Mark D. Neuman

Comparative Effectiveness of Regional versus General Anesthesia for Hip Fracture Surgery in Adults

Background: Hip fracture is a common, morbid, and costly event among older adults. Data are inconclusive as to whether epidural or spinal (regional) anesthesia improves outcomes after hip fracture surgery. Methods: The authors examined a retrospective cohort of patients undergoing surgery for hip fracture in 126 hospitals in New York in 2007 and 2008. They tested the association of a record indicating receipt of regional versus general anesthesia with a primary outcome of inpatient mortality and with secondary outcomes of pulmonary and cardiovascular complications using hospital fixed-effects logistic regressions. Subgroup analyses tested the association of anesthesia type and outcomes according to fracture anatomy. Results: Of 18,158 patients, 5,254 (29%) received regional anesthesia. In-hospital mortality occurred in 435 (2.4%). Unadjusted rates of mortality and cardiovascular complications did not differ by anesthesia type. Patients receiving regional anesthesia experienced fewer pulmonary complications (359 [6.8%] vs. 1,040 [8.1%], P < 0.005). Regional anesthesia was associated with a lower adjusted odds of mortality (odds ratio: 0.710, 95% CI 0.541, 0.932, P = 0.014) and pulmonary complications (odds ratio: 0.752, 95% CI 0.637, 0.887, P < 0.0001) relative to general anesthesia. In subgroup analyses, regional anesthesia was associated with improved survival and fewer pulmonary complications among patients with intertrochanteric fractures but not among patients with femoral neck fractures. Conclusions: Regional anesthesia is associated with a lower odds of inpatient mortality and pulmonary complications among all hip fracture patients compared with general anesthesia; this finding may be driven by a trend toward improved outcomes with regional anesthesia among patients with intertrochanteric fractures.

Anesthesia Technique, Mortality, and Length of Stay After Hip Fracture Surgery

IMPORTANCE More than 300,000 hip fractures occur each year in the United States. Recent practice guidelines have advocated greater use of regional anesthesia for hip fracture surgery. OBJECTIVE To test the association of regional (ie, spinal or epidural) anesthesia vs general anesthesia with 30-day mortality and hospital length of stay after hip fracture. DESIGN, SETTING, AND PATIENTS We conducted a matched retrospective cohort study involving patients 50 years or older who were undergoing surgery for hip fracture at general acute care hospitals in New York State between July 1, 2004, and December 31, 2011. Our main analysis was a near-far instrumental variable match that paired patients who lived at different distances from hospitals that specialized in regional or general anesthesia. Supplementary analyses included a within-hospital match that paired patients within the same hospital and an across-hospital match that paired patients at different hospitals. EXPOSURES Spinal or epidural anesthesia; general anesthesia. MAIN OUTCOMES AND MEASURES Thirty-day mortality and hospital length of stay. Because the distribution of length of stay had long tails, we characterized this outcome using the Huber M estimate with Huber weights, a robust estimator similar to a trimmed mean. RESULTS Of 56,729 patients, 15,904 (28%) received regional anesthesia and 40,825 (72%) received general anesthesia. Overall, 3032 patients (5.3%) died. The M estimate of the length of stay was 6.2 days (95% CI, 6.2 to 6.2). The near-far matched analysis showed no significant difference in 30-day mortality by anesthesia type among the 21,514 patients included in this match: 583 of 10,757 matched patients (5.4%) who lived near a regional anesthesia-specialized hospital died vs 629 of 10,757 matched patients (5.8%) who lived near a general anesthesia-specialized hospital (instrumental variable estimate of risk difference, -1.1%; 95% CI, -2.8 to 0.5; P = .20). Supplementary analyses of within and across hospital patient matches yielded mortality findings to be similar to the main analysis. In the near-far match, regional anesthesia was associated with a 0.6-day shorter length of stay than general anesthesia (95% CI, -0.8 to -0.4, P < .001). Supplementary analyses also showed regional anesthesia to be associated with shorter length of stay, although the observed association was smaller in magnitude than in the main analysis. CONCLUSIONS AND RELEVANCE Among adults in acute care hospitals in New York State undergoing hip repair, the use of regional anesthesia compared with general anesthesia was not associated with lower 30-day mortality but was associated with a modestly shorter length of stay. These findings do not support a mortality benefit for regional anesthesia in this setting.

