Use of preoperative antidepressants is not associated with postoperative hospital length of stay

Preoperative Antidepressant Prescriptions Are Associated With Increased Opioid Prescriptions and Health Care Use but Similar Rates of Secondary Surgery Following Primary Anterior Cruciate Ligament Reconstruction in a Young Adult Population

PURPOSE

To compare adverse events, postoperative opioid-prescribing patterns, health care use, and secondary anterior cruciate ligament reconstruction (ACLR) surgery rates of patients undergoing primary ACLR with a preoperative antidepressant prescription (ADP) against a propensity-matched group with no preoperative antidepressant prescription (NADP) using the TriNetX Diamond Network.

METHODS

Patients undergoing primary ACLR between ages 18 and 35 years of age were queried from the database using International Classification of Diseases, Tenth Revision/Current Procedural Terminology codes. Patients with an ADP were propensity matched in a 1:1 ratio to patients with NADP based on 11 patient characteristics. Postoperative rates of adverse events, emergency department (ED) visits, in-patient hospitalizations, outpatient services, physical therapy evaluations, postoperative opioid prescriptions, and secondary ACLR were compared at various time points.

RESULTS

In total, 3,736 patients with an ADP with an average age of 21.4 ± 4.5 years undergoing primary ACLR were propensity matched to patients with NADP. A significantly greater percentage of patients with an ADP received opioid prescriptions at 2 weeks (ADP 21%, NADP 11.3%, odds ratio [OR] 2.08), 6 weeks (ADP 25.5%, NADP 13.9%, OR 2.13), 3 months (ADP 27.6%, NADP 15.6%, OR 2.07), 6 months (ADP 30.5%, NADP 17.2%, OR 2.1), and 1 year (ADP 35.3%, NADP 20.2%, OR 2.16) postoperatively (P <.0001 for each time point). Patients with ADP had greater rates of ED visits (ADP 9.7%, NADP 7.1%, P < .0001, OR 1.39) and outpatient appointments (ADP 28.3%, NADP 21.8%) P < .0001, OR 1.42) at 3 months' postoperatively. Secondary surgery rates at 1 and 2 years were nonsignificant (P = .381 and P = .062, respectively).

CONCLUSIONS

Following ACLR, patients with ADP had a significant increase in postoperative opioid prescriptions at all time points and used more ED resources and outpatient services compared with patients with NADP at 3 months' postoperatively. Thirty-day postoperative adverse events and both 1- and 2-year secondary ACL surgery rates demonstrated no significant differences between the groups.

LEVEL OF EVIDENCE

Level III, retrospective comparative case series.

Impact of preoperative treatment with antidepressants and/or anxiolytics on outcomes after colorectal surgery with an enhanced recovery programme: a monocentric retrospective study. Acta Chir Belg 2023;123:54-61. [PMID: 34121612 DOI: 10.1080/00015458.2021.1940727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BACKGROUND

Preoperative use of antidepressants and anxiolytics was reported to increase length of hospital stay (LOS) and worsen surgical outcomes. However, the surgical procedures studied were seldom performed with an enhanced recovery programme (ERP). This study investigated whether these medications impaired postoperative recovery after colorectal surgery with an ERP.

METHODS

The data of all patients scheduled for colorectal surgery between November 2015 and December 2019 prospectively included in our database were analysed. All the patients were managed with the same ERP. Demographic data, risk factors, incidence of postoperative complications, LOS, and adherence to the ERP were compared between patients with and without preoperative antidepressant and/or anxiolytic treatment.

RESULTS

Of the 502 patients, 157 (31.3%) were treated with antidepressants and/or anxiolytics. They were older (65.7 vs. 59.5 years, p < 0.001), sicker (higher ASA physical status score, p = 0.001), and underwent surgery more frequently for cancer (73.9 vs. 56.8%, p < 0.001). Overall adherence to ERP (p = 0.99) and adherence to the postoperative items of ERP (p = 0.29), incidence of postoperative complications (35.7 vs. 33.2%, p = 0.61), and LOS (4 [2-7] vs. 4 [2-7], p = 0.99) were similar in the two groups.

CONCLUSIONS

Our findings suggest that preoperative treatment with antidepressants and/or anxiolytics does not worsen outcome after elective colorectal surgery with an ERP, does not impact adherence to ERP, and does not prolong LOS. ERP seems efficacious in patients treated with these medications, who should therefore not be excluded from this programme.

Preoperative opioid, sedative, and antidepressant use is associated with increased postoperative hospital costs in colorectal surgery

Background

Opioid (OPD), sedative (SDT), and antidepressant (ADM) prescribing has increased dramatically over the last 20 years. This study evaluated preoperative OPD, SDT, and ADM use on hospital costs in patients undergoing colorectal resection at a single institution.

