Association of Race and Ethnicity With Postoperative Gabapentinoid and Opioid Prescribing Trends for Older Adults.

BACKGROUND: Disparities in opioid prescribing by race/ethnicity have been described in many healthcare settings, with White patients being more likely to receive an opioid prescription than other races studied. As surgeons increase prescribing of nonopioid medications in response to the opioid epidemic, it is unknown whether postoperative prescribing disparities also exist for these medications, specifically gabapentinoids. METHODS: We conducted a retrospective cohort study using a 20% Medicare sample for 2013-2018. We included patients ≥66 years without prior gabapentinoid use who underwent one of 14 common surgical procedures. The primary outcome was the proportion of patients prescribed gabapentinoids at discharge among racial and ethnic groups. Secondary outcomes were days' supply of gabapentinoids, opioid prescribing at discharge, and oral morphine equivalent (OME) of opioid prescriptions. Trends over time were constructed by analyzing proportion of postoperative prescribing of gabapentinoids and opioids for each year. For trends by year by racial/ethnic groups, we ran a multivariable logistic regression with an interaction term of procedure year and racial/ethnic group. RESULTS: Of the 494,922 patients in the cohort (54% female, 86% White, 5% Black, 5% Hispanic, mean age 73.7 years), 3.7% received a new gabapentinoid prescription. Gabapentinoid prescribing increased over time for all groups and did not differ significantly among groups (P = 0.13). Opioid prescribing also increased, with higher proportion of prescribing to White patients than to Black and Hispanic patients in every year except 2014. CONCLUSIONS: We found no significant prescribing variation of gabapentinoids in the postoperative period between racial/ethnic groups. Importantly, we found that despite national attention to disparities in opioid prescribing, variation continues to persist in postoperative opioid prescribing, with a higher proportion of White patients being prescribed opioids, a difference that persisted over time.

Use of Professional Interpreters for Patients With Limited English Proficiency Undergoing Surgery.

This cohort study examines measures of hospital interpreter usage for surgical patients with limited English proficiency (LEP) undergoing common general operations.

Screening for Intimate Partner Violence in Trauma: Results of a Quality Improvement Project.

INTRODUCTION: Intimate partner violence (IPV) is common, especially among patients presenting with traumatic injury. We implemented an IPV screening program for patients admitted after trauma. We sought to determine whether specific demographic or clinical characteristics were associated with being screened or not screened for IPV and with IPV screen results. METHODS: Retrospective cohort study evaluating all patients admitted after trauma from July 2020-July 2022 in an Adult Level 1 Trauma Center. RESULTS: There were 4147 admissions following traumatic injury, of which 70% were men and 30% were women. The cohort was 46% White, 20% Asian, 15% Black, and 17% other races. Twenty-three percent were Hispanic or Latino/a. Seventy-seven percent were admitted for blunt injuries and 16% for penetrating injuries. Thirteen percent (n = 559) of the cohort was successfully screened for IPV. Screening rates did not differ by gender, race, or ethnicity. After adjustment for demographic and clinical factors, patients admitted to the intensive care unit were significantly less likely to be screened. Of the screened patients, 30% (165) screened positive. These patients were more commonly Hispanic or Latino/a, insured by Medicaid and presented with a penetrating injury. There were no differences in injury severity in patients who screened positive versus those who screened negative. CONCLUSIONS: There are significant barriers to universal screening for IPV, including injury acuity, in patients admitted following trauma. However, the 30% rate of positive screens for IPV in patients admitted following trauma highlights the urgent need to understand and address barriers to screening in trauma settings to enable universal screening.

Electronic health record intervention to increase use of NSAIDs as analgesia for hospitalised patients: a cluster randomised controlled study.

BACKGROUND: Prescribing non-opioid pain medications, such as non-steroidal anti-inflammatory (NSAIDs) medications, has been shown to reduce pain and decrease opioid use, but it is unclear how to effectively encourage multimodal pain medication prescribing for hospitalised patients. Therefore, the aim of this study is to evaluate the effect of prechecking non-opioid pain medication orders on clinician prescribing of NSAIDs among hospitalised adults. METHODS: This was a cluster randomised controlled trial of adult (≥18 years) hospitalised patients admitted to three hospital sites under one quaternary hospital system in the USA from 2 March 2022 to 3 March 2023. A multimodal pain order panel was embedded in the admission order set, with NSAIDs prechecked in the intervention group. The intervention group could uncheck the NSAID order. The control group had access to the same NSAID order. The primary outcome was an increase in NSAID ordering. Secondary outcomes include NSAID administration, inpatient pain scores and opioid use and prescribing and relevant clinical harms including acute kidney injury, new gastrointestinal bleed and in-hospital death. RESULTS: Overall, 1049 clinicians were randomised. The study included 6239 patients for a total of 9595 encounters. Both NSAID ordering (36 vs 43%, p<0.001) and administering (30 vs 34%, p=0.001) by the end of the first full hospital day were higher in the intervention (prechecked) group. There was no statistically significant difference in opioid outcomes during the hospitalisation and at discharge. There was a statistically but perhaps not clinically significant difference in pain scores during both the first and last full hospital day. CONCLUSIONS: This cluster randomised controlled trial showed that prechecking an order for NSAIDs to promote multimodal pain management in the admission order set increased NSAID ordering and administration, although there were no changes to pain scores or opioid use. While prechecking orders is an important way to increase adoption, safety checks should be in place.

