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Background: Studies have demonstrated beneficial outcomes associated with timely surgical treatment of hip fracture. Subsequently, practice recommendations changed with 24–48 h as the recommended time for surgery from admission; however, recent data on timing of hip fracture surgery and how this impacts outcomes are lacking. Methods: This retrospective cohort study included patients who had a primary diagnosis of hip fracture and underwent a subsequent surgical repair within 3 days of admission (Premier Healthcare claims 2006–2021 data). The primary exposure of interest was time from hip fracture diagnosis to surgery (categorized as 0–1 day, 2 days, and 3 days). Outcomes included any major complication, mortality, and intensive care unit (ICU) admission. Mixed‐effects models measured the association between timing of surgery and outcomes. We report odds ratios (OR) and 95% confidence intervals. Results: Among 501,267 surgical hip fracture patients, 26.0%, 56.0%, and 18.1% of patients received surgery on days 0–1, 2, and 3, respectively. The median ages were 83, 84, and 84 years old, and there were 73.3%, 72.2%, and 68.8% female in each group respectively. Compared with repair on day 0–1, hip fracture surgical treatment on day 2 or day 3 was associated with increased odds of major complications (OR 1.06, 95% CI 1.03–1.08 and OR 1.17, 95% CI 1.13–1.2), mortality (OR 1.08, 95% CI 1.02–1.14 and OR 1.2, 95% CI 1.12–1.28), and ICU admission (OR 1.06, 95% CI 1.04–1.09 and OR 1.36, 95% CI 1.32–1.4) after adjusting major comorbidities; all p < 0.001. Conclusion: Despite the publication of society guidelines in 2015, most fracture patients still received surgery on day 2 or day 3 of admission and were associated with worse outcomes. Balancing optimization of clinical factors with timing of surgery can be challenging, and further research is needed. Nonetheless, our findings reiterate the importance of timely surgical intervention. [ABSTRACT FROM AUTHOR]

In particular, low-effort, high-impact interventions that minimize healthcare worker burden, including electronic health record (EHR) alert fatigue, are needed.[3] METHODS This quality improvement initiative was set in 10 hospitals within a single, large, urban safety net system by the System High Value Care Council, an interdisciplinary, representative group consisting of clinicians and leadership of the hospitals and system. Low-value care remains a pervasive problem in the US healthcare system.[1] Growing evidence demonstrates how low-value care can translate to patient harm.[2] However, reducing low-value care continues to challenge organizations. [Extracted from the article]

For example, one spine article recommended reporting the FI in conjunction with the p value "to indicate the strength of statistical findings" [[11]]; this language of "strength" may imply to the clinician that the FI reflects the effect size. Myth 4: The FI Can Only Be Used to Evaluate Randomized Trials The traditional FI proposed by Walsh et al. [[30]] was specifically intended for two-arm RCTs. Myths and Misperceptions Myth 1: There Is a Consensus on What FI Value Is Considered "Fragile" There are no clear thresholds for interpreting the FI and what would be considered "fragile." Additionally, the low FI in smaller trials can increase clinicians' awareness of the limitations of smaller trials, which tend to have larger treatment effects than larger trials [[28]]. [Extracted from the article]

Summary Background Methods Results Discussion Demand for total hip and knee arthroplasty procedures continues to rise. Ongoing changes in surgical care and patient populations require continued monitoring of outcome trends. Using nationwide data from the USA, we aimed to describe updated trends in patient and peri‐operative care characteristics as well as complications among total hip and knee arthroplasty recipients.We included patients who underwent elective primary total hip or knee arthroplasty between 2016 and 2021. Trends were reported for a variety of patient and peri‐operative care characteristics as well as complications.We identified significant trends in patient and peri‐operative care characteristics as well as the incidence of complications. While patient median age increased, demographic composition remained consistent over the time period studied. There was a shift towards outpatient total hip and knee arthroplasty procedures, with one in five performed in the outpatient setting in 2021; the median duration of hospital stay decreased by 1 day over the time period for both procedures. Parallel increasing trends of total procedure numbers were found for patients without comorbidities and those with ≥ 3 comorbidities. Postoperative mortality increased significantly over the time period analysed for patients having total hip arthroplasty but not those having total knee arthroplasty (0.08 to 0.15 events per 1000 inpatient days, p = 0.037 and 0.09 to 0.33 events per 1000 inpatient days, p = 0.149, respectively).Compared with previous trend analyses of patients having total hip or knee arthroplasty, the present study shows: an increasing rate of outpatient surgeries; increasing numbers of arthroplasty procedures in high comorbidity burden groups; and an increase incidence of certain serious postoperative complications. [ABSTRACT FROM AUTHOR]

A recent study in the British Journal of Anaesthesia examining trajectories of anxiety and depressive symptoms after diverse surgical procedures sheds light on an often overlooked, yet important, factor in postoperative recovery—mental health. The authors applied ecological momentary assessment to collect high-resolution data to identify and characterise a subgroup of vulnerable patients who experience worsening of psychological symptoms after surgery. The study prompts not only consideration of psychological factors, but also how best to leverage ecological momentary assessment to understand the perioperative experience. [ABSTRACT FROM AUTHOR]

