Pediatric Fellowship-Trained Anesthesiologists Improve Anesthesia-Controlled Time in a Pediatric Endoscopy Suite.

OBJECTIVES: The objective of this study was to determine the difference in anesthesia-controlled time (ACT) between subspecialty-trained pediatric anesthesiologists and general anesthesiologists during esophagogastroduodenoscopy (EGD) and colonoscopy. We hypothesized pediatric anesthesiologists would demonstrate a shorter ACT compared to general anesthesiologists. METHODS: We conducted a retrospective analysis of pediatric endoscopy cases requiring general endotracheal anesthesia within our pediatric sedation unit from 2017 to 2020. Demographic and procedural variables were collected and assessed for potential confounding. The imbalance in baseline variables was controlled for utilizing a generalized linear model (GLM). The GLM had a model fit of adjusted R2 = 0.146 and was statistically significant with P < 0.001. A priori power analysis was performed for a 2-tailed independent means t test with alpha = 0.05, and Power = 0.80, which revealed a minimum sample size of 64 patients per group to detect a mean difference of 3 minutes of ACT. RESULTS: A total of 269 cases met inclusion criteria. Adjusted results demonstrated fellowship-trained pediatric anesthesiologists were associated with a 3.7-minute (95% CI: 2.005-5.478; P < 0.001) reduction in ACT when compared to general practice anesthesiologists. Patient age was associated with a 0.4-minute (95% CI: -0.558 to -0.243; P < 0.001) decrease in ACT for each advancing year in age. CONCLUSIONS: We observed an association between the subspecialty training of the anesthesiology provider and ACT for EGDs and colonoscopies. When EGDs and colonoscopies are performed under the supervision of pediatric anesthesiologists, ACT reduction potentially reduces cost and improves efficiency.

Post-total joint arthroplasty opioid prescribing practices vary widely and are not associated with opioid refill: an observational cohort study.

INTRODUCTION: Optimized health system approaches to improving guideline-congruent care require evaluation of multilevel factors associated with prescribing practices and outcomes after total knee and hip arthroplasty. MATERIALS AND METHODS: Electronic health data from patients who underwent a total knee or hip arthroplasty between January 2016-January 2020 in the Military Health System Data were retrospectively analyzed. A generalized linear mixed-effects model (GLMM) examined the relationship between fixed covariates, random effects, and the primary outcome (30-day opioid prescription refill). RESULTS: In the sample (N = 9151, 65% knee, 35% hip), the median discharge morphine equivalent dose was 660 mg [450, 892] and varied across hospitals and several factors (e.g., joint, race and ethnicity, mental and chronic pain conditions, etc.). Probability of an opioid refill was higher in patients who underwent total knee arthroplasty, were white, had a chronic pain or mental health condition, had a lower age, and received a presurgical opioid prescription (all p < 0.01). Sex assigned in the medical record, hospital duration, discharge non-opioid prescription receipt, discharge morphine equivalent dose, and receipt of an opioid-only discharge prescription were not significantly associated with opioid refill. CONCLUSION: In the present study, several patient-, care-, and hospital-level factors were associated with an increased probability of an opioid prescription refill within 30 days after arthroplasty. Future work is needed to identify optimal approaches to reduce unwarranted and inequitable healthcare variation within a patient-centered framework.

Variation by default: cesarean section discharge opioid prescription patterns and outcomes in Military Health System hospitals: a retrospective longitudinal cohort study.

BACKGROUND: To examine factors associated with post-Cesarean section analgesic prescription variation at hospital discharge in patients who are opioid naïve; and examine relationships between pre-Cesarean section patient and care-level factors and discharge morphine equivalent dose (MED) on outcomes (e.g., probability of opioid refill within 30 days) across a large healthcare system. METHODS: The Walter Reed Institutional Review Board provided an exempt determination, waiver of consent, and waiver of HIPAA authorization for research use in the present retrospective longitudinal cohort study. Patient records were included in analyses if: sex assigned in the medical record was "female," age was 18 years of age or older, the Cesarean section occurred between January 2016 to December 2019 in the Military Health System, the listed TRICARE sponsor was an active duty service member, hospitalization began no more than three days prior to the Cesarean section, and the patient was discharged to home < 4 days after the Cesarean section. RESULTS: Across 57 facilities, 32,757 adult patients had a single documented Cesarean section procedure in the study period; 24,538 met inclusion criteria and were used in analyses. Post-Cesarean section discharge MED varied by facility, with a median MED of 225 mg and median 5-day supply. Age, active duty status, hospitalization duration, mental health diagnosis, pain diagnosis, substance use disorder, alcohol use disorder, gestational diabetes, discharge opioid type (combined vs. opioid-only medication), concurrent tubal ligation procedure, single (vs. multiple) births, and discharge morphine equivalent dose were associated with the probability of an opioid prescription refill in bivariate analyses, and therefore were included as covariates in a generalized additive mixed model (GAMM). Generalized additive mixed model results indicated that non-active duty beneficiaries, those with mental health and pain conditions, those who received an opioid/non-opioid combination medication, those with multiple births, and older patients were more likely to obtain an opioid refill, relative to their counterparts. CONCLUSION: Significant variation in discharge pain medication prescriptions, as well as the lack of association between discharge opioid MED and probability of refill, indicates that efforts are needed to optimize opioid prescribing and reduce unnecessary healthcare variation.