Methods

This study was a retrospective record review. The local ACS-NSQIP database was queried for adult patients (age ≥ 18 years) undergoing open/laparoscopic, partial/total colectomy, or proctectomy from January 1, 2013 to December 31, 2016. Individual patient medical records were reviewed to determine preoperative OPD, SDT, and AD use. Hospital cost data from index admission were captured by the hospital cost accounting system and matched to NSQIP query-identified cases. All ACS-NSQIP categorical patient characteristic, operative risk, and outcome variables were compared in medication groups using chi-square tests or Fisher’s exact tests, and continuous variables were compared using Mann–Whitney U tests.

Results

A total of 1185 colorectal procedures were performed by 30 different surgeons. Of these, 27.6% patients took OPD, 18.5% SDT, and 27.8% ADM preoperatively. Patients taking OPD, SDT, and ADM were found to have increased mean total hospital costs (MTHC) compared to non-users (30.8 vs 23.6 for OPD, 31.6 vs 24.4 for SDT, and 30.7 vs 23.8 for ADM). OPD and SDT use were identified as independent risk factors for increased MTHC on multivariable analysis.

Conclusion

Preoperative OPD and SDT use can be used to predict increased MTHC in patients undergoing colorectal resections.

Depressive and Anxiety Symptoms Screening in Cardiac Inpatients: A Virtuous Italian Approach to Psychocardiology

Despite the fact that American Heart Association (AHA) recommended a systematic screening for depression in cardiovascular inpatients, poor attention has been given to this issue. Furthermore, no specific guidelines exist for anxiety screening in cardiovascular inpatients. Thus, the aims of this study were to verify the feasibility of a depressive and anxiety symptoms screening protocol in an Italian hospital specializing in cardiovascular diseases and to evaluate both anxiety and depressive symptoms prevalence. A group of 2009 consecutive inpatients completed the 9-item Patient Health Questionnaire (PHQ-9) and the 7-item Generalized Anxiety Disorder (GAD-7). The rates of depressive and anxiety symptoms were almost 9% and 16% respectively. Men were less likely than women to experience both depressive and anxiety symptoms. Patients who were admitted to the heart failure unit reported higher risk of experiencing both symptoms compared to patients in other wards. Similarly, patients admitted to the cardiac surgery unit showed a higher risk of experiencing anxiety symptoms compared to other patients. The proposed screening procedure showed a good feasibility and acceptance. This study highlighted the importance of implementing a short screening procedure in hospitals dealing with cardiovascular inpatients to identify those individuals who require specific attention and interventions.

A Retrospective Review: Patient-Reported Preoperative Prescription Opioid, Sedative, or Antidepressant Use Is Associated with Worse Outcomes in Colorectal Surgery

BACKGROUND

Prescription opioid, sedative, and antidepressant use has been on the rise. The effect of these medications on outcomes in colorectal surgery has not been established.

OBJECTIVE

This study aimed to evaluate the impact of preoperative prescription opioid, sedative, and antidepressant use on postoperative outcomes following colorectal surgery.

DESIGN

This study was a retrospective database and medical record review.

SETTINGS

This study was conducted at University of Kentucky utilizing the local American College of Surgeons National Surgical Quality Improvement Project database.

PATIENTS

All patients ≥18 years of age who underwent colorectal resection for all indications, excluding trauma, between January 1, 2013, and December 31, 2016, were included.

MAIN OUTCOME MEASURES

The primary outcomes measured were the rates of 30-day postoperative morbidity and mortality.

RESULTS

Of 1201 patients, 30.2% used opioids, 18.4% used sedatives, and 28.3% used antidepressants preoperatively. Users of any medication class had higher ASA classification, rates of dyspnea, and severe chronic obstructive pulmonary disease than nonusers. Opioid users also had higher rates of ostomy creation, contaminated wound classification, prolonged operation time, and postoperative transfusion. Postoperatively, patients had higher rates of intra-abdominal infection (opioids: 21.5% vs 15.2%, p = 0.009; sedatives: 23.1% vs 15.7%, p = 0.01; antidepressants: 22.4% vs 15.0%, p = 0.003) and respiratory failure (opioids: 11.0% vs 6.3%, p = 0.007; sedatives: 12.2% vs 6.7%, p = 0.008; antidepressants: 10.9% vs 6.5%, p = 0.02). Reported opioid or sedative users had a prolonged hospital length of stay of 2 days (p < 0.001) compared with nonusers. After adjustment for all predictors of poor outcome, opioid and sedative use was associated with increased 30-day morbidity and mortality following colorectal procedures (OR, 1.43; 95% CI, 1.07-1.91 and OR, 1.48; 95% CI, 1.05-2.08).

LIMITATIONS

This study was a retrospective review and a single-institution study, and it had unmeasured confounders.