Background: With increasing use of tranexamic acid in total hip and knee arthroplasties, safety concerns remain. Using national claims data, this study examined tranexamic acid use in patients with preexisting comorbidities. The hypothesis was that tranexamic acid use is not associated with increased complication risk in hip and knee arthroplasty patients with comorbidities.Methods: Among 765,011 total hip/knee arthroplasties (2013 to 2016, Premier Healthcare claims), tranexamic acid use was assessed in three high-risk groups: group I with patients with a history of venous thromboembolism, myocardial infarction, seizures, or ischemic stroke/transient ischemic attack (n = 27,890); group II with renal disease (n = 44,608); and group III with atrial fibrillation (n = 45,952). The coprimary outcomes were blood transfusion and new-onset "composite complications" (venous thromboembolism, myocardial infarction, seizures, and ischemic stroke/transient ischemic attack). Associations between tranexamic acid use and outcomes were measured separately by high-risk group. The odds ratios and Bonferroni-adjusted 99.9% CIs are reported.Results: Overall, 404,974 patients (52.9%) received tranexamic acid, with similar frequencies across high-risk groups I (13,004 of 27,890 [46.6%]), II (22,424 of 44,608 [50.3%]), and III (22,379 of 45,952 [48.7%]). Tranexamic acid use was associated with decreased odds of blood transfusion in high-risk groups I (721 of 13,004 [5.5%] vs. 2,293 of 14,886 [15.4%]; odds ratio, 0.307; 99.9% CI, 0.258 to 0.366), group II (2,045 of 22,424 [9.1%] vs. 5,159 of 22,184 [23.3%]; odds ratio, 0.315; 99.9% CI, 0.263 to 0.378), and group III (1,325 of 22,379 [5.9%] vs. 3,773 of 23,573 [16.0%]; odds ratio, 0.321; 99.9% CI, 0.266 to 0.389); all adjusted comparisons P < 0.001. No increased odds of composite complications were observed in high-risk group I (129 of 13,004 [1.0%] vs. 239 of 14,886 [1.6%]; odds ratio, 0.89, 99.9% CI, 0.49 to 1.59), group II (238 of 22,424 [1.1%] vs. 369 of 22,184 [1.7%]; odds ratio, 0.98; 99.9% CI, 0.58 to 1.67), and group III (187 of 22,379 [0.8%] vs. 290 of 23,573 [1.2%]; odds ratio, 0.93; 99.9% CI, 0.54 to 1.61); all adjusted comparisons P > 0.999.Conclusions: Although effective in reducing blood transfusions, tranexamic acid is not associated with increased complications, irrespective of patient high-risk status at baseline.Editor’s Perspective: [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic has impacted healthcare in various vulnerable patient subpopulations. However, data are lacking on the impact of COVID-19 on hip fractures, seen mainly in older patients. Using national claims data, we aimed to describe the epidemiology during the first COVID-19 wave in the USA.Methods: We compared patients admitted for hip fractures during March and April of 2020 with those admitted in 2019 in terms of patient and healthcare characteristics, COVID-19 diagnosis, and outcomes. An additional comparison was made between COVID-19-positive and -negative patients. Outcomes included length of hospital stay (LOS), admission to an ICU, ICU LOS, use of mechanical ventilation, 30-day readmission, discharge disposition, and a composite variable of postoperative complications.Results: Overall, 16 068 hip fractures were observed in 2019 compared with 7498 in 2020. Patients with hip fractures in 2020 (compared with 2019) experienced earlier hospital discharge and were less likely to be admitted to ICU, but more likely to be admitted to home. Amongst 83 patients with hip fractures with concomitant COVID-19 diagnosis, we specifically observed more non-surgical treatments, almost doubled LOS, a more than 10-fold increased mortality rate, and higher complication rates compared with COVID-19-negative patients.Conclusions: The COVID-19 pandemic significantly impacted not only volume of hip fractures, but also patterns in care and outcomes. These results may inform policymakers in future outbreaks and how this may affect vulnerable patient populations, such as those experiencing a hip fracture. [ABSTRACT FROM AUTHOR]

Purpose: Several factors lead to medication non-adherence after hospital discharge. Hospitals and pharmacies have implemented bedside medication delivery (BMD) programs for patients, in an attempt to reduce barriers and improve medication adherence. Here, we provide a critical review of the literature on these programs.Data Sources: We conducted a literature search on BMD programs in PubMed, Google Scholar, Scopus and a general Google search using these keywords: 'medication delivery bedside', 'discharge medication delivery', 'meds to bedside' and 'meds to beds'.Study Selection: We identified 10 reports and include data from all reports.Data Extraction: Data on study characteristics and settings were extracted along with four outcomes: medication error, patient satisfaction, 30-day hospital readmission and visits to the emergency department.Results Of Data Synthesis: Of the 10 reports, only 4 were peer-reviewed publications; others were reported in the lay press. Outcomes were reported in both qualitative and quantitative terms. Less than half of reports provided quantitative data on 30-day readmission and patient satisfaction. Others suggested qualitative improvement in these outcomes but did not provide data or specific details. None reported outcomes of their programs beyond 30 days.Conclusion: We highlight the need for increased use of optimal program design and more rigorous evaluations of the impact of BMD programs. We also provide guidelines on the types of evaluations that are likely needed and encourage improved reporting. [ABSTRACT FROM AUTHOR]

Background: It is currently unknown to what extent routine histological examination of joint arthroplasty specimens occurs across hospitals nationwide. Although this practice is neither supported nor refuted by the available evidence, given the increasing demand for joint arthroplasties, it is crucial to study overall utilization as well as its main drivers.Questions/purposes: Using national data on joint replacements, we aimed to evaluate: (1) What is the current use of routine histological examination of joint arthroplasty specimens? (2) Does the use vary by geographic location and hospital characteristics? (3) Has use changed over time?Methods: From the Premier Healthcare database (2006-2016) we included claims data from 87,667 shoulder (595 hospitals, median age 70 years, 16% nonwhite), 564,577 hip (629 hospitals, median age 65 years, 21% nonwhite), and 1,131,323 (630 hospitals, median age 66 years, 24% nonwhite) knee arthroplasties (all elective). Our study group has extensive experience with this data set, which contains information on 20% to 25% of all US hospitalizations. Included hospitals are mainly concentrated in the South (approximately 40%) with equal distributions among the Northeast, West, and Midwest (approximately 20% each). Moreover, the Premier data set has detailed billing information, which allows for evaluations of real-world clinical practice. There was no missing information on the main variables of interest for this specific study. We assessed frequency of histology examination (defined by Current Procedural Terminology codes) overall as well as by hospital characteristics (urban/rural, bed size, teaching status, arthroplasty volume), geographic region (Northeast, South, Midwest, West), and year. Given the large sample size, instead of p values, standardized differences were applied in assessing group differences where a standardized difference of > 0.1 (or 10%) was assumed to represent a meaningful difference between groups. For significance of trends, p values were applied. Percentages provided represent proportions of individual procedures.Results: In most hospitals, histology testing was either rare (1%-10%, used in 187 of 595, 189 of 629, and 254 of 630 hospitals) or ubiquitous (91%-100%, used in 121 of 595, 220 of 629, and 195 of 630 hospitals) for shoulder, hip, and knee arthroplasties, respectively. Overall, histology testing occurred more often in smaller hospitals (37%-53% compared with 26%-45% in larger hospitals) and those located in the Northeast (59%-68% compared with 22%-44% in other regions) and urban areas (32%-49% compared with 20%-31% in rural areas), all with standardized differences > 10%. Histologic examination is slowly decreasing over time: from 2006 to 2016, it decreased from 34% to 30% for shoulder arthroplasty, from 50% to 45% for THAs, and from 43% to 38% for TKAs (all p < 0.001).Conclusions: Although overall use is decreasing, a substantial number of hospitals still routinely perform histology testing of arthroplasty specimens. Moreover, variation between regions and hospital types suggests that this practice is driven by a variety of factors. This is the first study addressing national utilization, which will be helpful for individual hospitals to assess how they compare with national utilization patterns. Moreover, the findings have clear implications for followup studies, which may be necessary given the exponentially growing demand for arthroplasties.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Introduction: Although obstructive sleep apnea (OSA) is a known risk factor for perioperative complications in various patient cohorts data is lacking for patients undergoing hysterectomies, one of the most frequently performed surgeries among women. Using national data we therefore aimed to assess the risk in this patient group.Materials and Methods: We extracted data on patients who underwent a hysterectomy between 2006 and 2014 from a large nationwide database (n = 459,508). OSA patients (identified by ICD-9 CM codes) were compared to non-OSA patients regarding perioperative outcomes: cardiac, central-nervous, gastrointestinal, genitourinary, renal, respiratory, and thromboembolic complications; as well as opioid prescription, need for blood transfusion, cost of hospitalization, length of stay and ICU admission. Odds ratios (OR) and 95% confidence intervals (CI) are reported.Results: Overall, 2.67% (n = 11,936) of patients were identified as having OSA. Compared to non-OSA patients, OSA was particularly associated with higher odds for renal (OR 1.98; 95% CI 1.70-2.32) and respiratory complications (OR 3.25; 95% CI 2.97-3.56), and ICU admission (OR 2.28; 95% CI 1.77-2.94). Further, while significant, OSA was associated with modestly increased cost of hospitalization (+6.24%; P < 0.0001) and length of stay (+2.58%; P < 0.0001).Conclusions: In patients undergoing hysterectomies, OSA was associated with substantially increased risk of complications and modestly increased resource utilization. Further research is needed to assess currently used perioperative care strategies for OSA patients undergoing hysterectomies, with the goal to improve outcomes. [ABSTRACT FROM AUTHOR]

