Antispasmodic medications may be associated with reduced recovery during inpatient rehabilitation after traumatic spinal cord injury

Objective: To determine whether antispasmodic medications are associated with neurological and functional outcomes during the first year after traumatic spinal cord injury (SCI).

Design/Methods: Retrospective analysis of prospectively collected data from six inpatient SCI rehabilitation centers. Baseline-adjusted outcomes at discharge and one-year follow-up were compared using analysis of covariance between patients who received antispasmodic medication on at least 5 days during inpatient rehabilitation and patients who did not.

Outcome measures: Rasch-transformed motor subscore of the Functional Independence Measure (FIM); International Standards for Neurological Classification of Spinal Cord Injury motor scores, grade, and level.

Results: Of 1,259 patients, 59.8%, 35.4%, and 4.8% were injured at the cervical, thoracic, and lumbosacral levels, respectively. 65.6% had motor complete injury. Rasch-transformed motor FIM score at admission averaged 23.3 (95% confidence interval (CI) 22.4–24.2). Total motor score averaged 39.2 (95% CI 37.8–40.6). 685 patients (54.4%) received one or more antispasmodic medications on at least 5 days. After controlling for demographic and injury variables at admission, Rasch-transformed motor FIM scores at discharge were significantly lower (P?=?0.018) in patients receiving antispasmodic medications than in those who did not. This trend persisted in secondary analyses for cervical, thoracic, and lumbosacral subgroups. Multivariate regression showed that receiving antispasmodic medication significantly contributed to discharge motor FIM outcome. At one-year follow-up, no outcomes significantly differed between patients ON or OFF antispasmodics.

Conclusions: Antispasmodic medications may be associated with decreased functional recovery at discharge from inpatient traumatic SCI rehabilitation. Randomized prospective studies are needed to directly evaluate the effects of antispasmodic medication on recovery.     

Interspinous device versus laminectomy for lumbar spinal stenosis: a comparative effectiveness study

Background contextCurrently no studies directly compare effectiveness between interspinous devices (IDs) and laminectomy in lumbar spinal stenosis (LSS) patients.PurposeTo compare reoperations, complications, and costs between LSS patients undergoing ID placement versus laminectomy.Study designRetrospective comparative study.Patient sampleThe MarketScan database (2007–2009) was queried for adults with LSS undergoing ID placement as a primary inpatient procedure.Outcome measuresReoperation rates, complication rates, and costs.MethodsEach ID patient was matched with a laminectomy patient using propensity score matching. Reoperations, complications, and costs were analyzed in patients with at least 18 months postoperative follow-up. The authors did not receive funding from any external sources for this study.ResultsAmong 498 inpatients that underwent ID placement between 2007 and 2009; the average age was 73 years. The cumulative reoperation rates after ID at 12 and 18 months were 21% and 23%, respectively. The average inpatient hospitalization lasted 1.6 days with an associated cost of $17,432. Two propensity-matched cohorts of 174 patients that had undergone ID versus laminectomy were analyzed. Longer length of stay was observed in the laminectomy cohort (2.5 days vs. 1.6 days, p<.0001), whereas ID patients accrued higher costs at index hospitalization ($17,674 vs. $12,670, p=.0001). Index hospitalization (7.5% vs. 3.5%, p=.099) and 90-day (9.2% vs. 3.5%, p=.028) complications were higher in the laminectomy cohort compared with the ID cohort. The ID patients had significantly higher reoperation rates than laminectomy patients at 12 months follow-up (12.6% vs. 5.8%, p=.026) and incurred higher cumulative costs than laminectomy patients at 12 months follow-up ($39,173 vs. $34,324, p=.289).ConclusionsTwelve-month reoperation rates and index hospitalization costs were significantly higher among patients who underwent ID compared with laminectomy for LSS.     

