Should Chronological Age be a Consideration in Patients Undergoing Elective Primary Total Knee Arthroplasty?

INTRODUCTION: The optimal time for total knee arthroplasty (TKA) requires a balance between patient disability and health state in order to minimize complications. While chronological age has not been shown to be predictive of complications in elective surgical patients, there is a point beyond which even optimized elderly patients would be at increased risk for complications. The purpose of this study was to examine the impact of chronological age on complications following primary TKA. METHODS: Using an administrative database, the records of 2,129,191 patients undergoing elective unilateral TKA between 2006 and 2021 were reviewed. The primary outcomes of interest were cardiac and pulmonary complications, and their relationship to the Charlson-Deyo Comorbidity Index (CDI) and chronological age. Secondary outcomes included risk of renal, neurologic, infection, and intensive care utilization postoperatively. The results were analyzed using a graphical method. The impact of chronological age as a modifier of overall risk for complications was modeled as a continuous variable. An age cutoff threshold of 80 years was also assigned for clinical convenience. RESULTS: The risk of complications correlated more closely to the Charlson-Deyo index (OR [odds ratio] 1.37 to 2.1) than chronological age (OR 1.0 to 1.1) across the various complications [Table-1. However, beyond age 80 years, the risks of cardiac, pulmonary, renal, and cerebrovascular complications were significantly increased for all CDI categories (OR 1.73 to 3.40) compared to patients below age 80 years [Table-2] [Figures 1A and 1B]. CONCLUSIONS: Chronologic age can impact the risk of complications even in well-optimized elderly patients undergoing primary TKA. As arthroplasty continues to transition to outpatient settings and inpatient denials increase, these results can help patients, physicians, and payors mitigate risk while optimizing the allocation of resources.

Impact of sugammadex and neostigmine on outcome after major orthopaedic surgery: A population-based analysis.

BACKGROUND: Residual neuromuscular blockade after surgery remains a major concern given its association with pulmonary complications. However, current clinical practices with and the comparative impact on perioperative risk of various reversal agents remain understudied. OBJECTIVE: We investigated the use of sugammadex and neostigmine in the USA, and their impact on postoperative complications by examining national data. DESIGN: This population-based retrospective study used national Premier Healthcare claims data. SETTING AND PARTICIPANTS: Patients undergoing total hip/knee arthroplasty (THA, TKA), or lumbar spine fusion surgery between 2016 and 2019 in the United States who received neuromuscular blocking agents. INTERVENTION: The effects of sugammadex and neostigmine for pharmacologically enhanced reversal were compared with each other and with controls who received no reversal agent. MAIN OUTCOMES: included pulmonary complications, cardiac complications, and a need for postoperative ventilation. Mixed-effects regression models compared the outcomes between neostigmine, sugammadex, and controls. We report odds ratios (OR) and 95% confidence intervals (CI). Bonferroni-adjusted P values of 0.008 were used to indicate significance. RESULTS: Among 361 553 patients, 74.5% received either sugammadex (20.7%) or neostigmine (53.8%). Sugammadex use increased from 4.4% in 2016 to 35.4% in 2019, whereas neostigmine use decreased from 64.5% in 2016 to 43.4% in 2019. Sugammadex versus neostigmine or controls was associated with significantly reduced odds for cardiac complications (OR 0.86, 95% CI, 0.80 to 0.92 and OR 0.83, 95% CI, 0.78 to 0.89, respectively). Both sugammadex and neostigmine versus controls were associated with reduced odds for pulmonary complications (OR 0.85, 95% CI, 0.77 to 0.94 and OR 0.91, CI 0.85 to 0.98, respectively). A similar pattern of sugammadex and neostigmine was observed for a reduction in severe pulmonary complications, including the requirement of invasive ventilation (OR 0.54, 95% CI, 0.45 to 0.64 and OR 0.53, 95% CI, 0.46 to 0.6, respectively). CONCLUSIONS: Population-based data indicate that sugammadex and neostigmine both appear highly effective in reducing the odds of severe life-threatening pulmonary complications. Sugammadex, especially, was associated with reduced odds of cardiac complications.

