Sociodemographic Factors Associated with Request for Labor Epidural Analgesia in a Tertiary Obstetric Hospital in Vietnam.

This study is aimed at examining the sociodemographic factors associated with the utilization of labor epidural analgesia at a large obstetric and gynecology hospital in Vietnam. This was a cross-sectional study of women who underwent vaginal delivery in September 2018 at the Hanoi Obstetrics and Gynecology Hospital. The utilization of epidural analgesia during labor was determined. Univariate and multivariate regression models were applied to evaluate the association between patient demographic and socioeconomic factors and request for labor epidural analgesia. A total of 417 women had vaginal deliveries during the study period. 207 women utilized epidural analgesia for pain relief during labor, and 210 did not. Parturients older than 35 years of age (OR 2.84, 95% CI 1.11-8.17), multiparous women (OR 2.8 95% CI 1.85-4.25), women living from an urban area, women with higher income (OR 6.47, 95% CI 2.59-19.23), and women with higher level of education were more likely to utilize labor epidurals. Factors related to a parturient request for epidural analgesia during labor at our tertiary obstetric hospital included age greater than 35 years, multiparity, and high income and education levels. Educational outreach to women about the benefits of epidural analgesia can target women who do not share these demographic characteristics.

The effect of initiating neuraxial analgesia service on the rate of cesarean delivery in Hubei, China: a 16-month retrospective study.

BACKGROUND: No Pain Labor &Delivery (NPLD) is a nongovernmental project to increase access to safe neuraxial analgesia through specialized training. This study explores the change in overall cesarean delivery (CD) rate and maternal request CD(MRCD) rate in our hospital after the initiation of neuraxial analgesia service (NA). METHODS: NA was initiated in May 1st 2015 by the help of NPLD. Since then, the application of NA became a routine operation in our hospital, and every parturient can choose to use NA or not. The monthly rates of NA, CD, MRCD, multiparous women, intrapartum CD, episiotomy, postpartum hemorrhage (PPH), operative vaginal delivery and neonatal asphyxia were analyzed from January 2015 to April 2016. RESULTS: The rate of NA in our hospital was getting increasingly higher from 26.1% in May 2015 to 44.6% in April 2016 (p < 0.001); the rate of CD was 48.1% (3577/7360) and stable from January to May 2015 (p>0.05), then decreased from 50.4% in May 2015 to 36.3% in April 2016 (p < 0.001); the rate of MRCD was 11.4% (406/3577) and also stable from January to May 2015 (p>0.05), then decreased from 10.8% in May 2015 to 5.7% in April 2016 (p < 0.001). At the same time, the rate of multiparous women remained unchanged during the 16 month of observation (p>0.05). There was a negative correlation between the rate of NA and rate of overall CD, r = - 0.782 (95%CI [- 0.948, - 0.534], p<0.001), and between the utilization rate of NA and rate of MRCD, r = - 0.914 (95%CI [- 0.989, - 0.766], p<0.001). The rates of episiotomy, PPH, operative vaginal delivery and neonatal asphyxia in women who underwent vaginal delivery as well as the rates of intrapartum CD, neonatal asphyxia, and PPH in women who underwent CD remained unchanged, and there was no correlation between the rate of NA and anyone of those rates from January 1st 2015 to April 30th 2016 (p>0.05). CONCLUSIONS: Our study shows that the rates of CD and MRCD in our department were significantly decreased from May 1st 2015 to April 30th 2016, which may be due to the increasing use of NA during vaginal delivery with the help of NPLD.

[Effects of double-catheter epidural analgesia by lidocaine injection respectively on the delivery outcomes and maternal-infant complications for persistent posterior or lateral occipital position of protracted active phase].