Large Language Model-Based Chatbot vs Surgeon-Generated Informed Consent Documentation for Common Procedures.

Importance: Informed consent is a critical component of patient care before invasive procedures, yet it is frequently inadequate. Electronic consent forms have the potential to facilitate patient comprehension if they provide information that is readable, accurate, and complete; it is not known if large language model (LLM)-based chatbots may improve informed consent documentation by generating accurate and complete information that is easily understood by patients. Objective: To compare the readability, accuracy, and completeness of LLM-based chatbot- vs surgeon-generated information on the risks, benefits, and alternatives (RBAs) of common surgical procedures. Design, Setting, and Participants: This cross-sectional study compared randomly selected surgeon-generated RBAs used in signed electronic consent forms at an academic referral center in San Francisco with LLM-based chatbot-generated (ChatGPT-3.5, OpenAI) RBAs for 6 surgical procedures (colectomy, coronary artery bypass graft, laparoscopic cholecystectomy, inguinal hernia repair, knee arthroplasty, and spinal fusion). Main Outcomes and Measures: Readability was measured using previously validated scales (Flesh-Kincaid grade level, Gunning Fog index, the Simple Measure of Gobbledygook, and the Coleman-Liau index). Scores range from 0 to greater than 20 to indicate the years of education required to understand a text. Accuracy and completeness were assessed using a rubric developed with recommendations from LeapFrog, the Joint Commission, and the American College of Surgeons. Both composite and RBA subgroup scores were compared. Results: The total sample consisted of 36 RBAs, with 1 RBA generated by the LLM-based chatbot and 5 RBAs generated by a surgeon for each of the 6 surgical procedures. The mean (SD) readability score for the LLM-based chatbot RBAs was 12.9 (2.0) vs 15.7 (4.0) for surgeon-generated RBAs (P = .10). The mean (SD) composite completeness and accuracy score was lower for surgeons' RBAs at 1.6 (0.5) than for LLM-based chatbot RBAs at 2.2 (0.4) (P < .001). The LLM-based chatbot scores were higher than the surgeon-generated scores for descriptions of the benefits of surgery (2.3 [0.7] vs 1.4 [0.7]; P < .001) and alternatives to surgery (2.7 [0.5] vs 1.4 [0.7]; P < .001). There was no significant difference in chatbot vs surgeon RBA scores for risks of surgery (1.7 [0.5] vs 1.7 [0.4]; P = .38). Conclusions and Relevance: The findings of this cross-sectional study suggest that despite not being perfect, LLM-based chatbots have the potential to enhance informed consent documentation. If an LLM were embedded in electronic health records in a manner compliant with the Health Insurance Portability and Accountability Act, it could be used to provide personalized risk information while easing documentation burden for physicians.

Optimizing Uptake of Multimodal Pain Management After Surgery Using the Electronic Health Record.

This quality improvement study evaluates the effect of an electronic health record intervention on multimodal pain management following surgery in 2 randomized clinical trials.

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.

A behavioral intervention to promote use of multimodal pain medication for hospitalized patients: A randomized controlled trial.