Survival and Functional Outcomes After Hip Fracture Among Nursing Home Residents

IMPORTANCE Little is known regarding outcomes after hip fracture among long-term nursing home residents. OBJECTIVE To describe patterns and predictors of mortality and functional decline in activities of daily living (ADLs) among nursing home residents after hip fracture. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 60,111 Medicare beneficiaries residing in nursing homes who were hospitalized with hip fractures between July 1, 2005, and June 30, 2009. MAIN OUTCOMES AND MEASURES Data sources included Medicare claims and the Nursing Home Minimum Data Set. Main outcomes included death from any cause at 180 days after fracture and a composite outcome of death or new total dependence in locomotion at the latest available assessment within 180 days. Additional analyses described within-residents changes in function in 7 ADLs before and after fracture. RESULTS Of 60,111 patients, 21,766 (36.2%) died by 180 days after fracture; among patients not totally dependent in locomotion at baseline, 53.5% died or developed new total dependence within 180 days. Within individual patients, function declined substantially after fracture across all ADL domains assessed. In adjusted analyses, the greatest decreases in survival after fracture occurred with age older than 90 years (vs ≤75 years: hazard ratio [HR], 2.17; 95% CI, 2.09-2.26 [P < .001]), nonoperative fracture management (vs internal fixation: HR for death, 2.08; 95% CI, 2.01-2.15 [P < .001]), and advanced comorbidity (Charlson score of ≥5 vs 0: HR, 1.66; 95% CI, 1.58-1.73 [P < .001]). The combined risk of death or new total dependence in locomotion within 180 days was greatest among patients with very severe cognitive impairment (vs intact cognition: relative risk [RR], 1.66; 95% CI, 1.56-1.77 [P < .001]), patients receiving nonoperative management (vs internal fixation: RR, 1.48; 95% CI, 1.45-1.51 [P < .001]), and patients older than 90 years (vs ≤75 years: RR, 1.42; 95% CI, 1.37-1.46 [P < .001]). CONCLUSIONS AND RELEVANCE Survival and functional outcomes are poor after hip fracture among nursing home residents, particularly for patients receiving nonoperative management, the oldest old, and patients with multiple comorbidities and advanced cognitive impairment. Care planning should incorporate appropriate prognostic information related to outcomes in this population.

Medical and financial risks associated with surgery in the elderly obese.

Objective: To study the medical and financial outcomes associated with surgery in elderly obese patients and to ask if obesity itself influences outcomes above and beyond the effects from comorbidities that are known to be associated with obesity. Background: Obesity is a surgical risk factor not present in Medicares risk adjustment or payment algorithms, as BMI is not collected in administrative claims. Methods: A total of 2045 severely or morbidly obese patients (BMI ≥ 35 kg/m2, aged between 65 and 80 years) selected from 15,914 elderly patients in 47 hospitals undergoing hip and knee surgery, colectomy, and thoracotomy were matched to 2 sets of 2045 nonobese patients (BMI = 20–30 kg/m2). A “limited match” controlled for age, sex, race, procedure, and hospital. A “complete match” also controlled for 30 additional factors such as diabetes and admission clinical data from chart abstraction. Results: Mean BMI in the obese patients was 40 kg/m2 compared with 26 kg/m2 in the nonobese. In the complete match, obese patients displayed increased odds of wound infection: OR (odds ratio) = 1.64 (95% CI: 1.21, 2.21); renal dysfunction: OR = 2.05 (1.39, 3.05); urinary tract infection: OR = 1.55 (1.24, 1.94); hypotension: OR = 1.38 (1.07, 1.80); respiratory events: OR = 1.44 (1.19, 1.75); 30-day readmission: OR = 1.38 (1.08, 1.77); and a 12% longer length of stay (8%, 17%). Provider costs were 10% (7%, 12%) greater in obese than in nonobese patients, whereas Medicare payments increased only 3% (2%, 5%). Findings were similar in the limited match. Conclusions: Obesity increases the risks and costs of surgery. Better approaches are needed to reduce these risks. Furthermore, to avoid incentives to underserve this population, Medicare should consider incorporating incremental costs of caring for obese patients into payment policy and include obesity in severity adjustment models.

