Controversies on the effectiveness of spinal cord stimulation continue. Recently Drs. Manchikanti, Sanapati, and Hirsch wrote a response to the JAMA article (Response), JAMA Randomized Controlled Trial Comparing Spinal Cord Burst Stimulation Versus Placebo Stimulation with Lack of Effectiveness (Full Article).
Drs. Manchikanti, Sanapati, and Hirsch describe multiple issues that limit the generalizability of this randomized clinical trial, specifically in the United States.
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Recently, Dhruva et al published an article on Long-Term Outcomes in Use of Opioids, Nonpharmacologic Pain Interventions, and Total Costs of Spinal Cord Stimulators Compared with Conventional Medical Therapy for Chronic Pain, showing no difference (click here to read the full article).
In response Drs. Manchikanti, Sanapati, and Hirsch sent a Letter to the Editor pointing out various issues related to this study and potential reasons (click here to read the letter).
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The Office of Inspector General for the United States Department of Health and Human Services has conducted yet another audit on facet joint interventions, this is the third audit. There have been extensive audits from UPICs, SMRC, Nordian, and RAC, and MAC contractors.
In this study (click here to read), OIG looked at 120 sample sessions, with only 54 complying with Medicare requirements.
The overall estimated overpayments appear to be $29.6 million for facet joint interventions for an audit period of August 1 through October 31, 2021, with new LCDs in effect.
Obviously, there will be even more audits and there will be recoupment from multiple providers on these claims.
It is crucial that we follow appropriate algorithmic approach and utilize checklists to avoid such issues.
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A look at the data, particularly for high-risk groups
It's been close to 6 months since the initial rollout of the fall (bivalent) booster. A lot of people are wondering: Do I need a spring booster?
The answer hinges on more questions: What is the purpose of vaccines? Does that purpose change depending on age or health status?
The Purpose of the COVID Vaccines
Last month, the FDA and CDC made it clear that the primary purpose of vaccines is to prevent severe disease and death. Decreases in infection and transmission are a bonus at this point, and unfortunately, protection against infection is only temporary.
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The prevalence of medical cannabis use in the United States has increased significantly from 2013 to 2020, according to study results published in the American Journal of Preventive Medicine.
Taeho Greg Rhee, PhD, FACE, an assistant professor of medicine and public health at Yale University, and Robert A. Rosenheck, MD, a professor of psychiatry and of health policy and affiliated faculty at the Yale Institute for Global Health, wrote that medical cannabis has been legalized in 37 states in the United States as well as the District of Columbia.
The researchers conducted a study to evaluate correlates and temporal trends of medical cannabis use in the U.S. They used data from the 2013 to 2020 National Survey on Drug Use and Health (NSDUH), which includes a question asking those who had used cannabis in the past 12 months whether any cannabis use was recommended by a physician. They then used a modified Poisson model to approximate the average annual percent change (AAPC) of medical cannabis use from 2013 to 2020 and repeated the analyses for key sociodemographic and clinical subgroups.
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Lumbar Endoscopic Spinal Decompression: |
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Peripheral Nerve Stimulation: |
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Interventional Techniques in IPM: |
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Republicans slam increased Title X funding, question funding of transgender surgery
Republicans and Democrats on the House Appropriations Committee sparred on Tuesday over provisions in President Biden's budget request for the Department of Health and Human Services (HHS).
Committee chair Robert Aderholt (R-Ala.) said he found it "disappointing" that the proposed budget "continues to double down on out-of-control government spending, which only adds to our already high inflation rate."
The fiscal year (FY) 2024 budget, which requests $1.7 trillion in mandatory funding for the agency and $144 billion in discretionary funding (about $17 billion over the 2023 budget), funnels money into "partisan priorities," such as NIH's Sexual & Gender Minority Research Office, he told HHS Secretary Xavier Becerra during the hearing.