Objective: To evaluate the effect of dual-tube epidural segmental injection of lidocaine analgesia on the delivery outcome and maternal and infant complications of persistent posterior occipital position postpartum or lateral occipital position postpartum patients with protracted active phase. Methods: The full and single-term primiparas (n=216, 37 to 42 weeks gestation, 22 to 35 years) diagnosed as persistent posterior or lateral occipital position during the active period were selected from the Department of Obstetrics of Qingdao Municipal Hospital from January 2015 to October 2019. The subjects were randomly assigned into two groups: double-tube epidural block group (n=108) and single-tube epidural block group (n=108), 1% lidocaine was used for epidural analgesia respectively under ultrasound guidance. Senior midwife or obstetricians implement new partogram, and guide women to perform position management, and push or rotate the fetal head in a timely manner. Observation indicators: general condition, the use of non-pharmacological analgesic measures, analgesia related conditions and pain visual analogue scale (VAS) score, delivery-related indicator, cesarean section indication, anesthesia-related indicator, maternal and child complications. Results: (1) General condition: the age, weight, height, gestational age, the ratio of persistent lateral or posterior occipital position, cephalic score, and neonatal birth weight between the two groups of women were not statistically significant (all P>0.05). (2) The use of non-pharmacological analgesic measures: the women's Lamaze breathing method, Doula delivery companionship, percutaneous electrical stimulation, and other measures between two groups were compared, and there were not significant differences (all P>0.05). (3) Analgesia related conditions and VAS scores of women undergoing vaginal delivery: compared with the single-tube epidural block group (n=40), the second-partum time of the women in the double-tube epidural block group (n=59) was significantly shortened [(124±44) vs (86±33) minutes, P<0.01]; after 30 minutes of analgesia (4.4±0.5 vs 0.9±0.5, P<0.01), during forced labor in the second stage of labor (5.7±0.6 vs 1.3±0.4, P<0.01), the VAS scores of pain were also significantly reduced (P<0.01). (4) Labor-related indicators: compared with the single-tube epidural block group, the natural delivery rate (21.3% vs 49.1%) and the delivery experience satisfaction rate (51.9% vs 98.1%) of women in the double-tube epidural block group were significantly increased (all P<0.01), cesarean section rate (63.0% vs 45.4%), instrument assisted rate (15.7% vs 5.6%) decreased significantly (all P<0.05). (5) Cesarean section indications: compared with the single-tube epidural block group, the cesarean section rate caused by prolonged labor or protracted active phase of women in the double-tube epidural block group was significantly reduced (38.0% vs 22.2%； P<0.05), and the fetal distress, intrauterine infection, and social factors caused by cesarean section between the two groups were compared, while the differences were not statistically significant (all P>0.05).(6) Anesthesia related indexes: the block planes of the maternal upper tube administration in the double-tube epidural block group were mostly T7, T8, T9-L2 and L3,While,the block planes in the single-tube epidural block group were mostly T10, T11-S1, S2, S3, and the modified Bromage score were all 0. (7) Maternal and child complications: compared with the single-tube epidural block group, the postpartum hemorrhage rate (18.5% vs 7.4%), the perineal lateral cut rate (20.4% vs 5.6%), the neonatal asphyxia rate (12.0% vs 3.7%), ICU rate of transferred neonates (13.9% vs 4.6%) in the double-tube epidural block group were significantly reduced (all P<0.05). Soft birth canal injury rate, puerperal disease rate and neonatal birth rate between two groups were compared, and there were not statistically significant differences (all P>0.05). Conclusion: Dual-tube epidural segmental injection of lidocaine analgesia could increase the natural delivery rate of women with posterior occipital or lateral occipital position with active stagnation, reduce the rate of cesarean section and the rate of transvaginal instruments, and reduce the complications of mother and child.

Education Program Regarding Labor Epidurals Increases Utilization by Hispanic Medicaid Beneficiaries: A Randomized Controlled Trial.

