Price Transparency and Consumer Perceptions of Generic and Brand-name Implants in Orthopaedic Surgery.

Background: Some have suggested the use of generic surgical implants to curb rising costs of orthopaedic care. However, there is evidence that patients are reluctant to use generic pharmaceuticals as compared to their brand name equivalents for fear of inferior quality. Public perception of the use of generic implants remains unknown. Methods: We conducted a cross-sectional survey using Amazon MTurk to identify factors associated with a consumer preference for generic orthopaedic screws and total hip. Results: While much of the public (52%) sees the value of generic implants, fewer (26%) would prefer them in their own care. Most respondents (75%) trust their surgeon's choice, yet the vast majority (83%) want to be informed about the cost of their implant, even if it makes no difference in what they pay. The agreement that older implants are safer than newer implants (OR 1.9 for screws; 2.5 for hip arthroplasty), and that generics are a better value than brand name implants (OR 3.0 for screws; 4.3 for hip arthroplasty) were independently associated with a preference for generics. Conclusion: The observation that many people view generic implants as being a good value, yet fewer would prefer to use them in their own care indicates that concerns over quality may initially limit utilization of generic implants. More evidence is needed to reassure most consumers of the safety and effectiveness of generic implants. Additionally, our findings demonstrate a desire for more implant price transparency when undergoing orthopaedic surgery.

Liposomal bupivacaine in posterior spine surgery: A piece of the puzzle for postoperative pain.

Background: Liposomal bupivacaine (LB) is a local analgesic that may be used at the time of surgery to limit postoperative pain around the surgical site. Its efficacy in decreasing pain, decreasing narcotic consumption, decreasing length of stay, and improving mobility is an area of intense research. The purpose of this study was to determine whether LB use was associated with improved patient-reported pain scores in the first 72 h following posterior spinal surgery, decreased postoperative narcotic need, and decreased length of stay. Methods: One hundred and five patients undergoing elective posterior cervical or lumbar surgery were included in retrospective analysis. Forty-eight patients who received LB intraoperatively were compared with a historical cohort of 56 patients who underwent similar procedures and did not receive postsurgical infiltration with local analgesia. The same pain medication protocol was utilized postoperatively. Results: Demographics, clinical characteristics, and total morphine milligram equivalents did not differ significantly between the groups. The treatment group averaged a decreased length of stay (1.85 days treatment, 2.68 days control, p = 0.057). Treatment with LB was associated with lower pain levels at 24 h (5.2 treatment, 6.4 control, p = 0.04) and 48-72 h (4.9 treatment, 6.6 control, p = 0.007) after surgery. Conclusions: LB improved patient perception of pain in the acute postoperative time period.Intraoperative LB injection, coupled with focused early mobilization efforts and multimodal pain control, may lead to improved patient-reported outcomes, shorter length of stay, and decreased risk of perioperative complications.

General Anxiety Is Associated with Problematic Initial Recovery After Carpal Tunnel Release.

BACKGROUND: Carpal tunnel release can stop the progression of idiopathic median neuropathy at the wrist (carpal tunnel syndrome). Intermittent symptoms tend to resolve after surgery, but loss of sensibility can be permanent. Both pathophysiology (severe neuropathy) and mental health (symptoms of despair or worry) contribute to problematic recovery after carpal tunnel release, but their relative associations are unclear. QUESTION/PURPOSE: Is problematic initial recovery after carpal tunnel release associated with psychologic distress rather than with disease severity? METHODS: We retrospectively studied 156 patients who underwent in-office carpal tunnel release between November 2017 and February 2020, and we recorded their symptoms of anxiety (Generalized Anxiety Disorder-7 [GAD]) and depression (Patient Health Questionnaire), signs of severe median neuropathy (loss of sensibility, thenar muscle atrophy, and palmar abduction weakness), and problematic recovery. The initial recovery (first 2 weeks) was categorized as problematic if the patient was upset about persistent numbness, experienced unsettling postoperative pain, developed hand stiffness, or experienced wound issues-all of which are routinely recorded in the medical record by the treating surgeon along with signs of severe median neuropathy. Twenty-four percent (38 of 156) of patients had a problematic initial recovery characterized by distress regarding persistent numbness (16% [25 of 156]), unsettling pain (8% [12 of 156]), hand stiffness (5% [8 of 156]), or wound issues (1% [2 of 156]); 6% (9 of 156) of patients had more than one issue. Associations between problematic initial recovery and age, gender, symptoms of anxiety and depression, disease severity, specific exam findings, and insurance were evaluated using t-tests, Mann-Whitney tests, and chi-square tests, with the plan to perform logistic regression if at least two variables had an association with p < 0.10. RESULTS: The only factor associated with problematic initial recovery was greater symptoms of anxiety (median GAD score 1.5 [interquartile range 0 to 7.8] for problematic initial recovery compared with a median score of 0 [IQR 0 to 2] for nonproblematic recovery; p = 0.04), so we did not perform a logistic regression. Physical examination findings consistent with severe median neuropathy were not associated with problematic initial recovery. CONCLUSION: The finding that problematic initial recovery after carpal tunnel release was related to symptoms of anxiety and not to the severity of median neuropathy highlights the need to study the ability of efforts to ameliorate anxiety symptoms before carpal tunnel release as an effective intervention to reduce unplanned visits and additional tests, therapy, and repeat surgery, while improving patient-reported outcomes and experience. LEVEL OF EVIDENCE: Level III, therapeutic study.

