Inpatient Surgery Research Articles

RURAL–URBAN DIFFERENCES IN POSTSURGICAL SERVICE USE AND OUTCOMES AMONG VETERANS WITH DEMENTIA

Abstract Adults with dementia have worse post-surgical outcomes than those without dementia, including readmission and death. The use of home health or facility-based skilled nursing after discharge may prevent poor outcomes. We know little about rural-urban differences in post-discharge services or outcomes among individuals with dementia. We examined the relationship between post-discharge service use and 30-day readmission or mortality using retrospective data for Veterans Affairs patients aged 65+ with dementia who underwent inpatient surgery between 2013-2019. We used merged VA and Medicare claims to categorize patients as discharged to home without services, home with home health, or skilled nursing/rehabilitation facility [SNF]. We excluded individuals who were transferred to another acute hospital, transferred to hospice, died or were readmitted within 3 days of discharge, or were not enrolled in Medicare. We used multivariable logistic regression to assess associations between rurality, discharge location, and outcomes, while controlling for demographics, frailty, comorbidities, surgical specialty, and surgical complexity. The analytic sample included 4534 Veterans; 48.7% discharged to a SNF, 40.1% to home without services, and 10.4% to home with home health. We did not find rural-urban differences in risk-adjusted readmission or mortality overall. Among those discharged to home (n=2324), receipt of home health was modestly associated with decreased readmission risk overall (OR=0.52; p=0.07), and lower risk of morality among urban Veterans (OR=0.34; p=0.05) but not rural Veterans. Although we did not find rurality disparities in outcomes, further research may identify reasons home health decreases post-surgical mortality among urban but not rural adults with dementia.

Preoperative Midazolam and Patient-Centered Outcomes of Older Patients

The effect of oral midazolam premedication on patient satisfaction in older patients undergoing surgery is unclear, despite its widespread use. To determine the differences in global perioperative satisfaction in patients with preoperative administration of oral midazolam compared with placebo. This double-blind, parallel-group, placebo-controlled randomized clinical trial was conducted in 9 German hospitals between October 2017 and May 2019 (last follow-up, June 24, 2019). Eligible patients aged 65 to 80 years who were scheduled for elective inpatient surgery for at least 30 minutes under general anesthesia and with planned extubation were enrolled. Data were analyzed from November 2019 to December 2020. Patients were randomized to receive oral midazolam, 3.75 mg (n = 309), or placebo (n = 307) 30 to 45 minutes prior to anesthesia induction. The primary outcome was global patient satisfaction evaluated using the self-reported Evaluation du Vécu de l'Anesthésie Generale (EVAN-G) questionnaire on the first postoperative day. Key secondary outcomes included sensitivity and subgroup analyses of the primary outcome, perioperative patient vital data, adverse events, serious complications, and cognitive and functional recovery up to 30 days postoperatively. Among 616 randomized patients, 607 were included in the primary analysis. Of these, 377 (62.1%) were male, and the mean (SD) age was 71.9 (4.4) years. The mean (SD) global index of patient satisfaction did not differ between the midazolam and placebo groups (69.5 [10.7] vs 69.6 [10.8], respectively; mean difference, -0.2; 95% CI, -1.9 to 1.6; P = .85). Sensitivity (per-protocol population, multiple imputation) and subgroup analyses (anxiety, frailty, sex, and previous surgical experience) did not alter the primary results. Secondary outcomes did not differ, except for a higher proportion of patients with hypertension (systolic blood pressure ≥160 mm Hg) at anesthesia induction in the placebo group. A single low dose of oral midazolam premedication did not alter the global perioperative patient satisfaction of older patients undergoing surgery or that of patients with anxiety. These results may be affected by the low dose of oral midazolam. Further trials-including a wider population with commonplace low-dose intravenous midazolam and plasma level measurements-are needed. ClinicalTrials.gov Identifier: NCT03052660.

Rescue designs in analgesic trials from 0 to 2 years of age: scoping review.