CORR Insights®: Has the Affordable Care Act Been Associated with Increased Insurance Coverage and Early-stage Diagnoses of Bone and Soft-tissue Sarcomas in Adults? AtaLevel-1, academic trauma center in a Medicaid expansion state, Beck et al. [2]found ThisCORRInsights ® isacommentaryonthe article"Has the Affordable Care Act Been Associated with Increased Insurance CoverageandEarly-stageDiagnosesofBone and Soft-tissue Sarcomas in Adults?" Unauthorized reproduction of this article is prohibited. that despite treating more Medicaid patients post-ACA, they collected less revenue per Medicaid patient postACA. [Extracted from the article]

What We Already Know About This Topic: WHAT THIS MANUSCRIPT TELLS US THAT IS NEW: BACKGROUND:: Although some trials suggest benefits of liposomal bupivacaine, data on real-world use and effectiveness is lacking. This study analyzed the impact of liposomal bupivacaine use (regardless of administration route) on inpatient opioid prescription, resource utilization, and opioid-related complications among patients undergoing total knee arthroplasties with a peripheral nerve block. It was hypothesized that liposomal bupivacaine has limited clinical influence on the studied outcomes.Methods: The study included data on 88,830 total knee arthroplasties performed with a peripheral nerve block (Premier Healthcare Database 2013 to 2016). Multilevel multivariable regressions measured associations between use of liposomal bupivacaine and (1) inpatient opioid prescription (extracted from billing) and (2) length of stay, cost of hospitalization, as well as opioid-related complications. To reflect the difference between statistical and clinical significance, a relative change of -15% in outcomes was assumed to be clinically important.Results: Overall, liposomal bupivacaine was used in 21.2% (n = 18,817) of patients that underwent a total knee arthroplasty with a peripheral nerve block. Liposomal bupivacaine use was not associated with a clinically meaningful reduction in inpatient opioid prescription (group median, 253 mg of oral morphine equivalents, adjusted effect -9.3% CI -11.1%, -7.5%; P < 0.0001) and length of stay (group median, 3 days, adjusted effect -8.8% CI -10.1%, -7.5%; P < 0.0001) with no effect on cost of hospitalization. Most importantly, liposomal bupivacaine use was not associated with decreased odds for opioid-related complications.Conclusions: Liposomal bupivacaine was not associated with a clinically relevant improvement in inpatient opioid prescription, resource utilization, or opioid-related complications in patients who received modern pain management including a peripheral nerve block. [ABSTRACT FROM AUTHOR]

Background: Neuraxial anesthesia is increasingly recommended for hip/knee replacements as some studies show improved outcomes on the individual level. With hospital-level studies lacking, we assessed the relationship between hospital-level neuraxial anesthesia utilization and outcomes.Methods: National data on 808,237 total knee and 371,607 hip replacements were included (Premier Healthcare 2006 to 2014; 550 hospitals). Multivariable associations were measured between hospital-level neuraxial anesthesia volume (subgrouped into quartiles) and outcomes (respiratory/cardiac complications, blood transfusion/intensive care unit need, opioid utilization, and length/cost of hospitalization). Odds ratios (or percent change) and 95% CI are reported. Volume-outcome relationships were additionally assessed by plotting hospital-level neuraxial anesthesia volume against predicted hospital-specific outcomes; trend tests were applied with trendlines' R statistics reported.Results: Annual hospital-specific neuraxial anesthesia volume varied greatly: interquartile range, 3 to 78 for hips and 6 to 163 for knees. Increasing frequency of neuraxial anesthesia was not associated with reliable improvements in any of the study's clinical outcomes. However, significant reductions of up to -14.1% (95% CI, -20.9% to -6.6%) and -15.6% (95% CI, -22.8% to -7.7%) were seen for hospitalization cost in knee and hip replacements, respectively, both in the third quartile of neuraxial volume. This coincided with significant volume effects for hospitalization cost; test for trend P < 0.001 for both procedures, R 0.13 and 0.41 for hip and knee replacements, respectively.Conclusions: Increased hospital-level use of neuraxial anesthesia is associated with lower hospitalization cost for lower joint replacements. However, additional studies are needed to elucidate all drivers of differences found before considering hospital-level neuraxial anesthesia use as a potential marker of quality. [ABSTRACT FROM AUTHOR]

Background: The value of intravenous acetaminophen in postoperative pain management remains debated. The authors tested the hypothesis that intravenous acetaminophen use, in isolation and in comparison to oral, would be associated with decreased opioid utilization (clinically significant reduction defined as 25%) and opioid-related adverse effects in open colectomy patients.Methods: Using national claims data from open colectomy patients (Premier Healthcare Database, Premier Healthcare Solutions, Inc., USA; 2011 to 2016; n = 181,640; 602 hospitals), we separately categorized oral and intravenous acetaminophen use: 1 (1,000 mg) or more than 1 dose on the day of surgery, postoperative day 1, or later. Multilevel models measured associations between intravenous or oral acetaminophen and (1) opioid utilization and (2) opioid-related adverse effects. Percent change and multiplicity-adjusted 99.5% CI are reported.Results: Overall, 25.1% of patients received intravenous acetaminophen, of whom 48.0% (n = 21,878) received 1 dose on the day of surgery. In adjusted analyses, particularly more than 1 dose of intravenous acetaminophen (versus nonuse) on postoperative day 1 was associated with a -12.4% (99.5% CI, -15.2 to -9.4%) change in opioid utilization. In comparison, a stronger reduction was seen in those receiving more than 1 oral acetaminophen dose: -22.6% (99.5% CI, -26.2 to -18.9%). Unadjusted group medians were 550 and 490 oral morphine equivalents, respectively. Intravenous versus oral differences were less pronounced among those receiving more than 1 acetaminophen dose on the day of surgery: -8.0% (99.5% CI, -11.0 to -4.9%) median 499 oral morphine equivalents versus -8.7% (99.5% CI, -14.4 to -2.7%) median 445 oral morphine equivalents, respectively; all statistically significant, but none clinically significant. Comparable outcome patterns existed for opioid-related adverse effects.Conclusions: The demonstrated marginal effects do not support routine use of intravenous acetaminophen given alternative nonopioid analgesic options. [ABSTRACT FROM AUTHOR]

