Strategies to Limit Benzodiazepine Use in Anesthesia for Older Adults: A Randomized Clinical Trial.

Importance: Despite guidelines recommending avoidance of benzodiazepine administration to older patients, many of them now receive benzodiazepines as a part of anesthesia care. The effectiveness of clinician- and patient-facing interventions to discourage such use remains insufficiently characterized. Objective: To evaluate the effect of clinician peer comparison, patient informational mail, or a combination of these interventions compared with usual care on the rate of perioperative benzodiazepine administration to older patients. Design, Setting, and Participants: This 2 × 2 factorial, stepped-wedge, cluster randomized clinical trial of a corporate quality improvement initiative was conducted between August 8, 2022, and May 28, 2023, across 415 hospitals, surgery centers, and physician offices in 8 US states served by anesthesia clinicians from a national anesthesia practice. Participants were adults aged 65 years or older who underwent an elective surgical or endoscopic procedure with general anesthesia. Data analyses followed the intention-to-treat principle. Intervention: Patients were randomly assigned to 1 of 4 groups-clinician peer comparison (wherein clinicians received feedback regarding their performance compared with other clinicians in the practice), patient informational mail (wherein patients received an informational letter encouraging them to have a discussion regarding medication selection with their clinician on the day of surgery), both interventions, or usual care (no intervention). Main Outcomes and Measures: Rate of benzodiazepine administration during anesthesia care and patient satisfaction with anesthesia care (measured by the Anesthesia Patient Satisfaction Questionnaire, version 2). Results: Among the 509 269 enrolled participants (255 871 females [50.2%]; mean [SD] age, 74 [7] years), 81 363 (16.0%) were assigned to clinician peer comparison, 98 520 (19.3%) to patient informational mail, 169 712 (33.3%) to both interventions, and 159 674 (31.4%) to usual care. Among patients who received benzodiazepine during anesthesia care, 24.5% were in the usual care group compared with 19.7% in the clinician peer comparison group, 20.0% in the patient informational mail group, and 19.7% in the combination group. After adjustment for time, none of the study interventions were associated with lower odds of benzodiazepine administration compared with usual care (odds ratio [OR], 1.02 [95% CI, 0.98-1.07]; P = .35 for clinician peer comparison; OR, 1.01 [95% CI, 0.96-1.05]; P = .81 for patient informational mail; and OR, 1.11 [95% CI, 1.05-1.16]; P < .001 for combined interventions). Satisfaction scores were high in all groups and did not vary by treatment assignment. Conclusions and Relevance: This randomized clinical trial found that clinician peer comparison, patient informational mail, or a combination of both interventions did not reduce benzodiazepine administration to older patients compared with usual care; patient satisfaction remained high throughout the study. Overall, the findings suggest a need to explore other patient-targeted interventions to improve anesthesia care. Trial Registration: Clinicaltrials.gov Identifier: NCT05436392.

Refining, implementing, and evaluating an anesthesia choice conversation aid for older adults with hip fracture: protocol for a stepped wedge cluster randomized trial.

BACKGROUND: Hip fracture surgery under general or spinal anesthesia is a common procedure for older adults in the United States (US). Although spinal or general anesthesia can be appropriate for many patients, and the choice between anesthesia types is preference-sensitive, shared decision-making is not consistently used by anesthesiologists counseling patients on anesthesia for this procedure. We designed an Option Grid™-style conversation aid, My Anesthesia Choice─Hip Fracture, to promote shared decision making in this interaction. This study will refine the aid and evaluate its implementation and effectiveness in clinical practice. METHODS: The study will be conducted over 2 phases: qualitative interviews with relevant clinicians and patients to refine the aid, followed by a stepped wedge cluster randomized trial of the intervention at 6 settings in the US. Primary outcomes will include the percentage of eligible patients who receive the intervention (intervention reach) and the change in quality of patient/clinician communication (intervention effectiveness). Secondary outcomes addressing other RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) domains will also be collected. Outcomes will be compared between baseline data and an active implementation period and then compared between the active implementation period and a sustainment period. Implementation strategies are guided by three constructs from the Practical, Robust Implementation and Sustainability Model (PRISM): intervention, recipients, and implementation and sustainability infrastructure. DISCUSSION: This is a novel, large-scale trial evaluating and implementing a shared decision-making conversation aid for anesthesia choices. Strong buy-in from site leads and expert advisors will support both the success of implementation and the future dissemination of results and the intervention. Results from this study will inform the broader implementation of this aid for patients with hip fractures and can lead to the development and implementation of similar conversation aids for other anesthesia choices. TRIAL REGISTRATION: ClinicalTrials.gov, NCT06438640.

