Racial-ethnic differences in liver transplant waitlist outcomes in patients with hepatocellular carcinoma before and after recent changes to allocation policy.

BACKGROUND: In May 2019, liver transplant (LT) allocation policy changed to limit MELD exception points for hepatocellular carcinoma (HCC) to median MELD at transplant minus three (MMaT-3). We evaluated this policy's impact on waitlist outcomes for HCC candidates, by race and ethnicity, hypothesizing that the introduction of the MMaT-3 reduced inequities in waitlist outcomes. METHODS: Retrospective cohort study of the Scientific Registry for Transplant Recipients, including all adult LT candidates (N = 10 751) who received HCC exception points from May 17, 2017 to May 18, 2019 (pre-policy; N = 6627) to May 19, 2019 to March 1, 2021 (post-policy; N = 4124). We compared incidence of LT and waitlist removal for death or becoming too sick pre- and post-policy for non-Hispanic White, non-Hispanic Black, Hispanic/Latinx, and Asian patients using competing risk regression adjusted for candidate characteristics. RESULTS: One-year cumulative incidence of LT decreased significantly pre-/post-policy among White (77.4% vs. 64.5%; p < .01) and Black (76.2% vs. 63.1%; p < .01) candidates only, while a 1-year incidence of death/non-LT waitlist removal decreased significantly only among Hispanics (13.4% vs. 7.5%; p < .01). After covariate adjustment, the effect of the policy change was a significantly decreased incidence of LT for White (SHR: .63 compared to pre-policy; p < .001), Black (SHR: .62; p < .001), and Asian (SHR: .68; p = .002), but no change for Hispanic patients. Only Hispanic patients had a significant decrease in death/waitlist removal after the policy change (SHR:  .69; p = .04). Compared to White patients in the pre-policy era, Hispanic (SHR:  .88, p < .007) and Asian candidates (SHR:  .72; p < .001) had lower unadjusted incidence of LT. This disparity was mitigated in the post-policy era where Hispanic patients had higher likelihood of LT than Whites (SHR: 1.22; p = .002). For the outcome of death/non-LT waitlist removal, the only significant difference was a 42% lower incidence of waitlist removal for Asian compared to White patients in the post-policy era (SHR:  .58; p = .03). CONCLUSION: Among LT recipients with HCC, racial/ethnic subpopulations were differentially affected by the MMAT-3 policy, resulting in a post-policy reduction of some of the previous disparities.

Association between donor kidney cysts and donor and recipient outcomes after living donor kidney transplantation.

INTRODUCTION: Incidental kidneys cysts are typically considered benign, but the presence of cysts is more frequent in individuals with other early markers of kidney disease. We studied the association of donor kidney cysts with donor and recipient outcomes after living donor kidney transplantation. METHODS: We retrospective identified 860 living donor transplants at our center (1/1/2011-7/31/2022) without missing data. Donor cysts were identified by review of pre-donation CT scan reports. We used linear regression to study the association between donor cysts and 6-month single-kidney estimated glomerular filtration rate (eGFR) increase, and time-to-event analyses to study the association between donor cysts and recipient death-censored graft failure. RESULTS: Among donors, 77% donors had no kidney cysts, 13% had ≥1 cyst on the kidney not donated, and 11% only had cysts on the donated kidney. In adjusted linear regression, cysts on the donated kidney and kidney not donated were not significantly associated with 6-month single-kidney eGFR increase. Among transplants, 17% used a transplanted kidney with a cyst and 6% were from donors with cysts only on the kidney not transplanted. There was no association between donor cyst group and post-transplant death-censored graft survival. Results were similar in sensitivity analyses comparing transplants using kidneys with no cysts versus 1-2 cysts versus ≥3 cysts. CONCLUSIONS: Kidney cysts in living kidney donors were not associated with donor kidney recovery or recipient allograft longevity, suggesting incidental kidney cysts need not be taken into account when determining living donor candidate suitability or the laterality of planned donor nephrectomy.

Sex-based Disparities in Access to Liver Transplantation for Waitlisted Patients With Model for End-stage Liver Disease Score of 40.

