scholarly journals Development of an Interventional Pain Management Specific Instrument for Methodologic Quality Assessment of Nonrandomized Studies of Interventional Techniques

2014 ◽  
Vol 3;17 (3;5) ◽  
pp. E291-E317 ◽  
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Pain Management ◽  
Observational Studies ◽  
Methodological Quality ◽  
Cochrane Review ◽  
Bias Assessment ◽  
Interventional Techniques ◽  
Specific Instrument ◽  
Methodologic Quality ◽  
Interventional Pain Management

Background: The major component of a systematic review is assessment of the methodologic quality and bias of randomized and nonrandomized trials. While there are multiple instruments available to assess the methodologic quality and bias for randomized controlled trials (RCTs), there is a lack of extensively utilized instruments for observational studies, specifically for interventional pain management (IPM) techniques. Even Cochrane review criteria for randomized trials is considered not to be a “gold standard,” but merely an indication of the current state of the art review methodology. Recently a specific instrument to assess the methodologic quality of randomized trials has been developed for interventional techniques. Objectives: Our objective was to develop an IPM specific instrument to assess the methodological quality of nonrandomized trials or observational studies of interventional techniques. Methods: The item generation for the instrument was based on a definition of quality, to the extent to which the design and conduct of the trial were congruent with the objectives of the study. Applicability was defined as the extent to which procedures produced by the study could be applied using contemporary IPM techniques. Multiple items based on Cochrane review criteria and Interventional Pain Management Techniques – Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR) were utilized. Results: A total of 16 items were developed which formed the IPM-QRBNR tool. The assessment was performed in multiple stages. The final assessment was 4 nonrandomized studies. The inter-rater agreement was moderate to good for IPM-QRBNR criteria. Limitations: Limited validity or accuracy assessment of the instrument and the large number of items to be scored were limitations. Conclusion: We have developed a new comprehensive instrument to assess the methodological quality of nonrandomized studies of interventional techniques. This instrument provides extensive information specific to interventional techniques is useful in assessing the methodological quality and bias of observational studies of interventional techniques. Key words: Methodological quality assessment, evidence-based medicine, comparative effectiveness research, Cochrane Reviews, interventional techniques, risk of bias assessment, nonrandomized trials, observational studies

scholarly journals Assessment of Methodologic Quality of Randomized Trials of Interventional Techniques: Development of an Interventional Pain Management Specific Instrument

2014 ◽  
Vol 3;17 (3;5) ◽  
pp. E263-E290 ◽  
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Pain Management ◽  
Methodological Quality ◽  
Randomized Trials ◽  
Cochrane Review ◽  
Bias Assessment ◽  
Interventional Techniques ◽  
Methodologic Quality ◽  
Interventional Pain Management ◽  
Review Criteria

Background: A major component of a systematic review is an assessment of the methodological quality and bias of randomized trials. The most commonly utilized methodological quality assessment and bias assessment for randomized trials is by the Cochrane Review Group. While this is not a “gold standard,” it is an indication of the current state-of-the-art review methodology. There is, however, no specific instrument to assess the methodological quality of manuscripts published for interventional techniques. Objectives: Our objective was to develop an instrument specifically for interventional pain management, to assess the methodological quality of randomized trials of interventional techniques. Methods: Item generation for the instrument was based on a definition of quality, to the extent to which the design and conduct of the trial were congruent with the objectives of the trial. Applicability was defined as the extent to which the trial produced procedures could be applied with contemporary interventional pain management techniques. Multiple items based on Cochrane review criteria were utilized along with specific requirements for interventional techniques. Results: A total of 22 items were developed which formed IPM-QRB or Interventional Pain Management Techniques – Quality Appraisal of Reliability and Risk of Bias Assessment tool. This included 9 of the 12 items from the Cochrane review criteria with deletion of some items that were repetitive or duplicate, and the addition of 13 new items. The results were compared for inter-rater reliability of Cochrane review criteria and IPM-QRB, and interinstrument reliability. The assessment was performed in multiple stages with an initial learning curve. The final assessment was for 4 randomized controlled trials (RCTs) utilizing both Cochrane review criteria and IPM-QRB criteria. The inter-rater agreement for Cochrane review criteria with overall intra-class correlation coefficient was 0.407 compared to an intra-class correlation coefficient of 0.833 for IPM-QRB criteria. The inter-rater agreement was superior for IPM-QRB criteria compared to Cochrane review criteria despite twice the items of Cochrane review criteria as IPM-QRB criteria with the detailed nature of assessment. Limitations: Limited validity or accuracy assessment of the instrument and the large number of items to be scored. Conclusion: We have developed a new comprehensive instrument to assess the methodological quality of randomized trials of interventional techniques. This instrument is superior to Cochrane review methodology criteria in that it provides more extensive and specific information for interventional techniques that will be useful in assessing the methodologic quality and bias of interventional techniques. Key words: Methodological quality assessment, evidence-based medicine, comparative effectiveness research, Cochrane Reviews, interventional techniques, risk of bias assessment

