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Purpose: The aim of this study is to describe trends in inpatient and outpatient upper extremity fracture surgery between 2008 and 2021, along with identifying patient factors (age, sex, race, socioeconomic status) associated with outpatient surgery. Methods: Retrospectively, 12,593 adult patients who underwent upper extremity fracture repair from 2008 to 2021 at one of five urban hospitals in the Northeastern USA were identified. Using Distressed Communities Index (DCI), patients were divided into five quintiles based on their level of socioeconomic distress. Multivariable logistic regression was performed on patients from 2008 to 2019 to identify independent factors associated with outpatient management. Results: From 2008 to 2019, outpatient procedures saw an average increase of 31%. The largest increases in the outpatient management were seen in humerus (132%) and forearm fractures (127%). Carpal and hand surgeries had the lowest percent increase of 8.1%. Clavicle and wrist fractures were independently associated with outpatient management. Older age, male sex, higher Elixhauser comorbidity index, DCI scores in the 4th or 5th quintile, and fractures of the scapula, humerus, elbow, and forearm were associated with inpatient management. During the onset of the COVID-19 pandemic, there was a decrease in outpatient procedures. Conclusion: There is a shift toward outpatient surgical management of upper extremity fractures from 2008 to 2021. Application of our findings can serve as an institutional guide to allocate patients to appropriate surgical settings. Moreover, physicians and institutions should be aware of the potential socioeconomic disparities and implement plans to allow for equal access to care. [ABSTRACT FROM AUTHOR]

Objective: Despite depression being a common comorbidity among adults with cancer, limited literature is available regarding pharmacologic depression treatment patterns and predictors in this population. This study aims to examine patterns and predictors of antidepressant prescribing among adults with cancer and depression in ambulatory care settings in the United States (US). Methods: This retrospective, cross-sectional study utilized data collected from the 2014 to 2015 National Ambulatory Medical Care Survey (NAMCS). The study sample consisted of adults (age ≥ 18 years) with cancer and depression (unweighted N = 539; weighted N = 11,361,000). A multivariable logistic regression analysis was used to adjust for individual-level factors to identify predictors of antidepressant prescribing. Results: Most patients were adults aged ≥ 65 years, female, and non-Hispanic whites. Thirty-seven percent of the study sample received antidepressant treatment. Multivariable logistic regression analysis revealed that race/ethnicity, physician specialty, and number of medications were significantly associated with receiving antidepressant(s). For example, non-Hispanic whites were two-and-half times more likely to receive an antidepressant [OR 2.43, 95% confidence interval 1.13–5.23] compared to other race/ethnic groups. Every unit increase in the number of prescribed medications increased the likelihood of receiving an antidepressant by 6% (OR 1.06, 95% CI: 1.01–1.11). Conclusion: Among adults with a comorbid cancer and depression diagnosis and a recorded U.S. ambulatory care visit in 2014–2015, 37% received antidepressant treatment. This suggests most patients with cancer and depression do not receive pharmacologic treatment for depression. Future studies are needed to investigate the impact of antidepressant treatment on health outcomes in this patient population. [ABSTRACT FROM AUTHOR]

Although outpatient spine surgery is becoming increasingly popular in the United States, unplanned readmission following outpatient surgery remains a significant postoperative concern. This study aimed to (1) describe the incidence and timing of 30-day unplanned readmission after ambulatory lumbar and cervical spine surgery (2) evaluate the common reasons for readmission, and (3) identify factors associated with readmission in this population. Retrospective cohort study. Patients who underwent ambulatory cervical or lumbar spine surgery between 2015 and 2020 were identified in the National Surgical Quality Improvement Program (NSQIP) database. Hospital readmission within 30 postoperative days. Patients who underwent ambulatory cervical or lumbar spine surgery between 2015 and 2020 were identified using the National Surgical Quality Improvement Program (NSQIP) database. Reasons for and timing of unplanned readmissions were recorded. Multivariable poisson regressions were employed to determine any independent predictors of readmission. A total of 33,092 ambulatory cervical and 68,115 ambulatory lumbar spine surgery patients were identified. Incidences of 30-day readmission were 3.37% and 3.07% among cervical and lumbar patients, respectively. The most common surgical site-related reasons for readmission included uncontrolled pain, recurrence of disc herniation or major symptom, and postoperative hematoma/seroma. Common nonsurgical site-related reasons included gastrointestinal, neurological, and cardiovascular complications. Factors associated with readmission among cervical patients included age ≥55, BMI ≥35, functional dependence, diabetes, smoking, COPD, and steroid use, whereas factors associated with readmission following lumbar spine surgery included age ≥65, female sex, BMI ≥35, functional dependence, ASA ≥3, diabetes, smoking, COPD, and hypertension (p<.05 for all). This study highlights the common reasons and factors associated with unplanned readmission following ambulatory spine surgery. Consideration of these factors may be critical to ensuring appropriate patient selection for ambulatory spine surgery. [ABSTRACT FROM AUTHOR]

