An Analysis of Trainee Salaries Offered in Nurse Practitioner and Physician Assistant/Associate Postgraduate Residency and Fellowship Programs in the United States.

Background Although there has been steady growth in the number of postgraduate nurse practitioner (NP) and physician assistant/associate (PA) residency and fellowship programs in the United States, little is known about annual salaries paid to trainees across a national sample of postgraduate programs and specialties. We describe postgraduate program NP and PA trainee salaries and the relationship to specific variables. Methodology An electronic survey was distributed via email to 336 postgraduate NP, PA, and joint NP/PA residency/fellowship programs between November 2023 and December 2023. Frequency tables (for categorical variables) and descriptive statistics (for continuous variables) were used to summarize the data. Chi-square tests of independence were used to determine the relationship between trainee salary and program type, geographical location, and clinical setting. Results There was a statistically significant association between trainee salary for primary care and clinical profession (χ2(6) = 13.993, p = 0.022). Over half of NP respondents (52.1%) reported that their trainees had an annual salary between $76000 and $86000. The majority of PA respondents (57.1%) reported that their trainees had an annual salary below $75000. Respondents who were non-clinical professionals (50.0%) reported that their trainees had an annual salary of over $86000. The single physician respondent also reported that their trainees' had an annual salary of over $86000. It appears that PA respondents were more likely to report lower trainee salaries than respondents who were NPs and non-clinical professionals. Additionally, respondents associated with primary care joint NP/PA cohorts were more likely to report higher trainee salaries than participants having NP-only cohorts. Lastly, there was a statistically significantly positive relationship between trainee salary and the number of postgraduate advanced practice provider (APP) trainees in psychiatric mental health (τb = 0.451, p = 0.006). Conclusion To the best of our knowledge, this national study is the first of its kind to examine and summarize APP postgraduate trainee annual salaries across multiple specialties. Additional studies are needed to clarify the relationships between trainee salaries and other variables.

Revisiting California's Supervising Physician-to-Physician Assistant Ratio Requirement: An Urgent Call to Action.

California like many other states is facing a severe shortage of primary care physicians and access to primary care is uneven across the state. It is well documented that California has the highest number of designated primary care health professional shortage areas in the country. Although physician assistants (PAs) and nurse practitioners (NPs) are estimated to make up a large portion of California's primary care workforce by 2030, outdated and unnecessary statutory requirements such as the physician-to-PA supervision ratio requirement represent a practice barrier in expanding access to care. Other states have either eliminated or revised their physician-to-PA supervision ratios in favor of expanding access to health care services. Therefore, this editorial represents a call for coordinated actions from local and state entities to address California's outdated physician-to-PA supervision ratio requirement. NPs are mentioned briefly as they have achieved a pathway to full practice authority in California.

National Survey on Support for Nurse Practitioner and Physician Assistant/Associate Postgraduate Fellowship/Residency Programs and Director Compensation.

Introduction Although there has been a significant and steady increase nationwide in the number of physician assistant/associate (PA) and nurse practitioner (NP) postgraduate residency/fellowship programs, there remains a paucity of research related to the level of operational support available in many of these programs to facilitate specialty training. Therefore, the primary aim of this study is to conduct a national survey to gather foundational data regarding advanced practice provider (APP) postgraduate fellowship/residency operational support and program director total compensation data in the United States. Methodology A descriptive cross-sectional survey consisting of 27 questions was distributed via email to 336 postgraduate NP, PA, joint NP/PA, and certified nurse-midwifery residency/fellowship programs between November 2023 and December 2023. Frequency tables and descriptive statistics were used to summarize the survey data. Additionally, Spearman's rank correlation coefficients were performed to determine the relationship between the dependent variables and the independent variable. Results There was a statistically significant positive relationship between the organization values the postgraduate program and having sufficient administrative time (rs = 0.342, p < 0.001), having adequate support staff (rs = 0.340, p < 0.001), and being fairly compensated (rs = 0.356, p < 0.001) for program roles and responsibilities. Moreover, slightly less than half of respondents reported having adequate support staff and sufficient administrative time to address program responsibilities. Only 50% of respondents believed they were fairly compensated for their position. Respondents moderately agreed that their organization values the postgraduate training program (M = 4.00, SD = 1.00). Conclusions The results of this study highlight the perceptions of postgraduate program directors regarding adequate administrative support and resources to facilitate specialty-specific training for NPs and PAs. Further research is warranted to evaluate the level of operational support needed to develop and sustain postgraduate APP residency/fellowship training programs now and in the future.

