Racial disparities in inpatient palliative care consultation among frail older patients undergoing high-risk elective surgical procedures in the United States: a cross-sectional study of the national inpatient sample.

Surgical interventions are common among seriously ill older patients, with nearly one-third of older Americans facing surgery in their last year of life. Despite the potential benefits of palliative care among older surgical patients undergoing high-risk surgical procedures, palliative care in this population is underutilized and little is known about potential disparities by race/ethnicity and how frailty my affect such disparities. The aim of this study was to examine disparities in palliative care consultations by race/ethnicity and assess whether patients' frailty moderated this association. Drawing on a retrospective cross-sectional study of inpatient surgical episodes using the National Inpatient Sample of the Healthcare Cost and Utilization Project from 2005 to 2019, we found that frail Black patients received palliative care consultations least often, with the largest between-group adjusted difference represented by Black-Asian/Pacific Islander frail patients of 1.6 percentage points, controlling for sociodemographic, comorbidities, hospital characteristics, procedure type, and year. No racial/ethnic difference in the receipt of palliative care consultations was observed among nonfrail patients. These findings suggest that, in order to improve racial/ethnic disparities in frail older patients undergoing high-risk surgical procedures, palliative care consultations should be included as the standard of care in clinical care guidelines.

Professionalism of Admitting and Consulting Services and Trauma Patient Outcomes.

OBJECTIVE: To determine whether trauma patients managed by an admitting or consulting service with a high proportion of physicians exhibiting patterns of unprofessional behaviors are at greater risk of complications or death. SUMMARY BACKGROUND DATA: Trauma care requires high-functioning interdisciplinary teams where professionalism, particularly modeling respect and communicating effectively, is essential. METHODS: This retrospective cohort study used data from 9 level I trauma centers that participated in a national trauma registry linked with data from a national database of unsolicited patient complaints. The cohort included trauma patients admitted January 1, 2012 through December 31, 2017. The exposure of interest was care by 1 or more high-risk services, defined as teams with a greater proportion of physicians with high numbers of patient complaints. The study outcome was death or complications within 30 days. RESULTS: Among the 71,046 patients in the cohort, 9553 (13.4%) experienced the primary outcome of complications or death, including 1875 of 16,107 patients (11.6%) with 0 high-risk services, 3788 of 28,085 patients (13.5%) with 1 high-risk service, and 3890 of 26,854 patients (14.5%) with 2+ highrisk services (P < 0.001). In logistic regression models adjusting for relevant patient, injury, and site characteristics, patients who received care from 1 or more high-risk services were at 24.1% (95% confidence interval 17.2% to 31.3%; P < 0.001) greater risk of experiencing the primary study outcome. CONCLUSIONS: Trauma patients who received care from at least 1 service with a high proportion of physicians modeling unprofessional behavior were at an increased risk of death or complications.

Intercostal nerve cryoablation during surgical stabilization of rib fractures.

BACKGROUND: Intercostal nerve cryoablation (IC) offers potential for targeted and durable analgesia for patients with traumatic rib fractures. Our pilot study aimed to investigate thoracoscopic IC's safety, feasibility, and preliminary efficacy for patients undergoing surgical stabilization of rib fractures (SSRF). We hypothesized that concurrent surgical stabilization of rib fractures and intercostal nerve cryoablation (SSRF-IC) is a safe and feasible procedure without immediate or long-term complications. METHODS: We retrospectively evaluated patients 18 years or older who underwent SSRF (with or without IC) for acute rib fractures at our level I trauma center between September 1, 2019, and September 30, 2020. We performed IC under thoracoscopic visualization (-70°C for 2 minutes per intercostal nerve bundle). Among patients whose only operative procedure during hospitalization was SSRF, we evaluated post-SSRF length of stay, operative times, opioid requirements (oral morphine equivalents), and pain scores (Numerical Rating Scale). Generalized estimating equations compared SSRF and SSRF-IC group outcomes (population mean [robust standard error]). We assessed long-term outcomes of patients who underwent SSRF-IC. RESULTS: Thirty-four patients (144 ribs) underwent SSRF; of these, 20 patients (135 ribs) underwent SSRF-IC. Patients who did and did not undergo concurrent IC had no significant difference demographic, injury, or hospitalization characteristics. Among 20 patients who did not undergo other operations, 12 underwent SSRF-IC. We did not find significant difference between SSRF and SSRF-IC groups' median operative times or post-SSRF length of stay. Compared with SSRF group, SSRF-IC group did not have statistically significant change in pain score (0.2 [1.5] lower) or opioid use (43.9 [86.1] mg/d greater) between 12 hours before SSRF and last 24 admission hours. Among 17 SSRF-IC patients who followed-up postdischarge (median [range], 160 [9-357] days), one reported mild chest wall paresthesia; no other complications were reported. CONCLUSION: This pilot study performing 135 intercostal nerve cryoablations on 20 patients suggests that IC is safe and feasible for patients undergoing SSRF. Evaluating IC's analgesic efficacy for rib fractures requires further study. LEVEL OF EVIDENCE: Therapeutic, Level V.