Inpatient pediatric palliative care (PPC) has grown substantially over the past 20 years; however, PPC in the outpatient setting remains underdeveloped. Outpatient PPC (OPPC) offers opportunities to improve access to PPC as well as facilitate care coordination and transitions for children with serious illness. This study aimed to characterize the national status of OPPC programmatic development and operationalization in the United States. Utilizing a national report, freestanding children's hospitals with existing PPC programs were identified to query OPPC status. An electronic survey was developed and distributed to PPC participants at each site. Survey domains included hospital and PPC program demographics; OPPC development, structure, staffing, and workflow; metrics of successful OPPC implementation; and other services/partnerships. Of 48 eligible sites, 36 (75%) completed the survey. Clinic-based OPPC programs were identified at 28 (78%) sites. OPPC programs reported a median age of 9 years [range: 1–18 years] with growth peaks in 2011, 2012 and 2020. OPPC availability was significantly associated with increased hospital size [ P = 0.05] and inpatient PPC billable full time equivalent staff [ P = 0.01]. Top referral indications included pain management, goals of care, and advance care planning. Funding primarily came from institutional support and billing revenue. Although OPPC remains a young field, many inpatient PPC programs are growing into the outpatient setting. Increasingly, OPPC services have institutional support and diverse referral indications from multiple subspecialties. However, despite high demand, resources remain limited. Characterization of the current OPPC landscape is crucial to optimize future growth. [ABSTRACT FROM AUTHOR]

Context: As pediatric palliative care (PPC) expands within institutions and nationally, little guidance is available on building outpatient programs. Objectives: We asked outpatient PPC (OPPC) program leaders in the United States about clinic development experiences to gather advice for growing programs. Methods: As part of a larger OPPC study, 48 freestanding children's hospitals with inpatient PPC programs were invited to complete a survey on OPPC. Self-selected participants were sent a follow-up survey soliciting free-text responses about development experiences. Quantitative data were analyzed with descriptive statistics. Qualitative data underwent inductive content analysis. Results: Thirty-six hospitals completed the initial survey, and 28 (78%) reported practicing clinic-based OPPC. Twenty-two of 28 completed program development questions. More than half (12/22, 55%) recommended a minimum total billable full-time equivalent (FTE) ≥3 before expanding into the outpatient setting. About two-thirds (14/22, 64%) suggested a minimum billable FTE ≥4 for 24/7 coverage. Half (50%) reported that their program grew from subspecialty clinics, most frequently hematology-oncology (10/11, 91%). Half (50%) placed initial limits on referrals, with many restricting schedule availability (7/11, 64%). Six of 12 participants (50%) willing to share more about their development experience completed a follow-up survey, from which three themes emerged: program logistics, expectations and boundaries, and establishing role and workflow. Participants focused advice on slow programmatic growth to optimize sustainability. Conclusion: Program leaders offer tangible guidance informed by their OPPC development experience. Future work is needed to leverage this advice within institutions to promote resilient and sustainable PPC growth.

Despite reimbursement pressures and scrutiny of procedural appropriateness, the demand for peripheral vascular ambulatory services remains strong. Improvements in minimally invasive technologies, coupled with a supportive regulatory environment and considerable preference for ambulatory services among purchasers, patients, and providers, have resulted in the rapid proliferation of ambulatory facilities in a number of markets. Emerging ecosystem dynamics, notably the rapid growth of Medicare Advantage and the growing presence of private equity and venture capital within healthcare, will likely have an impact on future growth trends but will not fundamentally alter the incentives driving the ambulatory shift. Indeed, it is likely that the dynamics currently at work within peripheral vascular services will become come to characterize a variety of other services, as more care shifts away from the hospital., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Study Objective: We examined the association of body mass index (BMI) with hospital admission, same-day complications, and 30-day hospital readmission following day-case eligible joint arthroscopy.Design: Retrospective cohort study.Setting: Multi-institutional.Patients: Adult patients undergoing arthroscopy of the knee, hip or shoulder in the outpatient setting.Intervention: None.Measurements: Using the American College of Surgeons National Surgical Quality Improvement Program dataset from 2012 to 2016, we examined seven BMI ranges: normal BMI (≥20 kg/m2 and <25 kg/m2), underweight (<20 kg/m2), overweight (≥25 kg/m2 and <30 kg/m2), Class 1 and 2 obese (≥30 kg/m2 and <40 kg/m2, reference variable), and severe obesity, which we divided into the following BMI ranges: ≥40 kg/m2 and <50 kg/m2, ≥50 kg/m2 and <60 kg/m2, and ≥60 kg/m2. The primary outcome was hospital admission. Secondary outcomes included same-day postoperative complications and 30-day hospital readmission. We performed multivariable logistic regression and reported odds ratios (OR) and their associated 95% confidence interval (CI) and considered a p-value of <0.05 as statistically significant.Main Results: There were a total of 99,410 patients included in the final analysis, in which there was a 2.6% rate of hospital admission. When compared to class 3 obesity, only those with BMI ≥50 kg/m2(OR 1.55, 95% CI 1.18-2.01, p = 0.005) had increased odds of hospital admission. There were no differences in 30-day hospital readmission or same-day postoperative complications.Conclusion: We found that only patients with BMI ≥50 kg/m2 had increased odds for same-day hospital admission even when patient's comorbid conditions are optimized, suggesting that a BMI ≥50 kg/m2 may be used as a sole factor for patient selection in patients undergoing joint arthroscopy. For patients with BMI <50 kg/m2, we recommend that BMI alone should not be solely used to exclude patients from having joint arthroscopies performed in an outpatient setting, especially since this patient group makes up a significant proportion of joint arthroscopy. [ABSTRACT FROM AUTHOR]

