A Novel Preoperative Patient Survey Predicts Adverse Patient Outcomes-Implementation and Preliminary Results of the Tennessee Preoperative Assessment Tool.

BACKGROUND: Accurate preoperative risk stratification remains elusive. Existing tools are often missing important patient-reported and functional factors. We sought to implement a novel tool, with dynamic functional data and comorbidity variables, to define factors which predict postoperative outcomes. MATERIALS AND METHODS: We expanded a previously validated functional questionnaire to create the Tennessee Preoperative Assessment Tool (TPAT). Unique elements included change in functional status, usual and best activity tolerance, and development of new conditions. The survey was administered to all new patients seen in several surgery clinics from July 2021 to June 2022. RESULTS: A total of 1950 patients completed the survey. Of the completed surveys, 197 patients underwent an elective, inpatient, abdominal surgery and were included in the study. Several patient-reported factors were associated with poor postoperative outcomes. For example, decrease in functional activity in the previous 60 days (n = 50; 25.4%) was a strong predictor of poor postoperative outcomes including readmission (30-day: 8.8% vs .0%; P = .034), wound dehiscence (12.0% vs 3.4%; P = .022), blood transfusion (6.0% vs .0%; P = .003), sepsis (4.0% vs .0%; P = .015), and wound infection (18.0% vs 6.8%; P = .076). DISCUSSION: In this preliminary implementation study, patients undergoing elective, inpatient, abdominal surgery, utilization of a novel, patient-reported survey tool proactively identifies patients at risk of clinically relevant postoperative outcomes. Patient-reported decreased activity in the 60 days prior to surgeon evaluation was associated with several adverse postoperative outcomes. Additionally, this study demonstrates that the TPAT can be seamlessly integrated into the usual clinical workflow and is hypothesis generating for future interventional studies.

Developing and Validating a Novel Tool to Enhance Functional Status Assessment: The Tennessee Functional Status Questionnaire (TFSQ).

PURPOSE: Functional status is a major contributor to overall health and reflects both daily activity level (performance) and maximum attainable activity level (capacity). Existing assessment tools evaluate only 1 domain of function and do not provide insight into contributors to functional decline. We addressed these deficiencies by developing the Tennessee Functional Status Questionnaire (TFSQ), which reports activity levels in metabolic equivalents (METs) and evaluates 5 key areas: performance, capacity, activity, pain, and acute care. We validated the activity levels reported by the TFSQ against the Duke Activity Status Index (DASI). METHODS: In this prospective, observational study, 120 patients completed both the TFSQ and the DASI. TFSQ-reported functional performance and capacity was correlated with DASI-calculated METs. RESULTS: Pearson correlation between TFSQ-reported capacity and DASI-calculated METs was r = 0.69, P < .001. TFSQ capacity was significantly lower in patients who reported recently decreased activity, pain affecting function, or recent acute care exposure. CONCLUSIONS: The TFSQ is a brief and efficient assessment of patient function, standardized to METs and validated against the DASI. Our study suggests that many patients may have the functional reserve to increase daily physical activity and that factors such as changes in activity, pain, and recent acute care interaction may lower functional capacity.

Racial and Socioeconomic Disparities in Spinal Cord Stimulation Among the Medicare Population.

INTRODUCTION: Spinal cord stimulation (SCS) is used in the treatment of many chronic pain conditions. This study investigates racial and socioeconomic disparities in SCS among Medicare patients with chronic pain. MATERIALS AND METHODS: Patients over the age of 18 with a primary diagnosis of postlaminectomy syndrome (ICD-10 M96.1) or chronic pain syndrome (ICD-10 G89.4) were identified in the Center for Medicare and Medicaid Services (CMS) Medicare Claims Limited Data Set. We defined our outcome as SCS therapy by race and socioeconomic status. Multivariable logistic regression was used to determine the variables associated with SCS. RESULTS: We identified 1,244,927 patients treated between 2016 and 2019 with a primary diagnosis of postlaminectomy syndrome (PLS) or chronic pain syndrome (CPS). Of these patients, 59,182 (4.8%) received SCS. Multivariable logistic regression analysis revealed that, compared with White patients, Black (OR [95%CI], 0.62 [0.6-0.65], p < 0.001), Asian (0.66 [0.56-0.76], p < 0.001), Hispanic (0.86 [0.8-0.93], p < 0.001), and North American Native (0.62 [0.56-0.69], p < 0.001) patients were significantly less likely to receive SCS. In addition, patients who were dual-eligible for Medicare and Medicaid were significantly less likely to receive SCS than those eligible for Medicare only (OR = 0.38 [95% CI: 0.37-0.39], p < 0.001). CONCLUSIONS: This study suggests that racial and socioeconomic disparities exist in SCS among Medicare and Medicaid patients with PLS and CPS. Further work is required to elucidate the complex etiology underlying these findings.

Targeting Occipital Headache Pain: Preliminary Data Supporting an Alternative Approach to Occipital Nerve Block.

BACKGROUND AND OBJECTIVES: Occipital nerve block (ONB) is an effective procedure for treating occipital headache pain. However, traditional suboccipital approaches to ONB remain underutilized in acute and chronic settings. An alternative location for ONB is the superior nuchal line, where anatomic studies show a reliable relationship between the occipital artery (OA) and greater occipital nerve. This study evaluated the efficacy and validity of an alternative, single skin insertion, paresthesia-based approach to block both the greater and lesser occipital nerve. MATERIALS AND METHODS: Patients with a clinical diagnosis of occipital headache were included in this study. External landmarks of the cervical spinous process and ipsilateral tragus were used to predict the location of the OA pulse at the superior nuchal line. Alternative ONB technique was used to block both the greater and lesser occipital nerves using single skin insertion and paresthesia confirmation. Demographic data, preprocedure, and postprocedure pain scores were collected, along with the incidence of procedural outcomes, including OA pulse palpation, paresthesia, and postprocedure numbness. RESULTS: Data were obtained prospectively from 50 patients. Mean pain scores for the sample decreased by 54.64% postprocedure (P<0.001). Greater occipital nerve paresthesia was confirmed 90.0% on the left (95% confidence interval [CI]: 76.3-97.2) and 90.9% on the right side (95% CI: 78.3-97.5). Postprocedure numbness in greater occipital nerve distribution was reported 80.6% on left (95% CI: 64.0-91.8) and 90% on right (95% CI: 76.3-97.2). DISCUSSION: The results suggest that this alternative approach to ONB effectively reduces occipital headache pain and reliably predicts OA pulse and related greater occipital nerve location as confirmed by paresthesia.