Impact of a Unit-Based Clinical Pharmacist on Communication of Medication Information in an Orthopedic Hospital

Background

Medication management, a complex yet essential part of patient care, requires that clinicians and patients understand indication, dosage, frequency, and adverse effects in order to maximize benefits and minimize errors, as well as to transition patients from hospital to home. Clinical pharmacists improve care transitions and safety by interacting with patients, prescribers, and nurses on medication management and self-care. However, little is known on the use of clinical pharmacists on interdisciplinary teams at the unit level within orthopedics.

Questions/Purposes

This study sought to measure the impact of unit-based clinical pharmacists on patient perceptions of communication specific to medication during hospitalization at an orthopedic specialty hospital and on the frequency of medication errors.

Methods

A retrospective, quasi-experimental, two-group evaluative design with nonequivalent controls was used. Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data on six inpatient units was analyzed 6 months before and 6 months after assignment of clinical pharmacists to half these units. Data specific to questions that measure quality of communication as well as medication understanding were analyzed. Additionally, data on medication error frequency were collected and compared between units with and without clinical pharmacists.

Results

A total of 2022 surveys were analyzed. The percentage of patients who reported receipt of medication information and medication understanding increased significantly after the implementation of unit-based clinical pharmacists. Comparison of intervention and non-intervention groups showed no statistically significant difference in the frequency of medication errors.

Conclusion

Results suggest that a clinical pharmacist assigned to an inpatient unit in orthopedics significantly influences patient perceptions of communication about and understanding of their medications.

     

Discontinuation of diabetes and lipid-lowering medications after bariatric surgery at Veterans Affairs medical centers

BackgroundBariatric surgery has largely been performed on middle-age female populations and been associated with significant medication discontinuation; however, it is unknown whether similar medication discontinuation rates could be achieved in men. The purpose of the present analysis was to examine the discontinuation rate of diabetes or lipid-lowering medications and the patient factors associated with medication discontinuation among veterans undergoing bariatric surgery.MethodsWe identified the demographic and health status information for 284 veterans with diabetes and 298 veterans with hyperlipidemia who had undergone bariatric surgery at 1 of 12 Veterans Affairs bariatric centers in 2000 to 2006 from the Veterans Affairs National Surgical Quality Improvement Program data. We also identified the medications that had been prescribed and discontinued using the Veterans Affairs administrative data. Medication discontinuation was estimated using a logistic regression model.ResultsOf the 284 veterans with diabetes and 298 with hyperlipidemia, 52% and 40% had discontinued their medications at 1 year, respectively. The veterans with diabetes were more likely to discontinue medication if they had been taking oral hypoglycemic agents alone (odds ratio 2.77, P <.001) than were those taking insulin or oral hypoglycemic agents and insulin. The veterans with hyperlipidemia were more likely to discontinue medication if they had only been taking fibrates (odds ratio 6.15, P <.01) than were those veterans taking statins and fibrates.ConclusionBariatric surgery led to significant medication discontinuation within 1 year for high-risk veterans with diabetes or hyperlipidemia.     

Prevalence and out-patient medical costs of comorbid conditions in patients with rheumatoid arthritis

ObjectivesTo evaluate the prevalence, types, and out-patient direct medical costs of comorbid conditions in patients with RA in Thailand.MethodsInformation of the patients with RA treated by rheumatologists with at least one disease modifying antirheumatic drugs (DMARDs), including demographic data, RA-related medication types and treatment costs, comorbidity-related medication types and treatment costs, and total direct medical costs, was captured from King Chulalongkorn Memorial Hospital databases.ResultsThe data from 684 patients with RA were included for analysis. The majority of the patients were prescribed combined DMARDs, while only 2.5% received biologics. Comorbid conditions were reported in 434 patients (63.5%). The most common comorbid condition was hypertension (51.2%). Advanced age and presence of healthcare coverage was associated with comorbid conditions. The average annual cost of non-RA-related treatments in patients with comorbid diseases was 15 times the cost in those without comorbidities (1546 vs. 104 USD; P < 0.001) while the total direct medical cost in patients with comorbid conditions was twice that in patients without comorbid diseases (4118 vs. 2045 USD; P < 0.001). Parameters that influenced total direct medical costs were RA medications costs, comorbidity, healthcare coverage, patient's age, and types of DMARDs.ConclusionsComorbid conditions were common in this study. However, the major cost component incurred in RA patients was the costs of RA medications and services, while the out-patient costs of comorbid conditions accounted for approximately 38% of the total costs.     

