Is Opioid-Limiting Legislation Effective for Hand Surgery Patients?

BACKGROUND: The Rhode Island State Legislature passed the Uniform Controlled Substances Act in 2016 to limit opioid prescriptions. We aimed to objectively evaluate its effect on opioid prescribing for hand surgery patients and also identify risk factors for prolonged opioid use. METHODS: A 6-month period (January-June 2016) prior to passage of the law was compared with a period following its implementation (July-December 2017). Thumb carpometacarpal arthroplasty and distal radius fracture fixation were classified as "major surgery" and carpal tunnel and trigger finger release as "minor surgery." Prescription Drug Monitoring Database was used to review controlled substances filled during the study periods. RESULTS: A total of 1380 patients met our inclusion criteria, with 644 prelaw and 736 postlaw patients. Patients undergoing "major surgery" saw a significant decrease in the number of pills issued in the first postoperative prescription (41.1 vs 21.0) and a corresponding decrease in morphine milligram equivalents (MMEs) (318.6 vs 159.2 MMEs) after implementation. A 30% decrease in MMEs was also seen in those undergoing "major surgery" in the first 30 days postoperatively (544.7 vs 381.7 MMEs). Risk factors for prolonged opioid use included male sex and preoperative opioid use. CONCLUSIONS: In Rhode Island, opioid-limiting legislation resulted in a significant decrease in the number of pills and MMEs of the initial prescription and a 30% decrease in total MMEs in the 30-day postoperative period after "major hand surgery." Additional research is needed to explore the association between legislation and clinical outcomes.

Improving the online presence of residency programs to ameliorate COVID-19's impact on residency applications.

Objectives: The coronavirus disease 2019 (COVID-19) pandemic has created several challenges for residency programs and prospective interns alike during the upcoming application cycle, including the cancellation of away sub-internships and in-person interviews. Given prior research documenting that applicants' application and ranking decisions are significantly influenced by residency webpages, a potential solution to the loss of in-person experiences during the pandemic is the expansion of residency programs' online presence through their program websites, provision of virtual grand rounds and pseudo-away rotations, and enhancement of virtual interviews. This study seeks to summarize the existing literature on these areas and provide concrete suggestions for improving programs' virtual presence.Methods: The authors summarize earlier literature querying the content of program websites across 14 medical specialties, which documented significant gaps in the content of interest to applicants.Results: Among 14 analyzed specialties, the majority of programs had a functional website (>90%), with the exception of interventional radiology (73.9%). However, significant gaps in content were documented, with the percentage of content variables contained on websites ranging from 33.3% to 70.5% (median = 47.0%, interquartile range = 37.8-52.6%). Program websites were also limited by underrepresentation of content most valued by applicants as well as potential areas of inaccurate or outdated information.Conclusions: There are several interventions programs can undertake to address existing gaps in online presence. During an application cycle facing unprecedented resource strain, bolstering the online presence of programs may facilitate an improved fit between programs and future residents.

Larger Initial Opioid Prescriptions Following Total Joint Arthroplasty Are Associated with Greater Risk of Prolonged Use.

BACKGROUND: The ongoing U.S. opioid epidemic threatens quality of life and poses substantial economic and safety burdens to opioid abusers and their communities, physicians, and health-care systems. Public health experts have argued that prescription opioids are implicated in this epidemic; however, opioid dosing following surgical procedures remains controversial. The purpose of this study was to evaluate the relationship between initial opioid prescribing following total hip arthroplasty (THA) and total knee arthroplasty (TKA) and the risk and quantity of long-term opioid use. METHODS: Patients undergoing THA or TKA from January 1, 2016, to June 30, 2016, were identified. Preoperative 30-day opioid and benzodiazepine exposures were evaluated using the Rhode Island Prescription Drug Monitoring Program. Cumulative morphine milligram equivalents (MMEs) in the postoperative inpatient stay, initial outpatient opioid prescription, and prescriptions filled from 31 to 90 days (prolonged use) and 91 to 150 days (chronic use) following the surgical procedure were calculated. Regression analyses evaluated the association between the initial postoperative opioid dosing and prolonged or chronic use, controlling for demographic characteristics, procedure, preoperative opioid and benzodiazepine exposures, anesthesia type, and use of a peripheral nerve block. RESULTS: A total of 507 patients (198 who underwent a THA and 309 who underwent a TKA) were identified. Increased inpatient opioid dosing (odds ratio [OR], 1.49 per 1 standard deviation increase in inpatient opioid MMEs; p = 0.001) and increased dosing in the first outpatient prescription (OR, 1.26 per 1 standard deviation increase in initial outpatient prescription MMEs; p = 0.049) were each independently associated with an increased risk of prolonged opioid use. Additionally, increased inpatient dosing postoperatively was strongly associated with a greater risk of chronic use (OR, 1.77 per 1 standard deviation increase in inpatient MMEs; p < 0.001). Among the 30% (151 of 507) of patients requiring prolonged postoperative opioids, each 1-MME increase in the initial outpatient prescription dose was associated with a 0.997-MME increase in quantity filled during the prolonged period (p < 0.001). Among the 14% (73 of 507) of patients requiring chronic opioids, every 1-MME increase in the initial outpatient dose was associated with a 1.678-MME increase in chronic opioid dosing (p = 0.008). CONCLUSIONS: Increased opioid dosing in the early postoperative period following total joint arthroplasty (TJA) is associated with an increased risk of extended opioid use. A dose-dependent relationship between initial outpatient dosing and greater future quantities consumed by those with prolonged usage and those with chronic usage was noted. This study suggests that providers should attempt to minimize inpatient and early outpatient opioid utilization following TJA. Multimodal pain management strategies may be employed to assist in achieving adequate pain control while minimizing opioid utilization. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Timing of Surgery for Thoracolumbar Spine Trauma: Patients With Neurological Injury.