Background: In the tenth revision of the International Statistical Classification of Disease and Health Related Problems (ICD-10), Z codes were added to improve documentation and understanding of health-related social needs. We estimated national Z code use in the ambulatory surgery setting from 2016 to 2019., Methods: Using the Nationwide Ambulatory Surgery Sample (NASS), we identified encounters for ambulatory surgery with an ICD-10 code between Z55.0 and Z65.9. Data were stratified by Z code domains from the Centers for Medicare and Medicaid Services (CMS)., Results: This analysis of 41,827 ambulatory surgery encounters with documented Z codes found that the most documented determinants of health related to multiparity or unwanted pregnancy, homelessness, and incarceration. There was a 16.1% increase in the use of Z codes from 2016 to 2019., Conclusion: Rates of Z code use in the ambulatory surgery setting are increasing with current documentation serving as a specific but not sensitive measure of socioeconomic need., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: About 80% of cardiovascular diseases (including heart failure [HF]) occur in low-income and developing countries. However, most clinical trials are conducted in developed countries., Hypothesis: The American Registry of Ambulatory or Acutely Decompensated Heart Failure (AMERICCAASS) aims to describe the sociodemographic characteristics of HF, comorbidities, clinical presentation, and pharmacological management of patients with ambulatory or acutely decompensated HF in America., Methodology: Descriptive, observational, prospective, and multicenter registry, which includes patients >18 years with HF in an outpatient or hospital setting. Collected information is stored in the REDCap electronic platform. Quantitative variables are defined according to the normality of the variable using the Shapiro-Wilk test., Results: This analysis includes data from the first 1000 patients recruited. 63.5% were men, the median age of 66 years (interquartile range 56.7-75.4), and 77.6% of the patients were older than 55 years old. The percentage of use of the four pharmacological pillars at the time of recruitment was 70.7% for beta-blockers (BB), 77.4% for angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB II)/angiotensin receptor-neprilysin inhibitor (ARNI), 56.8% for mineralocorticoid receptor antagonists (MRA), and 30.7% for sodium-glucose cotransporter type-2 inhibitors (SGLT2i). The main cause of decompensation in hospitalized patients was HF progression (64.4%), and the predominant hemodynamic profile was wet-warm (68.3%)., Conclusions: AMERICCAASS is the first continental registry to include hospitalized or outpatient patients with HF. Regarding optimal medical therapy, approximately a quarter of the patients still need to receive BB and ACEI/ARB/ARNI, less than half do not receive MRA, and more than two-thirds do not receive SGLT2i., (© 2023 The Authors. Clinical Cardiology published by Wiley Periodicals, LLC.)

Introduction: In the United States, ambulatory surgeries account for up to 87% of all surgical procedures. (1) It was estimated that 19.2 million ambulatory surgeries were performed in 2018 (https://www.hcup-us.ahrq.gov/reports/statbriefs/sb287-Ambulatory-Surgery-Overview-2019.pdf). Cataract procedures and musculoskeletal surgeries are the most common surgical interventions performed in ambulatory centers. However, more complex surgical interventions, such as sleeve gastrectomies, oncological, and spine surgeries, and even arthroplasties are routinely performed as day cases or in a model of an ambulatory extended recovery. (2-5) The ambulatory surgery centers industry has grown since 2017 by 1.1% per year and reached a market size of $31.2 billion. According to the Ambulatory Surgery Center Association, there is a potential to save $57.6 billion in Medicare costs over the next decade (https://www.ibisworld.com/industry-statistics/market-size/ambulatory-surgery-centers-united-states/). These data suggest an expected rise in the volume of ambulatory (same day) or extended ambulatory (23 h) surgeries in coming years. Similar increases are also observed in other countries. For example, 75% of elective surgeries are performed as same-day surgery in the United Kingdom. (6) To reduce costs and improve the quality of care after those more complex procedures, ambulatory surgery centers have started implementing patient-centered, high-quality, value-based practices. To achieve those goals, Enhanced Recovery After Surgery (ERAS) protocols have been implemented to reduce the length of stay, decrease costs, increase patients' satisfaction, and transform clinical practices. The ERAS fundamentals for ambulatory surgery are based on five pillars, including (1) preoperative patient counseling, education, and optimization; (2) multimodal and opioid-sparing analgesia; (3) nausea and vomiting, wound infection, and venous thromboembolism prophylaxis; (4) maintenance of euvolemia; and (5) encouragement of early mobility. Those pillars rely on interdisciplinary teamwork led by anesthesiologists, surgery-specific workgroups, and safety culture. (2) Research shows that a team of ambulatory anesthesiologists is crucial in improving postoperative nausea and vomiting (PONV) and pain control. (7) This review will summarize the current evidence on the elements and clinical importance of implementing ERAS protocol for ambulatory surgery., Competing Interests: Declaration of competing interest Tong Joo Gan, MD – Honoraria and travel expenses from Acacia, Edwards, Merck, and Medtronic. Juan Cata, MD – None. Daniel Cukierman, MD – None., (Copyright © 2023. Published by Elsevier Ltd.)