Incidence of Surgically Managed Post-Tonsillectomy Hemorrhage Associated With NSAID Prescribing for Postoperative Pain Management.

INTRODUCTION: Tonsillectomy ranks high among the most common pediatric surgical procedures in the United States. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), such as ibuprofen, are routinely prescribed to manage post-tonsillectomy pain, but may carry the risk of hemorrhage. MATERIALS AND METHODS: This retrospective, longitudinal, secondary-data analysis study compared the incidence of surgically managed post-tonsillectomy hemorrhage (sPTH) in pediatric patients prescribed ibuprofen at Brooke Army Medical Center (BAMC) after tonsillectomy compared to a similar cohort of pediatric patients at the Children's Hospital of Philadelphia (CHOP) not prescribed ibuprofen. Additional regression analysis examined predictors of sPTH at BAMC. RESULTS: The odds of sPTH was lower in patients who were prescribed ibuprofen at BAMC, relative to patients who were not at CHOP (OR 0.57, 95% CI, 0.37, 0.87; P < 0.01). In a generalized linear model evaluating BAMC patient data, there was a lack of a relationship between reason for tonsillectomy (tonsillitis versus tonsillar obstruction), primary procedure (tonsillectomy-only versus tonsillectomy with adenoidectomy), and presence of a co-occurring procedure. CONCLUSIONS: Post-tonsillectomy ibuprofen prescribing practices were not associated with an elevated risk of sPTH, relative to patients at CHOP not exposed to ibuprofen.

Fibromyalgia Diagnosis and Treatment Receipt in the U.S. Military Health System.

INTRODUCTION: Meta-analytic findings and clinical practice guidance recommend pharmacological (e.g., pregabalin, duloxetine, and milnacipran) and non-pharmacological (e.g., exercise and sleep hygiene) interventions to reduce symptoms and improve quality of life in people living with fibromyalgia. However, some of these therapies may lack robust evidence as to their efficacy, have side effects that may outweigh benefits, or carry risks. Although the annual prevalence of fibromyalgia in active duty service members was estimated to be 0.015% in 2018, the likelihood of receiving a fibromyalgia diagnosis was 9 times greater in patients assigned female than male and twice as common in non-Hispanic Black than White service members. Therefore, the primary goal of this retrospective study is to examine co-occurring conditions and pain-management care receipt in the 3 months before and 3 months after fibromyalgia diagnosis in active duty service members from 2015 to 2022. MATERIALS AND METHODS: Medical record information from active duty service members who received a fibromyalgia diagnosis between 2015 and 2022 in the U.S. Military Health System was included in the analyses. Bivariate analyses evaluated inequities in co-occurring diagnoses (abdominal and pelvic pain, insomnia, psychiatric conditions, and migraines), health care (acupuncture and dry needling, biofeedback and other muscle relaxation, chiropractic and osteopathic treatments, exercise classes and activities, massage therapy, behavioral health care, other physical interventions, physical therapy, self-care management, and transcutaneous electrical nerve stimulation), and prescription receipt (anxiolytics, gabapentinoids, muscle relaxants, non-opioid pain medication, opioids, selective serotonin and norepinephrine inhibitors, and tramadol) across race and ethnicity and assigned sex. Pairwise comparisons were made using a false discovery rate adjusted P value. RESULTS: Overall, 13,663 service members received a fibromyalgia diagnosis during the study period. Approximately 52% received a follow-up visit within 3 months of index diagnosis. Most service members received a co-occurring psychiatric diagnosis (35%), followed by insomnia (24%), migraines (20%), and abdominal and pelvic pain diagnoses (19%) fibromyalgia diagnosis. At least half received exercise classes and activities (52%), behavioral health care (52%), or physical therapy (50%). Less commonly received therapies included other physical interventions (41%), chiropractic/osteopathic care (40%), massage therapy (40%), transcutaneous electrical nerve stimulation (33%), self-care education (29%), biofeedback and other muscle relaxation therapies (22%), and acupuncture or dry needling (14%). The most common prescriptions received were non-opioid pain medications (72%), followed by muscle relaxers (44%), opioids (32%), anxiolytics (31%), gabapentinoids (26%), serotonin-norepinephrine reuptake inhibitor (21%), selective serotonin reuptake inhibitors (20%), and tramadol (15%). There were many inequities identified across outcomes. CONCLUSION: Overall, service members diagnosed with fibromyalgia received variable guideline-congruent health care within the 3 months before and after fibromyalgia diagnosis. Almost 1 in 3 service members received an opioid prescription, which has been explicitly recommended against use in guidelines. Pairwise comparisons indicated unwarranted variation across assigned sex and race and ethnicity in both co-occurring health conditions and care receipt. Underlying reasons for health and health care inequities can be multisourced and modifiable. It is unclear whether the U.S. Military Health System has consolidated patient resources to support patients living with fibromyalgia and if so, the extent to which such resources are accessible and known to patients and their clinicians.