日间模式下腔静脉滤器取出术的安全性与住院费用构成分析

背景与目的：2022年2月,国家卫生健康委办公厅关于印发日间手术推荐目录（2022年版）的通知,其中并未纳入下腔静脉滤器取出术。本文分析笔者医院日间手术和常规住院行下腔静脉滤器取出的临床特征、中期结局和住院费用构成,探讨将日间模式应用于这一术式的安全性与合理性。方法：回顾性分析2017年5月—2022年8月大连医科大学附属第一医院行下腔静脉滤器取出术的229例患者资料,其中,91例患者采用日间模式下腔静脉滤器取出术（日间模式组）,138例常规住院行滤器取出术（常规住院组）。比较两组患者一般资料、并发症及随访结果,并使用结构变动分析法统计费用明细。结果：两组间抗凝血酶与丙氨酸氨基转移酶水平有明显差异（均P<0.05）,但均值都位于正常范围内,其余基线特征均无明显差异（均P>0.05）。两组的手术成功率与手术时间均无明显差异（均P>0.05）。两组的住院时间与住院费用有明显差异（均P<0.05）,日间模式组所有患者均在48 h内出院,中位住院时间1.6 d,常规住院组最长15 d,中位住院时间6.0 d。日间模式组住院人均标准金额22 547.1元,比常规住院组减少...     

Documented and Undocumented Psychiatric Conditions Affect the Length of Stay and Discharge Disposition Following Total Hip Arthroplasty

BackgroundDespite increased efforts toward patient optimization, some patients have undocumented conditions that can affect costs and quality metrics for institutions and physicians. This study evaluates the effect of documented and undocumented psychiatric conditions on length of stay (LOS) and discharge disposition following total hip arthroplasty (THA).MethodsA retrospective review of all primary THAs from 2015 to 2020 at a high-volume academic orthopedic specialty hospital was conducted. Patients were separated into 3 cohorts: patients with a documented psychiatric diagnosis (+Dx), patients without a documented psychiatric diagnosis but with an actively prescribed psychiatric medication (?Dx), and patients without a psychiatric diagnosis or medication (control). Patient demographics, LOS, and discharge disposition were assessed.ResultsA total of 5309 patients were included; 3048 patients had no recorded psychiatric medications (control); 2261 patients took at least 1 psychiatric medication, of which 1513 (65.9%) and 748 (34.1%) patients were put in the ?Dx and +Dx cohorts, respectively. American Society of Anesthesiologists class differed between groups (P < .001). The ?Dx and +Dx groups had increased LOS (3.15 ± 2.37 [75.6 ± 56.9] and 3.12 ± 2.27 [74.9 ± 54.5] vs 2.42 ± 1.70 [57.6 ± 40.8] days (hours), P < .001) and were more likely to be discharged to a secondary facility (23.0% and 21.7% vs 13.8%, P < .001) than the control group. Outcomes did not significantly differ between the ?Dx and +Dx cohorts.ConclusionMost THA patients’ psychiatric diagnoses were not documented. The presence of psychiatric medications was associated with longer LOS and a greater likelihood of discharge to secondary facilities. This has implications for both cost and quality metrics. Review of medications can help identify and optimize these patients before surgery.Level III EvidenceRetrospective Cohort Study.     