STUDY DESIGN: Large multicenter retrospective cohort study. OBJECTIVE: The objective of this study was to analyze the effect of fusion timing on inpatient outcomes in a nationally representative population with thoracolumbar fracture and concurrent neurological injury. SUMMARY OF BACKGROUND DATA: Among thoracolumbar trauma admissions, concurrent neurological injury is associated with greater long-term morbidity. There is little consensus on optimal surgical timing for these patients; previous investigations fail to differentiate thoracolumbar fracture with and without neurological injury. MATERIALS AND METHODS: We analyzed 19,136 nonelective National Inpatient Sample cases (2004-2014) containing International Classifications of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes for closed thoracic/lumbar fracture with neurological injury and procedure codes for primary thoracolumbar/lumbosacral fusion, excluding open/cervical fracture. Timing classification from admission to fusion was same-day, 1-2-, 3-6-, and ≥7-day delay. Primary outcomes included in-hospital mortality, complications, and infection; secondary outcomes included total and postoperative length of stay and charges. Logistic regressions and generalized linear models with gamma distribution and log-link evaluated the effect of surgical timing on primary and secondary outcomes, respectively, controlling for age, sex, fracture location, fusion approach, multiorgan system injury severity score, and medical comorbidities. RESULTS: Patients undergoing surgery ≤72 hours (n=12,845) had the lowest odds of in-hospital cardiac [odds ratio (OR)=0.595; 95% confidence interval (CI), 0.357-0.991] and respiratory complications (OR=0.495; 95% CI, 0.313-0.784) and infection (OR=0.615; 95% CI, 0.390-0.969). No differences were observed between same-day (n=4724) and 1-2-day delay (n=8121) (P>0.05). Lowest odds of hemorrhage or hematoma was observed following 3-6-day delay (OR=0.467; 95% CI, 0.236-0.922). A ≥7-day delay to fusion (n=2,002) was associated with greatest odds of hemorrhage/hematoma (OR=2.019; 1.107-3.683), respiratory complications (OR=1.850; 95% CI, 1.076-3.180), and infection (OR=3.155; 95% CI, 1.891-5.263) and greatest increases in mean postoperative length of stay (4.26% or 35.3% additional days) and charges (163,562 or 71.7% additional US dollars) (P<0.001). CONCLUSIONS: Patients with thoracolumbar fracture and associated neurological injury who underwent surgery within 3 days of admission experienced fewer in-hospital complications. These benefits may be due to secondary injury mechanism avoidance and earlier mobilization. LEVEL OF EVIDENCE: Level III.

Thoracic surgery program websites: Bridging the content gap for improved applicant recruitment.

OBJECTIVE: To evaluate the website content of all US thoracic training programs, assessing the available content to identify areas for improvement. METHODS: A total of 98 accredited thoracic surgery fellowship and integrated residency programs were evaluated for the presence of 25 important online content items. Two authors assessed each website and social media page individually, and a third author resolved <4% of the initial data disagreement. The total number of alumni represented for each program was also recorded, including a breakdown of what the alumni pursued. RESULTS: Of the 98 accredited programs, 91 (92.9%) had a website. All 26 integrated residencies had a website, compared with 65 of 72 fellowships (90.3%). The 91 websites contained a mean of 8.2 ± 3.0 out of the 25 online content variables evaluated (33.0%), with rotation information (n = 69; 75.8%), application information (n = 65; 71.4%), program coordinator contact (n = 60; 65.9%), hospital affiliation (n = 49; 53.8%), number of positions per year (n = 49; 53.8%), and faculty listing (n = 46; 50.5%) found on ≥50% of the program websites. Areas lacking were retention rate (0% reported), social media links (n = 3; 3.3%), written and oral exam pass rates (both n = 5; 5.5%), graduate placement (n = 11; 12%), call duties (n = 12; 13.2%), cases performed (n = 17; 18.7%), and salary/benefits (n = 25; 27.5%). CONCLUSIONS: This study identifies gaps in content for prospective thoracic surgery applicants. Important information such as retention rate, social media links, exam pass rates, outcomes of graduates, call duties, cases performed, and salary/benefits were lacking in program websites. The improvement of websites may represent a straightforward and low-cost intervention that programs can undertake to enhance the recruitment of prospective applicants.

Orthopaedic Surgery Faculty: An Evaluation of Gender and Racial Diversity Compared with Other Specialties.