OBJECTIVE: To determine the association of sex with access to liver transplantation among candidates with the highest possible model for end-stage liver disease score (MELD 40). BACKGROUND: Women with end-stage liver disease are less likely than men to receive liver transplantation due in part to MELD's underestimation of renal dysfunction in women. The extent of the sex-based disparity among patients with high disease severity and equally high MELD scores is unclear. METHODS: Using national transplant registry data, we compared liver offer acceptance (offers received at match MELD 40) and waitlist outcomes (transplant vs death/delisting) by sex for 7654 waitlisted liver transplant candidates from 2009 to 2019 who reached MELD 40. Multivariable logistic and competing-risks regression was used to estimate the association of sex with the outcome and adjust for the candidate and donor factors. RESULTS: Women (N = 3019, 39.4%) spent equal time active at MELD 40 (median: 5 vs 5 days, P = 0.28) but had lower offer acceptance (9.2% vs 11.0%, P < 0.01) compared with men (N = 4635, 60.6%). Adjusting for candidate/donor factors, offers to women were less likely accepted (odds ratio = 0.87, P < 0.01). Adjusting for candidate factors, once they reached MELD 40, women were less likely to be transplanted (subdistribution hazard ratio = 0.90, P < 0.01) and more likely to die or be delisted (subdistribution hazard ratio = 1.14, P = 0.02). CONCLUSIONS: Even among candidates with high disease severity and equally high MELD scores, women have reduced access to liver transplantation and worse outcomes compared with men. Policies addressing this disparity should consider factors beyond MELD score adjustments alone.

Impact of Median MELD at Transplant Minus 3 National Policy on Quality of Transplanted Livers for Patients With and Without Hepatocellular Carcinoma.

BACKGROUND: Patients with hepatocellular carcinoma (HCC) have been overprioritized in the deceased donor liver allocation system. The United Network for Organ Sharing adopted a policy in May 2019 that limited HCC exception points to the median Model for End-Stage Liver Disease at transplant in the listing region minus 3. We hypothesized this policy change would increase the likelihood to transplant marginal quality livers into HCC patients. METHODS: This was a retrospective cohort study of a national transplant registry, including adult deceased donor liver transplant recipients with and without HCC from May 18, 2017, to May 18, 2019 (prepolicy) to May 19, 2019, to March 1, 2021 (postpolicy). Transplanted livers were considered of marginal quality if they met ≥1 of the following: (1) donation after circulatory death, (2) donor age ≥70, (3) macrosteatosis ≥30% and (4) donor risk index ≥95th percentile. We compared characteristics across policy periods and by HCC status. RESULTS: A total of 23 164 patients were included (11 339 prepolicy and 11 825 postpolicy), 22.7% of whom received HCC exception points (prepolicy versus postpolicy: 26.1% versus 19.4%; P = 0.03). The percentage of transplanted donor livers meeting marginal quality criteria decreased for non-HCC (17.3% versus 16.0%; P < 0.001) but increased for HCC (17.7% versus 19.4%; P < 0.001) prepolicy versus postpolicy. After adjusting for recipient characteristics, HCC recipients had 28% higher odds of being transplanted with marginal quality liver independent of policy period (odds ratio: 1.28; confidence interval, 1.09-1.50; P < 0.01). CONCLUSIONS: The median Model for End-Stage Liver Disease at transplant in the listing region minus 3 policy limited exception points and decreased the quality of livers received by HCC patients.

Incorporating Well-Being into Mentorship Meetings: A Case Demonstration at Massachusetts General Hospital Department of Surgery a Harvard Medical School Affiliate.

Surgeons have been under great pressure during the COVID pandemic. Their careers are filled with fast paced decisions, life and death situations, and long hours at work. The COVID pandemic created more tasks and even new responsibilities at times, but when the operating rooms were closed down, there was less work. The COVID experience invited the opportunity to rethink mentoring in the surgery department at the Massachusetts General Hospital. The leadership experimented with a new style of mentoring which involved a team approach. In addition, they tried something else that was new: adding a lifestyle medicine expert and wellness coach to the mentoring team. The program was tested on 13 early stage surgeons who found the experience to be beneficial, and they commented that they wished they had it even earlier in their careers. Including a non-surgeon who was a lifestyle medicine physician and wellness coach added an element of whole person health that was acceptable to the surgeons and even embraced as the majority of them elected to follow up with one on one coaching after the mentoring meeting. This team mentoring program with senior surgeons and a lifestyle medicine expert is one that can be explored by other departments and other hospitals given its success at the department of surgery at Massachusetts General Hospital.

