Successful implementation of a quality improvement bundle to reduce opioid overprescribing following total hip and knee arthroplasty.

BACKGROUND: Opioid overprescribing is commonplace after total hip (THA) and total knee arthroplasty (TKA). Preliminary data demonstrated that approximately 32% of the opioids prescribed at discharge from our hospital following THA and TKA remain unused. This is a concern given that unused prescribed opioids are available for diversion and may result in misuse and abuse. METHODS: Pre-intervention data were collected between 1 November 2018 and 10 December 2018. An intervention bundle was then introduced, including education of patients and providers, a standardised pain management algorithm and an autopopulated discharge prescription. The aim of this quality improvement initiative was to reduce the amount of opioid (average oral morphine equivalents (OME)) dispensed (based on the discharge prescription provided) following THA and TKA at our institution by 15% by 1 April 2019. DESIGN: Using an interrupted time series design, the outcome measure was the amount of opioid (OME) dispensed from the discharge prescription provided. Process measures included the percentage of autopopulated discharge prescriptions, the percentage of patients receiving education at discharge and the percentage of nurses and residents receiving standardised education. Balancing measures included patient satisfaction with postoperative pain management, and the percentage of patients filling the second half of the part-fill or requiring a subsequent opioid prescription. RESULTS: With 600 patients identified, mean OME dispensed at discharge was reduced by 26.3% (from 522.2 to 384.9 mg) after our interventions started. Utilisation of autopopulated part-fill prescriptions was 95.8%. There was no change in patient satisfaction nor in the proportion of patients requiring an additional opioid prescription post-intervention. Only 39% of patients filled the second half of the part-fill prescription post-intervention. CONCLUSIONS: Mean OME dispensed at discharge per patient was reduced with no change in patient satisfaction after introduction of the intervention bundle.

Opioid prescribing and utilization patterns in patients having elective hip and knee arthroplasty: association between prescription patterns and opioid consumption.

PURPOSE: Although guidelines can reduce postoperative opioid prescription, the problem of unused opioids persists. We assessed the pattern of opioid prescription and utilization after total hip arthroplasty (THA) and total knee arthroplasty (TKA). We hypothesized that opioid prescription patterns can influence opioid utilization. METHODS: With institutional ethics approval, patients undergoing THA and TKA were enrolled prospectively. Surveys on opioid use were completed at two, six, and 12 weeks after surgery. Patients' age, sex, American Society of Anesthesiologists' Physical Status score, first 24-hr opioid consumption, quantity of opioid prescribed, and quantity of opioid utilized were analyzed to evaluate their effect on opioid consumption, unused opioid, and patient satisfaction. RESULTS: Patients received prescriptions ranging from 200 morphine milligram equivalents (MME) to 800 MME. Three hundred and thirty THA and 230 TKA patients completed the surveys. Opioid utilization was influenced by the amount of prescribed opioids for both THA and TKA. The percentage of prescribed opioids used (~55% in THA and ~75% in TKA) and the proportion of patients using all prescribed opioids (~22% in THA and ~50% in TKA) were higher after TKA vs THA (P < 0.001 for both). Patients who used opioids for two days or less accounted for most (~50%) of the unused opioid. Patient satisfaction remained high and was not influenced by the amount of prescribed opioid. CONCLUSION: This study showed that larger prescriptions are associated with higher opioid consumption. A wide variation in opioid consumption requires approaches to minimize the initial opioid prescription and to provide additional prescriptions for patients that require higher levels of analgesia.