Does the impact of peripheral nerve blocks vary by age and comorbidity subgroups? A nationwide population-based study.

INTRODUCTION: A large body of literature suggests that peripheral nerve blockade (PNB) is associated with improved perioperative outcomes in total hip and knee joint arthroplasty patients. However, it is unclear to what extent this association exists across patient subgroups based on age and health status. METHODS: Patients who underwent total joint arthroplasty were identified from the Premier Healthcare database (2006-2019). Mixed-effects models were applied to assess the relationship between exposure of interest (PNB use on the day of surgery) and various outcomes (postoperative respiratory complications, acute renal failure, delirium, intensive care unit admission, prolonged length of stay, and high opioid consumption) across multiple subgroups stratified by patient age and pre-existing comorbidities. RESULTS: PNB use and outcome association varies based on the patient's health and age characteristics. For adults and older adults with excellent or fair, there was a decrease in the likelihood of respiratory complication with the use of PNB (OR: 0.92, 95% CI 0.86 to 0.98; OR: 0.88, 95% CI 0.81 to 0.95; OR: 0.94, 95% CI 0.89 to 0.99, respectively). Peripheral nerve blocks were also associated with a reduction in the odds of high opioid consumption across all categories except adult patients in poor health. CONCLUSION: PNB use is associated with beneficial effects more commonly observed among patients with a lower comorbidity burden, without a clear pattern of association with patient age.

Trends of liposomal bupivacaine utilization in major lower extremity total joint arthroplasty in the USA: a population-based study.

INTRODUCTION: Liposomal bupivacaine has been marketed for the achievement of long-acting local or regional anesthesia after major lower extremity total joint arthroplasty. However, it is comparatively expensive and controversy remains regarding its ability to decrease healthcare costs. With mounting evidence suggesting non-superiority in efficacy, compared with plain bupivacaine, we sought to investigate trends in liposomal bupivacaine use and identify changes in practice. METHODS: We identified adult patients from the Premier Healthcare Database who underwent elective total joint arthroplasty between 2012 and 2021. Prevalence and trends of liposomal bupivacaine utilization were compared on the individual patient and hospital levels. Log-rank tests were performed to assess the influence of location, teaching status, or hospital size on time to hospital-level liposomal bupivacaine termination. RESULTS: Among 103,165 total joint arthroplasty cases, liposomal bupivacaine use increased between 2012 and 2015 (from 0.4% to 22.8%) and decreased by approximately 1%-3% annually thereafter (15.7% in 2021). Liposomal bupivacaine was ever used in approximately 60% of hospitals. Hospital-level initiation of liposomal bupivacaine use peaked in 2014 and decreased thereafter (from 32.8% in 2013 to 4.3% in 2021), while termination rates increased (from 1.4% in 2014 to 9.9% in 2019). Non-teaching hospitals and those located in the South and West regions were more likely to retain liposomal bupivacaine longer than teaching or Midwest/Northeast hospitals, respectively (p=0.023 and p=0.014). DISCUSSION: Liposomal bupivacaine use peaked around 2015 and has been declining thereafter on individual patient and hospital levels. How these trends correlate with health outcomes and expenditures would be a strategic target for future research.

The impact of multimodal analgesia in coronary artery bypass graft surgery-a population-based analysis.