Improving Nurse-Physician Bedside Communication Using a Patient Experience Quality Improvement Pilot Project at an Academic Medical Center.

Introduction  Patient experience is a crucial aspect of healthcare delivery, and it encompasses various elements that contribute to a patient's perception of the care they receive. Patient satisfaction and patient experience are related but distinct concepts. Patient experience focuses on whether specific aspects of care occurred, while patient satisfaction gauges whether patient expectations were met. It goes beyond mere satisfaction and delves into the broader aspects of how patients interact with the healthcare system and the quality of those interactions, with health plans, doctors, nurses, and staff in various healthcare facilities. Other aspects highly valued by patients include elements such as timely access to care and information, good communication with the healthcare team, and friendly staff. Patient experience can influence both the healthcare and financial outcomes of healthcare facilities. It is well understood that positive patient experiences may lead to better care adherence, improved clinical outcomes, enhanced patient safety, and better care coordination. Payers, both public and private, have recognized the importance of patient experience. Improving patient experience benefits healthcare facilities financially by strengthening customer loyalty, building a positive reputation, increasing referrals, and reducing medical malpractice risk and staff turnover.  Methodology A multidisciplinary retrospective quality improvement initiative was initiated to effectively improve nurse-physician communication and organizational outcomes in several hospital units. Results Using an innovative staff-developed and driven acronym, IMOMW (I'm on my way), the study demonstrated significant positive outcomes such as increased Epic documentation (Epic Systems Corporation, Verona, Wisconsin, United States) of physician and nursing rounding by 13%, a 10.5% rise in recommend facility net promoter score (NPS) patient experience survey scores, 13.4% increase in physician and nurse team communication, 5.4% increase in nursing communication, and a 5.3% increase in physician communication. Moreover, pilot units outperformed the control group consisting of medical-surgical units located in newer portions of the hospital. Conclusion This quality improvement study demonstrates improved interdisciplinary nurse-physician communication, Epic documentation, and patient experience scores. Further investigation is necessary to better understand the specific factors and/or processes that influence the sustainability of interventions that improve nurse-physician communication and patient experience.

The Perceived Impact of the New Medicare Rules for Split/Shared Visits: A Survey of Advanced Practice Administrators.

Background The Centers for Medicare and Medicaid Services (CMS) recently updated its split/shared policy but delayed enforcing sole time-based billing methodology in 2023 after industry pushback. However, the new time-based requirement is set for 2024. Yet, there is no published literature addressing perceived organizational impacts associated with new split/shared rules. Methods A cross-sectional survey study was administered via electronic email Listserv (n = 108) over a two-and-a-half-week period in 2023. The survey was conducted to examine the potential organizational impact of complying with the new Medicare split/shared visit policy. The collected survey data were analyzed using descriptive statistics. Results Despite the small sample size, this novel research study seems to suggest that there is a range of perceived issues associated with the new split/shared rules, including a perceived decrease in physician compensation due to changes in work relative value unit (wRVU) attribution and potential conflict between physicians and advanced practice providers (APPs) as they compete for wRVU credit for inpatient services. Additionally, respondents felt that the new regulatory change would lead to layoffs and/or hiring freezes of inpatient APP positions, thereby impacting team-based care dynamics. Further work is needed to better understand the impact of the new split/shared rules on coding practices, revenue, efficiency, provider, and patient satisfaction. Conclusion The findings reported in this study shed new light on the perceived impacts of the new split/shared visit rules on healthcare institutions. Although the updated rules are designed to provide greater transparency and better align reimbursement with services performed, concerns persist around the potential impact on day-to-day workflows, physician compensation, net revenue, and potential economic impact on the traditional team-based care model.

Exploring Motivations and Barriers To Accreditation Adoption Among Physician Assistant and Nurse Practitioner Emergency Medicine and Orthopedic Surgery Residency and Fellowship Programs.

