Nicole Zubizarreta

The impact of peripheral nerve blocks on perioperative outcome in hip and knee arthroplasty-a population-based study.

Abstract The role of anesthesia techniques on perioperative outcomes on a population level has recently gained widespread interest. Although mainly neuraxial vs general anesthesia has been addressed, population-level data on the impact of peripheral nerve blocks (PNBs) are still lacking. Therefore, we investigated the association between PNB use and outcomes using retrospective data on 1,062,152 recipients of hip and knee arthroplasties (total hip arthroplasty [THA]/total knee arthroplasty [TKA]) from the national Premier Perspective database (2006-2013). Multilevel multivariable logistic regression models measured associations between PNB use and outcomes. Complications included cardiac, pulmonary, gastrointestinal and renal complications, cerebrovascular events, infections, wound complications, thromboembolic complications, inpatient falls, and mortality. Resource utilization variables included blood transfusions, intensive care unit admissions, opioid consumption, cost, and length of stay. Overall, 12.5% of patients received a PNB, with an increase over time particularly among TKAs. Peripheral nerve block use was associated with lower odds for most adverse outcomes mainly among patients with THA. Notable beneficial effects were seen for wound complications (odds ratio 0.60 [95% confidence interval, 0.49-0.74]) among THA recipients and pulmonary complications (odds ratio 0.83 [95% confidence interval, 0.72-0.94]) in patients with TKA. Peripheral nerve block use was significantly (P < 0.0001) associated with a −16.2% and −12.7% reduction in opioid consumption for patients with THA and TKA, respectively. In conclusion, our results indicate that PNBs might be associated with superior perioperative population-level outcomes. In light of the inability to establish a causal relationship and the presence of residual confounding, we strongly advocate for further prospective investigation, ideally in multicenter, randomized trials, to establish the potential impact of PNBs on outcomes on a population level.

Trends in the Use of Regional Anesthesia: Neuraxial and Peripheral Nerve Blocks.

Background A growing body of evidence indicates that the use of regional anesthesia offers advantages over general anesthesia, not only in terms of reducing complications but also regarding resource utilization and patient satisfaction. Because of the paucity of data on the nationwide adoption of regional anesthesia techniques, we aimed to elucidate trends in the use of neuraxial anesthesia (NA) and peripheral nerve blocks (PNBs) in orthopedic surgeries. Methods We extracted data from N = 959,257 (Premier Perspective database; 2006–2013) total hip and knee arthroplasties (THA, TKA) and assessed NA/PNB use by a 2-year period, stratified by demographics and hospital factors. Cochran-Armitage trend tests assessed significance of trends. Results Comparing 2006–2007 with 2012–2013, NA utilization decreased slightly from 21.7% to 19.7% for THA patients; this was 24.7% to 21.3% for TKA patients (with the main drop between 2012 and 2013). Conversely, PNB utilization increased from 6.5% to 8.7% for THA patients and 10.3% to 20.4% for TKA patients (all P < 0.001). These general trends did not change when stratified by patient demographics, whereas stratification by hospital factors did show differences: the highest NA utilization was seen in rural, nonteaching, and small hospitals, whereas the highest PNB utilization was seen in large and teaching hospitals. Conclusions Our findings provide important insight into the dynamics of the adoption of regional anesthetic techniques. Whereas PNB utilization is significantly increasing, overall, NA and PNBs are performed in the minority of cases. With accumulating evidence in favor of regional anesthesia, promoting the use of NA and a further increase in PNB utilization could have far-reaching medical and economic implications.

Opioid prescription levels and postoperative outcomes in orthopedic surgery

Abstract Given the basic need for opioids in the perioperative setting, we investigated associations between opioid prescription levels and postoperative outcomes using population-based data of orthopedic surgery patients. We hypothesized that increased opioid amounts would be associated with higher risk for postoperative complications. Data were extracted from the national Premier Perspective database (2006-2013); N = 1,035,578 lower joint arthroplasties and N = 220,953 spine fusions. Multilevel multivariable logistic regression models measured associations between opioid dose prescription and postoperative outcomes, studied by quartile of dispensed opioid dose. Compared to the lowest quartile of opioid dosing, high opioid prescription was associated with significantly increased odds for deep venous thrombosis and postoperative infections by approx. 50%, while odds were increased by 23% for urinary and more than 15% for gastrointestinal and respiratory complications (P < 0.001 respectively). Furthermore, higher opioid prescription was associated with a significant increase in length of stay (LOS) and cost by 12% and 6%, P < 0.001 respectively. Cerebrovascular complications risk was decreased by 25% with higher opioid dose (P = 0.004), while odds for myocardial infarction remained unaltered. In spine cases, opioid prescription was generally higher, with stronger effects observed for increase in LOS and cost as well as gastrointestinal and urinary complications. Other outcomes were less pronounced, possibly because of smaller sample size. Overall, higher opioid prescription was associated with an increase in most postoperative complications with the strongest effect observed in thromboembolic, infectious and gastrointestinal complications, cost, and LOS. Increase in complication risk occurred stepwise, suggesting a dose–response gradient.