OBJECTIVE: Multimodal pain management aims to concurrently target several pain pathways for improved treatment efficacy and recovery. We investigated associations between multimodal analgesia use and postoperative complications, length of hospital stay (LOS), and opioid consumption among patients undergoing coronary artery bypass graft surgery. METHODS: This retrospective cohort study included 349,940 adult patients undergoing elective coronary artery bypass graft surgery (January 2006 to December 2019), from the national Premier Healthcare claims dataset. The study intervention was multimodal analgesia, defined as opioid use with the addition of nonopioid analgesic modalities. These included, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, paracetamol/acetaminophen, neuraxial anesthesia, steroids, gabapentin/pregabalin, and ketamine. Analgesic management was stratified into 4 categories: opioids only and multimodal analgesia with the addition of 1, 2 or ≥3 nonopioid analgesic modalities. Mixed-effects regression models measured associations between multimodal analgesia and postoperative complications, LOS, and opioid consumption measured in milligram oral morphine equivalents. RESULTS: Multimodal analgesia was associated with a beneficial dose response pattern. With increasing nonopioid analgesic modalities added to opioid analgesia, a stepwise decrease in complication risk was consistently observed, eg, with the addition of 1, 2, or ≥3 nonopioid modalities the odds for any complication decreased by 8% (odds ratio [OR], 0.92; confidence interval [CI], 0.90-0.94), 17% (OR, 0.83; CI, 0.81-0.86), and 22% (OR, 0.78; CI 0.69-0.79), respectively. This stepwise pattern was consistent in respiratory, cardiac, and renal complications individually. Similarly, LOS decreased stepwise with added analgesic modalities. CONCLUSIONS: These nationally representative data indicate that enhanced pain management by multiple pain pathways is associated with significant reductions in postoperative complications and shortened patient recovery.

Evidence-based Perioperative Practice Utilization among Various Racial Populations-A Retrospective Cohort Trending Analysis of Lower Extremity Total Joint Arthroplasty Patients.

BACKGROUND: Various studies have demonstrated racial disparities in perioperative care and outcomes. The authors hypothesize that among lower extremity total joint arthroplasty patients, evidence-based perioperative practice utilization increased over time among all racial groups, and that standardized evidence-based perioperative practice care protocols resulted in reduction of racial disparities and improved outcomes. METHODS: The study analyzed 3,356,805 lower extremity total joint arthroplasty patients from the Premier Healthcare database (Premier Healthcare Solutions, Inc., USA). The exposure of interest was race (White, Black, Asian, other). Outcomes were evidence-based perioperative practice adherence (eight individual care components; more than 80% of these implemented was defined as "high evidence-based perioperative practice"), any major complication (including acute renal failure, delirium, myocardial infarction, pulmonary embolism, respiratory failure, stroke, or in-hospital mortality), in-hospital mortality, and prolonged length of stay. RESULTS: Evidence-based perioperative practice adherence rate has increased over time and was associated with reduced complications across all racial groups. However, utilization among Black patients was below that for White patients between 2006 and 2021 (odds ratio, 0.94 [95% CI, 0.93 to 0.95]; 45.50% vs. 47.90% on average). Independent of whether evidence-based perioperative practice components were applied, Black patients exhibited higher odds of major complications (1.61 [95% CI, 1.55 to 1.67] with high evidence-based perioperative practice; 1.43 [95% CI, 1.39 to 1.48] without high evidence-based perioperative practice), mortality (1.70 [95% CI, 1.29 to 2.25] with high evidence-based perioperative practice; 1.29 [95% CI, 1.10 to 1.51] without high evidence-based perioperative practice), and prolonged length of stay (1.45 [95% CI, 1.42 to 1.48] with high evidence-based perioperative practice; 1.38 [95% CI, 1.37 to 1.40] without high evidence-based perioperative practice) compared to White patients. CONCLUSIONS: Evidence-based perioperative practice utilization in lower extremity joint arthroplasty has been increasing during the last decade. However, racial disparities still exist with Black patients consistently having lower odds of evidence-based perioperative practice adherence. Black patients (compared to the White patients) exhibited higher odds of composite major complications, mortality, and prolonged length of stay, independent of evidence-based perioperative practice use, suggesting that evidence-based perioperative practice did not impact racial disparities regarding particularly the Black patients in this surgical cohort.

Anesthesia practice among joint arthroplasty patients with a previous lumbar spine surgery.