RéSUMé: OBJECTIF: Bien que les lignes directrices puissent réduire la prescription d'opioïdes postopératoires, le problème des opioïdes inutilisés persiste. Nous avons évalué les schémas de prescription et d'utilisation d'opioïdes après une arthroplastie totale de la hanche (ATH) et une arthroplastie totale du genou (ATG). Nous avons émis l'hypothèse que les schémas de prescription d'opioïdes pouvaient influencer l'utilisation des opioïdes. MéTHODE: Avec l'approbation du comité d'éthique de notre établissement, les patients bénéficiant d'une ATH et une ATG ont été recrutés de manière prospective. Les questionnaires sur la consommation d'opioïdes ont été complétés deux, six et 12 semaines après la chirurgie. L'âge, le sexe et le score de statut physique selon l'American Society of Anesthesiologists des patients, ainsi que la consommation d'opioïdes au cours des premières 24 heures postopératoires, la quantité d'opioïdes prescrits et la quantité d'opioïdes utilisés ont été analysés pour évaluer leur effet sur la consommation d'opioïdes, les opioïdes inutilisés et la satisfaction des patients. RéSULTATS: Les patients ont reçu des ordonnances allant de 200 équivalents de morphine en milligrammes (EMM) à 800 EMM. Trois cent trente patients bénéficiant d'une ATH et 230 patients d'une ATG ont répondu aux questionnaires. L'utilisation des opioïdes a été influencée par la quantité d'opioïdes prescrits pour l'ATH et l'ATG. Le pourcentage d'opioïdes prescrits utilisés (~55 % dans l'ATH et ~75 % dans l'ATG) et la proportion de patients utilisant tous les opioïdes prescrits (~22 % dans l'ATH et ~50 % dans l'ATG) étaient plus élevés après l'ATG vs l'ATH (P < 0,001 pour les deux). Les patients qui ont utilisé des opioïdes pendant deux jours ou moins étaient à l'origine de la plupart (~ 50%) des opioïdes inutilisés. La satisfaction des patients est demeurée élevée et n'a pas été influencée par la quantité d'opioïdes prescrits. CONCLUSION: Cette étude a démontré que les ordonnances plus élevées sont associées à une consommation plus élevée d'opioïdes. Une grande variation dans la consommation d'opioïdes nécessite des approches visant à minimiser la prescription initiale d'opioïdes et à fournir des ordonnances supplémentaires aux patients qui nécessitent des niveaux plus élevés d'analgésie.

Comparative clinical and cost analysis between surgical and non-surgical intervention for knee osteoarthritis.

OBJECTIVE: To evaluate the management and costs of osteoarthritis of the knee (OAK), a progressive joint disease due to bone and cartilage degeneration, with significant personal and societal impact. METHODS: We prospectively analyzed the clinical outcomes and quantifiable cumulative direct costs of patients with OAK referred to our multidisciplinary OA program over a two year time period. One hundred thirty-one subjects were assessed. All demonstrated radiographic criteria for moderate to severe OAK. Western Ontario McMaster Osteoarthritis Index (WOMAC), Minimal Clinically Important Improvement (MCII), and change in BMI were recorded and analyzed. Total medical and surgical direct costs for all subjects during the two year time period were determined. RESULTS: Five patients underwent total joint replacement during the two years of study. Among the group as a whole, a significant overall improvement in WOMAC scores was noted at the two year time point follow-up. After dividing the group into tertiles by baseline WOMAC scores, 46% achieved MCII. Significant weight loss was noted for individuals with baseline BMI of > 30. As all patients were considered "de facto" surgical candidates at referral, an average net savings of $9551.10 of direct costs per patient, or a potential total of $1,203,438.60 for the entire group, could be inferred as a result of medical as opposed to surgical management. CONCLUSION: These findings support the benefits of multidisciplinary medical management for patients with significant OAK. This approach is clinically beneficial and may provide significant cost savings. Such models of care can substantially improve the long-term outcome of this highly prevalent condition and reduce societal and financial burdens.

Telemedicine delivery of patient education in remote Ontario communities: feasibility of an Advanced Clinician Practitioner in Arthritis Care (ACPAC)-led inflammatory arthritis education program.