BACKGROUND: Hispanic women choose epidural labor analgesia less commonly than non-Hispanic women. This may represent a healthcare disparity related to a language barrier and inadequate opportunities for labor analgesia education. It was hypothesized that a language-concordant, educational program regarding labor epidurals would improve epidural utilization in two independent cohorts of Hispanic and non-Hispanic women. METHODS: A randomized controlled trial, blinded to anesthesia, nursing, and obstetric providers, was completed at an academic hospital (February 2015 to February 2017). Two cohorts of Medicaid beneficiaries of Hispanic (English- and/or Spanish-speaking) and non-Hispanic ethnicity were enrolled concurrently. The patients were randomized to routine care alone or routine care and an additional educational program comprised of three components: a video show, corresponding pamphlet, and in-person counseling. The primary endpoint was use of epidural labor analgesia. The secondary endpoint was change in response before and after delivery on common misconceptions based on a 12-point epidural questionnaire. RESULTS: Hispanic women randomized to the intervention group were 33% more likely to choose epidural analgesia compared to the routine care group (40 of 50 [80%] vs. 30 of 50 [60%]; risk ratio, 1.33 [95% CI, 1.02 to 1.74]; P = 0.029). For the non-Hispanic cohort, no difference was detected in epidural use between the intervention and routine care groups (41 of 50 [82%] vs. 42 of 49 [86%]; risk ratio, 0.96 [95% CI, 0.80 to 1.14]; P = 0.62), but the study was underpowered to determine a result of no difference. Patients assigned to the intervention had a greater improvement in epidural understanding compared with routine care, among both Hispanic (2.26 vs. 0.74, respectively; difference in change from baseline, 1.52 [95% CI, 0.77 to 2.27]; P < 0.001) and non-Hispanic (1.36 vs. 0.33, respectively; difference in change from baseline, 1.03 [95% CI, 0.23 to 1.75]; P = 0.005) cohorts. There were no adverse events during the trial. CONCLUSIONS: The educational program increased epidural use among Hispanic women. The educational program reduced misconceptions regarding epidural analgesia in both Hispanic and non-Hispanic cohorts.

[Universalization, parity and evolution of the demand of epidural analgesia in labor in Andalusia (Spain)]. / Universalización, paridad y evolución de la demanda de anestesia epidural durante el parto en Andalucía.

OBJECTIVE: Assess whether the universalization of epidural analgesia supplied in hospitals of the Andalusia Public Health Service (SSPA) has ended up with the inequalities shown in previous studies regarding to their demand: the percentage of women who rejected epidural analgesia was higher among the users having low educational level, lower income and working as housekeeper. METHOD: The data are based on satisfaction surveys conducted by the Institute for Advanced Social Studies amongst of SSPA users. This survey includes a section aimed at women attended in labor (N = 21,300). The hierarchical segmentation analysis shows which variables are the ones that discriminate most in the usage of epidural analgesia. Subsequently, through a model of binary logistic regression we analyze which socio-demographic variables are significant (2012) and how its impact is on the choice of epidural analgesia in childbirth. RESULTS: Overall, the socio-demographic variables of the users are statistically significant in the demand or not of epidural analgesia during labor. However, the detailed analysis of the last year (2012) shows that none of the socio-demographic variables introduced in the model has a significant effect on the decision of using epidural analgesia. CONCLUSIONS: The process of universalization of epidural anesthesia in childbirth has ended with social inequalities in their use, that is, with those differences that are not due to a real choice but are induced by socio-cultural characteristics of women.

Liposomal Bupivacaine Transversus Abdominis Plane Block Versus Epidural Analgesia in a Colon and Rectal Surgery Enhanced Recovery Pathway: A Randomized Clinical Trial.