Purpose: Caring for patients with low-acuity conditions in Emergency Departments (ED) is often thought to cost more than treating those patients in other ambulatory settings. Understanding the relative cost of care between settings has critical implications for healthcare policy and system design., Methods: We conducted a systematic review of papers comparing the cost of care for low-acuity and ambulatory care sensitive conditions in ED and other outpatient settings. We searched PubMed, EMBASE, CINAHL, and Web of Science for peer reviewed papers, plus Google for grey literature. We conducted duplicate screening and data extraction, and quality assessment of included studies using an adapted SIGN checklist for economic studies. We calculated an unweighted mean charge ratio across studies and summarized our findings in narrative and tabular format., Results: We identified one study comparing costs. 18 studies assessed physician or facility charges, conducted in the United States, United Kingdom, and Canada, including cohort analyses (5), charge analyses (5), survey (1), and database searches (5) assessing populations ranging from 370 participants to 60 million. Charge ratios ranged from 0.60 to 13.45 with an unweighted mean of 4.20. Most (12) studies were of acceptable quality., Conclusion: No studies since 2001 assess the comparative costs of ED versus non-ED care for low-acuity ambulatory conditions. Physician and facility charges for ED care are higher than in other ambulatory settings for low-acuity conditions. Empirical evidence is lacking to support that ED care is more costly than similar care in other ambulatory settings., (© 2023. The Author(s), under exclusive licence to Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).)

Background: Outpatient total joint arthroplasty (TJA) has been shown to be both safe and cost-effective in appropriately selected patients and continues to expand substantially across the United States. Using online crowdsourcing, we aimed to assess population perceptions regarding outpatient TJA and to determine factors associated with preference for outpatient versus inpatient arthroplasty., Methods: A closed-ended survey consisting of 39 questions was administered to members of a public platform. Study participants responded to questions regarding demographic factors and outpatient TJA. Validated assessments to capture health literacy and engagement were also used. To determine factors associated with preference for outpatient TJA, multivariable logistic regression analyses were performed., Results: In total, 900 participants completed the survey. After exclusion of surveys with incomplete data, 725 responses remained for analysis (80.6%). Over half (59.9%) of the survey participants would feel comfortable going home the same day of surgery following TJA. However, two-thirds (64.6%) would prefer to stay in the hospital following TJA. The majority (68.0%) of respondents perceive a hospital setting as the safest location for TJA. The 3 major concerns regarding outpatient TJA were cost, post-operative pain control, and post-operative complication. Among the 111 respondents (15.3%) who would prefer outpatient TJA, 45% would pay more out-of-pocket, 63.1% travel further, and 55.9% would be willing to wait longer to have their surgery performed as an outpatient. On multivariable regressions, those living in a suburban setting (adjusted odds ratios, 95% confidence intervals: 4.2 [1.3-2.7], P = .02) and >60 year old adjusted odds ratios (95% confidence intervals: 8 [2-33.1], P = .004) were more likely to prefer outpatient TJA., Conclusion: Despite the rise in outpatient TJA, the majority of the public appears to prefer inpatient TJA and the minority would expect to be discharged home the same day. Our data can be used to address specific patient concerns regarding outpatient TJA and set realistic expectations for hospital systems and ambulatory facilities., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background context There is a persistent trend for more outpatient lumbar discectomies in the United States. Purpose To investigate the characteristics of the patients selected for ambulatory procedures. Study design Retrospective cohort study. Patient sample Forty-seven thousand one hundred twenty-five patients who underwent outpatient and 102,592 patients undergoing inpatient lumbar discectomies and were were registered in the State Ambulatory Surgery Database (SASD) and State Inpatient Database (SID), respectively, for New York, California, Florida, and North Carolina from 2005 to 2008. Outcome measures Rate of outpatient procedures, 30-day readmissions, and hospital charges. Methods We performed a retrospective cohort study involving patients who underwent outpatient and inpatient lumbar discectomies and were registered in SASD and SID, respectively, for New York, California, Florida, and North Carolina from 2005 to 2008. Logistic regression models were used to demonstrate the association of socioeconomic factors with the odds of undergoing an outpatient procedure. Results Male gender (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03-1.08), private insurance (OR, 1.93; 95% CI, 1.86-2.01), lower Charlson Comorbidity Index (OR, 4.04; 95% CI, 3.17-5.16), and higher volume hospitals (OR, 1.06; 95% CI, 1.04-1.08) were significantly associated with outpatient procedures. Higher income (OR, 0.83; 95% CI, 0.81-0.85), older age (OR, 0.996; 95% CI, 0.995-0.997), coverage by Medicaid (OR, 0.89; 95% CI, 0.83-0.96), African Americans (OR, 0.65; 95% CI, 0.60-0.70), and other minority races were associated with decreased odds of outpatient procedures. The rate of 30-day postoperative readmissions was higher among inpatients. Institutional charges were significantly lower for outpatient lumbar discectomies. The median charge for inpatient surgery was $24,273 as compared with $11,339 for the outpatient setting (p<.0001). Conclusions Access to ambulatory lumbar discectomies appears to be more common for younger, white, male patients, with private insurance and less comorbidities, in the setting of higher volume hospitals. Further investigation is needed in the direction of mapping these disparities for appropriate resource utilization. [ABSTRACT FROM AUTHOR]