Discharge Opioid Dose Indirectly Associated With Functional Outcomes 2 Weeks After Shoulder and Knee Arthroscopy in a US Military Sample.

INTRODUCTION: Postsurgical opioid utilization may be directly and indirectly associated with a range of patient-related and surgery-related factors, above and beyond pain intensity. However, most studies examine postsurgical opioid utilization without accounting for the multitude of co-occurring relationships among predictors. Therefore, this study aimed to identify factors associated with opioid utilization in the first 2 weeks after arthroscopic surgery and examine the relationship between discharge opioid prescription doses and acute postsurgical outcomes. METHODS: In this prospective longitudinal observational study, 110 participants undergoing shoulder or knee arthroscopies from August 2016 to August 2018 at Walter Reed National Military Medical Center completed self-report measures before and at 14 days postoperatively. The association between opioid utilization and both patient-level and surgery-related factors was modeled using structural equation model path analysis. RESULTS: Participants who were prescribed more opioids took more opioids, which was associated with worse physical function and sleep problems at day 14, as indicated by the significant indirect effects of discharge opioid dose on day 14 outcomes. Additional patient-level and surgery-related factors were also significantly related to opioid utilization dose and day 14 outcomes. Most participants had opioid medications leftover at day 14. CONCLUSION: Excess opioid prescribing was common, did not result in improved pain alleviation, and was associated with poorer physical function and sleep 14 days after surgery. As such, higher prescribed opioid doses could reduce subacute functioning after surgery, without benefit in reducing pain. Future patient-centered studies to tailor opioid postsurgical prescribing are needed.

Factors Associated With Postoperative Opioid Prescribing After Primary Elective Cesarean Section.

INTRODUCTION: Guidelines indicate the need to balance the risks of opioid prescribing with the need to adequately manage pain after cesarean section (CS). Although guidelines suggest the need for tailored opioid prescribing, it is unclear whether providers currently tailor opioid prescribing practices given patient-related factors. Thus, research is needed to first understand post-CS pain management and opioid prescribing. The objective of the present study was to identify factors related to CS discharge opioid prescriptions. MATERIAL AND METHODS: This retrospective cohort study was approved by the Brooke Army Medical Center Institutional Review Board (San Antonio, Texas; #C.2020.094e) on June 23, 2020. Electronic health record data of healthy adult women undergoing primary elective CS, performed under regional neuraxial anesthesia at a single, academic, tertiary medical center from 2018 to 2019, were included. Multivariable regression examined patient and medical factors associated with post-CS opioid prescriptions. RESULTS: In the present sample (N = 169), 23% (n = 39) of patients did not use opioids postoperatively, while inpatient and almost all of those patients (n = 36) received a discharge prescription for opioids with a median amount of 225 morphine milligram equivalent doses. There was a lack of evidence indicating that patient and medical factors were associated with discharge opioid dose. CONCLUSION: Patient and medical factors were not associated with post-CS opioid prescribing. Larger studies are needed to better elucidate optimal post-CS pain management in the days and months that follow CS. Such findings are needed to better tailor opioid prescribing, consistent with clinical practice guidelines.

Medical School Clinical Knowledge Exam Scores, Not Demographic or Other Factors, Associated With Residency In-Training Exam Performance.