BACKGROUND: Multimodal pain management is an integral part of enhanced recovery pathways. The most effective pain management strategies have not been determined. OBJECTIVE: The purpose of this study was to compare liposomal bupivacaine transversus abdominis plane block with epidural analgesia in patients undergoing colorectal surgery. DESIGN: This is a single-institution, open-label randomized (1:1) trial. SETTING: This study compared liposomal bupivacaine transversus abdominis plane block with epidural analgesia in patients undergoing elective open and minimally invasive colorectal surgery in an enhanced recovery pathway. PATIENTS: Two hundred were enrolled. Following randomization, allocation, and follow-up, there were 92 patients with transversus abdominis plane block and 87 patients with epidural analgesia available for analysis. INTERVENTIONS: The interventions comprised liposomal bupivacaine transversus abdominis plane block versus epidural analgesia. MAIN OUTCOME MEASURES: The primary outcomes measured were numeric pain scores and the overall benefit of analgesia scores. RESULTS: There were no significant differences in the Numeric Pain Scale and Overall Benefit of Analgesia Score between groups. Time trend analysis revealed that patients with transversus abdominis plane block had higher numeric pain scores on the day of surgery, but that the relationship was reversed later in the postoperative period. Opioid use was significantly less in the transversus abdominis plane block group (206.84 mg vs 98.29 mg, p < 0.001). There were no significant differences in time to GI recovery, hospital length of stay, and postoperative complications. Cost was considerably more for the epidural analgesia group. LIMITATIONS: This study was conducted at a single institution. CONCLUSIONS: This randomized trial shows that perioperative pain management with liposomal bupivacaine transversus abdominis plane block is as effective as epidural analgesia and is associated with less opioid use and less cost. These data and the more favorable risk profile suggest that liposomal bupivacaine transversus abdominis plane block is a viable multimodal perioperative pain management option for this patient population in an established enhanced recovery pathway. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov (NCT02591407). See Video Abstract at http://links.lww.com/DCR/A737.

United States State-Level Variation in the Use of Neuraxial Analgesia During Labor for Pregnant Women.

Importance: Neuraxial labor analgesia is recognized as the most effective method of providing pain relief during labor. Little is known about variation in the rates of neuraxial analgesia across US states. Identifying the presence and extent of variation may provide insights into practice variation and may indicate where access to neuraxial analgesia is inadequate. Objective: To test the hypothesis that variation exists in neuraxial labor analgesia use among US states. Design, Setting, and Participants: Retrospective, population-based, cross-sectional analysis using US birth certificate data. Participants were 2 625 950 women who underwent labor in 2015. Main Outcomes and Measures: State-specific prevalence of neuraxial analgesia per 100 women who underwent labor and variability in neuraxial analgesia use among states, assessed using multilevel multivariable regression modeling with the median odds ratio and the intraclass correlation coefficient to evaluate variation by state. Results: In the study population of 2 625 950 women, 0.1% (n = 2010) were younger than 15 years, 7.0% (n = 183 546) were between the ages of 15 and 19 years, 23.6% (n = 620 118) were between the ages of 20 and 24 years, 29.6% (n = 777 957) were between the ages of 25 and 29 years, 26.0% (n = 683 656) were between the ages of 30 and 34 years, 11.4% (n = 298 237) were between the ages of 35 and 39 years, 2.2% (n = 57 130) were between the ages of 40 and 44 years, and 0.1% (n = 3296) were between the ages of 45 and 54 years. More than 90% were privately insured or insured with Medicaid. Neuraxial analgesia was used by 73.1% (n = 1 920 368) of women. After adjustment for antepartum, obstetric, and intrapartum factors, Maine had the lowest neuraxial analgesia prevalence (36.6%; 95% CI, 33.2%-40.1%) and Nevada the highest (80.1%; 95% CI, 78.3%-81.7%). The adjusted median odds ratio was 1.5 (95% CI, 1.4-1.6), and the intraclass correlation coefficient was 5.4% (95% CI, 4.0%-7.9%). Conclusions and Relevance: Results of this study suggest that a small portion of the overall variation in neuraxial analgesia use is explained by US states. Unmeasured patient-level and hospital-level factors likely account for a large portion of the variation between states. Efforts should be made to understand what the main reasons are for this variation and whether the variation influences maternal or perinatal outcomes.

Reversal of Growth of Utilization of Interventional Techniques in Managing Chronic Pain in Medicare Population Post Affordable Care Act.

