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Adams MCB, Hurley RW, Topaloglu U. Connecting Chronic Pain and Opioid Use Disorder Clinical Trials Through Data Harmonization: Wake Forest IMPOWR Dissemination, Education, and Coordination Center (IDEA-CC). Subst Use Addctn J 2024:29767342241236287. [PMID: 38516882 DOI: 10.1177/29767342241236287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
The National Institutes of Health (NIH) has developed the NIH HEAL Integrative Management of chronic Pain and OUD for Whole Recovery (IMPOWR) network to address the interconnected nature of chronic pain (CP) and opioid use disorder (OUD), which are influenced by mental health. The network aims to develop integrated treatment pathways across multiple sites in the United States. The IMPOWR Dissemination, Education, and Coordination Center (IDEA-CC) is proposed to support the NIH HEAL IMPOWR network by developing a CP- and OUD-focused infrastructure that includes measures of stigma, trauma, and quality of life. This includes deploying a data framework to link clinical sites, developing an educational infrastructure to address stigma and health disparities, and disseminating research findings. The IDEA-CC will standardize data collection processes, develop web-based data commons, and facilitate data sharing opportunities. The IDEA-CC will support the development and validation of composite CP and OUD measures and will develop educational materials to address stigma and health disparities. Overall, the IDEA-CC will create a research community and data commons that connect NIH HEAL IMPOWR centers to translate findings and develop a key CP-OUD research data, and education infrastructure.
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Affiliation(s)
- Meredith C B Adams
- Department of Anesthesiology, Biomedical Informatics, Translational Neuroscience, and Public Health Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Robert W Hurley
- Department of Anesthesiology, Translational Neuroscience and Public Health Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Umit Topaloglu
- Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Chief of the Clinical Translational Research Informatics Branch, National Cancer Institute, Bethesda, MD, USA
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Boyd T, Chibueze J, Pester BD, Saini R, Bar N, Edwards RR, Adams MCB, Silver JK, Meints SM, Burton-Murray H. Age, Race, Ethnicity, and Sex of Participants in Clinical Trials Focused on Chronic Pain. J Pain 2024:104511. [PMID: 38492711 DOI: 10.1016/j.jpain.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 03/06/2024] [Accepted: 03/09/2024] [Indexed: 03/18/2024]
Abstract
There is limited data on equitable inclusion in chronic pain trials. We aimed to 1) identify the frequency of reporting age, race, ethnicity, and sex in clinical trials targeting chronic pain, and 2) compare sociodemographic representation to the United States (US) population. We examined US-based intervention trials for chronic pain initiated between 2007 and 2021 and registered on ClinicalTrials.gov. We 1) assessed the frequency of reporting each demographic variable, 2) compared representation with US population estimates, and 3) explored change in reporting over time. Of 501 clinical trials, the frequency of reporting was as follows: 36.9% reported older adults, 54.3% reported race, 37.4% reported ethnicity, and 100% reported sex. Rates of race and ethnicity reporting increased, but older adult age reporting decreased over time (ps < .00001). Compared to 2020 US population estimates, there was an equitable representation of older adults, under-representation of individuals identifying as American Indian or Alaska Native (.8% vs .6%), Asian (5.6% vs 2.9%), Black or African American (12.6% vs 12.2%), with more than one race (2.9% vs 1.2%), and Hispanic/Latino (16.9% vs 14.1%). There was an over-representation of individuals identifying as Native Hawaiian or Pacific Islander (.2% vs .5%) or White (70.4% vs 72.9%), and of females (50.8% vs 68.4%). Some representation rates varied by chronic pain condition. Reporting of older adult age, race, and ethnicity was low in chronic pain trials in ClinicalTrials.gov, reinforcing the need for adhering to reporting guidelines. Representation varied across trials compared with US population data, particularly among those identifying as Hispanic/Latino and certain minority racial groups. PERSPECTIVE: Despite initiatives to increase the reporting of demographic information, doing so in clinical pain trials is far from ubiquitous. Moreover, efforts to improve diversity in these trials continue to be insufficient. Indeed, Black, Indigenous, and People of Color (BIPOC) remain under-represented in clinical pain trials.
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Affiliation(s)
- Taylor Boyd
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Joseph Chibueze
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Bethany D Pester
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Chestnut Hill, Massachusetts
| | - Rhea Saini
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Nir Bar
- Gastroenterology and Hepatology Department, Tel Aviv Medical center, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Robert R Edwards
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Chestnut Hill, Massachusetts; Department of Anesthesiology, Harvard Medical School, Boston, Massachusetts
| | - Meredith C B Adams
- Department of Anesthesiology, Biomedical Informatics, Physiology & Pharmacology, and Public Health Sciences, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Julie K Silver
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts; Department of Physical Medicine and Rehabilitiation, Harvard Medical School, Boston, Massachusetts
| | - Samantha M Meints
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Chestnut Hill, Massachusetts; Department of Anesthesiology, Harvard Medical School, Boston, Massachusetts
| | - Helen Burton-Murray
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
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Adams MCB, Wandner LD, Kolber BJ. Challenges and opportunities for growing and retaining a pain research workforce. Pain Med 2024:pnae008. [PMID: 38459612 DOI: 10.1093/pm/pnae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/24/2024] [Accepted: 02/01/2024] [Indexed: 03/10/2024]
Affiliation(s)
- Meredith C B Adams
- Departments of Anesthesiology, Biomedical Informatics, Physiology & Pharmacology, and Public Health Sciences, Wake Forest University School of Medicine, Winston Salem, NC, 27157
| | - Laura D Wandner
- National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD, 20824
| | - Benedict J Kolber
- University of Texas at Dallas, Department of Neuroscience, Center for Advanced Pain Studies, Richardson, TX, 75080
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Stundner O, Adams MCB, Fronczek J, Kaura V, Li L, Allen ML, Vail EA. Academic anaesthesiology: a global perspective on training, support, and future development of early career researchers. Br J Anaesth 2023; 131:871-881. [PMID: 37684165 PMCID: PMC10636519 DOI: 10.1016/j.bja.2023.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 09/10/2023] Open
Abstract
As anaesthesiologists face increasing clinical demands and a limited and competitive funding environment for academic work, the sustainability of academic anaesthesiologists has never been more tenuous. Yet, the speciality needs academic anaesthesiologists in many roles, extending beyond routine clinical duties. Anaesthesiologist educators, researchers, and administrators are required not only to train future generations but also to lead innovation and expansion of anaesthesiology and related specialities, all to improve patient care. This group of early career researchers with geographically distinct training and practice backgrounds aim to highlight the diversity in clinical and academic training and career development pathways for anaesthesiologists globally. Although multiple routes to success exist, one common thread is the need for consistent support of strong mentors and sponsors. Moreover, to address inequitable opportunities, we emphasise the need for diversity and inclusivity through global collaboration and exchange that aims to improve access to research training and participation. We are optimistic that by focusing on these fundamental principles, we can help build a more resilient and sustainable future for academic anaesthesiologists around the world.