STUDY OBJECTIVE: To analyze the use of neuraxial techniques in total hip or knee arthroplasty patients who previously underwent lumbar spine surgeries. DESIGN: Retrospective analysis of a national database. SETTING: U.S. hospitals. PATIENTS: Patients undergoing a total hip or knee arthroplasty, stratified by those with a previous lumbar fusion or decompression procedure. MEASUREMENTS: Our primary outcome was the use of neuraxial anesthesia; secondary outcomes included combined complications, cardio-pulmonary complications, and prolonged length of stay. Patients with and without a history of a lumbar procedure were compared using mixed-effects regression. MAIN RESULTS: Among 758,857 THAs 8961 had a history of lumbar fusion and 8599 of decompression. Among 1,387,335 TKAs 15,827 had a history of lumbar fusion and 13,652 of decompression. History of a lumbar fusion was associated with lower odds of neuraxial anesthesia use in THA (OR: 0.74 CI: 0.70-0.79, p ≤0.0001) and TKA (OR: 0.80 CI: 0.77-0.84, p ≤0.0001). CONCLUSIONS: Previous lumbar fusion -but not decompression- surgery is associated with lower neuraxial anesthesia in THA/TKA patients, despite its use being universally associated with decreased length of stay. More research is needed to address the importance of neuraxial techniques in patients with prior spine surgery.

Women authorship in pain research: A bibliometric analysis from 2002 to 2021.

OBJECTIVES: There is a lack of data on the distribution of women first and senior authorships in pain journals. Using articles published in top North American pain journals over the past two decades, we sought to describe the prevalence and changes in women representation among first and last authors. METHODS: We retrieved all published research articles in four pain journals (Regional Anesthesia and Pain Medicine, Clinical Journal of Pain, Pain and The Journal of Pain) from 2002 to 2021 using the easyPubMed package. Subsequently, the 'gender' package in R was used to determine authors' gender by first names. Trends in gender authorship change over time were assessed. RESULTS: The final cohort consisted of 20,981 authors (from an initial total of 11,842 publications and 23,684 authors retrieved). Women authors were more often first compared to senior authors (46.7% vs. 30.5%). The proportion of women first authors (46.2% in 2002 vs. 48.4% in 2021) and women senior authors (22.4% in 2002 vs. 36.3% in 2021) increased over the course of the study period (all p-value <0.001). The Clinical Journal of Pain having the highest percentage of women authors and Regional Anesthesia and Pain Medicine had the lowest percentage of women authors. DISCUSSION: Our data demonstrated increasing women authorship in pain journals in the past 20 years, largely driven by an increase in first authorships. There still remains a large gap between first and senior authorship, indicative of disparity in the role that women play in research.

Inconsistent Surgical Implant Documentation: A Case Study in Total Knee and Hip Arthroplasty.

Value-based care initiatives require accurate quantification of resource utilization. This study explores hospital resource documentation performance for total knee and hip arthroplasty (TKA, THA) implants and how this may differ between hospitals. This retrospective study utilized the Premier discharge database, years 2006 to 2020. TKA/THA cases were categorized into 5 tiers based upon the completeness of implant component documentation: Platinum, Gold, Silver, Bronze, Poor. Correlation between TKA and THA documentation performance (per-hospital percentage of Platinum cases) was assessed. Logistic regression analyses measured the association between hospital characteristics (region, teaching status, bed size, urban/rural) and satisfactory documentation. TKA/THA implant documentation performance was compared to documentation for endovascular stent procedures. Individual hospitals tended to have very complete (Platinum) or very incomplete (Poor) documentation for both TKA and THA. TKA and THA documentation performance were correlated (correlation coefficient = .70). Teaching hospitals were less likely to have satisfactory documentation for both TKA (P = .002) and THA (P = .029). Documentation for endovascular stent procedures was superior compared to TKA/THA. Hospitals' TKA and THA-related implant documentation performance is generally either very proficient or very poor, in contrast with often well-documented endovascular stent procedures. Hospital characteristics, other than teaching status, do not appear to impact TKA/THA documentation completeness.