Pediatric analgesic trials are challenging, especially in newborns and infants. Following an FDA-academic consensus meeting, we analyzed pragmatic rescue designs in postoperative trials of local anesthetics, acetaminophen, opioids, and NSAIDs involving children ages 0-2 years and assessed surgical volumes to provide trial design recommendations. Searches of PubMed, Embase, CINAHL, The Cochrane Library, and Web of Science were conducted. A scoping approach identified trends in analgesic trials with an emphasis on randomized controlled trials (RCTs) utilizing immediate rescue designs. Age-specific surgical volumes were estimated from French national databases. Of 3563 studies identified, 23 RCTs used study medication(s) of interest and immediate rescue paradigms in children ages 0-2 years. A total of 270 studies met at least one of these criteria. Add-on and head-to-head designs were common and often used sparing of non-opioid or opioid rescue medication as a primary outcome measure. According to French national data, inguinal and penile surgeries were most frequent in ages 1 month to 2 years; abdominal and thoracic surgeries comprise approximately 75% of newborn surgeries. Analgesic trials with rescue sparing paradigm are currently sparse among children ages 0-2 years. Future trials could consider age-specific surgical procedures and use of add-on or head-to-head designs. IMPACT: Clinical trials of analgesic medications have been challenging in pediatrics, especially in the group from newborns to 2 years of age. Following an FDA-academic workshop, we analyzed features of completed analgesic trials in this age group. Studies using immediate rescue in placebo control, add-on, and head-to-head trial designs are pragmatic approaches that can provide important information regarding clinical effectiveness, side effects, and safety. Using a French national dataset with a granular profile of inpatient, outpatient, and short-stay surgeries, we provide information to future investigators on relative frequencies of different operations in neonates and through the first 2 years of life.

Ketamine for postoperative avoidance of depressive symptoms: the K-PASS feasibility randomised trial

BackgroundSurgical patients with previous depression frequently experience postoperative depressive symptoms. This study's objective was to determine the feasibility of a placebo-controlled trial testing the impact of a sustained ketamine infusion on postoperative depressive symptoms. MethodsThis single-centre, triple-blind, placebo-controlled randomised clinical trial included adult patients with depression scheduled for inpatient surgery. After surgery, patients were randomly allocated to receive ketamine (0.5 mg kg−1 over 10 min followed by 0.3 mg kg−1 h−1 for 3 h) or an equal volume of normal saline. Depressive symptoms were measured using the Montgomery–Asberg Depression Rating Scale. On post-infusion day 1, participants guessed which intervention they received. Feasibility endpoints included the fraction of patients approached who were randomised, the fraction of randomised patients who completed the study infusion, and the fraction of scheduled depression assessments that were completed. ResultsIn total, 32 patients were allocated a treatment, including 31/101 patients approached after a protocol change (31%, 1.5 patients per week). The study infusion was completed without interruption in 30/32 patients (94%). In each group, 7/16 participants correctly guessed which intervention they received. Depression assessments were completed at 170/192 scheduled time points (89%). Between baseline and post-infusion day 4 (pre-specified time point of interest), median depressive symptoms decreased in both groups, with difference-in-differences of −1.00 point (95% confidence interval −3.23 to 1.73) with ketamine compared with placebo. However, the between-group difference did not persist at other time points. ConclusionsPatient recruitment, medication administration, and clinical outcome measurement appear to be highly feasible, with blinding maintained. A fully powered trial may be warranted. Clinical trial registrationNCT05233566.

