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Functional Restoration Program
S138
Abstracts / PM R 9 (2017) S131-S290
Participants: 57 patients with cervical spondylosis and cervical radicular pain who were deemed appropriate surgical candidates but elected to undergo CESI first. 21/47 (37%) patients with depression (defined as Zung Depression Scale 33) were included. Interventions: All patients received one or more cervical epidural steroid injections. Main Outcome Measures: Patient reported outcomes including neck disability index (NDI), Numeric Rating Scale (NRS) for arm pain (AP), NRS for neck pain (NP), and EuroQol-5D (EQ-5D) were collected at baseline and 3-month follow up. Minimal clinically important difference (MCID) were then calculated to provide dichotomous outcomes measures of success. Results: Overall, 24 (42.1% 95%CI 12.8%) and 28 (49.1% 95%CI 13.0%) patients achieved at least 50% improvement in AP and NP respectively. In terms of disability, 25/57 (43.9% 95%Ci 12.9%) patients achieved greater than 13.2-point improvement on NDI overall. In patients with depression, 4/21 (19.0% 95%CI 16.8%) and 5/21(23.8% 95%CI 18.2%) achieved at least 50% improvement on NRS for AP and NP respectively compared to 20 (55.5% 95%CI 16.2%) and 23 (63.9% 95%CI 15.7%) in patients without depression. This difference was statistically significant for both pain measures (non-overlapping 95% CI for both, p <.002 AP, p<.006 NP). Statistically fewer patients, 5/21 (24% 95%CI 18%) with depression achieved at least 13.2 point improvement on NDI compared to 20/36 (55% 95%CI 16%) nondepressed patients (95% CI overlapping, p<.01). There was no difference in outcomes between groups on EQ-5D. Conclusions: Patients with cervical spondylosis and co-morbid depression who undergo CESI are less likely to achieve successful outcomes in both pain and function compared to non-depressed patients at 3 months. Level of Evidence: Level II Poster 104: Development and Design of a Predictive Nomogram for Missed Appointments at an Academic Pain Treatment Center: A Prospective Year-Long Longitudinal Study Charles A. Odonkor, MD, MA (Johns Hopkins University School of Med, Baltimore, MD, United States), Steven P. Cohen, MD Disclosures: Charles Odonkor: I Have No Relevant Financial Relationships To Disclose Objective: Missed appointments cost the American healthcare system more than $150 billion per year. In the setting of interventional pain treatment centers, this poses major barriers to care with negative implications for patient health outcomes. To address these challenges, various specialty clinics have taken steps to identify and remedy missed clinic appointments. To date, however, no prospective studies have sought to delineate factors associated with pain clinic “noshows.” The objective of this study was to design a predictive nomogram for missed pain clinic appointments. Design: A prospective longitudinal study was performed to assess which factors among a comprehensive list of demographic, clinical and environmental variables were predictive of no-shows to clinic. The logistic regression model predicting no-shows was internally validated with cross validation and bootstrapping methods. A predictive nomogram was developed to display effect size of predictors for no-shows. Setting: Inner city academic pain clinic. Participants: 5134 patients scheduled for pain clinic visits and procedures from January to December 2015. Interventions: Not applicable. Main Outcome Measures: Primary outcome measure was show vs. noshow rate to scheduled appointments without canceling the day before. Results: The overall no-show rate was 24.6%. Factors associated with no shows included age < 65 yrs, ethnicity, marital status (single),
health payer (Medicare/Medicaid), primary diagnosis of low back pain or headaches, initial consult, rain or snow on day of appointment and having at least 1 prior pain provider. Model discrimination (area under curve) was 0.738, 99% CI: 0.70-0.85. A minimum threshold of 350 points on the nomogram predicted greater than 55% risk of no-shows. Conclusions: A high no-show rate was associated with predictable and unpredictable (e.g. snow) factors. Pain clinic operation managers could use a prediction nomogram as a risk stratification tool to maximize access to care. Accounting for patient-level risk of predictable no-shows can potentially help to optimize clinic scheduling by staggering low vs. high probability no-shows. Level of Evidence: Level I Poster 105: Reduction in Opioid Use for Injured Workers Following Completion of a 4-Week Interdisciplinary Pain/Functional Restoration Program James W. Atchison, DO, FAAPMR (RIC Center for Pain Management, Chicago, IL, United