Trends in the Use of Gabapentinoids and Opioids in the Postoperative Period Among Older Adults.

Importance: In response to the opioid epidemic, recommendations from some pain societies have encouraged surgeons to embrace multimodal pain regimens with the intent of reducing opioid use in the postoperative period, including by prescribing gabapentinoids. Objective: To describe trends in postoperative prescribing of both gabapentinoids and opioids after a variety of surgical procedures by examining nationally representative Medicare data and further understand variation by procedure. Design, Setting, and Participants: This serial cross-sectional study of gabapentinoid prescribing from January 1, 2013, through December 31, 2018, used a 20% US Medicare sample. Gabapentinoid-naive patients 66 years or older undergoing 1 of 14 common noncataract surgical procedures performed in older adults were included. Data were analyzed from April 2022 to April 2023. Exposure: One of 14 common surgical procedures in older adults. Main Outcomes and Measures: Rate of postoperative prescribing of gabapentinoids and opioids, defined as a prescription filled between 7 days before the procedure and 7 days after discharge from surgery. Additionally, concomitant prescribing of gabapentinoids and opioids in the postoperative period was assessed. Results: The total study cohort included 494 922 patients with a mean (SD) age of 73.7 (5.9) years, 53.9% of whom were women and 86.0% of whom were White. A total of 18 095 patients (3.7%) received a new gabapentinoid prescription in the postoperative period. Of those receiving a new gabapentinoid prescription, 10 956 (60.5%) were women and 15 529 (85.8%) were White. After adjusting for age, sex, race and ethnicity, and procedure type in each year, the rate of new postoperative gabapentinoid prescribing increased from 2.3% (95% CI, 2.2%-2.4%) in 2014 to 5.2% (95% CI, 5.0%-5.4%) in 2018 (P < .001). While there was variation between procedure types, almost all procedures saw an increase in both gabapentinoid and opioid prescribing. In this same period, opioid prescribing increased from 56% (95% CI, 55%-56%) to 59% (95% CI, 58%-60%) (P < .001). Concomitant prescribing also increased from 1.6% (95% CI, 1.5%-1.7%) in 2014 to 4.1% (95% CI, 4.0%-4.3%) in 2018 (P < .001). Conclusions and Relevance: The findings of this cross-sectional study of Medicare beneficiaries suggest that new postoperative gabapentinoid prescribing increased without a subsequent downward trend in the proportion of patients receiving postoperative opioids and a near tripling of concurrent prescribing. Closer attention needs to be paid to postoperative prescribing for older adults, especially when using multiple types of medications, which can have adverse drug events.

Disparities in advance care planning rates persist among emergency general surgery patients: Current state and recommendations for improvement.

BACKGROUND: Unanticipated changes in health status and worsening of chronic conditions often prompt the need to consider emergency general surgery (EGS). Although discussions about goals of care may promote goal-concordant care and reduce patient and caregiver depression and anxiety, these conversations, as well as standardized documentation, remain infrequent for EGS patients. METHODS: We conducted a retrospective cohort study using electronic health record data from patients admitted to an EGS service at a tertiary academic center to determine the prevalence of clinically meaningful advance care planning (ACP) documentation (conversations and legal ACP forms) during the EGS hospitalization. Multivariable regression was performed to identify patient, clinician, and procedural factors associated with the lack of ACP. RESULTS: Among 681 patients admitted to the EGS service in 2019, only 20.1% had ACP documentation in the electronic health record at any time point during their hospitalization (of those, 75.5% completed before and 24.5% completed during admission). Two thirds (65.8%) of the total cohort had surgery during their admission, but none of them had a documented ACP conversation with the surgical team preoperatively. Patients with ACP documentation tended to have Medicare insurance (adjusted odds ratio, 5.06; 95% confidence interval, 2.09-12.23; p < 0.001) and had greater burden of comorbid conditions (adjusted odds ratio, 4.19; 95% confidence interval, 2.55-6.88; p < 0.001). CONCLUSION: Adults experiencing a significant, often abrupt change in health status leading to an EGS admission are infrequently engaged in ACP conducted by the surgical team. This is a critical missed opportunity to promote patient-centered care and to communicate patients' care preferences to the surgical and other inpatient medical teams. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Prolonged use of newly prescribed gabapentin after surgery.