Influence of organ quality on the observed association between deceased donor kidney procurement biopsy findings and graft survival.

Deceased donor kidney procurement biopsies findings are the most common reason for kidney discard. Retrospective studies have found inconsistent associations with post-transplant outcomes but may have been limited by selection bias because kidneys with advanced nephrosclerosis from high-risk donors are typically discarded. We conducted a retrospective cohort study of kidneys transplanted in the United States from 2015 to 2019 with complete biopsy data available, defining "suboptimal histology" as glomerulosclerosis ≥11%, IFTA ≥mild, and/or vascular disease ≥mild. We used time-to-event analyses to determine the association between suboptimal histology and death-censored graft failure after stratification by kidney donor profile index (KDPI) (≤35%, 36%-84%, ≥85%) and final creatinine (<1 mg/dl, 1-2 mg/dl, >2 mg/dl). Among 30 469 kidneys included, 36% had suboptimal histology. In adjusted analyses, suboptimal histology was associated with death-censored graft failure among kidneys with KDPI 36-84% (HR 1.22, 95% CI 1.09-1.36), but not KDPI≤35% (HR 1.24, 0.94-1.64) or ≥ 85% (HR 0.99, 0.81-1.22). Similarly, suboptimal histology was associated with death-censored graft failure among kidneys from donors with creatinine 1-2 mg/dl (HR 1.39, 95% CI 1.20-1.60) but not <1 mg/dl (HR 1.07, 0.93-1.23) or >2 mg/dl (HR 0.95, 0.75-1.20). The association of procurement histology with graft longevity among intermediate-quality kidneys that were likely to be both biopsied and transplanted suggests biopsies provide independent organ quality assessments.

The Association Between Preoperative Opioid Exposure and Prolonged Postoperative Use.

OBJECTIVE: To determine the effect of nonchronic, periodic preoperative opioid use on prolonged opioid fills after surgery. BACKGROUND: Nonchronic, periodic opioid use is common, but its effect on prolonged postoperative opioid fills is not well understood. We hypothesize greater periodic opioid use before surgery is correlated with persistent postoperative use. METHODS: We used a national private insurance claims database, Optum's de-identifed Clinformatics Data Mart Database, to identify adults undergoing general, gynecologic, and urologic surgical procedures between 2008 and 2015 (N = 191,043). We described patterns of opioid fills based on dose, recency, duration, and continuity to categorize preoperative opioid exposure. Patients with chronic use were excluded. Our primary outcome was persistent postoperative use, defined as filling an opioid prescription between 91- and 180-days post-discharge. The association between preoperative opioid use and persistent use was determined using multivariable logistic regression, controlling for clinical covariates. RESULTS: In the year before surgery, 41% of patients had nonchronic, periodic opioid fills. Compared with other risk factors, patterns of preoperative fills were most strongly correlated with persistent postoperative opioid use. Patients with recent intermittent use were significantly more likely to have prolonged fills after surgery compared with opioid-naïve patients [minimal use: odds ratio (OR): 2.0, 95% confidence interval (CI) 1.89-2.03; remote intermittent: OR 4.7, 95% CI 4.46-4.93; recent intermittent: OR 12.2, 95% CI 11.49-12.90]. CONCLUSIONS: Patients with nonchronic, periodic opioid use before surgery are vulnerable to persistent postoperative opioid use. Identifying opioid use before surgery is a critical opportunity to optimize care after surgery.

Prevalence and Patterns of Opioid Use Before and After Liver Transplantation.

BACKGROUND: Opioid use in liver transplantation is poorly understood and has potential associated morbidity. METHODS: Using a national data set of employer-based insurance claims, we identified 1257 adults who underwent liver transplantation between December 2009 and February 2015. We categorized patients based on their duration of opioid fills over the year before and after transplant admission as opioid-naive/no fills, chronic opioid use (≥120 d supply), and intermittent use (all other use). We calculated risk-adjusted prevalence of peritransplant opioid fills, assessed changes in opioid use after transplant, and identified correlates of persistent or increased opioid use posttransplant. RESULTS: Overall, 45% of patients filled ≥1 opioid prescription in the year before transplant (35% intermittent use, 10% chronic). Posttransplant, 61% of patients filled an opioid prescription 0-2 months after discharge, and 21% filled an opioid between 10-12 months after discharge. Among previously opioid-naive patients, 4% developed chronic use posttransplant. Among patients with pretransplant opioid use, 84% remained intermittent or increased to chronic use, and 73% of chronic users remained chronic users after transplant. Pretransplant opioid use (risk factor) and hepatobiliary malignancy (protective) were the only factors independently associated with risk of persistent or increased posttransplant opioid use. CONCLUSIONS: Prescription opioid use is common before and after liver transplant, with intermittent and chronic use largely persisting, and a small development of new chronic use posttransplant. To minimize the morbidity of long-term opioid use, it is critical to improve pain management and optimize opioid use before and after liver transplant.

