Pain is one of the most common complaints that patients present to the emergency department for; emergency medicine providers are tasked with providing appropriate pain relief while simultaneously limiting the risk of personal and societal harm that may result from opioid misuse. The Lakeland Regional Medical Center developed a medical management program that identified frequent emergency department visitors with a chief complaint of pain. Individualized care plans were developed for these patients. A retrospective review was then conducted to assess the efficacy of these care plans in reducing the number of emergency department visits for pain-related complaints by the patients entered into the medical management program.There were 294 patients; 65% were male, and the median age was 41 (interquartile range: 33 to 51). A total of 80% percent of the patients were white, and the payors were as follows: 53% were self-pay, 42% were government programs, and 5% had private insurance. The three most common chronic pain complaints were 39% abdominal pain, 24% back/neck pain, and 23% headache/migraine (patients could have more than one area of pain). A total of 60% of the patients had a primary care provider, and another 18% had a pain management provider in addition to primary care. Post plan admissions were significantly reduced to a median of 1 (IQR 0 to 3) with the Wilcoxon signed-rank test's p-value of less than 0.001.The authors describe their experience with a quality improvement initiative that identifies frequent emergency department visitors with a chief complaint of pain and provides individualized care plans to these patients. The goals of the program are to improve patient's quality and consistency of care, through interventions that eliminate the prescribing of opioids while providing non-opioid alternatives.
Background: Capsule endoscopy (CE) is now a well established method for investigating the small bowel (SB). However, its yield in detecting significant findings in patients with iron deficiency anemia (IDA) who have undergone a negative endoscopic workup is not well investigated.
Purpose: Little is known about how to change practice to achieve withdrawal times (WT) recommended by current guidelines. Our Section's previous attempts to improve performance in this area—by providing the endoscopist post-procedure feedback on WT— resulted in initial success but results were not sustained. The aim of this study was to determine whether intra-procedure feedback of WT, through the use of a timer, could lead to a sustained change in that measure. Methods: Over a two month period, nurses identified all patients receiving a screening colonoscopy and recorded baseline WTs without endoscopist knowledge. Subsequently, a timer was placed on all endoscopy monitors and all WTs for screening colonoscopies were tracked. The main outcome of interest was overall sectional withdrawal time (observed over 23 weeks) comparing post timer intervention to baseline withdrawal times. A secondary outcome of interest was overall sectional polypectomy and adenoma detection rate (determined by chart review) comparing the same two periods as our main outcome measure. Statistical significance determined using chi2 and one-sided Fisher exact test. Results: 104 screening colonoscopies were used to establish baseline performance. The mean WT was 7 minutes 19 seconds (±3:08 min). 58/104 colonoscopies (55.8%) had WT ≥6 minutes. Following the initiation of timers, 528/566 (93.3%) with WT ≥ 6 min, Chi2, P < 0.001. Mean WT was 8 minutes 9 seconds (±2:15 min). There was a trend towards improved polyp find rate (P= 0.09) No change in adenoma detection rate was noted. Adenoma detection rate in women, pre-intervention was 17.2%, and post intervention was 18.3%. Adenoma detection in men, pre-timer was 28.4% and post-timer was 30.4%. Conclusion: Real time, intra-procedure feedback improved performance resulting in a significantly greater number of exams having WT≥6 minutes. The active, force-functioned, timer intervention resulted in sustained change in WT unlike prior passive education intervention and feedback which we had previously tried. Adherence to guidelines, even in a high performing endoscopy center, may result in higher polyp find rates and adenoma detection rates, but this needs further study.Figure
In Brief Study Design. Descriptive analysis of cross-sectional data collected prospectively in 20 National Spine Network (NSN) centers. Objectives. First, to summarize clinical and demographic characteristics of patients likely to need servicesfor psychosocial concerns. Second, to determine the rate and variability of referrals for behavioral medicine interventions (BMED) across the NSN. Summary of Background Data. The prevalence of mental distress resulting from or coexisting with spinal pain is unclear. There is evidence that psychological treatments, particularly BMED, can aid the recovery of patients with symptoms of mental distress. Methods. From 1998 to 2001, 28,349 patients presenting to NSN centers completed the SF-36 General Health Survey. Patients were dichotomized by the mental component summary (MCS) score into two groups: 1) those scoring ≤35 on the MCS scale (patients self-reporting significant signs of mental distress) and 2) those scoring >35. Clinicians recorded a “treatment plan” comprised of a standard array of treatment options. For patients scoring ≤35 on the MCS, the rate and variation of referrals to BMED was assessed. Results. Baseline health status scores were lower across all SF-36 scales for the patients scoring an MCS ≤ 35. For mentally distressed patients, the overall average referral rate for any BMED service for patients scoring MCS ≤ 35 was 11.8%. The rate varied across NSN sites from 0 to 41%. Conclusion. With only 11.8% of mentally distressed NSN patients receiving a referral for any form of BMED, it appears that a large proportion of eligible patients are not receiving a potentially beneficial treatment. Wide variation across centers may indicate an inability to adequately assess mental distress via the usual clinical interview and examination for spinal conditions or a lack of consensus regarding BMED’s availability and utility. This study of 28,349 initial patients from the National Spine Network investigated the prevalence of patients scoring 35 or below on the SF-36 mental component summary, the frequency and variation with which these patients were referred for behavioral medicine interventions. The results demonstrate significant variation in the use of behavioral medicine services across the National Spine Network.
