Public Health Informatics and the Perioperative Physician: Looking to the Future.

The role of informatics in public health has increased over the past few decades, and the coronavirus disease 2019 (COVID-19) pandemic has underscored the critical importance of aggregated, multicenter, high-quality, near-real-time data to inform decision-making by physicians, hospital systems, and governments. Given the impact of the pandemic on perioperative and critical care services (eg, elective procedure delays; information sharing related to interventions in critically ill patients; regional bed-management under crisis conditions), anesthesiologists must recognize and advocate for improved informatic frameworks in their local environments. Most anesthesiologists receive little formal training in public health informatics (PHI) during clinical residency or through continuing medical education. The COVID-19 pandemic demonstrated that this knowledge gap represents a missed opportunity for our specialty to participate in informatics-related, public health-oriented clinical care and policy decision-making. This article briefly outlines the background of PHI, its relevance to perioperative care, and conceives intersections with PHI that could evolve over the next quarter century.

Changing a clinical pathway to increase spinal anesthesia use for elective hip arthroplasty: a single-centre historical cohort study.

PURPOSE: International consensus recommendations support neuraxial anesthesia as the preferred anesthetic technique for total hip arthroplasty. We hypothesized that an institutional initiative to promote spinal anesthesia within a clinical pathway would result in increased use of this technique. METHODS: We reviewed primary unilateral total hip arthroplasty data between June 2017 and June 2019-one year before vs one year after implementation. The primary outcome was rate of spinal anesthesia use. Secondary outcomes included postoperative pain scores and opioid use, rates of postoperative complications, and unplanned resource use. We built a run chart-tracking rates of spinal anesthesia; compared postoperative outcomes based on anesthetic technique; and developed a mixed model, multivariable logistic regression with margins analysis evaluating the use of spinal anesthesia. RESULTS: The final sample included 172 patients (87 before and 85 after implementation) with no significant differences in baseline characteristics. For the primary outcome, 42/87 (48%) patients received spinal anesthesia before implementation compared with 48/85 (56%) postimplementation (unadjusted difference, 8%; 95% confidence interval, -7 to 23; P = 0.28). There were no differences in secondary outcomes. Factors associated with receipt of spinal anesthesia included American Society of Anesthesiologists Physical Status II (vs III), lower body mass index, and shorter case duration. Using a reduced mixed model, the average marginal effect was 10.7%, with an upper 95% confidence limit of 25.7%. CONCLUSION: Implementation of a clinical pathway change to promote spinal anesthesia for total hip arthroplasty may not have been associated with increased use of spinal anesthesia, but utilization rates can vary widely. Baseline spinal anesthesia usage at our institution was higher than the USA national average, and many factors may influence choice of anesthesia technique. Patients who receive spinal anesthesia have decreased opioid requirements and pain scores postoperatively.

RéSUMé: OBJECTIF: Les recommandations consensuelles internationales soutiennent l'anesthésie neuraxiale comme technique anesthésique à privilégier lors d'une arthroplastie totale de la hanche. Nous avons émis l'hypothèse qu'une initiative institutionnelle visant à promouvoir la rachianesthésie dans le cadre d'une trajectoire clinique entraînerait une utilisation accrue de cette technique. MéTHODE: Nous avons examiné les données sur l'arthroplastie totale unilatérale primaire de la hanche entre juin 2017 et juin 2019, soit un an avant vs un an après la mise en œuvre. Le critère d'évaluation principal était le taux d'utilisation de la rachianesthésie. Les critères d'évaluation secondaires comprenaient les scores de douleur postopératoire et la consommation d'opioïdes, les taux de complications postopératoires et l'utilisation imprévue des ressources. Nous avons construit un graphique de séquence faisant le suivi des taux de rachianesthésie, comparé les résultats postopératoires basés sur la technique anesthésique, et développé un modèle mixte et une régression logistique multivariée avec analyse des marges évaluant l'utilisation de la rachianesthésie. RéSULTATS: L'échantillon final comprenait 172 patients (87 avant et 85 après la mise en œuvre) sans différences significatives dans leurs caractéristiques initiales. Pour le critère d'évaluation principal, 42/87 (48 %) patients ont reçu une rachianesthésie avant la mise en œuvre, contre 48/85 (56 %) après la mise en œuvre de l'initiative (différence non ajustée, 8 %; intervalle de confiance à 95 %, -7 à 23; P = 0,28). Aucune différence significative n'a été observée dans les critères d'évaluation secondaires. Les facteurs associés à l'administrion d'une rachianesthésie comprenaient : l'état physique selon l'American Society of Anesthesiologists (II vs III), un indice de masse corporelle inférieur et une durée de cas plus courte. En utilisant un modèle mixte réduit, l'effet marginal moyen était de 10,7 %, avec une limite supérieure de confiance de 95 % de 25,7 %. CONCLUSION: La mise en œuvre d'un changement de trajectoire clinique pour promouvoir la rachianesthésie pour l'arthroplastie totale de la hanche n'a peut-être pas été associée à une utilisation accrue de la rachianesthésie, mais les taux d'utilisation peuvent varier considérablement. L'utilisation initiale de la rachianesthésie dans notre établissement était supérieure à la moyenne nationale des États-Unis, et de nombreux facteurs peuvent influencer le choix de la technique d'anesthésie. Les patients qui reçoivent une rachianesthésie ont diminué leurs besoins en opioïdes et leurs scores de douleur postopératoires.