Classifying Preoperative Opioid Use for Surgical Care.

OBJECTIVE: We characterized patterns of preoperative opioid use in patients undergoing elective surgery to identify the relationship between preoperative use and subsequent opioid fill after surgery. BACKGROUND: Preoperative opioid use is common, and varies by dose, recency, duration, and continuity of fills. To date, there is little evidence to guide postoperative prescribing need based on prior opioid use. METHODS: We analyzed claims data from Clinformatics DataMart Database for patients aged 18 to 64 years undergoing major and minor surgery between 2008 and 2015. Preoperative use was defined as any opioid prescription filled in the year before surgery. We used cluster analysis to group patients by the dose, recency, duration, and continuity of use. Our primary outcome was second postoperative fill within 30 postoperative days. Our primary explanatory variable was opioid use group. We used logistic regression to examine likelihood of second fill by opioid use group. RESULTS: Out of 267,252 patients, 102,748 (38%) filled an opioid prescription in the 12 months before surgery. Cluster analysis yielded 6 groups of preoperative opioid use, ranging from minimal (27.6%) to intermittent (7.7%) to chronic use (2.7%). Preoperative opioid use was the most influential predictor of second fill, with larger effect sizes than other factors even for patients with minimal or intermittent opioid use. Increasing preoperative use was associated with risk-adjusted likelihood of requiring a second opioid fill compared with naive patients [minimal use: odds ratio (OR) 1.49, 95% confidence interval (95% CI) 1.45-1.53; recent intermittent use: OR 6.51, 95% CI 6.16-6.88; high chronic use: OR 60.79, 95% CI 27.81-132.92, all P values <0.001). CONCLUSION: Preoperative opioid use is common among patients who undergo elective surgery. Although the majority of patients infrequently fill opioids before surgery, even minimal use increases the probability of needing additional postoperative prescriptions in the 30 days after surgery when compared with opioid-naive patients. Going forward, identifying preoperative opioid use can inform surgeon prescribing and care coordination for pain management after surgery.

Provider Characteristics Associated With Outpatient Opioid Prescribing After Surgery.

OBJECTIVE: To characterize differences in postoperative opioid prescribing across surgical, nonsurgical, and advanced practice providers. BACKGROUND: There is a critical need to identify best practices around perioperative opioid prescribing. To date, differences in postoperative prescribing among providers are poorly understood. METHODS: This is a retrospective multicenter analysis of commercial insurance claims from a statewide quality collaborative. We identified 15,657 opioid-naïve patients who underwent a range of surgical procedures between January 2012 and October 2015 and filled an opioid prescription within 30 days postoperatively. Our primary outcome was total amount of opioid filled per prescription within 30 days postoperatively [in oral morphine equivalents (OME)]. Hierarchical linear regression was used to determine the association between provider characteristics [specialty, advanced practice providers (nurse practitioners and physician assistants) vs. physician, and gender] and outcome while adjusting for patient factors. RESULTS: Average postoperative opioid prescription amount was 326 ± 285 OME (equivalent: 65 tablets of 5 mg hydrocodone). Advanced practice providers accounted for 19% of all prescriptions, and amount per prescription was 18% larger in this group compared with physicians (315 vs. 268, P < 0.001). Primary care providers accounted for 13% of all prescriptions and prescribed on average 279 OME per prescription. The amount of opioid prescribed varied by surgical specialty and ranged from 178 OME (urology) to 454 OME (neurosurgery). CONCLUSIONS: Advanced practice providers account for 1-in-5 postoperative opioid prescriptions and prescribe larger amounts per prescription relative to surgeons. Engaging all providers involved in postoperative care is necessary to understand prescribing practices, identify barriers to reducing prescribing, and tailor interventions accordingly.