Utilization of Reimbursed Acupuncture Therapy for Low Back Pain.

Importance: Treating low back pain (LBP) often involves a combination of pharmacologic, nonpharmacologic, and interventional treatments; one approach is acupuncture therapy, which is safe, effective, and cost-effective. How acupuncture is used within pain care regimens for LBP has not been widely studied. Objective: To document trends in reimbursed acupuncture between 2010 and 2019 among a large sample of patients with LBP, focusing on demographic, socioeconomic, and clinical characteristics associated with acupuncture use and the nonpharmacologic, pharmacologic, and interventional treatments used by patients who utilize acupuncture. Design, Setting, and Participants: This cross-sectional study included insurance claims of US adults in a deidentified database. The study sample included patients diagnosed with LBP between 2010 and 2019. Data were analyzed between September 2023 and June 2024. Main Outcomes and Measures: Changes in rates of reimbursed acupuncture utilization between 2010 and 2019, including electroacupuncture use, which involves the electrical stimulation of acupuncture needles. Covariates included age, sex, race and ethnicity, income, educational attainment, region, and a chronic LBP indicator. Secondary analyses tracked other nonpharmacologic treatments (eg, physical therapy, chiropractic care), pharmacologic treatments (eg, opioids, gabapentinoids), and interventional treatments (eg, epidural steroid injections). Results: The total sample included 6 840 497 adults with LBP (mean [SD] age, 54.6 [17.8] years; 3 916 766 female [57.3%]; 802 579 Hispanic [11.7%], 258 087 non-Hispanic Asian [3.8%], 804 975 non-Hispanic Black [11.8%], 4 974 856 non-Hispanic White [72.7%]). Overall, 106 485 (1.6%) had 1 or more acupuncture claim, while 61 503 (0.9%) had 1 or more electroacupuncture claim. The rate of acupuncture utilization increased consistently, from 0.9% in 2010 to 1.6% in 2019; electroacupuncture rates were relatively stable. Patients who were female (male: odds ratio [OR], 0.68; 99% CI, 0.67-0.70), Asian (OR, 3.26; 99% CI, 3.18-3.35), residing in the Pacific region (New England: OR, 0.26; 99% CI, 0.25-0.28), earning incomes of over $100 000 (incomes less than $40 000: OR, 0.59; 99% CI, 0.57-0.61), college educated (high school or less: OR, 0.32; 99% CI, 0.27-0.35), and with chronic LBP (OR, 2.39; 99% CI, 2.35-2.43) were more likely to utilize acupuncture. Acupuncture users were more likely to engage in other nonpharmacologic pain care like physical therapy (39.2%; 99% CI, 38.9%-39.5% vs 29.3%; 99% CI, 29.3%-29.3%) and less likely to utilize prescription drugs, including opioids (41.4%; 99% CI, 41.1%-41.8% vs 52.5%; 99% CI, 52.4%-52.5%), compared with nonusers. Conclusions and Relevance: In this cross-sectional study, we found that acupuncture utilization among patients with LBP was rare but increased over time. Demographic, socioeconomic, and clinical characteristics were associated with acupuncture utilization, and acupuncture users were more likely to utilize other nonpharmacologic treatments and less likely to utilize pharmacologic treatments.

Preoperative vs Postoperative Opioid Prescriptions and Prolonged Opioid Refills Among US Youths.