OBJECTIVE: Telemedicine-based approaches to health care service delivery improve access to care. It was recognized that adults with inflammatory arthritis (IA) living in remote areas had limited access to patient education and could benefit from the 1-day Prescription for Education (RxEd) program. The program was delivered by extended role practitioners with advanced training in arthritis care. Normally offered at one urban center, RxEd was adapted for videoconference delivery through two educator development workshops that addressed telemedicine and adult education best practices. This study explores the feasibility of and participant satisfaction with telemedicine delivery of the RxEd program in remote communities. MATERIALS AND METHODS: Participants included adults with IA attending the RxEd program at one of six rural sites. They completed post-course program evaluations and follow-up interviews. Educators provided post-course feedback to identify program improvements that were later implemented. RESULTS: In total, 123 people (36 in-person and 87 remote, across 6 sites) participated, attending one of three RxEd sessions. Remote participants were satisfied with the quality of the video-conference (% agree/strongly agree): could hear the presenter (92.9%) and discussion between sites (82.4%); could see who was speaking at other remote sites (85.7%); could see the slides (95.3%); and interaction between sites adequately facilitated (94.0%). Educator and participant feedback were consistent. Suggested improvements included: use of two screens (speaker and slides); frontal camera angles; equal interaction with remote sites; and slide modifications to improve the readability on screen. Interview data included similar constructive feedback but highlighted the educational and social benefits of the program, which participants noted would have been inaccessible if not offered via telemedicine. CONCLUSION: Study findings confirm the feasibility of delivering the RxEd program to remote communities by using telemedicine. Future research with a focus on the sustainability of this and other models of technology-supported patient education for adults with IA across Ontario is warranted.

A prospective comparison of telemedicine versus in-person delivery of an interprofessional education program for adults with inflammatory arthritis.

Introduction We evaluated two modes of delivery of an inflammatory arthritis education program ("Prescription for Education" (RxEd)) in improving arthritis self-efficacy and other secondary outcomes. Methods We used a non-randomized, pre-post design to compare videoconferencing (R, remote using telemedicine) versus local (I, in-person) delivery of the program. Data were collected at baseline (T1), immediately following RxEd (T2), and at six months (T3). Self-report questionnaires served as the data collection tool. Measures included demographics, disorder-related, Arthritis Self-Efficacy Scale (SE), previous knowledge (Arthritis Community Research and Evaluation Unit (ACREU) rheumatoid arthritis knowledge questionnaire), coping efficacy, Illness Intrusiveness, and Effective Consumer Scale. Analysis included: baseline comparisons and longitudinal trends (R vs I groups); direct between-group comparisons; and Generalized Estimating Equations (GEE) analysis. Results A total of 123 persons attended the program (I: n = 36; R: n = 87) and 111 completed the baseline questionnaire (T1), with follow-up completed by 95% ( n = 117) at T2 and 62% ( n = 76) at T3. No significant baseline differences were found across patient characteristics and outcome measures. Both groups (R and I) showed immediate effect (improved arthritis SE, mean change (95% confidence interval (CI)): R 1.07 (0.67, 1.48); I 1.48 (0.74, 2.23)) after the program that diminished over six months (mean change (95% CI): R 0.45 (-0.1, 0.1); I 0.73 (-0.25, 1.7)). For each of the secondary outcomes, both groups showed similar trends for improvement (mean change scores (95% CI)) over time. GEE analysis did not show any meaningful differences between groups (R vs I) over time. Discussion Improvements in arthritis self-efficacy and secondary outcomes displayed similar trends for I and R participant groups.

Visual assessment of the spine bruckel instrument, a novel status tool to reflect appearance of the spine in patients with ankylosing spondylitis.

OBJECTIVE: The Visual Assessment of the Spine Bruckel Instrument (VASBI) is a new status tool developed by the Spondylitis Association of America and the University of Toronto to reflect spinal appearance in patients with ankylosing spondylitis (AS). Our objective was to validate the VASBI according to the Outcome Measures in Rheumatoid Arthritis Clinical Trials filter (truth, discrimination, and feasibility). METHODS: Three hundred patients with AS were asked to rate their degree of perceived spinal deformity using the VASBI. To evaluate construct validity, VASBI scores were compared with functional outcome, spinal mobility, and radiographic spinal damage. Test-retest reliability was evaluated using kappa statistic (kappa). RESULTS: Patient VASBI demonstrated strong correlation with spinal mobility (r = 0.543) and moderate correlation with functional impairment (r = 0.490) and structural damage (r = 0.309). Reliability for VASBI was very good (kappa = 0.973, p < 0.001). CONCLUSION: The VASBI is a novel tool with practical applications in a busy clinical setting as it simplifies assessment of AS spinal deformity. Our study demonstrates that the VASBI has good feasibility, construct validity, and reliability.