A quasi-experimental evaluation of the association between implementation of Quality-Based Procedures funding for hip fractures and improvements in processes and outcomes for hip fracture patients in Ontario: an interrupted time series analysis.

PURPOSE: In 2013, Ontario introduced a patient-based funding model for hip fracture care (Quality-Based Procedures [QBP]). The association of QBP implementation with changes in processes and outcomes has not been evaluated. METHODS: We conducted a quasi-experimental study using linked health data for adult hip fractures as an interrupted time series. The pre-QBP period was from 2008 to 2012 and the post-QBP period was from 2014 to 2018; 2013 was excluded as a wash-in period. We used segmented regression analyses to estimate the association of QBP implementation with changes in processes (surgery in less than two days from admission, use of echocardiography, use of nerve blocks, and provision of geriatric care) and clinical outcomes (90-day mortality, 90-day readmissions, length of stay, and days alive at home). We estimated the immediate (level) change, trend (slope) postimplementation, and total counterfactual differences. Sensitivity analyses included case-mix adjustment and stratification by hospital type and procedure. RESULTS: We identified 45,500 patients in the pre-QBP period and 41,256 patients in the post-QBP period. There was a significant total counterfactual increase in the use of nerve blocks (11.1%; 95% confidence interval [CI], 6.2 to 16.0) and a decrease in the use of echocardiography (-2.5%; 95% CI, -3.7 to -1.3) after QBP implementation. The implementation of QBP was not associated with a clinically or statistically meaningful change in 90-day mortality, 90-day readmission, length of stay, or number of days alive at home. CONCLUSION: Evaluation of the QBP program is crucial to inform ongoing and future changes to policy and funding for hip fracture care. The introduction of the QBP Hip Fracture program, supported by evidence-based recommendations, was associated with improved application of some evidence-based processes of care but no changes in clinical outcomes. There is a need for ongoing development and evaluation of funding models to identify optimal strategies to improve the value and outcomes of hip fracture care. STUDY REGISTRATION: Open Science Framework ( https://osf.io/2938h/ ); first posted 13 June 2022.

RéSUMé: OBJECTIF: En 2013, l'Ontario a mis en place un modèle de financement axé sur les patient·es pour les soins suivant une fracture de la hanche (procédures fondées sur la qualité [PFQ]). L'association entre la mise en œuvre des PFQ et les changements dans les processus et les devenirs n'a pas été évaluée. MéTHODE: Nous avons mené une étude quasi expérimentale en utilisant des données de santé couplées pour les fractures de la hanche chez l'adulte comme une série chronologique interrompue. La période précédant les PFQ s'étendait de 2008 à 2012, et la période subséquente à l'implantation des PFQ allait de 2014 à 2018. L'année 2013 a été exclue en tant que période de rodage. Nous avons utilisé des analyses de régression segmentées pour estimer l'association entre la mise en œuvre des PFQ avec des changements aux processus (chirurgie en moins que deux jours suivant l'admission, utilisation de l'échocardiographie, utilisation de blocs nerveux et prestation de soins gériatriques) et des issues cliniques (mortalité à 90 jours, réadmissions à 90 jours, durée de séjour et jours de vie à domicile). Nous avons estimé le changement immédiat (niveau), la tendance (pente) après la mise en œuvre et les différences contrefactuelles totales. Les analyses de sensibilité comprenaient l'ajustement et la stratification de la combinaison de cas par type d'hôpital et par procédure. RéSULTATS: Nous avons identifié 45 500 patient·es dans la période pré-PFQ et 41 256 patient·es dans la période post-PFQ. Il y a eu une augmentation contrefactuelle totale significative de l'utilisation de blocs nerveux (11,1 %; intervalle de confiance [IC] à 95 %, 6,2 à 16,0) et une diminution de l'utilisation de l'échocardiographie (−2,5 %; IC 95 %, −3,7 à −1,3) après la mise en œuvre des PFQ. La mise en œuvre des PFQ n'a pas été associée à un changement cliniquement ou statistiquement significatif de la mortalité à 90 jours, de la réadmission à 90 jours, de la durée de séjour ou du nombre de jours de vie à domicile. CONCLUSION: L'évaluation du programme de PFQ est cruciale pour guider les changements actuels et futurs aux politiques et au financement des soins suivant une fracture de la hanche. La mise en place du programme de PFQ pour les fractures de la hanche, appuyée par des recommandations fondées sur des données probantes, a été associée à une meilleure application de certains processus de soins fondés sur des données probantes, mais à aucun changement dans les devenirs cliniques. Il est nécessaire d'élaborer et d'évaluer continuellement des modèles de financement afin de déterminer les stratégies optimales pour améliorer la valeur et les devenirs des soins suivant une fracture de la hanche. ENREGISTREMENT DE L'éTUDE: Open Science Framework ( https://osf.io/2938h/ ); première publication le 13 juin 2022.