BACKGROUND: The American Academy of Orthopaedic Surgeons has adopted the strategic goal of evolving its culture and governance to become more strategic, innovative, and diverse. Given the charge to increase diversity, a focus on assessing and increasing diversity at the faculty level may help this cause. However, an analysis of gender and racial diversity among orthopaedic faculty has not been performed. The purpose of this study was to evaluate faculty appointments for underrepresented minority (URM) and female orthopaedic surgeons. We also aim to draw comparisons between orthopaedic surgery and other specialties. METHODS: Data on gender, race, and faculty rank (clinical instructor, assistant professor, associate professor, and professor) of academic faculty for 18 specialties from 1997 to 2017 were obtained from the Association of American Medical Colleges (AAMC) Faculty Roster. Assistant professors were designated as junior faculty, whereas associate professor and professor were considered senior faculty. URMs were defined using the AAMC definition-groups having lower representation than in the general population. Regression analysis was used to evaluate and compare the change over time and to compare the change across different specialties. RESULTS: Over the 20-year study period, the number of female faculty increased (8.8% pts) but represents a lower proportion than other specialties (13.9% pts) (p = 0.029). Female orthopaedic senior faculty grew slower (7.3% pts) than other specialties (14.7% pts) (p < 0.001). There was no difference in the growth of URM faculty positions (2.0% pts) compared with all other specialties (2.4% pts) (p = 0.165). The proportion of orthopaedic URM senior faculty increased less (0.5% pts) than other specialties (2.5% pts) (p < 0.001), whereas more orthopaedic URM junior faculty were added than other specialties (2.2% pts) (p = 0.012). CONCLUSIONS: Although orthopaedic surgery has increased the representation of female and URM faculty members, it continues to lag behind other specialties. In addition, fewer female and URM orthopaedic faculty members obtained senior faculty status than other specialties. To address the differences seen in faculty diversity, a concerted effort should be made to recruit and promote more diverse faculty, given similar qualifications and capabilities. LEVEL OF EVIDENCE: Prognostic Level IV.

Has a Prescription-limiting Law in Rhode Island Helped to Reduce Opioid Use After Total Joint Arthroplasty?

BACKGROUND: In the United States, since 2016, at least 28 of 50 state legislatures have passed laws regarding mandatory prescribing limits for opioid medications. One of the earliest state laws (which was passed in Rhode Island in 2016) restricted the maximum morphine milligram equivalents provided in the first postoperative prescription for patients defined as opioid-naïve to 30 morphine milligram equivalents per day, 150 total morphine milligram equivalents, or 20 total doses. While such regulations are increasingly common in the United States, their effects on opioid use after total joint arthroplasty are unclear. QUESTIONS/PURPOSES: (1) Are legislative limitations to opioid prescriptions in Rhode Island associated with decreased opioid use in the immediate (first outpatient prescription postoperatively), 30-day, and 90-day periods after THA and TKA? (2) Is this law associated with similar changes in postoperative opioid use among patients who are opioid-naïve and those who are opioid-tolerant preoperatively? METHODS: Patients undergoing primary THA or TKA between January 1, 2016 and June 28, 2016 (before the law was passed on June 28, 2016) were retrospectively compared with patients undergoing surgery between June 1, 2017 and December 31, 2017 (after the law's implementation on April 17, 2017). The lapse between the pre-law and post-law periods was designed to avoid confounding from potential voluntary practice changes by physicians after the law was passed but before its mandatory implementation. Demographic and surgical details were extracted from a large multi-specialty orthopaedic group's surgical billing database using Current Procedural Terminology codes 27130 and 27447. Any patients undergoing revision procedures, same-day bilateral arthroplasties, or a second primary THA or TKA in the 3-month followup period were excluded. Secondary data were confirmed by reviewing individual electronic medical records in the associated hospital system which included three major hospital sites. We evaluated 1125 patients. In accordance with the state's department of health guidelines, patients were defined as opioid-tolerant if they had filled any prescription for an opioid medication in the 30-day preoperative period. Data on age, gender, and the proportion of patients who were defined as opioid tolerant preoperatively were collected and found to be no different between the pre-law and post-law groups. The state's prescription drug monitoring program database was used to collect data on prescriptions for all controlled substances filled between 30 days preoperatively and 90 days postoperatively. The primary outcomes were the mean morphine milligram equivalents of the initial outpatient postoperative opioid prescription after discharge and the mean cumulative morphine milligram equivalents at the 30- and 90-day postoperative intervals. Secondary analyses included subgroup analyses by procedure and by preoperative opioid tolerance. RESULTS: After the law was implemented, the first opioid prescriptions were smaller for patients who were opioid-naïve (mean 156 ± 106 morphine milligram equivalents after the law's passage versus 451 ± 296 before, mean difference 294 morphine milligram equivalents; p < 0.001) and those who were opioid-tolerant (263 ± 265 morphine milligram equivalents after the law's passage versus 534 ± 427 before, mean difference 271 morphine milligram equivalents; p < 0.001); however, for cumulative prescriptions in the first 30 days postoperatively, this was only true among patients who were previously opioid-naïve (501 ± 416 morphine milligram equivalents after the law's passage versus 796 ± 597 before, mean difference 295 morphine milligram equivalents; p < 0.001). Those who were opioid-tolerant did not have a decrease in the cumulative number of 30-day morphine milligram equivalents (1288 ± 1632 morphine milligram equivalents after the law's passage versus 1398 ± 1274 before, mean difference 110 morphine milligram equivalents; p = 0.066). CONCLUSIONS: The prescription-limiting law was associated with a decline in cumulative opioid prescriptions at 30 days postoperatively filled by patients who were opioid-naïve before total joint arthroplasty. This may substantially impact public health, and these policies should be considered an important tool for healthcare providers, communities, and policymakers who wish to combat the current opioid epidemic. However, given the lack of a discernible effect on cumulative opioids filled from 30 to 90 days postoperatively, further investigations are needed to evaluate more effective policies to prevent prolonged opioid use after total joint arthroplasty, particularly in patients who are opioid-tolerant preoperatively. LEVEL OF EVIDENCE: Level III, therapeutic study.

