Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

For patients undergoing total knee replacement surgical procedures, what is the comparative effectiveness of a continuous peripheral nerve block versus intravenous or oral drug therapy to treat postoperative pain and improve recovery outcomes such as early mobilization and hospital length of stay.

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

Continuous peripheral nerve block: involves placement of an infusion catheter and an ambulatory infusion pump filled with local anesthetic, versus IV or oral drug therapy for control of postoperative pain.

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

All patients undergoing total knee replacement surgery.

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

None specifically

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

Decreased need for opioid pain management Decreased opioid related side effects Early mobilization Increased ability to effectively participate in physical therapy Decreased length of hospital stay

Describe any health-related risks, side effects, or harms that you are concerned about.

Continuous peripheral nerve block may cause:

• Excessive motor block creating a risk of falls or sustained immobility,
• Toxicity effects from the local anesthetics,
• Bleeding at the catheter placement site due to vascular puncture,
• Infection at catheter placement site,
• Malfunction of infusion device Drug therapy may cause nausea, vomiting, oversedation, confusion, urinary retention, itching, toxicity related to overdose

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Arthritis and nontraumatic joint disorders

AHRQ Priority Populations

• Low income groups
• Minority groups
• Women
• Children
• Elderly

Federal Health Care Program

• Medicaid
• Medicare

Importance

Describe why this topic is important.

Current opioid based therapies for postoperative pain management following total knee replacement surgery are associated with extended hospital lengths of stay and preventing early physical therapy due to the side effects of these drugs (i.e. over sedation, nausea, vomiting) . The utilization of a continuous peripheral nerve block for postoperative pain management may decrease opioid use, decrease hospital length of stay, improve pain management and patient outcomes following total knee replacement surgical procedures. These improvements in recovery variables will lead to economic savings and the ability of institutions to increase the throughput of patients requiring these procedures.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

Current research in the safety and efficacy of a continuous peripheral nerve block approach for postoperative pain management after total knee replacement has illustrated the efficacy and safety of this therapy. However, its use is not widely adopted due to concerns about risks and costs. Larger scale studies are needed to further support its safety, efficacy, and effect on the greater economic needs of the healthcare system.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

Clinicians currently rely on opioid based management of pain either by intravenous patient controlled analgesia (PCA) or oral routes. This schema leads to longer lengths of hospital stay and delayed physical therapy due to the side effects of these drugs. Providing continuous peripheral nerve block techniques may improve outcomes following these procedures and provide a means for improvement in economic results for institutions providing care.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

The answer to the research questions will be used to standardize treatment protocols for pain management following total joint replacement surgeries.

Describe the timeframe in which an answer to your question is needed.

The answer to this is needed in the next 18-24 months

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

The improvement in recovery outcomes is important to all vulnerable populations highlighted in section 7. Low income: reducing the costs of total knee replacement surgery through improved pain management will make it more available to this population. Elderly: Opioids are especially detrimental in this population and have a negative effect on their overall recovery. This will allow for earlier mobilization which can decrease the risks of pneumonia, and DVTs. It may reduce the incidence of postoperative delirium and potential for emotional or physical distress. Children: The use of opioids in this population is associated with many risks, most importantly oversedation, inability to undergo physical therapy and the risk of overdosage.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

The answer to the research questions will be used to standardize treatment protocols for pain management following total joint replacement surgeries.

Are you making a suggestion as an individual or on behalf of an organization?

Organization

Please tell us how you heard about the Effective Health Care Program