Neuraxial Use Among Total Knee and Hip Arthroplasty Patients With Multiple Sclerosis or Myasthenia Gravis.

BACKGROUND: Surgical patients with preexisting neurological diseases create greater challenges to perioperative management, and choice of anesthetic is often complicated. We investigated neuraxial anesthesia use in total knee and hip arthroplasty (TKA/THA) recipients with multiple sclerosis or myasthenia gravis compared to the general population. METHODS: We retrospectively analyzed patients undergoing a TKA/THA with a diagnosis of multiple sclerosis or myasthenia gravis (Premier Health Database, 2006-2019). The primary outcome was neuraxial anesthesia use in multiple sclerosis or myasthenia gravis patients compared to the general population. Secondary outcomes were length of stay, intensive care unit admission, and mechanical ventilation. We measured the association between the aforementioned subgroups and neuraxial anesthesia use. Subsequently, subgroup-specific associations between neuraxial anesthesia and secondary outcomes were measured. We report odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Among 2,184,193 TKA/THAs, 7559 and 3176 had a multiple sclerosis or myasthenia gravis diagnosis, respectively. Compared to the general population, neuraxial anesthesia use was lower in multiple sclerosis patients (OR, 0.61; CI, 0.57-0.65; P < .0001) and no different in myasthenia gravis patients (OR, 1.05; CI, 0.96-1.14; P = .304). Multiple sclerosis patients administered neuraxial anesthesia (compared to those without neuraxial anesthesia) had lower odds of prolonged length of stay (OR, 0.63; CI, 0.53-0.76; P < .0001) mirroring neuraxial anesthesia benefits seen in the general population. CONCLUSIONS: Neuraxial anesthesia use was lower in surgical patients with multiple sclerosis compared to the general population but no different in those with myasthenia gravis. Neuraxial use was associated with lower odds of prolonged length of stay.

Opioid sparing effects of intravenous and oral acetaminophen in hip fracture patients: A population-based study.

STUDY OBJECTIVE: Acetaminophen (APAP) and intravenous acetaminophen (IVAPAP) has been proposed as a part of many opioid-sparing multimodal analgesic pathways. The aim of this analysis was to compare the effectiveness of IVAPAP with oral APAP on opioid utilization and opioid-related adverse effects. DESIGN: Retrospective study of population-based database. PATIENTS: The Premier Healthcare database was queried patients undergoing surgery for a primary diagnosis of hip fracture from 2011 to 2019 yielding 245,976 patients. Primary exposure was use of IVAPAP or oral APAP on the day of surgery. INTERVENTIONS: None. MEASUREMENTS: The primary outcome of interest was opioid utilization over the hospital stay, secondary outcomes included opioid-related adverse effects, length, and costs of hospital stay. Mixed effect models measured the association of IVPAP and APAP and outcomes. MAIN RESULTS: In the study population 30.67% (75,445) received at least 1 dose of IVAPAP on the day of surgery. Upon adjusting for relevant covariates, patients who received IVPAP on the day of surgery had slightly higher opioid use standardized by length of hospital stay (2.8% CI: 2%, 3.6%; p < .001), higher hospital cost (2.7% CI: 2.1%, 3.4%), and higher odds of naloxone use (1.18, CI: 1.1, 1.27; p < .001) when compared with patients who received oral APAP. CONCLUSIONS: In this population, IVAPAP use on the day of surgery failed to reduce opioid use or associated opioid related adverse effects when compared with oral APAP. IVAPAP was associated with increased overall costs, opioid requirements, and naloxone use. These results do not support the use of IV over oral APAP routinely for hip fracture surgery patients.

Pediatric anesthesia practices during the COVID-19 pandemic: A retrospective cohort study.

