Postoperative Emergency Department Research Articles

Concurrent Perioperative Benzodiazepine and Opioid Utilization in Opioid-Naive Patients Undergoing Soft Tissue Hand Surgery.

While concomitant opioid and benzodiazepine use is discouraged due to an increased risk of sedation/overdose, the extent of perioperative opioid utilization in hand surgery patients already using benzodiazepines is unknown. Using an administrative claims database, we identified adults undergoing carpal tunnel, DeQuervain, or trigger finger release, palmar fasciectomies, ganglion/mucoid cyst removals, and hand/wrist soft tissue mass excisions from 2011 to 2021. We identified opioid-naive patients with a benzodiazepine prescription within 90 days before surgery. Outcomes included the percentage of patients prescribed opioids and the amount of opioids prescribed, new persistent opioid utilization, postoperative emergency department (ED) visits, hand therapy utilization, and opioid overdose. We used multivariable regression models to adjust for age, sex, region, insurance, procedure, and comorbidities. Patients with benzodiazepine utilization had a higher adjusted odds of perioperative opioid prescriptions, amount of opioids filled, and new, persistent opioid use compared with patients without benzodiazepine use (all P < .001). In the multivariable analysis, patients with benzodiazepine use received +30.8 (95% CI: 28.9-32.8) morphine milligram equivalents and had an odds ratio of 1.48 (95% CI: 1.44-1.52) for developing new, persistent opioid use compared with patients without benzodiazepine use. Patients with preoperative benzodiazepine use also had increased postoperative ED visits and hand therapy utilization. Opioid-naive patients undergoing soft tissue hand surgery who are using benzodiazepines were prescribed opioids more frequently/at higher amounts and experienced an increased odds of developing new, persistent opioid use. Surgeons could consider reducing opioid prescriptions in patients already using benzodiazepines in favor of nonopioid pain strategies.

Perioperative Outcomes in Patients with and Without Chronic Preoperative Therapeutic Anticoagulation Undergoing Metabolic Surgery at an Academic Medical Center.

Background/Objectives: Patients on chronic anticoagulation undergoing metabolic surgery represent an increased risk of complications, including both bleeding and thrombotic events, such as deep vein thrombosis (DVT) and pulmonary embolism (PE). The optimal perioperative management of patients who are receiving chronic anticoagulation therapy (CAT) is complex. In the colorectal surgery literature, patients on CAT have a 10% rate of peri-procedural bleeding and a 3% rate of thromboembolism. The aim of this study was to evaluate and compare the safety and postoperative outcomes between patients with and without CAT undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at a tertiary referral center in the United Arab Emirates (UAE). Methods: All patients who underwent primary bariatric surgery between September 2015 and July 2019 were retrospectively reviewed. The first group included patients with CAT, and the second group included patients without CAT. Demographics, perioperative outcomes, and postoperative results were examined. Results: Our study included 542 patients, 22 (4%) with CAT and 520 (96%) without CAT. Mean age was 46.3 ± 10.5 years in the CAT group and 36.0 ± 11.7 years in the non-CAT group (p < 0.001); median BMI was 41.8 (range 33.1-61.3) and 42.7 (range 30.1-78.4) kg/m2, respectively (p = 0.52). The CAT group had significantly higher rates of hypertension (77.2% vs. 32.5%, p < 0.001), obstructive sleep apnea (81.8% vs. 31.5%, p < 0.001), and coronary artery disease (31.8% vs. 2.8%, p < 0.001). In the CAT group, 8/22 (36.4%) patients underwent Roux-en-Y gastric bypass and 14/22 (63.6%) sleeve gastrectomy, compared to 228/520 (43.8%) and 292/520 (56.2%), respectively, in the non-CAT group (p = 0.51). There were no statistically significant differences in postoperative emergency department (ED) visits (18.1% vs. 24.2%, p = 0.51), early major complications (4.5% vs. 3.4%, p = 0.54), readmission rates within 30 days (4.5% vs. 3.6%, p = 0.56), or late complications (4.5% vs. 4.2%, p = 0.60). Mean length of stay was significantly longer in the CAT group (4.6 vs. 2.6 days, p < 0.001). The mean follow-up was 10 ± 7.3 months for the CAT cohort and 11 ± 9.7 months for the non-CAT cohort (p = 0.22). Weight loss outcomes at 12 months were comparable, with a percent total body weight loss (TBWL) of 27.0 ± 7.3% in the CAT group and 28.9 ± 8.3% in the non-CAT group (p = 0.29). There were no deaths in either group. Conclusions: In this series, at a tertiary referral center in the UAE, metabolic surgery is safe for CAT patients. Multidisciplinary preoperative preparation might be warranted to avert potential complications.

