Erinn Ayres, MD

Clinical question: Have the Choosing Wisely campaign recommendations led to changes in practice?

Background: The Choosing Wisely campaign aims to reduce the incidence of low-value care by providing evidence-based recommendations for common clinical situations. The rate of adoption of these recommendations is unknown.

Study design: Retrospective review.

Setting: Anthem insurance members.

Synopsis: The study examined the claims data from 25 million Anthem insurance members to compare the rate of services that were targeted by seven Choosing Wisely campaign recommendations before and after the recommendations were published in 2012.

Investigators found the incidence of two of the services declined after the Choosing Wisely recommendations were published; the other five services remained stable or increased slightly. Furthermore, the declines were statistically significant but not a marked absolute difference, with the incidence of head imaging in patients with uncomplicated headaches going down to 13.4% from 14.9% and the use of cardiac imaging in the absence of cardiac disease declining to 9.7% from 10.8%.

The main limitations are the narrow population of Anthem insurance members and the lack of specific data that could help answer why clinical practice has not changed, but that could be the aim of future studies.

Bottom line: Choosing Wisely recommendations have not been adopted on a population level; widespread implementation likely will require financial incentives, provider-level data feedback, and systems interventions.

Citation: Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. doi:10.1001/jamainternmed.2015.5441.

Clinical question: Have the Choosing Wisely campaign recommendations led to changes in practice?

Background: The Choosing Wisely campaign aims to reduce the incidence of low-value care by providing evidence-based recommendations for common clinical situations. The rate of adoption of these recommendations is unknown.

Study design: Retrospective review.

Setting: Anthem insurance members.

Synopsis: The study examined the claims data from 25 million Anthem insurance members to compare the rate of services that were targeted by seven Choosing Wisely campaign recommendations before and after the recommendations were published in 2012.

Investigators found the incidence of two of the services declined after the Choosing Wisely recommendations were published; the other five services remained stable or increased slightly. Furthermore, the declines were statistically significant but not a marked absolute difference, with the incidence of head imaging in patients with uncomplicated headaches going down to 13.4% from 14.9% and the use of cardiac imaging in the absence of cardiac disease declining to 9.7% from 10.8%.

The main limitations are the narrow population of Anthem insurance members and the lack of specific data that could help answer why clinical practice has not changed, but that could be the aim of future studies.

Bottom line: Choosing Wisely recommendations have not been adopted on a population level; widespread implementation likely will require financial incentives, provider-level data feedback, and systems interventions.

Citation: Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. doi:10.1001/jamainternmed.2015.5441.

Clinical question: Have the Choosing Wisely campaign recommendations led to changes in practice?

Background: The Choosing Wisely campaign aims to reduce the incidence of low-value care by providing evidence-based recommendations for common clinical situations. The rate of adoption of these recommendations is unknown.

Study design: Retrospective review.

Setting: Anthem insurance members.

Synopsis: The study examined the claims data from 25 million Anthem insurance members to compare the rate of services that were targeted by seven Choosing Wisely campaign recommendations before and after the recommendations were published in 2012.

Investigators found the incidence of two of the services declined after the Choosing Wisely recommendations were published; the other five services remained stable or increased slightly. Furthermore, the declines were statistically significant but not a marked absolute difference, with the incidence of head imaging in patients with uncomplicated headaches going down to 13.4% from 14.9% and the use of cardiac imaging in the absence of cardiac disease declining to 9.7% from 10.8%.

The main limitations are the narrow population of Anthem insurance members and the lack of specific data that could help answer why clinical practice has not changed, but that could be the aim of future studies.

Bottom line: Choosing Wisely recommendations have not been adopted on a population level; widespread implementation likely will require financial incentives, provider-level data feedback, and systems interventions.

Citation: Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. doi:10.1001/jamainternmed.2015.5441.

Clinical question: Is there a difference in patient experience on hospitalist teams compared with teaching teams?

Background: Hospitalist-intensive hospitals tend to perform better on patient-satisfaction measures on HCAHPS survey; however, little is known about the difference in patient experience between patients cared for by hospitalist and trainee teams.

Study design: Retrospective cohort analysis.

Setting: University of Chicago Medical Center.

Synopsis: A 30-day post-discharge survey was sent to 14,855 patients cared for by hospitalist and teaching teams, with 57% of teaching and 31% of hospitalist team patients returning fully completed surveys. A higher percentage of hospitalist team patients reported satisfaction with their overall care (73% vs. 67%; P<0.001; regression model odds ratio = 1.33; 95% CI, 1.15–1.47). There was no statistically significant difference in patient satisfaction with the teamwork of their providers, confidence in identifying their provider, or ability to understand the role of their provider.

Other than the inability to mitigate response-selection bias, the main limitation of this study is the single-center setting, which impacts the generalizability of the findings. Hospital-specific factors like different services and structures (hospitalists at their institution care for renal and lung transplant and oncology patients) could influence patients’ perception of their care. More research needs to be done to determine the specific factors that lead to a better patient experience.

Bottom line: At a single academic center, overall patient satisfaction was higher on a hospitalist service compared with teaching teams.

Citation: Wray CM, Flores A, Padula WV, Prochaska MT, Meltzer DO, Arora VM. Measuring patient experiences on hospitalist and teaching services: patient responses to a 30-day postdischarge questionnaire [published online ahead of print September 18, 2015]. J Hosp Med. doi:10.1002/jhm.2485.

Clinical question: Is there a difference in patient experience on hospitalist teams compared with teaching teams?

Background: Hospitalist-intensive hospitals tend to perform better on patient-satisfaction measures on HCAHPS survey; however, little is known about the difference in patient experience between patients cared for by hospitalist and trainee teams.

Study design: Retrospective cohort analysis.

Setting: University of Chicago Medical Center.

Synopsis: A 30-day post-discharge survey was sent to 14,855 patients cared for by hospitalist and teaching teams, with 57% of teaching and 31% of hospitalist team patients returning fully completed surveys. A higher percentage of hospitalist team patients reported satisfaction with their overall care (73% vs. 67%; P<0.001; regression model odds ratio = 1.33; 95% CI, 1.15–1.47). There was no statistically significant difference in patient satisfaction with the teamwork of their providers, confidence in identifying their provider, or ability to understand the role of their provider.

Other than the inability to mitigate response-selection bias, the main limitation of this study is the single-center setting, which impacts the generalizability of the findings. Hospital-specific factors like different services and structures (hospitalists at their institution care for renal and lung transplant and oncology patients) could influence patients’ perception of their care. More research needs to be done to determine the specific factors that lead to a better patient experience.

Bottom line: At a single academic center, overall patient satisfaction was higher on a hospitalist service compared with teaching teams.

Citation: Wray CM, Flores A, Padula WV, Prochaska MT, Meltzer DO, Arora VM. Measuring patient experiences on hospitalist and teaching services: patient responses to a 30-day postdischarge questionnaire [published online ahead of print September 18, 2015]. J Hosp Med. doi:10.1002/jhm.2485.

Clinical question: Is there a difference in patient experience on hospitalist teams compared with teaching teams?

Background: Hospitalist-intensive hospitals tend to perform better on patient-satisfaction measures on HCAHPS survey; however, little is known about the difference in patient experience between patients cared for by hospitalist and trainee teams.

Study design: Retrospective cohort analysis.

Setting: University of Chicago Medical Center.

Synopsis: A 30-day post-discharge survey was sent to 14,855 patients cared for by hospitalist and teaching teams, with 57% of teaching and 31% of hospitalist team patients returning fully completed surveys. A higher percentage of hospitalist team patients reported satisfaction with their overall care (73% vs. 67%; P<0.001; regression model odds ratio = 1.33; 95% CI, 1.15–1.47). There was no statistically significant difference in patient satisfaction with the teamwork of their providers, confidence in identifying their provider, or ability to understand the role of their provider.

Other than the inability to mitigate response-selection bias, the main limitation of this study is the single-center setting, which impacts the generalizability of the findings. Hospital-specific factors like different services and structures (hospitalists at their institution care for renal and lung transplant and oncology patients) could influence patients’ perception of their care. More research needs to be done to determine the specific factors that lead to a better patient experience.

Bottom line: At a single academic center, overall patient satisfaction was higher on a hospitalist service compared with teaching teams.