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ASIPP has been actively addressing recent coverage issues through letter correspondence to various agencies. The issues and letters include the following:
AIM published new guidelines effective 04/09/2023. Owned by Anthem, Inc (ANTM), the AIM guidelines are utilized by multiple insurers. ASIPP has addressed the guidelines with a comment letter on the guidelines for Appropriate Use Criteria: Interventional Pain Management. Our comments were related to paravertebral facet joint injection/medial branch nerve block/neurolysis/therapeutic facet joint interventions.
We are requesting LCD reconsideration requests to all of the Medicare Contractors for the LCD covering Facet Joint Interventions for Pain Management.
ASIPP immediate past president, Amol Soin, sent a letter to Cigna on February 7 addressing their Medical Policy Update on Peripheral Nerve Block Procedures (for trigeminal and occipital neuralgia) which considering them experimental, investigational, or unproven, with an efficacy date of April 18th, 2023. In the letter, we ask that the policy update restricting the use of peripheral nerve blocks be re-evaluated and modified. We recommended that these procedures continue to be covered and we find the characterization of these procedures to be experimental or investigational to be inaccurate.
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ABIPP Part I; ABIPP Path - Combined DCCPM/CSM virtual exam; ABIPP Competency Exam in IPM; ABIPP Competency Exam in Regenerative Medicine
ABIPP Part II; ABIPP Competency Exam - Practical Portion; ABIPP Regenerative Medicine Competency Exam - Practical Portion
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For more than a decade, the medical community as a whole, and particularly the field of rheumatology, has been trying to move away from opioids for the management of chronic pain — with varying degrees of success.
However, for a growing number of medical experts — in rheumatology and elsewhere — a completely new paradigm and understanding of pain, and its management, is needed. According to these sources, this new understanding should focus on and accept the reality that many patients with chronic pain are already facing — that living pain-free is an unrealistic goal that only serves to further their despair when it is not achieved.
“In the United States, we have this notion that we have this God-given right to be pain-free,” Michael E. Schatman, PhD, CPE, a clinical instructor at the New York University Grossman School of Medicine’s Department of Anesthesiology, Perioperative Care and Pain Medicine, and editor-in-chief of the Journal of Pain Research, told Healio Rheumatology. “But that is clearly an unrealistic goal, particularly for patients with chronic conditions.”
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Despite decades of research, there's still considerable uncertainty about the comparative effectiveness and safety of analgesics for the treatment of acute low back pain, new research shows.
Higher-quality randomized controlled trials of head-to-head comparisons are needed, study investigator Michael A. Wewege, PhD candidate, research fellow, University of New South Wales and Neuroscience Research Australia, Sydney, told Medscape Medical News.
"Until then, doctors should use caution when prescribing analgesic medicines for adults with nonspecific acute low back pain. They should use this new evidence in line with their own expertise and the patient sitting in front of them when making any decision about a medication," he added.
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- ASIPP Members Only Site Information - |
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To log in for the first time you will need to click “forgot password” at the bottom of the login window.
- Check your email and then log in as directed.
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If you have problems logging into your account, click here.
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Alternative anthropometrics, such as waist-to-height ratio, may better predict HF hospitalization and CV death in patients with HF with reduced ejection fraction and overweight compared with BMI alone, researchers reported.
These findings may question the validity of the “obesity paradox” of reduced mortality among patients with HF who are overweight compared with normal weight, according to a study published in the European Heart Journal.
“Although obesity has been repeatedly shown to be an independent risk factor for the development of HF, its prognostic importance in established HF, especially HFrEF, is less clear and an ‘obesity-survival paradox’ has been described in patients with HFrEF,” Jawad H. Butt, MD, research fellow in the department of cardiology at Rigshospitalet at Copenhagen University Hospital in Denmark, and colleagues wrote. “However, the associations between obesity and outcomes in HFrEF have generally been based on BMI ... which has many limitations as a measure of adiposity. BMI does not take into account the location of body fat or its amount, relative to muscle, or the weight of the skeleton, which may differ according to sex, age and race.”