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Affiliation(s)
- Ottokar Stundner
- Department of Anesthesiology and Intensive Care, Innsbruck Medical University, Innsbruck, Austria.
| | - Meredith C B Adams
- Departments of Anesthesiology, Biomedical Informatics, Pharmacology & Physiology, and Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jakub Fronczek
- Centre for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Vikas Kaura
- Leeds Institute of Medical Research at St James's, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Li Li
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - Megan L Allen
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital and Department of Critical Care, The University of Melbourne, Melbourne, Australia
| | - Emily A Vail
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Mazurenko O, McCord E, McDonnell C, Apathy NC, Sanner L, Adams MCB, Mamlin BW, Vest JR, Hurley RW, Harle CA. Examining primary care provider experiences with using a clinical decision support tool for pain management. JAMIA Open 2023; 6:ooad063. [PMID: 37575955 PMCID: PMC10412405 DOI: 10.1093/jamiaopen/ooad063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 06/22/2023] [Accepted: 07/25/2023] [Indexed: 08/15/2023] Open
Abstract
Objective To evaluate primary care provider (PCP) experiences using a clinical decision support (CDS) tool over 16 months following a user-centered design process and implementation. Materials and Methods We conducted a qualitative evaluation of the Chronic Pain OneSheet (OneSheet), a chronic pain CDS tool. OneSheet provides pain- and opioid-related risks, benefits, and treatment information for patients with chronic pain to PCPs. Using the 5 Rights of CDS framework, we conducted and analyzed semi-structured interviews with 19 PCPs across 2 academic health systems. Results PCPs stated that OneSheet mostly contained the right information required to treat patients with chronic pain and was correctly located in the electronic health record. PCPs used OneSheet for distinct subgroups of patients with chronic pain, including patients prescribed opioids, with poorly controlled pain, or new to a provider or clinic. PCPs reported variable workflow integration and selective use of certain OneSheet features driven by their preferences and patient population. PCPs recommended broadening OneSheet access to clinical staff and patients for data entry to address clinician time constraints. Discussion Differences in patient subpopulations and workflow preferences had an outsized effect on CDS tool use even when the CDS contained the right information identified in a user-centered design process. Conclusions To increase adoption and use, CDS design and implementation processes may benefit from increased tailoring that accommodates variation and dynamics among patients, visits, and providers.
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Affiliation(s)
- Olena Mazurenko
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA
- Clem McDonald Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
| | - Emma McCord
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA
| | - Cara McDonnell
- Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Nate C Apathy
- Clem McDonald Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
- MedStar Health Research Institute
| | - Lindsey Sanner
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA
| | - Meredith C B Adams
- Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Burke W Mamlin
- Clem McDonald Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
- School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Joshua R Vest
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA
- Clem McDonald Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
| | - Robert W Hurley
- Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Christopher A Harle
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA
- Clem McDonald Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
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Adams MCB, Nelson AM, Narouze S. Daring discourse: artificial intelligence in pain medicine, opportunities and challenges. Reg Anesth Pain Med 2023; 48:439-442. [PMID: 37169486 PMCID: PMC10525018 DOI: 10.1136/rapm-2023-104526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 04/28/2023] [Indexed: 05/13/2023]
Abstract
Artificial intelligence (AI) tools are currently expanding their influence within healthcare. For pain clinics, unfettered introduction of AI may cause concern in both patients and healthcare teams. Much of the concern stems from the lack of community standards and understanding of how the tools and algorithms function. Data literacy and understanding can be challenging even for experienced healthcare providers as these topics are not incorporated into standard clinical education pathways. Another reasonable concern involves the potential for encoding bias in healthcare screening and treatment using faulty algorithms. And yet, the massive volume of data generated by healthcare encounters is increasingly challenging for healthcare teams to navigate and will require an intervention to make the medical record manageable in the future. AI approaches that lighten the workload and support clinical decision-making may provide a solution to the ever-increasing menial tasks involved in clinical care. The potential for pain providers to have higher-quality connections with their patients and manage multiple complex data sources might balance the understandable concerns around data quality and decision-making that accompany introduction of AI. As a specialty, pain medicine will need to establish thoughtful and intentionally integrated AI tools to help clinicians navigate the changing landscape of patient care.
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Affiliation(s)
- Meredith C B Adams
- Departments of Anesthesiology, Biomedical Informatics, Physiology & Pharmacology, and Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Ariana M Nelson
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, California, USA
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Adams MCB, Hurley RW, Siddons A, Topaloglu U, Wandner LD. NIH HEAL Clinical Data Elements (CDE) implementation: NIH HEAL Initiative IMPOWR network IDEA-CC. Pain Med 2023; 24:743-749. [PMID: 36799548 PMCID: PMC10321760 DOI: 10.1093/pm/pnad018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 02/18/2023]
Abstract
OBJECTIVE The National Institutes of Health (NIH) HEAL Initiative is making data findable, accessible, interoperable, and reusable (FAIR) to maximize the value of the unprecedented federal investment in pain and opioid-use disorder research. This involves standardizing the use of common data elements (CDE) for clinical research. METHODS This work describes the process of the selection, processing, harmonization, and design constraints of CDE across a pain and opioid use disorder clinical trials network (NIH HEAL IMPOWR). RESULTS The network alignment allowed for incorporation of newer data standards across the clinical trials. Specific advances included geographic coding (RUCA), deidentified patient identifiers (GUID), shareable clinical survey libraries (REDCap), and concept mapping to standardized concepts (UMLS). CONCLUSIONS While complex, harmonization across a network of chronic pain and opioid use disorder clinical trials with separate interventions can be optimized through use of CDEs and data standardization processes. This standardization process will support the robust secondary data analyses. Scaling this process could standardize CDE results across interventions or disease state which could help inform insurance companies or government organizations about coverage determinations. The development of the HEAL CDE program supports connecting isolated studies and solutions to each other, but the practical aspects may be challenging for some studies to implement. Leveraging tools and technology to simplify process and create ready to use resources may support wider adoption of consistent data standards.