scholarly journals Reassessment of Evidence Synthesis of Occupational Medicine Practice Guidelines for Interventional Pain Management

2008 ◽  
Vol 4;11 (8;4) ◽  
pp. 393-482
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Chronic Pain ◽  
Pain Management ◽  
Strong Evidence ◽  
Guideline Development ◽  
Medial Branch ◽  
Low Back ◽  
Quality Of Evidence ◽  
Interventional Techniques ◽  
Interventional Pain Management

Background: Appropriately developed practice guidelines present statements of best practice based on a thorough evaluation of the evidence from published studies on the outcomes of treatments, which include the application of multiple methods for collecting and evaluating evidence for a wide range of clinical interventions and disciplines. However, the guidelines are neither infallible, nor a substitute for clinical judgment. While the guideline development process is a complex phenomenon, conflict of interest in guideline development and inappropriate methodologies must be avoided. It has been alleged that the guidelines by the American College of Occupational and Environmental Medicine (ACOEM) prevent injured workers from receiving the majority of medically necessary and appropriate interventional pain management services. An independent critical appraisal of both chapters of the ACOEM guidelines showed startling findings with a conclusion that these guidelines may not be applied in patient care as they scored below 30% in the majority of evaluations utilizing multiple standardized criteria. Objective: To reassess the evidence synthesis for the ACOEM guidelines for the low back pain and chronic pain chapters utilizing an expanded methodology, which includes the criteria included in the ACOEM guidelines with the addition of omitted literature and application of appropriate criteria. Methods: For reassessment, randomized trials were utilized as it was in the preparation of the guidelines. In this process, quality of evidence was assessed and recommendations were made based on grading recommendations of Guyatt et al. The level of evidence was determined utilizing the quality of evidence criteria developed by the U.S. Preventive Services Task Force (USPSTF), as well as the outdated quality of evidence criteria utilized by ACOEM in the guideline preparation. Methodologic quality of each individual article was assessed utilizing the Agency for Healthcare Research and Quality (AHRQ) methodologic assessment criteria for diagnostic interventions and Cochrane methodologic quality assessment criteria for therapeutic interventions. Results: The results of reassessment are vastly different from the conclusions derived by the ACOEM guidelines. The differences in strength of rating for the diagnosis of discogenic pain by provocation discography and facet joint pain by diagnostic facet joint nerve blocks is established with strong evidence. Therapeutic cervical and lumbar medial branch blocks and radiofrequency neurolysis, therapeutic thoracic medial branch blocks, cervical interlaminar epidural steroid injections, caudal epidural steroid injections, lumbar transforaminal epidural injections, percutaneous and endoscopic adhesiolysis, and spinal cord stimulation qualified for moderate to strong evidence. Additional insight is also provided for evidence rating for intradiscal electrothermal therapy (IDET), automated percutaneous disc decompression, and intrathecal implantables. Conclusion: The reassessment and reevaluation of the low back and chronic pain chapters of the ACOEM guidelines present results that are vastly different from the published and proposed guidelines. Contrary to ACOEM’s conclusions of insufficient evidence for most interventional techniques, the results illustrate moderate to strong evidence for most diagnostic and therapeutic interventional techniques. Key words: Guidelines, evidence-based medicine, systematic reviews, ACOEM, interventional pain management, interventional techniques, guideline development, workers’ compensation, chronic pain guidelines, low back pain guidelines

scholarly journals A Prospective Evaluation of Bleeding Risk of Interventional Techniques in Chronic Pain