What factors are associated with perceived disease onset in patients with hip and knee osteoarthritis?

INTRODUCTION: Newly symptomatic osteoarthritis (OA) is often misinterpreted as new pathology or injury, which is associated with pain intensity and incapability. METHODS: Adult patients with hip and knee OA completed measures of catastrophic thinking, depression, capability, symptom duration, and perceived injury. RESULTS: Symptom duration was associated with OA grade and symptoms of depression. Perceived injury was common (31%) and associated with men and knee arthritis. Capability was associated with misinterpretation of symptoms and the work status 'other,' but not radiographic severity. CONCLUSIONS: Misinterpretation of OA symptoms is common and has a greater influence on capability than radiographic grade of pathophysiology.

Convenience is Key for Patient Engagement with Remote Video Visits in a Musculoskeletal Practice.

BACKGROUND: Remote video visits (aka telemedicine, virtual care) have the potential to increase access to orthopaedic specialty evaluation while decreasing the overall cost of care. Clinical implementation of remote video visits may benefit from an understanding of potential barriers to participation. METHODS: We enrolled one hundred and thirty participants from a university-based musculoskeletal clinic with a large uninsured population. We asked participants to complete a survey, including demographics and scaled perception questions about remote video visits. Data from these surveys were analyzed with multivariable logistic regression to determine factors associated with willingness to participate in video visits, as well as the situations in which patients would consider a video visit. RESULTS: Willingness to participate in video visits was associated with the perception of video visits being more convenient (OR 3.0) and a decreased perceived importance of physical exam (OR 0.36) but not age, technology comfort, or travel distance to the clinic. Additionally, those with prior video visit experience were more comfortable with technology, perceived video visits to be more convenient, and were more willing to have another video visit. Fifteen percent were willing to have a video visit for their first visit, while 78% would participate for a routine non-surgical follow-up. CONCLUSION: Musculoskeletal telemedicine programs can become established by focusing on people that prioritize convenience, place less importance on a hands-on exam, and are established patients.

Mental-Health Phenotypes and Patient-Reported Outcomes in Upper-Extremity Illness.

BACKGROUND: Prior studies have suggested that misconceptions (i.e., unhelpful thoughts or cognitive errors resulting from cognitive bias) and distress (symptoms of anxiety or depression) are key factors associated with variation in health, as quantified with use of patient-reported outcome measures. The primary purpose of the present study was to identify mental-health phenotypes (i.e., combinations of various types of misconceptions and distress) that might help direct care and to test for differences in magnitude of activity tolerance, pain intensity, and self-efficacy in response to pain between phenotypes. We also studied demographic factors and diagnostic categories associated with mental-health phenotypes. METHODS: In a cross-sectional study, 137 patients seeking upper-extremity musculoskeletal specialty care completed a survey including demographics, mental-health questionnaires, and measures of upper-extremity-specific activity tolerance, pain intensity, and pain self-efficacy. We used cluster analysis to identify groups of patients with similar phenotypes. We used analysis of variance testing to assess differences in activity tolerance, pain intensity, and pain self-efficacy among phenotypes. RESULTS: The cluster analysis yielded 4 unique mental-health phenotypes, which fit the theoretical conceptualizations of "low misconception and low distress," "notable misconception," "notable depression and notable misconception," and "notable anxiety, depression, and misconception." Patients with low bias and low distress had significantly greater activity tolerance and greater pain self-efficacy than the other phenotypes, as well as a significantly lower pain intensity than phenotypes with notable distress. CONCLUSIONS: Cluster analysis of mental-health questionnaire data can identify mental-health phenotypes that are associated with greater activity tolerance and pain intensity. This approach might help clinicians to strategize and prioritize approaches that correct unhelpful thoughts and ameliorate symptoms of distress among patients seeking musculoskeletal specialty care. Such strategies have the potential to achieve more comprehensive, whole-person care, more selective operative treatment, and improved outcomes. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinician Telemedicine Perceptions During the COVID-19 Pandemic.

Background: Telemedicine utilization increased exponentially due to the coronavirus disease 2019 (COVID-19) pandemic. As a result, most clinicians now have experience with telemedicine. Questions/Purposes: We studied factors independently associated with a clinician desiring to continue telemedicine services after the COVID-19 pandemic. Secondarily, we sought factors independently associated with clinician satisfaction with the quality of care provided through telemedicine and factors associated with telemedicine platform preference by clinicians. Methods: A large multispecialty medical group of physicians were invited to complete a survey, including demographics, telemedicine experience, satisfaction with various elements of telemedicine encounters, desired features in a telemedicine platform, personality traits, and preferences. A total of 220 complete responses were analyzed. Results: A desire to continue offering telemedicine visits after the COVID-19 pandemic was independently associated with a higher satisfaction with the quality of telemedicine care, endorsement of the ease of performing a physical examination with telemedicine, belief that adaptability is an important element of being a clinician, and less preference for in-person work meetings over virtual meetings. Higher satisfaction with the quality of telemedicine care was associated with belief that adaptability is an important element of being a clinician, clinicians who identify as being more perceiving (value flexibility) than judging (value organization), providers from relatively urban counties, and those with less preference for in-person work meetings over virtual meetings. Clinicians ranked ease of use for patients and physicians as the most important features of telemedicine platforms. Conclusions: The observed association of clinician personality and interpersonal preferences with the appeal, satisfaction, and perceived effectiveness of telemedicine merit additional study. Early implementation of telemedicine might be easiest with clinicians that take pride in their adaptability and value a technology-based workstyle.