BACKGROUND: Over the past 2 decades, the increase in the utilization of interventional techniques has been a cause for concern. Despite multiple regulations to reduce utilization of interventional techniques, growth patterns continued through 2009. A declining trend was observed in a previous evaluation; however, a comparative analysis of utilization patterns of interventional techniques has not been performed showing utilization before and after the enactment of the Affordable Care Act (ACA). OBJECTIVES: Our aim is to assess patterns of utilization and variables of interventional techniques in chronic pain management in the fee-for-service (FFS) Medicare population, with a comparative analysis of pre- and post-ACA. STUDY DESIGN: Utilization patterns and variables of interventional techniques were assessed from 2000 to 2009 and from 2009 to 2016 in the FFS Medicare population of the United States in managing chronic pain. METHODS: The master data from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2016 was utilized to assess overall utilization and comparative utilization at various time periods. RESULTS: The analysis of Medicare data from 2000 to 2016 showed an overall decrease in utilization of interventional techniques 0.6% per year from 2009 to 2016, whereas from 2000 to 2009, there was an increase of 11.8% per year per 100,000 individuals of the Medicare population. In addition, the United States experienced an increase of 0.7% per year of population growth, 3.2% of those 65 years or older and a 3% annual increase in Medicare participation from 2009 to 2016. Further analysis also showed a 1.7% annual decrease in the rate of utilization of epidural and adhesiolysis procedures per 100,000 individuals of the Medicare population, with a 2.2% decrease for disc procedures and other types of nerve blocks, whereas there was an increase of 0.8% annually for facet joint interventions and sacroiliac joint blocks from 2009 to 2016. Epidural and adhesiolysis procedures showed an 8.9% annual increase, facet joint interventions and sacroiliac joint blocks showed a 17.6% increase, and disc procedures and other types of nerve blocks showed a 7.2% increase annually per 100,000 individuals of the Medicare population from 2000 to 2009. LIMITATIONS: The limitations of this assessment include lack of analysis of individual procedures. Additional limitations include lack of inclusion of patients from Medicare Advantage plans and lack of complete and accurate data for statewide utilization. CONCLUSION: From 2009 to 2016, interventional techniques decreased at an annual rate of 0.6% with an overall decrease of 3.9%, compared to an overall increase of 173.6% from 2000 to 2009 with an annual increase of 11.8%. An additional analysis of data with individual procedures is essential to gain further insights into utilization patterns. KEY WORDS: Interventional pain management, chronic spinal pain, interventional techniques, epidural injections, adhesiolysis, facet joint interventions, sacroiliac joint injections, disc procedures, other types of nerve blocks.

Obstetric Outcomes of First- and Second-Generation Pakistani Immigrants: A Comparison Study at a Low-Risk Maternity Ward in Norway.

This population-based study compares obstetric outcomes of first- and second-generation Pakistani immigrants and ethnic Norwegians who gave birth at the low-risk maternity ward in Baerum Hospital in Norway from 2006 to 2013. We hypothesized that second-generation Pakistani immigrants are more similar to the ethnic Norwegians because of increased acculturation. Outcome measures were labor onset, epidural analgesia, labor dystocia, episiotomy, vaginal/operative delivery, postpartum hemorrhage, preterm birth, birth weight, transfer to a neonatal intensive care unit, and neonatal jaundice. Compared to first-generation Pakistani immigrants, the second-generation reported more health issues before pregnancy, and they had a higher proportion of preterm births compared to Norwegians. Newborns of first-generation immigrants were more often transferred to a neonatal intensive care compared to Norwegian newborns. Few intergenerational differences in the obstetric outcomes were found between the two generations. A high prevalence of consanguinity in second-generation immigrants suggests the maintenance of a traditional Pakistani marriage pattern.

Latent class instrumental variables: a clinical and biostatistical perspective.

In some two-arm randomized trials, some participants receive the treatment assigned to the other arm as a result of technical problems, refusal of a treatment invitation, or a choice of treatment in an encouragement design. In some before-and-after studies, the availability of a new treatment changes from one time period to this next. Under assumptions that are often reasonable, the latent class instrumental variable (IV) method estimates the effect of treatment received in the aforementioned scenarios involving all-or-none compliance and all-or-none availability. Key aspects are four initial latent classes (sometimes called principal strata) based on treatment received if in each randomization group or time period, the exclusion restriction assumption (in which randomization group or time period is an instrumental variable), the monotonicity assumption (which drops an implausible latent class from the analysis), and the estimated effect of receiving treatment in one latent class (sometimes called efficacy, the local average treatment effect, or the complier average causal effect). Since its independent formulations in the biostatistics and econometrics literatures, the latent class IV method (which has no well-established name) has gained increasing popularity. We review the latent class IV method from a clinical and biostatistical perspective, focusing on underlying assumptions, methodological extensions, and applications in our fields of obstetrics and cancer research.