“I can’t imagine having to do it on your own”: a qualitative study on postoperative transitions in care from the perspectives of older adults with frailty

BackgroundAdults aged 65 and older have surgery more often than younger people and often live with frailty. The postoperative transition in care from hospital to home after surgey is a challenging time for older adults with frailty as they often experience negative outcomes. Improving postoperative transitions in care for older adults with frailty is a priority. However, little knowledge from the perspective of older adults with frailty is available to support meaningful improvements in postoperative transitions in care.ObjectiveTo explore what is important to older adults with frailty during a postoperative transition in care.MethodsThis qualitative study used an interpretive description methodology. Twelve adults aged ≥ 65 years with frailty (Clinical Frailty Scale score ≥ 4) who had an inpatient elective surgery and could speak in English participated in a telephone-based, semi-structured interview. Audio files were transcribed and analyzed using thematic analysis.ResultsFive themes were constructed: 1) valuing going home after surgery; 2) feeling empowered through knowledge and resources; 3) focusing on medical and functional recovery; 4) informal caregivers and family members play multiple integral roles; and 5) feeling supported by healthcare providers through continuity of care. Each theme had 3 sub-themes.ConclusionFuture programs should focus on supporting patients to return home by empowering patients with resources and clear communication, ensuring continuity of care, creating access to homecare and virtual support, focusing on functional and medical recovery, and recognizing the invaluable role of informal caregivers.

Uncovering Risk Factors and Outcomes of Pulmonary Embolism in a Nationwide Cohort of Hospitalized Children.

The incidence of pulmonary embolism (PE) in hospitalized children has increased in recent years. This study sought to characterize factors and outcomes associated with PE using a national pediatric cohort. The Nationwide Readmissions Database was queried (2016-2018) for patients (<18years) with a diagnosis of PE. Index and prior hospitalizations (PHs) within 1year were analyzed. A binary logistic regression utilizing 37 covariates (demographics, procedures, comorbidities, etc.) was constructed to examine a primary outcome of in-hospital mortality. 3440 patients were identified (57% female) with the majority >12years old (77%). One-third had a known deep vein thrombosis (69% lower and 31% upper extremity). Nineteen percent underwent central venous catheter (CVC) placement. Twenty-one percent had a PH within 1year. Nine percent underwent an operation with the majority being cardiothoracic (5%). Overall mortality was 5%. Neurocranial surgery, cardiothoracic surgery, and CVC placement were associated with the highest odds of inpatient mortality after logistic regression. Pediatric patients with PE have a high rate of PHs, CVC placement, and inpatient operations, which may be associated with higher mortality. This information can be utilized to improve screening measures and clinical suspicion for PE in hospitalized children.

Lumbar Laminotomy: Variables Affecting 90-day Overall Reimbursement.

Lumbar laminotomy/diskectomy is a common procedure performed to address radiculopathy that persists despite conservative treatment. Understanding cost/reimbursement variability and its drivers has the potential to help optimize related healthcare delivery. The goal of this study was to assess variability and factors associated with reimbursement through 90 days after single-level lumbar laminotomy/diskectomy. Lumbar laminotomies/diskectomies were isolated from the 2010 to 2021 PearlDiver M151 data set. Exclusion criteria included patients younger than 18 years; other concomitant spinal procedures; and indications of trauma, oncologic, or infectious diagnoses. Patient, surgical, and perioperative data were abstracted. These variables were examined using a multivariable linear regression model with Bonferroni correction to determine factors independently correlated with reimbursement. A total of 28,621 laminotomies/diskectomies were identified. The average ± standard deviation 90-day postoperative reimbursement was $9,453.83 ± 19,343.99 and, with a non-normal distribution, the median (inner quartile range) was $3,314 ($5,460). By multivariable linear regression, variables associated with greatest increase in 90-day postoperative reimbursement were associated with admission (with the index procedure [+$11,757.31] or readmission [+$31,248.80]), followed by insurance type (relative to Medicare, commercial +$4,183.79), postoperative adverse events (+$2,006.60), and postoperative emergency department visits (+$1,686.89) ( P < 0.0001 for each). Lesser associations were with Elixhauser Comorbidity Index (+$286.67 for each point increase) and age (-$24.65 with each year increase) ( P < 0.001 and P = 0.003, respectively). This study assessed a large cohort of lumbar laminotomies/diskectomies and found substantial variations in reimbursement/cost to the healthcare system. The largest increase in reimbursement was associated with admission (with the index procedure or readmission), followed by insurance type, postoperative adverse events, and postoperative emergency department visits. These results highlight the need to balance inpatient versus outpatient surgeries while limiting postoperative readmissions to minimize the costs associated with healthcare delivery.