The Current State of Nuclear Medicine and Nuclear Radiology: Workforce Trends, Training Pathways, and Training Program Websites.

BACKGROUND: Nuclear medicine (NM) is a multidisciplinary field. Its overlap with nuclear radiology (NR) creates unique training considerations, opportunities, and challenges. Various factors impact the workforce, training needs, and training pathways. This state of flux may be perplexing to prospective NM/NR trainees. PURPOSE: To evaluate the state of NM/NR training by assessing the (1) workforce trends and job prospects for NM/NR trainees, (2) NM and NR training pathways, and (3) applicant-accessible online presence of training programs. METHODS: Workforce trends were analyzed using data collected from the 2017 American College of Radiology Commission on Human Resources Workforce Survey. Information regarding the training pathways leading to board certification(s) for NM and NR physicians were obtained through the American Board of Nuclear Medicine, the American Board of Radiology (ABR), and the Society of Nuclear Medicine and Medical Imaging. Each Accreditation Council for Graduate Medical Education-accredited NM residency or NR fellowship training program's website was reviewed for 20 content items to assess its comprehensiveness for those seeking information regarding eligibility, applications, training curriculum, and program characteristics. RESULTS: Number of hires for NM/NR physicians has exceeded the projected number of hires from 2014 to 2017. In the last decade, there has been a greater than 25% decrease in the combined number of traditional NM residencies and NR fellowships (79-58 programs) and a greater than 50% decrease in the combined number of NM and NR trainees (173-82 trainees). In 2017, the ABR redesigned its 16-month pathway leading to specialty certification in diagnostic radiology and subspecialty certification in NR. As of March 24, 2019, there are 36 diagnostic radiology or IR residency programs with 64 trainees participating in this redesigned NR pathway. Of the 93.1% (54/58) of traditional Accreditation Council for Graduate Medical Education-accredited NM and NR training programs having websites in the 2017-2018 academic year, the mean number of online criteria met per program was 7.74 ± 3.2 of 20 (38.7%). CONCLUSION: Recruitment into the traditional NM/NR training pathways has been steadily declining, but there has been a renewed interest with the redesigned ABR 16-month pathway. There is a paucity of online information available to prospective NM/NR applicants. In this rapidly evolving and unique field, it is important to streamline NM/NR training and bolster the information accessible to potential NM/NR applicants as they weigh career options.

Opioid-Limiting Regulation: Effect on Patients Undergoing Knee and Shoulder Arthroscopy.

PURPOSE: To determine the effect prescription-limiting legislation passed in Rhode Island has had on opioids prescribed following arthroscopic knee and shoulder surgery at various time points, up to 90 days postoperatively. METHODS: All patients undergoing the 3 most common arthroscopic procedures at our institution (anterior cruciate ligament reconstruction, partial meniscectomy, and rotator cuff repair) were included. Patients were selected from 2 6-month study periods (prepassage and postimplementation of the law). The state's Prescription Drug Monitoring Program database was queried for controlled substances filled in the perioperative period (from 30 days preoperatively to 90 days postoperatively). Multiple logistic regressions were used to identify predictors of chronic (>30 days) opioid use. RESULTS: The morphine milligram equivalents (MMEs) prescribed in the initial postoperative script decreased from 319.04 (∼43 5-mg oxycodone tablets) in the prepassage to 152.45 MMEs (∼20 5-mg oxycodone tablets) in the postimplementation group (P < .001). The total MMEs filled in the first 30 days decreased from 520.93 to 299.94 MMEs (∼70 to ∼40 5-mg oxycodone tablets) (P < .001). MMEs filled between 30 and 90 days fell by 22.5% for all patients in this study; however, this change was not statistically significant (P = .263). Preoperative opioid use (odds ratio, 10.85; P < .001) and preoperative benzodiazepine use (odds ratio, 2.13; P = .005) predicted chronic opioid use postoperatively. CONCLUSIONS: State opioid-limiting legislation reduced cumulative MMEs following arthroscopic knee and shoulder surgery in the first 30 days. Further research assessing the impact of this legislation on postoperative pain control, patient satisfaction, and functional outcomes following surgery is warranted. LEVEL OF EVIDENCE: Level III, case-control study.

Opioid-limiting legislation associated with decreased 30-day opioid utilization following anterior cervical decompression and fusion.