The financial burden of rib fractures: National estimates 2007 to 2016

BackgroundThe aim of this study is to define the cost of rib fracture hospitalization by single, multiple, and flail type using a nationally representative sample.MethodsThe national inpatient sample (NIS) was used to identify patients with a primary diagnosis of rib fracture hospitalization 2007-2016. International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes were used to characterize patients as having single, multiple, or flail chest rib fractures. Patients with only trauma related diagnosis groups (DRG) at the time discharge were included in the final sample. The cost of hospitalization was obtained by converting reported charges into cost using the all-payer inpatient cost-to-charge ratio (CCR) for all hospitals in the NIS data. The log of cost was modeled using multivariate linear regression. The rib fracture type was the primary predictor in the model.ResultsThere were 373,053 rib fracture admissions during 2007-2016. The average cost per hospitalization was $10,169 (95%Confidence Interval [CI]: 9,942–10,395), which translated into a national expenditure of $3.64 billion over 10 years. The cost of rib fracture hospitalization increased from $209 million in 2007 to $469 million in 2016. Compared to single rib fracture patients, the cost of hospitalization for multiple rib fractures and flail chest was 3% (p = 0.001) and 5% (p=0.02) higher, respectively. Higher injury severity score, total number of body regions injured and longer length of stay were associated with higher rib fracture hospitalization cost.ConclusionsRib fractures affect ~22,000-45,000 people per year in the United States. The cost of rib fractures is over $469 million per year and is increasing over time. Multiple rib fractures and flail chest rib fractures are associated with increased cost. Pathways to improve care in patients with rib fractures should consider the cost of treatment.     

Surgical treatment of metastatic spine disease: an update on national trends and clinical outcomes from 2010 to 2014

BACKGROUND CONTEXTMetastatic spine disease (MSD) is becoming more prevalent as medical treatment for cancers advance and extend survival. More MSD patients are treated surgically to maintain neurological function, ambulation, and quality of life.PURPOSEThe purpose of this study was to use a large, nationally representative database to examine the trends, patient outcomes, and health-care resource utilization associated with surgical treatment of MSD.DESIGNThis was an epidemiologic study using national administrative data from the Nationwide Readmissions Database (NRD).PATIENT SAMPLEAll patients in the NRD from 2010 to 2014 who underwent spinal surgery were included in the study.OUTCOME MEASURESMortality, blood transfusion, complications, length of stay, cost, and discharge location during index hospitalization as well as hospital readmission and revision surgery within 90-days of surgery were analyzed.METHODSInternational Classification of Diseases, Ninth Revision, (ICD-9) codes was used to identify patients of interest within the NRD from 2010 to 2014. Patients were separated into two cohorts – those with MSD and those without. Trends for surgical treatment of MSD were assessed and outcomes measures for both cohorts were analyzed and compared.RESULTSThe number of surgical treatments for MSD increased from 6,007 in 2010 to 7,032 in 2014 (p-trend<.0001) which represented a 17.1% increase. During index hospitalization, MSD patients had an increased risk of mortality (odds ratio [OR]=3.22, 95% confidence interval [CI]: 2.85–3.63, p<.0001), blood transfusion (OR=2.93, 95% CI: 2.66–3.23, p<.0001), any complication (OR=1.24, 95% CI: 1.18–1.31, p<.0001), and discharge to skilled nursing facility (OR=1.51, 95% CI:1.41–1.61, p<.0001). MSD patients had longer average length of stay (13.05 vs. 4.56 days, p<.0001) and cost ($49,421.75 vs. $26,190.37, p<.0001) during index hospitalization. Furthermore, MSD patients had an increased risk of hospital readmission (OR=2.82, 95% CI: 2.68–2.96, p<.0001), readmission for surgical site infection (OR=2.38, 95% CI: 2.20–2.58, p<.0001), and readmission with neurologic deficits (OR=1.62, 95% CI: 1.27–2.06, p<.0001) despite a decreased risk of revision fusion (OR=0.71, 95% CI: 0.53–0.96, p=.026).CONCLUSIONSThe number of MSD patients who undergo surgical treatments is increasing. Not only do these patients have worse outcomes during index hospitalization, but they are also at an increased risk of hospital readmission for surgical site infection and neurologic complications. These findings stress the need for multidisciplinary perioperative treatment plans that mitigate risks and facilitate quick, effective recovery in these unique, at-risk patients.     

