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.

Early Opioid Use and Postoperative Delirium Following Open Abdominal Aortic Aneurysm Repair.

BACKGROUND: Postoperative delirium is a common complication following open abdominal aortic aneurysm repair (OAR). Opioids have been found to contribute to delirium, especially at higher doses. This study assessed the impact of early postoperative opioid analgesia on postoperative delirium incidence and time to onset. We hypothesized that higher early postoperative opioid utilization would be associated with increased postoperative delirium incidence. METHODS: This was a retrospective analysis of OAR cases at a single quaternary care center from years 2012-2020. The primary exposure was oral morphine equivalents use (OME), calculated for postoperative days 1-7. A cut point analysis using a receiver operator curve for postoperative delirium determined the threshold for high OME (OME>37 mg). The primary outcome was postoperative delirium incidence identified via chart review. Multivariable logistic regression was performed for postoperative delirium and adjusted for covariates meeting P < 0.1 on bivariate analysis. RESULTS: Among 194 OAR cases, 67 (35%) developed postoperative delirium with median time to onset of 3 days (IQR = 2-6). Patients with postoperative delirium were older (74 years vs. 69 years), more frequently presented with symptomatic AAA (47% vs. 27%) and had a higher proportion of comorbidities (all P < 0.05). Cases with high OME utilization on postoperative day 1 (55%) were younger (69 vs. 73 years), less frequently had an epidural (46% vs. 77%), and more frequently developed delirium (42% vs. 25%, all P < 0.05). Epidural use was associated with a significant decrease in OME utilization on postoperative day 1 (33 vs. 83, P < 0.01). Postoperative delirium onset was later in those with high OME use (4 vs. 2 days, P = 0.04). On multivariable analysis, high OME remained associated with postoperative delirium (Table II). CONCLUSIONS: High opioid utilization on postoperative day 1 is associated with increased postoperative delirium and epidural along with acetaminophen use reduced opioid utilization. Future study should examine the impact of opioid reduction strategies on outcomes after major vascular surgery.

Use of Muscle Relaxants After Surgery in Traditional Medicare Part D Enrollees.

BACKGROUND: Surgeons have come under increased scrutiny for postoperative pain management, particularly for opioid prescribing. To decrease opioid use but still provide pain control, nonopioid medications such as muscle relaxants are being used, which can be harmful in older adults. However, the prevalence of muscle relaxant prescribing, trends in use over time, and risk of prolonged use are unknown. STUDY DESIGN: Using a 20% representative Medicare sample, we conducted a retrospective analysis of muscle relaxant prescribing to patients ≥ 65 years of age. We merged patient data from Medicare Carrier, MedPAR, and Outpatient Files with Medicare Part D for the years 2013-2018. A total of 14 surgical procedures were included to represent a wide range of anatomic regions and specialties. RESULTS: The study cohort included 543,929 patients. Of the cohort, 8111 (1.5%) received a new muscle relaxant prescription at discharge. Spine procedures accounted for 12% of all procedures but 56% of postoperative prescribing. Overall, the rate of prescribing increased over the time period (1.4-2.0%, p < 0.001), with increases in prescribing primarily in the spine (7-9.6%, p < 0.0001) and orthopedic procedure groups (0.9-1.4%, p < 0.0001). Of patients discharged with a new muscle relaxant prescription, 10.7% had prolonged use. CONCLUSIONS: The use of muscle relaxants in the postoperative period for older adults is low, but increasing over time, especially in ortho and spine procedures. While pain control after surgery is crucial, surgeons should carefully consider the risks of muscle relaxant use, especially for older adults who are at higher risk for medication-related problems.

Barriers and facilitators to screening for intimate partner violence at a level 1 trauma center.

BACKGROUND: Intimate partner violence (IPV) is a significant public health problem that is associated with substantial health sequelae, including traumatic injury. Surgical professional societies recommend universal intimate partner violence screening in patients presenting after trauma, but this recommendation is not uniformly implemented. We designed and implemented a quality improvement project at our institution in July 2020 to enhance intimate partner violence screening. Although screening rates improved, they remained suboptimal. Therefore, we sought to examine barriers and facilitators to intimate partner violence screening from trauma clinicians' perspectives. STUDY DESIGN: We conducted a qualitative study using in-depth, semistructured interviews to understand the perspectives and experiences of trauma clinicians conducting intimate partner violence screening. A constructivist paradigm informed our study whereby our data collection approaches aimed to understand intimate partner violence screening from the perspectives of those tasked with implementing screening within real-world clinical settings. We used thematic analysis to analyze our data and generate themes related to barriers and facilitators to screening. RESULTS: We conducted interviews with 12 resident physicians and 2 advance practice providers. We identified 6 themes, 3 reflecting facilitator themes as (1) standardized education and workflow, (2) benefits of interdisciplinary teamwork, and (3) context of screening, and 3 reflecting barrier themes as (1) lack of time, (2) language misinterpretation, and (3) perceived inappropriateness of universal screening. CONCLUSION: Trauma clinicians described multiple facilitators and barriers to screening for intimate partner violence following traumatic injury, some of which were unique to the trauma setting. Projects seeking to achieve universal screening following traumatic injury may benefit from accounting for these factors when designing interventions.