Although there has been a rapid increase in the number of physician assistant (PA) and nurse practitioner postgraduate residency/fellowship specialty training programs in the United States, voluntary accreditation of these programs is a relatively new phenomenon. There is little research examining which factors may be predictors of accreditation adoption among PA and nurse practitioner (NP) postgraduate programs. Therefore, the primary aim of this study was to investigate which motivating factors influence postgraduate programs choice on whether to pursue accreditation. Methodology A descriptive cross-sectional survey consisting of 10 questions was distributed to 56 postgraduate emergency medicine and orthopedic surgery PA, NP, and joint PA/NP residency/fellowship programs via email between November 2022 and February 2023. Descriptive statistics were performed. Results Nineteen postgraduate programs responded to the survey. Two programs submitted incomplete surveys where less than 50% of the total items were completed. The partially completed surveys were omitted from the data analysis. The final response rate was 30% (17/56). Among the responded programs, 47% (8/17) offer dual PA and NP training, and 53% (9/17) are PA only. Although 88% (15/17) of postgraduate programs have discussed accreditation funding with their sponsoring institution only 76% are planning to do so or are in the process of pursuing accreditation. The two most common reasons for pursuing accreditation are program validation and assessment of educational quality 59% (10/17) and competition for applicants 24% (4/17). However, Magnet hospital designation, requirement of the sponsoring institution, or demand from employers were not determining factors of whether to pursue accreditation or not. Reasons for not pursuing accreditation included high costs of accreditation 18% (3/17), lack of perceived value of accreditation 6% (1/17), and lack of protected time to pursue accreditation 6% (1/17). Conclusion Although literature is still lacking on the effectiveness and impact of PA and NP postgraduate program accreditation, the findings of this rare study indicate that postgraduate programs are motivated to pursue accreditation. It is important for accreditors to communicate the utility of program-level accreditation and other value-added benefits to programs and their sponsoring institutions. Further work is necessary to better understand the value of external validation, specific drivers for validation, and barriers that influence accreditation adoption among these postgraduate programs.

Optimal Use of Advanced Practice Providers at an Academic Medical Center: A First-Year Retrospective Review.

Background Physician assistants/associates (PAs) and nurse practitioners (NPs), together known as advanced practice providers (APPs), practice with a high degree of clinical autonomy and professional respect, and play a critical role in team-based care. Aligning APP care delivery models to promote top-of-license practice is essential to improving ambulatory capacity and bottom-line expectations at academic medical centers (AMCs) in the 21st century and beyond. This administrative quality improvement study assesses the downstream impact of restructuring our APP care models to promote independent practice sessions. Methods Our AMC formed an APP oversight committee in April 2021 to optimize the ambulatory care model, realign APP funds flow, and set performance standards to which PAs and NPs are being held accountable. We conducted a one-year retrospective review of internal data from July 2021 to June 30, 2022. Certified registered nurse anesthetists (CRNAs) were excluded from this analysis. Results  APP productivity year-over-year (YOY) aggregate data across all School of Medicine (SOM) departments, demonstrated a 53% increase in work relative value units (wRVUs), 84% increase in payments, and 79% increase in charges from the prior fiscal year (July to June). Regarding APP ambulatory clinical effort (YOY), there was a 45% increase in the number of APP completed visits (92% return patient visits, 8% new visits). An increase in APP productivity did not adversely impact patient satisfaction, physician-generated wRVUs, or delay programmatic expansion efforts. Lastly, in a recent engagement survey, the majority of PA and NP respondents (78%) reported working either "most of the time" or "always" at the top-of-license. Conclusion This quality improvement study demonstrates that enhancement of PA and NP utilization through top-of-license initiatives can be achieved without jeopardizing physician wRVUs or performance. While we acknowledge, there are differences between healthcare institutions in terms of care delivery and compensation models, organizational culture, and distribution of clinical resources, there remains an opportunity among hospitals and health systems to optimize this critical and essential APP workforce.

An Evaluation of the Postgraduate Physician Assistant/Associate and Nurse Practitioner Orthopedic Surgery Fellowship and Residency Websites in the United States.