Background: Feeding difficulties are among the most common concerns expressed by parents in younger children. However, few studies have reported on the characteristics of patients with clinically significant feeding diagnoses. The aim of the current study is to describe the characteristics of patients diagnosed with feeding difficulties including concurrent conditions, age, and sex, sampled nationwide utilizing the Cerner Health Facts Database., Methods: We identified patients with a diagnosis of feeding difficulties (ICD-9 783.3 or ICD-10 R63.3), age 7 months to 17 years, with an outpatient visit between 2010 and 2017. The demographics and complex clinical conditions of this population were categorized. The cohort was then collapsed into a matrix defining recognized phenotype codes for ICD-9 and ICD-10 diagnoses to identify associated conditions., Results: We identified 39,674 patients (0.95%) representing 101,684 encounters from 68 health systems across the United States; 43% of patients were female. Gastrointestinal conditions were the most common, followed by malnutrition, developmental and behavioral diagnoses, and neurologic conditions., Conclusions: This study is one of the most robust studies defining the prevalence, demographic characteristics, and phenotypic profiling of patients with feeding difficulties. Our observations have implications on screening and resource allocation to recognize and manage this poorly understood population., (© 2022 American Society for Parenteral and Enteral Nutrition.)

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Introduction: Hypertension is a modifiable risk factor in patients at the highest risk for cardiovascular events. New invasive treatment options are becoming available that might be particularly appealing for high-risk patients. Therefore, the aim of this study was to determine the prevalence of high-risk patients on routine therapy that do not meet guideline recommended ambulatory blood pressure (ABP) targets., Methods: This single-center, cross-sectional study was conducted at the Erasmus University Medical Center (Rotterdam, The Netherlands). Inclusion criteria were: (1) age 18-80 years, (2) drugs prescribed for hypertension or history of hypertension and (3) high cardiovascular risk as defined according to the European Society of Cardiology/European Society of Hypertension (ESC/ESH) guidelines. Patients underwent standardized office blood pressure (OBP) and same-day 24-h ABP measurements. Blood pressure (BP) control was defined according to the 2018 ESC/ESH and 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines., Results: A total of 100 patients were enrolled (median age 71 years, 35% female). Mean OBP was 142.2/81.9 ± 18.6/12.6 mmHg and mean 24-h ABP was 126.1/70.1 ± 14.3/9.2 mmHg. Patients were on 2.0 [25th-75th percentile: 1.0-3.3] Defined Daily Doses of antihypertensive drugs. ESC/ESH guideline 24-h ABP and OBP targets were not met in 41.8% (95%CI: 31.5-52.6%) and 52.7% (95%CI: 42.0-63.3%), respectively. ACC/AHA guideline 24-h ABP and OBP targets were not met in 59.3% (95%CI: 48.5-69.5%) and 79.1% (95%CI: 69.3-86.9%), respectively., Conclusions: BP remains uncontrolled in 40-60% of high-risk hypertensive patients despite routine use of guideline-recommended therapy. Our findings support the search towards novel invasive BP lowering treatment options., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Antimicrobial resistance is one of the most important public health risks facing our world today. Antimicrobials are commonly prescribed in equine veterinary medicine, but limited information exists documenting their use in practice. The goal of this study was to investigate antimicrobial prescription patterns in regards to prescription frequency, duration, drug class, clinician and affected body system in an equine ambulatory setting via retrospective analysis of billing and electronic medical records. Risk factors associated with antimicrobial prescription including the nature of the visit, submission of a culture, body system affected and clinician were assessed using multivariable regression. We found that antimicrobials were prescribed in 8.5 % of visits with a median number of 3.5 (IQR 0.8−12.2) animal-defined daily doses (ADD), defined as the number of daily doses of all antimicrobials prescribed to a patient at a single visit. Aminoglycosides were the most common class of antimicrobials prescribed and trimethoprim sulfamethoxazole was the most common drug prescribed overall. Amikacin was primarily used for patients presenting with musculoskeletal signs, and the median number of ADDs for visits where amikacin was prescribed was 1 (IQR 0.9–1.9), while the median number of antimicrobial ADDs for all other visits was 4.4 (IQR 0–14.1). Statistically significant differences in antimicrobial use patterns existed across clinicians, months, years and affected body systems. Horses presenting with ocular (OR 1199; 95 % CI 204-7,037; p < 0.001) and integumentary (OR 365; 95 % CI 87.2−1532; p < 0.001) signs were most likely to be prescribed an antimicrobial. Emergency visits (OR 5.61; 95 % CI 3.19−9.89; p < 0.001) and submission of a bacterial culture (OR 3.58; 95 % CI 2.11−6.09; p < 0.001) were associated with an increased likelihood of an antimicrobial prescription. This observational study was the first to quantitatively characterize antimicrobial use patterns in equine ambulatory practice in the United States, which is an important step needed to determine appropriateness of use and develop and evaluate antimicrobial stewardship guidelines. [ABSTRACT FROM AUTHOR]