Comparing costs of renal preservation versus radical nephroureterectomy management among patients with non-metastatic upper tract urothelial carcinoma

BackgroundTo describe overall and categorical cost components in the management of patients with non-metastatic upper tract urothelial carcinoma (UTUC) according to treatment.MethodsWe identified 4,114 patients diagnosed with non-metastatic UTUC from 2004 to 2013 in the Survival Epidemiology and End Results-Medicare linked database. Patients were stratified into renal preservation (RP) vs. radical nephroureterectomy (NU) groups. Total Medicare costs within 1 year of diagnosis were compared for patients managed with RP vs. NU using inverse probability of treatment-weighted propensity score models.ResultsA total of 1,085 (26%) and 3,029 (74%) patients underwent RP and NU, respectively. Median costs were significantly lower for RP vs. NU at 90 days (median difference –$4,428, Hodges-Lehmann [H-L] 95% confidence interval [CI], –$7,236 to –$1,619) and 365 days (median difference –$7,430, H-L 95% CI, –$13,166 to –$1,695), respectively. Median costs according to categories of services were significantly less for RP vs. NU patients by hospitalization, office visits, emergency room/critical care, consultations, and anesthesia. The only category which was significantly higher for RP vs. NU was inpatient visits ($1,699 vs. $1,532; median difference $152; HL 95% CI, $19–$286).ConclusionsMedian costs were significantly lower for RP vs. NU up to 1-year and by hospitalization, office visits, emergency room/critical care, consultations, and anesthesia costs. In appropriately selected patients, such as patients with low-risk disease, these findings suggest the utility of RP as a suitable high-value management option in UTUC     

Treatment compliance in children and adults with Cystic Fibrosis

ObjectivesTo determine treatment compliance and how compliance was perceived by patients, parents and by a multidisciplinary team in Cystic Fibrosis (CF) patients. Also to analyse the relative importance given to each of the prescribed treatments, reasons for non-adherence and to investigate possible predictors of therapeutic compliance.Patients and methods34 CF patients (21 females), aged between 1.6 and 40.6 years, attending an outpatient CF clinic. Design: cross-sectional. A self-administered questionnaire was given to all patients whilst attending a programmed visit which was used to determine compliance to different treatments (physiotherapy, nutritional supplements, respiratory and digestive medications). Patients were subjectively classified as compliant or non-compliant by medical staff involved in their care.ResultsTreatment compliance was greater for digestive (88.2%) and respiratory medication (61.8%), compared to physiotherapy (41.2%) or nutritional supplements (59%). CF patients considered digestive medication indispensable (94.1%), compared to nutritional supplements (44.1%). Whilst 26.4% of CF patients considered that respiratory medications or nutritional supplements influenced little or nothing in their quality of life. Comparing age groups younger patients were found to be more compliant (10.4 vs. 20.5 years p = 0.008) and had less severe disease (Shwachman score 83.2 vs. 73.9 p = 0.048).ConclusionsCF patients had greater treatment adherence when prescribed digestive and respiratory medications, compared to physiotherapy or nutritional supplements. Therapeutic adherence was found to worsen with age and disease severity, however improved with treatments which were perceived by patients as more important or had a greater influence in their quality of life.     

Hospital outcomes and early readmission for the most common gastrointestinal and liver diseases in the United States: Implications for healthcare delivery