BACKGROUND: The anesthesiology in-training exam (ITE) is a 200-item multiple-choice assessment completed annually by physician residents. Because all matriculated U.S. Department of Defense (DoD) anesthesiology residents are "hired" by the DoD after residency graduation, it is important to ensure that ITE performance, as a proxy for core competencies achievement, is maximized. METHODS: Graduated resident program files from 2013 to 2020 were queried for age, sex, matriculant status (medical student vs. other), medical school (Uniformed Services University vs. other), military service (Army vs. Air Force), preresidency military service (yes vs. no), U.S. Medical Licensing Exam (USMLE) Step 2 Clinical Knowledge (CK) score, and the American Board of Anesthesiologists ITE Score from the third clinical anesthesia year (CA-3 year). RESULTS: For every 1-point increase in USMLE Step 2 CK true z-score, the CA-3 ITE z-score increased by 0.59 points. Age was not associated with CA-3 ITE z-score in any dataset regression. Categorical covariates of sex, application status, medical school, service, and preresidency military service were not significantly associated with CA-3 ITE z-score (all P >.05), as shown by estimated adjusted marginal means. The estimated adjusted grand mean of CA-3 ITE z-scores was 0.48 (standard error ± 0.14). CONCLUSION: Resident physicians enter residency with varying degrees of past academic success, and it is important to develop early strategies to support them in acquiring the requisite knowledge base.

Anesthesiology Fellowships in the Military Health System: An Education Analysis of the Supply and Demand.

INTRODUCTION: Evidence indicates that desire for fellowship training is most influenced by personal interest, enhancement of career options, and a specific interest in an academic medicine career. The overall objective of this study is to evaluate anesthesiology fellowship interest and its potential impact on military retention and other outcomes. We hypothesized that current fellowship training accessibility is outpaced by the interest for fellowship training and that additional factors will be associated with the desire for fellowship training. METHODS: This prospective cross-sectional survey study was approved as Exempt Research by the Brooke Army Medical Center Institutional Review Board in November 2020. Participants were eligible to complete the online voluntary survey if they were active duty anesthesiologists. Anonymous surveys were administered via the Research Electronic Data Capture System from December 2020 to January 2021. Aggregated data were evaluated using univariate statistics, bivariate analyses, and a generalized linear model. RESULTS: Seventy-four percent of general anesthesiologists (those without fellowship training) were interested in pursuing future fellowship training versus 23% of subspecialist anesthesiologists (those currently in fellowship training or have completed fellowship training), odd ratio 9.71 (95% CI, 4.3-21.7). Of subspecialist anesthesiologists, 75% indicated serving in a nongraduate medical education (GME) leadership position (e.g., service/department chief), with 38% serving in a GME leadership position (e.g., program or associate program director). Almost half (46%) of subspecialist anesthesiologists reported being "extremely likely" to serve ≥20 years, versus 28% of general anesthesiologists. CONCLUSIONS: There is a high demand among active duty anesthesiologists for fellowship training, which in turn, may improve military retention. The demand for fellowship training is outpaced by what the Services currently offer, including training in Trauma Anesthesiology. Leveraging this interest in subspecialty fellowship training, particularly when the skills align with combat casualty care-related requirements, would greatly benefit the Services.

Lagged effect of Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep Disturbance on subacute postsurgical PROMIS Pain Behavior.

Sleep disturbance is a modifiable risk factor that, when reduced, may improve subacute postsurgical outcomes (e.g., pain-related impact). Evidence also indicates that pain and sleep may have a bidirectional longitudinal relationship before to (sub) acutely after surgery. The objective of the present study is to examine the degree to which sleep disturbances and pain behavior have uni- or bidirectional relationships in a sample of patients undergoing sports orthopedic surgery. In this observational, longitudinal cohort study, participants ( = 296) were adult (ages 18+) active duty service members who underwent open or arthroscopic shoulder or knee surgery at Walter Reed National Military Medical Center. Participants were asked to complete PROMIS Sleep Disturbance and Pain Behavior computer adaptive testing item banks before surgery, 6 weeks postsurgery, and 3 months postsurgery. Patient-level covariates were analyzed for interrelationships using nonparametric bivariate statistics. Autoregressive and cross-lagged structural equation modeling examined the bidirectional relationships of patient-level covariates and PROMIS outcomes. When controlling for patient-level covariates, sleep disturbance at presurgical and 2-week postsurgical timepoints were positively associated with both sleep disturbance and pain behavior at the subsequent timepoint. Sleep disturbance may contribute to pain-related functioning and quality of life after sports orthopedic surgery. Future studies utilizing multidimensional patient report outcomes and robust analytics are needed to better understand whether sleep-targeted interventions can improve subacute and long-term orthopedic sports surgery outcomes.