Citation: Wray CM, Flores A, Padula WV, Prochaska MT, Meltzer DO, Arora VM. Measuring patient experiences on hospitalist and teaching services: patient responses to a 30-day postdischarge questionnaire [published online ahead of print September 18, 2015]. J Hosp Med. doi:10.1002/jhm.2485.

Clinical question: Is the Caprini risk assessment model (RAM) a valid tool to predict venous thromboembolism (VTE) risk in critically ill surgical patients?

Background: VTE is a major source of morbidity and mortality among hospitalized patients; prevention is critical to reduce morbidity and cut healthcare costs. Risk assessment is important to determine thromboprophylaxis, yet data are lacking regarding an appropriate tool for risk stratification in the critically ill.

Study design: Retrospective cohort.

Setting: University of Michigan Health System; 20-bed surgical ICU at an academic hospital.

Synopsis: This study included 4,844 surgical ICU patients. Primary outcome was VTE during the patient’s hospital admission. A retrospective risk scoring method based on the 2005 Caprini RAM was used to calculate the risk for all patients at the time of ICU admission. Patients were divided into low (Caprini score 0–2), moderate, high, highest, and super-high (Caprini score > 8) risk levels. The incidence of VTE increased in linear fashion with increasing Caprini score.

This study was limited to one academic medical center. The retrospective scoring model limits the ability to identify all patient risk factors. VTE outcomes were reported only for the length of hospitalization and did not include post-discharge follow-up. Replicating this study across a larger patient population and performing a prospective study with follow-up after discharge would address these limitations.

Bottom line: The Caprini risk assessment model is a valid instrument to assess VTE risk in critically ill surgical patients.

Citation: Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948.

Clinical question: Is the Caprini risk assessment model (RAM) a valid tool to predict venous thromboembolism (VTE) risk in critically ill surgical patients?

Background: VTE is a major source of morbidity and mortality among hospitalized patients; prevention is critical to reduce morbidity and cut healthcare costs. Risk assessment is important to determine thromboprophylaxis, yet data are lacking regarding an appropriate tool for risk stratification in the critically ill.

Study design: Retrospective cohort.

Setting: University of Michigan Health System; 20-bed surgical ICU at an academic hospital.

Synopsis: This study included 4,844 surgical ICU patients. Primary outcome was VTE during the patient’s hospital admission. A retrospective risk scoring method based on the 2005 Caprini RAM was used to calculate the risk for all patients at the time of ICU admission. Patients were divided into low (Caprini score 0–2), moderate, high, highest, and super-high (Caprini score > 8) risk levels. The incidence of VTE increased in linear fashion with increasing Caprini score.

This study was limited to one academic medical center. The retrospective scoring model limits the ability to identify all patient risk factors. VTE outcomes were reported only for the length of hospitalization and did not include post-discharge follow-up. Replicating this study across a larger patient population and performing a prospective study with follow-up after discharge would address these limitations.

Bottom line: The Caprini risk assessment model is a valid instrument to assess VTE risk in critically ill surgical patients.

Citation: Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948.

Clinical question: Is the Caprini risk assessment model (RAM) a valid tool to predict venous thromboembolism (VTE) risk in critically ill surgical patients?

Background: VTE is a major source of morbidity and mortality among hospitalized patients; prevention is critical to reduce morbidity and cut healthcare costs. Risk assessment is important to determine thromboprophylaxis, yet data are lacking regarding an appropriate tool for risk stratification in the critically ill.

Study design: Retrospective cohort.

Setting: University of Michigan Health System; 20-bed surgical ICU at an academic hospital.

Synopsis: This study included 4,844 surgical ICU patients. Primary outcome was VTE during the patient’s hospital admission. A retrospective risk scoring method based on the 2005 Caprini RAM was used to calculate the risk for all patients at the time of ICU admission. Patients were divided into low (Caprini score 0–2), moderate, high, highest, and super-high (Caprini score > 8) risk levels. The incidence of VTE increased in linear fashion with increasing Caprini score.

This study was limited to one academic medical center. The retrospective scoring model limits the ability to identify all patient risk factors. VTE outcomes were reported only for the length of hospitalization and did not include post-discharge follow-up. Replicating this study across a larger patient population and performing a prospective study with follow-up after discharge would address these limitations.

Bottom line: The Caprini risk assessment model is a valid instrument to assess VTE risk in critically ill surgical patients.

Citation: Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948.

Clinical question: Does total knee replacement followed by a 12-week non-surgical treatment program provide greater pain relief and improvement in function and quality of life than non-surgical treatment alone?

Background: The number of total knee replacements in the U.S. has increased dramatically since the 1970s and is expected to continue to rise. To date, evidence to support the effectiveness of surgical intervention compared to non-surgical intervention is lacking.

Study design: Randomized, controlled trial.

Setting: Aalborg University Hospital Outpatient Clinics, Denmark.

Synopsis: One hundred patients with osteoarthritis were randomly assigned to undergo total knee replacement followed by 12 weeks of non-surgical treatment or to receive only 12 weeks of non-surgical treatment. The non-surgical treatment program consisted of exercise, education, dietary advice, insoles, and pain medication. Change from baseline to 12 months was assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS).

The total knee replacement group had a significantly greater improvement in the KOOS score than did the non-surgical group. Serious adverse events were more common in the total knee replacement group.

The study did not include a sham-surgery control group. It is unknown whether the KOOS pain subscale is generalizable to patients with severe pain. Additionally, the intensity of non-surgical treatment may have differed between groups.

Bottom line: Total knee replacement followed by non-surgical treatment is more efficacious than non-surgical treatment alone in providing pain relief and improving function and quality of life, but it is associated with higher number of adverse events.

Citation: Skou ST, Roos EM, Laursen MB, et al. A randomized, controlled trial of total knee replacement. N Engl J Med. 2015;373(17):1597-1606.

Clinical question: Does total knee replacement followed by a 12-week non-surgical treatment program provide greater pain relief and improvement in function and quality of life than non-surgical treatment alone?

Background: The number of total knee replacements in the U.S. has increased dramatically since the 1970s and is expected to continue to rise. To date, evidence to support the effectiveness of surgical intervention compared to non-surgical intervention is lacking.

Study design: Randomized, controlled trial.

Setting: Aalborg University Hospital Outpatient Clinics, Denmark.

Synopsis: One hundred patients with osteoarthritis were randomly assigned to undergo total knee replacement followed by 12 weeks of non-surgical treatment or to receive only 12 weeks of non-surgical treatment. The non-surgical treatment program consisted of exercise, education, dietary advice, insoles, and pain medication. Change from baseline to 12 months was assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS).

The total knee replacement group had a significantly greater improvement in the KOOS score than did the non-surgical group. Serious adverse events were more common in the total knee replacement group.

The study did not include a sham-surgery control group. It is unknown whether the KOOS pain subscale is generalizable to patients with severe pain. Additionally, the intensity of non-surgical treatment may have differed between groups.

Bottom line: Total knee replacement followed by non-surgical treatment is more efficacious than non-surgical treatment alone in providing pain relief and improving function and quality of life, but it is associated with higher number of adverse events.

Citation: Skou ST, Roos EM, Laursen MB, et al. A randomized, controlled trial of total knee replacement. N Engl J Med. 2015;373(17):1597-1606.

Clinical question: Does total knee replacement followed by a 12-week non-surgical treatment program provide greater pain relief and improvement in function and quality of life than non-surgical treatment alone?

Background: The number of total knee replacements in the U.S. has increased dramatically since the 1970s and is expected to continue to rise. To date, evidence to support the effectiveness of surgical intervention compared to non-surgical intervention is lacking.

Study design: Randomized, controlled trial.

Setting: Aalborg University Hospital Outpatient Clinics, Denmark.

Synopsis: One hundred patients with osteoarthritis were randomly assigned to undergo total knee replacement followed by 12 weeks of non-surgical treatment or to receive only 12 weeks of non-surgical treatment. The non-surgical treatment program consisted of exercise, education, dietary advice, insoles, and pain medication. Change from baseline to 12 months was assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS).

The total knee replacement group had a significantly greater improvement in the KOOS score than did the non-surgical group. Serious adverse events were more common in the total knee replacement group.

The study did not include a sham-surgery control group. It is unknown whether the KOOS pain subscale is generalizable to patients with severe pain. Additionally, the intensity of non-surgical treatment may have differed between groups.

Bottom line: Total knee replacement followed by non-surgical treatment is more efficacious than non-surgical treatment alone in providing pain relief and improving function and quality of life, but it is associated with higher number of adverse events.