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Affiliation(s)
- Meredith C B Adams
- Departments of Anesthesiology, Biomedical Informatics, and Public Health Sciences, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, United States
| | - Robert W Hurley
- Departments of Anesthesiology, Translational Neuroscience, and Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC 27157, United States
| | - Andrew Siddons
- National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
| | - Umit Topaloglu
- Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC 27157, United States
| | - Laura D Wandner
- National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
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Adams MCB, Brummett CM, Wandner LD, Topaloglu U, Hurley RW. Michigan body map: connecting the NIH HEAL IMPOWR network to the HEAL ecosystem. Pain Med 2023; 24:907-909. [PMID: 36847455 PMCID: PMC10321764 DOI: 10.1093/pm/pnad028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 03/01/2023]
Affiliation(s)
- Meredith C B Adams
- Department of Anesthesiology, Biomedical Informatics, and Public Health Sciences, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, United States
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI 48104, United States
| | - Laura D Wandner
- National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
| | - Umit Topaloglu
- Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC 27157, United States
| | - Robert W Hurley
- Departments of Anesthesiology, Neurobiology and Anatomy, and Public Health Sciences; Wake Forest University School of Medicine, Winston-Salem, NC 27157, United States
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Adams MCB, Smith JR, Wang SJ, Shimoyama M. Representation of Pain Concepts and Terms in Existing Ontologies and Taxonomies. Pain Med 2023; 24:727-729. [PMID: 36394234 PMCID: PMC10233479 DOI: 10.1093/pm/pnac178] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Meredith C B Adams
- Departments of Anesthesiology, Biomedical Informatics, and Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jennifer R Smith
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Shur-Jen Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mary Shimoyama
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Apathy NC, Sanner L, Adams MCB, Mamlin BW, Grout RW, Fortin S, Hillstrom J, Saha A, Teal E, Vest JR, Menachemi N, Hurley RW, Harle CA, Mazurenko O. Assessing the use of a clinical decision support tool for pain management in primary care. JAMIA Open 2022; 5:ooac074. [PMID: 36128342 PMCID: PMC9476612 DOI: 10.1093/jamiaopen/ooac074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/11/2022] [Accepted: 08/18/2022] [Indexed: 01/23/2023] Open
Abstract
Objective Given time constraints, poorly organized information, and complex patients, primary care providers (PCPs) can benefit from clinical decision support (CDS) tools that aggregate and synthesize problem-specific patient information. First, this article describes the design and functionality of a CDS tool for chronic noncancer pain in primary care. Second, we report on the retrospective analysis of real-world usage of the tool in the context of a pragmatic trial. Materials and methods The tool known as OneSheet was developed using user-centered principles and built in the Epic electronic health record (EHR) of 2 health systems. For each relevant patient, OneSheet presents pertinent information in a single EHR view to assist PCPs in completing guideline-recommended opioid risk mitigation tasks, review previous and current patient treatments, view patient-reported pain, physical function, and pain-related goals. Results Overall, 69 PCPs accessed OneSheet 2411 times (since November 2020). PCP use of OneSheet varied significantly by provider and was highly skewed (site 1: median accesses per provider: 17 [interquartile range (IQR) 9-32]; site 2: median: 8 [IQR 5-16]). Seven "power users" accounted for 70% of the overall access instances across both sites. OneSheet has been accessed an average of 20 times weekly between the 2 sites. Discussion Modest OneSheet use was observed relative to the number of eligible patients seen with chronic pain. Conclusions Organizations implementing CDS tools are likely to see considerable provider-level variation in usage, suggesting that CDS tools may vary in their utility across PCPs, even for the same condition, because of differences in provider and care team workflows.
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Affiliation(s)
- Nate C Apathy
- Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA
- Clem McDonald Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
| | - Lindsey Sanner
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA
| | - Meredith C B Adams
- Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Burke W Mamlin
- Clem McDonald Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
- Internal Medicine, Eskenazi Health, Indianapolis, Indiana, USA
- Department of Clinical Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Randall W Grout
- Clem McDonald Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Informatics, Eskenazi Health, Indianapolis, Indiana, USA
| | - Saura Fortin
- Primary Care, Eskenazi Health, Indianapolis, Indiana, USA
| | - Jennifer Hillstrom
- IS Ambulatory & Research Solutions, Eskenazi Health, Indianapolis, Indiana, USA
| | - Amit Saha
- Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Evgenia Teal
- Data Core, Regenstrief Institute, Indianapolis, Indiana, USA
| | - Joshua R Vest
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA
- Clem McDonald Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
| | - Nir Menachemi
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA
- Clem McDonald Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
| | - Robert W Hurley
- Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Christopher A Harle
- Clem McDonald Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida, USA
| | - Olena Mazurenko
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA
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Wachnik AA, Welch-Coltrane JL, Adams MCB, Blumstein HA, Pariyadath M, Robinson SG, Saha A, Summers EC, Hurley RW. A Standardized Emergency Department Order Set Decreases Admission Rates and In-Patient Length of Stay for Adults Patients with Sickle Cell Disease. Pain Med 2022; 23:2050-2060. [PMID: 35708651 PMCID: PMC9714532 DOI: 10.1093/pm/pnac096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/20/2022] [Accepted: 06/10/2022] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Pain associated with sickle cell disease (SCD) causes severe complications and frequent presentation to the emergency department (ED). Patients with SCD frequently report inadequate pain treatment in the ED, resulting in hospital admission. A retrospective analysis was conducted to assess a quality improvement project to standardize ED care for patients presenting with pain associated with SCD. METHODS A 3-year prospective quality improvement initiative was performed. Our multidisciplinary team of providers implemented an ED order set in 2019 to improve care and provide adequate analgesia management. Our primary outcome was the overall hospital admission rate for patients after the intervention. Secondary outcome measures included ED disposition, rate of return to the ED within 72 hours, ED pain scores at admission and discharge, ED treatment time, in-patient length of stay, non-opioid medication use, and opioid medication use. RESULTS There was an overall 67% reduction in the hospital admission rate after implementation of the order set (P = 0.005) and a significant decrease in the percentage admission rate month over month (P = 0.047). Time to the first non-opioid analgesic decreased by 71 minutes (P > 0.001), and there was no change in time to the first opioid medication. The rate of return to the ED within 72 hours remained unchanged (7.0% vs 7.1%) (P = 0.93), and the ED elopement rate remained unchanged (1.3% vs 1.85%) (P = 0.93). After the implementation, there were significant increases in the prescribing of orally administered acetaminophen (7%), celecoxib (1.2%), and tizanidine (12.5%) and intravenous ketamine (30.5%) and ketorolac (27%). ED pain scores at discharge were unchanged for both hospital-admitted (7.12 vs 7.08) (P = 0.93) and non-admitted (5.51 vs 6.11) (P = 0.27) patients. The resulting potential cost reduction was determined to be $193,440 during the 12-month observation period, with the mean cost per visit decreasing by $792. CONCLUSIONS Use of a standardized and multimodal ED order set reduced hospital admission rates and the timeliness of analgesia without negatively impacting patients' pain.