Background: Multimodal analgesia is increasingly considered routine practice in joint arthroplasties, but supportive large-scale data are scarce. The authors aimed to determine how the number and type of analgesic modes is associated with reduced opioid prescription, complications, and resource utilization.Methods: Total hip/knee arthroplasties (N = 512,393 and N = 1,028,069, respectively) from the Premier Perspective database (2006 to 2016) were included. Analgesic modes considered were opioids, peripheral nerve blocks, acetaminophen, steroids, gabapentin/pregabalin, nonsteroidal antiinflammatory drugs, cyclooxygenase-2 inhibitors, or ketamine. Groups were categorized into "opioids only" and 1, 2, or more than 2 additional modes. Multilevel models measured associations between multimodal analgesia and opioid prescription, cost/length of hospitalization, and opioid-related adverse effects. Odds ratios or percent change and 95% CIs are reported.Results: Overall, 85.6% (N = 1,318,165) of patients received multimodal analgesia. In multivariable models, additions of analgesic modes were associated with stepwise positive effects: total hip arthroplasty patients receiving more than 2 modes (compared to "opioids only") experienced 19% fewer respiratory (odds ratio, 0.81; 95% CI, 0.70 to 0.94; unadjusted 1.0% [N = 1,513] vs. 2.0% [N = 1,546]), 26% fewer gastrointestinal (odds ratio, 0.74; 95% CI, 0.65 to 0.84; unadjusted 1.5% [N = 2,234] vs. 2.5% [N = 1,984]) complications, up to a -18.5% decrease in opioid prescription (95% CI, -19.7% to -17.2%; 205 vs. 300 overall median oral morphine equivalents), and a -12.1% decrease (95% CI, -12.8% to -11.5%; 2 vs. 3 median days) in length of stay (all P < 0.05). Total knee arthroplasty analyses showed similar patterns. Nonsteroidal antiinflammatory drugs and cyclooxygenase-2 inhibitors seemed to be the most effective modalities used.Conclusions: While the optimal multimodal regimen is still not known, the authors' findings encourage the combined use of multiple modalities in perioperative analgesic protocols. [ABSTRACT FROM AUTHOR]

The role of anesthesia techniques on perioperative outcomes on a population level has recently gained widespread interest. Although mainly neuraxial vs general anesthesia has been addressed, population-level data on the impact of peripheral nerve blocks (PNBs) are still lacking. Therefore, we investigated the association between PNB use and outcomes using retrospective data on 1,062,152 recipients of hip and knee arthroplasties (total hip arthroplasty [THA]/total knee arthroplasty [TKA]) from the national Premier Perspective database (2006-2013). Multilevel multivariable logistic regression models measured associations between PNB use and outcomes. Complications included cardiac, pulmonary, gastrointestinal and renal complications, cerebrovascular events, infections, wound complications, thromboembolic complications, inpatient falls, and mortality. Resource utilization variables included blood transfusions, intensive care unit admissions, opioid consumption, cost, and length of stay. Overall, 12.5% of patients received a PNB, with an increase over time particularly among TKAs. Peripheral nerve block use was associated with lower odds for most adverse outcomes mainly among patients with THA. Notable beneficial effects were seen for wound complications (odds ratio 0.60 [95% confidence interval, 0.49-0.74]) among THA recipients and pulmonary complications (odds ratio 0.83 [95% confidence interval, 0.72-0.94]) in patients with TKA. Peripheral nerve block use was significantly (P < 0.0001) associated with a -16.2% and -12.7% reduction in opioid consumption for patients with THA and TKA, respectively. In conclusion, our results indicate that PNBs might be associated with superior perioperative population-level outcomes. In light of the inability to establish a causal relationship and the presence of residual confounding, we strongly advocate for further prospective investigation, ideally in multicenter, randomized trials, to establish the potential impact of PNBs on outcomes on a population level. [ABSTRACT FROM AUTHOR]

Background: Differences in health care represent a major health policy issue. Despite increasing evidence on the mediating role of anesthesia type used for surgery on perioperative outcome, there is a lack of data on potential care differences in this field. The authors aimed to determine whether anesthesia practice (use of neuraxial anesthesia [NA] or peripheral nerve block [PNB]) differs by patient and hospital factors.Methods: The authors extracted data on n = 1,062,152 hip and knee arthroplasty procedures from the Premier Perspective database (2006 to 2013). Multilevel multivariable logistic regression models measured associations (odds ratios [ORs] and 95% CIs) between patient/hospital factors and NA or PNB use.Results: Of all patients, 22.2% (n = 236,083) received NA and 17.9% (n = 189,732) received PNB. Lower adjusted odds for receiving NA were seen for black patients (OR, 0.88; 95% CI, 0.86 to 0.91) and those on Medicaid (OR, 0.78; 95% CI, 0.74 to 0.82) or without insurance (OR, 0.89; 95% CI, 0.81 to 0.98). Furthermore, teaching hospitals (compared with nonteaching hospitals) had lower adjusted odds for NA utilization (OR, 0.35; 95% CI, 0.14 to 0.89). Although generally similar patterns were seen for PNB utilization, the main difference was that particularly Hispanic patients were less likely to receive PNB compared with white patients (OR, 0.60; 95% CI, 0.56 to 0.65). Sensitivity analyses generally validated our results.Conclusions: Significant differences exist in the provision of regional anesthetic care with factors such as race and insurance type being important determinants of anesthetic practice. Further and in-depth research is needed to fully assess the background of these differences. [ABSTRACT FROM AUTHOR]

Following the "fetal origins of adult disease" hypothesis, environmental determinants of birth weight regained interest. The authors applied a detailed spatial-time exposure model for climatological factors thought to affect fetal growth: seasonality, temperature, and sunshine. Daily climatological data (29 stations) were linked to 1,460,401 term births with an individual exposure matrix for each pregnancy. Linear regression was utilized to determine effects of climatological factors on individual birth weight and existing spatial variations in birth weight. In the Netherlands substantial regional climatological differences exist. Summer was associated with significantly reduced birth weight (16-19 g). Minimum and maximum temperatures were significantly associated with increased and reduced birth weight, respectively. Spatial birth weight differences ranged from -11 to +25 g, with lowest birth weights in inland areas. The authors demonstrate birth weight to be associated with climatological factors; negative birth weight effects of maximum temperature exposure confirm results from animal studies. Consequently, a climate footprint is visible in the spatial birth weight differences. [ABSTRACT FROM AUTHOR]

The article presents a study which investigates the effects of general anesthesia on patients who underwent open lung resection. Topics discussed include the use of the database of the health insurance company Premier Perspective Inc. to acquire the relevant data for the study, the use of the SAS version 9.3 statistical software in the analysis, and the study finding illustrating the association between adding neuraxial to general anesthesia in open lung resections in cancer patients.