BACKGROUND: The use of nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce pain and has become a core strategy to decrease opioid use, but there is a lack of data to describe encouraging use when admitting patients using electronic health record systems. OBJECTIVE: Assess an electronic health record system to increase ordering of NSAIDs for hospitalized adults. DESIGNS, SETTINGS AND PARTICIPANTS: We performed a cluster randomized controlled trial of clinicians admitting adult patients to a health system over a 9-month period. Clinicians were randomized to use a standard admission order set. INTERVENTION: Clinicians in the intervention arm were required to actively order or decline NSAIDs; the control arm was shown the same order but without a required response. MAIN OUTCOME AND MEASURES: The primary outcome was NSAIDs ordered and administered by the first full hospital day. Secondary outcomes included pain scores and opioid prescribing. RESULTS: A total of 20,085 hospitalizations were included. Among these hospitalizations, patients had a mean age of 58 years, and a Charlson comorbidity score of 2.97, while 50% and 56% were female and White, respectively. Overall, 52% were admitted by a clinician randomized to the intervention arm. NSAIDs were ordered in 2267 (22%) interventions and 2093 (22%) control admissions (p = .10). Similarly, there were no statistical differences in NSAID administration, pain scores, or opioid prescribing. Average pain scores (0-5 scale) were 3.36 in the control group and 3.39 in the intervention group (p = .46). There were no differences in clinical harms. CONCLUSIONS AND RELEVANCE: Requiring an active decision to order an NSAID at admission had no demonstrable impact on NSAID ordering. Multicomponent interventions, perhaps with stronger decision support, may be necessary to encourage NSAID ordering.

Experiences with targeting inpatient advance care planning for emergency general surgery patients: A resident-led quality improvement project.

BACKGROUND: For patients who may permanently or temporarily lose their ability to communicate preferences, advance care planning is a critical mechanism to guide medical decision-making but is currently underused among surgical patients. METHODS: A resident-led quality improvement project, including education and performance measurement, was conducted on an emergency general surgery service to increase the completion of inpatient advance care planning notes using a specialized template in the electronic health record. Advance care planning documentation was defined as either preadmission advance care planning documentation (eg, advance directive) or inpatient advance care planning (use of the electronic health record template). Data from patients admitted to the emergency general surgery service for 12+ hours were analyzed, and baseline data (July 2020 to June 2021) were compared with data from the intervention period (July 2021 to June 2022). The chart review evaluated the content of the inpatient advance care planning documentation from the intervention period. RESULTS: The frequency of inpatient advance care planning documentation increased (9.3%, n = 56 to 16.6%, n = 92, P < .001) with a greater contribution of inpatient advance care planning notes by the surgery team (16.7% to 55.4%) in the intervention period. Content analysis indicated that 79.0% of inpatient advance care planning notes listed preferences for life-sustaining therapy, 78.3% listed surrogacy, 57.3% listed overall health goals, and 50.3% listed treatment goals specific to the surgical encounter. CONCLUSION: Although a resident-led quality improvement project contributed to greater adoption of standardized inpatient advance care planning documentation on an emergency general surgery service, progress was slow, and integration into standard work was not achieved. Future efforts are needed to better understand the integration of essential advance care planning elements into workflows and to establish inclusive educational programming to prepare all team members for conducting and documenting advance care planning conversations.

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.

Discharge Opioid Over- and Underprescription to Patients after General Surgery: A Retrospective Cohort Study.

BACKGROUND: Although postoperative opioid overprescription has been well studied, little is known about opioid underprescription. This study aims to determine the extent of improper discharge opioid prescription in patients undergoing general surgery procedures. STUDY DESIGN: This retrospective cohort study investigated opioid-naïve adult patients who underwent inpatient general surgery at an academic medical center between June 2012 and December 2019. The primary outcome was the difference between individual patient's inpatient daily oral morphine milligram equivalent (MME) 24 hours before discharge and patient's prescribed daily MME at discharge. The data were analyzed using chi-square, Mann-Whitney, Wilcoxon, and Kruskal-Wallis tests and multivariable logistic regression. RESULTS: Among 5,531 patients, 58.1% had opioid overprescription, and 22.4% had opioid underprescription. Median prescribed daily MME was 311% of median inpatient daily MME in overprescribed patients and 56.3% of median inpatient daily MME in underprescribed patients. About half (52.3%) of patients who consumed no opioids on the day before discharge were opioid overprescribed, and 69.9% of patients who required inpatient daily opioid of >100 MME were opioid underprescribed. Opioid-underprescribed patients had an increased opioid refill rate 1 to 30 days after discharge, whereas opioid-overprescribed patients had an increased refill rate 31 to 60 days after discharge. From 2017 to 2019, the percentage of overprescribed patients decreased by 35.8%, but the percentage of underprescribed patients increased by 42.4%. CONCLUSIONS: Although avoiding postoperative opioid overprescription remains imperative, preventing postoperative opioid underprescription is also essential. We recommend using a patient-centered approach to match the daily dose of opioid prescription with each patient's inpatient daily opioid consumption.

Prospective validation and application of the Trauma-Specific Frailty Index: Results of an American Association for the Surgery of Trauma multi-institutional observational trial.

