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

1.Edwards DA, Hedrick TL, Jayaram J, Argoff C, Gulur P, Holubar SD, Gan TJ, Mythen MG, Miller TE, Shaw AD, Thacker JKM, McEvoy MD; POQI-4 Working Group. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Management of Patients on Preoperative Opioid Therapy. Anesth Analg. 2019 Aug;129(2):553-566.
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.
4.Rim F, Liu SS, Kelly M, Kim D, Sideris A, Langford DJ. Preoperative pain screening and optimisation by a perioperative pain service to support complex surgical patients: no patient left behind. Br J Anaesth. 2024 Feb;132(2):437-439. doi: 10.1016/j.bja.2023.11.024. Epub 2023 Dec 12.
5.Sideris A, Chan W, Kelly M, et al EP037 Development of an automated registry in the electronic health record to track patients managed by the perioperative pain service: a research and quality improvement tool. Regional Anesthesia & Pain Medicine 2023;48:A59-A60.
6.Wood TJ, Gazendam AM, Kabali CB; Hamilton Arthroplasty Group. Postoperative Outcomes Following Total Hip and Knee Arthroplasty in Patients with Pain Catastrophizing, Anxiety, or Depression. J Arthroplasty. 2021 Jun;36(6):1908-1914. doi: 10.1016/j.arth.2021.02.018. Epub 2021 Feb 11. PMID: 33648844
7.Bruehl S, Billings FT 4th, Anderson S, Polkowski G, Shinar A, Schildcrout J, Shi Y, Milne G, Dematteo A, Mishra P, Harden RN. Preoperative Predictors of Complex Regional Pain Syndrome Outcomes in the 6 Months Following Total Knee Arthroplasty. J Pain. 2022 Oct;23(10):1712-1723. Epub 2022 Apr 22.

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