Background Although considerable research on physician fellowship training program websites has demonstrated critical deficiencies in accessibility and content, there is no published study regarding the website content of physician assistant/associate (PA) and nurse practitioner (NP) orthopedic surgery postgraduate residency/fellowship programs in the United States. Therefore, this study aims to conduct a web-based content analysis to assess the available information on program websites and identify the potential areas for improvement. Methods The methodology for this study was replicated from prior research on graduate medical education (GME) websites. Twenty-two PA and joint PA/NP orthopedic surgery postgraduate residency/fellowship training program websites were assessed between August and September 2022. The criteria comprised 17 items related to postgraduate education and recruitment content. All program websites were evaluated for pertinent content relevant to prospective applicants applying to orthopedic surgery residency/fellowship programs. Descriptive statistics were performed. Results Out of the 22 PA and joint PA/NP orthopedic postgraduate websites evaluated, all had a functional website link. Only one orthopedic surgery postgraduate website met all 17 criteria. All program websites assessed contained program descriptions and contact information. Other information present on websites included program admission requirements 95% (21/22), salary/benefits 77% (17/22), interview requirement 73% (16/22), faculty listing 68% (15/22), journal club 59% (13/22), program objectives/goals 59% (13/22), and acceptance process 54% (12/22). Less than half of the program websites contained the following information: listing of current PA/NP postgraduate trainees, sample rotation schedule, orientation activities, curriculum, wellness/well-being strategy, graduation and research requirements, and link to program handbook. However, accredited PA orthopedic surgery program websites contained more content relevant to prospective applicants than non-accredited programs. Conclusion This is the first study to provide a detailed analysis of PA and joint PA/NP postgraduate orthopedic surgery residency/fellowship program websites. Not surprisingly, there is a wide variation in the available content on these websites. Study results provide further evidence to support the urgent need to improve program website content for prospective applicants.

A survey of implicit bias training in physician assistant and nurse practitioner postgraduate fellowship/residency programs.

BACKGROUND: There has been renewed focus on advancing inclusivity within organized medicine to reduce health disparities and achieve health equity by addressing the deleterious effects of implicit bias in healthcare and clinical outcomes. It is well documented that negative implicit attitudes and stereotypes perpetuate inequity in healthcare. The aim of this study is to investigate implicit bias training in postgraduate physician assistant (PA) and nurse practitioner (NP) education; describe delivery of content to trainees; and detail program directors' attitudes toward this type of training. Although there is research examining implicit bias training in physician residency education, there are no published studies on implicit bias training in postgraduate PA and NP postgraduate residency/fellowship programs. METHOD: A non-experimental, descriptive study was designed to obtain information via survey from members of the Association of Postgraduate Physician Assistant Programs (APPAP). RESULTS: The response rate was 41%. The majority of respondents (76%) felt that PA and NP postgraduate programs should include implicit bias instruction. Educational strategies used by PA and joint PA/NP postgraduate programs or their sponsoring institution to deliver implicit bias content to trainees include: implicit bias training modules (50%), facilitated group discussions (36%), invited speaker on implicit bias (33%), case studies on implicit bias (16%), and implicit association test (10%); however, 30% of postgraduate programs do not provide implicit bias training to PA and/or NP trainees. Barriers to implementing implicit bias training expressed by some postgraduate programs include: uncertainty in how to incorporate implicit bias training (16%); lack of strategic alignment with training program or sponsoring institution (13%); time constraints (10%); financial constraints (6%); lack of access to content experts (6%); and unfamiliarity with evidence supporting implicit bias training (6%). CONCLUSION: The present study sheds some light on the current state of implicit bias training in PA and joint PA/NP postgraduate residency/fellowship programs. While the majority of programs offer some sort of implicit bias training, there is a need to standardize this training in PA and joint PA/NP postgraduate education curricula using an actionable framework.

The development of a visual dashboard report to assess physician assistant and nurse practitioner financial and clinical productivity.

The evolving COVID-19 pandemic has unevenly affected academic medical centers (AMCs), which are experiencing resource-constraints and liquidity challenges while at the same time facing high pressures to improve patient access and clinical outcomes. Technological advancements in the field of data analytics can enable AMCs to achieve operational efficiencies and improve bottom-line expectations. While there are vetted analytical tools available to track physician productivity, there is a significant paucity of analytical instruments described in the literature to adequately track clinical and financial productivity of physician assistants (PAs) and nurse practitioners (NPs) employed at AMCs. Moreover, there is no general guidance on the development of a dashboard to track PA/NP clinical and financial productivity at the individual, department, or enterprise level. At our institution, there was insufficient tracking of PA/NP productivity across many clinical areas within the enterprise. Thus, the aim of the project is to leverage our institution's existing visualization tools coupled with the right analytics to track PA/NP productivity trends using a dashboard report.MethodsWe created an intuitive and customizable highly visual clinical/financial analytical dashboard to track productivity of PAs/NPs employed at our AMC.ResultsThe APP financial and clinical dashboard is organized into two main components. The volume-based key performance indicators (KPIs) included work relative value units (wRVUs), gross charges, collections (payments), and payer-mix. The session utilization (KPIs) included (e.g., new versus return patient ratios, encounter type, visit volume, and visits per session by provider). After successful piloting, the dashboard was deployed across multiple specialty areas and results showed improved data transparency and reliable tracking of PAs/NPs productivity across the enterprise. The dashboard analytics were also helpful in assessing PA/NP recruitment requests, independent practice sessions, and performance expectations.ConclusionTo our knowledge, this is the first paper to highlight steps AMCs can take in developing, validating, and deploying a financial/clinical dashboard specific to PAs/NPs. However, empirical research is needed to assess the impact of qualitative and quantitative dashboards on provider engagement, revenue, and quality of care.