Importance: High-risk practices, including dispensing an opioid prescription before surgery when not recommended, remain poorly characterized among US youths and may contribute to new persistent opioid use. Objective: To characterize changes in preoperative, postoperative, and refill opioid prescriptions up to 180 days after surgery. Design, Setting, and Participants: This retrospective cohort study was performed using national claims data to determine opioid prescribing practices among a cohort of opioid-naive youths aged 11 to 20 years undergoing 22 inpatient and outpatient surgical procedures between 2015 and 2020. Statistical analysis was performed from June 2023 to April 2024. Main Outcomes and Measures: The primary outcome was the percentage of initial opioid prescriptions filled up to 14 days prior to vs 7 days after a procedure. Secondary outcomes included the likelihood of a refill up to 180 days after surgery, including refills at 91 to 180 days, as a proxy for new persistent opioid use, and the opioid quantity dispensed in the initial and refill prescriptions in morphine milligram equivalents (MME). Exposures included patient and prescriber characteristics. Multivariable logistic regression models were used to estimate the association between prescription timing and prolonged refills. Results: Among 100 026 opioid-naive youths (median [IQR] age, 16.0 [14.0-18.0] years) undergoing a surgical procedure, 46 951 (46.9%) filled an initial prescription, of which 7587 (16.2%) were dispensed 1 to 14 days before surgery. The mean quantity dispensed was 227 (95% CI, 225-229) MME; 6467 youths (13.8%) filled a second prescription (mean MME, 239 [95% CI, 231-246]) up to 30 days after surgery, and 1216 (3.0%) refilled a prescription 91 to 180 days after surgery. Preoperative prescriptions, increasing age, and procedures not typically associated with severe pain were most strongly associated with new persistent opioid use. Conclusions and Relevance: In this retrospective study of youths undergoing surgical procedures, of which, many are typically not painful enough to require opioid use, opioid dispensing declined, but approximately 1 in 6 prescriptions were filled before surgery, and 1 in 33 adolescents filled prescriptions 91 to 180 days after surgery, consistent with new persistent opioid use. These findings should be addressed by policymakers and communicated by professional societies to clinicians who prescribe opioids.

Lung Donation and Transplant Recipient Outcomes at Independent vs Hospital-Based Donor Care Units.

Importance: Centralizing deceased organ donor management and organ recovery into donor care units (DCUs) may mitigate the critical organ shortage by positively impacting donation and recipient outcomes. Objective: To compare donation and lung transplant outcomes between 2 common DCU models: independent (outside of acute-care hospitals) and hospital-based. Design, Setting, and Participants: This is a retrospective cohort study of Organ Procurement and Transplantation Network deceased donor registry and lung transplant recipient files from 21 US donor service areas with an operating DCU. Characteristics and lung donation rates among deceased donors cared for in independent vs hospital-based DCUs were compared. Eligible participants included deceased organ donors (aged 16 years and older) after brain death, who underwent organ recovery procedures between April 26, 2017, and June 30, 2022, and patients who received lung transplants from those donors. Data analysis was conducted from May 2023 to March 2024. Exposure: Organ recovery in an independent DCU (vs hospital-based DCU). Main Outcome and Measures: The primary outcome was duration of transplanted lung survival (through December 31, 2023) among recipients of lung(s) transplanted from cohort donors. A Cox proportional hazards model stratified by transplant year and program, adjusting for donor and recipient characteristics was used to compare graft survival. Results: Of 10 856 donors in the starting sample (mean [SD] age, 42.8 [15.2] years; 6625 male [61.0%] and 4231 female [39.0%]), 5149 (primary comparison group) underwent recovery procedures in DCUs including 1466 (28.4%) in 11 hospital-based DCUs and 3683 (71.5%) in 10 independent DCUs. Unadjusted lung donation rates were higher in DCUs than local hospitals, but lower in hospital-based vs independent DCUs (418 donors [28.5%] vs 1233 donors [33.5%]; P < .001). Among 1657 transplant recipients, 1250 (74.5%) received lung(s) from independent DCUs. Median (range) duration of follow-up after transplant was 734 (0-2292) days. Grafts recovered from independent DCUs had shorter restricted mean (SE) survival times than grafts from hospital-based DCUs (1548 [27] days vs 1665 [50] days; P = .04). After adjustment, graft failure remained higher among lungs recovered from independent DCUs than hospital-based DCUs (hazard ratio, 1.85; 95% CI, 1.28-2.65). Conclusions and Relevance: In this retrospective analysis of national donor and transplant recipient data, although lung donation rates were higher from deceased organ donors after brain death cared for in independent DCUs, lungs recovered from donors in hospital-based DCUs survived longer. These findings suggest that further work is necessary to understand which factors (eg, donor transfer, management, or lung evaluation and acceptance practices) differ between DCU models and may contribute to these differences.

My anesthesia Choice-HF: development and preliminary testing of a tool to facilitate conversations about anesthesia for hip fracture surgery.