Music-Based Interventions for Symptom Management in Critically Ill, Mechanically Ventilated Adults: A Scoping Review of the Literature.

Background: Patients in intensive care units experience high symptom burden during mechanical ventilation (MV). Pharmacologic symptom management is associated with side effects and increased morbidity. Music-based interventions (MBIs) have been associated with reductions in both anxiety in MV adults and pain for critically ill adults, yet their use for the management of other burdensome symptoms has not been evaluated. The purpose of this scoping review is to map the state of evidence for the use of prerecorded music listening MBIs for symptom management in MV adults. Methods: A systematic search of the literature was conducted across four electronic databases (PubMed, EMBASE, CINAHL, and Web of Science) for experimental designed studies that measured the efficacy of MBIs for the management of physical and psychological symptoms including anxiety, sedation/agitation, dyspnea, distress, delirium, sleep, stress, fear, loneliness, or depression in critically ill, MV adults between January 1, 1998, and April 18, 2023. Results: A total of 643 abstracts and 29 clinical trials were included. Overall, the risk of bias, assessed using the Evidence Project tool, was moderate. MBIs were mostly delivered with headphones using music selected either by investigators or from a limited selection. MBIs were associated with reduced pain, agitation, dyspnea, distress and anxiety, and improved tolerance of MV and sedative weaning. Outcomes of delirium were mixed. No studies explored sleep disturbances, fear, or loneliness. Conclusions: Use of MBIs improved symptom experience for critically ill adults during MV. Future studies employing unrestricted patient-preferred music selections and exploring outcomes of sleep quality, psychological distress, and delirium are needed in this highly symptomatic patient population.

Impact of hospitalizations on problematic medication use among community dwelling persons with dementia.

BACKGROUND: Hospitalizations are frequently disruptive for persons with dementia (PWD) in part due to the use of potentially problematic medications for complications such as delirium, pain, and insomnia. We sought to determine the impact of hospitalizations on problematic medication prescribing in the months following hospitalization. METHODS: We included community-dwelling PWD in the Health and Retirement Study aged ≥66 with a hospitalization from 2008-2018. We characterized problematic medications as medications that negatively affect cognition (strongly anticholinergics/sedative-hypnotics), medications from 2019 Beers criteria, and medications from STOPP-V2. To capture durable changes, we compared problematic medications 4 weeks pre-hospitalization (baseline) to 4 months post-hospitalization period. We used a generalized linear mixed model with Poisson distribution adjusting for age, sex, comorbidity count, pre-hospital chronic medications, and timepoint. RESULTS: Among 1,475 PWD, 504 had a qualifying hospitalization (median age 84 (IQR=79-90), 66% female, 17% Black). There was a small increase in problematic medications from the baseline to post-hospitalization timepoint that did not reach statistical significance (adjusted mean 1.28 vs. 1.40, difference 0.12 (95% CI -0.03, 0.26), p=0.12). Results were consistent across medication domains and certain subgroups. In one pre-specified subgroup, individuals on <5 pre-hospital chronic medications showed a greater increase in post-hospital problematic medications compared to those on ≥5 medications (p=0.04 for interaction, mean increase from baseline to post-hospitalization of 0.25 for those with <5 medications (95% CI 0.05, 0.44) vs. 0.06 (95% CI -0.12, 0.25) for those with ≥5 medications). CONCLUSIONS: Hospitalizations had a small, non-statistically significant effect on longer-term problematic medication use among PWD.

Geriatric trauma triage: optimizing systems for older adults-a publication of the American Association for the Surgery of Trauma Geriatric Trauma Committee.

Background: Geriatric trauma patients are an increasing population of the United States (US), sustaining a high incidence of falls, and suffer greater morbidity and mortality to their younger counterparts. Significant variation and challenges exist to optimize outcomes for this cohort, while being mindful of available resources. This manuscript provides concise summary of locoregional and national practices, including relevant updates in the triage of geriatric trauma in an effort to synthesize the results and provide guidance for further investigation. Methods: We conducted a review of geriatric triage in the United States (US) at multiple stages in the care of the older patient, evaluating existing literature and guidelines. Opportunities for improvement or standardization were identified. Results: Opportunities for improved geriatric trauma triage exist in the pre-hospital setting, in the trauma bay, and continue after admission. They may include physiologic criteria, biochemical markers, radiologic criteria and even age. Recent Trauma Quality Improvement Program (TQIP) Best Practices Guidelines for Geriatric Trauma Management published in 2024 support these findings. Conclusion: Trauma systems must adjust to provide optimal care for older adults. Further investigation is required to provide pertinent guidance.

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.

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.