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Affiliation(s)
| | | | | | | | | | | | - Amit Saha
- Department of Anesthesiology and Pain Service Line
| | - Erik C Summers
- Department of Internal Medicine Section of Hospital Medicine
| | - Robert W Hurley
- Correspondence to: Robert W. Hurley, MD, PhD, FASA, Department of Anesthesiology, Neurobiology and Anatomy, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27051, USA. Tel: 336-716-2266; Fax: 336-716-8773; E-mail:
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Mazurenko O, Sanner L, Apathy NC, Mamlin BW, Menachemi N, Adams MCB, Hurley RW, Erazo SF, Harle CA. Evaluation of electronic recruitment efforts of primary care providers as research subjects during the COVID-19 pandemic. BMC Prim Care 2022; 23:95. [PMID: 35484491 PMCID: PMC9047458 DOI: 10.1186/s12875-022-01705-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 04/12/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Recruiting healthcare providers as research subjects often rely on in-person recruitment strategies. Little is known about recruiting provider participants via electronic recruitment methods. In this study, conducted during the COVID-19 pandemic, we describe and evaluate a primarily electronic approach to recruiting primary care providers (PCPs) as subjects in a pragmatic randomized controlled trial (RCT) of a decision support intervention. METHODS We adapted an existing framework for healthcare provider research recruitment, employing an electronic consent form and a mix of brief synchronous video presentations, email, and phone calls to recruit PCPs into the RCT. To evaluate the success of each electronic strategy, we estimated the number of consented PCPs associated with each strategy, the number of days to recruit each PCP and recruitment costs. RESULTS We recruited 45 of 63 eligible PCPs practicing at ten primary care clinic locations over 55 days. On average, it took 17 business days to recruit a PCP (range 0-48) and required three attempts (range 1-7). Email communication from the clinic leaders led to the most successful recruitments, followed by brief synchronous video presentations at regularly scheduled clinic meetings. We spent approximately $89 per recruited PCP. We faced challenges of low email responsiveness and limited opportunities to forge relationships. CONCLUSION PCPs can be efficiently recruited at low costs as research subjects using primarily electronic communications, even during a time of high workload and stress. Electronic peer leader outreach and synchronous video presentations may be particularly useful recruitment strategies. TRIAL REGISTRATION ClinicalTrials.gov , NCT04295135 . Registered 04 March 2020.
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Affiliation(s)
- Olena Mazurenko
- Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University, 1050 Wishard Blvd, Ste 6140, Indianapolis, IN, 46202, USA.
| | - Lindsey Sanner
- Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University, 1050 Wishard Blvd, Ste 6140, Indianapolis, IN, 46202, USA
| | - Nate C Apathy
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Burke W Mamlin
- Regenstrief Institute, Inc., Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nir Menachemi
- Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University, 1050 Wishard Blvd, Ste 6140, Indianapolis, IN, 46202, USA
- Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Meredith C B Adams
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston Salem, NC, USA
- Department of Public Health Sciences, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Robert W Hurley
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston Salem, NC, USA
- Department of Neurobiology and Anatomy, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Saura Fortin Erazo
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Eskenazi Health Centers, Eskenazi Health, Indianapolis, IN, USA
| | - Christopher A Harle
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, USA
- University of Florida Health, Jacksonville, FL, USA
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13
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Gökçınar A, Çakanyıldırım M, Price T, Adams MCB. Balanced Opioid Prescribing via a Clinical Trade-Off: Pain Relief vs. Adverse Effects of Discomfort, Dependence, and Tolerance/Hypersensitivity. Decision Analysis 2022. [DOI: 10.1287/deca.2021.0447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In the backdrop of the opioid epidemic, opioid prescribing has distinct medical and social challenges. Overprescribing contributes to the ongoing opioid epidemic, whereas underprescribing yields inadequate pain relief. Moreover, opioids have serious adverse effects including tolerance and increased sensitivity to pain, paradoxically inducing more pain. Prescribing trade-offs are recognized but not modeled in the literature. We study the prescribing decisions for chronic, acute, and persistent pain types to minimize the cumulative pain that incorporates opioid adverse effects (discomfort and dependence) and the risk of tolerance or hypersensitivity (THS) developed with opioid use. After finding closed-form solutions for each pain type, we analytically investigate the sensitivity of acute pain prescriptions and examine policies on incorporation of THS, patient handover, and adaptive treatments. Our analyses show that the role of adverse effects in prescribing decisions is as critical as that of the pain level. Interestingly, we find that the optimal prescription duration is not necessarily increasing with the recovery time. We show that not incorporating THS or information curtailment at patient handovers leads to overprescribing that can be mitigated by adaptive treatments. Last, using real-life pain and opioid use data from two sources, we estimate THS parameters and discuss the proximity of our model to clinical practice. This paper has a pain management framework that leads to tractable models. These models can potentially support balanced opioid prescribing after their validation in a clinical setting. Then, they can be helpful to policy makers in assessment of prescription policies and of the controversy around over- and underprescribing.
