Worldwide, the use of prescription opioid analgesics more than doubled between 2001 and 2013, with several countries, including the USA, Canada, and Australia, experiencing epidemics of opioid misuse ...and abuse over this period. In this context, excessive prescribing of opioids for pain treatment after surgery has been recognised as an important concern for public health and a potential contributor to patterns of opioid misuse and related harm. In the second paper in this Series we review the evolution of prescription opioid use for pain treatment after surgery in the USA, Canada, and other countries. We summarise evidence on the extent of opioid overprescribing after surgery and its potential association with subsequent opioid misuse, diversion, and the development of opioid use disorder. We discuss evidence on patient, physician, and system-level predictors of excessive prescribing after surgery, and summarise recent work on clinical and policy efforts to reduce such prescribing while ensuring adequate pain control.
Comparative effectiveness research aims to understand the benefits and harms of different treatments to assist patients and clinicians in making better decisions. Within anesthesia practice, ...comparing outcomes of spinal versus general anesthesia in older adults represents an important focus of comparative effectiveness research. The authors review methodologic issues involved in studying this topic and summarize available evidence from randomized studies in patients undergoing hip fracture surgery, elective knee and hip arthroplasty, and vascular surgery. Across contexts, randomized trials show that spinal and general anesthesia are likely to be equivalent in terms of safety and acceptability for most patients without contraindications. Choices between spinal and general anesthesia represent "preference-sensitive" care in which decisions should be guided by patients' preferences and values, informed by best available evidence.
Hip fracture is a common, morbid, and costly event among older adults. Data are inconclusive as to whether epidural or spinal (regional) anesthesia improves outcomes after hip fracture surgery.
The ...authors examined a retrospective cohort of patients undergoing surgery for hip fracture in 126 hospitals in New York in 2007 and 2008. They tested the association of a record indicating receipt of regional versus general anesthesia with a primary outcome of inpatient mortality and with secondary outcomes of pulmonary and cardiovascular complications using hospital fixed-effects logistic regressions. Subgroup analyses tested the association of anesthesia type and outcomes according to fracture anatomy.
Of 18,158 patients, 5,254 (29%) received regional anesthesia. In-hospital mortality occurred in 435 (2.4%). Unadjusted rates of mortality and cardiovascular complications did not differ by anesthesia type. Patients receiving regional anesthesia experienced fewer pulmonary complications (359 6.8% vs. 1,040 8.1%, P < 0.005). Regional anesthesia was associated with a lower adjusted odds of mortality (odds ratio: 0.710, 95% CI 0.541, 0.932, P = 0.014) and pulmonary complications (odds ratio: 0.752, 95% CI 0.637, 0.887, P < 0.0001) relative to general anesthesia. In subgroup analyses, regional anesthesia was associated with improved survival and fewer pulmonary complications among patients with intertrochanteric fractures but not among patients with femoral neck fractures.
Regional anesthesia is associated with a lower odds of inpatient mortality and pulmonary complications among all hip fracture patients compared with general anesthesia; this finding may be driven by a trend toward improved outcomes with regional anesthesia among patients with intertrochanteric fractures.
Adverse events related to opioid analgesics are common.
1
,
2
Although opioids represent a component of pain treatment regimens following low-risk surgery,
3
,
4
few data exist regarding patterns of ...postoperative opioid prescribing over time. We assessed trends in the amount of hydrocodone/acetaminophen and oxycodone/acetaminophen prescribed, 2 opioids commonly used for postoperative pain management.
Day People, Night People: Being Chuck Bosk Neuman, Mark D.