Citation: Skou ST, Roos EM, Laursen MB, et al. A randomized, controlled trial of total knee replacement. N Engl J Med. 2015;373(17):1597-1606.

Clinical question: Is there an improved 30-day mortality rate if patients receive blood transfusion at higher hematocrit values after postoperative myocardial infarction (MI)?

Background: Prior studies evaluating patients with a history of coronary artery disease (CAD) who undergo non-cardiac surgery have shown similar mortality outcomes with liberal and restrictive transfusion strategies. Data are lacking for transfusion strategies in patients with CAD who experience postoperative MI after non-cardiac surgeries.

Study design: Retrospective cohort.

Setting: Veterans Affairs health system.

Synopsis: The study included 7,361 patients with a history of CAD who underwent non-cardiac surgery whose postoperative hematocrit was between 20% and 30%. Patients were stratified by postoperative hematocrit nadir and presence of postoperative MI. In patients with postoperative MI, transfusion was associated with lower mortality with hematocrit nadir of 20%–24% but not with hematocrit of 24%–27% or 27%–30%. In patients without postoperative MI, transfusion was associated with higher mortality in patients with hematocrit of 27%–30%.

This retrospective study was limited to the VA population of mostly male patients. The sample size was limited. The study was unable to determine if postoperative blood transfusion is a risk for developing MI.

Bottom line: Patients with a history of CAD and MI who have a postoperative MI following non-cardiac surgery may benefit from higher blood transfusion thresholds; however, further controlled studies are needed.

Citation: Hollis RH, Singeltary BA, McMurtrie JT, et al. Blood transfusion and 30-day mortality in patients with coronary artery disease and anemia following noncardiac surgery [published online ahead of print October 7, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.3420.

Clinical question: Is there an improved 30-day mortality rate if patients receive blood transfusion at higher hematocrit values after postoperative myocardial infarction (MI)?

Background: Prior studies evaluating patients with a history of coronary artery disease (CAD) who undergo non-cardiac surgery have shown similar mortality outcomes with liberal and restrictive transfusion strategies. Data are lacking for transfusion strategies in patients with CAD who experience postoperative MI after non-cardiac surgeries.

Study design: Retrospective cohort.

Setting: Veterans Affairs health system.

Synopsis: The study included 7,361 patients with a history of CAD who underwent non-cardiac surgery whose postoperative hematocrit was between 20% and 30%. Patients were stratified by postoperative hematocrit nadir and presence of postoperative MI. In patients with postoperative MI, transfusion was associated with lower mortality with hematocrit nadir of 20%–24% but not with hematocrit of 24%–27% or 27%–30%. In patients without postoperative MI, transfusion was associated with higher mortality in patients with hematocrit of 27%–30%.

This retrospective study was limited to the VA population of mostly male patients. The sample size was limited. The study was unable to determine if postoperative blood transfusion is a risk for developing MI.

Bottom line: Patients with a history of CAD and MI who have a postoperative MI following non-cardiac surgery may benefit from higher blood transfusion thresholds; however, further controlled studies are needed.

Citation: Hollis RH, Singeltary BA, McMurtrie JT, et al. Blood transfusion and 30-day mortality in patients with coronary artery disease and anemia following noncardiac surgery [published online ahead of print October 7, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.3420.

Clinical question: Is there an improved 30-day mortality rate if patients receive blood transfusion at higher hematocrit values after postoperative myocardial infarction (MI)?

Background: Prior studies evaluating patients with a history of coronary artery disease (CAD) who undergo non-cardiac surgery have shown similar mortality outcomes with liberal and restrictive transfusion strategies. Data are lacking for transfusion strategies in patients with CAD who experience postoperative MI after non-cardiac surgeries.

Study design: Retrospective cohort.

Setting: Veterans Affairs health system.

Synopsis: The study included 7,361 patients with a history of CAD who underwent non-cardiac surgery whose postoperative hematocrit was between 20% and 30%. Patients were stratified by postoperative hematocrit nadir and presence of postoperative MI. In patients with postoperative MI, transfusion was associated with lower mortality with hematocrit nadir of 20%–24% but not with hematocrit of 24%–27% or 27%–30%. In patients without postoperative MI, transfusion was associated with higher mortality in patients with hematocrit of 27%–30%.

This retrospective study was limited to the VA population of mostly male patients. The sample size was limited. The study was unable to determine if postoperative blood transfusion is a risk for developing MI.

Bottom line: Patients with a history of CAD and MI who have a postoperative MI following non-cardiac surgery may benefit from higher blood transfusion thresholds; however, further controlled studies are needed.

Citation: Hollis RH, Singeltary BA, McMurtrie JT, et al. Blood transfusion and 30-day mortality in patients with coronary artery disease and anemia following noncardiac surgery [published online ahead of print October 7, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.3420.

Clinical question: Does taking a perioperative beta-blocker increase the risk of major adverse cardiovascular events (MACEs) and all-cause mortality in low-risk patients with essential hypertension (HTN)?

Background: Guidelines for the use of perioperative beta-blockers are being reevaluated due to concerns about validity of prior studies that supported the use of perioperative beta-blockers. This study sought to evaluate effectiveness and safety of beta-blockers in patients with uncomplicated HTN.

Study design: Observational cohort study.

Setting: Denmark.

Synopsis: This study included 55,320 hypertensive patients using at least two antihypertensive drugs who underwent non-cardiac surgery. Of these, 14,644 patients were treated with a beta-blocker. Patients with secondary cardiovascular conditions, renal disease, or liver disease were excluded; 30-day MACEs and all-cause mortality were analyzed.

In patients treated with a beta-blocker, the incidence of 30-day MACEs was 1.32% compared with 0.84% in the non-beta-blockers group; 30-day mortality in those treated with beta-blocker was 1.9% compared with 1.3% in the non-beta-blocker group. Risk of beta-blocker-associated MACEs was higher in patients 70 and older. Causality cannot be concluded based on observational data.

Bottom line: In patients with uncomplicated HTN, treatment with a beta-blocker may be associated with increased 30-day risk of perioperative MACEs after non-cardiac surgery.

Citation: Jorgensen ME, Hlatky MA, Kober L, et al. Beta-blocker-associated risks in patients with uncomplicated hypertension undergoing noncardiac surgery. JAMA Intern Med. 2015;175(12):1923-1931.

Clinical question: Does taking a perioperative beta-blocker increase the risk of major adverse cardiovascular events (MACEs) and all-cause mortality in low-risk patients with essential hypertension (HTN)?

Background: Guidelines for the use of perioperative beta-blockers are being reevaluated due to concerns about validity of prior studies that supported the use of perioperative beta-blockers. This study sought to evaluate effectiveness and safety of beta-blockers in patients with uncomplicated HTN.

Study design: Observational cohort study.

Setting: Denmark.

Synopsis: This study included 55,320 hypertensive patients using at least two antihypertensive drugs who underwent non-cardiac surgery. Of these, 14,644 patients were treated with a beta-blocker. Patients with secondary cardiovascular conditions, renal disease, or liver disease were excluded; 30-day MACEs and all-cause mortality were analyzed.

In patients treated with a beta-blocker, the incidence of 30-day MACEs was 1.32% compared with 0.84% in the non-beta-blockers group; 30-day mortality in those treated with beta-blocker was 1.9% compared with 1.3% in the non-beta-blocker group. Risk of beta-blocker-associated MACEs was higher in patients 70 and older. Causality cannot be concluded based on observational data.

Bottom line: In patients with uncomplicated HTN, treatment with a beta-blocker may be associated with increased 30-day risk of perioperative MACEs after non-cardiac surgery.

Citation: Jorgensen ME, Hlatky MA, Kober L, et al. Beta-blocker-associated risks in patients with uncomplicated hypertension undergoing noncardiac surgery. JAMA Intern Med. 2015;175(12):1923-1931.

Clinical question: Does taking a perioperative beta-blocker increase the risk of major adverse cardiovascular events (MACEs) and all-cause mortality in low-risk patients with essential hypertension (HTN)?

Background: Guidelines for the use of perioperative beta-blockers are being reevaluated due to concerns about validity of prior studies that supported the use of perioperative beta-blockers. This study sought to evaluate effectiveness and safety of beta-blockers in patients with uncomplicated HTN.

Study design: Observational cohort study.

Setting: Denmark.