Failure to rescue following postoperative pneumonia in pediatrics: Is there a racial disparity?

Racial disparities in measures of health and healthcare processes are well described. Limited work exists on disparities in failure to rescue - hospital mortality following a major adverse event. Postoperative pneumonia is a serious, potentially preventable adverse event that often leads to death, i.e., failure to rescue. This study examined the association of racial grouping with failure to rescue following postoperative pneumonia. We utilized the National Surgical Quality Improvement Program-Pediatrics Participant Use Data File to assemble a cohort of children <18 years who underwent inpatient surgery from 2012 to 2022. We included Black and White patients who developed pneumonia following an index surgery. The primary outcome was failure to rescue, defined as mortality following postoperative pneumonia. We used logistic regression models to estimate the odds ratio and 95% confidence intervals of failure to rescue, comparing Black and White children. The study cohort included 3139 children <18 years who developed pneumonia following inpatient surgery. Of those, 2333 (74.3%) were White and 806 (25.7%) were Black. Failure to rescue occurred in 117 of the children (3.7%); 82 were White (3.5%) and 35 were Black (4.3%). After adjusting for gender, age, American Society of Anesthesiologists Physical Status classification, emergent/urgent vs. elective case status, year of operation, and pre-existing comorbidities, the odds of failure to rescue for Black children with postoperative pneumonia did not differ from White children (adjusted-Odds Ratio: 1.00; 95% Confidence Interval 0.62-1.61; p-value = .992). We found no significant difference in the odds of failure to rescue following postoperative pneumonia between Black or White children. To improve postoperative care for all children and to narrow the racial gap in postoperative mortality, future studies should continue to investigate the association of race with failure to rescue following other postoperative complications.

EE285 Economic Evaluation of Knee Arthroscopic Surgery: A Comparison of Ambulatory and In-Patient Knee Arthroscopic Surgery in Thailand

EE285 Economic Evaluation of Knee Arthroscopic Surgery: A Comparison of Ambulatory and In-Patient Knee Arthroscopic Surgery in Thailand

Internal brace augmentation reconstruction versus standard anterior cruciate ligament reconstruction: a randomised controlled clinical trial study protocol

IntroductionAnterior cruciate ligament (ACL) rupture is one of the most common knee injuries in sports, and the gold standard for treating ACL rupture is tendon graft reconstruction. Internal brace technology...

2482. Cross Validation of Surgical Procedure Data in National Healthcare Safety Network vs Hospital Discharge Data

Abstract Background California acute care hospitals (ACH) are required to report data on 28 types of inpatient surgical procedures via the National Healthcare Safety Network (NHSN). ACH also report discharge data, including procedure data, to the California Department of Healthcare Access and Information (HCAI). We compared the number of adult (age &amp;gt;=18) procedures reported in NHSN versus HCAI in 2019 for cardiac surgery (CARD), coronary bypass with chest and donor incisions (CBGB), hip prosthesis (HPRO), kidney transplant (KTP), and rectal surgery (REC). Methods For both systems, we aggregated procedure counts to the facility level and matched individual facilities. HCAI ICD-10 codes were mapped to NHSN procedure codes. Because NHSN counts multiple procedures that map to the same procedure code done via the same incision as one procedure and HCAI does not specify how many procedures were done per incision, CARD, CBGB, and REC were counted only once per procedure code per patient per day. HPRO and KTP were counted up to twice per patient per day if ICD-10 codes for both right and left side surgeries were present. ANOVA was used to compare the means of log standardized infection ratio (SIR) by NHSN to HCAI procedure count ratio as categories of less than 0.9, between 0.9 and 1.1, and more than 1.1. Results Three hundred eleven facilities reported 82,847 procedures to NHSN and 300 facilities reported 91,961 procedures to HCAI. Median and interquartile interval for the facility-specific ratio of NHSN to HCAI procedures among facilities that reported procedures in both systems are displayed in Table 1. ANOVA failed to detect any difference in mean of log SIR by different NHSN to HCAI procedure count ratio at α of 0.05. Conclusion For all procedure types, there were more procedures documented in HCAI than NHSN, but the ratios of NHSN procedures to HCAI procedures varied widely by procedure type. However, difference in ratio was not associated with SIR. Ability to compare procedure counts was limited by inability to ascertain operating room deaths (which are not counted in NHSN) and if procedures were done using the same incision in HCAI. Further analysis is recommended since SSI denominator quality is crucial to the accuracy of SIR, which informs many analyses and interventions. Disclosures All Authors: No reported disclosures