Unplanned Postoperative Emergency Department Visits After Upper Extremity Fracture Surgery.

This study aimed to determine whether outpatient upper extremity fracture surgery was associated with increased postoperative emergency department (ED) visits and identify related risk factors. Retrospective cohort. This multicenter study was conducted within a single academic institution, encompassing two Level 1, two Level 2, and one Level 3 trauma centers. All patients >18 years of age who underwent upper extremity fracture surgery from 2015 to 2021 were included. Risk factors for postoperative ED visit that were investigated included age, sex, tobacco use, alcohol abuse, psychiatric diagnosis, Elixhauser comorbidity score, race, location of upper extremity fracture, surgical setting (inpatient vs. outpatient), upper extremity block, surgical specialty, and Area Deprivation Index. Variables with a P < 0.1 in bivariate analysis were included in a multivariable logistic regression to determine factors associated with a postoperative ED visit at 30 and 90 days. A total of 6315 patients with an average age of 51 ± 19 years were identified of whom 52% were women and 65% had outpatient surgery. Postoperatively, 188 patients (3.0%) presented to the ED within 30 days and 304 (4.8%) presented within 90 days. Thirty-seven percent of ED visits were directly related to the procedure, most commonly for pain (20%), cast issues (4.3%), and swelling (3.9%). At 30 days postoperatively, 2.8% of patients who underwent surgery in an outpatient setting and 3.4% of those who underwent inpatient surgery returned to the ED, with these rates increased to 4.4% and 5.6%, respectively, by 90 days. In multivariable analysis, outpatient surgery (odds ratio [OR]: 1.5, P = 0.030), tobacco use (OR: 2.1, P < 0.001), higher Elixhauser comorbidity scores (OR: 1.2, P < 0.001), non-White race (OR: 1.9, P < 0.001), elbow fractures (OR: 1.8, P = 0.016), and hand fractures (OR: 1.6, P = 0.046) were associated with 30-day ED visits. Outpatient surgery was associated with increased rate of 30-day ED visits. Patients who smoke, had increased number of comorbidities, or were non-White presented to the ED more frequently. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Emergency Department Visits After Total Joint Arthroplasty in a Closed Urban Setting: A Report of 1,000 Consecutive Cases.

Rates of emergency department (ED) visits and readmissions after total joint arthroplasty (TJA) have been cited as indicators of TJA quality. Understanding the incidence and nature of these events is critical for prevention. The purpose of this study was to analyze readmission rates 30 and 90 days after TJA at a safety-net hospital in an urban setting and to compare this readmission rate with that for non-safety-net hospitals found in the current literature. In addition, we aimed to quantify the readmissions in our safety-net hospital that led to future complications. This would help us identify if there is a high incidence of preventable readmission rates in this unique socioeconomic environment. Using our institutional electronic medical record system, we retrospectively studied 1000 consecutive TJA encounters between 2014 and 2019 to determine the rates of treat-and-release ED visits within 30 and 90 days after surgery. The ED charts were reviewed, and patients who returned to the operating room (OR) for a TJA complication within 1 year of surgery were identified. We compared the OR return rates of people who had ED visits with those in the control group. A total of 110 (11%) and 191 (19.1%) patients visited the ED within 30 and 90 days of surgery, respectively. Fisher exact test confirmed that having an ED visit within 90 days of TJA because of lower extremity pain and/or swelling or a social issue was associated with returning to the OR within a year of TJA. Having an ED visit within 30 or 90 days of total hip replacement was associated with returning to the OR for total hip replacement complications. ED visits after TJA at an urban safety-net hospital were markedly higher than those reported in the literature for nonurban safety-net hospitals. In addition, postoperative ED visits for specific diagnoses may predict complications. This indication may have implications for a risk adjustment in programs such as bundled payments. Our results also indicate overutilization of the ED by avoidable ED visits. This represents a call for alternatives to the ED for patients after TJA in environments served by safety-net hospitals.

Looped Penrose Drainages of Acute Hand Infections in Vulnerable Populations.