BACKGROUND: Surgeons have made substantial efforts to decrease postoperative opioid prescribing, largely because it can lead to prolonged use. These efforts include adoption of non-opioid pain medication including gabapentin. Like opioids, gabapentin use may be prolonged, increasing the risk of altered mental status and even overdose and death when taken concurrently with opioids. However, little is known about postoperative prolonged use of gabapentin in older adults. METHODS: We merged a 20% sample of Medicare Carrier, MedPAR and Outpatient Files with Part D for 2013-2018. We included patients >65 years old without prior gabapentinoid use who underwent common non-cataract surgical procedures. We defined new postoperative gabapentin as fills for 7 days before surgery until 7 days after discharge. We excluded patients whose discharge disposition was hospice or death. The primary outcome was prolonged use of gabapentin, defined as a fill>90 days after discharge. To identify risk factors for prolonged use, we constructed logistic regression models, adjusted for procedure and patient characteristics, length of stay, disposition location, and care complexity. RESULTS: Overall, 17,970 patients (3% of all eligible patients) had a new prescription for gabapentin after surgery. Of these, the mean age was 73 years old and 62% were female. The most common procedures were total knee (45%) and total hip (21%) replacements. Prolonged use occurred in 22%. Those with prolonged use were more likely to be women (64% vs. 61%), be non-White (14% vs. 12%), have concurrent prolonged opioid use (44% vs. 18%), and have undergone emergency surgery (8% vs. 4%). On multivariable analysis, being female, having a higher Charlson comorbidity score, having an opioid prescription at discharge and at >90 days and having a higher care complexity were associated with prolonged use of gabapentin. CONCLUSIONS: More than one-fifth of older adults prescribed gabapentin postoperatively filled a prescription >90 days after discharge, especially among patients with more comorbidities and concurrent prolonged opioid use, increasing the risk of adverse drug events and polypharmacy.

The Association of Limited English Proficiency With Morbidity and Mortality After Trauma.

INTRODUCTION: Disparities following traumatic injury by race/ethnicity and insurance status are well-documented. However, the relationship between limited English proficiency (LEP) and outcomes after trauma is poorly understood. This study describes the association between LEP and morbidity and mortality after traumatic injury. METHODS: A retrospective cohort study was conducted of adult trauma patients admitted to a level 1 trauma center from 2012 to 2018. Morbidity (length of stay [LOS], intensive care unit admission, intensive care unit LOS, discharge destination) and in-hospital mortality for LEP and English proficient (EP) patients were compared using univariate and multivariable logistic and generalized linear models controlling for patient demographics (age, sex, race/ethnicity, insurance) and clinical characteristics (mechanism, activation level, Glasgow Coma Scale, Injury Severity Score, traumatic brain injury). RESULTS: Of the 13,104 patients, 16% were LEP patients. LEP languages included Chinese (44%) and Spanish (38%), and 18% categorized as "Other," including 33 languages. In multivariable models, LEP was statistically significantly associated with increased hospital LOS (P = 0.003) and increased discharge to home with home health services (P = 0.042) or to skilled nursing facility/rehabilitation (P = 0.006). Mortality rate was 7% for LEP versus 4% for EP patients (P < 0.0001). In multivariable analysis, speaking an LEP language other than Chinese or Spanish was statistically significantly associated with increased mortality compared to EP (P = 0.006). CONCLUSIONS: Following traumatic injury, LEP patients experience increased hospital LOS and are more frequently discharged to home with home health services or to skilled nursing facilities/rehabilitation. LEP patients speaking languages other than Chinese or Spanish experience increased mortality compared to EP patients.

Limited English Proficiency Associated With Suboptimal Pain Assessment in Hospitalized Trauma Patients.