A Comparative Utility Score for Digital Health Tools.

Digital health tools (DHT) are increasingly poised to change healthcare delivery given the Coronavirus Disease 2019 (COVID-19) pandemic and the drive to telehealth. Establishing the potential utility of a given DHT could aid in identifying how it could be best used and further opportunities for healthcare improvement. We propose a metric, a Utility Factor Score, which quantifies the benefits of a DHT by explicitly defining adherence and linking it directly to satisfaction and health goals met. To provide data for how the comparative utility score can or should work, we illustrate in detail the application of our metrics across four DHTs with two simulated users. The Utility Factor Score can potentially facilitate integration of DHTs into various healthcare settings and should be evaluated within a clinical study.

Practice Patterns in Perioperative Nonopioid Analgesic Administration by Anesthesiologists in a Veterans Affairs Hospital.

OBJECTIVE: Although multimodal analgesia (MMA) is recommended for perioperative pain management, previous studies have found substantial variability in its utilization. To better understand the factors that influence anesthesiologists' choices, we assessed the associations between patient or surgical characteristics and number of nonopioid analgesic modes received intraoperatively across a variety of surgeries in a university-affiliated Veteran Affairs hospital. METHODS: We included elective inpatient surgeries (orthopedic, thoracic, spine, abdominal, and pelvic procedures) that used at least one nonopioid analgesic within a one-year period. Multivariable multinomial logistic regression models were used to estimate adjusted odds ratios and 95% confidence intervals (CIs). We also described the combinations of analgesia used in each surgical subtype and conducted exploratory analyses to test the associations between the number of modes used and postoperative outcomes. RESULTS: Of the 1,087 procedures identified, 33%, 53%, and 14% were managed with one, two, and three or more modes, respectively. Older patients had lower odds of receiving three or more modes (adjusted odds ratio [aOR] = 0.28, 95% confidence interval [CI] = 0.15-0.52), as were patients with more comorbidities (two modes: aOR = 0.87, 95% CI = 0.79-0.96; three or more modes: aOR = 0.81, 95% CI = 0.71-0.94). Utilization varied across surgical subtypes P < 0.0001). Increasing the number of modes, particularly use of regional anesthesia, was associated with shorter length of stay. CONCLUSIONS: Our study suggests that age, comorbidities, and surgical type contribute to variability in MMA utilization. Risks and benefits of multiple modes should be carefully considered for older and sicker patients. Future directions include developing patient- and procedure-specific perioperative MMA recommendations.

Perioperative Opioid Prescribing Patterns and Readmissions After Total Knee Arthroplasty in a National Cohort of Veterans Health Administration Patients.

OBJECTIVE: Among Veterans Health Administration (VHA) patients who undergo total knee arthroplasty (TKA) nationally, what are the underlying readmission rates and associations with perioperative opioid use, and are there associations with other factors such as preoperative health care utilization? METHODS: We retrospectively examined the records of 5,514 TKA patients (primary N = 4,955, 89.9%; revision N = 559, 10.1%) over one fiscal year (October 1, 2010-September 30, 2011) across VHA hospitals nationwide. Opioid use was classified into no opioids, tramadol only, short-acting only, or any long-acting. We measured readmission within 30 days and the number of days to readmission within 30 days. Extended Cox regression models were developed. RESULTS: The overall 30-day hospital readmission rate was 9.6% (N = 531; primary 9.5%, revision 11.1%). Both readmitted patients and the overall sample were similar on types of preoperative opioid use. Relative to patients without opioids, patients in the short-acting opioids only tier had the highest risk for 30-day hospital readmission (hazard ratio = 1.38, 95% confidence interval = 1.14-1.67). Preoperative opioid status was not associated with 30-day readmission. Other risk factors for 30-day readmission included older age (≥66 years), higher comorbidity and diagnosis-related group weights, greater preoperative health care utilization, an urban location, and use of preoperative anticonvulsants. CONCLUSIONS: Given the current opioid epidemic, the routine prescribing of short-acting opioids after surgery should be carefully considered to avoid increasing risks of 30-day hospital readmissions and other negative outcomes, particularly in the context of other predisposing factors.

