December’s #JHSJC lively discussion addressed two articles from Volume 44, Issue 12 of The Journal of Hand Surgery: The Impact of Pre-Referral Advanced Diagnostic Testing on Wait Time to See a Hand Surgeon for Common Upper-Extremity Conditions and Reduction of Opioid Use After Upper-Extremity Surgery through a Predictive Pain Calculator and Comprehensive Pain Plan.
Feel free to continue the conversation below in the comments! And please check out previous #JHSJC transcripts (please scroll to the bottom of the page).
Part 1 of the December #JHSJC Discussion (keep scrolling for Part 2!):
J Hand Surg Am- ASSH @JHandSurg:
December’s #JHSJC starts now! Let’s get the discussion going!
Brent Graham @BgTalkinman:
Welcome to this trial of a Twitter-based discussion. Before we get going, a few housekeeping words. Sign in with #jhsjc to show you’re here. Usually the sessions are 1 hr. We will start and see how far we get. Send me your impressions and feedback via email tomorrow. #jhsjc
I will start by discussing a few methodology points and then we’ll get into the findings. #jhsjc
Let’s begin with the paper on pre-referral testing: This study was conducted at one institution. How does that study design have an impact on the generalizability of the findings? #jhsjc
What I am getting at is whether these findings would likely be the same in another setting. Any opinions about that? #jhsjc
Amelia Van Handel @AmeliaVanHandel to @BgTalkinman:
At our institution, the amount of time you wait to see a provider is highly variable based on factors other than pre-referral tests #jhsjc
Brent Graham @BgTalkinman to @AmeliaVanHandel:
What are some of those factors? #jhsjc
Lee Reichel @lee_reichel to @AmeliaVanHandel:
Amelia, what are the other factors? #jhsjc
Amelia Van Handel @AmeliaVanHandel to @lee_reichel and @BgTalkinman:
Such as attending provider availability, insurance status, internal vs. external referral #jhsjc
I know some of our attendings screen their referrals for patients who need pre-appointment testing, but many don’t #jhsjc
Amelia Van Handel @AmeliaVanHandel:
Does anyone here routinely go through their clinic lists ahead of time to note patients who would benefit from pre-appt testing? #jhsjc
Lee Reichel @lee_reichel:
Some multispecialty groups have predefined workflows where patients cannot get to see a hand specialist without having EDX first #jhsjc
Carl Nunziato @CarlNunziato:
I assume there are a lot of confounders in likelihood of ordering pre-referral tests as well #jhsjc
Brent Graham @BgTalkinman to @AmeliaVanHandel:
Understood. What kind of pre-referral testing? Like EDx in CTS? #jhsjc
Brent Graham @BgTalkinman to @lee_reichel:
So, that gets right to the point here. Isn’t the hand surgeon best positioned to decide if that testing is required? #jhsjc
Amelia Van Handel @AmeliaVanHandel:
Yes. I’m particularly thinking of attgs who get referrals from far away, so pts can get testing same day, but get appropriate testing #jhsjc
Brent Graham @BgTalkinman to @AmeliaVanHandel:
Shouldn’t the tests be ordered as required? Evidence shows that isn’t often the case with CTS. #jhsjc
Lauren Bechtold @bechtold_lauren to @BgTalkinman:
I agree – while many people have common presentations, I think clinical judgement is key in ordering tests #jhsjc
Brent Graham @BgTalkinman:
Seemingly the PCPs order the test to expedite the referral but this study shows it slows it down. #jhsjc
Amelia Van Handel @AmeliaVanHandel to @BgTalkinman:
Yes, that is definitely a good point. Many referrers don’t know what is necessary, or surgeons are particular about who performs certain studies (like EDX), which could contribute to the repeat testing observed in CTS. #jhsjc
Brent Graham @BgTalkinman to @AmeliaVanHandel:
Would they see the pt first and decide if a test be done same day or the tests happen w/o the hand surgeon input? #jhsjc
Brent Graham @BgTalkinman to @AmeliaVanHandel:
@CarlNunziato made a similar point about confounders. There are hand surgeons who require these in every case. #jhsjc
Jordan G Bruce @JordanGBruce1:
EDx is also highly dependent upon the performing physician, many high volume nerve surgeons do not trust OSH studies #jhsjc
Amelia Van Handel @AmeliaVanHandel to @BgTalkinman:
Depends on attg. Some pre-screen their clinic list and have assistants order tests to be done prior to visit…others wait to see pt and then can get some testing done same day (e.g. same day EDX often available here) #jhsjc
Brent Graham @BgTalkinman to @bechtold_lauren:
Agreed and that seems to be the point here – that many tests could be avoided AND referrals expedited! #jhsjc
Brent Graham @BgTalkinman to @JordanGBruce1:
OSH – is that outside tests? #jhsjc
Jordan G Bruce @JordanGBruce1 to @BgTalkinman:
yes, OSH = outside hospital #jhsjc
Brent Graham @BgTalkinman to @bechtold_lauren:
Do you find that appropriate in the absence of a clinical exam? #jhsjc
Lauren Bechtold @bechtold_lauren to @BgTalkinman:
I also think cost to the pt is important to consider – will they end up with a bigger bill and a useless test result? #jhsjc
Lee Reichel @lee_reichel:
Previsit testing potentially save the patient a visit if they return to the hand surgeon after the hand surgeon orders the study (4 visits verses 3 visits with preorder). #jhsjc
Brent Graham @BgTalkinman to @AmeliaVanHandel:
What I’m getting at is that in many – maybe most cases, the evidence suggests that EDx are not required. #jhsjc
Lee Reichel @lee_reichel:
Visits are an important to patients secondary to time off work, lost income, inconvenience, travel cost etc. #jhsjc
Lauren Bechtold @bechtold_lauren to @BgTalkinman:
I think we MUST rely on our clinical exam, and should likely examine prior to ordering tests #jhsjc
Amelia Van Handel @AmeliaVanHandel to @bechtold_lauren:
I agree all tests would be more appropriately and efficiently ordered if examined by hand specialist first #jhsjc
Brent Graham @BgTalkinman:
…therefore ordering just when the clinical eval suggest uncertainty could reduce cost AND time to referral #jhsjc
Brent Graham @BgTalkinman:
The only risk is in inconveniencing the surgeon. Is that a biased view? #jhsjc
Carl Nunziato @CarlNunziato:
But the article doesnt comment on how appropriate the testing was or how severe the condition. #jhsjc
Brent Graham @BgTalkinman to @lee_reichel:
That is an extremely important point. It gets down to a systems question. #jhsjc
Carl Nunziato @CarlNunziato:
It also doesnt comment on why there is a delay for patients who receive pre-referral tests #jhsjc
Amelia Van Handel @AmeliaVanHandel to @BgTalkinman:
You definitely have a good point. I think the people ordering tests ahead are well-intentioned, but this study gives good evidence that pre-referral testing doesn’t expedite care in the way people hope it will. #jhsjc
Lee Reichel @lee_reichel;
Previsit testing saves the patient one visit 3 verses 4, not a small thing to patients. #jhsjc
Brent Graham @BgTalkinman to @CarlNunziato:
That is very true. Should be decided by the hand surgeon i.e. very severe involvement means even less need for tests. #jhsjc
Brent Graham @BgTalkinman to @lee_reichel:
How will that be treated when there is bundled fees and those tests come out of the bottom line? #jhsjc
Brent Graham @BgTalkinman to @CarlNunziato and @AmeliaVanHandel:
That seems to be what the findings show. #jhsjc
Brent Graham @BgTalkinman to @CarlNunziato:
That is a good observation – that can’t be told from this data. They assume the two phenomena are linked. #jhsjc
Benjamin Kopp @bkopp0:
I think another interesting question would be whether the pre-visit tests expedited time to surgery, especially CTS with EDx #jhsjc
Brent Graham @BgTalkinman to @JordanGBruce1:
Do those experienced individuals often need EDx? #jhsjc
Brent Graham @BgTalkinman:
What do you think would be the best approach to this? #jhsjc
Amelia Van Handel @AmeliaVanHandel to @bkopp0:
I had the same thought after reading the article. Time to appointment could be delayed because of adding time to testing. #jhsjc
Jordan G Bruce @JordanGBruce1 to @BgTalkinman:
I think it depends, high volume nerve surgeons often perform severe CTS or re-do #jhsjc
Brent Graham @BgTalkinman to @bkopp0:
That is an excellent point and it could be studied using this kind of data. #jhsjc
Amelia Van Handel @AmeliaVanHandel to @bkopp0:
but would be interesting to compare time to intervention in those patients who went on to surgery #jhsjc
Jordan G Bruce @JordanGBruce1 to @BgTalkinman:
which would require different approaches to standard release, including possible transfers in which case EDX could be helpful #jhsjc