INTRODUCTION: Traumatic injury causes significant acute and chronic pain, and accurate pain assessment is foundational to optimal pain control. Prior literature has revealed disparities in the treatment of pain by race and ethnicity, but the effect of patient language on pain assessment remains unknown. We aimed to investigate the relationship between Limited English Proficiency (LEP) in pain assessment frequency and pain score magnitude for hospitalized trauma patients. METHODS: We conducted a cross-sectional, retrospective study including all hospitalized adult trauma patients from 2012 to 2018 at a single urban Level-1 trauma center. Patient language, 0-10 Numeric Rating Scale (NRS) pain scores, and demographic and clinical covariates were extracted from the electronic medical record. We used multivariable negative binomial regressions to compare NRS pain assessment frequency and multivariable linear regression to compare NRS pain score magnitude between LEP and English Proficient patients. RESULTS: Between 2012 and 2018, 9754 English proficient and 1878 LEP patients were hospitalized for traumatic injury. In multivariable models adjusted for demographic and injury characteristics, LEP patients had 2.4 fewer pain assessments per day compared to English proficient patients (7.21 versus 9.61, P = 0.001). Excluding days spent in the ICU, LEP patients had 2.6 fewer assessments per day (9.28 versus 11.88, P = 0.001). Median pain scores were lower in the LEP group (2.2 versus 3.61, P < 0.001), with a difference of 1.19 points in adjusted multivariable models. CONCLUSIONS: Compared to English Proficient patients, LEP patients had fewer pain assessments and lower NRS scores. Differences in pain assessment by patient language may be associated with disparities in pain management and morbidity.

Unplanned hospital visits after ambulatory surgical care.

OBJECTIVES: We sought to assess the rate of unplanned hospital visits among patients undergoing ambulatory surgery. SUMMARY BACKGROUND DATA: The majority of surgeries performed in the United States now take place in outpatient settings. Post-discharge hospital visit rates have been shown to vary widely, suggesting variation in surgical or discharge care quality. Complicating efforts to address quality, most facilities and surgeons are unaware of their patients' hospital visits after surgery since patients may present to a different hospital. METHODS: We used state-level, administrative data from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project from California to assess unplanned hospital visits after ambulatory surgery. To compare rates across centers, we determined the age, sex, and procedure-adjusted rates of hospital visits for each facility using 2-level, hierarchical, generalized linear models using methods similar to existing Centers for Medicare and Medicaid Services measures. RESULTS: Among a total of 1,260,619 ambulatory same-day surgeries from 440 surgical facilities, the risk adjusted 30-day rate of unplanned hospital visits was 4.8%, with emergency department visits of 3.1% and hospital admissions of 1.7%. Several patient characteristics were associated with increased risk of unplanned hospitals visits, including increased age, increased number of comorbidities (using the Elixhauser score), and type of procedure (p<0.001). CONCLUSIONS: The overall rate unplanned hospital visits within 30 days after same-day surgery is low but variable, suggesting a difference in the quality of care provided. Further, these rates are higher among specific patient populations and procedure types, suggesting areas for targeted improvement.

Emergency general surgery utilization and disparities during COVID-19: an interrupted time-series analysis.

OBJECTIVE: We aimed to compare general surgery emergency (GSE) volume, demographics and disease severity before and during COVID-19. BACKGROUND: Presentations to the emergency department (ED) for GSEs fell during the early COVID-19 pandemic. Barriers to accessing care may be heightened, especially for vulnerable populations, and patients delaying care raises public health concerns. METHODS: We included adult patients with ED presentations for potential GSEs at a single quaternary-care hospital from January 2018 to August 2020. To compare GSE volumes in total and by subgroup, an interrupted time-series analysis was performed using the March shelter-in-place order as the start of the COVID-19 period. Bivariate analysis was used to compare demographics and disease severity. RESULTS: 3255 patients (28/week) presented with potential GSEs before COVID-19, while 546 (23/week) presented during COVID-19. When shelter-in-place started, presentations fell by 8.7/week (31%) from the previous week (p<0.001), driven by decreases in peritonitis (ß=-2.76, p=0.017) and gallbladder disease (ß=-2.91, p=0.016). During COVID-19, patients were younger (54 vs 57, p=0.001), more often privately insured (44% vs 38%, p=0.044), and fewer required interpreters (12% vs 15%, p<0.001). Fewer patients presented with sepsis during the pandemic (15% vs 20%, p=0.009) and the average severity of illness decreased (p<0.001). Length of stay was shorter during the COVID-19 period (3.91 vs 5.50 days, p<0.001). CONCLUSIONS: GSE volumes and severity fell during the pandemic. Patients presenting during the pandemic were less likely to be elderly, publicly insured and have limited English proficiency, potentially exacerbating underlying health disparities and highlighting the need to improve care access for these patients. LEVEL OF EVIDENCE: III.