Synopsis: This study included 55,320 hypertensive patients using at least two antihypertensive drugs who underwent non-cardiac surgery. Of these, 14,644 patients were treated with a beta-blocker. Patients with secondary cardiovascular conditions, renal disease, or liver disease were excluded; 30-day MACEs and all-cause mortality were analyzed.

In patients treated with a beta-blocker, the incidence of 30-day MACEs was 1.32% compared with 0.84% in the non-beta-blockers group; 30-day mortality in those treated with beta-blocker was 1.9% compared with 1.3% in the non-beta-blocker group. Risk of beta-blocker-associated MACEs was higher in patients 70 and older. Causality cannot be concluded based on observational data.

Bottom line: In patients with uncomplicated HTN, treatment with a beta-blocker may be associated with increased 30-day risk of perioperative MACEs after non-cardiac surgery.

Citation: Jorgensen ME, Hlatky MA, Kober L, et al. Beta-blocker-associated risks in patients with uncomplicated hypertension undergoing noncardiac surgery. JAMA Intern Med. 2015;175(12):1923-1931.

Clinical question: Does pharmacist involvement in transitions of care decrease medication errors (MEs), adverse drug events (ADEs), and 30-day ED visits and inpatient readmissions?

Background: Previous studies show pharmacist involvement in discharge can reduce ADEs and improve patient satisfaction, but there have been inconsistent data on the impact of pharmacist involvement on readmissions, ADEs, and MEs.

Study design: Prospective, randomized, single-period, longitudinal study.

Setting: Northwestern Memorial Hospital, Chicago.

Synopsis: Investigators included 278 patients (137 in study arm, 141 in control arm) in the final analysis. The study arm received intensive pharmacist involvement on admission and discharge, followed by phone calls at three, 14, and 30 days post-discharge. The study arm had lower composite 30-day ED visits and inpatient readmission rates compared to the control group (25% vs. 39%; P=0.001) but did not have lower isolated inpatient readmission rates (20% vs. 24%; P=0.43). ADEs and MEs were not significantly different between the two groups.

This study had extensive exclusion criteria, limiting the patient population to which these results can be applied. It was underpowered, which could have prevented the detection of a significant improvement in readmission rates.

Care transitions are high-risk periods in patient care, and there is benefit to continuity of care of an interdisciplinary team, including pharmacists.

Bottom line: Pharmacist involvement in transitions of care was shown to reduce the composite of ED visits and inpatient readmissions.

Citation: Phatak A, Prusi R, Ward B, et al. Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study). J Hosp Med. 2016;11(1):39-44. doi:10.1002/jhm.2493.

Clinical question: Does pharmacist involvement in transitions of care decrease medication errors (MEs), adverse drug events (ADEs), and 30-day ED visits and inpatient readmissions?

Background: Previous studies show pharmacist involvement in discharge can reduce ADEs and improve patient satisfaction, but there have been inconsistent data on the impact of pharmacist involvement on readmissions, ADEs, and MEs.

Study design: Prospective, randomized, single-period, longitudinal study.

Setting: Northwestern Memorial Hospital, Chicago.

Synopsis: Investigators included 278 patients (137 in study arm, 141 in control arm) in the final analysis. The study arm received intensive pharmacist involvement on admission and discharge, followed by phone calls at three, 14, and 30 days post-discharge. The study arm had lower composite 30-day ED visits and inpatient readmission rates compared to the control group (25% vs. 39%; P=0.001) but did not have lower isolated inpatient readmission rates (20% vs. 24%; P=0.43). ADEs and MEs were not significantly different between the two groups.

This study had extensive exclusion criteria, limiting the patient population to which these results can be applied. It was underpowered, which could have prevented the detection of a significant improvement in readmission rates.

Care transitions are high-risk periods in patient care, and there is benefit to continuity of care of an interdisciplinary team, including pharmacists.

Bottom line: Pharmacist involvement in transitions of care was shown to reduce the composite of ED visits and inpatient readmissions.

Citation: Phatak A, Prusi R, Ward B, et al. Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study). J Hosp Med. 2016;11(1):39-44. doi:10.1002/jhm.2493.

Clinical question: Does pharmacist involvement in transitions of care decrease medication errors (MEs), adverse drug events (ADEs), and 30-day ED visits and inpatient readmissions?

Background: Previous studies show pharmacist involvement in discharge can reduce ADEs and improve patient satisfaction, but there have been inconsistent data on the impact of pharmacist involvement on readmissions, ADEs, and MEs.

Study design: Prospective, randomized, single-period, longitudinal study.

Setting: Northwestern Memorial Hospital, Chicago.

Synopsis: Investigators included 278 patients (137 in study arm, 141 in control arm) in the final analysis. The study arm received intensive pharmacist involvement on admission and discharge, followed by phone calls at three, 14, and 30 days post-discharge. The study arm had lower composite 30-day ED visits and inpatient readmission rates compared to the control group (25% vs. 39%; P=0.001) but did not have lower isolated inpatient readmission rates (20% vs. 24%; P=0.43). ADEs and MEs were not significantly different between the two groups.

This study had extensive exclusion criteria, limiting the patient population to which these results can be applied. It was underpowered, which could have prevented the detection of a significant improvement in readmission rates.

Care transitions are high-risk periods in patient care, and there is benefit to continuity of care of an interdisciplinary team, including pharmacists.

Bottom line: Pharmacist involvement in transitions of care was shown to reduce the composite of ED visits and inpatient readmissions.

Citation: Phatak A, Prusi R, Ward B, et al. Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study). J Hosp Med. 2016;11(1):39-44. doi:10.1002/jhm.2493.

Clinical question: Does price display impact order costs and volume as well as patient safety outcomes, and is it acceptable to providers?

Background: Up to one-third of national healthcare expenditures are wasteful, with physicians playing a central role in overall cost, purchasing almost all tests and therapies for patients. Increasing the transparency of costs for physicians is one strategy to reduce unnecessary spending.

Study design: Systematic review.

Setting: Yale School of Medicine, New Haven, Conn.

Synopsis: Nineteen publications were selected for final analysis. Thirteen studies reported the impact of price display on costs, nine of which showed a statistically significant decrease in order costs. Only three of eight studies reporting the impact of price display on order volume showed statistically significant decreases in order volume. One study showed adverse safety findings in the form of higher rates of unscheduled follow-up care in a pediatric ED. Physicians were overall satisfied with price display in the five studies reporting this.

There was high heterogeneity among studies, which did not allow for pooling of data. Furthermore, more than half of the studies were conducted more than 15 years ago, limiting their generalizability to the modern era of electronic health records (EHRs).

Overall, this review supports the conclusion that price display has a modest effect on order costs. Additional studies utilizing EHR systems are required to more definitively confirm these findings.

Bottom line: Displaying prices to physicians can have a modest effect on overall order costs.

Citation: Silvestri MT, Bongiovanni TR, Glover JG, Gross CP. Impact of price display on provider ordering: a systematic review. J Hosp Med. 2016;11(1):65-76. doi:10.1002/jhm.2500.

Clinical question: Does price display impact order costs and volume as well as patient safety outcomes, and is it acceptable to providers?

Background: Up to one-third of national healthcare expenditures are wasteful, with physicians playing a central role in overall cost, purchasing almost all tests and therapies for patients. Increasing the transparency of costs for physicians is one strategy to reduce unnecessary spending.

Study design: Systematic review.

Setting: Yale School of Medicine, New Haven, Conn.

Synopsis: Nineteen publications were selected for final analysis. Thirteen studies reported the impact of price display on costs, nine of which showed a statistically significant decrease in order costs. Only three of eight studies reporting the impact of price display on order volume showed statistically significant decreases in order volume. One study showed adverse safety findings in the form of higher rates of unscheduled follow-up care in a pediatric ED. Physicians were overall satisfied with price display in the five studies reporting this.

There was high heterogeneity among studies, which did not allow for pooling of data. Furthermore, more than half of the studies were conducted more than 15 years ago, limiting their generalizability to the modern era of electronic health records (EHRs).

Overall, this review supports the conclusion that price display has a modest effect on order costs. Additional studies utilizing EHR systems are required to more definitively confirm these findings.

Bottom line: Displaying prices to physicians can have a modest effect on overall order costs.

Citation: Silvestri MT, Bongiovanni TR, Glover JG, Gross CP. Impact of price display on provider ordering: a systematic review. J Hosp Med. 2016;11(1):65-76. doi:10.1002/jhm.2500.