Anesthetic Care for Orthopedic Patients: Is There a Potential for Differences in Care?

Background:Differences in health care represent a major health policy issue. Despite increasing evidence on the mediating role of anesthesia type used for surgery on perioperative outcome, there is a lack of data on potential care differences in this field. The authors aimed to determine whether anesthesia practice (use of neuraxial anesthesia [NA] or peripheral nerve block [PNB]) differs by patient and hospital factors. Methods:The authors extracted data on n = 1,062,152 hip and knee arthroplasty procedures from the Premier Perspective database (2006 to 2013). Multilevel multivariable logistic regression models measured associations (odds ratios [ORs] and 95% CIs) between patient/hospital factors and NA or PNB use. Results:Of all patients, 22.2% (n = 236,083) received NA and 17.9% (n = 189,732) received PNB. Lower adjusted odds for receiving NA were seen for black patients (OR, 0.88; 95% CI, 0.86 to 0.91) and those on Medicaid (OR, 0.78; 95% CI, 0.74 to 0.82) or without insurance (OR, 0.89; 95% CI, 0.81 to 0.98). Furthermore, teaching hospitals (compared with nonteaching hospitals) had lower adjusted odds for NA utilization (OR, 0.35; 95% CI, 0.14 to 0.89). Although generally similar patterns were seen for PNB utilization, the main difference was that particularly Hispanic patients were less likely to receive PNB compared with white patients (OR, 0.60; 95% CI, 0.56 to 0.65). Sensitivity analyses generally validated our results. Conclusions:Significant differences exist in the provision of regional anesthetic care with factors such as race and insurance type being important determinants of anesthetic practice. Further and in-depth research is needed to fully assess the background of these differences.

Association of Multimodal Pain Management Strategies with Perioperative Outcomes and Resource UtilizationA Population-based Study

Background: Multimodal analgesia is increasingly considered routine practice in joint arthroplasties, but supportive large-scale data are scarce. The authors aimed to determine how the number and type of analgesic modes is associated with reduced opioid prescription, complications, and resource utilization. Methods: Total hip/knee arthroplasties (N = 512,393 and N = 1,028,069, respectively) from the Premier Perspective database (2006 to 2016) were included. Analgesic modes considered were opioids, peripheral nerve blocks, acetaminophen, steroids, gabapentin/pregabalin, nonsteroidal antiinflammatory drugs, cyclooxygenase-2 inhibitors, or ketamine. Groups were categorized into “opioids only” and 1, 2, or more than 2 additional modes. Multilevel models measured associations between multimodal analgesia and opioid prescription, cost/length of hospitalization, and opioid-related adverse effects. Odds ratios or percent change and 95% CIs are reported. Results: Overall, 85.6% (N = 1,318,165) of patients received multimodal analgesia. In multivariable models, additions of analgesic modes were associated with stepwise positive effects: total hip arthroplasty patients receiving more than 2 modes (compared to “opioids only”) experienced 19% fewer respiratory (odds ratio, 0.81; 95% CI, 0.70 to 0.94; unadjusted 1.0% [N = 1,513] vs. 2.0% [N = 1,546]), 26% fewer gastrointestinal (odds ratio, 0.74; 95% CI, 0.65 to 0.84; unadjusted 1.5% [N = 2,234] vs. 2.5% [N = 1,984]) complications, up to a –18.5% decrease in opioid prescription (95% CI, –19.7% to –17.2%; 205 vs. 300 overall median oral morphine equivalents), and a –12.1% decrease (95% CI, –12.8% to –11.5%; 2 vs. 3 median days) in length of stay (all P < 0.05). Total knee arthroplasty analyses showed similar patterns. Nonsteroidal antiinflammatory drugs and cyclooxygenase-2 inhibitors seemed to be the most effective modalities used. Conclusions: While the optimal multimodal regimen is still not known, the authors’ findings encourage the combined use of multiple modalities in perioperative analgesic protocols.