BACKGROUND: The frailty index is a known predictor of adverse outcomes in geriatric patients. Trauma-Specific Frailty Index (TSFI) was created and validated at a single center to accurately identify frailty and reliably predict worse outcomes among geriatric trauma patients. This study aims to prospectively validate the TSFI in a multi-institutional cohort of geriatric trauma patients. METHODS: This is a prospective, observational, multi-institutional trial across 17 American College of Surgeons Levels I, II, and III trauma centers. All geriatric trauma patients (65 years and older) presenting during a 3-year period were included. Frailty status was measured within 24 hours of admission using the TSFI (15 variables), and patients were stratified into nonfrail (TSFI, ≤0.12), prefrail (TSFI, 0.13-0.25), and frail (TSFI, >0.25) groups. Outcome measures included index admission mortality, discharge to rehabilitation centers or skilled nursing facilities (rehab/SNFs), and 3-month postdischarge readmissions, fall recurrences, complications, and mortality among survivors of index admission. RESULTS: A total of 1,321 geriatric trauma patients were identified and enrolled for validation of TSFI (nonfrail, 435 [33%]; prefrail, 392 [30%]; frail, 494 [37%]). The mean ± SD age was 77 ± 8 years; the median (interquartile range) Injury Severity Score was 9 (5-13). Overall, 179 patients (14%) had a major complication, 554 (42%) were discharged to rehab/SNFs, and 63 (5%) died during the index admission. Compared with nonfrail patients, frail patients had significantly higher odds of mortality (adjusted odds ratio [aOR], 1.93; p = 0.018), major complications (aOR, 3.55; p < 0.001), and discharge to rehab/SNFs (aOR, 1.98; p < 0.001). In addition, frailty was significantly associated with higher adjusted odds of mortality, major complications, readmissions, and fall recurrence at 3 months postdischarge ( p < 0.05). CONCLUSION: External applicability of the TSFI (15 variables) was evident at a multicenter cohort of 17 American College of Surgeons trauma centers in geriatric trauma patients. The TSFI emerged as an independent predictor of worse outcomes, both in the short-term and 3-month postdischarge. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

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.

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.

Characteristics and Procedures Among Adults Discharged to Hospice After Gastrointestinal Tract Surgery in California.

Importance: Hospice care is associated with improved quality of life and goal-concordant care. Limited data suggest that provision of hospice services after surgery is suboptimal; however, literature in this domain is in its nascency, leaving gaps in our understanding of patients who enroll in hospice after surgery. Objective: To characterize the transition to hospice after gastrointestinal tract surgery and identify areas that warrant further attention and intervention. Design, Setting, and Participants: This retrospective cohort study included patients discharged to hospice after a surgical hospitalization for a digestive disorder in California-licensed hospitals between January 1, 2015, and December 31, 2019. Data were analyzed from August 1 to November 30, 2021. Exposures: Patient age, race and ethnicity, principal language, payer, and Distressed Community Index (DCI). Main Outcomes and Measures: Admission type and most common diagnoses and procedures for surgical hospitalizations that resulted in discharge to hospice, annual hospitalization trend for 3 years preceding hospice enrollment, and most common diagnoses for patients who were readmitted after hospice enrollment were summarized. Age, race and ethnicity, principal language, payer, and DCI were compared between patients who were readmitted after hospice enrollment and those who were not. Results: Of 2688 patients with surgical hospitalizations resulting in discharge to hospice (mean [SD] age, 73.2 [14.7] years; 1459 women [54.3%]), 2389 (88.9%) had urgent or emergent discharges. The most common diagnoses were cancer (primary and metastatic; 1541 [57.3%]) and bowel obstruction (563 [20.9%]). The most common procedures were bowel resection, fecal diversion, inferior vena cava filter, gastric bypass, and paracentesis. In the 3 years preceding hospice enrollment, this cohort had a mean (SD) of 2.21 (2.77) hospitalizations per patient (1537 of 5953 surgical [25.8%]). Of these, 3594 of 5953 total (60.4%) and 840 of 1537 surgical (54.7%) hospitalizations were within 1 year of hospice enrollment. Three hundred and sixty-eight patients (13.7%) were readmitted after hospice enrollment, with infection being the most common readmission diagnosis. Readmitted patients were more likely to be younger (mean [SD] age, 69.7 [16.4] vs 73.8 [14.3] years; P < .001), to speak a principal language other than English (62 of 368 [16.8%] vs 292 of 2320 [12.6%]; P = .02), to be insured through Medicaid (70 of 368 [19.0%] vs 223 of 2320 [9.6%]; P < .001), and to be from a community with higher DCI (198 of 360 [55.0%] vs 1117 of 2269 [49.2%]; P = .04) and were less likely to be White (195 of 368 [53.0%] vs 1479 of 2320 [63.8%]; P < .001). Conclusions and Relevance: These findings suggest multiple opportunities for advance care planning in this surgical cohort, with a particular focus on emergent care. Further study is needed to understand the reasons for rehospitalization after hospice discharge and identify ways to improve communication and decision-making support for patients who choose to enroll in hospice care. Given the frequent antecedent interactions with the health care system among this population, longitudinal and tailored approaches may be beneficial to promote equitable end-of-life care; however, further research is needed to clarify barriers and understand differing patient needs.

