Introduction: Using health-related goals to direct care could improve quality and reduce cost of medical care; however, the effect of these goals for patients with spinal pathologies is not well understood. The purpose of this study was to describe patient-reported goals by provider type and to evaluate the effect of patient-provider goal awareness on patient satisfaction and treatment pathway. Methods: A pilot program was instituted in which all new or existing patients scheduled with either a single spine surgeon or a nonsurgical spine nurse practitioner were asked to complete a paper survey instrument regarding their goals of care before their visit. The patient goals were then discussed between the provider and the patient. Univariate and multivariate analyses were performed to evaluate relationships between patient goals, provider seen, diagnosis, and treatment recommendations. Results: There were 703 respondents to the survey, of whom 416 were included for subgroup analysis. Patient-reported goals varied by provider type. When examining rates of recommended interventions by patient goals, notable differences were observed for 7 of the 13 goal categories. Significant differences in intervention recommendations by provider type existed for physical therapy, medications, MRI, and surgery (all P < 0.001). After controlling for other variables, seeing a surgeon, thoracolumbar pathology, and goals of “return to activity or social events I enjoy,” and “learn about spine surgery” were significant independent predictors of recommendation for surgery (all odds ratio > 3 and P < 0.05). This model generated an area under the curve of 0.923 (95% confidence interval, 0.861 to 0.986), indicating outstanding discrimination in predicting recommendation for surgery. Patient satisfaction scores rose from 91.5% to 92.2%, but this difference was not statistically significant (P = 0.782). Conclusion: Specific patient-reported goals vary by provider type and are associated with specific diagnosis and treatment recommendations. Goal-directed care may improve the design of treatment pathways and the overall patient experience.

INTRODUCTION: As the scope of the opioid-addiction epidemic increases, so does the need for supportive providers and for comprehensive interventions to best manage a patient’s addiction. Treating pain following cesarean section necessitates such an intervention as hyperalgesia and increased tolerance have been well established in patients treated with methadone and buprenorphine. METHODS: A quality improvement project was conducted to guide postoperative pain control for patients on medication assisted treatment (MAT) through the University of Massachusetts Medical School’s Green Clinic for Addiction and Recovery. Providers were instructed to administer a regimen of increased post-operative opiate pain medication for an initial cohort of Green clinic patients scheduled to undergo a primary or repeat cesarean section. A retrospective chart review was then conducted, collecting pain scores and quantity of opiate pain medication given from the time of delivery to 72 hours post-operative. Adherence to the protocol was determined by type and quantity of pain medication received. RESULTS: Of 16 Green clinic patients to receive the protocol, only 41% of patients received the treatment protocol and the remaining 59% received standard post-operative orders. There was no significant difference in pain scores between groups receiving the treatment protocol vs. those receiving standard postoperative orders. CONCLUSION: Failure to follow the protocol for patients on MAT indicates the need for more effective systems-based implementation protocols but also the need for concurrent education of healthcare workers involved in the care of patients with addiction, as stigma and knowledge gaps cannot be excluded as factors contributing to failure to follow the protocol.

OBJECTIVE:The American Heart Association recently endorsed guidelines that lower the diagnostic criteria for chronic hypertension outside of pregnancy to 130/80 mm Hg. We investigated the relationship between blood pressure (BP) during the first half of pregnancy and maternal-fetal outcomes. We hypothesized that using the same lower diagnostic threshold of BP 130/80 mm Hg prior to 20 weeks gestation would identify women at increased risk for adverse maternal and fetal outcomes compared with normotensive controls. STUDY DESIGN: We conducted a retrospective cohort study of women with singleton pregnancies who received prenatal care and delivered at a single tertiary care center from 2010-2017. Women were categorized into three distinct groups based on their BP status. Group 1: Women with chronic hypertension based on current ACOG guidelines (existing diagnosis of chronic hypertension or BP 140/90 mm Hg prior to 20 weeks gestation). Group 2: Women with no prepregnancy diagnosis of hypertension, but with systolic BP 130 mm Hg or diastolic BP 80 mm Hg on two occasions prior to 20 weeks gestation. Group 3: Normotensive controls. Maternal and fetal outcomes were collected and compared between groups. The primary outcome was development of preeclampsia. One-way ANOVA was used to compare groups for continuous outcomes and logistic regression analyses were used to compare groups for categorical outcomes. RESULTS: Of the 3,761 women that met criteria for study entry, 134 were found to have chronic hypertension based on current guidelines (group 1), 327 had BP 130/80 mm Hg prior to 20 weeks gestation (group 2), and 3300 were normotensive controls (group 3). Women in groups 1 and 2 had similar demographic characteristics. (Table 1). They were more likely to be older, have a higher prepregnancy BMI, and have pregestational diabetes. 25.4% of women in group 1 and 15% of women in group 2 developed preeclampsia as compared to 4.8% of controls (p<0.001). Women in group 2 were also more likely to develop gestational hypertension, gestational diabetes, deliver preterm, and undergo cesarean delivery than were controls. (Table 2). CONCLUSION: Women with BP 130/80 mm Hg prior to 20 weeks gestation are at increased risk for developing hypertensive disorders of pregnancy. Additional analyses will clarify if blood pressure prior to 20 weeks gestation is an independent predictor of preeclampsia.

INTRODUCTION: Literature reports women with hypertensive disorders of pregnancy are at threefold increased risk of having hypertension and twofold increased risk of developing cardiovascular disease later in life. We sought to identify characteristics associated with hypertension in the 12 weeks to 24 months postpartum period. METHODS: We performed an IRB approved, retrospective cohort study on postpartum hypertension from deliveries from 07/09 to 07/16. Inclusion criteria were delivery at our institution, presence of a hypertensive disorder of pregnancy, and a documented blood pressure between 12 weeks to 24 months postpartum. Exclusion criteria were discharge home on antihypertensive medication. Postpartum hypertension was defined as a systolic blood pressure ≥-140 or diastolic blood pressure ≥90. Chi-square test was used for categorical and Student T-test was used for continuous variables. RESULTS: 697 women met inclusion and exclusion criteria. Of these women, 245 were identified as having hypertension 12 weeks to 24 months postpartum. Women with hypertension were more likely to be older (p=0.046), have a higher pre-pregnancy BMI (p<0.001), and be multiparous (p=0.002). There was a statistically significant difference in hypertension when comparing the hypertensive disorders of pregnancy (p<0.001). There were no differences amongst other study variables. CONCLUSION: Of the women who delivered at our institution with a hypertensive disorder of pregnancy, 35% had hypertension in the 12 weeks to 24 months postpartum period. Characteristics more likely associated with postpartum hypertension include older age, higher pre-pregnancy BMI, and multiparity. These characteristics may be important to consider when counseling patients on the importance of continued follow up beyond the fourth trimester.