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

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

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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

Direct observation of charge inversion by multivalent ions as a universal electrostatic phenomenon

We have directly observed reversal of the polarity of charged surfaces in water upon the addition of tri- and quadrivalent ions using atomic force microscopy. The bulk concentration of multivalent ions at which charge inversion reversibly occurs depends only very weakly on the chemical composition, surface structure, size and lipophilicity of the ions, but is dominated by their valence. These results support the theoretical proposal that spatial correlations between ions are the driving mechanism behind charge inversion.Comment: submitted to PRL, 26-04-2004 Changed the presentation of the theory at the end of the paper. Changed small error in estimate of prefactor ("w" in first version) of equation

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

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

Isolation Without Taxation: {N}ear-Zero-Cost Transitions for {WebAssembly} and {SFI}

Software sandboxing or software-based fault isolation (SFI) is a lightweight approach to building secure systems out of untrusted components. Mozilla, for example, uses SFI to harden the Firefox browser by sandboxing third-party libraries, and companies like Fastly and Cloudflare use SFI to safely co-locate untrusted tenants on their edge clouds. While there have been significant efforts to optimize and verify SFI enforcement, context switching in SFI systems remains largely unexplored: almost all SFI systems use \emph{heavyweight transitions} that are not only error-prone but incur significant performance overhead from saving, clearing, and restoring registers when context switching. We identify a set of \emph{zero-cost conditions} that characterize when sandboxed code has sufficient structured to guarantee security via lightweight \emph{zero-cost} transitions (simple function calls). We modify the Lucet Wasm compiler and its runtime to use zero-cost transitions, eliminating the undue performance tax on systems that rely on Lucet for sandboxing (e.g., we speed up image and font rendering in Firefox by up to 29.7\% and 10\% respectively). To remove the Lucet compiler and its correct implementation of the Wasm specification from the trusted computing base, we (1) develop a \emph{static binary verifier}, VeriZero, which (in seconds) checks that binaries produced by Lucet satisfy our zero-cost conditions, and (2) prove the soundness of VeriZero by developing a logical relation that captures when a compiled Wasm function is semantically well-behaved with respect to our zero-cost conditions. Finally, we show that our model is useful beyond Wasm by describing a new, purpose-built SFI system, SegmentZero32, that uses x86 segmentation and LLVM with mostly off-the-shelf passes to enforce our zero-cost conditions; our prototype performs on-par with the state-of-the-art Native Client SFI system