A Multidisciplinary Patient-Specific Opioid Prescribing and Tapering Protocol Is Associated with a Decrease in Total Opioid Dose Prescribed for Six Weeks After Total Hip Arthroplasty.

OBJECTIVE: This retrospective cohort study tested the hypothesis that implementing a multidisciplinary patient-specific discharge protocol for prescribing and tapering opioids after total hip arthroplasty (THA) will decrease the morphine milligram equivalent (MME) dose of opioids prescribed. METHODS: With institutional review board approval, we analyzed a Perioperative Surgical Home database and prescription data for all primary THA patients three months before (PRE) and three months after (POST) implementation of this new discharge opioid protocol based on patients' prior 24-hour inpatient opioid consumption. The primary outcome was total opioid dosage in MME prescribed and opioid refills for six weeks after surgery. Secondary outcomes included the number of tablets and MME prescribed at discharge, in-hospital opioid consumption, length of stay, and postoperative complications. RESULTS: Forty-nine cases (25 PRE and 24 POST) were included. Total median (10th-90th percentiles) MME for six weeks postoperatively was 900 (57-2082) MME PRE vs 295 (69-741) MME POST (mean difference = 721, 95% confidence interval [CI] = 127-1316, P = 0.007, Mann-Whitney U test). Refill rates did not differ. The median (10th-90th percentiles) initial discharge prescription in MME was 675 (57-1035) PRE vs 180 (18-534) POST (mean difference = 387, 95% CI = 156-618, P = 0.003, Mann-Whitney U test) MME. There were no differences in other outcomes. CONCLUSIONS: Implementation of a patient-specific prescribing and tapering protocol decreases the mean six-week dosage of opioid prescribed by 63% after THA without increasing the refill rate.

Impact of an Opioid Safety Initiative on Patients Undergoing Total Knee Arthroplasty: A Time Series Analysis.

BACKGROUND: The Opioid Safety Initiative decreased high-dose prescriptions across the Veterans Health Administration. This study sought to examine the impact of this intervention (i.e., the Opioid Safety Initiative) on pain scores and opioid prescriptions in patients undergoing total knee arthroplasty. METHODS: This was an ecological study of group-level data among 700 to 850 patients per month over 72 consecutive months (January 2010 to December 2015). The authors examined characteristics of cohorts treated before versus after rollout of the Opioid Safety Initiative (October 2013). Each month, the authors aggregated at the group-level the differences between mean postoperative and preoperative pain scores for each patient (averaged over 6-month periods), and measured proportions of patients (per 1,000) with opioid (and nonopioid) prescriptions for more than 3 months in 6-month periods, preoperatively and postoperatively. The authors compared postintervention trends versus trends forecasted based on preintervention measures. RESULTS: After the Opioid Safety Initiative, patients were slightly older and sicker, but had lower mortality rates (postintervention n = 28,509 vs. preintervention n = 31,547). Postoperative pain scores were slightly higher and the decrease in opioid use was statistically significant, i.e., 871 (95% CI, 474 to 1,268) fewer patients with chronic postoperative prescriptions. In time series analyses, mean postoperative minus preoperative pain scores had increased from 0.65 to 0.81, by 0.16 points (95% CI, 0.05 to 0.27). Proportions of patients with chronic postoperative and chronic preoperative opioid prescriptions had declined by 20% (n = 3,355 vs. expected n = 4,226) and by 13% (n = 5,861 vs. expected n = 6,724), respectively. Nonopioid analgesia had increased. Sensitivity analyses confirmed all findings. CONCLUSIONS: A system-wide initiative combining guideline dissemination with audit and feedback was effective in significantly decreasing opioid prescriptions in populations undergoing total knee arthroplasty, while minimally impacting pain scores.

Outcomes of Ambulatory Upper Extremity Surgery Patients Discharged Home with Perineural Catheters from a Veterans Health Administration Medical Center.