Clinical question: Does price display impact order costs and volume as well as patient safety outcomes, and is it acceptable to providers?

Background: Up to one-third of national healthcare expenditures are wasteful, with physicians playing a central role in overall cost, purchasing almost all tests and therapies for patients. Increasing the transparency of costs for physicians is one strategy to reduce unnecessary spending.

Study design: Systematic review.

Setting: Yale School of Medicine, New Haven, Conn.

Synopsis: Nineteen publications were selected for final analysis. Thirteen studies reported the impact of price display on costs, nine of which showed a statistically significant decrease in order costs. Only three of eight studies reporting the impact of price display on order volume showed statistically significant decreases in order volume. One study showed adverse safety findings in the form of higher rates of unscheduled follow-up care in a pediatric ED. Physicians were overall satisfied with price display in the five studies reporting this.

There was high heterogeneity among studies, which did not allow for pooling of data. Furthermore, more than half of the studies were conducted more than 15 years ago, limiting their generalizability to the modern era of electronic health records (EHRs).

Overall, this review supports the conclusion that price display has a modest effect on order costs. Additional studies utilizing EHR systems are required to more definitively confirm these findings.

Bottom line: Displaying prices to physicians can have a modest effect on overall order costs.

Citation: Silvestri MT, Bongiovanni TR, Glover JG, Gross CP. Impact of price display on provider ordering: a systematic review. J Hosp Med. 2016;11(1):65-76. doi:10.1002/jhm.2500.

Managing chronic pain in an older adult can be a complicated task, with risks for adverse effects, under- or overmedication, and nonadherence. Pain can be alleviated in many cases, however, if you address potential complications and barriers to effective treatment when prescribing analgesic medications.

Pain is a part of daily life for many older adults

As many as 50% of community-dwelling older adults experience a chronic pain disorder, defined as pain on most days for at least 3 consecutive months.¹ Prevalence rates are typically higher (49%-84%) among residents of long-term care facilities.² Untreated chronic pain can lead to health consequences such as depression, decreased ability to socialize, impaired ambulation, impaired sleep, increased falls, malnutrition, and decreased quality of life.^1,3 Among older women, pain is the most common reported cause of impairment in activities of daily living.⁴

Arthritis and arthritis-related diseases (such as back pain) are common causes of chronic pain in older adults.⁵ Other causes include neuropathies, vertebral compression fractures, cancer and cancer treatments, and advanced chronic diseases such as end-stage heart, lung, and kidney disease.^6-10

Substantial literature documents that chronic pain is underdetected and undertreated with advancing age^11,12 and strongly supports efforts to improve pain care in later life. Treatment guidelines recommend a multimodal approach, including evidence-based nonpharmacologic treatments such as cognitive-behavioral therapy, exercise, and physical therapy.¹ At the same time, pharmacotherapies remain the primary treatment used by physicians,¹³ and studies indicate that older people use analgesics frequently:

• When 551 older black and non-Hispanic white adults with osteoarthritis were interviewed, more than 80% of each group reported regular use of prescription and over-the-counter (OTC) analgesic medications.¹⁴
• In a cross-sectional study of 272 community-dwelling older adults with chronic pain from diverse causes, 59% reported routine use of an analgesic medication.¹⁵

The following 6 steps can improve the likelihood of a successful analgesic trial when managing chronic pain in people ages 65 and older. They take into account barriers you are likely to encounter, including polypharmacy, multimorbidity, cognitive and sensory impairment, sociodemographic factors, specific health beliefs about pain and pain treatments, and age-related physiologic changes.

TABLE

Refine your approach to chronic pain in older patients with these 6 steps

Step 1. Conduct a comprehensive pain history

The first step in pain management is to perform a comprehensive pain assessment. Without a proper pain assessment, it will be difficult to effectively treat and monitor response to treatment. Whichever pain scale you decide to use, it is important to use the same pain scale consistently each time a pain assessment takes place.³ The numeric rating scale and verbal descriptor scales (or pain thermometer) are widely used and have been shown to be preferred in the older adult population.^3,16 The numeric rating scale asks a patient to rate his or her pain on a scale of 0 to 10, with 0 being no pain and 10 being the most severe pain imaginable. The verbal descriptor scale is a measure of pain intensity on a vertical scale (typically a thermometer) from “no pain” to “excruciating.”³

Recommendations. In addition to assessing the intensity of the pain using a pain assessment tool, it is important to determine certain characteristics of the pain. What is the location and quality of the pain? Ask patients how the pain limits them. What prior treatments have been tried and failed? What has worked the best? What treatment/coping strategies are they using now? Have they had any intolerable adverse effects from specific treatments? Reliable predictors of treatment response require further definition,¹⁷ but a successful trial of a given analgesic in the past is often a good indicator of what might work again.

Step 2. Review the patient’s problem list

Use of multiple medications. Polypharmacy—with 5 or more being a typical threshold criterion—is common in people ages 65 and older and frequently complicates the pharmacologic management of chronic pain.^16,18 Complications most often occur as a result of drug-drug interactions.

Multiple coexisting chronic conditions. Multimorbidity is common in older adults with chronic pain. Consider co-occurring diabetes, hypertension, and osteoporosis when initiating any trial of a pain medication. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be effective in treating pain syndromes, but their use can be hazardous in older individuals, particularly those with coexisting hypertension, cardiovascular disease, history of peptic ulcer disease or gastropathy, or impaired renal function. NSAID use has been implicated as a cause of approximately one-quarter of all hospitalizations related to drug adverse effects among adults over age 65.¹

The geriatric syndrome of frailty is defined by deficits in physiologic reserve and decreased resistance to multiple stressors.¹⁹ Risk of fracture is a particular concern of clinicians, older patients, and their caregivers. Opioids are the analgesic medications most often associated with increased fracture risk. In a recent analysis of Medicare claims data, opioid users were found to have a significantly increased fracture risk compared with users of nonselective NSAIDs.²⁰ Mechanisms underlying this association include opioid-associated cognitive dysfunction and worsening gait/balance function.

Recommendations. Obtain a full list of the patient’s medications, including all OTC and complementary preparations. Also consider chronic kidney problems, liver disease, movement disorders, and neurologic problems when selecting a pharmacologic agent. Consider what chronic conditions might be made worse by an analgesic trial or would operate as a contraindication to starting a specific pain medication. Establish which medications or comorbidities might modify your treatment choices.

Step 3. Establish the patient’s treatment goals

We recommend shared decision-making when planning treatment and monitoring outcomes for older adults with chronic pain. Use your patient’s reports of the experience of pain— including pain intensity and how pain affects daily functioning¹ —and identify his or her treatment goals, which might differ from yours. You may be aiming for the best pain relief possible, but your patient might be focused on practical issues such as increased mobility or ability to socialize. By talking openly, you can reach consensus and agree upon realistic treatment goals.

This approach can improve patients’ outcomes and satisfaction with treatment; it also has been shown to improve physician satisfaction when treating patients with chronic pain.²¹ In a recent qualitative study, older individuals varied in how much they wanted to participate in making decisions and being a “source of control” in their pain treatment. ²² Some patients—particularly those ages 80 and older—prefer to have their physicians make treatment decisions for them, whereas others embrace active participation. Regardless of how much older individuals wish to share in treatment decisions, they all value being listened to and understood by their physicians.²¹

Recommendations. The patient’s goals and expectations for treatment may or may not be the same as yours. Before starting a medication trial, address potential unrealistic expectations such as complete relief of pain or a belief that treatment is not likely to help. Come to a mutual decision as to what constitutes the most important outcomes, and you will then be able to monitor and assess treatment success.

Step 4. Identify barriers to initiating and adhering to therapy

Cognitive impairment is a strong risk factor for undertreatment of pain. It can lead to underreporting of pain by patients or difficulty for clinicians in assessing treatment response from those who are unable to communicate pain effectively. A study of nursing home residents found that only 56% of those with cognitive impairment received pain medications, compared with 80% of those with intact cognition.²³ Older patients with cognitive deficits and memory loss also may take analgesic medications inappropriately or forget when/if they took them, increasing the risk of undertreatment or overdosing.

Sensory impairment. Patients with visual deficits may have difficulty reading prescription bottle labels and information sheets. Those with auditory deficits may have trouble hearing, communicating, and understanding treatment instructions during a busy clinical encounter.