Brent Graham @BgTalkinman to @bkopp0:
There could be justification if it expedited the whole episode of care, not just the referral piece. #jhsjc
Lee Reichel @lee_reichel to @bkopp0:
That was my thought too Ben. I think any appropriate pretesting helps the patient and surgeon. (key is appropriate) #jhsjc
Lee Reichel @lee_reichel:
One area where this could really help is using decision aids previsit. Then patients come ready to discuss. #jhsjc
Brent Graham @BgTalkinman:
These are some excellent points! I hope you discuss this further with your attendings. #jhsjc
Brent Graham @BgTalkinman:
Let’s move on to the other paper on opioid management. #jhsjc
At this point it is clear that there is an opioid epidemic. This is a strategic to help manage it. #jhsjc
I want to point out the excellent methodology used here. They created a model on 1 sample and tested it on a later sample. #jhsjc
That is called a “split-sample” approach. #jhsjc
You are from a generation that does a lot on your phones. Is this practical approach? #jhsjc
Lee Reichel @lee_reichel:
For common problems like carpal tunnel syndrome, most surgeons I know are now using nsaids or few narcotic doses. I think there is a lot of value in less common procedures where the surgeon is unsure of how much narcotics to use. #jhsjc
Lee Reichel @lee_reichel to @BgTalkinman:
Loved the phone app idea #jhsjc
Amelia Van Handel @AmeliaVanHandel to @BgTalkinman:
I like the accessibility of the app calculator & the hypothetical objective way to decide how many tablets to prescribe #jhsjc
Brent Graham @BgTalkinman:
If you haven’t seen it, the calculator is here: https://jscalc.io/calc/9hH05AdFRt4iV6YD #jhsjc
Jordan G Bruce @JordanGBruce1:
I certainly think so. I use epocrates frequently for medication questions, a similar app backed by good data would be welcome #jhsjc
Amelia Van Handel @AmeliaVanHandel:
There has been a lot of criticism about policies that use blanket number of tablets for a certain procedure (e.g. x#tabs for LRTI) because they don’t take into account patient variables. I think they addressed that nicely with this calculator. #jhsjc
Lee Reichel @lee_reichel:
For common procedures CTR, probably don’t need, less common procedures might really be helpful #jhsjc
Brent Graham @BgTalkinman to @lee_reichel:
All the patients received pre-op counselling as well. Is that an important confounder? #jhsjc
By confounding, I am referring to the positive impact attributed to the app. #jhsjc
Lauren Bechtold @bechtold_lauren:
I think pre-op counseling, as well as counseling about opioid usage at each postoperative visit if pt still using is very important #jhsjc
Lee Reichel @lee_reichel:
They discussed pre surgery purchase of Aleve, Tylenol, Colace, Pepcid. Does anyone do this? I don’t #jhsjc
Jordan G Bruce @JordanGBruce1:
a study was performed at our institution some a few years ago, and showed WIDE variation among # of pills prescribed even for CTS… #jhsjc
Carl Nunziato @CarlNunziato:
I’m not sure how useful something so granular would be. I like the idea but maybe base it off specific procedures with modifiers #jhsjc
Lauren Bechtold @bechtold_lauren:
I prescribe tylenol/ibuprofen, and colace… #jhsjc
Brent Graham @BgTalkinman to @lee_reichel:
I do not. I give 6 Tylenol no 3 tabs #jhsjc
Lee Reichel @lee_reichel to @BgTalkinman:
I think so. My preop talk for CTR is positive priming for NO narcotics. I believe it helps. #jhsjc
Carl Nunziato @CarlNunziato:
ex: 100yo with a 10 min surgery who has regional anesthesia/can take NSAIDs/tylenol and doest take narcotics still gets 4 pills #jhsjc
Jordan G Bruce @JordanGBruce1:
so i think a calculator backed by good data could be a helpful guide to estimation of appropriate number of pills (if any) #jhsjc
Brent Graham @BgTalkinman to @JordanGBruce1:
No doubt. I think there has been a lot greater sensitivity to this issue recently. There have been many papers in JHS. #jhsjc
Brent Graham @BgTalkinman to @CarlNunziato:
Even old people can have pain! All aids of this nature require some judgment too! #jhsjc
Brent Graham @BgTalkinman to @lee_reichel:
Personal counselling! #jhsjc
Amelia Van Handel @AmeliaVanHandel to @BgTalkinman:
I think all of these calculators are meant to be used with some clinical judgements. An app cannot replace experience. #jhsjc