OBJECTIVE: The feasibility and safety of managing ambulatory continuous peripheral nerve blocks (CPNB) in Veterans Health Administration (VHA) patients are currently unknown. We aimed to characterize the outcomes of a large VHA cohort of ambulatory upper extremity surgery patients discharged with CPNB and identify differences, if any, between catheter types. METHODS: With institutional review board approval, we reviewed data for consecutive patients from a single VHA hospital who had received ambulatory CPNB for upper extremity surgery from March 2011 to May 2017. The composite primary outcome was the occurrence of any catheter-related issue or additional all-cause health care intervention after discharge. Our secondary outcome was the ability to achieve regular daily telephone contact. RESULTS: Five hundred one patients formed the final sample. The incidence of any issue or health care intervention was 104/274 (38%) for infraclavicular, 58/185 (31%) for interscalene, and 14/42 (33%) for supraclavicular; these rates did not differ between groups. Higher ASA status was associated with greater odds of having any issue, whereas increasing age was slightly protective. Distance was associated with an increase in catheter-related issues (P < 0.01) but not additional health care interventions (P = 0.51). Only interscalene catheter patients (3%) reported breathing difficulty. Infraclavicular catheter patients had the most emergency room visits but rarely for CPNB issues. Consistent daily telephone contact was not achieved. CONCLUSIONS: For VHA ambulatory CPNB patients, the combined incidence of a catheter-related issue or additional health care intervention was approximately one in three patients and did not differ by brachial plexus catheter type. Serious adverse events were generally uncommon.

Overdose Risk Associated with Opioid Use upon Hospital Discharge in Veterans Health Administration Surgical Patients.

OBJECTIVE: To determine an association between opioid use upon hospital discharge (ongoing and newly started) in surgical patients and risks of opioid overdose and delirium for the first year. DESIGN: Retrospective, cohort study. SETTING: Population-level study of Veterans Health Administration patients. SUBJECTS: All Veterans Health Administration patients (N = 64,391) who underwent surgery in 2011, discharged after one or more days, and without a diagnosis of opioid overdose or delirium from 90 days before admission through 30 days postdischarge (to account for additional opioid dosing in the context of chronic use). METHODS: Patients' opioid use was categorized as 1) no opioids, 2) tramadol only, 3) short-acting only, 4) long-acting only, 5) short- and long-acting. We calculated unadjusted incidence rates and the incidence rate ratio (IRR) for opioid overdose and drug delirium for two time intervals: postdischarge days 0-30 and days 31-365. We then modeled outcomes of opioid overdose and delirium for postdischarge days 31-365 using a multivariable extended Cox regression model. Sensitivity analysis examined risk factors for overdose for postdischarge days 0-30. RESULTS: Incidence of overdose was 11-fold greater from postdischarge days 0-30 than days 31-365: 26.3 events/person-year (N = 68) vs 2.4 events/person-year (N = 476; IRR = 10.80, 95% confidence interval [CI] = 8.37-13.92). Higher-intensity opioid use was associated with increasing risk of overdose for the year after surgery, with the highest risk for the short- and long-acting group (hazard ratio = 4.84, 95% CI = 3.28-7.14). Delirium (IRR = 10.66, 95% CI = 7.96-14.29) was also associated with higher opioid intensity. CONCLUSIONS: Surgical patients should be treated with the lowest effective intensity of opioids and be monitored to prevent opioid-related adverse events.

Development and validation of a predictive model for American Society of Anesthesiologists Physical Status.

BACKGROUND: The American Society of Anesthesiologists Physical Status (ASA-PS) classification system was developed to categorize the fitness of patients before surgery. Increasingly, the ASA-PS has been applied to other uses including justification of inpatient admission. Our objectives were to develop and cross-validate a statistical model for predicting ASA-PS; and 2) assess the concurrent and predictive validity of the model by assessing associations between model-derived ASA-PS, observed ASA-PS, and a diverse set of 30-day outcomes. METHODS: Using the 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data File, we developed and internally cross-validated multinomial regression models to predict ASA-PS using preoperative NSQIP data. Accuracy was assessed with C-Statistics and calibration plots. We assessed both concurrent and predictive validity of model-derived ASA-PS relative to observed ASA-PS and 30-day outcomes. To aid further research and use of the ASA-PS model, we implemented it into an online calculator. RESULTS: Of the 566,797 elective procedures in the final analytic dataset, 8.9% were ASA-PS 1, 48.9% were ASA-PS 2, 39.1% were ASA-PS 3, and 3.2% were ASA-PS 4. The accuracy of the 21-variable model to predict ASA-PS was C = 0.77 +/- 0.0025. The model-derived ASA-PS had stronger association with key indicators of preoperative status including comorbidities and higher BMI (concurrent validity) compared to observed ASA-PS, but less strong associations with postoperative complications (predictive validity). The online ASA-PS calculator may be accessed at https://s-spire-clintools.shinyapps.io/ASA_PS_Estimator/ CONCLUSIONS: Model-derived ASA-PS better tracked key indicators of preoperative status compared to observed ASA-PS. The ability to have an electronically derived measure of ASA-PS can potentially be useful in research, quality measurement, and clinical applications.