Sociodemographic factors. Many older adults live alone and have limited social support to encourage medication adherence.²⁴ Some have significant caregiving responsibilities of their own (such as a spouse in poor health), which can lead to stress and inconsistent use of prescribed medications.²⁵ Some older adults can’t afford the costs of certain pain medications and may take less than the prescribed amount.

Many older adults lack the necessary skills to read and process basic health care information, including understanding pill bottle instructions, information that appears in patient handouts, and clinicians’ instructions about possible adverse effects.^26,27 Low health literacy can lead to problems with medication adherence (taking too much or too little of an analgesic medication) and associated complications.

Health beliefs. Many older adults believe chronic pain is a natural part of aging; in one study, this was true of 61% of approximately 700 primary care patients with osteoarthritis pain.²⁸ Some older adults believe pain only gets worse over time,²⁸ and others believe treatment for pain is not likely to provide any meaningful benefit.^29,30 Beliefs such as these can lead to stoicism or acceptance of the status quo.³¹

Older adults also may endorse beliefs about pain medications that are likely to decrease their willingness to engage in, or adhere to, recommended pharmacologic interventions. Some use pain medicines sparingly because they fear addiction or dependence.^32,33 Caregivers—often a spouse or adult child—also may express fears about the possibility of addiction.³² Finally, some older adults believe that using prescription analgesic medications invariably results in adverse effects;³² those who endorse this belief report minimizing medication use except when the pain is “very bad.”³⁴

Recommendations. Elicit concerns patients may have about using analgesic medications and discuss them openly. Although not all barriers (such as economic issues) are modifiable, most (such as beliefs that pain medications are addictive) can be successfully addressed through patient education.

If other social support, such as a family member or caregiver in the home, could positively affect analgesic engagement/adherence, include these facilitators when discussing treatment decisions and in monitoring for medication effectiveness and adverse effects.

Step 5. Start low and go slow when initiating analgesia

Advancing age is associated with increased sensitivity to the anticholinergic effects of many commonly prescribed and OTC medications, including NSAIDs and opioids.³⁵ Increasing the anticholinergic load can lead to cognitive impairments, including confusion, which can be particularly troublesome for older adults.¹

Changes in pharmacokinetics (what the body does to the drug in terms of altering absorption, distribution, metabolism and excretion) and pharmacodynamics (what the drug does to the body in the form of adverse effects) occur as a function of advancing age. ¹ Body fat increases by 20% to 40% on average, which increases the volume of distribution for fat-soluble medications.¹⁶ Hepatic and renal clearance decrease, leading to an increased half-life and decreased excretion of medications cleared by the liver or kidneys. Age-associated changes in gastrointestinal (GI) absorption and function include slower GI transit times and the possibility of increased opioid-related constipation from dysmotility problems.¹

As a result of these physiologic changes, advancing age is associated with a greater incidence of drug-related adverse effects. Even so, individuals within the older population are highly heterogeneous, and no geriatric-specific dosing guidelines exist for prescribing pain medications to older adults.

Recommendations. We recommend the adage “start low and go slow” when initiating an analgesic trial for an older patient with chronic pain. This does not mean you should “start low and stay low,” which can contribute to undertreatment.³⁶ If treatment goals are not being met and the patient is tolerating the therapy, advancing the dose is reasonable before moving on to another intervention.

Step 6. Assess for effects and outcomes outside the office

Adverse effects are a primary reason older adults discontinue an analgesic trial.³⁷ Make certain the patient (or caregiver, as appropriate) understands what adverse effects might occur, and create a plan to address them if they do.

Recommendations. Because many older people are reluctant to communicate with their physicians outside of an office visit, establish how often and when communication should occur. Telephone calls and/or e-mail are practical tools for patients to communicate questions or concerns to you, and you can enhance treatment outcomes with timely replies. In the near future, mobile health technologies may play a key role in monitoring for adverse effects and communicating positive treatment outcomes.

Managing chronic pain in an older adult can be a complicated task, with risks for adverse effects, under- or overmedication, and nonadherence. Pain can be alleviated in many cases, however, if you address potential complications and barriers to effective treatment when prescribing analgesic medications.

Pain is a part of daily life for many older adults

As many as 50% of community-dwelling older adults experience a chronic pain disorder, defined as pain on most days for at least 3 consecutive months.¹ Prevalence rates are typically higher (49%-84%) among residents of long-term care facilities.² Untreated chronic pain can lead to health consequences such as depression, decreased ability to socialize, impaired ambulation, impaired sleep, increased falls, malnutrition, and decreased quality of life.^1,3 Among older women, pain is the most common reported cause of impairment in activities of daily living.⁴

Arthritis and arthritis-related diseases (such as back pain) are common causes of chronic pain in older adults.⁵ Other causes include neuropathies, vertebral compression fractures, cancer and cancer treatments, and advanced chronic diseases such as end-stage heart, lung, and kidney disease.^6-10

Substantial literature documents that chronic pain is underdetected and undertreated with advancing age^11,12 and strongly supports efforts to improve pain care in later life. Treatment guidelines recommend a multimodal approach, including evidence-based nonpharmacologic treatments such as cognitive-behavioral therapy, exercise, and physical therapy.¹ At the same time, pharmacotherapies remain the primary treatment used by physicians,¹³ and studies indicate that older people use analgesics frequently:

• When 551 older black and non-Hispanic white adults with osteoarthritis were interviewed, more than 80% of each group reported regular use of prescription and over-the-counter (OTC) analgesic medications.¹⁴
• In a cross-sectional study of 272 community-dwelling older adults with chronic pain from diverse causes, 59% reported routine use of an analgesic medication.¹⁵

The following 6 steps can improve the likelihood of a successful analgesic trial when managing chronic pain in people ages 65 and older. They take into account barriers you are likely to encounter, including polypharmacy, multimorbidity, cognitive and sensory impairment, sociodemographic factors, specific health beliefs about pain and pain treatments, and age-related physiologic changes.

TABLE

Refine your approach to chronic pain in older patients with these 6 steps

Step 1. Conduct a comprehensive pain history

The first step in pain management is to perform a comprehensive pain assessment. Without a proper pain assessment, it will be difficult to effectively treat and monitor response to treatment. Whichever pain scale you decide to use, it is important to use the same pain scale consistently each time a pain assessment takes place.³ The numeric rating scale and verbal descriptor scales (or pain thermometer) are widely used and have been shown to be preferred in the older adult population.^3,16 The numeric rating scale asks a patient to rate his or her pain on a scale of 0 to 10, with 0 being no pain and 10 being the most severe pain imaginable. The verbal descriptor scale is a measure of pain intensity on a vertical scale (typically a thermometer) from “no pain” to “excruciating.”³

Recommendations. In addition to assessing the intensity of the pain using a pain assessment tool, it is important to determine certain characteristics of the pain. What is the location and quality of the pain? Ask patients how the pain limits them. What prior treatments have been tried and failed? What has worked the best? What treatment/coping strategies are they using now? Have they had any intolerable adverse effects from specific treatments? Reliable predictors of treatment response require further definition,¹⁷ but a successful trial of a given analgesic in the past is often a good indicator of what might work again.

Step 2. Review the patient’s problem list

Use of multiple medications. Polypharmacy—with 5 or more being a typical threshold criterion—is common in people ages 65 and older and frequently complicates the pharmacologic management of chronic pain.^16,18 Complications most often occur as a result of drug-drug interactions.

Multiple coexisting chronic conditions. Multimorbidity is common in older adults with chronic pain. Consider co-occurring diabetes, hypertension, and osteoporosis when initiating any trial of a pain medication. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be effective in treating pain syndromes, but their use can be hazardous in older individuals, particularly those with coexisting hypertension, cardiovascular disease, history of peptic ulcer disease or gastropathy, or impaired renal function. NSAID use has been implicated as a cause of approximately one-quarter of all hospitalizations related to drug adverse effects among adults over age 65.¹

The geriatric syndrome of frailty is defined by deficits in physiologic reserve and decreased resistance to multiple stressors.¹⁹ Risk of fracture is a particular concern of clinicians, older patients, and their caregivers. Opioids are the analgesic medications most often associated with increased fracture risk. In a recent analysis of Medicare claims data, opioid users were found to have a significantly increased fracture risk compared with users of nonselective NSAIDs.²⁰ Mechanisms underlying this association include opioid-associated cognitive dysfunction and worsening gait/balance function.