An analysis of the selection criteria for postgraduate physician assistant residency and fellowship programs in the United States.

BACKGROUND: This study aims to investigate the admission criteria used by physician assistant postgraduate education programs in selecting licensed PA applicants for postgraduate training in the United States. To our knowledge, there have been no previously published reports on selection criteria and/or other factors influencing postgraduate PA admission decisions. METHOD: A non-experimental, descriptive research study was designed to obtain information from members of the Association of Postgraduate Physician Assistant Programs (APPAP). RESULTS: Twenty-three out of 73 postgraduate programs (35%) responded to the survey. The study reported that applicant PAs and NPs are largely selected on the basis of several factors. The most heavily weighted factor is the interview itself; other selection criteria perceived to be extremely/very important included board certification/eligibility, letters of recommendation, advanced degree, and personal essay. Survey data suggest that publications, undergraduate transcripts, and class rankings are not considered to be of high importance in applicant selection. The number of PA applicants applying to each postgraduate training program averages around 26 and total number of enrollees is about 3.6 per program. Additionally, some programs reported furloughing of trainees (temporary suspension of didactic and clinical training) during the pandemic, whereas the vast majority of postgraduate PA programs remained operational and some even experienced an increase in application volume. The total cost of training a PA resident or fellow in postgraduate programs is currently $93,000 whereas the average cost of training a categorical physician resident is estimated at $150,000 per year when considering both salary and benefits. CONCLUSIONS: This novel study examined criteria and other factors used by postgraduate PA programs in selecting candidates for admission. Results can be used by postgraduate programs to improve or modify current selection criteria to enhance the quality of trainee selection. Further research is needed to examine correlations between applicant attributes, selection criteria, and trainee success in completing postgraduate training.

Postgraduate Programs in Orthopaedic Surgery for Physician Assistants and Nurse Practitioners.

Postgraduate orthopaedic programs for physician assistants (PAs) and nurse practitioners (NPs) number 14 as of 2020. To better understand the characteristics of these programs a census was undertaken. The result is that most programs are 1 year in duration and in 2019 produced 40 graduates. The role of the orthopaedic PA and NP fellow is to gain an understanding of a wide range of musculoskeletal disorders, develop procedural skills, first assist in the operating room, and facilitate management of patients and discharge throughput. PA and NP fellows work alongside categorical orthopaedic physician residents. The number of graduates from PA orthopaedic training programs is estimated at 200, spanning 20 years. The other 11,145 + PAs (99%) are trained on-the-job. For hospital systems, the employment of orthopaedic postgraduate PA and NP fellows provides value through cost management and billable services.

A National Survey of postgraduate physician assistant fellowship and residency programs.

INTRODUCTION: The development of postgraduate programs for physician assistants (PAs) began in 1973 and by 2020 there were approximately 72 programs spread across a broad range of medical and surgical disciplines. PA Post-graduate education programs are voluntary and available to American licensed PAs. Therefore, an assessment of the characteristics of PA post-graduate fellowships and residencies programs was initiated. METHOD: A non-experimental, descriptive research study was designed to obtain information on the characteristics of PA postgraduate education programs in the US. The source of information was from surveyed members of the Association of Postgraduate Physician Assistant Programs (APPAP). Questions were drawn from consensus discussions. Directors of postgraduate programs that were operational in 2020 were eligible to participate. RESULTS: Seventy-two postgraduate program directors were invited to the survey and 34 program directors replied. These programs are geographically distributed across the US in 13 states. The respondents represent a wide range of medicine: surgery, emergency medicine, critical care, orthopaedics, hospitalist, psychiatry, oncology, primary care, pediatrics, and cardiology. Most programs are associated with an academic medical center and some institutions have more than one postgraduate specialty track. The curriculum includes bedside teaching, lectures, mentorship, assigned reading, procedures, simulation, and conferences. An average program length is 12 months and awards a certificate. Stipends for PA fellows are $50,000-80,000 (2020 dollars) and benefits include paid time off, health and liability insurance. About half of the programs bill for the services rendered by the PA. Over 90% of graduates are employed within 2 months of completing a PA postgraduate training program. CONCLUSION: A trend is underway in American medicine to include PAs in postgraduate education. PA postgraduate training occurs across a broad spectrum of medical and surgical areas, as well as diverse institutions and organizations overseeing these programs. Most PA postgraduate programs are in teaching hospitals where the PA resident or PA fellow also serves as a house officer alongside a categorical resident. This study sets the stage for more granular economic and social research on this growing phenomenon in American medicine.