Objectives: The ideal clinical model to deliver palliative care to patients with advanced kidney disease is currently unknown. Internationally, ambulatory kidney palliative care clinics have emerged with positive outcomes, yet there is limited data from the United States (US). In this exploratory study we report perceptions of a US-based ambulatory kidney palliative care clinic from the perspective of patient and caregiver attendees. The objective of this study was to inform further improvement of our clinical program., Methods: Semi-structured interviews were conducted to elicit the patient and caregiver experience. Eleven interviews (8 patients with chronic kidney disease stage IV or V and 3 caregivers) were analyzed using qualitative description design., Results: We identified 2 themes: "Communication addressing the emotional and physical aspects of disease" and "Filling gaps in care"; Subthemes include perceived value in symptom management, assistance with coping with disease, engagement in advance care planning, program satisfaction and patient activation., Significance of Results: Qualitative analysis showed that attendees of an ambulatory kidney palliative care clinic found the clinic enhanced the management of their kidney disease and provided services that filled current gaps in their care. Shared experiences highlight the significant challenges of life with kidney disease and the possible benefits of palliative care for this population. Further study to determine the optimal model of care for kidney palliative care is needed. Inclusion of the patient and caregiver perspective will be essential in this development.

Study Objective: Among the various types of outpatient surgery centers, there are differences in higher American Society of Anesthesiologists Physical Status (ASA PS) scores and surgical complexity among patients who are undergoing surgery. The primary objective of this study was to describe the differences performed at various types of outpatient surgery facilities.Design: We performed a retrospective analysis of the National Anesthesia Clinical Outcomes Registry (NACOR) data.Setting: NACOR from 2012 to 2017.Patients: From 2012 to 2017, there were a total of 13,053,115 outpatient surgeries in the database. After removing cases with unknown facility type, the final study sample was 9,217,336.Interventions: None.Measurements: To calculate the probability of either American Society of Anesthesiologists Physical Status (ASA PS) score ≥ 3 or physiologically complex cases (defined as Common Procedural Terminology start-up units ≥8), we performed mixed effects logistic regression for each institution per facility type, controlling for year and using facility identification as the random effect. We present the mean rate of these two classifications as case per 10,000 cases and report the 99.9% confidence interval (CI), to control for multiple comparisons.Main Results: Among all cases, 5,919,844 (64.2%) were classified as ASA PS 1 or 2 and 254,110 (2.8%) of surgical procedures were considered physiologically complex. The mean rate of cases with ASA PS ≥ 3in the university setting was 2982 per 10,000 cases [99.9% CI 2701-3278 per 10,000 cases]. Large community hospitals had a higher proportion of ASA PS ≥3 patients, medium-sized hospitals had no difference, and all other facility types had a decreased proportion. The mean rate of cases that were physiologically complex in the university setting was 133 per 10,000 cases [99.9% CI 117-151 per 10,000 cases]. Large community hospitals had a higher proportion of physiologically complex cases, medium-sized and small-sized hospitals had no difference, and all other facility types had a decreased proportion.Conclusions: Freestanding and attached surgery centers exhibited smaller rates of patients that were ASA PS ≥ 3, as well as a decrease in surgically complex cases, when compared to university settings. This suggests that the level of conservativeness for patient and surgery appropriateness for outpatient surgery differs across various facility types. [ABSTRACT FROM AUTHOR]

Background: As the health care system in the United States shifts toward value-based care, there has been increased interest in performing total joint arthroplasty in the outpatient setting to optimize costs, outcomes, and patient satisfaction. Several studies have demonstrated success in performing ambulatory total knee and hip arthroplasty. The purpose of this study was to compare short-term outcomes and complications after total elbow arthroplasty (TEA) across the inpatient and outpatient operative settings., Methods: The American College of Surgeons National Quality Improvement Program database was queried to identify 575 patients undergoing primary TEA using the Current Procedural Terminology code 24363. Of this sample, 458 were inpatient and 117 were outpatient procedures. Propensity score matching using a 3:1 inpatient-to-outpatient ratio was performed to account for baseline differences in several variables-age, sex, body mass index class, American Society of Anesthesiologists class, and various comorbidities-between the inpatient and outpatient groups. After matching, the rates of various short-term outcomes and complications were compared between the inpatient and outpatient groups., Results: Inpatient TEA was associated with a higher rate of complications relative to outpatient TEA, including non-home discharge (14.9% vs. 7.5%, P = .05), unplanned hospital readmission (7.4% vs. 0.9%, P = .01), surgical complications (7.6% vs. 2.6%, P = .04), and medical complications (3.6% vs. 0.0%, P = .04)., Conclusion: Outpatient TEA has a lower short-term complication rate than inpatient TEA. Outpatient TEA should be considered for patients for whom such a discharge pathway is feasible. Future research should focus on risk stratification of patients and specific criteria for deciding when to pursue outpatient TEA., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Hazardous drug exposure is an occupational health hazard to oncology nurses. Sparse data are available regarding the frequency and characteristics of hazardous drug spills., Objectives: This article aims to describe nurses' hazardous drug exposures and use of personal protective equipment during drug spills., Methods: The Drug Exposure Feedback and Education for Nurses' Safety study launched in March 2015. When drug spills occurred, consented RNs administering chemotherapy in ambulatory infusion settings completed brief questionnaires. Descriptive statistics were used to summarize equipment use and spill events., Findings: Spills were common, despite the use of closed-system transfer devices. Over two years, 51 nurses from 12 participating academic infusion centers reported 61 unique spills. Spills commonly involved highly toxic drugs. Personal protective equipment use during drug spills was suboptimal. These foundational data reveal gaps in clinical practice.