Recommendations. Obtain a full list of the patient’s medications, including all OTC and complementary preparations. Also consider chronic kidney problems, liver disease, movement disorders, and neurologic problems when selecting a pharmacologic agent. Consider what chronic conditions might be made worse by an analgesic trial or would operate as a contraindication to starting a specific pain medication. Establish which medications or comorbidities might modify your treatment choices.

Step 3. Establish the patient’s treatment goals

We recommend shared decision-making when planning treatment and monitoring outcomes for older adults with chronic pain. Use your patient’s reports of the experience of pain— including pain intensity and how pain affects daily functioning¹ —and identify his or her treatment goals, which might differ from yours. You may be aiming for the best pain relief possible, but your patient might be focused on practical issues such as increased mobility or ability to socialize. By talking openly, you can reach consensus and agree upon realistic treatment goals.

This approach can improve patients’ outcomes and satisfaction with treatment; it also has been shown to improve physician satisfaction when treating patients with chronic pain.²¹ In a recent qualitative study, older individuals varied in how much they wanted to participate in making decisions and being a “source of control” in their pain treatment. ²² Some patients—particularly those ages 80 and older—prefer to have their physicians make treatment decisions for them, whereas others embrace active participation. Regardless of how much older individuals wish to share in treatment decisions, they all value being listened to and understood by their physicians.²¹

Recommendations. The patient’s goals and expectations for treatment may or may not be the same as yours. Before starting a medication trial, address potential unrealistic expectations such as complete relief of pain or a belief that treatment is not likely to help. Come to a mutual decision as to what constitutes the most important outcomes, and you will then be able to monitor and assess treatment success.

Step 4. Identify barriers to initiating and adhering to therapy

Cognitive impairment is a strong risk factor for undertreatment of pain. It can lead to underreporting of pain by patients or difficulty for clinicians in assessing treatment response from those who are unable to communicate pain effectively. A study of nursing home residents found that only 56% of those with cognitive impairment received pain medications, compared with 80% of those with intact cognition.²³ Older patients with cognitive deficits and memory loss also may take analgesic medications inappropriately or forget when/if they took them, increasing the risk of undertreatment or overdosing.

Sensory impairment. Patients with visual deficits may have difficulty reading prescription bottle labels and information sheets. Those with auditory deficits may have trouble hearing, communicating, and understanding treatment instructions during a busy clinical encounter.

Sociodemographic factors. Many older adults live alone and have limited social support to encourage medication adherence.²⁴ Some have significant caregiving responsibilities of their own (such as a spouse in poor health), which can lead to stress and inconsistent use of prescribed medications.²⁵ Some older adults can’t afford the costs of certain pain medications and may take less than the prescribed amount.

Many older adults lack the necessary skills to read and process basic health care information, including understanding pill bottle instructions, information that appears in patient handouts, and clinicians’ instructions about possible adverse effects.^26,27 Low health literacy can lead to problems with medication adherence (taking too much or too little of an analgesic medication) and associated complications.

Health beliefs. Many older adults believe chronic pain is a natural part of aging; in one study, this was true of 61% of approximately 700 primary care patients with osteoarthritis pain.²⁸ Some older adults believe pain only gets worse over time,²⁸ and others believe treatment for pain is not likely to provide any meaningful benefit.^29,30 Beliefs such as these can lead to stoicism or acceptance of the status quo.³¹

Older adults also may endorse beliefs about pain medications that are likely to decrease their willingness to engage in, or adhere to, recommended pharmacologic interventions. Some use pain medicines sparingly because they fear addiction or dependence.^32,33 Caregivers—often a spouse or adult child—also may express fears about the possibility of addiction.³² Finally, some older adults believe that using prescription analgesic medications invariably results in adverse effects;³² those who endorse this belief report minimizing medication use except when the pain is “very bad.”³⁴

Recommendations. Elicit concerns patients may have about using analgesic medications and discuss them openly. Although not all barriers (such as economic issues) are modifiable, most (such as beliefs that pain medications are addictive) can be successfully addressed through patient education.

If other social support, such as a family member or caregiver in the home, could positively affect analgesic engagement/adherence, include these facilitators when discussing treatment decisions and in monitoring for medication effectiveness and adverse effects.

Step 5. Start low and go slow when initiating analgesia

Advancing age is associated with increased sensitivity to the anticholinergic effects of many commonly prescribed and OTC medications, including NSAIDs and opioids.³⁵ Increasing the anticholinergic load can lead to cognitive impairments, including confusion, which can be particularly troublesome for older adults.¹

Changes in pharmacokinetics (what the body does to the drug in terms of altering absorption, distribution, metabolism and excretion) and pharmacodynamics (what the drug does to the body in the form of adverse effects) occur as a function of advancing age. ¹ Body fat increases by 20% to 40% on average, which increases the volume of distribution for fat-soluble medications.¹⁶ Hepatic and renal clearance decrease, leading to an increased half-life and decreased excretion of medications cleared by the liver or kidneys. Age-associated changes in gastrointestinal (GI) absorption and function include slower GI transit times and the possibility of increased opioid-related constipation from dysmotility problems.¹

As a result of these physiologic changes, advancing age is associated with a greater incidence of drug-related adverse effects. Even so, individuals within the older population are highly heterogeneous, and no geriatric-specific dosing guidelines exist for prescribing pain medications to older adults.

Recommendations. We recommend the adage “start low and go slow” when initiating an analgesic trial for an older patient with chronic pain. This does not mean you should “start low and stay low,” which can contribute to undertreatment.³⁶ If treatment goals are not being met and the patient is tolerating the therapy, advancing the dose is reasonable before moving on to another intervention.

Step 6. Assess for effects and outcomes outside the office

Adverse effects are a primary reason older adults discontinue an analgesic trial.³⁷ Make certain the patient (or caregiver, as appropriate) understands what adverse effects might occur, and create a plan to address them if they do.

Recommendations. Because many older people are reluctant to communicate with their physicians outside of an office visit, establish how often and when communication should occur. Telephone calls and/or e-mail are practical tools for patients to communicate questions or concerns to you, and you can enhance treatment outcomes with timely replies. In the near future, mobile health technologies may play a key role in monitoring for adverse effects and communicating positive treatment outcomes.

Managing chronic pain in an older adult can be a complicated task, with risks for adverse effects, under- or overmedication, and nonadherence. Pain can be alleviated in many cases, however, if you address potential complications and barriers to effective treatment when prescribing analgesic medications.

Pain is a part of daily life for many older adults

As many as 50% of community-dwelling older adults experience a chronic pain disorder, defined as pain on most days for at least 3 consecutive months.¹ Prevalence rates are typically higher (49%-84%) among residents of long-term care facilities.² Untreated chronic pain can lead to health consequences such as depression, decreased ability to socialize, impaired ambulation, impaired sleep, increased falls, malnutrition, and decreased quality of life.^1,3 Among older women, pain is the most common reported cause of impairment in activities of daily living.⁴

Arthritis and arthritis-related diseases (such as back pain) are common causes of chronic pain in older adults.⁵ Other causes include neuropathies, vertebral compression fractures, cancer and cancer treatments, and advanced chronic diseases such as end-stage heart, lung, and kidney disease.^6-10

Substantial literature documents that chronic pain is underdetected and undertreated with advancing age^11,12 and strongly supports efforts to improve pain care in later life. Treatment guidelines recommend a multimodal approach, including evidence-based nonpharmacologic treatments such as cognitive-behavioral therapy, exercise, and physical therapy.¹ At the same time, pharmacotherapies remain the primary treatment used by physicians,¹³ and studies indicate that older people use analgesics frequently:

• When 551 older black and non-Hispanic white adults with osteoarthritis were interviewed, more than 80% of each group reported regular use of prescription and over-the-counter (OTC) analgesic medications.¹⁴
• In a cross-sectional study of 272 community-dwelling older adults with chronic pain from diverse causes, 59% reported routine use of an analgesic medication.¹⁵

The following 6 steps can improve the likelihood of a successful analgesic trial when managing chronic pain in people ages 65 and older. They take into account barriers you are likely to encounter, including polypharmacy, multimorbidity, cognitive and sensory impairment, sociodemographic factors, specific health beliefs about pain and pain treatments, and age-related physiologic changes.