BACKGROUND CONTEXT: Since 2016, 35 of 50 US states have passed opioid-limiting laws. The impact on postoperative opioid prescribing and secondary outcomes following anterior cervical discectomy and fusion (ACDF) remains unknown. PURPOSE: To evaluate the effect of opioid-limiting regulations on postoperative opioid prescriptions, emergency department (ED) visits, unplanned readmissions, and reoperations following elective ACDF. STUDY DESIGN/SETTING: Retrospective review of prospectively-collected data. PATIENT SAMPLE: Two hundred and eleven patients (101 pre-law, 110 post-law) undergoing primary elective 1-3 level ACDF during specified pre-law (December 1st, 2015-June 30th, 2016) and post-law (June 1st, 2017-December 31st, 2017) study periods were evaluated. METHODS: Demographic, medical, surgical, clinical, and pharmacological data was collected from all patients. Total morphine milligram equivalents (MMEs) filled was compared at 30-day postoperative intervals, before and after stratification by preoperative opioid-tolerance. Thirty- and 90-day ED visit, readmission, and reoperation rates were calculated. Independent predictors of increased 30-day and chronic (>90 day) opioid utilization were evaluated. RESULTS: Demographic, medical, and surgical factors were similar pre-law versus post-law (all p>.05). Post-law, ACDF patients received fewer opioids in their first postoperative prescription (26.65 vs. 62.08 pills, p<.001; 202.23 vs. 549.18 MMEs, p<.001) and in their first 30 postoperative days (cumulative 30-day MMEs 444.14 vs. 877.87, p<.001). Furthermore, post-law reductions in cumulative 30-day MMEs were seen among both opioid-naïve (363.54 vs. 632.20 MMEs, p<.001) and opioid-tolerant (730.08 vs. 1,122.90 MMEs, p=.022) patient populations. Increased 30-day opioid utilization was associated with surgery in the pre-law period, preoperative opioid exposure, preoperative benzodiazepine exposure, and number of levels fused (all p<.05). Chronic (>90 day) opioid requirements were associated with preoperative opioid exposure (odds ratio 4.42, p<.001) but not with pre/post-law status (p>.05). Pre- and post-law patients were similar in terms of 30- or 90-day ED visits, unplanned readmissions, and reoperations (all p>.05). CONCLUSIONS: Implementation of mandatory opioid prescribing limits effectively decreased 30-day postoperative opioid utilization following ACDF without a rebound increase in prescription refills, ED visits, unplanned hospital readmissions, or reoperations for pain.

Opioid-Limiting Legislation Associated With Reduced Postoperative Prescribing After Surgery for Traumatic Orthopaedic Injuries.

OBJECTIVES: To evaluate opioid-prescribing patterns after surgery for orthopaedic trauma before and after implementation of opioid-limiting mandates in one state. DESIGN: Retrospective review. SETTING: Level-1 trauma center. PATIENTS/PARTICIPANTS: Seven hundred fifty-three patients (297 pre-law and 456 post-law) undergoing isolated fixation for 6 common fracture patterns during specified pre-law (January 1, 2016-June 28, 2016) and post-law (June 01, 2017-December 31, 2017) study periods. Polytrauma patients were excluded. INTERVENTION: Implementation of statewide legislation establishing strict limits on initial opioid prescriptions [150 total morphine milligram equivalents (MMEs), 30 MMEs per day, or 20 total doses]. MAIN OUTCOME MEASUREMENTS: Initial opioid prescription dose, cumulative MMEs filled by 30 and 90 days postoperatively. RESULTS: Pre-law and post-law patient groups did not differ in terms of age, sex, opioid tolerance, recent benzodiazepine use, or open versus closed fracture pattern (P > 0.05). The post-law cohort received significantly less opioids (363.4 vs. 173.6 MMEs, P < 0.001) in the first postoperative prescription. Furthermore, the post-law group received significantly less cumulative MMEs in the first 30 postoperative days (677.4 vs. 481.7 MMEs, P < 0.001); This included both opioid-naïve (633.7 vs. 478.1 MMEs, P < 0.001) and opioid-tolerant patients (1659.2 vs. 880.0 MMEs, P = 0.048). No significant difference in opioid utilization between pre- and post-law groups was noted after postoperative day 30. Independent risk factors for prolonged (>30 days) postoperative opioid use included male gender (odds ratio 2.0, 95% confidence interval 1.4-2.9, P < 0.001) and preoperative opioid use (odds ratio 5.1, 95% confidence interval 2.4-10.5, P < 0.001). CONCLUSIONS: Opioid-limiting legislation is associated with a statistically and clinically significant reduction in initial and 30-day opioid prescriptions after surgery for orthopaedic trauma. Preoperative opioid use and male gender are independently associated with prolonged postoperative opioid use in this population. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Mandatory Prescription Limits and Opioid Utilization Following Orthopaedic Surgery.

BACKGROUND: Since 2016, over half of the states in the United States have passed mandatory limits on opioid prescriptions, with limited evidence of effectiveness. In this study, we evaluated postoperative opioid prescriptions following orthopaedic surgery before and after the implementation of one of the earliest such laws. METHODS: Following the implementation of state legislation limiting opioid prescriptions for opioid-naïve patients, 2 patient cohorts (pre-law and post-law) were compared. Both opioid-tolerant and opioid-naïve patients undergoing 6 common orthopaedic procedures (total knee arthroplasty, rotator cuff repair, anterior cruciate ligament reconstruction, open reduction and internal fixation for a distal radial fracture, open reduction and internal fixation for an ankle fracture, and lumbar discectomy) met inclusion criteria. Patients undergoing >1 primary procedure in the same operative session were excluded. All benzodiazepine and opioid prescriptions from 30 days before to 90 days after the surgical procedure were recorded. Logistic regression was performed to determine risk factors for prolonged postoperative opioid use. RESULTS: In this study, 836 pre-law patients were compared with 940 post-law patients. The 2 groups were similar with regard to demographic variables, baseline opioid tolerance, and recent benzodiazepine use (all p > 0.05). Post-law, for all patients, there were decreases in the initial prescription pill quantity (49.65 pills pre-law and 22.08 pills post-law; p < 0.001) and the total morphine milligram equivalents (MMEs) (417.67 MMEs pre-law and 173.86 MMEs post-law; p < 0.001), regardless of patient preoperative opioid exposure (all p < 0.001). Additionally, there were decreases in the mean cumulative 30-day MMEs (790.01 MMEs pre-law and 524.61 MMEs post-law; p < 0.001) and the 30 to 90-day MMEs (243.51 MMEs pre-law and 208.54 MMEs post-law; p = 0.008). Despite being specifically exempted from the legislation, opioid-tolerant patients likewise experienced a significant decrease in cumulative 30-day MMEs (1,304.08 MMEs pre-law and 1,015.19 MMEs post-law; p = 0.0016). Opioid-tolerant patients required more postoperative opioids at all time points and had an increased likelihood of prolonged opioid use compared with those who were opioid-naïve preoperatively (odds ratio, 8.73 [95% confidence interval, 6.21 to 12.29]). CONCLUSIONS: A clinically important and significant reduction in opioid utilization after orthopaedic surgery was observed following the implementation of statewide mandatory opioid prescription limits. CLINICAL RELEVANCE: After implementation of mandatory opioid prescription regulations, a clinically important and significant decline in the volume of opioids dispensed in the short term and intermediate term following orthopaedic surgery was observed. Furthermore, important clinical predictors of prolonged postoperative opioid use, including preoperative opioid use and preoperative benzodiazepine use, were identified. These findings have important implications for public health, as well as the potential to influence policymakers and to change practice among orthopaedic surgeons.