BACKGROUND: Patients often desire involvement in anesthesia decisions, yet clinicians rarely explain anesthesia options or elicit preferences. We developed My Anesthesia Choice-Hip Fracture, a conversation aid about anesthesia options for hip fracture surgery and tested its preliminary efficacy and acceptability. METHODS: We developed a 1-page, tabular format, plain-language conversation aid with feedback from anesthesiologists, decision scientists, and community advisors. We conducted an online survey of English-speaking adults aged 50 and older. Participants imagined choosing between spinal and general anesthesia for hip fracture surgery. Before and after viewing the aid, participants answered a series of questions regarding key outcomes, including decisional conflict, knowledge about anesthesia options, and acceptability of the aid. RESULTS: Of 364/409 valid respondents, mean age was 64 (SD 8.9) and 59% were female. The proportion indicating decisional conflict decreased after reviewing the aid (63-34%, P < 0.001). Median knowledge scores increased from 50% correct to 67% correct (P < 0.001). 83% agreed that the aid would help them discuss options and preferences. 76.4% would approve of doctors using it. CONCLUSION: My Anesthesia Choice-Hip Fracture decreased decisional conflict and increased knowledge about anesthesia choices for hip fracture surgery. Respondents assessed it as acceptable for use in clinical settings. PRACTICE IMPLICATIONS: Use of clinical decision aids may increase shared decision-making; further testing is warranted.

Characterizing proximity and transfers of deceased organ donors to donor care units in the United States.

Some United States organ procurement organizations transfer deceased organ donors to donor care units (DCUs) for recovery procedures. We used Organ Procurement and Transplantation Network data, from April 2017 to June 2021, to describe the proximity of adult deceased donors after brain death to DCUs and understand the impact of donor service area (DSA) boundaries on transfer efficiency. Among 19 109 donors (56.1% of the cohort) in 25 DSAs with DCUs, a majority (14 593 [76.4%]) were in hospitals within a 2-hour drive. In areas with DCUs detectable in the study data set, a minority of donors (3582 of 11 532 [31.1%]) were transferred to a DCU; transfer rates varied between DSAs (median, 27.7%, range, 4.0%-96.5%). Median hospital-to-DCU driving times were not meaningfully shorter among transferred donors (50 vs 51 minutes for not transferred, P < .001). When DSA boundaries were ignored, 3241 cohort donors (9.5%) without current DCU access were managed in hospitals within 2 hours of a DCU and thus potentially eligible for transfer. In summary, approximately half of United States deceased donors after brain death are managed in hospitals in DSAs with a DCU. Transfer of donors between DSAs may increase DCU utilization and improve system efficiency.

Long-term Outcomes with Spinal versus General Anesthesia for Hip Fracture Surgery: A Randomized Trial.

BACKGROUND: The effects of spinal versus general anesthesia on long-term outcomes have not been well studied. This study tested the hypothesis that spinal anesthesia is associated with better long-term survival and functional recovery than general anesthesia. METHODS: A prespecified analysis was conducted of long-term outcomes of a completed randomized superiority trial that compared spinal anesthesia versus general anesthesia for hip fracture repair. Participants included previously ambulatory patients 50 yr of age or older at 46 U.S. and Canadian hospitals. Patients were randomized 1:1 to spinal or general anesthesia, stratified by sex, fracture type, and study site. Outcome assessors and investigators involved in the data analysis were masked to the treatment arm. Outcomes included survival at up to 365 days after randomization (primary); recovery of ambulation among 365-day survivors; and composite endpoints for death or new inability to ambulate and death or new nursing home residence at 365 days. Patients were included in the analysis as randomized. RESULTS: A total of 1,600 patients were enrolled between February 12, 2016, and February 18, 2021; 795 were assigned to spinal anesthesia, and 805 were assigned to general anesthesia. Among 1,599 patients who underwent surgery, vital status information at or beyond the final study interview (conducted at approximately 365 days after randomization) was available for 1,427 (89.2%). Survival did not differ by treatment arm; at 365 days after randomization, there were 98 deaths in patients assigned to spinal anesthesia versus 92 deaths in patients assigned to general anesthesia (hazard ratio, 1.08; 95% CI, 0.81 to 1.44, P = 0.59). Recovery of ambulation among patients who survived a year did not differ by type of anesthesia (adjusted odds ratio for spinal vs. general, 0.87; 95% CI, 0.67 to 1.14; P = 0.31). Other outcomes did not differ by treatment arm. CONCLUSIONS: Long-term outcomes were similar with spinal versus general anesthesia.