Background Nocturnal hypertension, defined by a mean asleep systolic blood pressure (SBP)/diastolic blood pressure (BP) ≥120/70 mm Hg, and nondipping SBP, defined by an awake-to-asleep decline in SBP <10%, are each associated with increased risk for cardiovascular disease. Methods and Results We developed predictive equations to identify adults with a high probability of having nocturnal hypertension or nondipping SBP using data from the CARDIA (Coronary Artery Risk Development in Young Adults) study (n=787), JHS (Jackson Heart Study) (n=1063), IDH (Improving the Detection of Hypertension) study (n=395), and MHT (Masked Hypertension) study (n=772) who underwent 24-hour ambulatory BP monitoring. Participants were randomized to derivation (n=2511) or validation (n=506) data sets. The prevalence rates of nocturnal hypertension and nondipping SBP were 39.7% and 44.9% in the derivation data set, respectively, and 36.6% and 44.5% in the validation data set, respectively. The predictive equation for nocturnal hypertension included age, race/ethnicity, smoking status, neck circumference, height, high-density lipoprotein cholesterol, albumin/creatinine ratio, and clinic SBP and diastolic BP. The predictive equation for nondipping SBP included age, sex, race/ethnicity, waist circumference, height, alcohol use, high-density lipoprotein cholesterol, and albumin/creatinine ratio. Concordance statistics (95% CI) for nocturnal hypertension and nondipping SBP predictive equations in the validation data set were 0.84 (0.80-0.87) and 0.73 (0.69-0.78), respectively. Compared with reference models including antihypertensive medication use and clinic SBP and diastolic BP as predictors, the continuous net reclassification improvement (95% CI) values for the nocturnal hypertension and nondipping SBP predictive equations were 0.52 (0.35-0.69) and 0.51 (0.34-0.69), respectively. Conclusions These predictive equations can direct ambulatory BP monitoring toward adults with high probability of having nocturnal hypertension and nondipping SBP.

Objectives: To report nationwide estimates of ambulatory tonsillectomies performed in hospitals and ambulatory surgery centers in the United States., Study Design: Cross-sectional survey., Setting: National databases., Subjects and Methods: We analyzed the 2010 National Hospital Ambulatory Medical Care Survey of hospitals and ambulatory surgery centers for pediatric patients undergoing tonsillectomy with or without adenoidectomy. We determined estimations of the number of procedures, demographics, and outcomes. A tonsillectomy cohort from the 2009 National Inpatient Sample served as a comparison group., Results: In 2010, there were an estimated 339,000 (95% CI, 288,000-391,000) ambulatory tonsillectomies in the United States. The mean age was 7.8 years (SD, 5.1), and 71,000 (21.0%) were <3 years old. The male:female ratio was even (51% vs 49%). The racial makeup mirrored the US census (69% white, 18% Hispanic, and 12% black). Obstructive sleep-disordered breathing was reported in 48%. Perioperative events such as apnea, hypoxia, or bleeding occurred 7.8% of the time. Approximately 9% of patients could not be discharged home. When compared with cases of inpatient tonsillectomies, ambulatory cases comprised older patients (7.8 vs 5.9 years, P < .001) and were less likely to include obstructive sleep-disordered breathing (48% vs 77%, P < .001)., Conclusion: Tonsillectomy was one of the most common ambulatory surgical procedures in 2010 in the United States. The majority of patients were low risk, but some at higher risk were included (age ≤3 years and obstructive sleep apnea). The National Hospital Ambulatory Medical Care Survey estimates provide useful baseline data for future research on quality measures and outcomes.

Objectives: Antimicrobial agents are commonly used in ambulatory care settings. Our objective was to examine national-level patterns of contraindications between oral antibacterial or antifungal agents and patients' other oral medications in the US ambulatory care setting., Methods: This cross-sectional study included multiple year pooled data (2003-2011) from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey (NHAMCS Outpatient Department). Visits by adults (age ≥18 years) in ambulatory settings in the United States who were prescribed oral antibacterial or antifungal agents were evaluated for potential drug-drug interaction (DDI) contraindications. Findings with relative standard error >30% or unweighted sample size <30 were not reported because these were deemed unreliable estimates., Results: From 2003 to 2011, there were 1 235 000 outpatient visits (proportion = 0.52%; 95% confidence interval (CI), 0.29-0.74) in which a patient was prescribed an antimicrobial agent associated with a contraindicated DDI. The most prevalent antimicrobials with contraindicated combination among outpatients were simultaneous use of macrolide-containing products (erythromycin or clarithromycin) with statin medication-containing products (simvastatin or lovastatin) (841 864 visits, proportion = 1.91%; 95% CI, 0.96-2.86). The next most common combination was use of fluoroquinolones with antiarrhythmic agents (amiodarone, sotalol, quinidine or procainamide) (365 622 visits, proportion = 0.19%; 95% CI, 0.06-0.32)., Conclusions: Providers should be aware of potential contraindicated DDIs when prescribing antibiotics, especially macrolides and fluoroquinolones., (Copyright © 2018 European Society of Clinical Microbiology and Infectious Diseases. All rights reserved.)