Patient Perceptions on Barriers and Facilitators to Accessing Low-acuity Surgery During COVID-19 Pandemic.

BACKGROUND: The onset of the COVID-19 pandemic led to the postponement of low-acuity surgical procedures in an effort to conserve resources and ensure patient safety. This study aimed to characterize patient-reported concerns about undergoing surgical procedures during the pandemic. METHODS: We administered a cross-sectional survey to patients who had their general and plastic surgical procedures postponed at the onset of the pandemic, asking about barriers to accessing surgical care. Questions addressed dependent care, transportation, employment and insurance status, as well as perceptions of and concerns about COVID-19. Mixed methods and inductive thematic analyses were conducted. RESULTS: One hundred thirty-five patients were interviewed. We identified the following patient concerns: contracting COVID-19 in the hospital (46%), being alone during hospitalization (40%), facing financial stressors (29%), organizing transportation (28%), experiencing changes to health insurance coverage (25%), and arranging care for dependents (18%). Nonwhite participants were 5 and 2.5 times more likely to have concerns about childcare and transportation, respectively. Perceptions of decreased hospital safety and the consequences of possible COVID-19 infection led to delay in rescheduling. Education about safety measures and communication about scheduling partially mitigated concerns about COVID-19. However, uncertainty about timeline for rescheduling and resolution of the pandemic contributed to ongoing concerns. CONCLUSIONS: Providing effective surgical care during this unprecedented time requires both awareness of societal shifts impacting surgical patients and system-level change to address new barriers to care. Eliciting patients' perspectives, adapting processes to address potential barriers, and effectively educating patients about institutional measures to minimize in-hospital transmission of COVID-19 should be integrated into surgical care.

Cultural influences on willingness to donate organs among urban native Americans.

BACKGROUND: The need for organ donation is substantial among Native Americans, driven by the disproportionate burden of ESRD. Due to the dearth of knowledge about willingness to donate (WTD) among urban Native Americans, a group that represents over half of the US Native population, we aimed to examine factors affecting donation. METHODS: We conducted a cross-sectional survey of a convenience sample, using a questionnaire developed specifically for this study using community-based participatory research. The questionnaire was designed to be culturally relevant to the Native community, based on questions from three previously validated instruments and developed through one-on-one interviews. We performed logistic regression to associate survey answers with WTD. RESULTS: Seventy percent of our 183 respondents stated that they would be willing to have their organs donated after death; however, only 41% were already registered as an organ donor on their driver's license. Logistic regression analysis found specific items in domains of trust of the medical community and spirituality most closely associated with WTD. Sixty-two percent of Native Americans surveyed reported they would not donate organs because they distrust the medical community. DISCUSSION: Our findings suggest multiple areas of focus for increasing organ donation within this subset of the diverse Native community. Efforts to promote donation should be aimed at building trust in the medical community.

Hospital Variation in Spending for Lung Cancer Resection in Medicare Beneficiaries.