TABLE

Refine your approach to chronic pain in older patients with these 6 steps

Step 1. Conduct a comprehensive pain history

The first step in pain management is to perform a comprehensive pain assessment. Without a proper pain assessment, it will be difficult to effectively treat and monitor response to treatment. Whichever pain scale you decide to use, it is important to use the same pain scale consistently each time a pain assessment takes place.³ The numeric rating scale and verbal descriptor scales (or pain thermometer) are widely used and have been shown to be preferred in the older adult population.^3,16 The numeric rating scale asks a patient to rate his or her pain on a scale of 0 to 10, with 0 being no pain and 10 being the most severe pain imaginable. The verbal descriptor scale is a measure of pain intensity on a vertical scale (typically a thermometer) from “no pain” to “excruciating.”³

Recommendations. In addition to assessing the intensity of the pain using a pain assessment tool, it is important to determine certain characteristics of the pain. What is the location and quality of the pain? Ask patients how the pain limits them. What prior treatments have been tried and failed? What has worked the best? What treatment/coping strategies are they using now? Have they had any intolerable adverse effects from specific treatments? Reliable predictors of treatment response require further definition,¹⁷ but a successful trial of a given analgesic in the past is often a good indicator of what might work again.

Step 2. Review the patient’s problem list

Use of multiple medications. Polypharmacy—with 5 or more being a typical threshold criterion—is common in people ages 65 and older and frequently complicates the pharmacologic management of chronic pain.^16,18 Complications most often occur as a result of drug-drug interactions.

Multiple coexisting chronic conditions. Multimorbidity is common in older adults with chronic pain. Consider co-occurring diabetes, hypertension, and osteoporosis when initiating any trial of a pain medication. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be effective in treating pain syndromes, but their use can be hazardous in older individuals, particularly those with coexisting hypertension, cardiovascular disease, history of peptic ulcer disease or gastropathy, or impaired renal function. NSAID use has been implicated as a cause of approximately one-quarter of all hospitalizations related to drug adverse effects among adults over age 65.¹

The geriatric syndrome of frailty is defined by deficits in physiologic reserve and decreased resistance to multiple stressors.¹⁹ Risk of fracture is a particular concern of clinicians, older patients, and their caregivers. Opioids are the analgesic medications most often associated with increased fracture risk. In a recent analysis of Medicare claims data, opioid users were found to have a significantly increased fracture risk compared with users of nonselective NSAIDs.²⁰ Mechanisms underlying this association include opioid-associated cognitive dysfunction and worsening gait/balance function.

Recommendations. Obtain a full list of the patient’s medications, including all OTC and complementary preparations. Also consider chronic kidney problems, liver disease, movement disorders, and neurologic problems when selecting a pharmacologic agent. Consider what chronic conditions might be made worse by an analgesic trial or would operate as a contraindication to starting a specific pain medication. Establish which medications or comorbidities might modify your treatment choices.

Step 3. Establish the patient’s treatment goals

We recommend shared decision-making when planning treatment and monitoring outcomes for older adults with chronic pain. Use your patient’s reports of the experience of pain— including pain intensity and how pain affects daily functioning¹ —and identify his or her treatment goals, which might differ from yours. You may be aiming for the best pain relief possible, but your patient might be focused on practical issues such as increased mobility or ability to socialize. By talking openly, you can reach consensus and agree upon realistic treatment goals.

This approach can improve patients’ outcomes and satisfaction with treatment; it also has been shown to improve physician satisfaction when treating patients with chronic pain.²¹ In a recent qualitative study, older individuals varied in how much they wanted to participate in making decisions and being a “source of control” in their pain treatment. ²² Some patients—particularly those ages 80 and older—prefer to have their physicians make treatment decisions for them, whereas others embrace active participation. Regardless of how much older individuals wish to share in treatment decisions, they all value being listened to and understood by their physicians.²¹

Recommendations. The patient’s goals and expectations for treatment may or may not be the same as yours. Before starting a medication trial, address potential unrealistic expectations such as complete relief of pain or a belief that treatment is not likely to help. Come to a mutual decision as to what constitutes the most important outcomes, and you will then be able to monitor and assess treatment success.

Step 4. Identify barriers to initiating and adhering to therapy

Cognitive impairment is a strong risk factor for undertreatment of pain. It can lead to underreporting of pain by patients or difficulty for clinicians in assessing treatment response from those who are unable to communicate pain effectively. A study of nursing home residents found that only 56% of those with cognitive impairment received pain medications, compared with 80% of those with intact cognition.²³ Older patients with cognitive deficits and memory loss also may take analgesic medications inappropriately or forget when/if they took them, increasing the risk of undertreatment or overdosing.

Sensory impairment. Patients with visual deficits may have difficulty reading prescription bottle labels and information sheets. Those with auditory deficits may have trouble hearing, communicating, and understanding treatment instructions during a busy clinical encounter.

Sociodemographic factors. Many older adults live alone and have limited social support to encourage medication adherence.²⁴ Some have significant caregiving responsibilities of their own (such as a spouse in poor health), which can lead to stress and inconsistent use of prescribed medications.²⁵ Some older adults can’t afford the costs of certain pain medications and may take less than the prescribed amount.

Many older adults lack the necessary skills to read and process basic health care information, including understanding pill bottle instructions, information that appears in patient handouts, and clinicians’ instructions about possible adverse effects.^26,27 Low health literacy can lead to problems with medication adherence (taking too much or too little of an analgesic medication) and associated complications.

Health beliefs. Many older adults believe chronic pain is a natural part of aging; in one study, this was true of 61% of approximately 700 primary care patients with osteoarthritis pain.²⁸ Some older adults believe pain only gets worse over time,²⁸ and others believe treatment for pain is not likely to provide any meaningful benefit.^29,30 Beliefs such as these can lead to stoicism or acceptance of the status quo.³¹

Older adults also may endorse beliefs about pain medications that are likely to decrease their willingness to engage in, or adhere to, recommended pharmacologic interventions. Some use pain medicines sparingly because they fear addiction or dependence.^32,33 Caregivers—often a spouse or adult child—also may express fears about the possibility of addiction.³² Finally, some older adults believe that using prescription analgesic medications invariably results in adverse effects;³² those who endorse this belief report minimizing medication use except when the pain is “very bad.”³⁴

Recommendations. Elicit concerns patients may have about using analgesic medications and discuss them openly. Although not all barriers (such as economic issues) are modifiable, most (such as beliefs that pain medications are addictive) can be successfully addressed through patient education.

If other social support, such as a family member or caregiver in the home, could positively affect analgesic engagement/adherence, include these facilitators when discussing treatment decisions and in monitoring for medication effectiveness and adverse effects.

Step 5. Start low and go slow when initiating analgesia

Advancing age is associated with increased sensitivity to the anticholinergic effects of many commonly prescribed and OTC medications, including NSAIDs and opioids.³⁵ Increasing the anticholinergic load can lead to cognitive impairments, including confusion, which can be particularly troublesome for older adults.¹

Changes in pharmacokinetics (what the body does to the drug in terms of altering absorption, distribution, metabolism and excretion) and pharmacodynamics (what the drug does to the body in the form of adverse effects) occur as a function of advancing age. ¹ Body fat increases by 20% to 40% on average, which increases the volume of distribution for fat-soluble medications.¹⁶ Hepatic and renal clearance decrease, leading to an increased half-life and decreased excretion of medications cleared by the liver or kidneys. Age-associated changes in gastrointestinal (GI) absorption and function include slower GI transit times and the possibility of increased opioid-related constipation from dysmotility problems.¹

As a result of these physiologic changes, advancing age is associated with a greater incidence of drug-related adverse effects. Even so, individuals within the older population are highly heterogeneous, and no geriatric-specific dosing guidelines exist for prescribing pain medications to older adults.

Recommendations. We recommend the adage “start low and go slow” when initiating an analgesic trial for an older patient with chronic pain. This does not mean you should “start low and stay low,” which can contribute to undertreatment.³⁶ If treatment goals are not being met and the patient is tolerating the therapy, advancing the dose is reasonable before moving on to another intervention.

Step 6. Assess for effects and outcomes outside the office

Adverse effects are a primary reason older adults discontinue an analgesic trial.³⁷ Make certain the patient (or caregiver, as appropriate) understands what adverse effects might occur, and create a plan to address them if they do.

Recommendations. Because many older people are reluctant to communicate with their physicians outside of an office visit, establish how often and when communication should occur. Telephone calls and/or e-mail are practical tools for patients to communicate questions or concerns to you, and you can enhance treatment outcomes with timely replies. In the near future, mobile health technologies may play a key role in monitoring for adverse effects and communicating positive treatment outcomes.