Costs of Care for Operative and Nonoperative Management of Emergency General Surgery Conditions.

OBJECTIVE: Many emergency general surgery (EGS) conditions can be managed operatively or nonoperatively, with outcomes that vary by diagnosis. We hypothesized that operative management would lead to higher in-hospital costs but to cost savings over time. BACKGROUND: EGS conditions account for $28 billion in health care costs in the United States annually. Compared with scheduled surgery, patients who undergo emergency surgery are at increased risk of complications, readmissions, and death, with accompanying costs of care that are up to 50% higher than elective surgery. Our prior work demonstrated that operative management had variable impacts on clinical outcomes depending on the EGS condition. METHODS: This was a nationwide, retrospective study using fee-for-service Medicare claims data. We included patients 65.5 years of age or older with a principal diagnosis for an EGS condition 7/1/2015-6/30/2018. EGS conditions were categorized as: colorectal, general abdominal, hepatopancreaticobiliary (HPB), intestinal obstruction, and upper gastrointestinal. We used near-far matching with a preference-based instrumental variable to adjust for confounding and selection bias. Outcomes included Medicare payments for the index hospitalization and at 30, 90, and 180 days. RESULTS: Of 507,677 patients, 30.6% received an operation. For HPB conditions, costs for operative management were initially higher but became equivalent at 90 and 180 days. For all others, operative management was associated with higher inpatient costs, which persisted, though narrowed, over time. Out-of-pocket costs were nearly equivalent for operative and nonoperative management. CONCLUSIONS: Compared with nonoperative management, costs were higher or equivalent for operative management of EGS conditions through 180 days, which could impact decision-making for clinicians, patients, and health systems in situations where clinical outcomes are similar.

Deceased Organ Donor Management and Organ Distribution From Organ Procurement Organization-Based Recovery Facilities Versus Acute-Care Hospitals.

Introduction: Organ recovery facilities address the logistical challenges of hospital-based deceased organ donor management. While more organs are transplanted from donors in facilities, differences in donor management and donation processes are not fully characterized. Research Question: Does deceased donor management and organ transport distance differ between organ procurement organization (OPO)-based recovery facilities versus hospitals? Design: Retrospective analysis of Organ Procurement and Transplant Network data, including adults after brain death in 10 procurement regions (April 2017-June 2021). The primary outcomes were ischemic times of transplanted hearts, kidneys, livers, and lungs. Secondary outcomes included transport distances (between the facility or hospital and the transplant program) for each transplanted organ. Results: Among 5010 deceased donors, 51.7% underwent recovery in an OPO-based recovery facility. After adjustment for recipient and system factors, mean differences in ischemic times of any transplanted organ were not significantly different between donors in facilities and hospitals. Transplanted hearts recovered from donors in facilities were transported further than hearts from hospital donors (median 255 mi [IQR 27, 475] versus 174 [IQR 42, 365], P = .002); transport distances for livers and kidneys were significantly shorter (P < .001 for both). Conclusion: Organ recovery procedures performed in OPO-based recovery facilities were not associated with differences in ischemic times in transplanted organs from organs recovered in hospitals, but differences in organ transport distances exist. Further work is needed to determine whether other observed differences in donor management and organ distribution meaningfully impact donation and transplantation outcomes.

Evaluation of a behavioural intervention to reduce perioperative midazolam administration to older adults.

Background: Older patients commonly receive benzodiazepines during anaesthesia despite guidelines recommending avoidance. Interventions to reduce perioperative benzodiazepine use are not well studied. We hypothesized an automated electronic medical record alert targeting anaesthesia providers would reduce administration of benzodiazepines to older adults undergoing general anaesthesia. Methods: We conducted a retrospective study of adults who underwent surgery at 5 hospitals within one US academic health system. One of the hospitals received an intervention consisting of provider education and an automated electronic medical record alert discouraging benzodiazepine administration to patients aged 70 years or older. We used difference-in-differences analysis to compare patterns of midazolam use 12-months before and after intervention at the intervention hospital, using the 4 non-intervention hospitals as contemporaneous comparators. Results: The primary analysis sample included 20,347 cases among patients aged 70 and older. At the intervention hospital, midazolam was administered in 454/4,240 (10.7%) cases pre-alert versus 250/3,750 (6.7%) post-alert (p<0.001). At comparator hospitals, respective rates were 3,186/6,366 (50.0%) versus 2,935/5,991 (49.0%) (p=0.24). After adjustment, the intervention was associated with a 3.2 percentage point (p.p.) reduction in the percentage of cases with midazolam administration (95% CI: (-5.2, -1.1); p=0.002). Midazolam dose was unaffected (adjusted mean difference -0.01 mg, 95% CI: (-0.20, 0.18); p=0.90). In 76,735 cases among patients aged 18-69, the percentage of cases with midazolam administration decreased by 6.9 p. p. (95% CI: (-8.0, -5.7); p<0.001). Conclusion: Provider-facing alerts in the intraoperative electronic medical record, coupled with education, can reduce midazolam administration to older patients presenting for surgery but may affect care of younger patients.

