Pain catastrophizing as a predictor for postoperative pain and opiate consumption in total joint arthroplasty patients.

BACKGROUND: Pain catastrophizing has been suggested as a prospective risk factor for poor postoperative pain outcomes in total joint arthroplasty (TJA). However, results from the previous studies have been mixed and have not controlled for postoperative opiate analgesic intake. This study investigates pain catastrophizing and postoperative pain intensity in TJA patients, adjusting for analgesic intake. We hypothesized that "pain catastrophizers" would exhibit higher pain scores and increased analgesic requirements postoperatively. METHODS: In this prospective cohort study, patients were defined as catastrophizers (PCS > 30), or non-catastrophizers (PCS ≤ 30). The primary outcome was the visual analog scale (VAS) pain score at 3-month follow-up. Secondary outcomes included length of stay (LOS) for the index hospitalization, total daily opiate analgesic intake, and VAS pain scores on postoperative days 0, 1, 2, and 3 through discharge. Multivariable regression was used to control for total daily morphine equivalent dose consumed during the stay in addition to other clinical and demographic factors. RESULTS: There were 87 patients in the "non-catastrophizing" and 36 in the "catastrophizing" groups. There was no clinically significant difference in VAS pain scores between groups at 3-month follow-up. Patients with a length of stay (LOS) ≥ 3 postoperative days differed in VAS pain scores ("non-catastrophizers" = 5.08 vs. "catastrophizers" = 7.13; p = 0.002) and were 2.4 times more likely to be catastrophizers than non-catastrophizers (p = 0.042). There were no differences in the remaining secondary outcomes. CONCLUSION: The pain catastrophizing scale is a poor predictor of postoperative pain at 3-month follow-up. However, it may be a risk factor for increased LOS.

Factors determining discharge destination for patients undergoing total joint arthroplasty.

Discharge destination to skilled nursing facilities (SNF) following total joint arthroplasty (TJA) plays an important role in healthcare costs. The pre-operative, intra-operative, and post-operative factors of 50 consecutive patients discharged to an SNF following TJA were compared to that of 50 consecutive patients discharged to home. Patients discharged to SNFs had slower pre-operative Get Up and Go scores (TGUG), lower pre-operative EQ-5D scores, higher ASA scores, increased hospital length of stay, increased self-reported post-operative pain, and decreased physical therapy achievements. We believe that the results of this study indicate that patients who get discharged to SNFs fit a certain criteria and this may be used to guide post-operative discharge destination during pre-operative planning, which can help lower costs while helping decrease the length of inpatient stay.

Do patients with income-based insurance have access to total joint arthroplasty?

The Patient Protection and Affordable Care Act (PPACA) is expected to increase health care availability through Medicaid expansion. The objective of this study was to evaluate potential effects of the PPACA by examining access to total hip arthroplasty in Southern California. 39 orthopaedic surgeons were called to schedule a hip arthroplasty. Insurances used included a Preferred Provider Organization (PPO), Medicare, and three income-based insurances. There was a significant difference in acceptance rate when comparing PPO and Medicare patients with income-based insurances (P < 0.001). This study showed that in Southern California, patients with income-based insurances are limited in the number of surgeons from whom they can receive care. Thus, although the PPACA will increase the number of insured patients, it may not similarly increase access to providers.