Acute hand infections (AHIs) remain a challenge for hand surgeons and represent a condition for which clinical outcomes are considerably affected by social barriers. We previously described the looped Penrose drainage technique, where a drain is sutured to itself in a loop and the outflow tract of egress is maintained, thus obviating the need for large incisions, wound closure, or repeat packing, thereby reducing the follow-up burden. In the face of escalating numbers of socioeconomically vulnerable patients, especially in urban settings, we aimed to characterize the clinical features and outcomes of this technique in an urban population of patients with AHI. A review of all surgical irrigations of AHI by a single, fellowship-trained hand surgeon at an urban hospital from 2013 through 2021 was performed. Patient demographics, procedure details, and postprocedure outcomes were analyzed. Fifty-three patients (average age, 48.6 years) with AHI underwent surgical irrigations with the looped Penrose drainage technique. The majority of patients were Black (50.9%). Approximately 81.1% of the patients received public insurance, 22.6% were unemployed, 35.9% had annual incomes <$40,000, and 17% experienced homelessness. Overall, 34% were lost to follow-up with the Penrose still intact, including 78% of those who were homeless. Most of the cases occurred on the hand, with involvement of the deep spaces (24.5%), tenosynovitis (39.3%), and bone (1.9%). Recurrent infection (1.9%) and abscess formation (5.7%) led to one reoperation (1.9%). There were no amputations or readmissions, and all postoperative emergency department visits (7.1%) were discharged. The looped Penrose technique is a simple and less invasive alternative to traditional incision and drainage with packing and serves as an effective single-episode intervention strategy for AHIs, particularly in patients with complex social challenges because of the ease of wound management and low rates of readmission and reoperation. Therapeutic IV.

Outliers of Total Shoulder Arthroplasty in the Bundled Payment Era.

The Centers for Medicare & Medicaid Services (CMS) implemented the Bundled Payments for Care Improvement Advanced (BPCIA) Model that covers 90-day care episodes after select orthopedic procedures including anatomic or reverse ball-and-socket total shoulder arthroplasty (TSA/rTSA). This study investigated whether patients undergoing TSA/rTSA for non-degenerative processes incur higher costs than patients undergoing arthroplasty for degenerative processes. A retrospective review was conducted of all patients at a single academic medical center enrolled in the BPCIA model for TSA/rTSA from October 1, 2018, through December 31, 2022. We investigated whether patients undergoing arthroplasty for non-degenerative indications accrued more 90-day postoperative costs compared to patients undergoing arthroplasty for degenerative processes. A Break Even Ratio (BER) was calculated to determine the number of degenerative TSA/rTSA that would need to be performed to account for the increased expenditures associated with non-degenerative TSA/rTSA. One hundred patients met inclusion criteria during the study period. Costs for TSA/rTSA due to non-degenerative indications exceeded bundle payment amounts at a significantly higher rate compared to degenerative indications (43% versus 18%, p = 0.021). TSA/rTSA for non-degenerative indications was also associated with significantly higher total costs ($27,100 versus $22,200, p = 0.014), significantly more postoperative Emergency Department visits (43% versus 18%, p = 0.035), and longer hospital length of stay (2.2 versus 1.6 days, p = 0.121). BER analysis demonstrated 1.22 to 1.54 TSA/rTSA for degenerative indications need to be performed to equal the total spending of one TSA/rTSA for non-degenerative indications. Patients undergoing shoulder arthroplasty for non-degenerative indications within the CMS BPCIA bundled payments program were at greater risk for incurring higher costs than allocated target payments, as well as significantly higher costs when compared to patients undergoing arthroplasty for degenerative processes. We may need to consider the roles bundled-payment programs have for these patients.

Impact of same-day sleeve gastrectomy surgery on postoperative emergency department visits: analysis from the Michigan Bariatric Surgery Collaborative.

Same-day discharge after sleeve gastrectomy (SDDSG) is being performed in select patient populations with increased regularity since2020. To evaluate the impact of SDDSG on emergency department (ED) visits. Academic and private practice bariatric surgery programs participating in a statewide quality improvement collaborative. Using a statewide bariatric specific data registry, all patients undergoing SDDSG between 2020 and 2023 were identified (n = 984). Rates of 30-day ED visits and complications were compared between SDDSG and a 2:1 propensity-matched cohort with a 1-2-day hospital length of stay (n = 1968). The mean age and body mass index of SDDSG patients were 41.7 years and 45.9, respectively. When compared to the matched cohort, SDDSG patients had higher rates of ED visits (9.2% versus 6.2%, P = .0029), were more likely to present to ED earlier (10.3 days versus 12.9 days, P = .0118), and were less likely to require hospital admission (87.8% versus 71.1%, P < .0037), even though the overall complication rates were similar (4.7% versus 3.7%, P = .2087). The most common reason for an ED visit after SDDSG was nausea, vomiting, and dehydration (58.9% versus 66.9%, P = .2294), and the most common day to present to the ED was Friday (20.0% versus 20.7%, P = .9061), which was similar between groups. Despite having similar complication rates, patients undergoing SDDSG were more likely to present to the ED after surgery when compared to a matched cohort of patients with a 1-2-day hospital stay.