BACKGROUNDGastrointestinal (GI) and liver diseases contribute to substantial inpatient morbidity, mortality, and healthcare resource utilization. Finding ways to reduce the economic burden of healthcare costs and the impact of these diseases is of crucial importance. Thirty-day readmission rates and related hospital outcomes can serve as objective measures to assess the impact of and provide further insights into the most common GI ailments.AIMTo identify the thirty-day readmission rates with related predictors and outcomes of hospitalization of the most common GI and liver diseases in the United States.METHODSA cross-sectional analysis of the 2012 National Inpatient Sample was performed to identify the 13 most common GI diseases. The 2013 Nationwide Readmission Database was then queried with specific International Classification of Diseases, Ninth Revision, Clinical Modification codes. Primary outcomes were mortality (index admission, calendar-year), hospitalization costs, and thirty-day readmission and secondary outcomes were predictors of thirty-day readmission.RESULTSFor the year 2013, the thirteen most common GI diseases contributed to 2.4 million index hospitalizations accounting for about $25 billion. The thirty-day readmission rates were highest for chronic liver disease (25.4%), Clostridium difficile (C. difficile) infection (23.6%), functional/motility disorders (18.5%), inflammatory bowel disease (16.3%), and GI bleeding (15.5%). The highest index and subsequent calendar-year hospitalization mortality rates were chronic liver disease (6.1% and 12.6%), C. difficile infection (2.3% and 6.1%), and GI bleeding (2.2% and 5.0%), respectively. Thirty-day readmission correlated with any subsequent admission mortality (r = 0.798, P = 0.001). Medicare/Medicaid insurances, ≥ 3 Elixhauser comorbidities, and length of stay > 3 d were significantly associated with thirty-day readmission for all the thirteen GI diseases.CONCLUSIONPreventable and non-chronic GI disease contributed to a significant economic and health burden comparable to chronic GI conditions, providing a window of opportunity for improving healthcare delivery in reducing its burden.     

The effect of inpatient versus outpatient location on postoperative healthcare utilization after neonatal circumcision

Background/PurposeNeonatal circumcision is a common pediatric procedure performed in both the inpatient and outpatient setting. We aimed to determine if procedure location affected 30-day post-procedure healthcare utilization rates, inpatient length of stay (LOS), and amount charged.MethodsWe performed a retrospective cohort study comparing 30-day postoperative healthcare utilization (emergency department (ED) visits, office visits, readmissions) of full-term infants who underwent an outpatient versus inpatient (same admission as birth) circumcision from 2015 to 2020. Statistical analyses included Chi-square tests, multivariable adjusted logistic regression models when appropriate.Results3137 infants were included, 1426 (45.5%) had an outpatient circumcision, 1711 (54.5%) an inpatient. Outpatient had similar overall healthcare utilization rates as inpatients (5.7% vs. 5.6%, p = 0.933). The number of ED visits (1.5% vs 0.8%, p = 0.055), office visits (4.5% vs. 5.1%, p = 0.437), and readmissions (0.2% vs. 0.0%, p = 0.058) were not significantly different. Infants with inpatient circumcisions had longer LOS after adjusting for age, ethnicity and delivery type (Cesarean versus vaginal) with an incident rate ratio of 1.97 (95% confidence interval 1.84–2.11, p<0.001). Outpatient circumcision resulted in average charges of $372 more than inpatient.ConclusionsOutpatient circumcision has a minimal effect on healthcare utilization rates but lead to a shorter hospital stay following birth and increased charge.Study DesignRetrospectiveLevel of EvidenceIII     

Comfortably numb? Exploring satisfaction with chronic back pain visits

Background contextChronic back pain is a condition characterized by high rates of disability, health-care service use, and costs.PurposeThe purpose of this study was to identify factors associated with patients' satisfaction with their last health-care provider visit for chronic low back pain (LBP).Study design/settingA cross-sectional, state-level, telephone survey was administered to patients with chronic LBP.Patient sampleThe sample consisted of 624 individuals with chronic LBP who reported seeing a health-care provider in the previous year.Outcome measuresDependent variables included satisfaction with last visit for LBP and intent to seek care from additional providers. Independent variables included the Roland-Morris Disability Questionnaire, 3-month pain ratings using a 0 to 10 Likert scale, the Medical Outcomes Survey Short Form 12, and self-reported health service utilization (provider type, number of visits to health-care providers, medication use during the previous month, and treatments and diagnostic tests during the previous year).MethodsBivariate and multivariate analyses were used to explore how demographic, insurance-related, and health-related characteristics were associated with patient satisfaction.ResultsParticipants who were not satisfied with one or more aspects of their last clinic visit were younger (51.0 vs. 54.21 years), reported higher 3-month pain ratings (7.23 vs. 6.53), and were more commonly Hispanic (53.2% vs. 46.8% for other ethnicities) and uninsured (43.1% vs. 29.3% for other insurance groups). Those who intended to seek care from additional providers were younger (50.05 vs. 55.49 years), had higher 3-month pain ratings (7.20 vs. 6.46), had lower Short Form 12 mental health component scores (44.75 vs. 49.55) and physical component scores (30.07 vs. 31.55), and were more commonly black (54.6% vs. 45.4% for other racial groups) and uninsured (56.9% vs. 43.1% for other insurance groups). Narcotic use was associated with satisfaction (odds ratio=2.12, p=.01), whereas lack of insurance was associated with respondents' intent to seek care from additional providers (odds ratio=2.97, p<.01).ConclusionsFactors other than disability were associated with satisfaction with chronic LBP visits. Understanding the role of medication in satisfaction and its implications for the health behaviors of this highly disabled population may be particularly important.     