The successful and safe conversion of joint arthroplasty to same-day surgery: A necessity after the COVID-19 pandemic.

A key strategy to address system pressures on hip and knee arthroplasty through the COVID-19 pandemic has been to shift procedures to the outpatient setting. This was a retrospective cohort and case-control study. Using the Discharge Abstract Database and the National Ambulatory Care Reporting System databases, we estimated the use of outpatient hip and knee arthroplasty in Ontario, Canada. After propensity-score matching, we estimated rates of 90-day readmission, 90-day emergency department (ED) visit, 1-year mortality, and 1-year infection or revision. 204,066 elective hip and 341,678 elective knee arthroplasties were performed from 2010-2022. Annual volumes of hip and knee arthroplasties increased steadily until 2020. Following the start of the COVID-19 pandemic (March 1, 2020) through December 31, 2022 there were 7,561 (95% CI 5,435 to 9,688) fewer hip and 20,777 (95% CI 17,382 to 24,172) fewer knee replacements performed than expected. Outpatient arthroplasties increased as a share of all surgeries from 1% pre-pandemic to 39% (hip) and 36% (knee) by 2022. Among inpatient arthroplasties, the tendency to discharge to home did not change since the start of the pandemic. During the COVID-19 era, patients receiving arthroplasty in the outpatient setting had a similar or lower risk of readmission than matched patients receiving inpatient arthroplasty [hip: RR 0.65 (0.56-0.76); knee: RR 0.86 (0.76-0.97)]; ED visits [hip: RR 0.78 (0.73-0.83); knee: RR 0.92 (0.88-0.96)]; and mortality, infection, or revision [hip: RR 0.65 (0.45-0.93); knee: 0.90 (0.64-1.26)]. Following the start of the COVID-19 pandemic in Ontario, the volume of outpatient hip and knee arthroplasties performed increased despite a reduction in overall arthroplasty volumes. This shift in surgical volumes from the inpatient to outpatient setting coincided with pressures on hospitals to retain inpatient bed capacity. Patients receiving arthroplasty in the outpatient setting had relatively similar outcomes to those receiving inpatient surgery after matching on known sociodemographic and clinical characteristics.

Thoracic day surgery versus thoracic inpatient surgery for treatment of patients with lung cancer: a systematic review and meta-analysis

BackgroundThe successful implementation of the Enhanced recovery after surgery (ERAS) concept in thoracic surgery has made it possible to complete the surgery in the day surgery unit. However, it is still unclear whether day surgery for lung cancer patients can achieve the same or even better results.MethodsA systematic literature search was completed in common databases for studies published before May 2022 and the data analyzed using the Review Manager 5.3 software.ResultsWe ultimately included 7 retrospective articles that met our criteria for the study. The results of age, smoking status, comorbidity and pulmonary function tests in day surgery group were better than in inpatient surgery group. Minimally invasive surgical method with segmentectomy was more used in day surgery group than in normal surgery group. The 30-day mortality was also lower in Day surgery group and it displayed that early discharged patients had fewer overall complications than the inpatient surgery group.ConclusionsWe demonstrate that younger patients, patients receiving segmental resections by VATS, and those with better pulmonary function tests or without comorbidity can be discharged early with low rates of complications and 30-day mortality, especial with ERAS program.