A statewide comparison of opioid prescribing in teaching versus nonteaching hospitals.

BACKGROUND: Postoperative opioid prescribing is often excessive, but the differences in opioid prescribing between teaching hospitals and nonteaching hospitals is not well understood. Given the workload of surgical training and frequent turnover of prescribers on surgical services, we hypothesized that postoperative opioid prescribing would be higher among teaching compared with nonteaching hospitals. STUDY DESIGN: We used insurance claims from a statewide quality collaborative in Michigan to identify 17,075 opioid-naïve patients who underwent 22 surgical procedures across 76 hospitals from 2012 to 2016. Our outcomes included the following: (1) the amount of opioid prescribed for the initial postoperative prescription in oral morphine equivalents and (2) high-risk prescribing in the 30 days after surgery (high daily dose [≥ 100 oral morphine equivalents], new long-acting/extended-release opioid, overlapping prescriptions, or concurrent benzodiazepine prescription). Teaching hospital status was obtained from the 2014 American Hospital Association survey. Multilevel regression was used to adjust for patient and procedural factors and to perform reliability adjustment. RESULTS: The amount of opioid prescribed per initial opioid prescription varied 4.7-fold across all hospitals from 130 oral morphine equivalents to 616 oral morphine equivalents. Patients discharged from teaching hospitals filled larger initial opioid prescriptions overall compared with nonteaching hospitals (251 oral morphine equivalents versus 232 oral morphine equivalents; P = .026). Teaching hospitals had higher risk-adjusted rates of high-risk prescribing compared with nonteaching hospitals (13.7% vs 10.3%; P = .034). CONCLUSION: In Michigan, surgical patients discharged from teaching hospitals received significantly larger postoperative opioid prescriptions and had higher rates of high-risk prescribing compared with nonteaching hospitals. All hospitals, and particularly teaching institutions, should ensure that adequate resources are devoted to facilitating safe postoperative opioid prescribing.

"Development of an Academic Surgical Student Program for Enhancing Student-Faculty Engagement".

OBJECTIVE: We describe an innovative medical student surgery interest group and its influence on mentorship and career exploration. DESIGN: SCRUBS, created to promote interest in academic surgery, is student-led, with continual surgical faculty and resident involvement. Its 3-component programming focuses on clinical skills, research, and mentorship opportunities for medical students to get involved in academic surgery early in medical education. SETTING: The University of Michigan Medical School, Ann Arbor, MI. PARTICIPANTS: First through fourth year medical students, surgery residents, and attending surgeons. RESULTS: SCRUBS is a multifaceted student organization providing longitudinal exposure to various aspects of surgery and academic medicine. The group grew annually from 2010 to 2014, with students and faculty expressing positive feedback. Over the time period reviewed, we had a greater percentage of students applying into surgical specialties compared with the national average (16.8 vs 12% in 2014). The group supported and facilitated mentorship, clinical skills development, and research opportunities for interested students. CONCLUSIONS: This innovative surgery interest group has been well received by students and surgeons, and our institution has seen above-average interest in surgical careers. Early, preclinical mentorship and exposure provided by SCRUBS may contribute to this higher surgical interest.

Prevalence of Preoperative Opioid Use and Characteristics Associated With Opioid Use Among Patients Presenting for Surgery.