Conditional Effects of Race on Operative and Nonoperative Outcomes of Emergency General Surgery Conditions.

INTRODUCTION: Many emergency general surgery (EGS) conditions can be managed both operatively or nonoperatively; however, it is unknown whether the decision to operate affects Black and White patients differentially. METHODS: We identified a nationwide cohort of Black and White Medicare beneficiaries, hospitalized for common EGS conditions from July 2015 to June 2018. Using near-far matching to adjust for measurable confounding and an instrumental variable analysis to control for selection bias associated with treatment assignment, we compare outcomes of operative and nonoperative management in a stratified population of Black and White patients. Outcomes included in-hospital mortality, 30-day mortality, nonroutine discharge, and 30-day readmissions. An interaction test based on a t test was used to determine the conditional effects of operative versus nonoperative management between Black and White patients. RESULTS: A total of 556,087 patients met inclusion criteria, of which 59,519 (10.7%) were Black and 496,568 (89.3%) were White. Overall, 165,932 (29.8%) patients had an operation and 390,155 (70.2%) were managed nonoperatively. Significant outcome differences were seen between operative and nonoperative management for some conditions; however, no significant differences were seen for the conditional effect of race on outcomes. CONCLUSIONS: The decision to manage an EGS patient operatively versus nonoperatively has varying effects on surgical outcomes. These effects vary by EGS condition. There were no significant conditional effects of race on the outcomes of operative versus nonoperative management among universally insured older adults hospitalized with EGS conditions.

Clinical reasoning in pragmatic trial randomization: a qualitative interview study.

BACKGROUND: Pragmatic trials, because they study widely used treatments in settings of routine practice, require intensive participation from clinicians who determine whether patients can be enrolled. Clinicians are often conflicted between their therapeutic obligation to patients and their willingness to enroll them in trials in which treatments are randomly determined and thus potentially suboptimal. Refusal to enroll eligible patients can hinder trial completion and damage generalizability. In order to help evaluate and mitigate clinician refusal, this qualitative study examined how clinicians reason about whether to randomize eligible patients. METHODS: We performed interviews with 29 anesthesiologists who participated in REGAIN, a multicenter pragmatic randomized trial comparing spinal and general anesthesia in hip fracture. Interviews included a chart-stimulated section in which physicians described their reasoning pertaining to specific eligible patients as well as a general semi-structured section about their views on clinical research. Guided by a constructivist grounded theory approach, we analyzed data via coding, synthesized thematic patterns using focused coding, and developed an explanation using abduction. RESULTS: Anesthesiologists perceived their main clinical function as preventing peri- and intraoperative complications. In some cases, they used prototype-based reasoning to determine whether patients with contraindications should be randomized; in others, they used probabilistic reasoning. These modes of reasoning involved different types of uncertainty. In contrast, anesthesiologists expressed confidence about anesthetic options when they accepted patients for randomization. Anesthesiologists saw themselves as having a fiduciary responsibility to patients and thus did not hesitate to communicate their inclinations, even when this complicated trial recruitment. Nevertheless, they voiced strong support for clinical research, stating that their involvement was mainly hindered by production pressure and workflow disruptions. CONCLUSIONS: Our findings suggest that prominent ways of assessing clinician decisions about trial randomization are based on questionable assumptions about clinical reasoning. Close examination of routine clinical practice, attuned to the features of clinical reasoning we reveal here, will help both in evaluating clinicians' enrollment determinations in specific trials and in anticipating and responding to them. TRIAL REGISTRATION: Regional Versus General Anesthesia for Promoting Independence After Hip Fracture (REGAIN). CLINICALTRIALS: gov NCT02507505. Prospectively registered on July 24, 2015.