States), Avanti Badrinathan II, MS, Christine M. Gagnon, PhD, Shana Margolis, MD, FAAPMR, Randy L. Calisoff, MD Disclosures: James Atchison: Consulting fees or other remuneration (payment) - Best Doctors, INSPE Objective: To assess changes in opioid use for pain by Injured Workers (IW) at the completion of a 4-week Interdisciplinary (ID) pain program. Design: Retrospective cohort study. Setting: Academic Outpatient Pain Center. Participants: IW (N¼114) admitted to ID program between 1/1/2014 and 12/31/2015. Interventions: Daily treatment by PT, OT, Clinical Psychology, and Biofeedback therapist for 7 hours/day, 5 days/week 4 weeks with biweekly physician visits. Main Outcome Measures: Overall reduction in opioid use by measurement of morphine milligram equivalents (MME). Stratify patients by low-dose versus high-dose use at the start of the program and compare their relative levels of opioid reduction. Results: The majority of the patients (80,70%) completed the 4-week program. More than half the patients (52,65%) started the program on opioids. Mean MME at the start of program was 75.59, and at completion was 39.0 MME. This is a reduction of 48.4% for the entire population. Ten of 52 (19.2%) discontinued all opioids. Further analysis indicates that 33 (63.5%) of the 52 patients starting the program on opioids were in the low-dose (50 MME) group with a mean starting dose of 168.6 MME. In the low-dose group, 24.2% discontinued use and 42.4% lowered opioid use by 50.9%. In the high-dose group, 10.5% discontinued use and 73.7% decreased opioid use by 89.9 MME (51.1%). Conclusions: This retrospective cohorts study demonstrates that injured workers on opioid management admitted to a comprehensive, interdisciplinary pain program for functional restoration can significantly reduce their opioid use by completion of the 4-week program. This reduction in opioid use occurred regardless of CDC Guideline Classification, as similar proportions of the patients in the low-dose and high-dose groups lowered their MME and patients in both groups did so by approximately 50%. Level of Evidence: Level IV Poster 106: What Characteristics of Initial Pain Presentation Best Predict Epidural Steroid Injection Response? Vincent Y. Ma, MD (VA Greater LA Hlth Care Sys/UCLA, Los Angeles, CA, United States), Ali Shakir, MD Disclosures: Vincent Ma: I Have No Relevant Financial Relationships To Disclose
Abstracts / PM R 9 (2017) S131-S290
Participants: 57 patients with cervical spondylosis and cervical radicular pain who were deemed appropriate surgical candidates but elected to undergo CESI first. 21/47 (37%) patients with depression (defined as Zung Depression Scale 33) were included. Interventions: All patients received one or more cervical epidural steroid injections. Main Outcome Measures: Patient reported outcomes including neck disability index (NDI), Numeric Rating Scale (NRS) for arm pain (AP), NRS for neck pain (NP), and EuroQol-5D (EQ-5D) were collected at baseline and 3-month follow up. Minimal clinically important difference (MCID) were then calculated to provide dichotomous outcomes measures of success. Results: Overall, 24 (42.1% 95%CI 12.8%) and 28 (49.1% 95%CI 13.0%) patients achieved at least 50% improvement in AP and NP respectively. In terms of disability, 25/57 (43.9% 95%Ci 12.9%) patients achieved greater than 13.2-point improvement on NDI overall. In patients with depression, 4/21 (19.0% 95%CI 16.8%) and 5/21(23.8% 95%CI 18.2%) achieved at least 50% improvement on NRS for AP and NP respectively compared to 20 (55.5% 95%CI 16.2%) and 23 (63.9% 95%CI 15.7%) in patients without depression. This difference was statistically significant for both pain measures (non-overlapping 95% CI for both, p <.002 AP, p<.006 NP). Statistically fewer patients, 5/21 (24% 95%CI 18%) with depression achieved at least 13.2 point improvement on NDI compared to 20/36 (55% 95%CI 16%) nondepressed patients (95% CI overlapping, p<.01). There was no difference in outcomes between groups on EQ-5D. Conclusions: Patients with cervical spondylosis and co-morbid depression who undergo CESI are less likely to achieve successful outcomes in both pain and function compared to non-depressed patients at 3 months. Level of Evidence: Level II Poster 104: Development and Design of a Predictive Nomogram for Missed Appointments at an Academic Pain Treatment Center: A Prospective Year-Long Longitudinal Study Charles A. Odonkor, MD, MA (Johns Hopkins University School of Med, Baltimore, MD, United States), Steven P. Cohen, MD Disclosures: Charles Odonkor: I Have No Relevant Financial Relationships To Disclose Objective: Missed appointments cost the American healthcare system more than $150 billion per