Objective: To monitor the incidence of neonatal herpes in The Netherlands between 2006 and 2011, as well as the adherence to the rather conservative Dutch prevention policy. Methods: Questionnaires were sent to all virology laboratories ( n = 44), gynaecology and paediatrics departments of all hospitals in The Netherlands ( n = 89). Questionnaires for the laboratories pertained to rates of proven cases of neonatal herpes; for the gynaecologists and paediatricians it pertained to rates of genital herpes during pregnancy and neonatal herpes, and their policy. For gynaecologists this concerned the risk of herpes simplex virus transmission in case of primary genital herpes during pregnancy or labour; for paediatricians it concerned the diagnostic policy in a neonate suspected of neonatal herpes. Results: For the period 2006-2011 38 cases of neonatal herpes were reported, yielding an incidence of 4.7 per 100 000 births. The estimated annual number of pregnant women with primary or recurrent genital herpes was 278. Of the responding gynaecologists and paediatricians, only 59% and up to 39%, respectively, reported a policy in accordance with the national guideline. Conclusions: The incidence of neonatal herpes in The Netherlands seems to have increased in the period 2006-2011. Combined with suboptimal guideline adherence this warrants strategies to improve awareness and subsequent adherence. [ABSTRACT FROM AUTHOR]

The main objective of this study was to estimate the contributing role of maternal, child, and organizational risk factors in perinatal mortality by calculating their population attributable risks (PAR). The primary dataset comprised 1,020,749 singleton hospital births from ≥22 weeks' gestation (The Netherlands Perinatal Registry 2000-2008). PARs for single and grouped risk factors were estimated in four stages: (1) creating a duplicate dataset for each PAR analysis in which risk factors of interest were set to the most favorable value (e.g., all women assigned 'Western' for PAR calculation of ethnicity); (2) in the primary dataset an elaborate multilevel logistic regression model was fitted from which (3) the obtained coefficients were used to predict perinatal mortality in each duplicate dataset; (4) PARs were then estimated as the proportional change of predicted- compared to observed perinatal mortality. Additionally, PARs for grouped risk factors were estimated by using sequential values in two orders: after PAR estimation of grouped maternal risk factors, the resulting PARs for grouped child, and grouped organizational factors were estimated, and vice versa. The combined PAR of maternal, child and organizational factors is 94.4 %, i.e., when all factors are set to the most favorable value perinatal mortality is expected to be reduced with 94.4 %. Depending on the order of analysis, the PAR of maternal risk factors varies from 1.4 to 13.1 %, and for child- and organizational factors 58.7-74.0 and 7.3-34.3 %, respectively. In conclusion, the PAR of maternal-, child- and organizational factors combined is 94.4 %. Optimization of organizational factors may achieve a 34.3 % decrease in perinatal mortality. [ABSTRACT FROM AUTHOR]

Background Adding neuraxial to general anesthesia (GA) has been associated with improved perioperative outcome after orthopedic surgery. Presuming a similar effect in major abdominal surgery we studied its effect on perioperative outcome in open colectomy patients. Materials and methods Retrospective study using the Premier Perspective database (n = 98,290 elective open colectomies, 2006-2012). Multilevel multivariable logistic regression models measured the association between anesthesia type (GA or general and neuraxial anesthesia combined [GNA]) and perioperative outcome with odds ratios (OR) and 95% confidence intervals (CI). Outcomes were thromboembolism, acute myocardial infarction, postoperative infection, postoperative ileus, cerebrovascular events, blood transfusion, admission to an intensive care unit, and mechanical ventilation. Results GA was used in 93.9%, GNA in 6.1%, with a similar Charlson comorbidity index between the groups (2.66 versus 2.72, respectively; P = 0.121). The multivariable analyses showed GNA (versus GA) to be associated with a significantly decreased risk for thromboembolism (OR 0.74; CI 0.58-0.93) and cerebrovascular events (OR 0.67; CI 0.51-0.88), whereas the association was nonsignificant for wound infections, pneumonia, and mechanical ventilation. However, GNA use was significantly associated with increased risk for acute myocardial infarction (OR 2.74; CI 2.19-3.43), urinary tract infection (OR 1.35; CI 1.21-1.50), postoperative ileus (OR 1.17; CI 1.09-1.26), blood transfusion (OR 1.12; CI 1.01-1.24), and admission to intensive care unit (OR 1.32; CI 1.22-1.43). Conclusions We found no clear pattern of consistent favorable results for patients undergoing their open colectomy under GNA. Further prospective research is needed to help identify those who are more likely to benefit from GNA use and its mechanism of actions. [ABSTRACT FROM AUTHOR]

