Impact of practicing internal benchmarking on continuous improvement of cataract surgery outcomes: a retrospective observational study at Aravind Eye Hospitals, India.

OBJECTIVE: We aim to assess the effectiveness of a cataract surgery outcome monitoring tool used for continuous quality improvement. The objectives are to study: (1) the quality parameters, (2) the monitoring process followed and (3) the impact on outcomes. DESIGN AND PROCEDURES: In this retrospective observational study we evaluated a quality improvement (QI) method which has been practiced at the focal institution since 2012: internal benchmarking of cataract surgery outcomes (CATQA). We evaluated quality parameters, procedures followed and clinical outcomes. We created tables and line charts to examine trends in key outcomes. SETTING: Aravind Eye Care System, India. PARTICIPANTS: Phacoemulsification surgeries performed on 718 120 eyes at 10 centres (five tertiary and five secondary eye centres) from 2012 to 2020 were included. INTERVENTIONS: An internal benchmarking of surgery outcome parameters, to assess variations among the hospitals and compare with the best hospital. OUTCOME MEASURES: Intraoperative complications, unaided visual acuity (VA) at postoperative follow-up visit and residual postoperative refractive error (within ±0.5D). RESULTS: Over the study period the intraoperative complication rate decreased from 1.2% to 0.6%, surgeries with uncorrected VA of 6/12 or better increased from 80.8% to 89.8%, and surgeries with postoperative refractive error within ±0.5D increased from 76.3% to 87.3%. Variability in outcome measures across hospitals declined. Additionally, benchmarking was associated with improvements in facilities, protocols and processes. CONCLUSION: Internal benchmarking was found to be an effective QI method that enabled the practice of evidence-based management and allowed for harnessing the available information. Continuous improvement in clinical outcomes requires systematic and regular review of results, identifying gaps between hospitals, comparisons with the best hospital and implementing lessons learnt from peers.

Medical Cannabis Certification Is Associated With Decreased Opiate Use in Patients With Chronic Pain: A Retrospective Cohort Study in Delaware.

Background Opioid medications are commonly used to treat chronic pain around the world. While these medications are quite effective at reducing pain, they can create opioid dependence and lead to further drug addiction. Long-term opioid use has significantly contributed to the "opioid epidemic" that is currently ravaging the United States, leading to opioid overdoses and unintentional deaths, particularly in Delaware. Objective To determine if medical marijuana certification helps patients in Delaware with chronic pain reduce their opiate use. Methods In this study, we examined individuals who were provided with legal; medical cannabis certifications in the state of Delaware between June 2018 and October 2019 and were concurrently being treated with opioid medications for chronic pain at a private pain management practice. Using a posthoc analysis, we conducted a retrospective cohort study on the individuals (n = 81) to determine if there was a decrease in their opioid use following medical cannabis certification. Opioid use was measured in morphine milligram equivalent (MME) through the Delaware prescription monitoring program (PMP) database. Results Overall, the average change in prescribed opioid use was found to be -12.3 morphine milligram equivalent (MME) units when including all individuals (p < 0.00001). Among the included individuals with baseline opioid use, medical cannabis certification was associated with a 31.3% average decrease in opioid use (n = 63). When examining subgroups based upon pain location, individuals with neck pain displayed a 41.5% average decrease in MME (n = 27), while individuals with low back pain were observed to have a 29.4% decrease in opioid use (n = 58). Similarly, individuals with knee pain (n = 14) reduced their opioid use by 32.6%. Conclusion The results display an association between medical cannabis certification and a decrease in opiate use among the study group individuals. This study suggests that medical cannabis use may help individuals to reduce their opiate requirements along with physician intervention. More research is needed to validate these findings with appropriate controls and verification of cannabis use.

Repetitive Transcranial Magnetic Stimulation in Chronic Pain: A Meta-analysis.

BACKGROUND: In this meta-analysis, we explore the role of repetitive transcranial magnetic stimulation (rTMS), a noninvasive neuromodulation technique in the treatment of chronic pain. METHODS: Studies comparing rTMS and conventional treatment for chronic pain were searched. The comparison was made for decrease in the pain scores with and without (sham) the use of rTMS after a follow-up interval of 4-8 weeks. All reported pain scores were converted into a common scale ranging from "0" (no pain) to "10" (worst pain). RESULTS: Nine trials with 183 patients in each of the groups were included in the analysis. The decrease in pain scores with rTMS was 1.12 (95% confidence interval [CI] being 1.46-0.78) (fixed effects, I2 = 0%, P < 0.001) and in sham-rTMS was 0.28 (95% CI being 0.49-0.07) (Fixed effects, I2 = 0, P = 0.01). The pooled mean drop in pain scores with rTMS therapy was higher by 0.79 (95% CI being 0.26-1.33) (fixed effects, I2 = 0, P < 0.01). The duration and frequency of rTMS were highly variable across trials. Publication bias was unlikely (Egger's test, X-intercept = 0.13, P = 0.75). CONCLUSIONS: Use of rTMS improves the efficacy of conventional medical treatment in chronic pain patients. This treatment is not associated with any direct adverse effects. However, the duration and frequency of rTMS therapy is presently highly variable and needs standardization.

Deep Transcranial Magnetic Stimulation: A Promising Drug-Free Treatment Modality in the Treatment of Chronic Low Back Pain.

UNLABELLED: Deep Transcranial Magnetic Stimulation (dTMS) is the next generation of technology used to treat Major Depressive Disorder (MDD). dTMS has been proven to be a safe and effective treatment modality for MDD and may have secondary benefits in patients with chronic low back pain by reducing pain related morbidity. We are presenting two case studies with MDD and chronic low back pain to demonstrate the effectiveness of both the antidepressant and analgesic effects of dTMS. BACKGROUND: Transcranial Magnetic Stimulation (rTMS) utilizes MRI-strength magnetic pulses outside the cranium to stimulate the brain to a depth of approximately 1 cm. The technique was approved by the US Food and Drug Administration (FDA) for the treatment of Major Depressive Disorder (MDD) in 2008. In 2013 the Brainsway Deep Transcranial Magnetic Stimulation (dTMS) device, which has the potential for cranial penetration up to 5 cm received FDA clearance for pharmacotherapy and psychotherapy resistant MDD. The mechanism of action of dTMS in MDD is not completely understood. However, its clinical efficacy is proven.' The effect of dTMS on the brain has been studied since 1985 in clinical trials and has been demonstrated as an effective treatment modality for refractory depressive symptoms. The mechanism of action of dTMS is thought to be mediated by increased connectivity between the dorsolateral prefrontal cortex (DLPFC) and the thalamus and reduced subgenual cingulate to caudate connectivity. These brain areas are believed to be responsible for modulating mood. Chronic pain is often accompanied by MDD. Specifically, chronic low back pain is highly prevalent and accompanied by significant disability.2 Low back pain is defined as chronic when the pain is continuous for more than three months. The current chronic pain treatment algorithm includes judicious use of non pharmacological interventions like physical therapy, chiropractic adjustments, therapeutic massage, or acupuncture combined with pharmacological interventions that utilize non-narcotic or narcotic oral medications, spinal/paraspinal injections and, in selected cases, surgery. In patients who fail this extensive algorithm for chronic pain management and are left with significant morbidity and disability, coincident MDD frequently becomes refractory to therapy. Two illustrative examples of chronic low back pain patients with medically refractory MDD treated successfully using dTMS are presented here to discuss the potential therapeutic benefits for both MDD and chronic low back pain in this setting.