Impact of beta blockers on perioperative complications in patients undergoing major noncardiac surgery

Abstract Introduction Beta blockers (BB) are broadly used in patients with cardiovascular disease because they are known to decrease myocardial oxygen consumption by decreasing heart rate and myocardial contractility. Pilot studies have shown conflicting results. Therefore, we aimed to evaluate the impact of preoperative BB therapy on (1) the incidence of cardiac perioperative myocardial injury/infarction (PMI) within 48 hours after surgery and (2) long-term MACE within 365 days in patients after major noncardiac surgery. Methods We prospectively included consecutive high-risk patients undergoing inpatient major noncardiac surgery at a university hospital and a hospital, both in Switzerland, who were eligible for the institutional active PMI surveillance and response program. The primary endpoint was PMI due to cardiac causes (type 1 myocardial infarction (MI), tachyarrhythmia, acute heart failure, or type 2 MI) within 3 days after surgery, centrally adjudicated by two independent experts. The secondary endpoint was the occurrence of MACE, defined as a composite of acute myocardial infarction, acute heart failure, life-threatening arrhythmia, and cardiovascular death, within 365 days. We used inverse probability of treatment weighting to account for differences between BB and non-BB users and then performed a univariable logistic regression with cardiac PMI and a univariable Cox proportional hazard model with MACE as a dependent variable. Results Between October 2014 and February 2018, we included 7751 high-risk patients undergoing major inpatient noncardiac surgery. The median age was 74 years and 45% were female. 2856 of 7751 patients (36.8%) received preoperative BB therapy. Patients receiving BB therapy had more cardiovascular comorbidities like known coronary artery disease, atrial fibrillation, or hypertension. After IPTW, we achieved a good balance between patients receiving BB therapy and those who did not. 812 patients (10.5%) had a cardiac PMI within 3 days after surgery. When comparing the patients receiving BB to those that did not, we did not see any difference in the occurrence of cardiac PMI, resulting in a weighted odds ratio of 0.99 (95% Confidence interval [CI] 0.89-1.10). The composite secondary endpoint MACE within 365 days occurred in 9% of all patients. In multivariable analysis, there was no difference between patients receiving BB and those that did not, with a weighted hazard ratio of 1.07 (95% CI 0.86-1.33). Conclusion In our patient cohort, we could not see any difference in cardiac PMI between patients receiving BB therapy and those who did not, suggesting that continuing BB perioperatively is safe but not associated with any benefit. Also after 1 year, we saw no difference in MACE between patients receiving BB therapy versus those who did not.MACE within 365 days

Improved postoperative outcomes in pediatric major surgery: evidence from hospital volume analysis.

This study aimed to examine the association between hospital volume and postoperative outcomes in pediatric major surgery using a nationwide database. The study included pediatric patients who underwent first major elective inpatient surgery and hospitalization for more than 1day. The results showed no significant difference in the risk of 30-day postoperative mortality based on hospital volume. However, patients in the middle- and high-volume groups had significantly lower rates of 30-day major complications, particularly deep wound infection. In terms of 90-day postoperative outcomes, patients in the high-volume group had a significantly lower risk of mortality and lower rates of major complications, particularly deep wound infection, pneumonia, and septicemia. Conclusions: The study suggests that pediatric patients undergoing major surgery in high and middle-volume groups have better outcomes in terms of major complications compared to the low-volume group. What is Known: • Limited evidence exists on the connection between hospital volume and pediatric surgery outcomes. What is New: • A Taiwan-based study, using national data, found that high and middle hospital-volume groups experienced significantly lower rates of major complications within 30 and 90 days after surgery. • High-volume hospitals demonstrated a substantial decrease in the risk of 90-day postoperative mortality. • The study underscores the importance of specialized pediatric surgical centers and advocates for clear guidelines for hospital selection, potentially improving outcomes and informing future health policies.