Impact of an enhanced recovery program for cesarean delivery on postoperative opioid use

BackgroundCesarean delivery is one of the most common surgeries performed worldwide and the adoption of enhanced recovery programs for cesarean delivery is gaining popularity. We tested the hypothesis that implementation of an enhanced recovery program for cesarean delivery would be associated with a decrease in postoperative opioid consumption.MethodsWe compared a retrospective cohort of women delivered by elective cesarean delivery (January 1, 2017 to June 30, 2018) to a prospective cohort exposed to the enhanced recovery protocol (July 1, 2018 to December 31, 2018). The primary outcome was inpatient maternal opioid use, measured as total oral morphine equivalents. Secondary outcomes included postoperative 0–10 pain scores, length of stay, 30-day postoperative complication rates, and hospital re-admissions.ResultsData from 541 patients were analyzed. The enhanced recovery cohort used significantly less oral morphine equivalents compared with the pre-enhanced recovery cohort (60.3 mg vs 104.3 mg, P <0.001). The number of patients who required opioid medication within 24 h of discharge was significantly reduced in the enhanced recovery cohort (41.1% vs 74.6%, P <0.001). There were no significant differences in average pain scores (1.6 vs 1.9, P=0.037).ConclusionsThe implementation of an enhanced recovery program for cesarean delivery was associated with a significant reduction in postoperative opioid consumption throughout hospitalization, with average pain scores remaining <2. Implementation of this program was also associated with an increase in the number of patients who were opioid-free 24 h prior to discharge.     

The effect of bariatric surgery on opioid consumption in patients with obesity: a registry-based cohort study

BackgroundMisuse of opioid medication has become a major health crisis in several countries. A significant number of patients with obesity use opioid medications, mostly to alleviate symptoms due to obesity-related co-morbidities.ObjectiveTo compare patterns of opioid drug usage before and after bariatric surgery in this population, hypothesizing that weight loss and improvement of obesity-related co-morbidities could reduce opioid consumption.SettingThe Ontario Bariatric Registry (Ontario, Canada).MethodsIn this retrospective cohort study, the Ontario Bariatric Registry was used to compare opioid consumption in adult patients undergoing bariatric surgery between 2010 and 2021. The primary outcome was the number of patients using opioid medication at 1 year after surgery. Multiple logistic regression analyses were performed to identify potential predictors of opioid consumption.ResultsData of 11,179 patients were analyzed. Mean age was 45.7 ± 10.2 years, mean baseline body mass index was 48.9 ± 8 kg/m², and 83.6% of patients were female. Roux-en-Y gastric bypass was performed in the majority of patients (85.6%), followed by sleeve gastrectomy (14.2%). At baseline, opioids were used by 7.7% and nonopioid pain medications by 42.3% of patients. At 1 year after surgery, these numbers significantly decreased (Δ–1.9% and Δ–18.0%, respectively). The decrease in the consumption of nonopioid pain medication needs to be interpreted in the context of the contraindication to nonsteroidal anti-inflammatory drugs after Roux-en-Y gastric bypass, which was the most commonly performed procedure. Presence of musculoskeletal pain and use of nonopioid pain medication at baseline were identified as independent predictors of opioid consumption at 1 year after surgery.ConclusionsAt 1 year after bariatric surgery, a significant decrease in opioid and nonopioid pain medication consumption was seen among patients with obesity. Aggressive management of excess weight, especially with bariatric surgery, can potentially reduce the impact of the opioid crisis in this population.     