Knee Osteoarthritis Treatment Costs in the Medicare Patient Population.

BACKGROUND: Several nonoperative options have been recommended for the treatment of knee osteoarthritis (OA), with varying degrees of evidence. Adhering to the American Academy of Orthopaedic Surgeons clinical practice guidelines has been suggested to decrease direct treatment costs by 45% in the year before knee arthroplasty, but this does not consider the cost of the entire episode of care, including the cost of surgery and postsurgery care. OBJECTIVES: To analyze the total treatment costs after a diagnosis of knee OA, as well as the proportion of arthroplasty interventions as part of the total knee OA-related costs, and whether the total costs differed for patients who received intra-articular hyaluronic acid and/or had knee arthroplasty. METHODS: We identified patients newly diagnosed with knee OA using the 5% Medicare data sample from January 2010 to December 2015. Patients were excluded if they were aged <65 years, had incomplete claim history, did not reside in any of the 50 states, had claim history <12 months before knee OA diagnosis, or did not enroll in Medicare Part A and Part B. The study analyzed knee OA-related costs from a payer perspective in terms of reimbursements provided by Medicare, as well as the time from the diagnosis of knee OA to knee arthroplasty for patients who had knee arthroplasty, and the time from the first hyaluronic acid injection to knee arthroplasty for those who received the injection. We compared patients who received hyaluronic acid and those who did not receive hyaluronic acid injections. Patients who received hyaluronic acid injection who subsequently had knee arthroplasty were also compared with those who did not have subsequent knee arthroplasty. RESULTS: Of the 275,256 patients with knee OA, 45,801 (16.6%) received a hyaluronic acid injection and 35,465 (12.9%) had knee arthroplasty during the study period. The median time to knee arthroplasty was 16.4 months for patients who received hyaluronic acid versus 5.7 months for those who did not receive hyaluronic acid. Non-arthroplasty-related therapies and knee arthroplasty accounted for similar proportions of knee OA-related costs, with hyaluronic acid injection comprising 5.6% of the total knee OA-related costs. For patients who received hyaluronic acid injections and subsequently had knee arthroplasty, hyaluronic acid injection contributed 1.8% of the knee OA-related costs versus 76.6% of the cost from knee arthroplasty. Patients who received hyaluronic acid injections and did not have knee arthroplasty incurred less than 10% of the knee OA-related costs that patients who had surgery incurred. CONCLUSION: Although limiting hyaluronic acid use may reduce the knee OA-related costs, in this study hyaluronic acid injection only comprised a small fraction of the overall costs related to knee OA. Among patients who had knee arthroplasty, those who received treatment with hyaluronic acid had surgery delayed by a median of 10.7 months and associated costs for a significant period. The ability to delay or avoid knee arthroplasty altogether can have a substantial impact on healthcare costs.

Decrease in opioid and intra-articular corticosteroid burden after intra-articular hyaluronic acid for knee osteoarthritis treatment.

Aim: We studied changes in opioid prescriptions and corticosteroid injection use for knee osteoarthritis patients before and after intra-articular hyaluronic acid (HA) use and opioid prescriptions before and after knee arthroplasty (KA). Materials & methods: A total of 1,017,578 knee osteoarthritis members were ascertained from a commercial claims database (Health Intelligence Company LLC, IL, USA) using ICD9/ICD10 diagnosis codes. Results: Eighty two percent of HA patients did not fill opioid prescriptions postinjection, with 54% of opioid users discontinuing fills. Two-thirds of KA patients filled opioid prescriptions within 6 months postsurgery, with 78% of opioid users continuing fills and 62% of nonusers initiating use. Conclusion: Alternative therapies, such as HA, that reduce opioid use may alleviate opioid addiction risks for KA patients who use opioids in the pre- and postoperative periods.