2011 ◽  
Vol 4;14 (4;7) ◽  
pp. 317-329
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Pain Management ◽  
Adverse Events ◽  
Antithrombotic Therapy ◽  
Cardiovascular Events ◽  
Observational Studies ◽  
Antiplatelet Drug ◽  
Prospective Evaluation ◽  
Interventional Techniques ◽  
Local Bleeding ◽  
Interventional Pain Management

Background: The role of antithrombotic therapy is well known for primary and secondary prevention of cardiovascular disease to decrease the incidence of acute cerebral and cardiovascular events. Data shows that the risk of coronary thrombosis after antiplatelet drug withdrawal is much higher than that of surgical bleeding if the antiplatelet drug therapy were continued. However, it has been a common practice to discontinue antiplatelet therapy prior to performing interventional techniques, which may potentially increase the risk of acute cerebral and cardiovascular events. Study Design: A prospective study of 3,179 patients undergoing interventional techniques with 12,000 encounters and 18,472 procedures from May 2008 to December 2009. Study Setting: An interventional pain management practice, a specialty referral center, a private practice setting in the United States. Objective: To assess the rates of adverse events in patients undergoing interventional techniques on antithrombotic therapy with cessation or without cessation and compare them to a group of patients without antithrombotic therapy. Methods: Measurable outcomes employed were intravascular entry of the needle, bruising, local bleeding, profuse bleeding, local hematoma, oozing, and postoperative soreness. The prospective evaluation was performed utilizing the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement which was developed with recommendations to improve the quality of reporting observational studies. Results: The results of this study illustrated that in one-quarter (3,087) of patient encounters utilizing interventional pain management techniques, antithrombotic therapy was included. Among these, for approximately 55%, or 1,711 encounters, antithrombotic therapy was continued during the interventional techniques, whereas, for 45%, or 1376 encounters, antithrombotic therapy was discontinued. Overall, these results illustrate that while intravascular penetration and oozing were higher in patients with continued antithrombotic therapy, bruising and local bleeding were higher in patients with discontinued antithrombotic therapy without any difference either statistical or clinical in any of the other aspects, either intraoperative, post procedure in the recovery room, or postoperative period. Limitations: Limitations include the nonrandomized observational nature of the study and that antiplatelet therapy was limited to aspirin and clopidogrel (Plavix). Conclusion: No significant prevalence of adverse events was observed in those who continued with or ceased antithrombotic therapy. Key words: Interventional pain management, interventional techniques, bleeding disorders, hemorrhagic complications, aspirin, nonsteroidal anti-inflammatory agents, clopidogrel (Plavix), warfarin (Coumadin), regional anesthesia, hemostasis, anticoagulants, antithrombotic agents

scholarly journals Pain management programmes via video conferencing: a rapid review

2020 ◽  
Vol 0 (0) ◽  
Author(s):  
Jackie Walumbe ◽  
Joletta Belton ◽  
Diarmuid Denneny
Keyword(s):  
Pain Management ◽  
Methodological Quality ◽  
Peer Group ◽  
Video Conferencing ◽  
Mesh Term ◽  
Rapid Review ◽  
Future Research ◽  
Chronic Pain Conditions ◽  
Pain Services

AbstractObjectivesDuring the current COVID-19 pandemic, healthcare has been transformed by the rapid switch from in person care to use of remote consulting, including video conferencing technology. Whilst much has been published on one-to-one video consultations, little literature exists on use of this technology to facilitate group interventions. Group pain management programmes are a core treatment provided by many pain services. This rapid review aimed to identify the extent of use of video conferencing technology for delivery of group pain management programmes and provide an overview of its use.MethodsA rapid review of the literature published up to April 2020 (PubMed, PsycINFO and PEDro) was performed. The search string consisted of three domains: pain/CP (MeSH term) AND Peer group[MeSH] AND Videoconferencing[MeSH]/Telemedicine[MeSH]/Remote Consultation[MeSH]. The studies were of poor methodological quality and study design, and interventions and chronic pain conditions were varied.ResultsLiterature searching yielded three eligible papers for this review. All studies had low methodological quality and risk of bias. Heterogeneity and variability in outcome reporting did not allow any pooling of data. The results demonstrated that videoconferencing for delivery of group programmes is possible, yet there is little extant literature on how to develop, deliver and measure outcomes of such programmes.ConclusionsThis review demonstrates that there is little evidence to support or guide the use of synchronous videoconferencing to deliver pain management programmes. We present issues to consider, informed by this review and our experience, when implementing video conferencing. Study quality of existing work is variable, and extensive future research is necessary.