BACKGROUND: As cancer payment models transition from fee for service toward payment "bundles" based on episodes of care, a deeper understanding of the costs associated with stage I lung cancer treatment becomes increasingly relevant. To better understand costs in early lung cancer care, we sought to characterize hospital-level variation in Medicare expenditure after lobectomy for stage I non-small cell lung carcinoma. METHODS: Patients who were diagnosed with stage I non-small cell lung carcinoma from 2006 through 2011 and undergoing lobectomy were selected from the Surveillance, Epidemiology and End Results-Medicare linked database. We used Medicare claims to estimate costs of care in the 90 days after initial surgical hospitalization. Hospitals were grouped into quintiles of mean excess cost, calculated as the mean difference between observed costs and risk-adjusted predicted costs. The association between hospital factors and mean excess cost were compared across hospitals, including complication rates and hospital volume. RESULTS: A total of 3530 patients underwent lobectomy at 156 hospitals. Hospitals in the lowest cost quintile had index hospitalizations $6226 less costly than predicted. Conversely, the most expensive hospital quintile had index hospital costs that were $6151 costlier than predicted. Increased costs were positively associated with the number of complications per patient (P < .001), but not hospital volume (P = .85). CONCLUSIONS: Among Medicare beneficiaries undergoing lobectomy for stage I non-small cell lung carcinoma, the cost of perioperative care varied substantially across hospitals and was strongly associated with complication rate, but not hospital volume.

Impact of Cost Display on Ordering Patterns for Hospital Laboratory and Imaging Services.

BACKGROUND: Physicians "purchase" many health care services on behalf of patients yet remain largely unaware of the costs of these services. Electronic health record (EHR) cost displays may facilitate cost-conscious ordering of health services. OBJECTIVE: To determine whether displaying hospital lab and imaging order costs is associated with changes in the number and costs of orders placed. DESIGN: Quasi-experimental study. PARTICIPANTS: All patients with inpatient or observation encounters across a multi-site health system from April 2013 to October 2015. INTERVENTION: Display of order costs, based on Medicare fee schedules, in the EHR for 1032 lab tests and 1329 imaging tests. MAIN MEASURES: Outcomes for both lab and imaging orders were (1) whether an order was placed during a hospital encounter, (2) whether an order was placed on a given patient-day, (3) number of orders placed per patient-day, and (4) cost of orders placed per patient-day. KEY RESULTS: During the lab and imaging study periods, there were 248,214 and 258,267 encounters, respectively. Cost display implementation was associated with a decreased odds of any lab or imaging being ordered during the encounter (lab adjusted odds ratio [AOR] = 0.97, p = .01; imaging AOR = 0.97, p < .001), a decreased odds of any lab or imaging being ordered on a given patient-day (lab AOR = 0.95, p < .001; imaging AOR = 0.97, p < .001), a decreased number of lab or imaging orders on patient-days with orders (lab adjusted count ratio = 0.93, p < .001; imaging adjusted count ratio = 0.98, p < .001), and a decreased cost of lab orders and increased cost of imaging orders on patient-days with orders (lab adjusted cost ratio = 0.93, p < .001; imaging adjusted cost ratio = 1.02, p = .003). Overall, the intervention was associated with an 8.5 and 1.7% reduction in lab and imaging costs per patient-day, respectively. CONCLUSIONS: Displaying costs within EHR ordering screens was associated with decreases in the number and costs of lab and imaging orders.

Impact of laboratory cost display on resident attitudes and knowledge about costs.

AIM: Cost awareness has been proposed as a strategy for curbing the continued rise of healthcare costs. However, most physicians are unaware of the cost of diagnostic tests, and interventions have had mixed results. We sought to assess resident physician cost awareness following sustained visual display of costs into electronic health record (EHR) order entry screens. STUDY DESIGN: We completed a preintervention and postintervention web-based survey. Participants were physicians in internal medicine, paediatrics, combined medicine and paediatrics, obstetrics and gynaecology, emergency medicine, and orthopaedic surgery at one tertiary co are academic medical centre. Costs were displayed in the EHR for 1032 unique laboratory orders. We measured attitudes towards costs and estimates of Medicare reimbursement rates for 11 common laboratory and imaging tests. RESULTS: We received 209 survey responses during the preintervention period (response rate 71.1%) and 194 responses during the postintervention period (response rate 66.0%). The proportion of residents that agreed/strongly agreed that they knew the costs of tests they ordered increased after the cost display (8.6% vs 38.2%; p<0.001). Cost estimation accuracy among residents increased after the cost display from 24.0% to 52.4% for laboratory orders (p<0.001) and from 37.7% to 49.6% for imaging orders (p<0.001). CONCLUSIONS: Resident cost awareness and ability to accurately estimate laboratory order costs improved significantly after implementation of a comprehensive EHR cost display for all laboratory orders. The improvement in cost estimation accuracy for imaging orders, which did not have costs displayed, suggested a possible spillover effect generated by providing a cost context for residents.