Collection of patient-reported outcomes (PROs) is increasingly viewed as the standard of care in various orthopedic surgeries given the intrinsic need for quality metrics and outcome collection requirements from government agencies and insurance carriers. Despite these incentives, low response rates to PRO collection tools remain a problem. Currently, most studies that address PRO response rates mainly focus on patients and few studies analyze strategies to improve response rates. To date, an evidence-based overview of successful PRO collection strategies incorporated into an overarching human-centered design framework is still absent. We aimed to systematically review existing literature, synthesize evidence, and develop an overarching framework of strategies to increase PRO collection rates. First, we systematically searched existing literature from 06-2011 to 06-2021 (using PubMed, EMBASE, Scopus, Business Source Complete) for studies that 1) included a primary or secondary outcome of PRO response rates evaluating one or more interventions, 2) included the PRO response rate achieved for each comparator group, 3) calculated response rates per PRO, 4) involved an orthopedic practice, 5) involved mainly adults. Included studies were assessed according to their focus on survey collection tool design or patient engagement; subsequently, a human-centered design approach was used to develop an evidence-based framework. In order to develop a comprehensive framework for strategies to increase PRO response rates, we developed a two-pronged framework: survey collection tool strategies and patient engagement strategies. Among 15 included studies (conducted in 3 countries) there were 3 randomized controlled trials, 1 prospective study and 11 retrospective studies. PRO response rates achieved by interventions ranged from 46% to 100%; 3 studies included more than one intervention, and only 1 of these studies looked at each intervention separately. The remaining two were unable to identify which specific intervention was most effective. The most common intervention studied was the method of survey distribution modality, however, modalities' effectiveness was not uniform. Additional interventions studied were: dedicated research assistants, length of surveys, frequency of surveys, automated provider reminders and communication regarding standard of care. Having a dedicated research assistant, shorter surveys, and automated reminders for the provider showed an increase in response rate. Color-coding indicates which strategies have been studied and examples are included in italics. There are significant gaps in the literature, especially on the patient engagement side. The strategy studied most for patient engagement is the number of dedicated research assistants, which has higher associated costs due to dedicated labor hours. Considering the two aspects of survey data collection: survey collection tool design and patient engagement, current literature has prioritized the former, leaving a considerable gap in the orthopedic community's understanding of strategies to improve PRO response rate. The framework presented strives to provide a systematic roadmap for orthopedic practices seeking to increase PRO response rates that do not drastically increase cost. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Collection of patient-reported outcomes (PROs) is increasingly viewed as the standard of care in various orthopedic surgeries given the intrinsic need for quality metrics and outcomecollection requirements from government agencies and insurance carriers. Despite these incentives, low response rates to PRO collection tools remain a problem. Currently, most studies that address PRO response rates mainly focus on patient factors (eg, demographics, socioeconomic status, comorbidities) and few studies analyze strategies to improve response rates, signifying significant gaps in evidence and contextual understanding of low PRO response rates. To date, majority of studies looking at patient engagement strategies to improve response rates focus on using a dedicated research assistant. Although effective, dedicated research assistants are one of the more expensive strategies for patient engagement. Therefore, we aimed to evaluate a low-resource patient engagement pilot intervention at an urban academic medical center spine clinic to determine if baseline PRO response rates could be improved with minimal resource investment. The intervention was carried out for 2.5 months in an urban spine clinic and included 52 patients. We employed customer journey mapping, a technique often used in the business and technology industry, to initially documented the current-state patient journey for spine clinic patients, defining the current points of engagement for introducing and collecting patient PROs. Based on the documented patient journey, we identified areas of opportunity for patient engagement regarding PROs and developed a subsequent future-state patient journey. The future-state journey included capitalizing on in-clinic time with the patient, introduce the PROs as standard of care, reiterating the importance of PROs in written and oral patient communication, and enabling patients to fill out baseline PROs on the day of their first appointment using a provided tablet. Patients also had the option to receive an email with a direct link to the PRO if they were not able to complete their survey in clinic. The intervention integrated into the existing clinic flow and did not require additional personnel. Baseline PRO response rates improved by 27%, increasing from 15% to 42%. Of the patients that completed the baseline PRO, 86% (n=19) of them completed the entire baseline survey using the tablet provided to them in clinic. The remaining 14% completed surveys at home using a direct link sent to their emails or completed their PRO partially in clinic or partially at home. For 27% of patients (n=14), operational challenges were encountered. On busy clinic days, there was not time for the patient to remain in an exam room after the clinician-patient encounter to complete their survey on the provided tablet. Therefore, on busy clinic days, few patients were given the opportunity to complete their baseline PRO in clinic. Of the 14 patients that encountered operational challenges, 2 patients completed their baseline PRO. For 17% (n=9) patients, technology issues were encountered. Technology issues ranged from Wi-Fi connection problems, patient profiles not being pre-loaded, and surveys not loading correctly. Of the patients who had technology issues, 2 patients completed the baseline survey fully, and one 1 patient completed the baseline survey partially. 17% (n=9) of patients refused to participate in PRO due to either pain (n=5) or stated they were not interested in participating (n=4). The majority of challenges throughout the pilot were technological, operational and patients refusing to participate. Majority of technology issues can be attributed to requiring configuration changes to the third-party survey platform provider. As configuration updates were rolled out, a few product issues were identified and rendered throughout the pilot. The operational challenge of busy clinic days is more complex to solve. Based on pilot results, patients were amenable to completing surveys in clinic, but a dedicated space is required for the patient to carry out the 10–15-minute baseline PRO. In a busy clinic shared with other practitioners, space is difficult to find. One future consideration is using the waiting room / lobby for PRO completion on the provided tablet. Patients refusing to participate due to lack of interest is also an area for improvement. Culturally, patients in the United States are not always familiar with PROs being the standard of care. Introducing the PRO as standard of care and having the surgeon reiterate its importance for receiving the highest quality of care could help decrease the prevalence of lack of interest in the future. Overall, the pilot highlighted that a 'low-resource' intervention with in-clinic PRO completion can improve completion rates, but response rates did remain lower than 50%. This could be attributed to technology issues, operational challenges, and patient lack of interest. The majority of problems encountered during the pilot that prevented survey completion are solvable and can help improve future 'low resource' intervention strategies. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

The article discusses research on the use of electronic health records (EHR) and computerized prescriber order entry (CPOE) in hospitals. Topics include the lack of information about how hospitals incorporated clinical decision support (CDS) for clinicians prescribing drugs to elderly patients, the implementation of CDS at Mount Sinai Hospital, and the reasons for the slow adoption of a geriatric context in CPOE systems.

Background: Promotion of healthy pregnancies has gained high priority in the Netherlands because of the relatively unfavourable perinatal health outcomes. In response a nationwide study Healthy Pregnancy 4 All was initiated. This study combines public health and epidemiologic research to evaluate the effectiveness of two obstetric interventions before and during pregnancy: (1) programmatic preconception care (PCC) and (2) systematic antenatal risk assessment (including both medical and non-medical risk factors) followed by patient-tailored multidisciplinary care pathways. In this paper we present an overview of the study setting and outlines. We describe the selection of geographical areas and introduce the design and outline of the preconception care and the antenatal risk assessment studies. Methods/design: A thorough analysis was performed to identify geographical areas in which adverse perinatal outcomes were high. These areas were regarded as eligible for either or both sub-studies as we hypothesised studies to have maximal effect there. This selection of municipalities was based on multiple criteria relevant to either the preconception care intervention or the antenatal risk assessment intervention, or to both. The preconception care intervention was designed as a prospective community-based cohort study. The antenatal risk assessment intervention was designed as a cluster randomised controlled trial - where municipalities are randomly allocated to intervention and control. Discussion: Optimal linkage is sought between curative and preventive care, public health, government, and social welfare organisations. To our knowledge, this is the first study in which these elements are combined. [ABSTRACT FROM AUTHOR]

Abstract: Social deprivation is considered a key factor in adverse perinatal outcomes. Rotterdam, the second largest city in The Netherlands, has large inequalities in perinatal health and a high number of deprived neighbourhoods. Social deprivation is measured here through a composite variable: ‘Social Index’ (SI). We studied the impact of the SI (2008–2009; 5 categories) in terms of perinatal mortality, congenital anomalies, preterm birth, small for gestational age (SGA) and low 5-minute Apgar score as registered in The Netherlands Perinatal Registry (Rotterdam 2000–2007, n = 56,443 singleton pregnancies). We applied ethnic dichotomisation as Western (European/North-American/Australian) vs. Non-Western (all others) ethnicity was expected to interact with the impact of SI. Tests for trend and multilevel regression analysis were applied. Gradually decreasing prevalence of adverse perinatal outcomes was observed in Western women from the lowest SI category (low social quality) to the highest SI category (high social quality). In Western women the low-high SI gradient for prevalence of spontaneous preterm birth (per 1000) changed from 57.2 to 34.1, for iatrogenic preterm birth from 35.2 to 19.0, for SGA from 119.6 to 59.4, for low Apgar score from 10.9 to 8.2, and for perinatal mortality from 14.9 to 7.6. These trends were statistically confirmed by Chi2-tests for trend (p < 0.001). For non-Western women such trends were absent. These strong effects for Western women were confirmed by significant odds ratios for almost all adverse perinatal outcomes estimated from multilevel regression analysis. We conclude social deprivation to play a different role among Western vs. non-Western women. Our results suggest that improvements in social quality may improve perinatal outcomes in Western women, but alternative approaches may be necessary for non-Western groups. Suggested explanations for non-Western ‘migrant’ groups include the presence of ‘protective’ effects through knowledge systems or intrinsic resilience. Implications concern both general and targeted policies. [Copyright &y& Elsevier]