Are Case Volume and Facility Complexity Level Associated With Postoperative Complications After Hip Fracture Surgery in the Veterans Affairs Healthcare System?

BACKGROUND: Hospital-related factors associated with mortality and morbidity after hip fracture surgery are not completely understood. The Veterans Health Administration (VHA) is the largest single-payer, networked healthcare system in the country serving a relatively homogenous patient population with facilities that vary in size and resource availability. These characteristics provide some degree of financial and patient-level controls to explore the association, if any, between surgical volume and facility resource availability and hospital performance regarding postoperative complications after hip fracture surgery. QUESTIONS/PURPOSES: (1) Do VHA facilities with the highest complexity level designation (Level 1a) have a disproportionate number of better-than-expected performance outliers for major postoperative complications compared with lower-complexity level facilities? (2) Do VHA facilities with higher hip fracture surgical volume have a disproportionate number of better-than-expected performance outliers for major postoperative complications compared with lower-volume facilities? METHODS: We explored the Veterans Affairs Surgical Quality Improvement Project (VASQIP) database from October 2001 to September 2012 for records of hip fracture surgery performed. Data reliability of the VASQIP database has been previously validated. We excluded nine of the 98 VHA facilities for contributing fewer than 30 records. The remaining 89 VHA facilities provided 23,029 records. The VHA designates a complexity level to each facility based on multiple criteria. We labeled facilities with a complexity Level 1a (38 facilities)-the highest achievable VHA designated complexity level-as high complexity; we labeled all other complexity level designations as low complexity (51 facilities). Facility volume was divided into tertiles: high (> 277 hip fracture procedures during the sampling frame), medium (204 to 277 procedures), and low (< 204 procedures). The patient population treated by low-complexity facilities was older, had a higher prevalence of severe chronic obstructive pulmonary disease (26% versus 22%, p < 0.001), and had a higher percentage of patients having surgery within 2 days of hospital admission (83% versus 76%, p < 0.001). High-complexity facilities treated more patients with recent congestive heart failure exacerbation (4% versus 3%, p < 0.001). We defined major postoperative complications as having at least one of the following: death within 30 days of surgery, cardiac arrest requiring cardiopulmonary resuscitation, new q-wave myocardial infarction, deep vein thrombosis and/or pulmonary embolism, ventilator dependence for at least 48 hours after surgery, reintubation for respiratory or cardiac failure, acute renal failure requiring renal replacement therapy, progressive renal insufficiency with a rise in serum creatinine of at least 2 mg/dL from preoperative value, pneumonia, or surgical site infection. We used the observed-to-expected ratio (O/E ratio)-a risk-adjusted metric to classify facility performance-for major postoperative complications to assess the performance of VHA facilities. Outlier facilities with 95% confidence intervals (95% CI) for O/E ratio completely less than 1.0 were labeled "exceed expectation;" those that were completely greater than 1.0 were labeled "below expectation." We compared differences in the distribution of outlier facilities between high and low-complexity facilities, and between high-, medium-, and low-volume facilities using Fisher's exact test. RESULTS: We observed no association between facility complexity level and the distribution of outlier facilities (high-complexity: 5% exceeded expectation, 5% below expectation; low-complexity: 8% exceeded expectation, 2% below expectation; p = 0.742). Compared with high-complexity facilities, the adjusted odds ratio for major postoperative complications for low-complexity facilities was 0.85 (95% CI, 0.67-1.09; p = 0.108).We observed no association between facility volume and the distribution of outlier facilities: 3% exceeded expectation and 3% below expectation for high-volume; 10% exceeded expectation and 3% below expectation for medium-volume; and 7% exceeded expectation and 3% below expectation for low-volume; p = 0.890). The adjusted odds ratios for major postoperative complications were 0.87 (95% CI, 0.73-1.05) for low- versus high-volume facilities and 0.89 (95% CI, 0.79-1.02] for medium- versus high-volume facilities (p = 0.155). CONCLUSIONS: These results do not support restricting facilities from treating hip fracture patients based on historical surgical volume or facility resource availability. Identification of consistent performance outliers may help health care organizations with multiple facilities determine allocation of services and identify characteristics and processes that determine outlier status in the interest of continued quality improvement. LEVEL OF EVIDENCE: Level III, therapeutic study.