Pain control for laparoscopic colectomy: an analysis of the incidence and utility of epidural analgesia compared to conventional analgesia.

PURPOSE: The aim of this study was to compare short-term outcomes between epidural analgesia and conventional intravenous analgesia for patients undergoing laparoscopic colectomy. This paper uses a large national database to add a current perspective on trends in analgesia and the outcomes associated with two analgesia options. Our evidence augments the opinions of recent randomized controlled trials. METHODS: The University HealthSystem Consortium, an alliance of more than 300 academic and affiliate institutions, was reviewed for the time period of October 2008 through September 2014. International Classification of Disease 9th Clinical Modification codes for laparoscopic colectomy and epidural catheter placement were used. RESULTS: A total of 29,429 patients met our criteria and underwent laparoscopic colectomy during the study period. One hundred and ten (0.374%) patients had an epidural catheter placed for analgesia. Baseline patient demographics were similar for the epidural and conventional analgesia groups. Total charges were significantly higher in the epidural group ($52,998 vs. $39,277; p < 0.001). Median length of stay was longer in the epidural group (6 vs. 5 days; p < 0.001). There was no statistical difference between the epidural and conventional analgesia groups in death (0 vs. 0.03%; p = 0.999), urinary tract infection (0 vs. 0.1%; p = 0.999), ileus (11.8 vs. 13.6%; p = 0.582), or readmission rate (9.1 vs. 9.3%; p = 0.942). CONCLUSION: Compared to conventional analgesic techniques, epidural analgesia does not reduce the rate of postoperative ileus, and it is associated with increased cost and increased length of stay. Based on our data, routine use of epidural analgesia for laparoscopic colectomy cannot be justified.

Group-based antenatal birth and parent preparation for improving birth outcomes and parenting resources: study protocol for a randomised trial.

OBJECTIVES: To examine the efficacy and cost-effectiveness of group based antenatal education for improving childbirth and parenting resources compared to auditorium based education. PARTICIPANTS: 2350 Danish pregnant women and their partners ≥18 years old, recruited before 20+0 gestational weeks. Population-based individually randomised superiority trial with two parallel arms: Four sessions of birth and parent preparation in small groups (experimental group); two lectures in an auditorium (control group). Data is collected by (1) questionnaires at baseline (≈18 weeks of gestation), 37 weeks of gestation, 9 weeks-, 6 months-, and 1 year post-partum, (2) the hospital obstetric database, (3) national registers. PRIMARY OUTCOME: use of epidural analgesia. SECONDARY OUTCOMES: stress, parenting alliance; explorative outcomes: depressive symptoms, use of health care services, self-efficacy, well-being, family break-ups. Analyses will be intention-to-treat as well as per protocol. Process evaluation will be conducted using questionnaires and qualitative interviews. The incremental societal cost of the intervention will be computed and compared to the measured outcomes in a cost-effectiveness analysis. CONCLUSION: To the best of our knowledge this is the largest well-designed randomised trial of its kind to date. The trial will bring much-needed evidence for decision makers of the content and form of antenatal education.

A nationwide analysis of the use and outcomes of epidural analgesia in open colorectal surgery.