The presence of a hernia sac in isolated congenital diaphragmatic hernia is associated with less disease severity: A retrospective cohort study

IntroductionWe aimed to determine if the presence of a hernia sac in neonates with isolated congenital diaphragmatic hernia (CDH) was associated with better clinical outcomes.MethodsWe performed a retrospective cohort study of infants with isolated CDH from 1991 to 2015. Primary outcome measures were oxygen-dependence and mortality at 28 days. Secondary measures were: inhaled nitric oxide use, vasoactive medication use, ventilator support, and recurrence rates.ResultsSeventy-one patients met the inclusion criteria: 14 patients (19.7%) had a hernia sac, and 57 patients (80.3%) did not. Mortality did not differ between the 2 groups [0 of 14 versus 3 of 57 (5.3%) (p = 1.000)]. Hernia sac patients had similar oxygen-dependence after 28 days [1 of 14 (7.1%) versus 14 of 57 (24.6%) (p = 0.273)]. Hernia sac children required less iNO (0.64 ± 2.41 vs. 6.35 ± 12.2 days, p = 0.002), vasoactive medications (2.79 ± 3.07 vs. 5.36 ± 5.52, p = 0.027), and time on ventilation (7.62 ± 6.12 vs. 15.9 ± 19.2, p = 0.010). Hernia sac children had similar recurrence rates within 2 years [0 of 14 versus 7 of 57 (12.3%) (p = 0.331)].ConclusionThe presence of a hernia sac was not associated with lower rates of oxygen dependency or death at 28 days but was associated with decreased inhaled nitric oxide, vasoactive medication, and ventilator use.Level of evidenceIII     

Enhanced Selection of Candidates for Same-Day and Outpatient Total Knee Arthroplasty

BackgroundMedicare removed total knee arthroplasty (TKA) from its inpatient-only list and private insurers created ambulatory surgical codes; these changes bring about logistical challenges for TKA episode planning. We identified preoperatively determined factors associated with hospital length of stay for (1) same-day discharge (SDD) and (2) inpatient TKA defined by Medicare’s 2-midnight rule benchmark.MethodsWe retrospectively reviewed 325 consecutive unilateral primary TKAs performed on patients completing the Perioperative Surgical Home preoperative optimization pathway within a single hospital system. Stepwise logistic regression modeling was performed to identify preoperatively determined factors associated with (1) SDD and (2) inpatient TKA. We compared these models’ ability to discern the length of stay category to the Risk Assessment and Prediction Tool (RAPT) score alone.ResultsThe cohort included 32 (10%) SDD, 189 (58%) next-day discharges, and 104 (32%) inpatients. Lower body mass index (BMI; odds ratio [OR], 0.92; 95% CI, 0.85-0.1.0; P = .04) and fewer self-reported allergies (OR, 0.66; 95% CI, 0.46-0.95; P = .03) were associated with SDD. The SDD model outperformed the RAPT alone (C-statistic, 0.73 vs 0.52; P < .01). Older age (OR, 0.96; P = .04), higher BMI (OR, 0.93; P 0.01), lower RAPT score (OR, 1.2; P = .04), and later surgery start time (OR, 0.80; P < .01) were associated with inpatient discharge. The inpatient model outperformed the RAPT alone (C-statistic, 0.74 vs 0.62; P < .01).ConclusionWe identified preoperatively determined factors associated with (1) SDD as BMI and allergies and (2) inpatient TKA as age, BMI, RAPT score, and surgery start time. Hospitals, providers, patients, families, and payers can use this information for TKA episode planning.