#JHSJC

December #JHSJC Transcript

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

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