Time-to-Cessation of Postoperative Opioids: A Population-Level Analysis of the Veterans Affairs Health Care System.

OBJECTIVE: This study aims to determine 1) the epidemiology of perioperative opioid use; and 2) the association between patterns of preoperative opioid use and time-to-cessation of postoperative opioids. DESIGN: Retrospective, cohort study. SETTING: National, population-level study of Veterans Healthcare Administration (VHA) electronic clinical data. SUBJECTS: All VHA patients (n = 64,391) who underwent surgery in 2011, discharged after stays of ≥1 day, and receiving ≥1 opioid prescription within 90 days of discharge. METHODS: Patients' preoperative opioid use were categorized as 1) no opioids, 2) tramadol only, 3) short-acting (SA) acute/intermittent (≤ 90 days fill), 4) SA chronic (> 90 days fill), or 5) any long-acting (LA). After defining cessation as 90 consecutive, opioid-free days, the authors calculated time-to-opioid-cessation (in days), from day 1 to day 365, after hospital discharge. The authors developed extended Cox regression models with a priori identified predictors. Sensitivity analyses used alternative cessation definitions (30 or 180 consecutive days). RESULTS: Almost 60% of the patients received preoperative opioids: tramadol (7.5%), SA acute/intermittent (24.1%), SA chronic (17.5%), and LA (5.2%). For patients opioid-free preoperatively, median time-to-cessation of opioids postoperatively was 15 days. The SA acute/intermittent cohort (HR =1.96; 95% CI =1.92-2.00) had greater risk for prolonged time-to-cessation than those opioid-free (reference), but lower risk than those taking tramadol only, SA chronic (HR = 9.09; 95% CI = 8.33-9.09), or LA opioids (HR = 9.09; 95% CI = 8.33-10.00). Diagnoses of chronic pain, substance-use, or affective disorders were weaker positive predictors. Sensitivity analyses maintained findings. CONCLUSION: Greater preoperative levels of opioid use were associated with progressively longer time-to-cessation postoperatively.

Implementation of an Anesthesia Information Management System in an Ambulatory Surgery Center.

Anesthesia information management systems (AIMS) are increasingly being implemented throughout the United States. However, little information exists on the implementation process for AIMS within ambulatory surgery centers (ASC). The objectives of this descriptive study are to document: 1) the phases of implementation of an AIMS at an ASC; and 2) lessons learnt from a socio-technical perspective. The ASC, within the Veterans Health Administration (VHA), has hosted an AIMS since 2008. As a quality improvement effort, we implemented a new version of the AIMS. This new version involved fundamental software changes to enhance clinical care such as real-time importing of laboratory data and total hardware exchange. The pre-implementation phase involved coordinated preparation over six months between multiple informatics teams along with local leadership. During this time, we conducted component, integration, and validation testing to ensure correct data flow from medical devices to AIMS and centralized databases. The implementation phase occurred in September 2014 over three days and was successful. Over the next several months, during post-implementation phase, we addressed residual items like latency of the application. Important lessons learnt from the implementation included the utility of partnering early with executive leadership; ensuring end user acceptance of new clinical workflow; continuous testing of data flow; use of a staged rollout; and providing additional personnel throughout implementation. Implementation of an AIMS at an ASC can utilize methods developed for large hospitals. However, issues unique to an ASC such as limited number of support personnel and distinctive workflows must be considered.

Continuous adductor canal blocks are superior to continuous femoral nerve blocks in promoting early ambulation after TKA.