Brent Graham @BgTalkinman to @AmeliaVanHandel:
Agreed! #jhsjc
Brent Graham @BgTalkinman:
What do you think about the impact of regional anesthesia? #jhsjc
Amelia Van Handel @AmeliaVanHandel to @BgTalkinman:
But it can help you be more objective in your prescribing and help remove unconscious bias, habit, etc. #jhsjc
Brent Graham @BgTalkinman to @AmeliaVanHandel:
I think that is a very insightful comment. #jhsjc
Lee Reichel @lee_reichel to @AmeliaVanHandel and @BgTalkinman:
Agree with that #jhsjc
Lee Reichel @lee_reichel:
Texas now has a law that if another narcotic script is needed within 10 days patient needs to be seen in person in office (T#3 and Tramadol excluded) #jhsjc
Brent Graham @BgTalkinman:
The study showed that regional anesthesia was associated with a need for more pills. That seems counter-intuitive. #jhsjc
Amelia Van Handel @AmeliaVanHandel to @BgTalkinman:
The regional findings were the most surprising of anything to me. #jhsjc
Brent Graham @BgTalkinman:
The reason regional anesthesia is important is bc of the increased use of #WALANT #jhsjc
Benjamin Kopp @bkopp0 to@BgTalkinman:
The regional anesthesia was definitely counter-intuitive. Maybe anxiety/catastrophic thinking as a confounder? #jhsjc
Carl Nunziato @CarlNunziato to @BgTalkinman:
agreed I just think stepwise increments might make more sense than a continuous output #jhsjc
Amelia Van Handel @AmeliaVanHandel to @BgTalkinman:
I am usually aggressive about suggesting blocks to limit opioids, so these results were surprising to me. #jhsjc
Lee Reichel @lee_reichel:
When the block wears off at 3am after distal radius fx, pain becomes a crisis #jhsjc
Brent Graham @BgTalkinman to @AmeliaVanHandel:
In the last 25 yrs all of my CTR have been done under BP block #jhsjc
Brent Graham @BgTalkinman to @CarlNunziato:
I agree. Some refinements are probably going to be required. #jhsjc
Brent Graham @BgTalkinman to @lee_reichel:
There was once an idea of pre-emptive pain control with a block but I’m not sure that has been proven. #jhsjc
Brent Graham @BgTalkinman:
Is it your impression that WALANT is associated with greater or lesser need for post-op analgesia? #jhsjc
Lee Reichel @lee_reichel to @BgTalkinman:
I don’t know the data but anecdotally, 3 day blocks seem better tolerated than single shot. (pain ball type) #Jhsjc
Amelia Van Handel @AmeliaVanHandel to @BgTalkinman:
we do very little WALANT at our institution, but I would love to hear more about your experience – what do you think? #jhsjc
Brent Graham @BgTalkinman:
WALANT wasn’t studied but it is a good area for future investigation. #jhsjc
Brent Graham @BgTalkinman to @AmeliaVanHandel:
I have never used it and I think that it is potentially dangerous – totally personal view. #jhsjc
We should be about maximizing safety, not efficiency. Both are possible! #jhsjc
Jordan G Bruce @JordanGBruce1 to @BgTalkinman:
I am also not experienced with WALANT, I’d be interested to hear your concerns with it #jhsjc
Lee Reichel @lee_reichel to @AmeliaVanHandel:
6-8 out of 10 WALANT. 20cc 1% with epi in subq, 30 ga needle in preop. Ibuprofen 600mg prior to d/c. I think visualization as good as LMA with tourniquet #jhsjc
Lee Reichel @lee_reichel to @JordanGBruce1:
Great experience for patients. I have them watch. Hardest part is having to do your own anesthesia and communicate all day. #jhsjc
Brent Graham @BgTalkinman to @JordanGBruce1:
1 Case report in JHS about a finger lost. Limits to what can be done. #jhsjc
Lee Reichel @lee_reichel:
6-8 out of 10 choose WALANT. Love it. Hardest part is extra work of ansthesia and talking all day. #jhsjc
Brent Graham @BgTalkinman to @JordanGBruce1:
We have excellent regional anesthesia at our hospital. That is what we should be aiming for. We need anesthetists! #jhsjc
Brent Graham @BgTalkinman:
This was an excellent discussion! Email me your feedback in the next few days. Join the main discussion tomorrow night, same time! #jhsjc
Thanks! Good night! #jhsjc
Amelia Van Handel @AmeliaVanHandel;
Goodnight, thanks! #jhsjc
Lee Reichel @lee_reichel:
Brent thanks for hosting this. #jhsjc
Jordan G Bruce @JordanGBruce1:
Good night all. Thank you, Dr.Graham for hosting! #jhsjc
Part 2 of the December #JHSJC Discussion:
J Hand Surg Am- ASSH @JHandSurg:
December’s #JHSJC starts now! Let’s get the discussion going!