Critical Analysis of Hematology and Oncology Fellowship Web Sites in the United States.

PURPOSE: Prospective hematology-oncology fellowship applicants use program Web sites as a critical source of information. The purpose of this study was to evaluate the current content and comprehensiveness of hematology-oncology fellowship Web sites and to identify specific areas for improvement. METHODS: This study assessed the presence of 27 commonly evaluated program and application and curriculum and training informational items for Web sites of all accredited hematology-oncology fellowship programs in 2018. The comprehensiveness score was calculated as the number of items present on a fellowship Web site out of 27 and was compared by program region and size using analysis of variance and two-tailed t tests. RESULTS: Of the 143 fellowship Web sites evaluated, the mean comprehensiveness score was 39.3% (10.6 ± 3.8 out of 27). Programs contained a mean of 42.1% (5.9 ± 2.3 out of 14) of program and application and 36.2% (4.7 ± 2.1 out of 13) of curriculum and training items. The program and application items most common among Web sites were program coordinator contact and faculty listing (83.2% and 74.1% of Web sites, respectively), whereas social events and salary and benefits were less common (31.5% and 20.3% of Web sites, respectively). Prevalent curriculum and training items were research publications and activity and rotation scheduling (86.0% and 81.1% of Web sites, respectively), whereas board examination pass rates and fellow call duties were uncommon (4.2% and 15.4% of Web sites, respectively). Large programs were associated with greater overall Web site items compared with small programs (43.0% [11.6 ± 4.1 out of 27] v 35.9% [9.7 ± 3.3 out of 27]; P = .003). CONCLUSION: Hematology-oncology fellowship Web sites vary considerably in the level and nature of content they contain. Because applicants rely on online information for decision making, more comprehensive online content may promote a better fit between program and applicant. There is room for improvement in hematology-oncology fellowship Web sites, and programs may consider directing resources toward enhancing these Web sites.

Malpractice Litigation Following Traumatic Fracture.

BACKGROUND: Poor clinical outcomes and adverse events following orthopaedic trauma are common, which may lead to litigation. To our knowledge, factors associated with litigation following fracture care have not previously been evaluated. METHODS: A retrospective review of fracture-related malpractice lawsuits from 1988 to 2015 was completed utilizing VerdictSearch (ALM Media Properties), a medicolegal database. Defendant and plaintiff characteristics along with fracture type, allegations, litigation outcomes, and the association of case characteristics with outcomes were analyzed. RESULTS: A total of 561 cases were evaluated; 360 cases were excluded, resulting in a total of 201 cases that were analyzed in detail. The mean age of the plaintiff was 43.1 years (standard deviation [SD],19.4 years). Twenty-four fracture types were represented among the analyzed cases. The most common fractures were of the radius (44), the femur (32), the tibia (30), the ulna (29), the humerus (26), the spine (24), the hip (17), and the fibula (15). Overall, 129 (64.2%) cases resulted in a defense verdict, 41 (20.4%) cases resulted in a plaintiff verdict, and 31 (15.4%) cases resulted in a settlement. For plaintiff verdicts, the mean indemnity payment was $3,778,657 (median, $753,057; range, $89,943 to $27,926,311). For settlements, the mean indemnity payment was $1,097,439 (median, $547,935; range, $103,541 to $9,445,113). The mean indemnity for plaintiff verdicts was significantly greater than the mean indemnity for settlements (p = 0.03). The presence of a neurological deficit was associated with a significantly greater likelihood of a favorable outcome for the plaintiff (52.8% for plaintiffs with neurological deficit versus 32.1% for plaintiffs without neurological deficit; p = 0.019). CONCLUSIONS: This study examined malpractice litigation following traumatic orthopaedic injuries. In cases with decisions for the plaintiff, indemnity payments were on average more than $2.5 million larger than payments for settlements. In fracture cases with neurological deficit, malpractice cases were more likely to result in a favorable outcome for the plaintiff.

Analysis of Accredited Gastroenterology Fellowship Internet-Available Content: Twenty-Nine Steps Toward a Better Program Website.