Higher Risk of Reoperation after Total Knee Arthroplasty in Young and Elderly Patients

As outcomes and survivorship improve, total knee arthroplasty (TKA) has expanded into broader age groups. The purpose of this study is to analyze the impact of age on TKA outcomes using the National Surgical Quality Improvement Program (NSQIP) database from 2015 to 2020. Patients were categorized into young (40–49 years), middle (50–79 years), and elderly (80–89 years) groups. Findings reveal notable differences across age groups. The young cohort had the highest BMI, smoking incidence, and steroid use, while the elderly group exhibited a higher prevalence of comorbidities. Young patients experienced shorter hospital stays (p &lt; 0.001) but longer operative times (p &lt; 0.001), and outpatient surgery was most common in the middle age group. Multivariable regression demonstrated that the elderly group faced increased risks of pneumonia (p &lt; 0.001), acute renal failure (p &lt; 0.001), stroke (p &lt; 0.001), cardiac arrest (p &lt; 0.001), and transfusions (p &lt; 0.001), while both young and elderly patients had higher 30-day reoperation risks (youngest cohort, 1.4% and elderly cohort 1.3% (p &lt; 0.001)). In summary, elderly patients undergoing TKA are at the highest risk for medical complications, while young patients are more likely to undergo inpatient surgery, experience reoperations, and have longer operative times. This study underscores the importance of age-specific counseling for TKA patients and contributes valuable insights into the evolving landscape of knee replacement surgery.

Incidence and Severity of Post-dural Puncture Headache in Non-obstetric Patients Undergoing Subarachnoid Block.

Background and goal of the study Post-dural puncture headache (PDPH) is a complication of central neuraxial block, either subarachnoid block (SAB) or epidural block. This clinical entity has a wide incidence and is affected by factors such as age, gender, needle gauge, needle shape/type, number of puncture attempts, and previous history of headache. Due to the lack of data in the non-obstetric population, this study assesses the incidence and severity of PDPH after SAB. Materials and methods A prospective observational study was carried out on patients undergoing SAB during the last trimester of 2020. Data were recorded on the day of surgery, 48 hours, and seven days after surgery. Data collected included demographic and medical clinic information, SAB procedure details, and clinical outcomes related to the presence of PDPH. Results and discussion Overall, 143 patients were included (median age: 62 years;53.1% were women (n=76)). Most patients were aged >60 years (55.9%; n=80) and ASA 2 classification (65.0%; n=93). The incidence of PDPH was 21.7% (n=31), and most cases were from inpatient surgery (58.3%, n=21). The incidence of PDPH was 2.5 times higher with the use of 25 gauge compared to the use of the 27 gauge needle and was more prevalent with the use of the Quincke needles. Conclusion Over 20% of patients undergoing SAB experienced PDPH. Previous history of headache, larger gauge, and the Quincke needle use were associated with a higher incidence of PDPH.

Adherence to legislation limiting opioid prescription duration following musculoskeletal injury.

North Carolina had implemented legislation (Strengthen Opioid Misuse Prevention (STOP) Act) limiting opioid prescriptions to 5 days for acute pain and 7 days for post-operative pain. This study aimed to identify patient, prescriber, and facility characteristics associated with STOP Act adherence for patients with acute or post-surgical musculoskeletal (MSK) conditions. A three-level hierarchical logistic regression model was used to predict odds of adherence with STOP Act duration limits, accounting for fixed and random effects at the patient, prescriber, and facility levels. A large healthcare system in North Carolina. Patients (N = 6,849) presenting from 2018 to 2020 with a diagnosis of an acute MSK injury. The STOP Act limited the duration of opioid prescriptions in North Carolina. Prescriptions adhering to the STOP Act duration limits of 5 days (nonoperative) or 7 days (operative) were the primary outcome. Opioids were compliant with STOP Act duration limits in 69.3 percent of encounters, with 33 percent of variation accounted for by clinician and 29 percent by facility. Patients prescribed >1 opioid (odds ratio (OR) 0.46, 95 percent confidence interval (CI): 0.36, 0.58) had reduced odds of a compliant prescription; surgical patients had increased odds of a compliant prescription (outpatient surgery: OR 5.89, 95 percent CI: 2.43-14.29; inpatient surgery: OR 7.71, 95 percent CI: 3.04-19.56). Primary care sports medicine clinicians adhered to legislation less frequently than orthopedic surgeons (OR 0.38, 95 percent CI: 0.15, 0.97). Most prescriptions adhered to STOP Act legislation. Tailored interventions to improve adherence among targeted groups of prescribers, eg, those treating nonoperative injuries and sport medicine clinicians, could be useful.