Discharge Against Medical Advice of Elderly Inpatients in the United States

Discharge against medical advice (DAMA) is associated with greater risk of hospital readmission and higher morbidity, mortality, and costs, but with a rapidly increasing elderly inpatient population, there is a lack of national data on DAMA in this subgroup. The National Inpatient Sample (2003–2013 for trends, 2013 for multivariable analysis, n = 29,290,852) was used to describe trends in DAMA in elderly inpatients, to study diagnosis codes associated with admission, and to assess factors associated with DAMA using multivariable logistic regression. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported for risk factors of interest. Although DAMA rates in individuals aged 65 and older were one fourth of those found in individuals aged 18 to 64, an increasing trend was found in both groups. From 2003 to 2013, rates increased in individuals aged 18 to 64 (from 1.44% to 1.78%) and in those aged 65 and older (from 0.37% to 0.42% (both P < .001). In both age groups, individuals admitted for mental illness had the highest risk of DAMA. Factors associated with higher adjusted odds of DAMA were generally similar between age groups, although risk of DAMA was higher in elderly adults than in those aged 18 to 64 for blacks (OR 1.65, 95% CI 1.49–1.82 vs OR 1.16, 95% CI 1.12–1.20), Hispanics (OR 1.58, 95% CI 1.41–1.77 vs OR 0.83, 95% CI 0.79–0.87), and those in the lowest income quartile (OR 1.57, 95% CI 1.43–1.72 vs OR 1.12, 95% CI 1.08–1.17), suggesting that race/ethnicity and poverty are more pronounced as risk factors for DAMA in elderly inpatients.

Characteristics of Antibiotic Prophylaxis and Risk of Surgical Site Infections in Open Colectomies.

BACKGROUND: Despite numerous trials assessing optimal antibiotic prophylaxis strategies for colorectal surgery, few studies have assessed real-world practice on a national scale with respect to risk of surgical site infections. OBJECTIVE: Using a large national claims database we aimed to describe current use of prophylactic antibiotics (type and duration) and associations with surgical site infection after open colectomies. DESIGN: This was a retrospective study using the Premier Perspective database. SETTINGS: Included were patient hospitalizations nationwide from January 2006 to December 2013. PATIENTS: A total of 90,725 patients who underwent an open colectomy in 445 different hospitals were included in the study. MAIN OUTCOME MEASURES: Multilevel, multivariable logistic regressions measured associations between surgical site infection and type of antibiotic used and duration (day of surgery only, day of surgery and the day after, and >1 day after surgery). RESULTS: Overall surgical site infection prevalence was 5.2% (n = 4750). Most patients (41.8%) received cefoxitin for prophylaxis; other choices were ertapenem (18.2%), cefotetan (10.3%), metronidazole with cefazolin (9.9%), and ampicillin with sulbactam (7.6%), whereas 12.2% received other antibiotics. Distribution of prophylaxis duration was 51.6%, 28.5%, and 19.9% for day of surgery only, day of surgery and the day after, and >1 day after surgery, respectively. Compared with cefoxitin, lower odds for surgical site infection were observed for ampicillin with sulbactam (OR = 0.71 (95% CI, 0.63–0.82)), ertapenem (OR = 0.65 (95% CI, 0.58–0.71)), metronidazole with cefazolin (OR = 0.56 (95% CI, 0.49–0.64)), and “other” (OR = 0.81 (95% CI, 0.73–0.90)); duration was not significantly associated with altered odds for surgical site infection. Sensitivity analyses supported the main findings. LIMITATIONS: The study was limited by its lack of detailed clinical information in the billing data set used. CONCLUSIONS: In this national study assessing real-world use of prophylactic antibiotics in open colectomies, the type of antibiotic used appeared to be associated with up to 44% decreased odds for surgical site infections. Although there are numerous trials on optimal prophylactic strategies, studies that particularly focus on factors that influence the choice of prophylactic antibiotic might provide insights into ways of reducing the burden of surgical site infections in colorectal surgeries.

Elevated glycohemoglobin HbA1c is associated with low back pain in nonoverweight diabetics

BACKGROUND CONTEXT Low back pain (LBP) is a common complaint in clinical practice of multifactorial origin. Although obesity has been thought to contribute to LBP primarily by altering the distribution of mechanical loads on the spine, the additional contribution of obesity-related conditions such as diabetes mellitus (DM) to LBP has not been thoroughly examined. PURPOSE To determine if there is a relationship between DM and LBP that is independent of body mass index (BMI) in a large cohort of adult survey participants. STUDY DESIGN Retrospective analysis of prospectively collected National Health and Nutrition Examination Survey (NHANES) data to characterize associations between LBP, DM, and BMI in adults subdivided into 6 subpopulations: normal weight (BMI 18.5-25), overweight (BMI 25-30), and obese (BMI >30) diabetics and nondiabetics. Diabetes was defined with glycohemoglobin A1c (HbA1c) ≥6.5%. PATIENT SAMPLE 11,756 participants from NHANES cohort. OUTCOME MEASURES Percentage of LBP reported. METHODS LBP reported in the 1999-2004 miscellaneous pain NHANES questionnaire was the dependent variable examined. Covariates included HbA1c, BMI, age, and family income ratio to poverty as continuous variables as well as race, gender, and smoking as binary variables. Individuals were further subdivided by weight class and diabetes status. Regression and graphical analyses were performed on the study population as a whole and also on subpopulations. RESULTS Increasing HbA1c did not increase the odds of reporting LBP in the full cohort. However, multivariate logistic regression of the 6 subpopulations revealed that the odds of LBP significantly increased with increasing HbA1c levels in normal weight diabetics. No other subpopulations reported significant relationships between LBP and HbA1c. LBP was also significantly associated with BMI for normal weight diabetics and also for obese subjects regardless of their DM status. CONCLUSIONS LBP is significantly related to DM status, but this relationship is complex and may interact with BMI. These results support the concept that LBP may be improved in normal weight diabetic subjects with improved glycemic control and weight loss, and that all obese LBP subjects may benefit from improved weight loss alone.