Sociological forum (Randolph, N.J.),
December 2023, 2023-12-00, 20231201, Letnik:
38, Številka:
4
Journal Article
Recenzirano
Through Forgive and Remember, Charles Bosk made the world of surgical complications and closed‐door morbidity and morbidity conferences visible to a wide audience, helping to remake medical errors ...from a private into a public issue. In so doing, his work helped to motivate a generation to advocate for higher‐quality, safer health care. But Bosk's introduction to The Price of Perfection: The Cost of Error also highlights how the managerial tools that advocates applied to these problems—“checklists, safety huddles, briefings and debriefings”—invariably missed deeper lessons that Bosk took from his work. Here, a former student and collaborator of Bosk's reflects on Bosk's legacy in relation to the patient safety movement he helped create and the lasting impact of his work on the culture of medical practice.
Background Frailty has emerged as an important predictor of operative risk among elderly surgical patients. However, the complexity of prospective frailty scores has limited their widespread use. Our ...goal was to develop two frailty-based surgical risk models using only routine preoperative data. Our hypothesis was that these models could easily integrate into an electronic medical record to predict 30-day morbidity and mortality. Study Design American College of Surgeons NSQIP Participant Use Data Files from 2005 to 2010 were reviewed, and patients 65 years and older who underwent elective lower gastrointestinal surgery were identified. Two multivariate logistic regression models were constructed and internally cross-validated. The first included simple functional data, a comorbidity index based on the Charlson Comorbidity Index, demographics, BMI, and laboratory data (ie, albumin <3.4 g/dL, hematocrit <35%, and creatinine >2 mg/dL). The second model contained only parameters that can directly autopopulate from an electronic medical record (ie, demographics, laboratory data, BMI, and American Society of Anesthesiologists score). To assess diagnostic accuracy, receiver operating characteristic curves were constructed. Results There were 76,106 patients who met criteria for inclusion. Thirty-day mortality was seen in 2,853 patients or 3.7% of the study population and 18,436 patients (24.2%) experienced a major complication. The c-statistic of the first expanded model was 0.813 for mortality and 0.629 for morbidity. The second simplified model had a c-statistic of 0.795 for mortality and 0.621 for morbidity. Both models were well calibrated per the Hosmer-Lemeshow test. Conclusions Our work demonstrates that routine preoperative data can approximate frailty and predict geriatric-specific surgical risk. The models' predicative powers were comparable with that of established prospective frailty scores. Our calculator could be used as a low-cost simple screen for high-risk individuals who might require additional evaluation or specialized services.
BACKGROUND:While persistent opioid use after surgery has been the subject of a large number of studies, it is unknown how much variability in the definition of persistent use impacts the reported ...incidence across studies. The objective was to evaluate the incidence of persistent use estimated with different definitions using a single cohort of postoperative patients, as well as the ability of each definition to identify patients with opioid-related adverse events.
METHODS:The literature was reviewed to identify observational studies that evaluated persistent opioid use among opioid-naive patients requiring surgery, and any definitions of persistent opioid use were extracted. Next, the authors performed a population-based cohort study of opioid-naive adults undergoing 1 of 18 surgical procedures from 2013 to 2017 in Ontario, Canada. The primary outcome was the incidence of persistent opioid use, defined by each extracted definition of persistent opioid use. The authors also assessed the sensitivity and specificity of each definition to identify patients with an opioid-related adverse event in the year after surgery.
RESULTS:Twenty-nine different definitions of persistent opioid use were identified from 39 studies. Applying the different definitions to a cohort of 162,830 opioid-naive surgical patients, the incidence of persistent opioid use in the year after surgery ranged from 0.01% (n = 10) to 14.7% (n = 23,442), with a median of 0.7% (n = 1,061). Opioid-related overdose or diagnosis associated with opioid use disorder in the year of follow-up occurred in 164 patients (1 per 1,000 operations). The sensitivity of each definition to identify patients with the composite measure of opioid use disorder or opioid-related toxicity ranged from 0.01 to 0.36, while specificity ranged from 0.86 to 1.00.
CONCLUSIONS:The incidence of persistent opioid use reported after surgery varies more than 100-fold depending on the definition used. Definitions varied markedly in their sensitivity for identifying adverse opioid-related event, with low sensitivity overall across measures.
PDF