The China Patient-Centred Evaluative Assessment of Cardiac Events (China PEACE)-Prospective Study of 3-Vessel Disease: rationale and design.

INTRODUCTION: Complex coronary artery disease (left main and three-vessel disease) carries high risks of adverse events and cost burden. However, in China, little is known about which patients are directed toward which treatment strategies and what outcomes are being achieved. METHODS AND ANALYSIS: Using the China PEACE (Patient-centered Evaluative Assessment of Cardiac Events) research network, this prospective study of three-Vessel Disease, the China PEACE-3VD study, has a plan to consecutively register over 4000 patients with a diagnosis of 3VD and/or left-main disease by elective coronary angiography at 24 large cardiovascular centres in China. We centrally conducted medical record abstraction and SYNTAX Score calculation for all registered patients. The sites invited patients to the prospective cohort, and conducted 1-year follow-up on major events, including cardiac events, symptoms, secondary prevention and quality of life. The estimated entire sample size of eligible patients of 4000 was determined based on both feasibility and consideration of adequate statistical precision for describing the treatment decisions, guidelines adherence and appropriateness of treatment for patients with complex coronary artery diseases. The study is designed to investigate patient, clinician and hospital factors associated with each treatment strategy (percutaneous coronary intervention, coronary artery bypass grafting or medical therapy) as well as appropriateness of treatment choice, current guideline compliance and patient-reported outcomes for patients with complex coronary artery disease in large cardiovascular centres in China, as a foundation for enhanced knowledge in the field and to assist quality improvement initiatives. ETHICS AND DISSEMINATION: The study protocol was approved by the ethics committee at the China National Center for Cardiovascular Diseases. Findings will be shared with participating hospitals, policymakers and the academic community, to promote quality monitoring, quality improvement and the efficient allocation, and use of coronary revascularisation procedures in China. TRIAL REGISTRATION NUMBER: NCT01625312; Pre-results.

Impact of price display on provider ordering: A systematic review.

BACKGROUND: Displaying order prices to physicians is 1 potential strategy to reduce unnecessary health expenditures, but its impact on patterns of care is unclear. OBJECTIVE: To review characteristics of previous price display interventions, impact on order costs and volume, effects on patient safety, acceptability to physicians, and the quality of this evidence. DESIGN: Systematic review of studies that showed numeric prices of laboratory tests, imaging studies, or medications to providers in real time during the ordering process and evaluated the impact on provider ordering. Two investigators independently extracted data for each study and evaluated study quality using a modified Downs and Black checklist. RESULTS: Of 1494 studies reviewed, 19 met inclusion criteria, including 5 randomized trials, 13 pre-post intervention studies, and 1 time series analysis. Studies were published between 1983 and 2014. Of 15 studies reporting the quantitative impact of price display on aggregate order costs or volume, 10 demonstrated a statistically significant decrease in the intervention group. Price display was found to decrease aggregate order costs (9 of 13 studies) more frequently than order volume (3 of 8 studies). Patient safety was evaluated in 5 studies and was unaffected by price display. Provider acceptability tended to be positive, although evidence was limited. Study quality was mixed, with checklist scores ranging from 5/21 to 20/21. CONCLUSIONS: Provider price display likely reduces order costs to a modest degree. Patient safety appeared unchanged, though evidence was limited. More high-quality evidence is needed to confirm these findings within a modern context.