Effectiveness of intravenous acetaminophen for postoperative pain management in shoulder arthroplasties: A population-based study

Background Intravenous acetaminophen (IV APAP) is an option in multimodal postoperative analgesia. Prior trials focus on hip and knee arthroplasties, whereas large-scale data on utilization and effectiveness in shoulder arthroplasties are lacking. Methods Data on 67,494 (452 hospitals) partial/total shoulder arthroplasties were extracted from the Premier claims database (2011–2016). Patients were categorized by receipt and dosage of IV APAP. Multilevel models measured associations between IV APAP and opioid utilization (in oral morphine equivalents), length/cost of stay and opioid-related complications. Effect estimates (adjusted % change) with 95% confidence intervals (CIs) are reported. Results IV APAP was used in 17.7% (n = 11,949) of patients with an increasing utilization trend. Most patients received only one dose on the day of surgery (69.5%; n = 8308). When adjusting for relevant covariates, IV APAP was not associated with meaningful effects on outcomes. Specifically, its use (versus no use) was not associated with decreased (but rather somewhat increased) opioid utilization: + 5.4% (CI 3.6–7.1%; P < 0.05). Conclusion In this first large-scale study that assesses IV APAP in shoulder arthroplasties, IV APAP use was not associated with decreased opioid utilization or the length/cost of stay. These results do not support routine use of IV APAP in this cohort, especially given its high cost. The translational potential for this article Multimodal pain control to assist in reducing the opioid pain medications are seen as a route to improved postoperative patient outcomes, better pain control and expedited hospital discharge. Acetaminophen plays a significant role in these protocols in many institutions, but it is not established if this expensive IV formulation is superior to the oral formulation. This study evaluates the use and effectiveness of IV acetaminophen following shoulder arthroplasty at a large number of institutions.

Non-opioid analgesic modes of pain management are associated with reduced postoperative complications and resource utilisation: a retrospective study of obstructive sleep apnoea patients undergoing elective joint arthroplasty

Background: Studies on the effectiveness of multimodal analgesia, particularly in patients at higher perioperative risk from obstructive sleep apnoea (OSA), are lacking. We aimed to assess the impact of multimodal analgesia on opioid use and complications in this high‐risk cohort. Methods: We conducted a population‐based retrospective cohort study of OSA patients undergoing elective lower extremity joint arthroplasty (2006–16, Premier Healthcare database). Multimodal analgesia was defined as opioid use with the addition of one, two, or more non‐opioid analgesic modes including, nonsteroidal anti‐inflammatory drugs (NSAIDs), cyclooxygenase‐2 inhibitors, paracetamol/acetaminophen, peripheral nerve blocks, steroids, gabapentin/pregabalin, or ketamine. Multilevel multivariable regression models measured associations between multimodal analgesia and opioid prescription (primary outcome; oral morphine equivalents). Secondary outcomes included opioid‐ and OSA‐related complications, and resource utilisation. Odds ratios (OR) or % change and 95% confidence intervals (CI) are reported. Results: Among 181 182 OSA patients included, 88.5% (n = 160 299) received multimodal analgesia with increasing utilisation trends. Multivariable models showed stepwise beneficial postoperative outcome effects with increasing additional analgesic modes compared with opioid‐only analgesia. In patients who received more than two additional analgesia modes (n = 64 174), opioid dose prescription decreased by 14.9% (CI −17.0%; −12.7%), while odds were significantly decreased for gastrointestinal complications (OR 0.65, CI 0.53; 0.78), mechanical ventilation (OR 0.23, CI 0.16; 0.32), and critical care admission (OR 0.60, CI 0.48; 0.75), all P<0.0001. Conclusions: In a population at high risk for perioperative complications from OSA, multimodal analgesia was associated with a stepwise reduction in opioid use and complications, including critical respiratory failure.