scholarly journals Review of Occupational Medicine Practice Guidelines for Interventional Pain Management and Potential Implications

2008 ◽  
Vol 3;11 (5;3) ◽  
pp. 271-289
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Pain Management ◽  
Workers Compensation ◽  
Nerve Blocks ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Interventional Pain Management ◽  
Epidural Steroid ◽  
The Cost ◽  
Based Medicine

In the modern day environment, workers’ compensation costs continue to be a challenge, with a need to balance costs, benefits, and quality of medical care. The cost of workers’ compensation care affects all stakeholders including workers, employers, providers, regulators, legislators, and insurers. Consequently, a continued commitment to quality, accessibility to care, and cost containment will help ensure that workers are afforded accessible, high quality, and cost-effective care. In 2004, workers’ compensation programs in all 50 states, the District of Columbia, and federal programs in the United States combined received an income of $87.4 billion while paying out only $56 billion in medical and cash benefits with $31.4 billion or 37% in administrative expenses and profit. Occupational diseases represented only 8% of the workers’ compensation claims and 29% of the cost. The American College of Occupational and Environmental Medicine (ACOEM) has published several guidelines; though widely adopted by WCPs, these guidelines evaluate the practice of medicine of multiple specialties without adequate expertise and expert input from the concerned specialties, including interventional pain management. An assessment of the ACOEM guidelines utilizing Appraisal of Guidelines for Research and Evaluation (AGREE) criteria, the criteria developed by the American Medical Association (AMA), the Institute of Medicine (IOM), and other significantly accepted criteria, consistently showed very low scores (< 30%) in most aspects of the these guidelines. The ACOEM recommendations do not appear to have been based on a careful review of the literature, overall quality of evidence, standard of care, or expert consensus. Based on the evaluation utilizing appropriate and current evidence-based medicine (EBM) principles, the evidence ratings for diagnostic techniques of lumbar discography; cervical, thoracic, and lumbar facet joint nerve blocks and sacroiliac joint nerve blocks; therapeutic cervical and lumbar medial branch blocks and radiofrequency neurolysis; cervical interlaminar epidural steroid injections, caudal epidural steroid injections, and lumbar transforaminal epidural injections; caudal percutaneous adhesiolysis; abd spinal cord stimulation were found to be moderate with strong recommendation applying for most patients in most circumstances. The evidence ratings for intradiscal electrothermal therapy (IDET), an automated percutaneous disc decompression and also deserve further scrutiny and analysis. In conclusion, these ACOEM guidelines for interventional pain management have no applicability in modern patient care due to lack of expertise by the developing organization (ACOEM), lack of utilization of appropriate and current EBM principles, and lack of significant involvement of experts in these techniques resulting in a lack of clinical relevance. Thus, they may result in reduced medical quality of care; may severely hinder access to appropriate, medically needed and essential medical care; and finally, they may increase costs for injured workers, third party payors, and the government by transferring the injured worker into a non-productive disability system. Key words: Guidelines, ACOEM, ASIPP, interventional pain management, interventional techniques, evidence-based medicine, systematic reviews, guideline development, AHCPR, AHRQ, IOM, AMA, AGREE, workers’ compensation, chronic pain guidelines, low back pain guidelines

Case Reports On The Multimodal Management of Refractory Chronic Oncological Pain of The Chest Wall: The Use of The Spinal Erector Plane Neurolysis

2021 ◽  
Author(s):  
John Cardenas ◽  
Juan Felipe Vargas-Silva ◽  
Alejandro Ramirez
Keyword(s):  
Pain Management ◽  
Chest Wall ◽  
Case Reports ◽  
Management Strategies ◽  
Erector Spinae ◽  
Opioid Rotation ◽  
Interventional Pain Management ◽  
Multimodal Management ◽  
Advanced Stage Cancer

