Browsing by Author "Kozak, Mary Ann"

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    Effect of introducing the mucosal atomization device for fentanyl use in out-of-hospital pediatric trauma patients
    (Cambridge Journals, 2013-10) O'Donnell, Daniel; Schafer, Luke; Stevens, Andrew; Weinstein, Elizabeth; Miramonti, Charles; Kozak, Mary Ann
    Background: Pain associated with pediatric trauma is often under-assessed and undertreated in the out-of-hospital setting. Administering an opioid such as fentanyl via the intranasal route is a safe and efficacious alternative to traditional routes of analgesic delivery and could potentially improve pain management in pediatric trauma patients. Objective: The study sought to examine the effect of introducing the mucosal atomization device (MAD) on analgesia administration as an alternative to intravenous fentanyl delivery in pediatric trauma patients. The hypothesis for the study is that the introduction of the MAD would increase the administration of fentanyl in pediatric trauma patients. Methods: The research utilized a 2-group design (pre-MAD and post-MAD) to study 946 pediatric trauma patients (age ,16) transported by a large, urban EMS agency to one of eight hospitals in Marion County, which is located in Indianapolis Indiana. Two emergency medicine physicians independently determined whether the patient met criteria for pain medication receipt and a third reviewer resolved any disagreements. A comparison of the rates of fentanyl administration in both groups was then conducted. Results: There was no statistically significant difference in the rate of fentanyl administration between the pre-MAD (30.4%) and post-MAD groups (37.8%) (P5.238). A subgroup analysis showed that age and mechanism of injury were stronger predictors of fentanyl administration. Conclusion: Contrary to the hypothesis, the addition of the MAD device did not increase fentanyl administration rates in pediatric trauma patients. Future research is needed to address the barriers to analgesia administration in pediatric trauma patients.
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    Opioid Use as a Predictor of Health Care Use and Pain Outcomes: Analysis of Clinical Trial Data
    (Oxford, 2016-07) Krebs, Erin E.; Kroenke, Kurt; Wu, Jingwei; Bair, Matthew J.; Kozak, Mary Ann; Yu, Zhangsheng; Medicine, School of Medicine
    Objective . To examine effects of pre-enrollment opioid use on outcomes of a 12-month collaborative pain care management trial. We hypothesized that participants with opioid use would have worse pain at baseline; use more health care services and analgesics; and have worse pain outcomes during the trial. Design . Secondary analysis of randomized controlled trial data. Setting . Veterans Affairs (VA) primary care. Subjects . Patients age 18-65 years with chronic pain of at least moderate severity who were enrolled in a 12-month pragmatic trial of a telephone-based collaborative care intervention for chronic musculoskeletal pain. Methods . Participants were categorized as opioid users (n = 84) or non-users (n = 166) at baseline and trial randomization was stratified by opioid use. We used logistic regression to examine cross-sectional associations with baseline opioid use and mixed-effect models for repeated measures to examine baseline opioid use as a predictor of Brief Pain Inventory (BPI) scores over 12 months. Results . At baseline, 33.6% reported use of prescribed opioids. Baseline opioid users had higher baseline BPI scores and higher health-related disability than non-users. Baseline opioid users also had more outpatient visits (15.0 vs. 10.1; p = 0.001) and received more analgesics (p < 0.001) during the trial. In the final multivariable model examining effects of baseline opioid use on BPI over 12 months, opioid users and nonusers had a non-significant difference of 0.25 points (p = 0.098). In conclusion, although baseline opioid users had worse pain at baseline and used more health care during the study, response to the intervention was not significantly modified by pre-existing opioid therapy.
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    Physicians in Postgraduate Training Characteristics and Support of Palliative Sedation for Existential Distress
    (Sage, 2017-09) Cripe, Larry D.; Perkins, Susan M.; Cottingham, Ann; Tong, Yan; Kozak, Mary Ann; Mehta, Rakesh; Medicine, School of Medicine
    Introduction: Palliative sedation for refractory existential distress (PS-ED) is ethically troubling but potentially critical to quality end-of-life (EOL) care. Physicians’ in postgraduate training support toward PS-ED is unknown nor is it known how empathy, hope, optimism, or intrinsic religious motivation (IRM) affect their support. These knowledge gaps hinder efforts to support physicians who struggle with patients’ EOL care preferences. Methods: One hundred thirty-four postgraduate physicians rated their support of PS for refractory physical pain (PS-PP) or PS-ED, ranked the importance of patient preferences in ethically challenging situations, and completed measures of empathy, hope, optimism, and IRM. Predictors of PS-ED and PS-PP support were examined using binary and multinomial logistic regression. Results: Only 22.7% of residents were very supportive of PS-ED, and 82.0% were very supportive of PS-PP. Support for PS-PP or PS-ED did not correlate with levels of empathy, hope, optimism, or IRM; however, for residents with lower IRM, greater optimism was associated with greater PS-ED support. In contrast, among residents with higher IRM, optimism was not associated with PS-ED support. Conclusions: Comparing current results to published surveys, a similar proportion of residents and practicing physicians support PS-ED and PS-PP. In contrast to practicing physicians, however, IRM does not directly influence residents’ supportiveness. The interaction between optimism and IRM suggests residents’ beliefs and characteristics are salient to their EOL decisions. End-of-life curricula should provide physicians opportunities to reflect on the personal and ethical factors that influence their support for PS-ED.