Clinical Outcomes of Revision Lumbar Fusion in the Aging Population

Study Design. Retrospective Cohort Objective. To examine the profile of older patients undergoing revision lumbar fusion and to evaluate the impact that advancing age may have on outcomes following revision lumbar fusion. Summary of Background Data. The proportion of older patients undergoing revision lumbar fusion is increasing, however, the benefit of revision lumbar fusion in an aging demographic is not well documented. Methods. Patients aged 55+ who underwent revision lumbar between 2011 and 2022 were included and were stratified into age groups: 55-64, 65-74, and 75+. Primary outcomes consisted of postoperative emergency department (ED) visits, 30- and 90-day readmissions, all-cause reoperations, and the need for secondary revisions. Secondary outcomes included patient-reported outcome measures (PROMs) obtained preoperatively, and at three months and one year postoperatively. Results. A total of 914 patients were included: 55-64 years (n=512, mean: 61.1 years), 65-74 years (n=296, mean:69.1 years), and 75+ (n=106, mean:78.9 years). Adjacent segment disease as a revision indication significantly increased with age(P=0.001). A circumferential approach was used most (N=200, 39.7%) in patients 55-64, while a posterior-only approach was used in 86.3% of patients 75+(P&lt;0.001). Levels decompressed increased with age, from 1.67 in the youngest group to 2.04 in the oldest (P&lt;0.001). The number of levels fused showed no significant difference (P=0.068). 90-day readmissions and the need for secondary revisions did not vary by age. Age groups were not independently associated with ΔPROMs at one year, but the oldest groups continued to experience improvement in PROMs in line with their younger counterparts. Conclusion. Patients 75 years and older derive similar benefits from revision lumbar fusion compared to their younger counterparts with no increased risk of ED visits, readmissions, or reoperations. Clinicians should be advised that there remains significant value in revising older patients when indicated. Level of Evidence. 3

Laparoscopic transabdominal vs. totally extraperitoneal inguinal hernia repair: outcomes, healthcare utilization, and cost differences.

Laparoscopic inguinal hernia repair utilizes either a transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) approach. The literature remains mixed on outcomes comparing TAPP versus TEP. The objective of our study was to assess outcomes, healthcare utilization, and cost differences between TAPP and TEP inguinal hernia repair. Adult patients who underwent elective inguinal hernia repair between 2013 and 2021 were retrospectively identified from our institution's electronic health record. Baseline characteristics and postoperative complications were compared using chi-squared test. Multivariable logistic regression was used to model the odds of experiencing a postoperative emergency department visit, readmission, and/or reoperation within 6months were surgery. Generalized linear models were used to investigate differences in cost between TAPP and TEP groups. 1086 patients underwent TAPP repair, while 1277 patients underwent TEP repair. TAPP patients had more than double the rates of readmissions (3.1% vs. 1.3%, p = 0.002) and reoperations (1.5% vs. 0.2%, p = 0.001) within 6months of surgery. On multivariable analysis, undergoing TAPP inguinal hernia repair was associated with higher odds of reoperations and/or readmissions within 6months of surgery (OR 2.8, CI [1.5, 5.1], p = 0.001). TAPP repair had a higher index surgery cost and higher costs associated with reoperations and readmissions compared to TEP repair. Although both approaches are very safe, TAPP inguinal hernia repair had higher rates of postoperative complications, increased healthcare utilization, and higher associated costs. Future studies should be directed toward decreasing postoperative healthcare utilization in order to decrease costs in inguinal hernia repair.

Reasons for 90-day emergency department visits after primary knee arthroplasty.

Postoperative visits to the emergency department (ED) generate additional costs on health care systems and consume already limited resources. We sought to determine the rate and reasons why patients who underwent primary knee arthroplasty returned to the ED within 90 days of postoperative discharge, which could guide the development of preventative measures. We identified patients who underwent primary knee arthroplasty at 2 hospitals in Nova Scotia, Canada, between April 2021 and March 2022 and who had an ED visit within 90 days of postoperative discharge. We reviewed data for timing and reason for ED visits. Of 687 patients who had primary knee arthroplasty surgeries, 145 (21.1%) patients visited the ED within 90 days of postoperative discharge. Most visits occurred in the early postoperative period, predominantly for surgical reasons (94.7% within 7 days) and shifting toward medical reasons over time. Pain was the most common surgical reason for ED visits (15.9%), followed by swelling (9.7%), and hematoma drainage (9.7%). Understanding the reasons for postoperative ED visits after knee arthroplasty is important in developing strategies to reduce ED overcrowding and improve patient outcomes. Implementing targeted interventions, such as enhanced pain management and patient education, may help alleviate the burden on EDs, reduce costs, and improve overall health care delivery for patients undergoing knee arthroplasty.