Hospital-, anaesthetist-, and patient-level variation in peripheral nerve block utilisation for hip fracture surgery: a population-based cross-sectional study.

BACKGROUND: Unwarranted variation in anaesthesia practice is associated with adverse outcomes. Despite high-certainty evidence of benefit, a minority of hip fracture surgery patients receive a peripheral nerve block. Our objective was to estimate variation in peripheral nerve block use at the hospital, anaesthetist, and patient levels, while identifying predictors of peripheral nerve block use in hip fracture patients. METHODS: After protocol registration (https://osf.io/48bvp/), we conducted a population-based cross-sectional study using linked administrative data in Ontario, Canada. We included adults >65 yr of age having emergency hip fracture surgery from April 1, 2012 to March 31, 2018. Logistic mixed models were used to estimate the variation in peripheral nerve block use attributable to hospital-, anaesthetist-, and patient-level factors with use of peripheral nerve block, quantified using the variance partition coefficient and median odds ratio. Predictors of peripheral nerve block use were estimated and temporally validated. RESULTS: Of 50 950 patients, 9144 (18.5%) received a peripheral nerve block within 1 day of surgery. Patient-level factors accounted for 14% of variation, whereas 42% and 44% were attributable to the hospital and anaesthetist providing care, respectively. The median odds ratio for receiving a peripheral nerve block was 5.73 at the hospital level and 5.97 at the anaesthetist level. No patient factors had large associations with receipt of a peripheral nerve block (odds ratios significant at the 5% level ranged from 0.86 to 1.35). CONCLUSIONS: Patient factors explain the minimal variation in peripheral nerve block use for hip fracture surgery. Interventions to increase uptake of peripheral nerve blocks for hip fracture patients will likely need to focus on structures and processes at the hospital and anaesthetist levels.

Persistent Postoperative Opioid Prescription Fulfillment and Peripheral Nerve Blocks for Ambulatory Shoulder Surgery: A Retrospective Cohort Study.

BACKGROUND: There is need to identify perioperative interventions that decrease chronic opioid use. The authors hypothesized that receipt of a peripheral nerve block would be associated with a lower incidence of persistent postoperative opioid prescription fulfillment. METHODS: This was a retrospective population-based cohort study examining ambulatory shoulder surgery patients in Ontario, Canada. The main outcome measure was persistent postoperative opioid prescription fulfillment. In opioid-naive patients (no opioid prescription fulfillment in 90 days preoperatively), this was present if an individual fulfilled an opioid prescription of at least a 60-day supply during postoperative days 90 to 365. In opioid-exposed (less than 60 mg oral morphine equivalent dose per day within 90 days preoperatively) or opioid-tolerant (60 mg oral morphine equivalent dose per day or above within 90 days preoperatively) patients, this was classified as present if an individual experienced any increase in opioid prescription fulfillment from postoperative day 90 to 365 relative to their baseline use before surgery. The authors' exposure was the receipt of a peripheral nerve block. RESULTS: The authors identified 48,523 people who underwent elective shoulder surgery from July 1, 2012, to December 31, 2017, at one of 118 Ontario hospitals. There were 8,229 (17%) patients who had persistent postoperative opioid prescription fulfillment. Of those who received a peripheral nerve block, 5,008 (16%) went on to persistent postoperative opioid prescription fulfillment compared to 3,221 (18%) patients who did not (adjusted odds ratio, 0.90; 95% CI, 0.83 to 0.97; P = 0.007). This statistically significant observation was not reproduced in a coarsened exact matching sensitivity analysis (adjusted odds ratio, 0.85; 95% CI, 0.71 to 1.02; P = 0.087) or several other subgroup and sensitivity analyses. CONCLUSIONS: This retrospective analysis found no association between receipt of a peripheral nerve block and a lower incidence of persistent postoperative opioid prescription fulfillment in ambulatory shoulder surgery patients.