GOAL: To assess publicly available content derived from official websites of accredited gastroenterology fellowship programs, specifically evaluating data pertinent to prospective applicants. BACKGROUND: The Internet provides access to key information for applicants applying to gastroenterology fellowship, particularly as competition drives applicants to apply to a large number of programs. Thus, it is important for fellowship program websites to be up to date and contain accurate and pertinent information. METHODS: Twenty-nine variables, determined as important website content on the basis of prior published website analyses and from surveys of preferences, were extracted from the relevant websites of all accredited gastroenterology fellowships in the USA. Results were binary-i.e., a website either contained or did not contain each item. RESULTS: A total of 178 websites were evaluated. The mean number of online content items was 14.1(± 3.2 SD) out of a possible 29 (47.1%). Program coordinator contact information, application information, and the number of current fellows were accessible on > 80% of websites. In contrast, the typical number and types of procedures performed by fellows and number of hospitals covered by fellows on call were found on < 10% of websites. Analysis revealed that 23.2% of lifestyle, 48.3% of training, and 59.6% of program variables were met. CONCLUSIONS: Gastroenterology fellowship websites lacked important content. Websites had a lower mean percentage of lifestyle content compared to training and program-related items. An organized website containing relevant information may not only attract qualified applicants but also avert unnecessary email inquiries and inappropriate applications. This study may provide guidance to gastroenterology fellowship programs seeking to improve their websites for applicants.

What's missing? An analysis of pediatric radiology fellowship website utility and recruitment potential.

BACKGROUND: Pediatric radiology fellowship web pages convey practical information and provide an opportunity to impress upon visitors the mission and principles that are core to the program. OBJECTIVE: The goal of the study was to assess pediatric radiology fellowship program websites and identify potential areas for improvement because applications and enrollment have been steadily declining since 2013. MATERIALS AND METHODS: We evaluated 41 websites of pediatric radiology fellowship programs for 17 criteria. We classified programs by region, size and separate web page status. We compared the met criteria using the Kruskal-Wallis and two-sided t-test, accounting for any unequal variances and distributions. RESULTS: Of the websites evaluated, the average content score was 42.3%, meeting only 7.2±2.9 of the 17 criteria. Programs in the Northeast were associated with higher online comprehensiveness (P=0.034), as were programs with a separate website for pediatric radiology (P<0.001). We also noted a higher number of positions offered per year than there were fellows enrolled (2.73±2.3 versus 1.39±2.3; P<0.001). CONCLUSION: The future of diverse pediatric radiology fellowship training opportunities is increasingly influenced by the availability and transparency of fellowship program and training attributes online. With an average content score of 42.3% across the examined fellowship websites, it is evident that there is room for improvement in the information provided by the pediatric radiology fellowship programs, particularly with respect to providing alumni information and job dispositions, listing current fellows whom applicants may contact regarding the program, and including realistic call and other work expectations of fellows.

Effect of narcotic prescription limiting legislation on opioid utilization following lumbar spine surgery.

BACKGROUND CONTEXT: Prescription opioid abuse is a public health emergency. Opioid prescriptions for spine patients account for a large proportion of use. Some states have implemented statutory limits on prescribers, however it remains unclear whether such laws are effective. PURPOSE: This investigation compares opioid prescription patterns for patients undergoing lumbar spine surgery before and after the passage of statewide narcotic-limiting legislation in Rhode Island. STUDY DESIGN/SETTING: Retrospective review of prospectively-collected medical and pharmacologic data. PATIENT SAMPLE: Two patient cohorts (pre-law January 1, 2016-June 31, 2016 and post-law June 1, 2017-December 31, 2017) that included all patients undergoing selected lumbar spine surgeries (lumbar discectomy, lumbar decompression without fusion, and posterior lumbar fusion). METHODS: Demographic and surgical variables were collected from the patient's medical charts, and information on controlled substances was collected from the state prescription drug monitoring program database. Variables collected included the number of pills and total morphine milligram equivalents (MMEs) of the first prescription, number of prescriptions filled within 30 days of surgery, total MMEs filled in the 30-day postoperative period, and total MMEs filled from 30 to 90 days after surgery. For comparison of continuous variables, t test or Mann-Whitney U test were used as appropriate. Chi-squared analysis was utilized for comparison of categorical variables. Independent risk factors for prolonged postoperative opioid use were evaluated using logistic regression. RESULTS: There were no significant differences between pre-law (n = 241) and post-law (n = 311) cohorts in terms of age, sex, preoperative opioid use, or preoperative anxiolytic use (p > .05). A greater than 50% decline was observed among all patients from the pre-law to the post-law period in terms of the number of pills (51.61 vs 23.60 pills, p < .001) and MMEs (525.56 vs 218.77 MMEs, p < .001) provided in the first postoperative opioid prescription. The mean total MMEs provided in the first 30 days decreased significantly (891.26 vs 628.63 MMEs, p < .001) despite an increase in the average number of opioid prescriptions filled (1.75 vs 2.04 prescriptions, p = .002) during this time. There was no significant difference in mean MMEs filled from 30 to 90 days. Upon subgroup analysis, there was a statistically significant decline in both the mean first prescription and total 30-day MMEs regardless of preoperative opioid status (all p < .05) or specific procedure performed (all p < .05). Preoperative opioid use was strongly associated with prolonged postoperative opioid requirements throughout the study period (OR 4.71, 95% CI 3.11-7.13, p < .001). There were no significant differences between cohorts in terms of emergency department (ED) visits or unplanned hospital readmissions at 30 and 90 days following surgery (all p > .05). CONCLUSIONS: The institution of mandatory statewide opioid prescription limits has resulted in a significant reduction in initial and 30-day opioid prescriptions following lumbar spine surgery. Decreased opioid utilization was observed in all patients, regardless of preoperative opioid tolerance or procedure performed. No significant change in postoperative ED visits or unplanned hospital readmissions was seen following implementation of the legislation. This investigation provides preliminary evidence that narcotic limiting legislation may be effective in decreasing opioid prescriptions after lumbar spine surgery for both opioid-naïve and opioid-tolerant patients.

