient reports are available for surgeons with real-time scores and trended outcome data to facilitate patient and surgeon shared treatment decision making. Conclusion/Implications: A secure reporting website was established to disseminate comparative outcome reports to all participating hospitals and surgeons. Returning comparative outcome data to hospitals and surgeons encourages their active participation in this national registry and allows them to undstand their relative performance compared to peers while supporting practice-level quality monitoring and improvement efforts in patient care

Lessons Learned From a Collaborative to Improve Care for Patients With Diabetes in 17 Community Health Centers, Massachusetts, 2006

INTRODUCTION: In 2006, the Massachusetts League of Community Health Centers convened a collaborative to systematically improve health care delivery for patients with diabetes in 17 community health centers. Our goal was to identify facilitators of and barriers to success reported by teams that participated in this collaborative. METHODS: The collaborative\u27s activities lasted 13 months. At their conclusion, we interviewed participating team members. We asked about their teams\u27 successes, challenges, and take-home messages for future collaborative efforts. We organized their responses into common themes by using the Chronic Care Model as a framework. RESULTS: Themes that emerged as facilitators of success included shifting clinic focus to more actively involve patients and to promote their self-management; improving the understanding and implementation of professional guidelines; and expanding staff roles to accommodate these goals. Patient registries were perceived as beneficial but lacking adequate technical support. Other barriers were staffing and time constraints. CONCLUSION: Cooperative efforts to improve health care delivery for people with diabetes may benefit from educating the health care team about guidelines, establishing a stronger role for the patient as part of the health care team, and providing adequate technical instruction and support for the use of clinical databases

A new approach to ensuring oral health care for people living with HIV/AIDS: the dental case manager

INTRODUCTION: The American Dental Association has identified several barriers to adequate dental care for vulnerable populations, including appropriate case management. The objective of this study was to examine the perceptions, attitudes, and beliefs of dental patients living with HIV/AIDS on the role and value of the dental case manager (DCM) and the effect of DCM services on their oral or overall health. METHODS: We used a qualitative descriptive study design and focus groups. Twenty-five people who had received DCM services on Cape Cod, Massachusetts, attended 1 of 5 focus groups in 2009 and 2010. Digital recordings of the groups were transcribed verbatim. Textual data were categorized using directed qualitative content analysis techniques. We identified major themes and representative quotes. RESULTS: The following themes emerged from discussions on the DCM\u27s role: being available, knowledgeable about clients and insurance, and empathetic; increasing access; and providing comfort. Most participants credited their oral and overall health improvements to the DCM. All participants believed that the DCM was a valuable addition to the clinic and noted that other at-risk populations, including the elderly and developmentally disabled, likely would benefit from working with a DCM. CONCLUSION: The addition of a DCM facilitated access to dental care among this sample of people living with HIV/AIDS, providing them with an advocate and resulting in self-reported improvements to oral and overall health

Social Support and Total Joint Replacement: Differences Preoperatively between Patients Living Alone and Those Living with Others

Introduction: Social relationships affect mental health, physical health, and mortality risk. Little is known about social support and patients electing to have total joint replacement (TJR) surgery. We explored the differences between participants living alone and those living with at least one other adult prior to TJR surgery. Materials & methods: Preoperative and 6 month postoperative FORCE-TJR Registry survey data were collected from 6269 primary unilateral TJR patients between May 2011 and December 2013. Data included demographics, comorbid conditions, operative joint pain severity (HOOS/KOOS), musculoskeletal disease burden, physical function (SF-36 PCS), and mental health (SF36 MCS). Results: Participants living alone were more likely to be older, female, on Medicare, with a high school education or less, and a racial/ethnic minority. Prior to surgery, they reported a greater number of comorbid conditions and non-surgical joints causing pain. Those living alone also had lower mean MCS summary measure, lower Social Functioning Scale score and a lower HOOS/KOOS Activities of Daily Living score before TJR. There were no differences preoperatively in mean BMI, mean PCS, or HOOS/KOOS surgical joint pain, symptoms, or quality of life scores between the two groups. Six months postoperatively, those living alone had lower mean PCS and MCS, but were more likely to report less pain and symptoms in the surgical joint. Unadjusted analyses of mean change over time found less improvement in PCS for those living alone compared to those not living alone. Conclusion: Recognizing differences in social support prior to TJR surgery could inform interventions and potentially influence patient reported outcomes postoperatively

Obesity Prevalence, Weight-Related Beliefs and Behaviors among Low-Income Ethnically Diverse National Job Corps Students

The obesity rates of Job Corps students, a predominantly ethnic minority and low income group of youth, are unknown. The purpose of this project was to examine obesity rates among these youth as well as their weight-related perceptions and behavior. First, medical charts (N=641) of all Job Corps students (ages 16-25) who were enrolled in the program in the past year were examined for height and weight. In the second phase of the study, 344 Job Corp students were recruited and information on weight perceptions, knowledge of obesity consequences, and weight loss behavior were examined. Almost half of the participants were overweight or obese. Overweight males were less likely to perceive themselves as being overweight than females. The majority of participants were aware of obesity-related health consequences but of those with past weight loss attempts, only 13% reported using both exercise and diet. High levels of overweight and obesity among Job Corps students are likely to impact employment and career goals. Evidence-based obesity interventions for Job Corps students are needed

Dissemination of Evidence-based Atypical Antipsychotic Information to Nursing Homes

Background: Accumulating evidence demonstrates minimal benefit and increased risk of off-label use of atypical antipsychotic medications for dementia-related behaviors. Optimal strategy for disseminating evidence-based guides to nursing home (NH) stakeholders is unclear. Our objective is to describe the impact of differing dissemination efforts in Connecticut NHs. Methods: Forty-three Connecticut NHs were randomized to one of 3 arms receiving incrementally intensive dissemination strategies of the Agency for Healthcare Research and Quality Comparative Effectiveness Review Summary Guide on the off-label use of atypical antipsychotic drugs, which was included in a toolkit informed by a needs assessment of NHs. All NHs received the paper-based toolkit and notifications regarding the online toolkit. Additionally, Arm 2 received individualized quarterly audit and feedback reports with atypical antipsychotic prescribing rates; Arm 3 received in-person educational visits and audit and feedback reports. Toolkit reach was assessed using interviews with NH leadership and staff. Online toolkit use was assessed using Google analytics. Results: Eighty leaders and 222 direct care staff were interviewed. Leadership and direct care staff in Arm 3 NHs were more likely to be familiar with the toolkit that those in Arm 1 (p=0.008) and Arm 2 (p Conclusions: Intensive dissemination, using multi-pronged approach including academic detailing and direct care staff trainings, appeared to be associated with higher familiarity with paper-based toolkit, but not Internet-based use of the toolkit in the NH setting