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Affiliation(s)
- Abdullah Gökçınar
- Jindal School of Management, University of Texas at Dallas, Richardson, Texas 75080
| | - Metin Çakanyıldırım
- Jindal School of Management, University of Texas at Dallas, Richardson, Texas 75080
| | - Theodore Price
- School of Behavioral and Brain Sciences, University of Texas at Dallas, Richardson, Texas 75080
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14
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Hurley RW, Adams MCB, Barad M, Bhaskar A, Bhatia A, Chadwick A, Deer TR, Hah J, Hooten WM, Kissoon NR, Lee DW, Mccormick Z, Moon JY, Narouze S, Provenzano DA, Schneider BJ, van Eerd M, Van Zundert J, Wallace MS, Wilson SM, Zhao Z, Cohen SP. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Pain Med 2021; 22:2443-2524. [PMID: 34788462 PMCID: PMC8633772 DOI: 10.1093/pm/pnab281] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 09/15/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND The past two decades have witnessed a surge in the use of cervical spine joint procedures including joint injections, nerve blocks and radiofrequency ablation to treat chronic neck pain, yet many aspects of the procedures remain controversial. METHODS In August 2020, the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine approved and charged the Cervical Joint Working Group to develop neck pain guidelines. Eighteen stakeholder societies were identified, and formal request-for-participation and member nomination letters were sent to those organizations. Participating entities selected panel members and an ad hoc steering committee selected preliminary questions, which were then revised by the full committee. Each question was assigned to a module composed of 4-5 members, who worked with the Subcommittee Lead and the Committee Chairs on preliminary versions, which were sent to the full committee after revisions. We used a modified Delphi method whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until consensus was reached. Before commencing, it was agreed that a recommendation would be noted with >50% agreement among committee members, but a consensus recommendation would require ≥75% agreement. RESULTS Twenty questions were selected, with 100% consensus achieved in committee on 17 topics. Among participating organizations, 14 of 15 that voted approved or supported the guidelines en bloc, with 14 questions being approved with no dissensions or abstentions. Specific questions addressed included the value of clinical presentation and imaging in selecting patients for procedures, whether conservative treatment should be used before injections, whether imaging is necessary for blocks, diagnostic and prognostic value of medial branch blocks and intra-articular joint injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for designating a block as positive, how many blocks should be performed before radiofrequency ablation, the orientation of electrodes, whether larger lesions translate into higher success rates, whether stimulation should be used before radiofrequency ablation, how best to mitigate complication risks, if different standards should be applied to clinical practice and trials, and the indications for repeating radiofrequency ablation. CONCLUSIONS Cervical medial branch radiofrequency ablation may provide benefit to well-selected individuals, with medial branch blocks being more predictive than intra-articular injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of false-negatives (ie, lower overall success rate). Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.
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Affiliation(s)
- Robert W Hurley
- Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Meredith C B Adams
- Anesthesiology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Meredith Barad
- Anesthesiology, Perioperative and Pain Medicine, Stanford Hospital and Clinics, Redwood City, California, USA
| | - Arun Bhaskar
- Anesthesiology, Imperial College Healthcare NHS Trust Haemodialysis Clinic, Hayes Satellite Unit, Hayes, UK
| | - Anuj Bhatia
- Anesthesia and Pain Management, University of Toronto and University Health Network - Toronto Western Hospital, Toronto, Ontario, Canada
| | - Andrea Chadwick
- Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Timothy R Deer
- Spine and Nerve Center of the Virginias, West Virginia University - Health Sciences Campus, Morgantown, West Virginia, USA
| | - Jennifer Hah
- Anesthesiology, Stanford University School of Medicine, Palo Alto, California, USA
| | | | | | - David Wonhee Lee
- Fullerton Orthopaedic Surgery Medical Group, Fullerton, California, USA
| | - Zachary Mccormick
- Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jee Youn Moon
- Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, South Korea
- Anesthesiology and Pain Medicine, Seoul National University Hospital, Jongno-gu, South Korea
| | - Samer Narouze
- Center for Pain Medicine, Summa Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - David A Provenzano
- Pain Diagnostics and Interventional Care, Sewickley, Pennsylvania, USA
- Pain Diagnostics and Interventional Care, Edgeworth, Pennsylvania, USA
| | - Byron J Schneider
- Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee, USA
| | - Maarten van Eerd
- Anesthesiology, Maastricht University Medical Centre, Maastricht, Limburg, The Netherlands
| | - Jan Van Zundert
- Anesthesiology, Maastricht University Medical Centre, Maastricht, Limburg, The Netherlands
| | - Mark S Wallace
- Anesthesiology, UCSD Medical Center - Thornton Hospital, San Diego, California, USA
| | | | - Zirong Zhao
- Neurology, VA Healthcare Center District of Columbia, Washington, District of Columbia, USA
| | - Steven P Cohen
- Anesthesia, WRNMMC, Bethesda, Maryland, USA
- Physical Medicine and Rehabilitation, WRNMMC, Bethesda, Maryland, USA
- Anesthesiology, Neurology, Physical Medicine and Rehabilitation and Psychiatry, Pain Medicine Division, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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15
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Hurley RW, Adams MCB, Barad M, Bhaskar A, Bhatia A, Chadwick A, Deer TR, Hah J, Hooten WM, Kissoon NR, Lee DW, Mccormick Z, Moon JY, Narouze S, Provenzano DA, Schneider BJ, van Eerd M, Van Zundert J, Wallace MS, Wilson SM, Zhao Z, Cohen SP. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Reg Anesth Pain Med 2021; 47:3-59. [PMID: 34764220 PMCID: PMC8639967 DOI: 10.1136/rapm-2021-103031] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/02/2021] [Indexed: 01/03/2023]
Abstract
Background The past two decades have witnessed a surge in the use of cervical spine joint
procedures including joint injections, nerve blocks and radiofrequency ablation to treat
chronic neck pain, yet many aspects of the procedures remain controversial. Methods In August 2020, the American Society of Regional Anesthesia and Pain Medicine and the
American Academy of Pain Medicine approved and charged the Cervical Joint Working Group
to develop neck pain guidelines. Eighteen stakeholder societies were identified, and
formal request-for-participation and member nomination letters were sent to those
organizations. Participating entities selected panel members and an ad hoc steering
committee selected preliminary questions, which were then revised by the full committee.