A Population-based Comparative Effectiveness Study of Peripheral Nerve Blocks for Hip Fracture Surgery.

BACKGROUND: Adverse outcomes and resource use rates are high after hip fracture surgery. Peripheral nerve blocks could improve outcomes through enhanced analgesia and decreased opioid related adverse events. We hypothesized that these benefits would translate into decreased resource use (length of stay [primary outcome] and costs), and better clinical outcomes (pneumonia and mortality). METHODS: The authors conducted a retrospective cohort study of hip fracture surgery patients in Ontario, Canada (2011 to 2015) using linked health administrative data. Multilevel regression, instrumental variable, and propensity scores were used to determine the association of nerve blocks with resource use and outcomes. RESULTS: The authors identified 65,271 hip fracture surgery patients; 10,030 (15.4%) received a block. With a block, the median hospital stay was 7 (interquartile range, 4 to 13) days versus 8 (interquartile range, 5 to 14) days without. Following adjustment, nerve blocks were associated with a 0.6-day decrease in length of stay (95% CI, 0.5 to 0.8). This small difference was consistent with instrumental variable (1.1 days; 95% CI, 0.9 to 1.2) and propensity score (0.2 days; 95% CI, 0.2 to 0.3) analyses. Costs were lower with a nerve block (adjusted difference, -$1,421; 95% CI, -$1,579 to -$1,289 [Canadian dollars]), but no difference in mortality (adjusted odds ratio, 0.99; 95% CI, 0.89 to 1.11) or pneumonia (adjusted odds ratio, 1.01; 95% CI, 0.88 to 1.16) was observed. CONCLUSIONS: Receipt of nerve blocks for hip fracture surgery is associated with decreased length of stay and health system costs, although small effect sizes may not reflect clinical significance for length of stay.

Peripheral Nerve Blocks for Ambulatory Shoulder Surgery: A Population-based Cohort Study of Outcomes and Resource Utilization.

BACKGROUND: Nerve blocks improve early pain after ambulatory shoulder surgery; impact on postdischarge outcomes is poorly described. Our objective was to measure the association between nerve blocks and health system outcomes after ambulatory shoulder surgery. METHODS: We conducted a population-based cohort study using linked administrative data from 118 hospitals in Ontario, Canada. Adults having elective ambulatory shoulder surgery (open or arthroscopic) from April 1, 2009, to December 31, 2016, were included. After validation of physician billing codes to identify nerve blocks, we used multilevel, multivariable regression to estimate the association of nerve blocks with a composite of unplanned admissions, emergency department visits, readmissions or death within 7 days of surgery (primary outcome) and healthcare costs (secondary outcome). Neurology consultations and nerve conduction studies were measured as safety indicators. RESULTS: We included 59,644 patients; blocks were placed in 31,073 (52.1%). Billing codes accurately identified blocks (positive likelihood ratio 16.83, negative likelihood ratio 0.03). The composite outcome was not significantly different in patients with a block compared with those without (2,808 [9.0%] vs. 3,424 [12.0%]; adjusted odds ratio 0.96; 95% CI 0.89 to 1.03; P = 0.243). Healthcare costs were greater with a block (adjusted ratio of means 1.06; 95% CI 1.02 to 1.10; absolute increase $325; 95% CI $316 to $333; P = 0.005). Prespecified sensitivity analyses supported these results. Safety indicators were not different between groups. CONCLUSIONS: In ambulatory shoulder surgery, nerve blocks were not associated with a significant difference in adverse postoperative outcomes. Costs were statistically higher with a block, but this increase is not likely clinically relevant.