Abstract Chronic pain of oncological origin is one of the most frequent complications and is difficult to control, that results in a decrease in the quality of life and disability among patients suffering from this pathology. Primary or metastatic tumors originating from lung, colonic, or breast neoplasms can invade the chest wall, causing progressive respiratory pain and symptoms that require multiple interventions to achieve adequate control. Many of these cases presenting with advanced-stage cancer are often incurable; thus, pain management and palliative care are primary objectives. Multimodal management is the strategy of choice in these cases through the participation of a multidisciplinary team. Analgesic therapy covers the use of potent opioids, opioid rotation, adjuvant analgesics, and interventional pain management strategies. We report two cases of chronic oncological pain of the chest wall refractory to pharmacological analgesic management. The optimization of multimodal management and the performance of neurolysis by phenolization of the erector spinae plane achieved an adequate response.

scholarly journals Quality Assurance for Interventional Pain Management Procedures in Private Practice

2008 ◽  
Vol 1;11 (1;1) ◽  
pp. 43-55
Author(s):  
YiLi Zhou
Keyword(s):  
Quality Assurance ◽  
Patient Satisfaction ◽  
Pain Management ◽  
Pain Relief ◽  
Private Practice ◽  
Complication Rates ◽  
Large Joint ◽  
Management Procedures ◽  
Interventional Pain Management

Background: A recent study has indicated that quality assurance for interventional pain management procedures (IPMPs) can be achieved in university pain clinics. However, the issue of quality assurance for IPMPs in private practice has not yet been addressed. Objective: This study was designed to monitor the quality of IPMPs in a private pain practice in north Florida. Methods: From November 2005 to July 2006, we monitored the quality of IPMPs in a private pain practice in north Florida. Questionnaires regarding degree of pain relief, patient satisfaction, and complications were handed to patients immediately after the completion of each IPMP. Follow-up phone calls were also made to patients 1 day after the IPMPs. Results: A total of 771 (male: 249, female: 522) patients with a mean age of 58.1 years participated in the study. Office-based IPMPs included lumbar and cervical epidural steroid injections, lumbar and cervical facet joint blocks, selective nerve root blocks, lumbar and cervical sympathetic nerve blocks, sacroiliac joint injection, and large joint injections. Seven-hundred patients (90.8%) reported various degrees of pain relief immediately following IPMPs. Average pain score decreased by 4.3 on a 0 to 10 scale (p=<0.001). Number needed to be treated (NNT) to reach 50% or more pain relief immediately after IPMPs was 1.4. Six-hundred ninety-two (89.7%) patients were satisfied or very satisfied with the results of IPMPs. sixty-two patients (8%) developed headaches after IPMPs, which lasted from 30 minutes to 4 days. None of these patients required a blood patch. Five patients developed moderate vasovagal responses during IPMPs, in which their heart rates decreased to <45/min, BP <90/60mmHg. The IPMPs were aborted immediately. All of these patients recovered uneventfully within a few minutes. No other serious adverse events were reported. Conclusions: The results of the current study suggest that high quality private interventional pain programs with high efficacy, high patient satisfaction, and low complication rates can be achieved through appropriate staff training, proper monitoring of patients during IPMPs, and adequate handling of patients after the IPMPs. Key words: Interventional pain management procedures, quality assurance, efficacy, patient satisfaction

scholarly journals Triaging Interventional Pain Procedures During COVID-19 or Related Elective Surgery Restrictions: Evidence-Informed Guidance from the American Society of Interventional Pain Physicians (ASIPP)

2020 ◽  
Vol 4S;23 (8;4S) ◽  
pp. E183-S204
Author(s):  
Christopher Gharibo
Keyword(s):  
Chronic Pain ◽  
Pain Management ◽  
Surgical Procedures ◽  
Task Force ◽  
Elective Surgery ◽  
Interventional Techniques ◽  
Elective Surgical Procedures ◽  
Chronic Pain Patients ◽  
Interventional Pain Management ◽  
Pain Patients