Each question was assigned to a module composed of 4–5 members, who worked with
the Subcommittee Lead and the Committee Chairs on preliminary versions, which were sent
to the full committee after revisions. We used a modified Delphi method whereby the
questions were sent to the committee en bloc and comments were returned in a non-blinded
fashion to the Chairs, who incorporated the comments and sent out revised versions until
consensus was reached. Before commencing, it was agreed that a recommendation would be
noted with >50% agreement among committee members, but a consensus
recommendation would require ≥75% agreement. Results Twenty questions were selected, with 100% consensus achieved in committee on 17
topics. Among participating organizations, 14 of 15 that voted approved or supported the
guidelines en bloc, with 14 questions being approved with no dissensions or abstentions.
Specific questions addressed included the value of clinical presentation and imaging in
selecting patients for procedures, whether conservative treatment should be used before
injections, whether imaging is necessary for blocks, diagnostic and prognostic value of
medial branch blocks and intra-articular joint injections, the effects of sedation and
injectate volume on validity, whether facet blocks have therapeutic value, what the
ideal cut-off value is for designating a block as positive, how many blocks should be
performed before radiofrequency ablation, the orientation of electrodes, whether larger
lesions translate into higher success rates, whether stimulation should be used before
radiofrequency ablation, how best to mitigate complication risks, if different standards
should be applied to clinical practice and trials, and the indications for repeating
radiofrequency ablation. Conclusions Cervical medial branch radiofrequency ablation may provide benefit to well-selected
individuals, with medial branch blocks being more predictive than intra-articular
injections. More stringent selection criteria are likely to improve denervation
outcomes, but at the expense of false-negatives (ie, lower overall success rate).
Clinical trials should be tailored based on objectives, and selection criteria for some
may be more stringent than what is ideal in clinical practice.
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Affiliation(s)
- Robert W Hurley
- Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Meredith C B Adams
- Anesthesiology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Meredith Barad
- Anesthesiology, Perioperative and Pain Medicine, Stanford Hospital and Clinics, Redwood City, California, USA
| | - Arun Bhaskar
- Anesthesiology, Imperial College Healthcare NHS Trust Haemodialysis Clinic, Hayes Satellite Unit, Hayes, UK
| | - Anuj Bhatia
- Anesthesia and Pain Management, University of Toronto and University Health Network - Toronto Western Hospital, Toronto, Ontario, Canada
| | - Andrea Chadwick
- Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Timothy R Deer
- Spine and Nerve Center of the Virginias, West Virginia University - Health Sciences Campus, Morgantown, West Virginia, USA
| | - Jennifer Hah
- Stanford University School of Medicine, Palo Alto, California, USA
| | | | | | - David Wonhee Lee
- Fullerton Orthopaedic Surgery Medical Group, Fullerton, California, USA
| | - Zachary Mccormick
- Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jee Youn Moon
- Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, South Korea.,Anesthesiology and Pain Medicine, Seoul National University Hospital, Jongno-gu, South Korea
| | - Samer Narouze
- Center for Pain Medicine, Summa Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - David A Provenzano
- Pain Diagnostics and Interventional Care, Sewickley, Pennsylvania, USA.,Pain Diagnostics and Interventional Care, Edgeworth, Pennsylvania, USA
| | - Byron J Schneider
- Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee, USA
| | - Maarten van Eerd
- Anesthesiology, Maastricht University Medical Centre, Maastricht, Limburg, The Netherlands
| | - Jan Van Zundert
- Anesthesiology, Maastricht University Medical Centre, Maastricht, Limburg, The Netherlands
| | - Mark S Wallace
- Anesthesiology, UCSD Medical Center - Thornton Hospital, San Diego, California, USA
| | | | - Zirong Zhao
- Neurology, VA Healthcare Center District of Columbia, Washington, District of Columbia, USA
| | - Steven P Cohen
- Anesthesiology, Neurology, Physical Medicine and Rehabilitation and Psychiatry, Pain Medicine Division, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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16
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Adams MCB, Denizard-Thompson NM, DiGiacobbe G, Williams BL, Brooks AK. Designing Actionable Solutions and Curriculum for Pain Disparities Education. Pain Med 2021; 23:288-294. [PMID: 34601612 DOI: 10.1093/pm/pnab289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 09/09/2021] [Accepted: 09/29/2021] [Indexed: 11/14/2022]
Abstract
The Liaison Committee on Medical Education (LCME) require medical schools to teach their students how to recognize and work towards eliminating health disparities. However, time constraints and a dearth of guidance for educators in teaching pain disparities curricula, pose significant challenges. Herein, we describe successes and lessons learned after designing, implementing, and evaluating an innovative pain disparities curriculum that was embedded in a longitudinal health equity curriculum for third year medical school students at an academic institution. Although the curriculum was developed for medical school students, the concepts may be broadly applicable to other training settings such as residency and fellowship programs.
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Affiliation(s)
- Meredith C B Adams
- Departments of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Departments of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nancy M Denizard-Thompson
- Departments of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Gia DiGiacobbe
- Educational Technology, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Brandon L Williams
- Departments of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Amber K Brooks
- Departments of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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17
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Welch-Coltrane JL, Wachnik AA, Adams MCB, Avants CR, Blumstein HA, Brooks AK, Farland AM, Johnson JB, Pariyadath M, Summers EC, Hurley RW. Implementation of Individualized Pain Care Plans Decreases Length of Stay and Hospital Admission Rates for High Utilizing Adults with Sickle Cell Disease. Pain Med 2021; 22:1743-1752. [PMID: 33690845 PMCID: PMC8346918 DOI: 10.1093/pm/pnab092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Patients with sickle cell disease (SCD) face inconsistent effective analgesic management, leading to high inpatient healthcare utilization and significant financial burden for healthcare institutions. Current evidence does not provide guidance for inpatient management of acute pain in adults with sickle cell disease. We conducted a retrospective analysis of a longitudinal cohort quality improvement project to characterize the role of individualized care plans on improving patient care and reducing financial burden in high healthcare-utilizing patients with SCD-related pain. METHODS Individualized care plans were developed for patients with hospital admissions resulting from pain associated with sickle cell disease. A 2-year prospective longitudinal cohort quality improvement project was performed and retrospectively analyzed. Primary outcome measure was duration of hospitalization. Secondary outcome measures included: pain intensity; 7, 30, and 90-day readmission rates; cost per day; total admissions; total cost per year; analgesic regimen at index admission; and discharge disposition. RESULTS Duration of hospitalization, the primary outcome, significantly decreased by 1.23 days with no worsening of pain intensity scores. Seven-day readmission decreased by 34%. Use of intravenous hydromorphone significantly decreased by 25%. The potential cost saving was $1,398,827 as a result of this quality initiative. CONCLUSIONS Implementation of individualized care plans reduced both admission rate and financial burden of high utilizing patients. Importantly, pain outcomes were not diminished. Results suggest that individualized care plans are a promising strategy for managing acute pain crisis in adult sickle cell patients from both care-focused and utilization outcomes.