Background: The aim of the study was to assess the rate of 30-d hospital readmissions after ambulatory laparoscopic cholecystectomy., Materials and Methods: The 2009 to 2011 State Ambulatory Surgery and Services and State Inpatient Databases from California, Florida, and New York were analyzed to evaluate the incidence of 30-d readmissions after laparoscopic cholecystectomy performed in outpatient settings. Hospital transfers and the principal diagnoses of hospital readmission were analyzed as secondary outcomes. Multilevel generalized mixed linear regression analyses with fixed and random effects were used to evaluate variables associated with increased likelihood of readmissions., Results: A total of 230,745 encounters for ambulatory laparoscopic cholecystectomies performed in 890 ambulatory facilities between 2009 and 2011 in the three states were analyzed. The rate of 30-d readmission was 20.2 per 1000 discharges. The rate of direct transfers from the ambulatory surgery center to an acute care hospital was 0.6 per 1000 discharges. The most common diagnoses of readmission were surgical complications, postoperative pain, infection, and nausea or vomiting. After adjusting for comorbidities, increasing age, male sex, non-Hispanic white race/ethnicity, any nonprivate insurance type, diagnosis of acute cholecystitis, use of intraoperative cholangiography, and having the procedure performed on a weekend were significantly associated with increased odds of 30-d readmissions., Conclusions: This large-state data analysis reveals that the unplanned admission and readmission rates after laparoscopic cholecystectomy are very low. Some causes of readmission (e.g., pain, nausea, and vomiting) are modifiable by the intervention of surgeons and anesthesia providers., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Nitrous oxide and the volatile inhalational anesthetics have defined anxiety and pain control in both dentistry and medicine for over a century. From curious experimentation to spectacular public demonstrations, the initial work of 2 dentists, Horace Wells and William T. G. Morton, persists to this day in modern surgery and anesthesia. This article reviews the history, similarities, differences, and clinical applications of the most popular inhalational agents used in contemporary dental surgical settings.

Objectives: Spinal cord stimulators (SCS) are increasingly placed in the United States in both the inpatient and outpatient setting. Although these interventions appear to be safe, the characteristics of the patients selected for ambulatory procedures have not been investigated., Materials and Methods: We performed a retrospective cohort study involving 4843 patients who underwent outpatient and 4197 who underwent inpatient SCS placements and were registered in State Ambulatory Surgery Databases and State Inpatient Databases, respectively, for New York, California, Florida, and North Carolina from 2005 to 2008., Results: In a multivariate analysis, male gender (odds ratio (OR) 1.22, 95% confidence interval (CI), 1.12, 1.33), high volume hospitals (OR 2.16, 95% CI, 1.94, 2.41), and Caucasian race (OR 1.25, 95% CI, 1.10, 1.41) were significantly associated with outpatient procedures. Higher Charlson Comorbidity Index (OR 0.36, 95% CI, 0.24, 0.54) and Medicare/Medicaid insurance (OR 0.75, 95% CI, 0.67, 0.83) were associated with a decreased chance of outpatient procedures. The rate of 30-day postoperative readmissions was higher among inpatients. Institutional charges were significantly lower for outpatient lumbar discectomies. The median total charge for inpatient hospitalization after SCS placement was $60,624 as compared with $22,288 for the outpatient setting (p < 0.0001)., Conclusions: Access to ambulatory SCS placement appears to be more common for Caucasians, male patients, with private insurance, and fewer comorbidities, in the setting of higher volume hospitals. Further investigation is needed in the direction of mapping these disparities for appropriate resource utilization., (© 2013 International Neuromodulation Society.)

Background: Data from prospective cohort studies regarding the association between ambulatory heart rate (HR) and cardiovascular events (CVE) are conflicting., Methods: To investigate whether ambulatory HR predicts CVE in hypertension, we performed 24-hour ambulatory blood pressure and HR monitoring in 7600 hypertensive patients aged 52 ± 16 years from Italy, U.S.A., Japan, and Australia, included in the 'ABP-International' registry. All were untreated at baseline examination. Standardized hazard ratios for ambulatory HRs were computed, stratifying for cohort, and adjusting for age, gender, blood pressure, smoking, diabetes, serum total cholesterol and serum creatinine., Results: During a median follow-up of 5.0 years there were 639 fatal and nonfatal CVE. In a multivariable Cox model, night-time HR predicted fatal combined with nonfatal CVE more closely than 24h HR (p=0.007 and =0.03, respectively). Daytime HR and the night:day HR ratio were not associated with CVE (p=0.07 and =0.18, respectively). The hazard ratio of the fatal combined with nonfatal CVE for a 10-beats/min increment of the night-time HR was 1.13 (95% CI, 1.04-1.22). This relationship remained significant when subjects taking beta-blockers during the follow-up (hazard ratio, 1.15; 95% CI, 1.05-1.25) or subjects who had an event within 5 years after enrollment (hazard ratio, 1.23; 95% CI, 1.05-1.45) were excluded from analysis., Conclusions: At variance with previous data obtained from general populations, ambulatory HR added to the risk stratification for fatal combined with nonfatal CVE in the hypertensive patients from the ABP-International study. Night-time HR was a better predictor of CVE than daytime HR., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)