Brent Graham @BgTalkinman:
Welcome to the December session! Let’s start the discussion. #jhsjc
Let’s start with the article on pre-referral testing. #EDS #CTS #jhsjc
Nina Suh @NinaSuh9:
I really enjoyed reading the manuscript by Sears et al. I was surprised tho by the high repeat EDX testing for CTS. #jhsjc
Ray Raven MD, MBA, FAAOS @RayRavenMD to @NinaSuh9 and @BgTalkinman:
I agree. Very surprised. actually disappointed. #jhsjc
Nina Suh @NinaSuh9:
I went back to review my own clinical practice and I found very little repeat EDX testing for those referred to CTS #jhsjc
Brent Graham @BgTalkinman to @NinaSuh9:
Before we get there a few methodology considerations… #jhsjc
Nina Suh @NinaSuh9:
I think the authors should explore the causes for the repeat testing. I was much more fascinated by that #jhsjc
Ray Raven MD, MBA, FAAOS @RayRavenMD to @NinaSuh9:
I see it a lot in my area, especially where the consultant has the modality available in their office. #jhsjc
Brent Graham @BgTalkinman:
This was a single institution study. Used on what you’ve noticed about your own experiences, are these findings generalizable? #jhsjc
Ray Raven MD, MBA, FAAOS @RayRavenMD to @BgTalkinman and @NinaSuh9:
Even though this study was conducted in a single institution, my bet is that the findings are generalizable. #jhsjc
Erika Sears @ErikaDSears to @NinaSuh9:
Thanks! we are definitely exploring that in some current qualitative work…i was also surprised #jhsjc
Brent Graham @BgTalkinman:
Presumably the PCPs are trying to expedite the referral but the study found the opposite was true. Why is that? #jhsjc
Nina Suh @NinaSuh9:
As a Canadian surgeon, I did not understand why the inclusion dates were chosen bc of the ICD 10 changeover #jhsjc
Ray Raven MD, MBA, FAAOS @RayRavenMD to @BgTalkinman:
it takes time to get authorization for studies in some cases. It also takes time to get the results to the consultant #jhsjc
Ray Raven MD, MBA, FAAOS @RayRavenMD:
It is unfortunate that some “specialists” require advanced diagnostic testing prior to seeing referrals. #jhsjc
So many unnecessary tests can be avoided if we had more conscientious “specialists” #jhsjc
Brent Graham @BgTalkinman to @RayRavenMD, @ErikaDSears and @NinaSuh9:
Presumably that has something to do with ritual. Any other theories? #jhsjc
Ray Raven MD, MBA, FAAOS @RayRavenMD to @BgTalkinman and 2 others:
I have a bunch, but the bottom line is this is adding the the problem. #jhsjc
Brent Graham @BgTalkinman to @RayRavenMD:
The main issue is that the routine use of EDx isn’t supported by the evidence so it is a particularly curious observation. #jhsjc
Erika Sears @ErikaDSears:
Even though routine EDS not supported, it remains a very common practice, the question is how can we encourage judicious use? #jhsjc
Brent Graham @BgTalkinman to @RayRavenMD:
Seemingly that is a very prevalent mode of practice. Why is that? #jhsjc
Nina Suh @NinaSuh9:
I feel sometimes the patients feel that they were well taken care of if they have a test. #jhsjc
Brent Graham @BgTalkinman to @ErikaDSears:
Sadly, it will probably come down to negative financial impact. #jhsjc
Brent Graham @BgTalkinman to @NinaSuh9:
There is some evidence about that from @DavidRing in JHS. #jhsjc
Ray Raven MD, MBA, FAAOS @RayRavenMD to @BgTalkinman:
I think it’s multifactorial. Some insurances especial WC require positive findings on NCS before authorizing treatment. #JHSJC
Nina Suh @NinaSuh9:
I’m optimistic tho that some of the overuse of edx is due to miscommunication to the PCPs what the surgeon wants #jhsjc
Brent Graham @BgTalkinman to @NinaSuh9 and @ErikaDSears:
What is your view of that – better communication? #jhsjc
Brent Graham @BgTalkinman to @RayRavenMD:
Of course that means authorizing some care that may not be required. #jhsjc
Nina Suh @NinaSuh9:
yes, I think communication is key. at our institution, we r putting together a seminar for community PCPs so they know what we want #jhsjc
Brent Graham @BgTalkinman to @RayRavenMD:
Once CTS is part of a bundled episode of care $ cost of EDx may be deducted from the bottom line, what will happen then? #jhsjc
Erika Sears @ErikaDSears:
Communication about who is unlikely to need testing (patients with classic sx, high CTS6 score for ex.) could be a start #jhsjc
Ray Raven MD, MBA, FAAOS @RayRavenMD to @BgTalkinman:
One way to streamline care in that context of #ValueBasedServices is to encourage primary care specialists to adopt clinical practice guidelines to help with decision making for tests and referrals #CPG #DecisionSupportTools #jhsjc
Nina Suh @NinaSuh9:
definitely I think once bundled payments occur and the bottom line is affected, that would certainly help judicious use #jhsjc
Erika Sears @ErikaDSears:
problem is among hand surgeons there is disagreement re: need, which leads to the confusion among PCPs #jhsjc
Brent Graham @BgTalkinman to @ErikaDSears:
Dissemination of evidence is always an obstacle including here? #jhsjc
Ray Raven MD, MBA, FAAOS @RayRavenMD to @BgTalkinman:
As we move closer to #ValuedBased compensation, these practices will likely decrease, as the only way to increase value will be to reduce utilization of #LowValueServices #jhsjc
Brent Graham @BgTalkinman to @ErikaDSears:
Agreed. Did you notice any differences btw referrals made from within and outside your system? #jhsjc
Nina Suh @NinaSuh9:
I was also shocked oddly about how few masses had ultrasounds. I rarely see a mass without imaging. #jhsjc
Ray Raven MD, MBA, FAAOS @RayRavenMD to @ErikaDSears:
the evidence is clear. #FactsMatter #jhsjc
@ErikaDSears:
we excluded patients referred from outside (not seeing PCP in system) b/c we thought that would confound timing to see hand surgeon #jhsjc
Brent Graham @BgTalkinman:
There was jhsjc with trainees last night and one brought up the question of whether pre-referral testing led to faster treatment. #jhsjc
Nina Suh @NinaSuh9 to @BgTalkinman and @ErikaDSears:
Good question! was there a difference within the institution vs outside referrals? #jhsjc
Brent Graham @BgTalkinman to @ErikaDSears:
Is it possible that referrals take longer but surgical treatment is faster? #jhsjc
Nina Suh @NinaSuh9 to @ErikaDSears:
Oh! I missed that exclusion criteria.That’s even more shocking that within institution referrals had so much pre-testing #jhsjc
Ray Raven MD, MBA, FAAOS @RayRavenMD to @BgTalkinman:
In some cases. It leads to delays in others. Certainly not value-based. Test may not be necessary. #jhsjc
Brent Graham @BgTalkinman to @ErikaDSears:
Referral times seem likely to have been longer had you included outside referrals. Agreed? #jhsjc
Ray Raven MD, MBA, FAAOS @RayRavenMD:
In cases of clear-cut #CTS, #ElectroDiagnosticTesting is not warranted either as a diagnostic test, where clinical symptoms are well defined or as a predictive indicator of surgical outcome! #EMG #NCS #ValueBasedCare #OrthoTwitter #jhsjc
Brent Graham @BgTalkinman to @RayRavenMD:
Agreed but overall, indicated or not, it seems possible that the whole episode of care might be faster. #jhsjc
Erika Sears @ErikaDSears to @BgTalkinman:
yes outside referrals are likely longer, but also harder to capture totality of care based on location of testing #jhsjc
Warren @whammert:
Time to referral may not equate to time to treatment -surgery may not be any later when tests are ordered #jhsjc
Brent Graham @BgTalkinman to @RayRavenMD:
This is a question that could be asked of these findings. #jhsjc
Ray Raven MD, MBA, FAAOS @RayRavenMD:
One of the reason for discrepancy in #healthcare spending and outcomes is the amount spent on #LowValueCare – $340 billion/yr #jhsjc
The US spends more, both per capita and as a % of GDP, on #HealthCare than any other country without commensurate outcomes! #waste #jhsjc
Erika Sears @ErikaDSears to @BgTalkinman:
def possible pre-referral testing sped up surgery, i think it depends on condition; looking at this now in VA for CTS #jhsjc
Brent Graham @BgTalkinman to @whammert:
Exactly! Over a large sample that could be true. #jhsjc
However, reducing test use could follow even if the overall time to completing treatment was less. #jhsjc
Ray Raven MD, MBA, FAAOS @RayRavenMD:
One of the reason for discrepancy in #healthcare spending and outcomes is the amount spent on #LowValueCare – $340 billion/yr #jhsjc
Erika Sears @ErikaDSears:
we’re seeing pre-ref testing has shorter time to CTR than post-referral testing, but worst is repeat testing, and best is no testing #jhsjc
Nina Suh @NinaSuh9 to@ErikaDSears:
That finding makes sense to me. #jhsjc
Brent Graham @BgTalkinman to @ErikaDSears:
Probably won’t surprise you that I rarely get EDx anyway so pre-referral testing only slows down care from me. #jhsjc
I look forward to seeing data with that kind of stratification! #jhsjc
Someone in your group should get a start on that by doing a decision analysis with cost as the utility tested #jhsjc
Erika Sears @ErikaDSears:
joint pain is much harder to assess b/c of variation in treatment and timing #jhsjc
Brent Graham @BgTalkinman to @ErikaDSears:
Agreed. My guess is that it also seems a smaller problem to the MDs. #jhsjc
Ray Raven MD, MBA, FAAOS @RayRavenMD:
What do you all think of #CostEffectiveness analyses and using the data for clinical practice guidelines #CPG? #jhsjc
Nina Suh @NinaSuh9:
These types of studies are great bc they make one take pause at evaluating how we manage these common conditions #jhsjc
Brent Graham @BgTalkinman to @ErikaDSears:
And as for the masses – I only think of imaging if it isn’t obviously a ganglion on phy exam. #jhsjc
Ray Raven MD, MBA, FAAOS @RayRavenMD to @BgTalkinman and @ErikaDSears:
CostEffectiveness analysis provides a quantitative basis to distinguish high from low-value care #jhsjc
Brent Graham @BgTalkinman to @RayRavenMD:
Very important! decision analysis models are very helpful for generating hypotheses and finding the key variables. #jhsjc
Hollie Power @HolliePowerMD to @BgTalkinman and @RayRavenMD:
I agree that pre-referral testing results in faster care in specific cases (e.g. severe CTS). However mild-mod CTS EDx may (appropriately) delay care in my practice. IMO patients don’t need a surgeon to advise them to try splinting. ?? bias #jhsjc
Brent Graham @BgTalkinman:
Excellent thoughts all around! I hope we get more well-designed studies on this kind of topic! #jhsjc
Let’s move on to the study on the opioid prescribing app. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
I fully agree – except for the office surgery but that is probably just me! #jhsjc
Brent Graham @BgTalkinman:
This study used an excellent methodology, a split-sample approach with a development cohort and then a validation cohort. #jhsjc
The patients also received pre-op opioid counselling. How important was that as a confounder? #jhsjc
Ray Raven MD, MBA, FAAOS @RayRavenMD to @BgTalkinman:
I agree that the methodology was excellent, but there is plenty of evidence that pre-operative counseling regarding post-operative analgesia reduces #opioid use in the post-operative period #jhsjc
Brent Graham @BgTalkinman:
Counselling is important but is there added value with this calculator? #jhsjc
Nina Suh @NinaSuh9:
Typically pre-op counselling helps but nowadays, the opioid crisis is all over the press I believe patients are well educated on risk #jhsjc
Brent Graham @BgTalkinman:
Here is a link to their app: https://jscalc.io/calc/9hH05AdFRt4iV6YD #jhsjc
Nina Suh @NinaSuh9:
some sort of calculator is needed tho to provide some objectivity and standardization I believe #jhsjc
Warren @whammert to @BgTalkinman:
counseling is important as it sets expectations. This can be done with written or verbal information #jhsjc
Brent Graham @BgTalkinman to @NinaSuh9:
Agreed! #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
This calculator would immediately increase the number of pills used in countries other than the US and Canada #jhsjc
We need to be careful not to export our opioid missteps. #jhsjc
Ray Raven MD, MBA, FAAOS @RayRavenMD to @DrDavidRing and @BgTalkinman:
why so? #jhsjc
Brent Graham @BgTalkinman:
The study also suggested regional anesthesia was associated with greater post-op opioid need. That seems counter-intuitive. Thoughts? #jhsjc
Nina Suh @NinaSuh9 to @DrDavidRing:
So TRUE! It is fascinating how little medications those outside North America need! #jhsjc
Ray Raven MD, MBA, FAAOS @RayRavenMD to @BgTalkinman:
I found it interesting that the use of #RegionalAnesthesia increased #opioid consumption. My guess is that pts were not informed about getting ahead of the #pain #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
Possibly but it was modelled on US patients so it shouldn’t be used in a different population. Agree? #jhsjc
Warren @whammert to @BgTalkinman:
I think this delays the onset, so important to take NSIADS/ tylenol or something prior to block wearing off #jhsjc
Rob Gray @robgraymd to @BgTalkinman:
I think that is a confounder. don’t need regional for trigger fingers. #jhsjc
Nina Suh @NinaSuh9 to @BgTalkinman:
I thought it was bc the patents go from no pain to sudden pain. hence, they overuse the medications #jhsjc
Ray Raven MD, MBA, FAAOS @RayRavenMD to @BgTalkinman:
After #RegionalAnesthesia I prescribe #NSAIDs around the clock for the first 72 hrs and advise pts to take start #PainMedication when they feel “pins and needles” #jhsjc
Brent Graham @BgTalkinman to @robgraymd:
I agree. At one time it was thought that, when used, RA would “pre-empt” pain in bigger cases. This suggests otherwise. #jhsjc
Ray Raven MD, MBA, FAAOS @RayRavenMD to @NinaSuh9 and @BgTalkinman:
Exactly! I prescribe #NSAIDs ATC for first 72 hrs and advise narcos when they feel “pins and needles” #jhsjc
Rob Gray @robgraymd:
Could be rebound effect as well. but happens with local too if you don’t tell them to “take ur first pill B4 u have pain” #jhsjc
Brent Graham @BgTalkinman to @NinaSuh9:
We have used regional anesthesia for >95% of all our cases for 20 yrs+ That hasn’t been something I’ve noticed. #jhsjc
Brent Graham @BgTalkinman:
How are you using opioids now? Never, with certain cases, certain patients, specific numbers of pills? #jhsjc
Will an app like this help trainees prescribe post-op analgesia? #jhsjc
Nina Suh @NinaSuh9:
I use narcotics for wrist bony work (ex. fusions) but don’t prescribe for minor procedure cases #jhsjc
I think trainees need to practice the “art” of medicine and not just blindly treat patients with algorithms. #jhsjc
but these types of calculators are good as guidelines #jhsjc
Brent Graham @BgTalkinman to @NinaSuh9:
At our hospital it is difficult for the pt to be discharged from the day care without a prescription. Nurses question it! #jhsjc
Agreed! #jhsjc
Nina Suh @NinaSuh9 to @BgTalkinman:
I totally understand. The nurses take a while to adjust to the new paradigm #jhsjc
Rob Gray @robgraymd:
CTR-10x Norco 5. TFR, DQR, Needle aponeurotomy get 5. Finger fx, CubTR, dupuy–15 Elbow, wrist forearm fx get 20. #jhsjc
Brent Graham @BgTalkinman:
In my practice setting there isa gulf btw the attitudes of doctors and nurse about opioid prescriptions. #jhsjc
Brent Graham @BgTalkinman to @robgraymd:
Seems very reasonable! #jhsjc
Rob Gray @robgraymd:
My team rarely refills and lets me know when they do. Pain increase can = problem I need to know about. #jhsjc
Brent Graham @BgTalkinman:
I’m not sure if an important education piece doesn’t lie with bringing our nursing colleagues up to speed. #jhsjc
Nina Suh @NinaSuh9:
to be honest, I’m surprised with all the press that the nurses don’t know. #jhsjc
Brent Graham @BgTalkinman to @robgraymd:
That is very true. #jhsjc
Brent Graham @BgTalkinman to @NinaSuh9:
That is my perception. I work in a large tertiary care hospital but nurses seem much less informed than are the doctors. #jhsjc
Nina Suh @NinaSuh9:
I don’t disagree with u. the nurses at my institution are the same. #jhsjc
Brent Graham @BgTalkinman to @NinaSuh9:
We work 200 miles apart so not surprising! US colleagues – any comments about nursing perceptions re: opioid crisis? #jhsjc
Rob Gray @robgraymd:
Our nurses seem to be on board. But getting them to accept WALANT took 3 years! #jhsjc
Nina Suh @NinaSuh9:
oh so interesting! WALANT was a pretty easy sell!! #jhsjc
Rob Gray @robgraymd:
“U barbarian. UR going to stick them w a 25 ga needle full of lido? Let me start 25 ga IV of dope in their other arm first #jhsjc
Nina Suh @NinaSuh9 to @robgraymd:
So FUNNY!!!! #jhsjc
Brent Graham @BgTalkinman to @robgraymd:
I haven’t used WALANT – I have my reasons! Has that had any impact on post-op analgesia requirements? #jhsjc
Rob Gray @robgraymd to @BgTalkinman:
If anything pills decreased. they just don’t think surgery is as big a deal. #managingExpectations #jhsjc
Brent Graham @BgTalkinman to @robgraymd:
I will be very interested to see how that plays out in the next few years. #jhsjc
Rob Gray @robgraymd to @NinaSuh9:
I wish I was kidding. Then BP cuff traps propofol in Nonop arm and they groan. Anesthesia hurts > surgery #jhsjc
Brent Graham @BgTalkinman:
Excellent discussion! Thanks to all for participating. Back here Jan 14, 2020. Happy/safe holidays everyone! #jhsjc
Nina Suh @NinaSuh9:
Thank you for hosting!! Happy Holidays all! #jhsjc