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Affiliation(s)
- Jena L Welch-Coltrane
- Department of Anesthesiology, Section of Pain Medicine, Wake Forest School of Medicine, North Carolina, USA
| | - Anthony A Wachnik
- Department of Anesthesiology, Section of Pain Medicine, Wake Forest School of Medicine, North Carolina, USA
| | - Meredith C B Adams
- Department of Anesthesiology, Section of Pain Medicine, Wake Forest School of Medicine, North Carolina, USA
| | - Cherie R Avants
- Department of Anesthesiology, Section of Pain Medicine, Wake Forest School of Medicine, North Carolina, USA
| | - Howard A Blumstein
- Department of Emergency Medicine, Wake Forest School of Medicine, North Carolina, USA
| | - Amber K Brooks
- Department of Anesthesiology, Section of Pain Medicine, Wake Forest School of Medicine, North Carolina, USA
| | - Andrew M Farland
- Department of Hematology, Wake Forest School of Medicine, North Carolina, USA
| | - Joshua B Johnson
- Department of Internal Medicine Section of Hospital Medicine, Wake Forest University School of Medicine, North Carolina, USA
| | - Manoj Pariyadath
- Department of Emergency Medicine, Wake Forest School of Medicine, North Carolina, USA
| | - Erik C Summers
- Department of Internal Medicine Section of Hospital Medicine, Wake Forest University School of Medicine, North Carolina, USA
| | - Robert W Hurley
- Department of Anesthesiology, Section of Pain Medicine, Wake Forest School of Medicine, North Carolina, USA
- Department of Neurobiology and Anatomy, Wake Forest School of Medicine, North Carolina USA
- Correspondence to: Robert W. Hurley, MD, PhD, FASA, Department of Anesthesiology, Neurobiology and Anatomy, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157-1009, USA. Tel: 336-716-2266; Fax: 336-716-8773; E-mail:
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18
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Affiliation(s)
- Meredith C B Adams
- Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem, North Carolina,
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19
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Boslett AJ, Denham A, Hill EL, Adams MCB. Unclassified drug overdose deaths in the opioid crisis: emerging patterns of inequity. J Am Med Inform Assoc 2021; 26:767-777. [PMID: 31034076 DOI: 10.1093/jamia/ocz050] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/21/2019] [Accepted: 03/28/2019] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE Examine whether individual, geographic, and economic phenotypes predict missing data on specific drug involvement in overdose deaths, manifesting inequities in overdose mortality data, which is a key data source used in measuring the opioid epidemic. MATERIALS AND METHODS We combined national data sources (mortality, demographic, economic, and geographic) from 2014-2016 in a multi-method analysis of missing drug classification in the overdose mortality records (as defined by the use of ICD-10 T50.9 on death certificates). We examined individual disparities in decedent-level multivariate logistic regression models, geographic disparities in spatial analysis (heat maps), and economic disparities in a combination of temporal trend analyses (descriptive statistics) and both decedent- and county-level multivariate logistic regression models. RESULTS Our analyses consistently found higher rates of unclassified overdoses in decedents of female gender, White race, non-Hispanic ethnicity, with college education, aged 30-59 and those from poorer counties. Despite the fact that unclassified drug overdose death rates have reduced over time, gaps persist between the richest and poorest counties. There are also striking geographic differences both across and within states. DISCUSSION Given the essential role of mortality data in measuring the scale of the opioid epidemic, it is important to understand the individual and community inequities underlying the missing data on specific drug involvements. Knowledge of these inequities could enhance our understanding of the opioid crisis and inform data-driven interventions and policies with more equitable resource allocations. CONCLUSION Multiple individual, geographic, and economic disparities underlie unclassified overdose deaths, with important implications for public health informatics and addressing the opioid crisis.
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Affiliation(s)
- Andrew J Boslett
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Alina Denham
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Elaine L Hill
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Meredith C B Adams
- Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
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20
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Nicol AL, Adams MCB, Gordon DB, Mirza S, Dickerson D, Mackey S, Edwards D, Hurley RW. AAAPT Diagnostic Criteria for Acute Low Back Pain with and Without Lower Extremity Pain. Pain Med 2020; 21:2661-2675. [PMID: 32914195 PMCID: PMC8453619 DOI: 10.1093/pm/pnaa239] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Low back pain is one of the most common reasons for which people visit their doctor. Between 12% and 15% of the US population seek care for spine pain each year, with associated costs exceeding $200 billion. Up to 80% of adults will experience acute low back pain at some point in their lives. This staggering prevalence supports the need for increased research to support tailored clinical care of low back pain. This work proposes a multidimensional conceptual taxonomy. METHODS A multidisciplinary task force of the ACTTION-APS-AAPM Pain Taxonomy (AAAPT) with clinical and research expertise performed a focused review and analysis, applying the AAAPT five-dimensional framework to acute low back pain. RESULTS Application of the AAAPT framework yielded the following: 1) Core Criteria: location, timing, and severity of acute low back pain were defined; 2) Common Features: character and expected trajectories were established in relevant subgroups, and common pain assessment tools were identified; 3) Modulating Factors: biological, psychological, and social factors that modulate interindividual variability were delineated; 4) Impact/Functional Consequences: domains of impact were outlined and defined; 5) Neurobiological Mechanisms: putative mechanisms were specified including nerve injury, inflammation, peripheral and central sensitization, and affective and social processing of acute low back pain. CONCLUSIONS The goal of applying the AAAPT taxonomy to acute low back pain is to improve its assessment through a defined evidence and consensus-driven structure. The criteria proposed will enable more rigorous meta-analyses and promote more generalizable studies of interindividual variation in acute low back pain and its potential underlying mechanisms.