Background: The BREAST-Q Reduction module evaluates outcomes in reduction mammaplasty. However, there are currently no published normative scores, limiting the interpretation of BREAST-Q data. Methods: The BREAST-Q Reduction module was administered via the Army of Women, an online community of women (with and without breast cancer) engaged in breast-cancer related research. Normative data were generated from women aged 18 years and older, without a history of breast cancer or breast surgery. Data analysis was performed using descriptive statistics and a linear multivariate regression. Generated normative data were compared to published BREAST-Q Reduction findings. Results: The preoperative version of the BREAST-Q Reduction module was completed by 1206 women. Participant mean age was 55 ± 13 years, mean body mass index was 27 ± 6 kg/m 2 , and 40 percent ( n = 481) had a bra cup size ≥ D. Mean normative scores were as follows: Satisfaction with Breasts, 57 ± 16; Psychosocial Well-being, 68 ± 19; Sexual Well-being, 55 ± 19; and Physical Well-being, 76 ± 11. Normative scores were lower in women with body mass index ≥ 30 and bra cup size ≥ D. In comparison to normative Army of Women scores, published BREAST-Q scores for women undergoing reduction mammaplasty were lower (worse) for preoperative patients and higher (better) for postoperative patients. Conclusion: These new Army of Women normative data provide insights into breast-related satisfaction and well-being in women not pursuing breast reduction, giving new clinical context to better understand the health burden of macromastia, and to demonstrate the value of reduction mammaplasty in certain patients.
The authors assessed the diagnostic potential of commonly used patient-reported measures, namely, the Boston Carpal Tunnel Questionnaire (function and symptom severity), QuickDASH (a shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire), and the Short Form-8.Measure scores were extracted retrospectively from the records of 262 patients (397 hands) and compared using analysis of variance to determine statistical differences among diagnoses assigned by the same surgeon at the time of visit. Patients were grouped into one of two diagnostic groups: those with Dupuytren disease and those with carpal tunnel, osteoarthritis, and tenosynovitis conditions. Logistic regression analysis was performed, and a receiver operating characteristic curve was used in data analysis.Analysis of variance showed statistical differences among the five diagnoses for each patient-reported measure. Results showed that Dupuytren disease was significantly different from the other diagnoses. Carpal tunnel, osteoarthritis, and tenosynovitis conditions were statistically associated with higher Boston Carpal Tunnel Questionnaire function and symptom severity and QuickDASH scores compared with Dupuytren disease. Lower physical and mental summary Short Form-8 scores were associated with the carpal tunnel, osteoarthritis, and tenosynovitis conditions. QuickDASH scores of 25 or higher and Boston Carpal Tunnel Questionnaire symptom severity scores and function scores of 2.5 or higher and of 2 or higher, respectively, are the best patient-reported measure threshold values for distinguishing between the two diagnostic groups.The QuickDASH and Boston Carpal Tunnel Questionnaire patient-reported measures have diagnostic potential. Establishing threshold values for predicting a diagnostic group may prove to be a useful tool for referring providers.Diagnostic, IV.
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