Background: The COVID-19 pandemic has worsened the pain and suffering of chronic pain patients due to stoppage of “elective” interventional pain management and office visits across the United States. The reopening of America and restarting of interventional techniques and elective surgical procedures has started. Unfortunately, with resurgence in some states, restrictions are once again being imposed. In addition, even during the Phase II and III of reopening, chronic pain patients and interventional pain physicians have faced difficulties because of the priority selection of elective surgical procedures. Chronic pain patients require high intensity care, specifically during a pandemic such as COVID-19. Consequently, it has become necessary to provide guidance for triaging interventional pain procedures, or related elective surgery restrictions during a pandemic. Objectives: The aim of these guidelines is to provide education and guidance for physicians, healthcare administrators, the public and patients during the COVID-19 pandemic. Our goal is to restore the opportunity to receive appropriate care for our patients who may benefit from interventional techniques. Methods: The American Society of Interventional Pain Physicians (ASIPP) has created the COVID-19 Task Force in order to provide guidance for triaging interventional pain procedures or related elective surgery restrictions to provide appropriate access to interventional pain management (IPM) procedures in par with other elective surgical procedures. In developing the guidance, trustworthy standards and appropriate disclosures of conflicts of interest were applied with a section of a panel of experts from various regions, specialties, types of practices (private practice, community hospital and academic institutes) and groups. The literature pertaining to all aspects of COVID-19, specifically related to epidemiology, risk factors, complications, morbidity and mortality, and literature related to risk mitigation and stratification was reviewed. The evidence -- informed with the incorporation of the best available research and practice knowledge was utilized, instead of a simplified evidence-based approach. Consequently, these guidelines are considered evidence-informed with the incorporation of the best available research and practice knowledge. Results: The Task Force defined the medical urgency of a case and developed an IPM acuity scale for elective IPM procedures with 3 tiers. These included emergent, urgent, and elective procedures. Examples of emergent and urgent procedures included new onset or exacerbation of complex regional pain syndrome (CRPS), acute trauma or acute exacerbation of degenerative or neurological disease resulting in impaired mobility and inability to perform activities of daily living. Examples include painful rib fractures affecting oxygenation and post-dural puncture headaches limiting the ability to sit upright, stand and walk. In addition, urgent procedures include procedures to treat any severe or debilitating disease that prevents the patient from carrying out activities of daily living. Elective procedures were considered as any condition that is stable and can be safely managed with alternatives. Limitations: COVID-19 continues to be an ongoing pandemic. When these recommendations were developed, different stages of reopening based on geographical regulations were in process. The pandemic continues to be dynamic creating every changing evidence-based guidance. Consequently, we provided evidence-informed guidance. Conclusion: The COVID-19 pandemic has created unprecedented challenges in IPM creating needless suffering for pain patients. Many IPM procedures cannot be indefinitely postponed without adverse consequences. Chronic pain exacerbations are associated with marked functional declines and risks with alternative treatment modalities. They must be treated with the concern that they deserve. Clinicians must assess patients, local healthcare resources, and weigh the risks and benefits of a procedure against the risks of suffering from disabling pain and exposure to the COVID-19 virus. Key words: Coronavirus, COVID-19, interventional pain management, COVID risk factors, elective surgeries, interventional techniques, chronic pain, immunosuppression

scholarly journals Ambulatory Surgery Centers and Interventional Techniques: A Look at Long-Term Survival

2011 ◽  
Vol 3;14 (2;3) ◽  
pp. E177-E212 ◽  
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Health Care ◽  
Pain Management ◽  
Ambulatory Surgery ◽  
Health Care Expenditures ◽  
The United States ◽  
Payment System ◽  
Ambulatory Surgery Centers ◽  
Interventional Techniques ◽  
Outpatient Procedures ◽  
Interventional Pain Management