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Pain Medicine Case Reports (PMCR) and Editor-in-Chief Alaa Abd-Elsayed, MD, PhD would like to invite you to submit case reports and case series to the PMCR journal. Your article will be published free of charge.
Open access journals are freely available online for immediate worldwide open access to the full text of published articles. There is no subscription fee for open access journals. Open access journals are no different from traditional subscription-based journals: they undergo the same peer-review and quality control as any other scholarly journal.
Interested in becoming a member of the PMCR Editorial Board?
Editorial board members are asked to review 2-6 manuscripts per year. Please submit your most up-to-date CV to sgold@asipp.org for consideration.
For more information or to submit your articles, click here.
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| CASE REPORT |
George Soliman, MD, Nathan Pham, MD, and Casey Pas, MD
Abstract
BACKGROUND: The axillary nerve is one of the most common peripheral nerve of the shoulder to be injured. If a patient does not desire invasive surgical intervention, then other options, such as neurostimulation, should be explored. Until recently, there were no specific devices for peripheral nerve stimulation (PNS), and the hardware for spinal cord stimulation was used, but these systems were powered by an implantable battery, which can be difficult to use for PNS. Externally powered systems are the ideal technology to target peripheral nerves.
CASE REPORT: A 67-year-old man presented with chronic right shoulder pain after multiple surgeries following a fracture. It was determined that the patient would not likely benefit from any further surgical interventions, and thus the patient was referred to pain management for further evaluation. The decision was made to trial the patient for PNS of the right axillary nerve.
RESULTS: The patient reported drastically reduced pain (pain reduction of approximately 90% at 6-month follow-up). Activities of daily living, quality of life, sleep, and range of motion were also all improved at 6 months after the permanent implant procedure.
CONCLUSIONS: Subthreshold, externally powered PNS at the axillary nerve was a successful choice for a patient suffering from chronic shoulder pain after multiple surgical interventions.
KEY WORDS: Peripheral nerve stimulation, shoulder pain, axillary nerve, externally powered stimulation
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| PROSPECTIVE STUDY |
Jing Zheng, MD, Ting Shen, MD, Xiao-Hu An, MD, Yong Bian, MD, Ying Shen, MSN, Zifeng Xu, MD, and Tao Xu, MD
Abstract
BACKGROUND: The standard solutions for epidural labor analgesia include both local anesthetics and opioids. The concept of the standard epidural use of local anesthetics in labor analgesia has shifted from high concentrations to high volumes with low concentrations. However, the optimal dosage of opioids needed to initiate and maintain epidural labor analgesia in different phases during the first labor stage has rarely been studied.
OBJECTIVE: The present study aimed to determine the optimal sufentanil dose for epidural initiation in the latent and active phases during the first stage of labor.
STUDY DESIGN: A prospective, double-blind, sequential dose-finding study.
SETTING: A Class A tertiary obstetrics and gynecology hospital.
METHODS: The study included 80 nulliparae with cervical dilatation of 2-4 cm and 5-6 cm, with 40 nulliparae in each group. A research dose of sufentanil combined with ropivacaine 13 mg in epidural initiation with a volume of 15 mL was administered to the puerperant. A 1-microgram sufentanil dose and a 2.5-micrograms sufentanil dose were used for the first puerperant of each group. The dose of sufentanil for the subsequent puerperant was determined by the response of the previous puerperant according to the biased coin up-and-down design in each trial. The primary outcome was a visual analog scale score of <= 3 at 15, 30, and 45 minutes after epidural administration, including the given dose of sufentanil. According to the response of each puerperant, the 90% effective doses and their 95% confidence intervals were estimated by isotonic regression and bootstrapping according to the response of each puerperant.