Importance: Patterns of preoperative opioid use are not well characterized across different surgical services, and studies in this patient population have lacked important self-reported data of pain and affect. Objectives: To assess the prevalence of preoperative opioid use and the characteristics of these patients in a broadly representative surgical cohort. Design, Setting, and Participants: Cross-sectional, observational study of patients undergoing surgery at a tertiary care academic medical center. Data were collected as a part of large prospective institutional research registries from March 1, 2010, through April 30, 2016. Exposures: Preoperative patient and procedural characteristics, including prospectively assessed self-reported pain and functional measures. Main Outcomes and Measures: Patient-reported opioid use before surgery. Results: Of the total 34 186 patients recruited (54.2% women; mean [SD] age, 53.1 [16.1] years), preoperative opioid use was reported in 7894 (23.1%). The most common opioids used were hydrocodone bitartrate (4685 [59.4%]), tramadol hydrochloride (1677 [21.2%]), and oxycodone hydrochloride (1442 [18.3%]). Age of 31 to 40 years (adjusted odds ratio [aOR], 1.26; 95% CI, 1.10-1.45), tobacco use (former use aOR, 1.32 [95% CI, 1.22-1.42]; current use aOR, 1.62 [95% CI, 1.48-1.78]), illicit drug use (aOR, 1.74; 95% CI, 1.16-2.60), higher pain severity (aOR, 1.33; 95% CI, 1.31-1.35), depression (aOR, 1.22; 95% CI, 1.12-1.33), higher Fibromyalgia Survey scores (aOR, 1.06, 95% CI, 1.05-1.07), lower life satisfaction (aOR, 0.95, 95% CI, 0.93-0.96), and more medical comorbidities (American Society of Anesthesiology score aOR, 1.47 [95% CI, 1.37-1.58]; Charlson Comorbidity Index aOR, 1.29 [95% CI, 1.18-1.41]) were all independently associated with preoperative opioid use. Preoperative opioid use was most commonly reported by patients undergoing orthopedic (226 [65.1%]) and neurosurgical spinal (596 [55.1%]) procedures and least common among patients undergoing thoracic procedures (244 [15.7%]). After adjusting for patient characteristics, the patients undergoing lower extremity procedures were most likely to report preoperative opioid use (aOR, 3.61; 95% CI, 2.81-4.64), as well as those undergoing pelvic (excluding hip) (aOR, 3.09; 95% CI, 1.88-5.08), upper extremity (aOR, 3.07; 95% CI, 2.12-4.45), and spinal or spinal cord (aOR, 2.68; 95% CI, 2.15-3.32) procedures, with the group undergoing intrathoracic surgery as the reference group. Conclusions and Relevance: In this large study of preoperative opioid use that includes patient-reported outcome measures, more than 1 in 4 patients presenting for surgery reported opioid use. These data provide important insights into this complicated patient population that would appear to help guide future preoperative optimization and perioperative opioid-weaning interventions.

Prescription Opioid Use among Opioid-Naive Women Undergoing Immediate Breast Reconstruction.

BACKGROUND: Cancer patients may be particularly vulnerable to the deleterious effects of prolonged opioid use. The authors explored the factors that influence postoperative opioid prescription fills among women following postmastectomy reconstruction. METHODS: Using the Truven Health MarketScan Research Databases, the authors identified a cohort of 4113 opioid-naive patients undergoing mastectomy and immediate breast reconstruction between January of 2010 and August of 2014. Outcomes included average daily oral morphine equivalents and the incidence of prolonged opioid fills (between 90 and 120 days after surgery). Using multivariable regression, the authors examined the effect of patient demographic characteristics, reconstructive technique, comorbid medical and psychiatric conditions, and postoperative complications on outcome variables. RESULTS: In this cohort, 90 percent of patients filled opioid prescriptions perioperatively, and 10 percent continued to fill prescriptions beyond 3 months after surgery. Patients with depression were more likely to fill prescriptions of higher average daily oral morphine equivalents (74.2 mg versus 58.3 mg; p < 0.01), and patients with anxiety were more likely to fill opioids for prolonged periods (13.4 percent versus 9.1 percent; p < 0.01). Patients undergoing autologous free flap reconstruction were less likely to fill prescriptions for a prolonged period following surgery (5.9 percent versus 10.2 percent; p < 0.001). CONCLUSIONS: Prescription opioid fills are common following breast reconstruction, and 10 percent of all patients continue to fill opioid prescriptions beyond 3 months after surgery. Prolonged fills are influenced by both patient factors and surgical procedure, and attention should be directed toward identifying opioid alternatives when possible. CLINCAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Effect of Preoperative Opioid Exposure on Healthcare Utilization and Expenditures Following Elective Abdominal Surgery.