BACKGROUND: Femoral continuous peripheral nerve blocks (CPNBs) provide effective analgesia after TKA but have been associated with quadriceps weakness and delayed ambulation. A promising alternative is adductor canal CPNB that delivers a primarily sensory blockade; however, the differential effects of these two techniques on functional outcomes after TKA are not well established. QUESTIONS/PURPOSES: We determined whether, after TKA, patients with adductor canal CPNB versus patients with femoral CPNB demonstrated (1) greater total ambulation distance on Postoperative Day (POD) 1 and 2 and (2) decreased daily opioid consumption, pain scores, and hospital length of stay. METHODS: Between October 2011 and October 2012, 180 patients underwent primary TKA at our practice site, of whom 93% (n = 168) had CPNBs. In this sequential series, the first 102 patients had femoral CPNBs, and the next 66 had adductor canal CPNBs. The change resulted from a modification to our clinical pathway, which involved only a change to the block. An evaluator not involved in the patients' care reviewed their medical records to record the parameters noted above. RESULTS: Ambulation distances were higher in the adductor canal group than in the femoral group on POD 1 (median [10(th)-90(th) percentiles]: 37 m [0-90 m] versus 6 m [0-51 m]; p < 0.001) and POD 2 (60 m [0-120 m] versus 21 m [0-78 m]; p = 0.003). Adjusted linear regression confirmed the association between adductor canal catheter use and ambulation distance on POD 1 (B = 23; 95% CI = 14-33; p < 0.001) and POD 2 (B = 19; 95% CI = 5-33; p = 0.008). Pain scores, daily opioid consumption, and hospital length of stay were similar between groups. CONCLUSIONS: Adductor canal CPNB may promote greater early postoperative ambulation compared to femoral CPNB after TKA without a reduction in analgesia. Future randomized studies are needed to validate our major findings. LEVEL OF EVIDENCE: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Variations in inpatient pediatric anesthesia in California from 2000 to 2009: a caseload and geographic analysis.

BACKGROUND: Regional referral systems are considered important for children hospitalized for surgery, but there is little information on existing systems. OBJECTIVES: To examine geographic variations in anesthetic caseloads in California for surgical inpatients ≤6 years and to evaluate the feasibility of regionalizing anesthetic care. METHODS: We reviewed California's unmasked patient discharge database between 2000 and 2009 to determine surgical procedures, dates, and inpatient anesthetic caseloads. Hospitals were classified as urban or rural and were further stratified as low, intermediate, high, and very high volume. RESULTS: We reviewed 257,541 anesthetic cases from 402 hospitals. Seventeen California Children's Services (CCS) hospitals conducted about two-thirds of all inpatient anesthetics; 385 non-CCS hospitals accounted for the rest. Urban hospitals comprised 82% of low- and intermediate-volume centers (n = 297) and 100% of the high- and very high-volume centers (n = 41). Ninety percent (n = 361) of hospitals performed <100 cases annually. Although potentially lower risk procedures such as appendectomies were the most frequent in urban low- and intermediate-volume hospitals, fairly complex neurosurgical and general surgeries were also performed. The median distance from urban lower-volume hospitals to the nearest high- or very high-volume center was 12 miles. Up to 98% (n = 40,316) of inpatient anesthetics at low- or intermediate-volume centers could have been transferred to higher-volume centers within 25 miles of smaller centers. CONCLUSIONS: Many urban California hospitals maintained low annual inpatient anesthetic caseloads for children ≤6 years while conducting potentially more complex procedures. Further efforts are necessary to define the scope of pediatric anesthetic care at urban low- and intermediate-volume hospitals in California.

Use of natural language processing method to identify regional anesthesia from clinical notes.

INTRODUCTION: Accurate data capture is integral for research and quality improvement efforts. Unfortunately, limited guidance for defining and documenting regional anesthesia has resulted in wide variation in documentation practices, even within individual hospitals, which can lead to missing and inaccurate data. This cross-sectional study sought to evaluate the performance of a natural language processing (NLP)-based algorithm developed to identify regional anesthesia within unstructured clinical notes. METHODS: We obtained postoperative clinical notes for all patients undergoing elective non-cardiac surgery with general anesthesia at one of six Veterans Health Administration hospitals in California between January 1, 2017, and December 31, 2022. After developing and executing our algorithm, we compared our results to a frequently used referent, the Corporate Data Warehouse structured data, to assess the completeness and accuracy of the currently available data. Measures of agreement included sensitivity, positive predictive value, false negative rate, and accuracy. RESULTS: We identified 27,713 procedures, of which 9310 (33.6%) received regional anesthesia. 96.6% of all referent regional anesthesia cases were identified in the clinic notes with a very low false negative rate and good accuracy (false negative rate=0.8%, accuracy=82.5%). Surprisingly, the clinic notes documented more than two times the number of regional anesthesia cases that were documented in the referent (algorithm n=9154 vs referent n=4606). DISCUSSION: While our algorithm identified nearly all regional anesthesia cases from the referent, it also identified more than two times as many regional anesthesia cases as the referent, raising concerns about the accuracy and completeness of regional anesthesia documentation in administrative and clinical databases. We found that NLP was a promising alternative for identifying clinical information when existing databases lack complete documentation.