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Affiliation(s)
- Andrea L Nicol
- Department of Anesthesiology, University of Kansas School of Medicine, Kansas City, Kansas
| | - Meredith C B Adams
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Debra B Gordon
- Department of Biobehavioral Nursing and Health Systems, University of Washington, Seattle, Washington
| | - Sohail Mirza
- Department of Orthopedic Surgery, Geisel School of Medicine at Dartmouth University, Hanover, New Hampshire
| | - David Dickerson
- Department of Anesthesiology, NorthShore University Health System, Evanston, Illinois
| | - Sean Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - David Edwards
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert W Hurley
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston Salem, North Carolina
- Department of Neurobiology and Anatomy, Wake Forest University School of Medicine, Winston Salm, North Carolina, USA
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21
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Adams MCB, Memtsoudis SG. The world needs our science: broadening the research pipeline in anesthesiology. Reg Anesth Pain Med 2020; 46:164-168. [PMID: 33028647 DOI: 10.1136/rapm-2020-102029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/07/2020] [Accepted: 09/11/2020] [Indexed: 11/04/2022]
Abstract
Anesthesiologists are innovative and adaptable problem solvers. Despite these talents, our field is still working to consistently develop and support the translation of innovation and creativity into productive scientists. This article is focused on opening the discussion on identifying the gaps and move toward developing a sustainable and diverse research pipeline.
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Affiliation(s)
- Meredith C B Adams
- Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Paracelsus Medical University, Salzburg, Austria
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Clark MR, Hurley RW, Adams MCB. Re-assessing the Validity of the Opioid Risk Tool in a Tertiary Academic Pain Management Center Population. Pain Med 2020; 19:1382-1395. [PMID: 29408996 DOI: 10.1093/pm/pnx332] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To analyze the validity of the Opioid Risk Tool (ORT) in a large. diverse population. DESIGN A cross-sectional descriptive study. SETTING Academic tertiary pain management center. SUBJECTS A total of 225 consecutive new patients, aged 18 years or older. METHODS Data collection included demographics, ORT scores, aberrant behaviors, pain intensity scores, opioid type and dose, smoking status, employment, and marital status. RESULTS In this population, we were not able to replicate the findings of the initial ORT study. Self-report was no better than chance in predicting those who would have an opioid aberrant behavior. The ORT risk variables did not predict aberrant behaviors in either gender group. There was significant disparity in the scores between self-reported ORT and the ORT supplemented with medical record data (enhanced ORT). Using the enhanced ORT, high-risk patients were 2.5 times more likely to have an aberrant behavior than the low-risk group. The only risk variable associated with aberrant behavior was personal history of prescription drug misuse. CONCLUSIONS The self-report ORT was not a valid test for the prediction of future aberrant behaviors in this academic pain management population. The original risk categories (low, medium, high) were not supported in the either the self-reported version or the enhanced version; however, the enhanced data were able to differentiate between high- and low-risk patients. Unfortunately, without technological automation, the enhanced ORT suffers from practical limitations. The self-report ORT may not be a valid tool in current pain populations; however, modification into a binary (high/low) score system needs further study.
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Affiliation(s)
- Meredith R Clark
- Division of Pain Medicine, Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, Wisconsin
| | - Robert W Hurley
- Section of Pain Medicine, Department of Anesthesiology, Wake Forest School of Medicine, Medical Center Drive, Winston-Salem, North Carolina, USA
| | - Meredith C B Adams
- Section of Pain Medicine, Department of Anesthesiology, Wake Forest School of Medicine, Medical Center Drive, Winston-Salem, North Carolina, USA
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Hurley RW, Lesley MR, Adams MCB, Brummett CM, Wu CL. Pregabalin as a treatment for painful diabetic peripheral neuropathy: a meta-analysis. Reg Anesth Pain Med 2008; 33:389-94. [PMID: 18774507 DOI: 10.1016/j.rapm.2008.02.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Revised: 02/15/2008] [Accepted: 02/15/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Painful diabetic peripheral neuropathy (DPN) is an increasingly prevalent disorder that is best managed through a multimodal approach. We examined the effects of pregabalin on pain control, sleep disturbance, and the patient's global impression of change (PGIC) for the treatment of this disorder. METHODS Studies were identified using the National Library of Medicine's PubMed and EMBase databases (1966 to July 15, 2007). Inclusion criteria were randomized trials comparing pregabalin to placebo in the treatment of DPN for adult patients. A total of 13 abstracts were identified of which 3 met inclusion criteria. Data were collected from each article and results were recorded. Primary outcome was pain at the conclusion of the study. Secondary outcomes included number of patients with 50% reduction in mean pain score, PGIC ratings at endpoint, and adverse events. A random-effects model was used. RESULTS The 3 studies yielded 728 total subjects from 5 centers, of which 476 received pregabalin (dose range 75 to 600 mg/day) and 252 received placebo. Pregabalin treatment was associated with a significant decrease in pain scores (weighted mean difference, 1.15), higher likelihood to achieve at least a 50% reduction in mean pain score (relative risk [RR], 4.05), and improved PGIC ratings (RR = 1.45). Pregabalin was associated with an increased risk of somnolence, dizziness, and edema. CONCLUSIONS Pregabalin has significant effects on the pain associated with DPN as well as secondary endpoints that affect patients' quality of life.
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Affiliation(s)
- Robert W Hurley
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, MD 21287, USA.
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Abstract
Traditionally, biomedical research in the field of pain has been conducted with male animals and subjects. Over the past 20-30 yr, it has been increasingly recognized that this narrow approach has missed an important variable: sex. An ever-increasing number of studies have established sex differences in response to pain and analgesics. These studies have demonstrated that the differences between the sexes appear to have a biological and psychological basis. We will provide brief review of the epidemiology, rodent, and human experimental findings. The controversies and widespread disagreement in the literature highlight the need for a progressive approach to the questions involving collaborative efforts between those trained in the basic and clinical biomedical sciences and those in the epidemiological and social sciences. In order for patients suffering from acute and/or chronic pain to benefit from this work, the approach has to involve the use or development of clinically relevant models of nociception or pain to answer the basic, but complex, question. The present state of the literature allows no translation of the work to our clinical decision-making.
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Affiliation(s)
- Robert W Hurley
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
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