Background & Aims
Perioperative optimization of complex patients through education, counseling, opioid weaning, medication management, and post-discharge care coordination may decrease the incidence of postoperative complications such as severe pain and opioid-related side effects [1-4]. To improve screening and risk stratification of complex patients, the Perioperative Pain Service (POPS) at Hospital for Special Surgery, an orthopedic specialty hospital, instituted new standard-of-care screening tools during preoperative pain consults, namely the pain catastrophizing scale (PCS) and wide-spread pain index (WPI). The objective of this preliminary study was to evaluate PCS and WPI scores after implementation to gain a richer understanding of our complex patient population and to lay the groundwork for future targeted interventions.
Methods
Starting in 2023, patients referred to a preoperative pain consultation for preexisting chronic pain with long-term opioid therapy, or substance use issues are automatically sent the PCS and WPI for online completion through a secure patient portal which is linked to the institution’s electronic health record (EHR) (Figure 1A). Patient-reported data are transcribed into the pain consult visit note (Figures 1B and 1C). After IRB approval for a prospective institutional registry capturing all surgical cases interacting with POPS [5], surgical cases requiring a pre-operative pain consult and performed between August 21, 2023, and October 5, 2023, immediately after PCS and WPI screening tool implementation, were extracted from the registry database. Descriptive statistics to characterize pain phenotypes and case details of this high-risk surgical cohort were performed; Kruskal-Wallis and Fisher’s Exact tests were used to analyze continuous and categorical variables, respectively.
Results
During the post-implementation phase, 99 out of 130 cases had the PCS and WPI in the EHR and were extracted for analysis; 59.6% of patients were female, and 88.9% were white and not Hispanic-Latinx. Patients primarily underwent total knee replacement (30.3%), total hip replacement (25.3%), or spine instrumentation (17.2%) procedures. The mean PCS was 23.1 out of the highest possible score of 52, while the mean WPI was 4.2 out of the highest possible score of 19 (Table 1). Clinically significant (high) PCS (score > 30) was present in 34.3% of patients, and approximately 8% of high PCS patients also had pain distribution in seven or more body areas (WPI of 7 or greater) within one week of questionnaire completion. Overall, 52.5% of pain consults were in-person office visits, while 47.5% were telemedicine visits. Patients who had a telemedicine consult were less likely to engage with the pain social worker for preoperative psychosocial support (4.3% vs. 59.6%; P< 0.001) (Table 2).
Conclusions
Implementation of pain-specific screening using PCS and WPI at our institution’s pre-operative pain consult program highlights additional potential risk factors for poor outcomes in orthopedic patients already at high risk. Preoperative high PCS and high WPI are associated with more pain, lower function [6], and the development of CRPS after total knee arthroplasty [7]. Complex patients with high PCS and/or WPI may benefit from more targeted interventions. Though post-pandemic care delivery models have incorporated telemedicine at higher rates, our preliminary data suggest that this method may translate into missed opportunities for patient engagement with more specialized support. Continued data collection through our registry will enable us to conduct studies that should allow for a more comprehensive and personalized approach to pain prevention and management, including the identification of preoperative multidimensional pain phenotypes associated with postoperative outcomes.
References
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2.Dickerson DM, Mariano ER, Szokol JW, Harned M, Clark RM, Mueller JT, Shilling AM, Udoji MA, Mukkamala SB, Doan L, Wyatt KEK, Schwalb JM, Elkassabany NM, Eloy JD, Beck SL, Wiechmann L, Chiao F, Halle SG, Krishnan DG, Cramer JD, Ali Sakr Esa W, Muse IO, Baratta J, Rosenquist R, Gulur P, Shah S, Kohan L, Robles J, Schwenk ES, Allen BFS, Yang S, Hadeed JG, Schwartz G, Englesbe MJ, Sprintz M, Urish KL, Walton A, Keith L, Buvanendran A. Multiorganizational consensus to define guiding principles for perioperative pain management in patients with chronic pain, preoperative opioid tolerance, or substance use disorder. Reg Anesth Pain Med. 2023 Apr 25:rapm-2023-104435. Epub ahead of print.
3.Soffin EM, Waldman SA, Stack RJ, Liguori GA. An Evidence-Based Approach to the Prescription Opioid Epidemic in Orthopedic Surgery. Anesth Analg. 2017 Nov;125(5):1704-1713. PMID: 29049115.
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Presenting Author
Faye Rim
Poster Authors
Fay Rim
Hospital for Special Surgery
Lead Author
Dale Langford
Hospital for Special Surgery, Pain Prevention Research Center & Weill Cornell Medicine
Lead Author
Dae Kim
MD
Hospital for Special Surgery
Lead Author
Roberta Stack
MS
Hospital for Special Surgery
Lead Author
William Chan
M. Eng.
Hospital for Special Surgery
Lead Author
Mary Kelly
NP
Hospital for Special Surgery
Lead Author
Samuel Schuessler
MHA
Hospital for Special Sugery
Lead Author
Patrick Fritz
B.B.A.
Hospital for Special Surgery
Lead Author
Mark Trentalange
MD
Hospital for Special Surgery
Lead Author
Brandon Lim
B.S.
Hospital for Special Surgery
Lead Author
Gregory Liguori
MD
Hospital for Special Surgery; Weill Cornell Medicine
Lead Author
Christopher L Wu
MD
Hospital for Special Surgery; Weill Cornell Medicine
Lead Author
Seth Waldman
MD
Hospital for Special Surgery; Weill Cornell Medicine
Lead Author
Jiabin Liu
MD
Hospital for Special Surgery; Weill Cornell Medicine
Lead Author
Stavros G. Memtsoudis
MD
Hospital for Special Surgery; Weill Cornell Medicine
Lead Author
Spencer Liu
MD
Hospital for Special Surgery; Weill Cornell Medicine
Lead Author
Alexandra Sideris
PhD
Hospital for Special Surgery
Lead Author
Topics
- Assessment and Diagnosis