The article presents a study which compared mortality rates among births conducted in the home, with those in hospitals. Data was obtained from the Netherlands Perinatal Registry from d679,952 low-risk women. It reports that the data was approached in two ways, a natural prospective approach, and a perfect guideline approach. Results showed that under normal conditions, home births did not result in more deaths, though exceptions existed for those in poorer areas.

Objective. Large urban areas have higher perinatal mortality rates. In attaining a better understanding, we conducted an analysis on a neighborhood level in Rotterdam, the second largest city of The Netherlands. Methods. Perinatal outcome of all single pregnancies (50,000) was analyzed for the period of 2000--2006. The prevalences of perinatal mortality and perinatal morbidity were determined for every neighborhood. Results. Large perinatal health inequalities exist between neighborhoods in the city of Rotterdam with perinatal mortality rates as high as 37 per 1000 births. The highest risks were observed in deprived neighborhoods. Conclusion. We observed high levels of perinatal health inequalities in the city of Rotterdam which have not been previously described in the Western world. Accumulation of medical risk factors as well as socioeconomic and urban risk factors seems to be a likely contributor. [ABSTRACT FROM AUTHOR]

• Significant racial difference exists in the provision of regional anesthesia and analgesia. • Hospitals with a low volume of joint arthroplasties tended to serve a relative larger proportion of minority patients. • Our data suggest a potential role of hospital-specific factors as targets to reduce these disparities. [ABSTRACT FROM AUTHOR]

Hip fractures are a serious health concern and a major contributor to healthcare resource utilisation. We aimed to investigate nationwide trends in the USA in patient characteristics and outcomes in patients after hip fracture repair surgery. From the Premier Healthcare dataset, we extracted patient encounters for surgical hip fracture repair from 2016 to 2021. Patient characteristics, comorbidities, complications, and anaesthetic and surgical details were analysed. Cochran–Armitage trend tests and simple linear regression were used to determine trends. We included 347 086 hip fracture repair encounters. Notable trends included the following: median patient age declined from 82 yr [interquartile range: 73–88 yr] to 81 yr [interquartile range: 73–88 yr], (P -value=0.002), the proportion of female patients decreased from 68% to 66.2% (P -value=0.019); internal fixation was the most common intervention initially, but with a declining percentage from 49.9% to 43.8% (P -value <0.001); in general, patients carried a greater comorbidity burden, with the proportion with three or more Elixhauser comorbidities increasing from 56.4% to 58.6% (P -value=0.006); general anaesthesia remained the most common anaesthetic technique, from 68.90% to 56.80% without a significant trend; per 1000 inpatient days, the most common complication remained acute renal failure; despite a higher comorbidity burden, no complication showed a statistically significant upward trend, and many showed downward trends. Over the 6-yr period from 2016 to 2021, a majority of hip fracture repairs continued to be performed under general anaesthesia but with that percentage declining over time. Notable trends included a lower percentage of female patients, an increase in femoral neck fractures, a higher comorbidity burden among patients, and a decrease in complications. [ABSTRACT FROM AUTHOR]

Introduction. Telemedicine was rapidly deployed at the onset of the COVID-19 pandemic. Little has been published on telemedicine in musculoskeletal care prior to the COVID-19 pandemic. This study is aimed at characterizing trends in telemedicine for musculoskeletal care preceding the COVID-19 pandemic. Methods. This retrospective study used insurance claims from the Truven MarketScan database. Musculoskeletal-specific outpatient visits from 2014 to 2018 were identified using the musculoskeletal major diagnostic category ICD-10 codes. Telemedicine visits were categorized using CPT codes and Healthcare Common Procedure Coding Systems. We described annual trends in telemedicine in the overall dataset and by diagnosis grouping. Multivariable logistic regression modeling estimated the association between patient-specific and telemedicine visit variables and telemedicine utilization. Results. There were 36,672 musculoskeletal-specific telemedicine visits identified (0.020% of all musculoskeletal visits). Overall, telemedicine utilization increased over the study period (0% in 2014 to 0.05% in 2018). Orthopedic surgeons had fewer telemedicine visits than primary care providers (OR 0.57, 95% CI 0.55-0.59). The proportion of unique patients utilizing telemedicine in 2018 was higher in the south (OR 2.28, 95% CI 2.19-2.38) and west (OR 5.58, 95% CI 5.36-5.81) compared to the northeast. Those with increased comorbidities and lower incomes and living in rural areas had lower rates of telemedicine utilization. Conclusions. From 2014 to 2018, there was an increase in telemedicine utilization for musculoskeletal visits, in part due to insurance reimbursement and telemedicine regulation. Despite this increase, the rates of telemedicine utilization are still lowest in some of the groups that could derive the most benefit from these services. Establishing this baseline is important for assessing how the roll-out of telemedicine during the pandemic impacted how/which patients and providers are utilizing telemedicine today. [ABSTRACT FROM AUTHOR]

This Viewpoint characterizes the evidence base underlying existing interventions to reduce complications and improve patient outcomes after surgery, and emphasizes the need for science to guide extension and development of new interventions in the face of pressures to use length-of-stay (LOS) as the primary measure of enhanced recovery and to use interventions shown effective for one population and setting to others. [ABSTRACT FROM AUTHOR]