Association of peripheral nerve blocks with postoperative outcomes in ambulatory shoulder surgery patients: a single-centre matched-cohort study.

PURPOSE: Regional anesthesia may have immediate postoperative advantages compared with general anesthesia, but its impact on post-discharge outcomes is poorly described. Our objective was to measure the association between regional anesthesia and outcomes after ambulatory shoulder surgery. METHODS: We conducted a historical cohort study at The Ottawa Hospital. Adults ≥ 18 yr old having elective ambulatory shoulder surgery from January 1, 2011 to December 31, 2016 were included. Using one-to-many coarsened exact matching (CEM) to adjust for potential confounders, we matched peripheral nerve block (PNB) patients to those without a PNB. Within the matched cohort, we assessed whether PNBs were associated with our primary composite outcomes, comprising unplanned admissions, emergency department visits, readmissions, or death within 30 days of surgery. RESULTS: There were 1,623 patients who met the inclusion criteria; PNBs were placed in 1,382 (85.2%) patients. CEM matched 211 patients who did not receive a PNB to 950 patients with similar characteristics who did receive a PNB (n = 1,161; 71.5% of total cohort). In patients who received a PNB compared with those who had no PNB, there was no difference in risk of composite outcome (relative risk, 1.58; 95% confidence interval [CI], 0.83 to 3.01), or hospital costs (ratio of means 0.73; 95% CI, 0.21 to 2.49). CONCLUSION: Peripheral nerve blocks in ambulatory shoulder surgery were not associated with a significant difference in a composite of adverse postoperative outcomes. Nevertheless, given the lower than expected incidence and moderate effect size associating PNBs with post-discharge events, future large prospective trials are needed to assess post-discharge outcomes. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT03309644). Registered 13 October 2017.

Continuous infraclavicular brachial plexus blockade: effect on survival of replanted digits.

In replantation surgery, the use of continuous brachial plexus blockade (CBPB) is popular as it improves postoperative analgesia and vascular flow. The aim of our study was to determine whether CBPB may affect the odds of survivability of replanted digit(s). A four-year retrospective chart review was performed and various parameters affecting replant survival were examined. Outcome was recorded as successful if the transplanted digit(s) survived six months after discharge. All the independent variables were forced into a regression model without using a specific variable selection algorithm. The data for 146 patients was obtained from our chart review. The success rate of replanted digits in the patients reviewed was 65.8%. The logistic regression model showed a relation between the number of digits injured and replanted digit(s) survival. Our study showed that CBPB has no effect on the survivability of the replanted digit(s) till six months after hospital discharge.

The utility of ultrasound imaging in predicting ease of performance of spinal anesthesia in an orthopedic patient population.

BACKGROUND AND OBJECTIVES: Ultrasonography of the spine improves technical performance of spinal anesthesia, but what is unclear is whether it can predict difficulty. We tested the hypothesis that a good ultrasound view at a given intervertebral level is associated with absence of technical difficulty. METHODS: We performed preprocedural ultrasound of the L1-S1 intervertebral spaces in 100 patients undergoing orthopedic surgery. Visibility of the ligamentum flavum-dura mater and the posterior longitudinal ligament was evaluated using paramedian sagittal oblique and transverse midline (TM) views. Views were classified as good if both of these structures were visible on ultrasound. An operator, blinded to the ultrasound scan, performed surface landmark-guided spinal anesthesia using a midline approach. Absence of technical difficulty was defined as successful dural puncture within 2 skin punctures or 10 needle passes. RESULTS: A good TM view had the best diagnostic accuracy; if this view was obtained, absence of technical difficulty with dural puncture at that level was highly likely (positive predictive value, 85%). Dural puncture could still be feasible despite the absence of a good TM view, as reflected by a negative predictive value of 30%. This was attributed to the limitations of ultrasound imaging in this patient population, as well as the low overall prevalence of difficult dural puncture. Parasagittal oblique views did not have significant diagnostic utility for a midline needle approach. CONCLUSIONS: Ultrasound can be useful in predicting the absence of technical difficulty in performing dural puncture and thus in selecting the optimal intervertebral level for spinal anesthesia.