Association of echocardiography before major elective non-cardiac surgery with postoperative survival and length of hospital stay: population based cohort study

Objective To determine the association of resting echocardiography before elective intermediate to high risk non-cardiac surgery with survival and length of hospital stay. Design Population based retrospective cohort study. Setting Acute care hospitals in Ontario, Canada, between 1 April 1999 and 31 March 2008. Participants Patients aged over 40 years who had elective intermediate to high risk non-cardiac surgery. Intervention Resting echocardiography within 6 months before surgery. Main outcome measures Postoperative survival (30 days and 1 year) and length of hospital stay; postoperative surgical site infection as an outcome for which no association with echocardiography would be expected. Results Of the 264 823 patients in the entire cohort, 15.1% (n=40 084) had echocardiography. After use of propensity score methods to assemble a matched cohort (n=70 996) that reduced differences between patients who had or had not had echocardiography, echocardiography was associated with increases in 30 day mortality (relative risk 1.14, 95% confidence interval 1.02 to 1.27), 1 year mortality (1.07, 1.01 to 1.12), and length of hospital stay but no difference in surgical site infections (1.03, 0.98 to 1.06). The association with mortality was influenced (P=0.02) by whether patients had had stress testing or had risk factors for cardiac complications. No association existed between echocardiography and mortality among patients who had stress testing (relative risk 1.01, 0.92 to 1.11) or among patients at high risk who had not had stress testing (1.00, 0.87 to 1.13). However, echocardiography was associated with mortality in patients at low risk (relative risk 1.44, 1.14 to 1.82) and intermediate risk (1.10, 1.02 to 1.18) who had not had stress testing. Conclusions Preoperative echocardiography was not associated with improved survival or shorter hospital stay after major non-cardiac surgery. These findings highlight the need for further research to guide better use of this common preoperative test.

Redesigning surgical decision making for high-risk patients.

Shared decision making in surgical care requires a culture shift. For patients at high risk for adverse events after surgery, or in cases with an equivocal risk–benefit balance, evidence-based decision making may require input from a multidisciplinary group of experts.

Neuraxial anesthesia decreases postoperative systemic infection risk compared with general anesthesia in knee arthroplasty.

BACKGROUND:Surgical stress has been shown to result in immune disturbance. Neuraxial anesthesia (NA) has long been hypothesized to blunt undesired surgical insults and thus limit immune compromise and improve surgical outcomes. We hypothesized that NA would decrease postoperative infectious complications compared with general anesthesia (GA) among knee arthroplasty patients. METHODS:We studied the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2010. There were 16,555 patients included in our final cohort, with 9167 patients receiving GA and 7388 patients receiving spinal or epidural anesthesia.. Outcomes of interest included infection-related 30-day postoperative complications, including surgical site–related infections, pneumonia, urinary tract infection, sepsis, septic shock, and a composite end point of any systemic infection. Multivariable logistic regression was performed to test for effect of anesthesia type while adjusting for the influence of preexisting comorbidities. RESULTS:The overall mortality was 0.24% and 0.15% among NA and GA subjects, respectively (P = 0.214). NA subjects had fewer unadjusted incidences of pneumonia (P = 0.035) and composite systemic infection (P = 0.006). After risk adjustment for preexisting comorbidities, NA was associated with lower odds of pneumonia (odds ratio = 0.51 [95% confidence interval, 0.29–0.90]) and lower odds of composite systemic infection (odds ratio = 0.77 [95% confidence interval, 0.64–0.92]). CONCLUSIONS:Our study suggested that NA was associated with lower adjusted odds of both pneumonia and a composite outcome of any systemic infectious complication within 30 days of surgery compared with GA.