Background and Aims: The onset of the coronavirus 2019 (COVID-19) pandemic brought together the American Society of Regional Anesthesia and Pain Medicine (ASRA) and the European Society of Regional Anaesthesia and Pain Therapy (ESRA) to release a joint statement on anesthesia use. Their statement included a recommendation to use regional anesthesia whenever possible to mitigate the risk associated with aerosolizing procedures. We sought to examine the utilization of anesthesia in pediatric patients undergoing a surgical procedure for fractures or ligament repairs before and during COVID-19. Methods: Using the Premier Health Database, we retrospectively analyzed pediatric patients undergoing a surgical intervention for fractures or ligament repair before and during COVID-19. We sought to determine if there were differences in anesthesia use among this cohort during the two time periods. Fracture groups included shoulder and clavicle, humerus and elbow, forearm and wrist, hand and finger, pelvis and hip, femur and knee, leg and ankles, and foot and toes. Ligament procedures included surgical intervention for the anterior cruciate ligament and ulnar collateral ligament repair. Results: We identified a total of 5935 patients undergoing a surgical procedure for fractures or ligament repairs before and during COVID-19. After exclusion for unknown anesthesia use, 2,807 patients were included in our cohort with 81.5% (n = 2288) of patients undergoing a procedure under general anesthesia, 6.4% (n = 181) under regional anesthesia, and 12.0% (n = 338) under combined general-regional anesthesia. There did not appear to be a significant difference in the type of anesthesia used before and during COVID-19 (p = 0.052). Conclusions: Our study did not identify a difference in anesthesia use before and during COVID-19 among pediatric patients undergoing a surgical procedure. Further studies should estimate the change in anesthesia used during the time period when elective procedures were resumed.

Perioperative Use of Antifibrotic Medications Associated With Lower Rate of Manipulation After Primary TKA: An Analysis of 101,366 Patients.

BACKGROUND: Several commonly prescribed medications have known antifibrotic properties and have been shown to reduce postoperative scar formation in other clinical areas, but it is unknown whether the use of such medications perioperatively in patients undergoing TKA may improve rates of postoperative stiffness. METHODS: A large US employer-sponsored healthcare database (Truven Marketscan) was queried for patients who underwent elective primary TKA for primary osteoarthritis between 2015-2019. Demographic information and comorbidities were recorded, along with whether patients were prescribed one of several medications with known antifibrotic properties during the three months before or after surgery. RESULTS: Complete data were available for 101,366 patients undergoing TKA, of which 4,536 underwent MUA (4.5%). Perioperative use of any antifibrotic medication was associated with a lower likelihood of undergoing MUA (P < .001). When controlling for age, sex, comorbidities, opioid use, length of stay, among other variables, perioperative use of specific ACE inhibitors (OR 0.91, CI 0.84-1, P = .042), COX-2 inhibitors (OR 0.88, CI 0.81-0.96, P = .002), and angiotensin II receptor blockers, specifically losartan (OR 0.80, CI 0.70-0.91, P = .007) all remained significantly associated with lower rates of MUA. CONCLUSION: This study, spanning over a hundred thousand primary TKA procedures over a recent five-year period, demonstrates an association between perioperative use of specific medications with antifibrotic properties and a decreased rate of MUA. These data will help inform future studies aimed to prospectively evaluate the potential of antifibrotic medications in preventing postoperative stiffness in high-risk patients undergoing knee arthroplasty.

The Perioperative Use of Benzodiazepines for Major Orthopedic Surgery in the United States.