Association of Race/Ethnicity With Substance Use Testing After Trauma: A Cross-Sectional Study.

INTRODUCTION: Race/ethnicity has been strongly associated with substance use testing but little is known about this association in injured patients. We sought to identify trends and associations between race/ethnicity and urine toxicology (UTox) or Blood Alcohol Concentration (BAC) testing in a diverse population after trauma. MATERIALS AND METHODS: We conducted a retrospective cross-sectional study of adult trauma patients admitted to a single Level-1 trauma center from 2012 to 2019. The prevalence of substance use testing was evaluated over time and analyzed using a multivariable logistic regression, with a subgroup analysis to evaluate the interaction of English language proficiency with race/ethnicity in the association of substance use testing. RESULTS: A total of 15,556 patients (40% White, 13% Black, 24% Latinx, 20% Asian, and 3% Native or Unknown) were included. BAC testing was done in 63.2% of all patients and UTox testing was done in 39.2%. The prevalence of substance use testing increased over time across all racial/ethnic groups. After adjustment, Latinx patients had higher odds of receiving a BAC test and Black patients had higher odds of receiving a UTox test (P < 0.001 and P < 0.001, respectively) compared to White patients. Asian patients had decreased odds of undergoing a UTox or BAC test compared to White patients (P < 0.001 and P < 0.001, respectively). Patients with English proficiency had higher odds of undergoing substance use testing compared to those with limited English proficiency (P < 0.001). CONCLUSIONS: Despite an increase in substance use testing over time, inequitable testing remained among racial/ethnic minorities. More work is needed to combat racial/ethnic disparities in substance use testing.

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.

Lessons learned from academic medical centers' response to the COVID-19 pandemic in partnership with the Navajo Nation.

INTRODUCTION: Structural forces that drive health inequalities are magnified in crises. This was especially true during the COVID-19 pandemic, and minority communities were particularly affected. The University of California San Francisco and Health, Equity, Action, Leadership Initiative jointly sent volunteer teams of nurses and doctors to work in the Navajo Nation during the COVID-19 pandemic. This presented an opportunity to explore how academic medical centers (AMCs) could effectively partner with vulnerable communities to provide support during healthcare crises. Therefore, the aims of this study were to describe volunteers' perspectives of academic-community partnerships by exploring their personal, professional and societal insights and lessons learned based on their time in the Navajo Nation during COVID-19. METHODS: We recruited key informants using purposeful sampling of physicians and nurses who volunteered to go to the Navajo Nation during the spring 2020 COVID-19 surge, as well as hospital administrators and leaders involved in organizing the COVID-19 efforts. We used in-depth qualitative interviews to explore key informants' experiences pre-departure, during their stay, and after their return, as well as perspectives of the partnership between an AMC and the Navajo Nation. We used thematic analysis to systematically identify, analyze and report patterns (themes) within the data. RESULTS: In total, 37 clinicians and hospital administrators were interviewed including 14 physicians, 16 nurses, and 7 health system leaders. Overall, we found 4 main themes each with several subthemes that defined the partnership between the AMC and the Navajo Nation. Mission and values incorporated civic duty, community engagement, leadership commitment and employee dedication. Solidarity, trust and humility encompassed pre-existing trust, workforce sustainability, humility and erasure of 'savior narratives.' Coordination included logistical coordination, flexibility, selectivity of who and what traveled to the response and coordination around media response. Workforce preparation and support encompassed understanding of historical context and providing healthcare in limited settings, dangers of inadequate preparation and the need for emotional support. CONCLUSION: This study provides guidelines which AMCs might use to develop and improve partnerships they have or would like to develop with vulnerable communities. These guidelines may even be broadly applied to partnerships outside of a pandemic response. Importantly, such partnerships need to be built with trust and with an eye towards sustainability and long-term relationships as opposed to 'medical missions'.