Cannabis-Related Disorders Are Associated with Increased Early Postoperative Opioid Prescriptions and Delayed Emergency Department Visits Following Open Carpal Tunnel Release.

The effect of cannabis on pain management following open carpal tunnel release (CTR) surgery is unknown. The purpose of this study is to compare outcomes for patients with cannabis-related disorder (CRD) undergoing open CTR to a propensity-matched cohort of patients without CRD (no cannabis-related disorder [NCRD]). The TriNetX Research Network was queried to identify patients undergoing primary open CTR between January 2010 and December 2022. Patients with CRD were propensity matched to a NCRD cohort in a 1:1 ratio based on 7 characteristics. Rates of postoperative opioid prescriptions, emergency department (ED) services, and outpatient appointments were reported at 0-2, 2-6, and 6-12 weeks postoperatively. A total of 925 CRD patients were propensity matched to 925 NCRD patients undergoing open CTR. Within 0-2 weeks postoperatively, CRD patients received significantly greater rates of opioid prescriptions compared to NCRD patients (30.9% and 25.6%, P = .011). No cannabis-related disorder (NCRD) patients presented for outpatient follow-up at significantly higher rates than CRD patients within 6 weeks postoperatively. CRD patients presented to the ED at significantly higher rates between 6 and 12 weeks postoperatively (11.0% vs. 8.0%, respectively, P = .027). Cannabis-related disorder (CRD) is associated with lower rates of outpatient follow-up but higher rates of postoperative opioid prescriptions and ED presentations following open CTR compared to a propensity-matched cohort of NCRD patients. Cohort Study; Level III.

The evolution of a large-scale facial gender affirmation program: A comparative outcomes analysis

BackgroundThe volume of facial feminization surgery (FFS) performed has increased tremendously over the last decade as new gender affirmation programs have formed. Advancements in surgical planning and treatment protocols have resulted in complex, multiprocedural FFS operations. This study examines the characteristics and outcomes of a large-scale FFS program over a 5-year lifespan. MethodsA retrospective analysis was performed of all patients who underwent FFS in a high-volume integrated healthcare system from program initiation in 2018-2019 (early cohort) to maturation in 2021-2022 (late cohort). Patient charts were reviewed for demographic factors, operative details, complications, postoperative Emergency Department or Urgent Care (ED/UC) visits, revisions, and readmissions. Patient characteristics and outcomes were compared between early and late cohorts. Results191 patients were included, with 109 in the early cohort and 82 in the late cohort. Patient demographics were similar except mean age (40.3 years early cohort versus 36.3 years late cohort, p=0.03). Patients in the late cohort had longer operations (5.40hours versus 6.16hours, p=0.008) with a greater percentage of patients receiving genioplasty, rhinoplasty, fat grafting, or lip lift. Despite this, fewer patients in the late cohort were admitted postoperatively (62.4% versus 13.4%, p<0.001). There were no differences in total complications, minor complications, revisions, ED/UC visits, or readmissions. However, major complications were significantly more common in the early cohort (4.6% versus 0.0%, p=0.05). ConclusionAs a nascent FFS program matures, the number of procedures in a single operation increased along with operative length. Major complications and postoperative admission rates decreased while total complications remained low.

Insurance Payor Status and Outcomes in Foot and Ankle Surgery

Category: Other Introduction/Purpose: The increasing prevalence of foot and ankle procedures in the United States has coincided with rising costs of care, exposing socioeconomic disparities within this area of orthopedics. Insurance payor status is one such factor that can affect the quality and accessibility of medical care and has been implicated in orthopedic patient outcomes. While previous studies in other fields of orthopedics have demonstrated an association between insurance status and access to treatment, length of hospital stay, postoperative outcomes and complication rates, no comprehensive review has explores this relationship in foot and ankle surgery. Thus, the goal of this study is to examine the association between insurance payor status and outcomes in foot and ankle procedures. Methods: A systematic review of five databases was conducted, focusing on the interplay between insurance coverage and foot/ankle procedures. Included studies reported on insurance payor status and patient outcomes following foot and ankle surgery. Extracted outcomes included time to be seen by a provider, complication and revision rates, post-operative Emergency Department (ED)/Urgent Care utilization, readmission rates, hospital length of stay, pain, functional scores, discharge destinations, return to work/activity, and follow-up. Meta-analyses were performed using the Revman 5.3 software. Studies that did not qualify for meta-analyses were described qualitatively. Results: Of 1401 studies identified, 24 texts met inclusion and exclusion criteria. Across the 24 studies, there were a total of 20,950 patients. Noninsured patients had a 59% higher risk of ED/urgent care utilization within 30 days of surgery compared to insured patients [Risk Ratio (RR) = 1.59, 95% Confidence Interval (CI) = 1.18 to 2.12, p &lt; 0.05]. Privately insured patients were seen 3.65 days earlier than patients with government insurance [95% CI = 2.02 to 5.27, p &lt; 0.0001]. Worker’s Compensation patients tended to have poorer outcomes, higher pain scores, and lower functional scores. Similarly, Medicaid patients also fared worse on functional scores and had delayed access to appointments and treatments. Conclusion: Patients without private insurance have worser pain and functional outcomes, delayed access to care, and increased utilization of emergency resources following foot and ankle procedures. It is crucial for providers to be cognizant of these discrepancies when caring for patients. Further research is needed to better understand the nuances of these insurance-related disparities within foot and ankle subspecialties.