With health care expenditures skyrocketing, coupled with pervasive quality deficits, pressures to provide better and more proficient care continue to shape the landscape of the U.S. health care system. Payers, both federal and private, have laid out several initiatives designed to curtail costs, including value-based reimbursement programs, cost-shifting expenses to the consumer, reducing reimbursements for physicians, steering health care to more efficient settings, and finally affordable health care reform. Consequently, one of the major aspects in the expansion of health care for improving quality and reducing costs is surgical services. Nearly 57 million outpatient procedures are performed annually in the United States, 14 million of which occur in elderly patients. Increasing use of these minor, yet common, procedures contributes to rising health care expenditures. Once exclusive within hospitals, more and more outpatient procedures are being performed in freestanding ambulatory surgery centers (ASCs), physician offices, visits to which have increased over 300% during the past decade. Concurrent with this growing demand, the number of ASCs has more than doubled since the 1990s, with more than 5,000 facilities currently in operation nationwide. Further, total surgical center ASC payments have increased from $1.2 billion in 1999 to $3.2 billion in 2009, a 167% increase. On the same lines, growth and expenditures for hospital outpatient department (HOPD) services and office procedures also have been evident at similar levels. Recent surveys have illustrated on overall annual growth per capita in Medicare allowed ASC services of pain management of 23%, with 27% growth seen in ASCs and 16% of the growth seen in HOPD. Further, the proportion of interventional pain management which was 4% of Medicare ASC spending in 2000 has increased to 10% in 2007. Thus, interventional pain management as an evolving specialty is one of the most commonly performed procedures in ASC settings apart from HOPDs and well-equipped offices. In June 1998, the Health Care Financing Administration (HCFA) proposed an ASC rule in which at least 60% of interventional procedures were eliminated from ASCs, and the remaining 40% faced substantial cuts in payments. Following the publication of this rule, based on public comments and demand, Congress intervened and delayed implementation of the rule for several years. The Centers for Medicare and Medicaid Services (CMS) published its proposed outpatient prospective system for ASCs in 2006, setting ASC payments at 62% of HOPD payments. Following multiple changes, the rule was incorporated with a 4-year transition formula which ended in 2010, with full effect occurring in 2011 with ASCs reimbursed at 57% of HOPD payments. Thus, the landscape of interventional pain management in ambulatory surgery centers has been constantly changing with declining reimbursements, issues of fraud and abuse, and ever-increasing regulations. Key words: Outpatient prospective payment system, ambulatory surgery center payment system, Government Accountability Office, Medicare Modernization and Improvement Act, interventional techniques

scholarly journals Analysis of Growth of Interventional Techniques in Managing Chronic Pain in the Medicare Population: A 10-Year Evaluation from 1997 to 2006

2009 ◽  
Vol 1;12 (1;1) ◽  
pp. 9-34 ◽  
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Chronic Pain ◽  
Pain Management ◽  
Ambulatory Surgery ◽  
Facet Joint ◽  
Medicare Beneficiaries ◽  
Interventional Techniques ◽  
Ambulatory Surgery Center ◽  
Interventional Pain Management ◽  
Joint Injections ◽  
Surgery Center

Background: Recent reports of the United States Government Accountability Office (GAO), the Medicare Payment Advisory Commission (MedPAC), and the Office of Inspector General (OIG) expressed significant concern with overall fiscal sustainability of Medicare and exponential increase in costs for interventional pain management techniques. Interventional pain management (IPM) is an evolving specialty amenable to multiple influences. Evaluation and isolation of appropriate factors for increasing growth patterns have not been performed. Study Design: Analysis of the growth of interventional techniques in managing chronic pain in Medicare beneficiaries from 1997 to 2006. Objective: To evaluate the use of all interventional techniques. Methods: The standard 5% national sample of the CMS carrier claim record data for 1997, 2002, and 2006 was utilized. This data set provides information on Medicare enrollees in the feefor-service Medicare program. Current procedural technology (CPT) codes for 1997, 2002, and 2006 were used to identify the number of procedures performed each year, and trends in expenditures. Results: Interventional techniques increased significantly in Medicare beneficiaries from 1997 to 2006. Overall, there was an increase of 137% in patients utilizing IPM services with an increase of 197% in IPM services, per 100,000 Medicare beneficiaries. The majority of the increases were attributed to exponential growth in the performance of facet joint interventions. There was a 13.9-fold difference in the increase between the state with the lowest rate and the state with the highest rate in utilization patterns of interventional techniques (California 37% vs. Connecticut 514%), with an 11.6-fold difference between Florida and California (431% vs. 37% increase). In 2006, Florida showed a 12.7-fold difference compared to Hawaii with the lowest utilization rate. Hospital outpatient department (HOPD) expenses constituted the highest increase with fewer patients treated either in an ambulatory surgery center (ASC) or in-office setting. Overall HOPD payments constituted 5% of total 2006 Medicare payments, in contrast to 57% of total IPM payments, an 11.4-fold difference. Limitations: The limitations of this study include a lack of inclusion of Medicare participants in Medicare Advantage plans and potential documentation, coding, and billing errors. Conclusion: This study shows an overall increase of IPM services of 197% compared to an increase of 137% in patients utilizing IPM services from 1997 to 2006. Key words: Interventional techniques, interventional pain management, facet joint injections, epidural steroid injections, sacroiliac joint injections, chronic pain, chronic spinal pain, ambulatory surgery center (ASC), hospital outpatient department (HOPD)

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