Comparative Effectiveness Research on Spinal versus General Anesthesia for Surgery in Older Adults.

Comparative effectiveness research aims to understand the benefits and harms of different treatments to assist patients and clinicians in making better decisions. Within anesthesia practice, comparing outcomes of spinal versus general anesthesia in older adults represents an important focus of comparative effectiveness research. The authors review methodologic issues involved in studying this topic and summarize available evidence from randomized studies in patients undergoing hip fracture surgery, elective knee and hip arthroplasty, and vascular surgery. Across contexts, randomized trials show that spinal and general anesthesia are likely to be equivalent in terms of safety and acceptability for most patients without contraindications. Choices between spinal and general anesthesia represent "preference-sensitive" care in which decisions should be guided by patients' preferences and values, informed by best available evidence.

The Conditional Effects of Multimorbidity on Operative Versus Nonoperative Management of Emergency General Surgery Conditions: A Retrospective Observational Study Using an Instrumental Variable Analysis.

OBJECTIVE: To understand how multimorbidity impacts operative versus nonoperative management of emergency general surgery (EGS) conditions. BACKGROUND: EGS is a heterogenous field, encompassing operative and nonoperative treatment options. Decision-making is particularly complex for older patients with multimorbidity. METHODS: Using an instrumental variable approach with near-far matching, this national, retrospective observational cohort study of Medicare beneficiaries examines the conditional effects of multimorbidity, defined using qualifying comorbidity sets, on operative versus nonoperative management of EGS conditions. RESULTS: Of 507,667 patients with EGS conditions, 155,493 (30.6%) received an operation. Overall, 278,836 (54.9%) were multimorbid. After adjustment, multimorbidity significantly increased the risk of in-hospital mortality associated with operative management for general abdominal patients (+9.8%; P = 0.002) and upper gastrointestinal patients (+19.9%, P < 0.001) and the risk of 30-day mortality (+27.7%, P < 0.001) and nonroutine discharge (+21.8%, P = 0.007) associated with operative management for upper gastrointestinal patients. Regardless of multimorbidity status, operative management was associated with a higher risk of in-hospital mortality among colorectal patients (multimorbid: + 12%, P < 0.001; nonmultimorbid: +4%, P = 0.003), higher risk of nonroutine discharge among colorectal (multimorbid: +42.3%, P < 0.001; nonmultimorbid: +55.1%, P < 0.001) and intestinal obstruction patients (multimorbid: +14.6%, P = 0.001; nonmultimorbid: +14.8%, P = 0.001), and lower risk of nonroutine discharge (multimorbid: -11.5%, P < 0.001; nonmultimorbid: -11.9%, P < 0.001) and 30-day readmissions (multimorbid: -8.2%, P = 0.002; nonmultimorbid: -9.7%, P < 0.001) among hepatobiliary patients. CONCLUSIONS: The effects of multimorbidity on operative versus nonoperative management varied by EGS condition category. Physicians and patients should have honest conversations about the expected risks and benefits of treatment options, and future investigations should aim to understand the optimal management of multimorbid EGS patients.

Outcomes with spinal versus general anesthesia for patients with and without preoperative cognitive impairment: Secondary analysis of a randomized clinical trial.

INTRODUCTION: The effect of spinal versus general anesthesia on the risk of postoperative delirium or other outcomes for patients with or without cognitive impairment (including dementia) is unknown. METHODS: Post hoc secondary analysis of a multicenter pragmatic trial comparing spinal versus general anesthesia for adults aged 50 years or older undergoing hip fracture surgery. RESULTS: Among patients randomized to spinal versus general anesthesia, new or worsened delirium occurred in 100/295 (33.9%) versus 107/283 (37.8%; odds ratio [OR] 0.85; 95% confidence interval [CI] 0.60 to 1.19) among persons with cognitive impairment and 70/432 (16.2%) versus 71/445 (16.0%) among persons without cognitive impairment (OR 1.02; 95% CI 0.71 to 1.47, p = 0.46 for interaction). Delirium severity, in-hospital complications, and 60-day functional recovery did not differ by anesthesia type in patients with or without cognitive impairment. DISCUSSION: Anesthesia type is not associated with differences in delirium and functional outcomes among persons with or without cognitive impairment.