Association Between Skilled Nursing Facility Quality Indicators and Hospital Readmissions

IMPORTANCE Hospital readmissions are common, costly, and potentially preventable. Little is known about the association between available skilled nursing facility (SNF) performance measures and the risk of hospital readmission. OBJECTIVE To measure the association between SNF performance measures and hospital readmissions among Medicare beneficiaries receiving postacute care at SNFs in the United States. DESIGN AND PARTICIPANTS Using national Medicare data on fee-for-service Medicare beneficiaries discharged to a SNF after an acute care hospitalization between September 1, 2009, and August 31, 2010, we examined the association between SNF performance on publicly available metrics (SNF staffing intensity, health deficiencies identified through site inspections, and the percentages of SNF patients with delirium, moderate to severe pain, and new or worsening pressure ulcers) and the risk of readmission or death 30 days after discharge to a SNF. Adjusted analyses controlled for patient case mix, SNF facility factors, and the discharging hospital. MAIN OUTCOMES AND MEASURES Readmission to an acute care hospital or death within 30 days of the index hospital discharge. RESULTS Of 1,530,824 patients discharged, 357,752 (23.3%; 99% CI, 23.3%-23.5%) were readmitted or died within 30 days; 72,472 died within 30 days (4.7%; 99% CI, 4.7%-4.8%), and 321,709 were readmitted (21.0%; 99% CI, 20.9%-21.1%). The unadjusted risk of readmission or death was lower at SNFs with better staffing ratings. SNFs ranked lowest (19.2% of all SNFs) had a 30-day risk of readmission or death of 25.5% (99% CI, 25.3%-25.8%) vs 19.8% (99% CI, 19.5%-20.1%) among those ranked highest. SNFs with better facility inspection ratings also had a lower risk of readmission or death. SNFs ranked lowest (20.1% of all SNFs) had a risk of 24.9% (99% CI, 24.7%-25.1%) vs 21.5% (99% CI, 21.2%-21.7%) among those ranked highest . Adjustment for patient factors, SNF facility factors, and the discharging hospital attenuated these associations; we observed small differences in the adjusted risk of readmission or death according to SNF facility inspection ratings (lowest vs highest rating: 23.7%; 99% CI: 23.7%, 23.7%; vs 23.0%; 99% CI: 23.0%, 23.1%). Other measures did not predict clinically meaningful differences in the adjusted risk of readmission or death. CONCLUSIONS AND RELEVANCE Among fee-for-service Medicare beneficiaries discharged to a SNF after an acute care hospitalization, available performance measures were not consistently associated with differences in the adjusted risk of readmission or death.

Opioids Prescribed After Low-Risk Surgical Procedures in the United States, 2004-2012.

Adverse events related to opioid analgesics are common.1,2 Although opioids represent a component of pain treatment regimens following low-risk surgery,3,4 few data exist regarding patterns of postoperative opioid prescribing over time. We assessed trends in the amount of hydrocodone/acetaminophen and oxycodone/acetaminophen prescribed, 2 opioids commonly used for postoperative pain management.

Comparative safety of anesthetic type for hip fracture surgery in adults: retrospective cohort study

Objective To evaluate the effect of anesthesia type on the risk of in-hospital mortality among adults undergoing hip fracture surgery in the United States. Design Retrospective cohort study. Setting Premier research database, United States. Participants 73 284 adults undergoing hip fracture surgery on hospital day 2 or greater between 2007 and 2011. Of those, 61 554 (84.0%) received general anesthesia, 6939 (9.5%) regional anesthesia, and 4791 (6.5%) combined general and regional anesthesia. Main outcome measure In-hospital all cause mortality. Results In-hospital deaths occurred in 1362 (2.2%) patients receiving general anesthesia, 144 (2.1%) receiving regional anesthesia, and 115 (2.4%) receiving combined anesthesia. In the multivariable adjusted analysis, when compared with general anesthesia the mortality risk did not differ significantly between regional anesthesia (risk ratio 0.93, 95% confidence interval 0.78 to 1.11) or combined anesthesia (1.00, 0.82 to 1.22). A mixed effects analysis accounting for differences between hospitals produced similar results: compared with general anesthesia the risk from regional anesthesia was 0.91 (0.75 to 1.10) and from combined anesthesia was 0.98 (0.79 to 1.21). Findings were also consistent in subgroup analyses. Conclusions In this large nationwide sample of hospital admissions, mortality risk did not differ significantly by anesthesia type among patients undergoing hip fracture surgery. Our results suggest that if the previously posited beneficial effect of regional anesthesia on short term mortality exists, it is likely to be more modest than previously reported.