year. In the setting of interventional pain treatment centers, this poses major barriers to care with negative implications for patient health outcomes. To address these challenges, various specialty clinics have taken steps to identify and remedy missed clinic appointments. To date, however, no prospective studies have sought to delineate factors associated with pain clinic “noshows.” The objective of this study was to design a predictive nomogram for missed pain clinic appointments. Design: A prospective longitudinal study was performed to assess which factors among a comprehensive list of demographic, clinical and environmental variables were predictive of no-shows to clinic. The logistic regression model predicting no-shows was internally validated with cross validation and bootstrapping methods. A predictive nomogram was developed to display effect size of predictors for no-shows. Setting: Inner city academic pain clinic. Participants: 5134 patients scheduled for pain clinic visits and procedures from January to December 2015. Interventions: Not applicable. Main Outcome Measures: Primary outcome measure was show vs. noshow rate to scheduled appointments without canceling the day before. Results: The overall no-show rate was 24.6%. Factors associated with no shows included age < 65 yrs, ethnicity, marital status (single),
health payer (Medicare/Medicaid), primary diagnosis of low back pain or headaches, initial consult, rain or snow on day of appointment and having at least 1 prior pain provider. Model discrimination (area under curve) was 0.738, 99% CI: 0.70-0.85. A minimum threshold of 350 points on the nomogram predicted greater than 55% risk of no-shows. Conclusions: A high no-show rate was associated with predictable and unpredictable (e.g. snow) factors. Pain clinic operation managers could use a prediction nomogram as a risk stratification tool to maximize access to care. Accounting for patient-level risk of predictable no-shows can potentially help to optimize clinic scheduling by staggering low vs. high probability no-shows. Level of Evidence: Level I Poster 105: Reduction in Opioid Use for Injured Workers Following Completion of a 4-Week Interdisciplinary Pain/Functional Restoration Program James W. Atchison, DO, FAAPMR (RIC Center for Pain Management, Chicago, IL, United States), Avanti Badrinathan II, MS, Christine M. Gagnon, PhD, Shana Margolis, MD, FAAPMR, Randy L. Calisoff, MD Disclosures: James Atchison: Consulting fees or other remuneration (payment) - Best Doctors, INSPE Objective: To assess changes in opioid use for pain by Injured Workers (IW) at the completion of a 4-week Interdisciplinary (ID) pain program. Design: Retrospective cohort study. Setting: Academic Outpatient Pain Center. Participants: IW (N¼114) admitted to ID program between 1/1/2014 and 12/31/2015. Interventions: Daily treatment by PT, OT, Clinical Psychology, and Biofeedback therapist for 7 hours/day, 5 days/week 4 weeks with biweekly physician visits. Main Outcome Measures: Overall reduction in opioid use by measurement of morphine milligram equivalents (MME). Stratify patients by low-dose versus high-dose use at the start of the program and compare their relative levels of opioid reduction. Results: The majority of the patients (80,70%) completed the 4-week program. More than half the patients (52,65%) started the program on opioids. Mean MME at the start of program was 75.59, and at completion was 39.0 MME. This is a reduction of 48.4% for the entire population. Ten of 52 (19.2%) discontinued all opioids. Further analysis indicates that 33 (63.5%) of the 52 patients starting the program on opioids were in the low-dose (50 MME) group with a mean starting dose of 168.6 MME. In the low-dose group, 24.2% discontinued use and 42.4% lowered opioid use by 50.9%. In the high-dose group, 10.5% discontinued use and 73.7% decreased opioid use by 89.9 MME (51.1%). Conclusions: This retrospective cohorts study demonstrates that injured workers on opioid management admitted to a comprehensive, interdisciplinary pain program for functional restoration can significantly reduce their opioid use by completion of the 4-week program. This reduction in opioid use occurred regardless of CDC Guideline Classification, as similar proportions of the patients in the low-dose and high-dose groups lowered their MME and patients in both groups did so by approximately 50%. Level of Evidence: Level IV Poster 106: What Characteristics of Initial Pain Presentation Best Predict Epidural Steroid Injection Response? Vincent Y. Ma, MD (VA Greater LA Hlth Care Sys/UCLA, Los Angeles, CA, United States), Ali Shakir, MD Disclosures: Vincent Ma: I Have No Relevant Financial Relationships To Disclose