Impact of Hospital Affiliation With a Flagship Hospital System on Surgical Outcomes.

To compare general surgery outcomes at flagship systems, flagship hospitals, and flagship hospital affiliates versus matched controls. It is unknown whether flagship hospitals perform better than flagship hospital affiliates for surgical patients. Using Medicare claims for 2018 to 2019, we matched patients undergoing inpatient general surgery in flagship system hospitals to controls who underwent the same procedure at hospitals outside the system but within the same region. We defined a "flagship hospital" within each region as the major teaching hospital with the highest patient volume that is also part of a hospital system; its system was labeled a "flagship system." We performed 4 main comparisons: patients treated at any flagship system hospital versus hospitals outside the flagship system; flagship hospitals versus hospitals outside the flagship system; flagship hospital affiliates versus hospitals outside the flagship system; and flagship hospitals versus affiliate hospitals. Our primary outcome was 30-day mortality. We formed 32,228 closely matched pairs across 35 regions. Patients at flagship system hospitals (32,228 pairs) had lower 30-day mortality than matched control patients [3.79% vs. 4.36%, difference=-0.57% (-0.86%, -0.28%), P<0.001]. Similarly, patients at flagship hospitals (15,571/32,228 pairs) had lower mortality than control patients. However, patients at flagship hospital affiliates (16,657/32,228 pairs) had similar mortality to matched controls. Flagship hospitals had lower mortality than affiliate hospitals [difference-in-differences=-1.05% (-1.62%, -0.47%), P<0.001]. Patients treated at flagship hospitals had significantly lower mortality rates than those treated at flagship hospital affiliates. Hence, flagship system affiliation does not alone imply better surgical outcomes.

An evaluation of three validated comorbidity indices to predict short-term postoperative outcomes after prosthetic urologic surgery.

Commonly used comorbidity indices include the Charlson Comorbidity Index (CCI), Elixhauser/Van Walraven Index (VWI), and modified frailty index (mFI). This study evaluates whether these indices predict postoperative readmissions and complications after inflatable penile prosthesis (IPP) and artificial urinary sphincter (AUS) placement. We identified adult males who underwent IPP or AUS placement using the State Inpatient and State Ambulatory Surgery and Services Databases for Florida (2010-2015) and California (2010-2011). CCI, VWI, and mFI scores were calculated for each patient. We extracted 30-day emergency department services, 30-day readmissions, 90-day device complications (e.g., removal, replacement, or infection), and 90-day postoperative complications (excluding device complications). Receiver-operating characteristic curves were constructed and areas under the curve (AUC) were compared between the indices using the VWI as the reference model. We considered an AUC < 0.7 to represent poor predictive power. We identified 4242 IPP and 1190 AUS patients. All three indices had AUCs and 95% confidence intervals less than 0.70 for all outcomes following IPP and AUS placement making these indices poor predictors for postoperative outcomes. There were no significant differences in predicting 90-day postoperative complications between the VWI (AUC = 0.59, 95% CI [0.54-0.63]), CCI (AUC = 0.59, 95% CI [0.54-0.63], p = 0.99), and mFI (AUC = 0.60, 95% CI [0.55-0.66], p = 0.53) for IPPs and VWI (AUC = 0.54, 95% CI [0.47-0.61]), CCI (AUC = 0.50, 95% CI [0.43-0.57], p = 0.30), and mFI (AUC = 0.52, 95% CI [0.43-0.60], p = 0.56) for AUS placements. All three comorbidity indices were poor predictors of readmissions and complications following urologic prosthetic surgeries. A better comorbidity index is needed for risk-stratification of patients undergoing these surgeries.