Patients with fibromyalgia have increased risk of 90-day postoperative adverse events following arthroscopic rotator cuff repair

BackgroundArthroscopic rotator cuff repair (RCR) is a common surgical intervention for symptomatic rotator cuff tears when conservative management fails. Understanding the potential correlation of short- and longer-term outcomes associated with defined comorbidities can help with patient selection, counseling, and related care pathways. The association of fibromyalgia, one potential comorbidity, with outcomes following RCR has not been reported in the literature. MethodsPatients with and without fibromyalgia diagnosed prior to undergoing RCR were identified from the PearlDiver Mariner161 database between 2016 and April 30, 2022, using Current Procedural Terminology (CPT) codes. Exclusion criteria were age less than 18 years, a diagnosis of neoplasm, trauma, or infection within 90 days prior to surgery, and postoperative records of fewer than 90 days. Patients with and without fibromyalgia were matched 1:4 based on age, sex, and Elixhauser Comorbidity Index (ECI).Ninety-day adverse events were assessed. Severe adverse events were defined as the occurrence of sepsis, surgical site infection, cardiac events, deep vein thrombosis, or pulmonary embolism. Minor adverse events were defined as the occurrence of wound dehiscence, urinary tract infection, pneumonia, transfusion, hematoma, or acute kidney injury. Also identified was the occurrence of any adverse event, emergency department (ED) visits, and readmission. These outcomes were compared with multivariate analysis. One-year revisions were assessed with Kaplan-Meier curves and compared with the log-rank test. ResultsIn total, 295,169 RCR patients were identified, of which fibromyalgia was noted for 12,366 (4.2%). Following matching, the final cohort sizes for those with and without fibromyalgia were 11,387 and 45,354 respectively.Diagnosis of fibromyalgia was independently associated with increased risk of all individual adverse events as well as aggregated incidence of severe, minor, and any adverse events (p<0.0001 for all). Additionally, patients with fibromyalgia had independently 90-day increased odds of ED utilization (p<0.0001). There was no statistically significant difference in reoperation between the cohorts within 1 year of surgery. Discussion and ConclusionFibromyalgia was associated with significantly increased 90-day postoperative adverse events and ED visits. These findings are relevant in surgical planning but are also balanced by a lack of difference in one-year revisions.

The Impact of Travel Distance on Patient-Reported Outcomes Following Primary Total Hip Arthroplasty

BackgroundTotal hip arthroplasties (THAs) are increasingly being performed at high-volume centers, causing some patients to travel further distances to receive care. Concerns remain that increased travel distance limits follow-up, which may impact outcomes and early return to the hospital. The purpose of this study is to evaluate the impact of travel distance on 90-day patient-reported outcomes (PROs) and 90-day complication rates. MethodsPatients undergoing inpatient primary THA at a single center by one of three surgeons between 2017 and 2021 were retrospectively reviewed. Patients whose local and distant medical records were available were included. Patients who lived ≥ 40 miles from the location or follow-up were labeled as “travelers,” and those < 40 miles were “locals.” Primary outcomes included PROs as measured by Veterans Rand 12 Item Health Survey, Harris Hip Score, and Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement. Secondary outcomes included rates of 90-day medical complications, emergency department visits, unplanned readmissions, and reoperations. ResultsA total of 413 patients were analyzed at a mean of 897.1 days (range, 92 to 2,196) including 96 travelers. Travelers averaged 96.1 miles for follow-up (range, 40.1 to 678 miles), and locals averaged 14.1 miles for follow-up (range, 0.3 to 39.8 miles). There were no differences in the percentage of patients achieving minimal clinically important difference in PROs. There was no difference in the rate of 90-day medical complications, 90-day readmissions, and reoperations. Local patients were significantly more likely to have unplanned postoperative emergency department visits (travelers = 0%, locals = 7.4%, P = 0.003). ConclusionsTravelers did not demonstrate any significant differences with respect to rates of achieving minimal clinically important difference in PROs or 90-day complication rates. These data suggest that increased travel distance to treatment centers does not impact outcomes following primary THA.

