Peter Whang, orthopedic surgeon affiliated with Yale-New Haven (Conn.) Hospital began the presentation by asking attendees how mindful they are of value-based purchasing or performance-based reimbursement, which factors patients’ satisfaction scores.
The Patient Protection and Affordable Care Act put some fangs into the concept of “patient experience” by tying it to a portion of hospitals’ Medicare reimbursement. Patient experience ratings will determine 30 percent of hospitals’ total bonus payments under the federal Value-Based Purchasing program. Those ratings are determined by patients’ answers on HCAHPS surveys, which pose a variety of questions, including one in which they must rank their pain management on a scale from 1 to 10.
While many spine and orthopedic procedures have shifted to the outpatient setting, Dr. Whang said there is still room for improvement when it comes to pain management. “We haven’t quite found the holy grail in terms of post-operative pain relief,” he said. “We really have to get the pain under control in the first 24 to 72 hours, otherwise it can spiral out of control.”
Unfortunately, current therapies don’t last quite that long, he said. “There’s been no major advancements in how we treat post-op pain. Many of us would still feel opiates, still the gold standard, still play a significant role in these types of procedures,” said Dr. Whang. But while opiate use to manage pain is still common, Dr. Whang pointed to some of the drawbacks of narcotic use, including pneumonia, fall risks, overdose and addiction.
“I think all of us will accept the fact that opiates play some role in post-op management, but as we know with icebergs, there is a hidden portion of this. There are side effects associated with opiates and the rate of adverse events is not insignificant,” he said. He also said there has been more media attention on the societal ills caused by addiction to narcotics, a problem that is sparked once the patient begins using the pain meds after a procedure.
Dr. Whang said one alternative for pain management is Exparel, a local and non-opioid analgesic with controlled-release. The drug uses DepoFoam technology to release bupivacaine over time, and the plasma levels of bupivacaine can persist for 96 hours. One intraoperative injection of Exparel can treat pain at the source for up to 72 hours. There is no need for catheters, pumps or other delivery device.
“One way Exparel could be beneficial is by reducing pain and opioid use, which will be reflected in HCAHPS scores,” said Dr. Whang. He also said the drug could potentially reduce length of stay for certain procedures, which may “facilitate efficiency throughout the entire hospital stay.” In other words, if the patient has controlled pain relief, they may be able to move throughout the continuum at a faster rate opposed to drawn out stays in which pain management is touch and go.
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