INTRODUCTION: Emerging literature suggests preoperative chronic pain increases the risk of acute perioperative and persistent postoperative pain. Furthermore, pre-surgical emotional health predicts pain and functional outcomes after surgery; depression, anxiety, insufficient social support, and ineffective coping strategies are all major predictors of poor surgical outcome, particularly after elective spine surgery. Due to poor preoperative optimization, these vulnerable chronic pain patients are at greater risk for adverse perioperative clinical outcomes, with concomitant excessive service utilization. At DUMC, between 2010-2011, 643/5,339 (12%) of patients visited the emergency room (ER) within 90 days of their elective spine surgery with 50% complaining of uncontrolled pain or a side effect of a pain medication.
PROBLEM: The current care pathway for patients scheduled for spine surgery is limiting, as the PreAnesthesia Testing Clinic does not provide sufficient time, resource, or expertise necessary to comprehensively address the impact that chronic pain, opioid medications, psychological stress, and deconditioning has on perioperative outcomes. Consequently, this inadequate preoperative optimization contributes to increased post-operative length of stay, high post discharge ER utilization rates, and poor patient satisfaction. To that end, we have created a comprehensive, multidisciplinary process to coordinate cost effective care of this high risk and marginalized group. We anticipate multidisciplinary optimization involving pain management, physical therapy, and pain psychology while utilizing multiple telehealth touchpoints prior to and after surgery will yield improved outcomes and patient satisfaction.
METHODS AND PROCESS IMPLEMENTATION: Patients are selected for the optimization program as they present to the spine surgery clinic, are prescribed greater than 100 morphine milligram equivalents (MME) of an opioid analgesic, and are willing to undergo a multidisciplinary pre and postoperative telehealth optimization program involving three phases of preoperative optimization involving pain management, physical therapy, and pain psychology. Initial visits will be in-person with subsequent telehealth and in-person visits as shown (Figure 1). The primary outcomes of patient satisfaction, postoperative length of stay, and post-operative ER utilization will be compared to a group undergoing standard surgical readiness. Secondary pain management, pain psychology, and physical therapy management goals will involve opioid reduction, adjuvant medication optimization, depression/anxiety management, adherence to physical therapy goals, pain coping strategies, and support for improved functionality. Post-operatively, similar touchpoints predominantly using telehealth will occur.
DISCUSSION: Telehealth touchpoints allow patients to gain meaningful but short interactions with providers. The multidisciplinary approach medically, psychologically, and physically optimizes patients pre and post surgery, leading to better outcomes, reduced costs, and improved value of care delivered. We hope to prevent exacerbation of chronic pain in a marginalized, high-risk population during an already high-cost episode of care. More broadly, however, this project exemplifies the comprehensive, coordinated value the anesthesiology profession must bring to healthcare systems as we expand into the perioperative arena.