Complications and revision rates after total shoulder arthroplasty are similar between patients with and without diabetes mellitus.

There is wide variability in the conclusions of studies examining the effects of diabetes mellitus (DM) on outcomes of shoulder arthroplasty (SA). The objective of this study was to determine if there are differences in complication profiles between patients with DM and those without undergoing anatomic and reverse total SA. A retrospective review of patients undergoing SA in a single center from January 2014 to December 2019 was performed. Patients were then stratified into two cohorts, patients with controlled DM (mean hemoglobin A1C < 7%) and those without. Outcomes analyzed included intraoperative complications, postoperative complications, and revision surgery rates. Emergency department (ED) visits and hospital readmissions within 30 days were also recorded. A total of 595 patients underwent SA. No significant difference was found between the diabetes (n = 151) and control group (n = 444) with regard to length of stay (P = .168), complications (P = .286), infection rate (P = .977), 30-day ED visits (P = .789), and readmissions (P = .230). The average time to revision was 26.8 months in the diabetes group and 26.6 months in the control group (P = .989). Following SA patients with controlled DM showed no increased risk of postoperative infection, ED visitation,hospital readmission, and revision surgery rate when compared to non-diabetics. Level III-retrospective cohort.

Association of non-English language preference with postoperative hospital visits among California Medicaid enrollees

BackgroundPatients with non-English language preference encounter language barriers across phases of surgical care. Patients with a non-English language preference represent 35% of California households and are disproportionately insured by Medicaid. To determine whether language predicts surgical outcomes, we investigated the association of patient non-English language preference with postoperative emergency department visits and readmissions among California Medicaid enrollees. MethodsOur retrospective analysis of adult Medicaid enrollees undergoing 1 of 10 common inpatient operations using California hospital administrative data (2016–2019) modeled the association between non-English language preference and 30-day postoperative emergency department visits and readmissions using mixed effects logistic regression with hospital random intercept, adjusting for patient, operation, hospital, and community characteristics. Secondary analyses stratified by operation urgency and by insurance type in an all-payor cohort. ResultsOf 115,527 Medicaid enrollees, 17.2% had non-English language preference (n = 19,881), 66% were female (n = 73,653), and 40% were Hispanic/Latino (n = 45,541). Patients with non-English language preference experienced fewer postoperative emergency department visits (non-English language preference: 13.5%, English preference: 17.9%, P < .001) and readmissions (non-English language preference: 7.5%, English preference: 8.5%, P < .001), which persisted in adjusted models (adjusted odds ratio emergency department, 0.80, 95% confidence interval, 0.77–0.85; readmissions: adjusted odds ratio, 0.86, 95% confidence interval, 0.80–0.92). Non-English language preference was associated with fewer emergency department visits after elective (adjusted odds ratio, 0.80; 95% confidence interval, 0.73–0.88) and urgent/emergent surgery (adjusted odds ratio, 0.80; 95% confidence interval, 0.75–0.85) but not readmissions after elective surgery (adjusted odds ratio, 0.89; 95% confidence interval, 0.78–1.01). This pattern was only observed for Medicaid and not other insurance types. ConclusionPatients with non-English language preference who receive Medicaid have fewer postoperative emergency department visits and readmissions, even after urgent surgery. Our findings suggest that patterns of health care seeking after surgery vary by patient language, and investigating explanatory mechanisms is needed.

Reduction of Pediatric Gastrostomy Tube Healthcare Utilization and Socioeconomic Disparities: Longitudinal Benefits of Quality Improvement