RESULTS: The 90% effective doses of sufentanil for puerperants were 1.91 micrograms (95% confidence intervals 1.82-2.35 micrograms) and 4.90 micrograms (95% confidence intervals 4.82-5.35 micrograms) in epidural initiation in the latent and active phases, respectively. The 90% effective doses were 62.5% (95% confidence intervals 50.8-64.0%) lower in the latent phase than that in the active phase during the first stage of labor.
LIMITATIONS: Both spontaneous labor and induced labor were included in this study, and the degree of pain in these 2 types of labor is different. Further, only nulliparae were recruited in the study.
CONCLUSIONS: Different sufentanil doses should be adopted in epidural initiation in different phases during the first stage of labor due to the large differences in the demand for sufentanil.
KEY WORDS: Sufentanil, 90% effective dose, epidural initiation, labor analgesia, active phase, latent phase, first labor stage
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| SYSTEMATIC REVIEW |
Sang Gyu Kwak, PhD, Yoo Jin Choo, MD, Soyoung Kwak, MD, and Min Cheol Chang, MD
Abstract
BACKGROUND: Epidural injection (EI) has been used to manage lower back and radicular leg pain caused by a herniated lumbar disc. There are 3 types of EI techniques currently being used: transforaminal (TFEI), interlaminar (ILEI), and caudal epidural injections (CEI).
OBJECTIVES: To evaluate the comparative effectiveness of TFEI, ILEI, and CEI in reducing pain and improving function in patients with HLD.
STUDY DESIGN: Systematic review and meta-analysis.
METHODS: The PubMed, Embase, Cochrane Library, and Scopus databases were searched from the earliest records up to August 2022 for randomized controlled trials (RCTs) and non-RCTs. The standard mean differences (SMDs) in the changes in the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) scores were calculated from one week through one month posttreatment (short-term) and from 4 months through 6 months posttreatment (long-term).
RESULTS: In total, 11 studies comprising 1,050 patients were included. Network meta-analysis showed that the improvement in the VAS scores was better with TFEI than with CEI (SMD = -1.16, 95% CI = -2.10 to -0.23). Ranking probability analysis showed that TFEI had the highest probability of being the best treatment for reducing pain and improving function in the short- and long-term evaluation periods.
LIMITATIONS: Only a small number of previous studies were included in our analysis. Also, subgroup analysis according to the injection volume, material type, or pain onset could not be conducted.
CONCLUSIONS: TFEI had the best potential of the 3 EI techniques to reduce pain and improve function in patients with a herniated lumbar disc. Further qualified trials comparing the effects of these 3 techniques are warranted to derive definitive conclusions.
KEY WORDS: Disc herniation, back pain, radicular pain, epidural injection, transforaminal injection, interlaminar injection, caudal injection, lumbar spine
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ASIPP is now in collaboration with Curi Medical Liability Program
Since this malpractice insurance program officially launched in November 2018, ASIPP has signed up hundreds of providers with an average savings of 30%. This is professional liability insurance tailored to our specialty and will stand up for us and defend our practices.
Curi is a full-service advisory firm that serves physicians and their practices. Their valued advice is grounded in your priorities and elevated in your outcomes. They are driven by a deep understanding of your specific circumstances in medicine, business, and life. To read a few important points to keep in mind about the program, including discounts, administrative defense, cyber coverage, aggressive claims handling, and complimentary risk management CME activities, visit our website.
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ASIPP® has formed a partnership with Henry Schein and PedsPal, a national GPO that has a successful history of negotiating better prices on medical supplies and creating value-added services for independent physicians. Working with MedAssets, PedsPal provides excellent pricing on products like contrast media that alleviate some of the financial pressures you experience today.
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ASIPP® is now offering our members the benefit of a unique revenue cycle management/ billing service.
We have received a tremendous amount of interest in the ASIPP® billing and coding program.
Click here to learn more about the negotiated rate for practices and more!
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up-to-date news related to you, your practice, and your patients!
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