INTRODUCTION: Epidural analgesia has demonstrated superiority over conventional analgesia in controlling pain following open colorectal resections. Controversy exists regarding cost-effectiveness and postoperative outcomes. METHODS: The Nationwide Inpatient Sample (2002-2010) was retrospectively reviewed for elective open colorectal surgeries performed for benign and malignant conditions with or without the use of epidural analgesia. Multivariate regression analysis was used to compare outcomes between epidural and conventional analgesia. RESULTS: A total 888,135 patients underwent open colorectal resections. Epidural analgesia was only used in 39,345 (4.4 %) cases. Epidurals were more likely to be used in teaching hospitals and rectal cancer cases. On multivariate analysis, in colonic cases, epidural analgesia lowered hospital charges by US$4,450 (p < 0.001) but was associated with longer length of stay by 0.16 day (p < 0.05) and a higher incidence of ileus (OR = 1.17; p < 0.01). In rectal cases, epidural analgesia was again associated with lower hospital charges by US$4,340 (p < 0.001) but had no effect on ileus and length of stay. The remaining outcomes such as mortality, respiratory failure, pneumonia, anastomotic leak, urinary tract infection, and retention were unaffected by the use of epidurals. CONCLUSION: Epidural analgesia in open colorectal surgery is safe but does not add major clinical benefits over conventional analgesia. It appears however to lower hospital charges.

Readmission rates after decompression surgery in patients with lumbar spinal stenosis among Medicare beneficiaries.

STUDY DESIGN: Retrospective observational cohort analysis of administrative claims. OBJECTIVE: Estimate readmission rates after spine stenosis decompression surgery in a 5% randomly selected sample of Medicare beneficiaries. SUMMARY OF BACKGROUND DATA: Operative management of lumbar spinal stenosis has significant and measurable benefits compared with nonoperative care. Revision rates for lumbar decompression with and without fusion have been reported with significant variability. An understanding of readmission and reoperation rates informs decisions regarding the cost-effective management of lumbar stenosis. METHODS: Patients were identified in 2005-2009 Medicare claims who had both a procedure code for decompression (03.09), and a diagnosis of lumbar spinal stenosis (724.02). Patients diagnosed with spondylolisthesis, and those receiving revision surgery or fusion of more than 3 segments were excluded. Kaplan-Meier product limit method was used to estimate univariate rates of readmission for fusion, decompression, or injection and Cox proportional hazards to examine whether fusion decreased the likelihood of readmission. RESULTS: The overall 1-year readmission rate was slightly higher in patients undergoing fusion with decompression (9.7%) than patients who underwent decompression alone (7.2%, P = 0.03). Rates at 2 years were 14.6% and 12.5%, respectively. Patients receiving decompression with fusion were slightly younger and more likely female. Procedures performed during readmission were similar for the fusion and no fusion cohorts with 56% receiving fusion, 23% decompression, and 22% injection for pain management. Of the patients who were not readmitted, more than 25% of patients received outpatient injections for pain management during the 3-month quarter of their surgery and approximately 20% in the subsequent quarter. CONCLUSION: Readmission rates for spinal stenosis decompression were approximately 8% to 10% per year. Fusion at the index procedure did not protect against subsequent readmission. Large databases can inform choice of surgical options by focusing examination on indications for surgery and reasons for readmission. Fusion along with decompression does not seem to impact readmission rates.

Effect of epidural analgesia on postoperative complications following pancreaticoduodenectomy.

BACKGROUND: The purpose of this study was to evaluate the effect of epidural analgesia use on postoperative complications in patients undergoing pancreaticoduodenectomy. METHODS: This retrospective cohort study used the 2009 Nationwide Inpatient Sample from the Agency for Healthcare Research and Quality. Patients who underwent pancreaticoduodenectomy were grouped on the basis of whether they received epidural analgesia. The effect of epidural use on the composite end point of major complications including death was investigated using a generalized linear model. RESULTS: Overall, 8,610 cases of pancreaticoduodenectomy occurred within the United States in 2009, and 11.0% of these patients received epidural analgesia. After controlling for various potential confounders, results of the multivariate regression indicated that epidural analgesia use was associated with lower odds of composite complications including death (odds ratio, .61; 95% confidence interval, .37-.99; P = .044). CONCLUSIONS: In patients who underwent pancreaticoduodenectomy, epidural analgesia was associated with significantly lower postoperative composite complications.

Ethnic differences in the use of intrapartum epidural analgesia.