BackgroundDisparities in emergency department (ED) utilization after gastrostomy (G-) tube placement were previously demonstrated at our children’s hospital. We aimed to reduce postoperative G-tube dislodgements and ED visits with a particular focus on socially vulnerable children. MethodsOur improvement team implemented a G-tube care bundle (6/2018-9/2019) targeting caregiver preparedness and standardizing care in the pre-, intra-, and post-operative periods. Patients who had G tubes placed between 1/2011-8/2022 were categorized to either pre- or post-intervention groups. Primary outcomes were tracked prospectively. National area deprivation index (ADI) was assigned retrospectively and employed to evaluate social risk. Univariate comparisons were made between pre- and post-intervention groups, and between High ADI (≥80) and Low ADI (<80) subgroups in both pre- and post- intervention periods. We used statistical process control methods to further analyze change over time. Results396 children were included (188 pre-intervention, 208 post-intervention). The post-intervention cohort demonstrated a lower rate of outpatient dislodgement at 90 days following G-tube placement (21.3% vs 10.1%, p=0.002) and fewer G-tube-related ED visits per G-tube placed within one year of placement (mean 0.8 visits vs 0.6 visits, p=0.012). Pre-intervention, children from high ADI neighborhoods had significantly greater healthcare utilization compared to those from lower ADI neighborhoods. Post-intervention, previously statistically significant disparities were no longer present. Outpatient G-tube dislodgements within 90 days were particularly mitigated. ConclusionsA longstanding quality improvement initiative has led to sustained reductions in overall G-tube-related health care utilization. Care standardization and improvement may mitigate outcome disparities related to socioeconomic advantage. Type of studyRetrospective Comparative Study and Prospective Quality Improvement Level of EvidenceLevel III

Unveiling the impact of opioid-free postoperative regimens in ureteroscopy: a comprehensive systematic review and meta-analysis.

Ureteroscopy (URS) and retrograde intrarenal surgery (RIRS) are minimally invasive urologic procedures that are commonly used to treat kidney stones. However, they often result in significant postoperative pain. Historically, patients undergoing these surgeries have predominantly been managed with opioids, which has contributed to the escalating global complications associated with these drugs, including abuse and addiction. As a result, over the recent years, many healthcare centers have made efforts to minimize opioid use, opting instead for safer alternative medications. In this study, we aim to compare the efficacy of both opioid and opioid-free pain management regimens following URS or RIRS procedures. A systematic search was conducted in MEDLINE, Embase, Scopus, Cochrane, LILACS, and Google Scholar. We included studies that compared opioid-based and opioid-free postoperative care for managing pain in patients who underwent URS or RIRS for lithotripsy. Our primary outcome of interest was the frequency of postoperative emergency department (ED) visits. Secondary outcomes included pain-related phone calls, postoperative unexpected encounters, need for opioids at discharge, and patients with opioid refills. We retrieved 10 articles, encompassing 6786 patients in the opioid group and 5276 patients in the opioid-free group. Overall, our findings lean towards favoring the opioid-free regimen, revealing notable differences between the groups. Opioid-free regimen was associated with less ED visits (OR=0.67; 95% CI: 0.58, 0.77; P=0.00001; I2=0%) and required less opioids at discharge (OR=0.11; 95% CI 0.02, 0.64; P=0.01; I2=89%). Through statistically superior results, our meta-analysis suggests that an opioid-free regimen outperforms the use of opioids after URS or RIRS, particularly in terms of pain management.

Evaluation of Limited English Proficiency in the Management and Outcomes of Appendicitis in Children

IntroductionAppendectomies are one of the most common pediatric surgical procedures. Limited English proficiency (LEP) may lead to disparities in health outcomes between English-proficient and LEP patients. This study assesses the association between LEP and postoperative outcomes in pediatric appendectomy. MethodsWe analyzed records from the American College of Surgeons National Surgical Quality Improvement Program–Pediatric database from 2010 to 2023 under 18 y of age undergoing appendectomy at our institution. LEP was defined as the need for an interpreter. Primary outcomes were postoperative complications, length of stay (LOS), and postoperative emergency department (ED) visits within 30 d of discharge. Multivariable analyses were performed. ResultsOne thousand one hundred forty three children with appendicitis were identified, with 208 (18.2%) LEP and 935 (81.8%) English-proficient patients. LEP children were more likely to present with complicated appendicitis (42.8% versus 25.5%, P < 0.0001) and sepsis (34.1% versus 21.6%, P = 0.0003). LEP patients experience more serious (8.6% versus 3.9%, P = 0.02), overall complications (10.1% versus 5.5%, P = 0.006), and organ/surgical space site infections (8.2% versus 3.3%, P = 0.003). On multivariable analysis controlling for ethnicity and factors associated with complicated presentation, LEP was associated with increased postoperative ED visits (adjusted odds ratio [aOR] 2.64, 95% confidence interval [CI] = 1.40-4.39), but not LOS (aOR 1.86, 95% CI = 0.87-3.97) or complications (aOR 1.76, 95% CI = 0.79-4.00). ConclusionsLEP is independently associated with increased postoperative ED visits. Higher rates of complications and longer LOS may be related to increased complicated appendicitis at presentation. The role of cultural preferences and other social determinants of health that contribute to these disparities needs more investigation.