Ultrasound-guided popliteal block distal to sciatic nerve bifurcation shortens onset time: a prospective randomized double-blind study.

BACKGROUND AND OBJECTIVES: Popliteal sciatic nerve block (SNB) in combination with saphenous nerve block provides anesthesia and analgesia for foot and ankle surgeries. Landmark-based and image-guided techniques, to date, aim at blocking the sciatic nerve proximal to its bifurcation. Sciatic nerve block is usually associated with a long onset time (30-60 mins). We hypothesized that SNB distal to its bifurcation (blocking its 2 main branches tibial and common peroneal nerves separately) is associated with a shorter onset time than blockade proximal to its bifurcation. METHODS: Fifty patients scheduled for major elective foot or ankle surgery were randomly allocated to receive ultrasound-guided SNB 5 cm proximal to (group P) or 3 cm distal to (group D) its bifurcation in the popliteal fossa. Thirty milliliters of a standardized local anesthetic solution of equal volumes of 2% lidocaine and 0.5% bupivacaine with 1:200,000 epinephrine was used. Sensory and motor assessments were performed every 5 mins by a blinded observer until complete sensory and motor blockade developed in both tibial and common peroneal nerve territories. RESULTS: All patients in both groups developed a complete block. Patients in group D presented a 30% shorter onset of both sensory (21.4 [SD, 9.9] vs 31.4 [SD, 13.9] mins) (P = 0.005) and motor block (21.5 [SD, 11.3] vs 32.4 [SD, 14.9] mins) (P = 0.006) than patients in group P. Procedure time, procedure-related discomfort, and patient satisfaction were similar in both groups. CONCLUSIONS: Our data suggest that popliteal SNB distal to the bifurcation has a shorter onset time than SNB proximal to its bifurcation, and therefore, it may be a good option when a fast onset for a surgical block is required.

Feasibility and efficacy of ultrasound-guided block of the saphenous nerve in the adductor canal.

BACKGROUND AND OBJECTIVES: Saphenous nerve (SN) block can be technically challenging because it is a small and exclusively sensory nerve. Traditional techniques using surface landmarks and nerve stimulation are limited by inconsistent success rates. This descriptive prospective study assesses the feasibility of performing an ultrasound-guided SN block in the distal thigh. METHODS: After the research ethics board's approval and written informed consent, 20 patients undergoing ankle or foot surgery underwent ultrasonography of the medial aspect of the thigh to identify the SN in the adductor canal, as it lies adjacent to the femoral artery (FA), deep to the sartorius muscle. An insulated needle was advanced in plane under real-time guidance toward the nerve. After attempting to elicit paresthesia with nerve stimulation, 2% lidocaine with 1:200,000 epinephrine (5 mL) and 0.5% bupivacaine (5 mL) were injected around the SN. RESULTS: The SN was identified in all patients, most frequently in an anteromedial position relative to the FA, at a depth of 2.7 +/- 0.6 cm and 12.7 +/- 2.2 cm proximal to the knee joint. Complete anesthesia in the SN distribution developed in all patients by 25 mins after injection. CONCLUSIONS: In this small descriptive study, ultrasound-guided SN block in the adductor canal was technically simple and reliable, providing consistent nerve identification and block success.