Analysis of Abdominal Radiology fellowship website content and comprehensiveness.

PURPOSE: Fellowship programs' online content plays a key role in prospective Abdominal Radiology applicants' evaluation of programs. The purpose of this study is to examine the online accessibility of Abdominal Radiology fellowships, the comprehensiveness of the program websites' content, and evaluate whether specific program characteristics are associated with differentiated website comprehensiveness. METHODS: A list of 67 Abdominal Radiology fellowship programs was obtained from the Society of Abdominal Radiology (SAR) website. Each of the 65 publicly-available fellowship websites was scored for the presence of 19 binary variables related to the program's attributes and curriculum to assess informational comprehensiveness. Comprehensiveness scores were compared by program characteristics (accreditation status, region, and size) using Kruskal-Wallis and two-tailed t tests. RESULTS: Mean comprehensiveness score of Abdominal Radiology fellowship websites as measured by online criteria met was 52.6% (10.0 ± 3.0/19). Application requirements and information, rotation scheduling, and program director contact were found on more than 87.5% of the 65 websites, whereas salary and benefits, social information, and alumni were listed on fewer than 33.8% (22/65) of websites. Program accreditation status, region, and size were not associated with difference in mean comprehensiveness scores. CONCLUSIONS: There is a discrepancy between information commonly sought by prospective Abdominal Radiology fellowship applicants and what is available on fellowship program websites. Programs and applicants alike may benefit from programs strengthening their online material.

Trends in the Orthopaedic Surgery Subspecialty Fellowship Match: Assessment of 2010 to 2017 Applicant and Program Data.

BACKGROUND: Orthopaedic surgery has become increasingly specialized, and most trainees currently complete subspecialty fellowship training. The purposes of this investigation were to evaluate recent trends in U.S. orthopaedic fellowship matches and to provide relevant analyses for future orthopaedic fellowship applicants and fellowship program directors. METHODS: This study analyzed data from orthopaedic fellowship match programs from 2010 to 2017. For each fellowship, the following variables were analyzed: numbers of positions offered, participating programs, applicant registrations, rank lists submitted by applicants (i.e., completed applications), applicants matched, and filled positions. Applicant-matching success rate and percentage of total fellowship positions filled for each subspecialty were calculated, and trends were evaluated for significance and difference between subspecialties utilizing ordinary least-square regressions, with p < 0.05 indicating significance. RESULTS: From 2010 to 2017, the number of fellowship positions that were offered increased in all subspecialties (p < 0.05) except for spine (p = 0.44) and trauma (p = 0.92). Participating fellowship programs increased in all subspecialties (p < 0.05) except spine (p = 0.38) and sports medicine; the latter experienced the only significant decrease (p < 0.05). The largest significant increases (p < 0.05) in both applicant registrations (33.5%) and rank lists submitted by applicants (45.3%) were in adult reconstruction. The subspecialty with the highest applicant-matching success rate during the study period of 2010 to 2017 was sports (mean, 93.5%). Spine and trauma had the lowest applicant-matching success rates in 2016 to 2017. The percentage of positions filled across all subspecialties increased from 2011 to 2017 (p < 0.05); hand had the highest mean (96.6% filled), and adult reconstruction had the largest significant increase from 82.0% in 2010 to 95.5% in 2017 (p < 0.05). CONCLUSIONS: This investigation provides data with regard to current trends in the orthopaedic fellowship match. Specifically, adult reconstruction fellowship training has recently gained popularity at a more rapid rate than the other subspecialty fellowship pathways, although hand surgery consistently maintains a very high rate of positions filled. Our results for orthopaedic subspecialty fellowship match trends may assist fellowship directors with program planning and career advising and may also assist current residents with fellowship application expectations and career planning.

Ileus Following Adult Spinal Deformity Surgery.

BACKGROUND: Postoperative ileus (POI) is a common complication after spine surgery, with particularly high rates after adult spinal deformity (ASD) surgery. Few studies have been conducted on predictors of POI following ASD surgery. The objective of this study was to determine risk factors for POI in patients undergoing ASD surgery and to determine association between POI and in-hospital mortality, length of stay, and total charges. METHODS: Data were obtained from the National (Nationwide) Inpatient Sample, years 2010-2014. Patients with ASD ≥26 years-old were selected using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Multiple logistic and linear regressions were used. RESULTS: The analysis included 59,410 patients; 7.4% of patients had POI. On adjusted analysis, the following variables were associated with increased risk of POI: male sex (OR = 1.43; CI, 1.10-1.85), anterior surgical approach (OR = 1.78; CI, 1.22-2.60), ≥9 levels fused (OR = 1.84; CI, 1.24-2.73), electrolyte disorders (OR = 2.70; CI, 2.15-3.39), and pathologic weight loss (OR = 1.94; CI, 1.08-3.46). POI was associated with significantly longer length of stay (+39% [CI, 29%-51%]) and higher total charges (+23% [CI, 14%-31%]). CONCLUSIONS: Risk factors for POI were identified. Length of stay was 2.9 days longer in patients with POI, and total charges were approximately $80,000 higher. These results may be applied clinically to identify patients at risk of POI and to address modifiable risk factors preoperatively. Future studies should be conducted with additional data to develop models capable of accurately predicting and preventing POI.