Objective: We aimed to investigate the impact of multimodal analgesia on postoperative complications and opioid prescription on a national level. Methods: This retrospective cross-sectional study included n = 1,307,923 hysterectomies (01/2006–12/2022, Premier Healthcare claims data). Multimodal analgesia was defined as opioid use with the addition of non-opioid analgesic modes, grouped into four categories: opioid-only and 1, 2, or 3 or more additional non-opioid analgesics. Multivariable regression models measured associations between multimodal categories and outcomes (composite/respiratory/cardiac/gastrointestinal/genitourinary, and CNS complications, oral morphine milligram equivalents [MME], and length of hospital stay [LOS]). Odds ratios (OR) and 95% confidence intervals (CI) are reported. Results: Overall, 84.3% (1,102,812/1,307,923) received multimodal analgesia, of which 58.9%, 28.0%, and 13.1% received 1, 2, or 3 or more additional non-opioid analgesics, respectively. The odds of any composite complication (any ≥1 complication) decreased with the addition of 1, 2, 3, or more analgesic modalities (versus opioid-only): OR 0.66 (CI 0.64; 0.68), OR 0.63 (CI 0.61; 0.66), OR 0.65 (CI 0.62; 0.67), respectively. Similar patterns existed for respiratory, cardiac, and genitourinary complications. Opioid prescription decreased incrementally with 1,2, 3, or more non-opioid analgesic modalities by 9.51 mg (CI 11.16; 7.86) and 15.29 mg (CI 17.21; 13.37) and 29.35 mg (CI 31.79; 26.91) cumulative MME. LOS was reduced by 0.52 days (CI 0.54; 0.51), 0.49 days (CI 0.51; 0.47), and 0.40 days (CI 0.43; 0.38), respectively. Costs were reduced by $765 (CI 817; 714) or $479 (CI 539; 419) with 1 or 2 multimodal modes. Conclusions: These findings suggest substantial benefits of multimodal analgesia, including significant decreases in serious complications (especially respiratory, cardiac, and genitourinary), opioid consumption, and hospitalizations. Multimodal analgesia may facilitate safe and efficient pain management with optimized opioid consumption. [ABSTRACT FROM AUTHOR]

Background: Approximately 25 million people in the United States have limited English proficiency. Current developments in orthopaedic surgery, such as the expansion of preoperative education classes or patient-reported outcome collection in response to bundled payment models, may exacerbate language-related barriers. Currently, there are mixed findings of the associations between limited English proficiency and care processes and outcomes, warranting a cross-study synthesis to identify patterns of associations. Questions/purposes: In this systematic review, we asked: Is limited English proficiency associated with (1) differences in clinical care processes, (2) differences in care processes related to patient engagement, and (3) poorer treatment outcomes in patients undergoing orthopaedic surgery in English-speaking countries?. Methods: On June 9, 2023, a systematic search of four databases from inception through the search date (PubMed, Ovid Embase, Web of Science, and Scopus) was performed by a medical librarian. Potentially eligible articles were observational studies that examined the association between limited English proficiency and the prespecified categories of outcomes among pediatric and adult patients undergoing orthopaedic surgery or receiving care in an orthopaedic surgery setting. We identified 10,563 records, of which we screened 6966 titles and abstracts after removing duplicates. We reviewed 56 full-text articles and included 29 peer-reviewed studies (outcome categories: eight for clinical care processes, 10 for care processes related to patient engagement, and 15 for treatment outcomes), with a total of 362,746 patients or encounters. We extracted data elements including study characteristics, definition of language exposure, specific outcomes, and study results. The quality of each study was evaluated using adapted Newcastle-Ottawa scales for cohort or crosssectional studies. Most studies had a low (48%) or moderate (45%) risk of bias, but two cross-sectional studies had a high risk of bias. To answer our questions, we synthesized associations and no-difference findings, further stratified by adjusted versus unadjusted estimates, for each category of outcomes. No meta-analysis was performed. Results: There were mixed findings regarding whether limited English proficiency is associated with differences in clinical care processes, with the strongest adjusted associations between non-English versus English as the preferred language and delayed ACL reconstruction surgery and receipt of neuraxial versus general anesthesia for other non-Spanish versus English primary language in patients undergoing THA or TKA. Limited English proficiency was also associated with increased hospitalization costs for THA or TKA but not opioid prescribing in pediatric patients undergoing surgery for fractures. For care processes related to patient engagement, limited English proficiency was consistently associated with decreased patient portal use and decreased completion of patientreported outcome measures per adjusted estimates. The exposure was also associated with decreased virtual visit completion for other non-Spanish versus English language and decreased postoperative opioid refill requests after TKA but not differences in attendance-related outcomes. For treatment outcomes, limited English proficiency was consistently associated with increased hospital length of stay and nonhome discharge per adjusted estimates, but not hospital returns. There were mixed findings regarding associations with increased complications and worse postoperative patient-reported outcome measure scores. Conclusion: Findings specifically suggest the need to remove language-based barriers for patients to engage in care, including for patient portal use and patient-reported outcome measure completion, and to identify mechanisms and solutions for increased postoperative healthcare use. However, interpretations are limited by the heterogeneity of study parameters, including the language exposure. Future research should include more-precise and transparent definitions of limited English proficiency and contextual details on available language-based resources to support quantitative syntheses. [ABSTRACT FROM AUTHOR]

The article discusses research which investigated trends in the use of epidural steroid injections to treat back pain before spine surgery. The study assessed the association of preoperative epidural steroid injections with postoperative chronic opioid in patients who underwent anterior cervical discectomy and fusion (ACDF) compared to those who underwent microdiscectomy. Mechanisms behind the association of epidural steroid injections with chronic postoperative opioid use are proposed.

Background/Objectives: The use of neuraxial anesthesia versus general anesthesia for hip fracture surgery remains an active area of research, with recent studies demonstrating mixed findings supporting neuraxial over general anesthesia. The benefits of neuraxial anesthesia have been documented in associated surgeries, including total joint arthroplasty. However, racial disparities in the administration of neuraxial anesthesia have been identified in numerous procedures. We aimed to examine the association of race/ethnicity with neuraxial anesthesia use and the effect of neuraxial anesthesia on length of stay, non-home discharge, 30-day severe adverse events, and rates of readmission among patients undergoing isolated hip and femoral shaft fracture operations. Methods: The American College of Surgeons National Quality Improvement Program database was queried for isolated hip or femoral shaft fractures from 2015 to 2019. Stepwise logistic regression was performed to assess the relationship between race/ethnicity and neuraxial anesthesia use. Within each sex–race stratum, neuraxial anesthesia recipients were propensity-matched to general anesthesia recipients in a 1:2 ratio. Logistic regression and negative binomial regression were performed on the propensity-matched cohort. Results: A total of 12,004 neuraxial and 64,250 general anesthesia hip and femoral shaft fracture patients were identified. Compared to White patients, Black and Hispanic patients were between 0.64 and 0.61 times less likely to receive neuraxial anesthesia over general anesthesia, respectively (p < 0.05). 11,993 patients who received neuraxial anesthesia were propensity matched to 23,946 patients who received general anesthesia. Propensity-matched logistic regressions found that neuraxial anesthesia was associated with decreased length of stay, 30-day severe adverse events, and acute rehab/skilled nursing facility discharge for White patients (p < 0.05 for all), but only decreased length of stay in Black and Hispanic patients (p = 0.01 and p = 0.02, respectively). Conclusions: Notable disparities exist in the administration of neuraxial anesthesia for isolated hip and femoral shaft fracture patients. Hispanic and Black race/ethnicity in particular influences provision of neuraxial anesthesia. Further research is required to understand the degree of effect modification and root causes of regional anesthesia access and benefits for this high-volume patient population. [ABSTRACT FROM AUTHOR]