Genicular Nerve Radiofrequency Ablation for Painful Knee Arthritis: The Why and the How.

BACKGROUND: Genicular nerve radiofrequency ablation (GNRFA), including conventional, cooled, and pulsed techniques, has been used in the management of symptomatic knee osteoarthritis (OA). This new and innovative treatment option has the capacity to decrease pain and improve function and quality of life in certain patients. GNRFA is reserved for patients with symptomatic knee OA who have had failure of conservative treatment and have had failure of or are poor candidates for surgery. GNRFA has been shown to consistently provide short-term (3 to 6-month), and sometimes longer, pain relief in patients. GNRFA has been demonstrated to be safe to administer repeatedly in patients who respond well to this minimally invasive procedure. DESCRIPTION: GNRFA is a 2-step procedure. First, patients are given a diagnostic block under fluoroscopy or ultrasound guidance. Specifically, 1 mL of lidocaine is injected using a 20-gauge, 3.5-in (8.9-cm) spinal needle around the superior lateral, superior medial, and inferior medial genicular nerve branches. The diagnostic block is extra-articular. If the patient reports a ≥50% reduction in baseline pain for a minimum of 24 hours following the injection, then the patient is a candidate for genicular ablation. The osseous landmarks for the diagnostic block are exactly the same as for the ablation procedure. Both procedures are well tolerated in the office setting under local skin anesthesia or can be done in the operating room under conscious sedation using a low-dose sedative such as midazolam for anxious patients. General anesthesia is not required for GNRFA. This procedure is most commonly performed by interventional pain specialists but may also be performed by any physician with appropriate training. In some jurisdictions, physician assistants and nurse practitioners may perform this procedure subject to their supervision requirements. ALTERNATIVES: Conservative treatment for symptomatic knee OA includes weight loss management, physical and aquatic therapy, bracing, lateral wedge insoles, transcutaneous nerve stimulation, nonsteroidal anti-inflammatory drugs in combination with a proton pump inhibitor, autologous blood-based therapies, and cortisone and hyaluronic acid injections1,2. Surgical treatment for symptomatic knee OA includes knee arthroscopy, high tibial osteotomy, total knee replacement, and unicompartmental knee replacement in patients without lateral compartment disease2. It should be noted that there is some evidence suggesting that steroid injection, viscosupplements, and arthroscopy are not effective for the management of knee OA. RATIONALE: Thermal GNRFA differs from all other treatment alternatives because this procedure causes denaturing of the 3 sensory nerves primarily responsible for transmitting knee pain from an arthritic joint to the central nervous system. In this procedure, heating occurs from an intense alternating electrical field at the tip of the cannula, which produces sufficient heat to denature the proteins in the target tissue. The accepted heating parameters for this procedure are 70° to 80°C for 60 or 90 seconds. A commonly raised question is whether this procedure precipitates a Charcot-type joint. The Charcot joint involves much more than reduced innervation; it occurs in the context of chronically compromised vascularity and altered soft-tissue characteristics as well as peripheral neuropathy. Moreover, a Charcot-type joint does not develop because the deafferentation of the weight-bearing joint is partial3. To our knowledge, no Charcot-type joints have been reported after this procedure. Conversely, data from an animal study have shown that selective joint denervation may lead to the progression of knee OA4. The ablation procedure is done outside the knee joint, unlike alternatives such as intra-articular therapies and surgery. The effectiveness of nonsurgical knee OA interventions in alleviating pain and improving joint function is generally inadequate1. However, GNRFA appears to be an emerging alternative for patients who have had failure of conservative and surgical treatments. It is not uncommon in our clinical practice for patients to achieve adequate pain control following ablation for up to 1 year. GNRFA provides temporary relief from symptomatic knee OA because it does not eliminate the potential for peripheral nerve regrowth and regeneration, and thus pain, to return.

Preparing for Autistic Patients in Orthopaedic Surgery: Tips for a Successful Health-Care Interaction.

The prevalence of autism in the United States has been climbing for the last 3 decades, and this comes at a time when the medical community is poorly equipped to address the various needs of individuals with autism spectrum disorder (ASD). Because busy orthopaedic surgery practices will invariably encounter more patients with ASD, they may want to develop pragmatic strategies and protocols that will promote a successful health-care interaction with these patients.