BACKGROUND: Obstetric epidural analgesia (EA) is widely applied, but studies have reported that its use may be less extensive among immigrant women or those from minority ethnic groups. Our aim was to examine whether this was the case in our geographic area, which contains an important immigrant population, and if so, to describe the different components of this phenomenon. METHODS: Cross-sectional observational study. SETTING: general acute care hospital, located in Marbella, southern Spain. Analysis of computer records of deliveries performed from 2004 to 2010. Comparison of characteristics of deliveries according to the mothers' geographic origins and of vaginal deliveries noting whether EA was received, using univariate and bivariate statistical analysis and multiple logistic regression (MLR). RESULTS: A total of 21,034 deliveries were recorded, and 37.4% of these corresponded to immigrant women. EA was provided to 61.1% of the Spanish women and to 51.5% of the immigrants, with important variations according to geographic origin: over 52% of women from other European countries and South America received EA, compared with around 45% of the African women and 37% of the Asian women. These differences persisted in the MLR model after adjusting for the mother's age, type of labor initiation, the weight of the neonate and for single or multiple gestation. With the Spanish patients as the reference category, all the other countries of origin presented lower probabilities of EA use. This was particularly apparent for the patients from Asia (OR 0.38; 95%CI 0.31-0.46), Morocco (OR 0.49; 95%CI 0.43-0.54) and other Africa (OR 0.55; 95%CI 0.37-0.81). CONCLUSIONS: We observed a different use of EA in vaginal deliveries, according to the geographic origin of the women. The explanation for this involves a complex set of factors, depending both on the patient and on the healthcare staff.

Social disparity and the use of intrapartum epidural analgesia in a publicly funded health care system.

OBJECTIVE: We sought to examine the difference in use of labor epidural analgesia among women from different neighborhood socioeconomic groups. STUDY DESIGN: Neighborhood socioeconomic variables from the 2001 Canadian Census were linked to singleton vaginal births from the Niday perinatal database (2004-2006) in Ontario, Canada. Births were divided into income and education groups by quintiles. Generalized estimating equations were employed to evaluate the association between labor epidural and neighborhood socioeconomic status. Supplementary analysis was conducted after stratifying data by hospital types. RESULTS: Compared with those from the richest neighborhood, women from the poorest quintile were the least likely to receive labor epidural analgesia (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.58-0.61). The differences were smallest in teaching hospitals (OR, 0.73; 95% CI, 0.67-0.79) and largest in small community hospitals (OR, 0.57; 95% CI, 0.50-0.64). Similar association was found in neighborhood education quintiles. CONCLUSION: The use of labor epidural analgesia is decreased with decreasing neighborhood economic and education levels.

Promoting epidural analgesia for labor: 2005-2007 diffusion in Lombardia, Italy.

BACKGROUND: Since January 2005 the Regional Government of Lombardia, a large Italian region with over 1/5 of all Italian births, allocated public funds for 3 consecutive years to help provide epidural analgesia (EA) for women in labor. The aim of the present study was to evaluate the trend of diffusion of EA in the triennium 2005-2007. METHODS: Data obtained from regional Obstetric Departments, recognized by the National Health Care System, were elaborated by the Epidemiological Service of Regione Lombardia. The software looked for specific codes for vaginal deliveries, with or without EA, and Cesarean sections included in the administrative patient records. RESULTS: A substantial increase in epidurals administered in comparison to total vaginal deliveries was recorded after assignment of regional financing: from 8.2% in 2005, to 10.4% in 2006 and 12.9% in 2007 (P<0.0001). More than 60% of epidurals were performed in 8 hospitals with >2 000 births per year. The rate of EAs in these hospitals was 18% in 2005, 22% in 2006 and 24.9% in 2007. In the 69 hospitals with <2000 births per year, the rate of EAs was markedly lower: 4% in 2005, 5.5% in 2006 and 7.8% in 2007. In both cases, the increase was statistically significant (P<0.0001). At the three-year time-point, the rate of Cesarean sections did not change. CONCLUSIONS: The continuous increase of EA for labor after regional financings suggests that the low rate of pain relief procedures in Lombardia was mainly due to economic and organizational issues, rather than to cultural and psychological factors.