Inappropriate prescribing of opioids for patients undergoing surgery.

In response to the opioid epidemic in the United States, states have passed policies aimed at regulating how opioids are prescribed by physicians. For such policies to be effective, however, opioids must be prescribed to the patients for whom they are intended. Whether opioid prescriptions are written for those who are not intended to consume them is empirically difficult to show. In a commercially insured population, we examined opioid prescriptions written for and filled by spouses of patients undergoing outpatient surgery on the day of a patient's surgery compared with the surrounding days. Because patients may be unable to fill prescriptions themselves immediately after surgery, surgeons may prescribe opioids to a patient's spouse, which would be clinically inappropriate. Among 450,125 opioid-naïve couples studied, for patients who did not fill perioperative opioid prescriptions themselves, the rate of spousal fills on the day of surgery (DOS) was 2.39 fills per 1,000 surgeries compared with 0.44 fills on all other perioperative days (adjusted odds ratio (aOR), 5.5, 95% CI, 4.6-6.5). Increases in spousal opioid fills were not present for patients that filled opioid prescriptions themselves. These findings suggest intentional, clinically inappropriate prescribing of opioids.

Association of Maternal Cervical Disease With Human Papillomavirus Vaccination Among Offspring.

Importance: Barriers to childhood vaccination against vaccine-preventable diseases, such as those due to human papillomavirus (HPV), are well known. However, the role of salience bias-the change in perception of risk due to increased familiarity with the outcome-in decisions to vaccinate children has not been explicitly studied. Objective: To assess for salience bias in parental decisions to vaccinate children. Design, Setting, and Participants: This retrospective cohort study used a time-to-event (survival) analysis to compare vaccination rates of children whose mothers had a history of cervical cancer or a cervical biopsy, who have experienced adverse vaccine-preventable outcomes, and for whom vaccination may be more salient, with a control group of children whose mothers had no such history. Participants were accrued from the MarketScan Commercial Database, including US children who turned 11 years old, when HPV vaccination is recommended, from January 1, 2014, to December 31, 2018. Data were analyzed from December 29, 2020, to September 17, 2021. Exposures: Maternal history of cervical cancer or cervical biopsy. Main Outcomes and Measures: Vaccination against HPV. Results: A total of 757 428 children (370 878 girls [49.0%] and 386 550 boys [51.0%]) were identified, of whom 38 366 had mothers with a history of cervical biopsy alone and 1084 had mothers with a history of cervical cancer. Overall, 54.2% of children (55.7% of girls and 52.7% of boys) received at least 1 vaccination by 16 years of age. In a time-to-event analysis, HPV vaccination did not differ between children whose mothers had cervical cancer vs those whose mothers did not (hazard ratio [HR] for girls, 0.99 [95% CI, 0.86-1.13]; HR for boys, 1.08 [95% CI, 0.94-1.24]). Maternal history of cervical biopsy was associated with a minimally increased hazard of vaccination (HR for girls, 1.06 [95% CI, 1.04-1.09]; HR for boys, 1.04 [95% CI, 1.01-1.06]). There were no clinically meaningful differences between groups for the tetanus/diphtheria/acellular pertussis and meningococcal vaccinations, which are also recommended at 11 years of age. Conclusions and Relevance: In this analysis of salience bias in childhood vaccination decisions, mothers' personal history of cervical cancer or cervical biopsy was not associated with greater vaccination rates among children against HPV. These findings suggest that salience of vaccine-preventable outcomes may not have a major impact on childhood vaccine hesitancy in HPV; the role of salience should be investigated for other vaccines.

Association between Palliative Care and End-of-Life Resource Use for Older Adults Hospitalized with Septic Shock.

Rationale: The care of critically ill patients often involves complex discussions surrounding prognosis, goals, and end-of-life decision-making. Yet, physician and hospital practice patterns, rather than patient goals, remain a major determinant of the intensity of end-of-life care. For critically ill patients, palliative care may help promote treatments that are concordant with patients' goals, while minimizing the use of invasive and costly intensive care unit resources that may not be consistent with those goals.Objectives: To determine whether inpatient palliative care, delivered by specialist consultants or a primary medical team, is associated with reduced hospital length of stay and costs for older adults with septic shock at the end of life.Methods: This was a retrospective cohort using the National Inpatient Sample from 2013 to 2014, examining patients aged ≥65 years with septic shock who died during their hospitalization. The exposure of interest was inpatient palliative care encounter, including either generalist- or specialist-delivered palliative care. Outcomes were hospital length of stay, total cost for the hospitalization, and daily hospital cost. Patient and hospital-level confounders were used to derive inverse probability of treatment weights and estimate the association between palliative care and outcomes in a generalized linear model.Results: We studied 45,868 patients who died with a diagnosis of septic shock; 15,370 of these patients had a palliative care encounter. After inverse probability of treatment weighting, there were no appreciable differences between the population characteristics. Palliative care was associated with a shorter adjusted mean hospital length of stay (12.0 vs. 13.1 d; difference, -1.1 d; 95% confidence interval [CI], -1.4 to -0.9; P < 0.001), lower total hospital costs (69,700 vs. 76,800 U.S. dollars [USD]; difference, -7,100 USD; 95% CI, -8.5 to -5.2 thousand USD; P < 0.001), and lower daily hospital cost (5,900 vs. 6,200 USD; difference, -310 USD per day; 95% CI, -420 to -200 USD; P < 0.001) when compared with no palliative care.Conclusions: In a nationally representative sample of adults who died during a hospitalization with septic shock, receipt of palliative care was associated with shorter length of stay and lower total and daily hospital costs. This finding was robust to adjustment for patient- and hospital-level confounders, though unmeasured confounders still could be affecting these findings.

The need for speed: observational study of physician driving behaviors.

OBJECTIVE: To determine whether fast driving, luxury car ownership, and leniency by police officers differ across medical specialties. DESIGN: Observational study. SETTING: Florida, USA. PARTICIPANTS: 5372 physicians and a sample of 19 639 non-physicians issued a ticket for speeding during 2004-17. MAIN OUTCOME MEASURES: Observed rates of extreme speeding (defined as driving >20 mph above the speed limit), luxury car ownership, and leniency of the speeding ticket by police officers, by physician specialty, after adjustment for age and sex. RESULTS: The sample included 5372 physicians who received 14 560 speeding tickets. The proportion of drivers who were reported driving at speeds greater than 20 mph was similar between physicians and a sample of 19 639 non-physicians who received a ticket for speeding (26.4% v 26.8% of tickets, respectively). Among physicians who received a ticket, psychiatrists were most likely to be fined for extreme speeding (adjusted odds ratio of psychiatry compared with baseline specialty of anesthesia 1.51, 95% confidence interval 1.07 to 2.14). Among drivers who received a ticket, luxury car ownership was most common among cardiologists (adjusted proportion of ticketed cardiologists who owned a luxury car 40.9%, 95% confidence interval 35.9% to 45.9%) and least common among physicians in emergency medicine, family practice, pediatrics, general surgery, and psychiatry (eg, adjusted proportion of luxury car ownership among family practice physicians 20.6%, 95% confidence interval 18.2% to 23.0%). Speed discounting, a marker of leniency by police officers in which ticketed speed is recorded at just below the threshold at which a larger fine would otherwise be imposed, was common, but rates did not differ by specialty and did not differ between physicians and a sample of non-physicians. CONCLUSIONS: Rates of extreme speeding were highest among psychiatrists who received a ticket, whereas cardiologists were the most likely to be driving a luxury car when ticketed. Leniency by police officers was similar across specialties and between physicians and non-physicians.