OBJECTIVE: To examine the extent to which preoperative opioid use is correlated with healthcare utilization and costs following elective surgical procedures. SUMMARY BACKGROUND DATA: Morbidity and mortality associated with prescription opioid use is escalating in the United States. The extent to which chronic opioid use influences postoperative outcomes following elective surgery is not well understood. METHODS: Truven Health Marketscan Databases were used to identify adult patients who underwent elective abdominal surgery between June 2009 and December 2012 (n = 200,005). Generalized linear regression was used to determine the effect of preoperative opioid use on postoperative healthcare utilization (length of stay, 30-d readmission, and discharge destination) and cost (hospital stay, 90-, 180-, and 365-d) after adjusting for number of comorbidities, psychological conditions, and demographic characteristics. RESULTS: In this cohort, 8.8% of patients used opioids preoperatively. Compared with non-users, patients using opioids preoperatively were more likely to have a longer hospital stay (2.9 d vs. 2.5 d, P <0.001) and were more likely to be discharged to a rehabilitation facility (3.6% vs. 2.5%, P <0.001), adjusting for covariates. Preoperative opioid use was also correlated with a greater rate of 30-day readmission (4.5% vs. 3.6%, P <0.001) and overall greater expenditures at 90- ($12036.60 vs. $3863.40, P <0.001), 180- ($16973.70 vs. $6790.60, P <0.001), and 365- ($25495.70 vs. $12113.80, P <0.001) days following surgery, adjusted for covariates. Additionally, dose-effects were observed regarding readmission, discharge destination, and late healthcare expenditures. CONCLUSIONS: Preoperative interventions focused on opioid cessation and alternative analgesics may improve the safety and efficiency of elective surgery among chronic opioid users.

Predictors of operative failure in parathyroidectomy for primary hyperparathyroidism.

INTRODUCTION: Many adjuncts guide surgical decision making in parathyroidectomy, yet their independent associations with outcome are poorly characterized. We examined a broad range of perioperative factors and used multivariate techniques to identify independent predictors of operative failure (persistent disease) after parathyroidectomy. METHODS: This was a retrospective review of 2239 patients with primary hyperparathyroidism who underwent parathyroidectomy at a single-center from 1999 to 2014. We used multivariate logistic regress to measure associations between multiple perioperative factors and an operative failure (persistent hypercalcemia). RESULTS: Operative failure was identified in 67 patients (3.0%). The following variables were independently associated with operative failure on multivariate analysis: IOPTH criteria met (protective, OR = 0.22, P < 0.001), preoperative calcium (risk factor, OR = 2.27 per unit increase, P < 0.001), weight of excised gland(s) (protective, OR = 0.70 per two-fold increase, P = 0.003), and preoperative PTH (protective, OR = 0.55 per two-fold increase, P = 0.008). CONCLUSION: In addition to the well-established IOPTH criteria, we suggest that consideration of the above independent perioperative risk factors may further inform surgical decision-making in parathyroidectomy.

Preoperative Opioid Use is Independently Associated With Increased Costs and Worse Outcomes After Major Abdominal Surgery.

OBJECTIVE: To explore the clinical and financial implications of preoperative opioid use in major abdominal surgery. BACKGROUND: Opioids are increasingly used to manage chronic pain, and chronic opioid users are challenging to care for perioperatively. Given the epidemic of opioid-related morbidity and mortality, it is critical to understand how preoperative opioid use impacts surgical outcomes. METHODS: This was an analysis of nonemergent, abdominopelvic surgeries from 2008 to 2014 from a single center within the Michigan Surgical Quality Collaborative clinical registry database. Preoperative opioid use (binary exposure variable) was retrospectively queried from the home medication list of the preoperative evaluation. Our primary outcome was 90-day total hospital costs. Secondary outcomes included hospital length of stay, 30-day major complication rates, discharge destination, and 30-day hospital readmission rates. Analyses were risk-adjusted for case complexity and patient-specific risk factors such as demographics, insurance, smoking, comorbidities, and concurrent medication use. RESULTS: In all, 2413 patients met the inclusion criteria. Among them, 502 patients (21%) used opioids preoperatively. After covariate adjustment, opioid users (compared with those who were opioid-naïve) had 9.2% higher costs [95% confidence interval (CI) 2.8%-15.6%; adjusted means $26,604 vs $24,263; P = 0.005), 12.4% longer length of stay (95% CI 2.3%-23.5%; adjusted means 5.9 vs 5.2 days; P = 0.015), more complications (odds ratio 1.36; 95% CI 1.04-1.78; adjusted rates 20% vs 16%; P = 0.023), more readmissions (odds ratio 1.57; 95% CI 1.08-2.29; adjusted rates 10% vs 6%; P = 0.018), and no difference in discharge destination (P = 0.11). CONCLUSIONS: Opioid use is common before abdominopelvic surgery, and is independently associated with increased postoperative healthcare utilization and morbidity. Preoperative opioids represent a potentially modifiable risk factor and a novel target to improve quality and value of surgical care.