Opioid use in cancer patients compared with noncancer pain patients in a veteran population.

BACKGROUND: Opioid safety initiatives may secondarily impact opioid prescribing and pain outcomes for cancer care. METHODS: We reviewed electronic health record data at a tertiary Veterans Affairs system (VA Palo Alto) for all patients from 2015 to 2021. We collected outpatient Schedule II opioid prescriptions data and calculated morphine milligram equivalents (MMEs) using Centers for Disease Control and Prevention conversion formulas. To determine the clinical impact of changes in opioid prescription, we used the highest level of pain reported by each patient on the 0-to-10 Numeric Rating Scale in each year, categorized into mild (0-3), moderate (4-6), and severe (7 and above). RESULTS: Among 89 569 patients, 9073 had a cancer diagnosis. Cancer patients were almost twice as likely to have an opioid prescription compared with noncancer patients (69.0% vs 36.7%, respectively). The proportion of patients who received an opioid prescription decreased from 27.1% to 18.1% (trend P < .01) in cancer patients and from 17.0% to 10.2% in noncancer patients (trend P < .01). Cancer and noncancer patients had similar declines of MMEs per year between 2015 and 2019, but the decline was more rapid for cancer patients (1462.5 to 946.4, 35.3%) compared with noncancer patients (1315.6 to 927.7, 29.5%) from 2019 to 2021. During the study period, the proportion of noncancer patients who experienced severe pain was almost unchanged, whereas it increased among cancer patients, reaching a significantly higher rate than among noncancer patients in 2021 (31.9% vs 27.4%, P < .01). CONCLUSIONS: Our findings suggest potential unintended consequences for cancer care because of efforts to manage opioid-related risks.

More Than a Perioperative Surgical Home: An Opportunity for Anesthesiologists to Advance Public Health.

Public health and the medical specialty of anesthesiology have been closely intertwined throughout history, dating back to the 1800s when Dr. John Snow used contact tracing methods to identify the Broad Street Pump as the source of a cholera outbreak in London. During the COVID-19 pandemic, leaders in anesthesiology and anesthesia patient safety came forward to develop swift recommendations in the face of rapidly changing evidence to help protect patients and healthcare workers. While these high-profile examples may seem like uncommon events, there are many common modern-day public health issues that regularly intersect with anesthesiology and surgery. These include, but are not limited to, smoking; chronic opioid use and opioid use disorder; and obstructive sleep apnea. As an evolving medical specialty that encompasses pre- and postoperative care and acute and chronic pain management, anesthesiologists are uniquely positioned to improve patient care and outcomes and promote long-lasting behavioral changes to improve overall health. In this article, we make the case for advancing the role of the anesthesiologist beyond the original perioperative surgical home model into promoting public health initiatives within the perioperative period.

Vascular surgery patients prescribed preoperative ß-blockers experienced a decrease in the maximal heart rate observed during induction of general anesthesia.

OBJECTIVE: To investigate the association of preoperative ß-blocker usage and maximal heart rates observed during the induction of general anesthesia. DESIGN: Retrospective descriptive, univariate, and multivariate analyses of electronic hospital and anesthesia medical records. SETTING: A tertiary-care medical center within the Veterans Health Administration. PARTICIPANTS: Consecutive adult elective and emergent patients presenting for vascular surgery during calendar years 2005 to 2011. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 430 eligible cases, 218 were prescribed ß-blockers, and 212 were not taking ß-blockers. The two groups were comparable across baseline patient factors (ie, demographic, morphometric, surgical duration, and surgical procedures) and induction medication doses. The ß-blocker group experienced a lower maximal heart rate during the induction of general anesthesia compared with the non-ß-blocker group (105 ± 41 beats/min v 115 ± 45 beats/min, respectively; p < 0.01). Adjusted linear regression found a statistically significant association between lower maximal heart rate and the use of ß-blockers (ß = -11.1 beats/min, p < 0.01). There was no difference between groups in total intraoperative ß-blocker administration. CONCLUSIONS: Preoperative ß-blockade of vascular surgery patients undergoing general anesthesia is associated with a lower maximal heart rate during anesthetic induction. There may be potential benefits in administering ß-blockers to reduce physiologic stress in this surgical population at risk for perioperative cardiac morbidity. Future research should further explore intraoperative hemodynamic effects in light of existing practice guidelines for optimal medication selection, dosage, and heart rate control.