BACKGROUND: Despite numerous indications for perioperative benzodiazepine use, associated risks may be exacerbated in elderly and comorbid patients. In the absence of national utilization data, we aimed to describe utilization patterns using national claims data from total hip/knee arthroplasty patients (THA/TKA), an increasingly older and vulnerable surgical population. METHODS: We included data on 1,863,996 TKAs and 985,471 THAs (Premier Healthcare claims data, 2006-2019). Benzodiazepine utilization (stratified by long- and short-acting agents) was assessed by patient- and health care characteristics, and analgesic regimens. Given the large sample size, standardized differences instead of P values were utilized to signify meaningful differences between groups (defined by value >0.1). RESULTS: Among 1,863,996 TKA and 985,471 THA patients, the utilization rate of benzodiazepines was 80.5% and 76.1%, respectively. In TKA, 72.6% received short-acting benzodiazepines, while 7.9% received long-acting benzodiazepines, utilization rates 68.4% and 7.7% in THA, respectively. Benzodiazepine use was particularly more frequent among younger patients (median age [interquartile range {IQR}]: 66 [60-73]/64 [57-71] among short/long-acting compared to 69 [61-76] among nonusers), White patients (80.6%/85.4% short/long-acting versus 75.7% among nonusers), commercial insurance (36.5%/34.0% short/long-acting versus 29.1% among nonusers), patients receiving neuraxial anesthesia (56.9%/56.5% short/long-acting versus 51.5% among nonusers), small- and medium-sized (≤500 beds) hospitals (68.5% in nonusers, and 74% and 76.7% in short- and long-acting benzodiazepines), and those in the Midwest (24.6%/25.4% short/long-acting versus 16% among nonusers) in TKA; all standardized differences ≥0.1. Similar patterns were observed in THA except for race and comorbidity burden. Notably, among patients with benzodiazepine use, in-hospital postoperative opioid administration (measured in oral morphine equivalents [OMEs]) was substantially higher. This was even more pronounced in patients who received long-acting agents (median OME with no benzodiazepines utilization 192 [IQR, 83-345] vs 256 [IQR, 153-431] with short-acting, and 329 [IQR, 195-540] with long-acting benzodiazepine administration). Benzodiazepine use was also more frequent in patients receiving multimodal analgesia (concurrently 2 or more analgesic modes) and regional anesthesia. Trend analysis showed a persistent high utilization rate of benzodiazepines over the last 14 years. CONCLUSIONS: Based on a representative sample, 4 of 5 patients undergoing major orthopedic surgery in the United States receive benzodiazepines perioperatively, despite concerns for delirium and delayed postoperative neurocognitive recovery. Notably, benzodiazepine utilization was coupled with substantially increased opioid use, which may project implications for perioperative pain management.

An Overview of Commonly Used Data Sources in Observational Research in Anesthesia.

Anesthesia research using existing databases has drastically expanded over the last decade. The most commonly used data sources in multi-institutional observational research are administrative databases and clinical registries. These databases are powerful tools to address research questions that are difficult to answer with smaller samples or single-institution information. Given that observational database research has established itself as valuable field in anesthesiology, we systematically reviewed publications in 3 high-impact North American anesthesia journals in the past 5 years with the goal to characterize its scope. We identified a wide range of data sources used for anesthesia-related research. Research topics ranged widely spanning questions regarding optimal anesthesia type and analgesic protocols to outcomes and cost of care both on a national and a local level. Researchers should choose their data sources based on various factors such as the population encompassed by the database, ability of the data to adequately address the research question, budget, acceptable limitations, available data analytics resources, and pipeline of follow-up studies.

Health Services Research in Anesthesia: A Brief Overview of Common Methodologies.

The use of large data sources such as registries and claims-based data sets to perform health services research in anesthesia has increased considerably, ultimately informing clinical decisions, supporting evaluation of policy or intervention changes, and guiding further research. These observational data sources come with limitations that must be addressed to effectively examine all aspects of health care services and generate new individual- and population-level knowledge. Several statistical methods are growing in popularity to address these limitations, with the goal of mitigating confounding and other biases. In this article, we provide a brief overview of common statistical methods used in health services research when using observational data sources, guidance on their interpretation, and examples of how they have been applied to anesthesia-related health services research. Methods described involve regression, propensity scoring, instrumental variables, difference-in-differences, interrupted time series, and machine learning.