CONCLUSIONS

We identified that patient-reported prescription opioid and sedative use is associated with higher 30-day composite adverse outcomes in colorectal resections, highlighting the need for the evaluation of opioid and sedative use as a component of the preoperative risk stratification. See Video Abstract at http://links.lww.com/DCR/B226. REVISIÓN RETROSPECTIVA: EL USO DE OPIOIDES, SEDANTES O ANTIDEPRESORES EN EL PREOPERATORIO SE ASOCIAN CON MALOS RESULTADOS EN CIRUGÍA COLORECTAL: El uso de opioides, sedantes y antidepresores esta en aumento. No se ha establecido el efecto de estos medicamentos en los resultados de la cirugía colorrectal.Evaluar el impacto del uso preoperatorio de opioides, sedantes y antidepresores en los resultados después de una cirugía colorrectal.Base de datos retrospectiva y revisión de registros médicos.Este estudio se realizó en la Universidad de Kentucky utilizando la base de datos del Proyecto de Mejora de Calidad Quirúrgica Nacional del Colegio Estadounidense de Cirujanos.Todos los pacientes ≥ 18 años que se sometieron a una resección colorrectal por diversas indicaciones, excluyendo los traumas, entre el 1 de Enero de 2013 y el 31 de Diciembre de 2016.Tasas de morbilidad y mortalidad postoperatorias a los 30 días.De 1201 pacientes, 30.2% usaron opioides, 18.4% usaron sedantes y 28.3% usaron antidepresores antes de la cirugía. Los pacientes tratados con cualquiera de los medicamentos mencionados, presentaban un ASA mas elevado, tasas de disnea y EPOC mas graves en comparación con pacientes sin tratamiento previo. Los consumidores de opioides también tuvieron tasas más altas de creación de ostomías, clasificación mas alta de heridas contaminadas, un tiempo de operación prolongado y transfusión postoperatoria mayor. Después de la cirugía los pacientes que tuvieron tasas más altas de infección intraabdominal (opioides: 21.5% vs 15.2%, p = 0.009, sedantes: 23.1% vs 15.7%, p = 0.01, antidepresivos: 22.4% vs 15.0%, p = 0.003) e insuficiencia respiratoria (opioides: 11.0% vs 6.3%, p = 0.007, sedantes: 12.2% vs 6.7%, p = 0.008, antidepresivos: 10.9% vs 6.5%, p = 0.02). Los consumidores de opioides o sedantes tuvieron una estadía hospitalaria prolongada de más de 2 días (p <0.001) en comparación con los consumidores. Después de haber realizado el ajuste de todos los predictores de mal pronóstico, el uso de opioides y sedantes se asoció con una mayor morbilidad y mortalidad a los 30 días después de cirugía colorrectal (OR 1.43 [IC 95% 1.07-1.91] y OR 1.48 [IC 95% 1.05-2.08], respectivamente)Revisión retrospectiva, estudio de una sola institución, factores de confusión no evaluados.Identificamos que el consumo de opiáceos y sedantes recetados a los pacientes se asocian con resultados adversos complejos más allá de 30 días en casos de resección colorrectal, destacando la necesidad de su respectiva evaluación como componentes de la estratificación de riesgo preoperatorio. Consulte Video Resumen http://links.lww.com/DCR/B226. (Traducción-Dr. Xavier Delgadillo).

Postoperative complications in adult spinal deformity patients with a mental illness undergoing reconstructive thoracic or thoracolumbar spine surgery

BACKGROUND CONTEXT

Previous studies have found an association between mental illness and poor outcomes in spine surgery, but little is known about the effects of depression and/or anxiety on the adult spinal deformity population. In addition, most relevant studies exclusively focused on the lumbar spine and had relatively small patient sizes.

PURPOSE

The aim of this study was to investigate whether adult spinal deformity patients with depression and/or anxiety have an increased risk of postoperative complications and reoperation following posterior thoracolumbar spinal surgery.

STUDY DESIGN/SETTING

Retrospective database study.

METHODS

Adult patients (over 18 years of age) with a diagnosis of spinal deformity undergoing any reconstructive thoracic or thoracolumbar spinal procedure with a posterior approach between 2007 and 2015 Q2 were identified using Current Procedural Terminology codes to query the Pearl Diver patient record database (Pearl Diver Technologies, West Conshohocken, PA, USA). The database includes records of approximately 18 million patients across the United States having Humana insurance. Further selection of patients with depression and/or anxiety and their associated postoperative complications were identified using ICD-9 and ICD-10 diagnosis codes (International Classification of Diseases 9th-10th edition). The mental illness cohort was matched to a control group according to age, sex, and Charlson Comorbidity Index. Patient data was analyzed for reoperation rates and incidence of common postoperative complications.

RESULTS

Multilevel posterolateral fusion was the most common included posterior thoracic reconstructive surgery. The mental illness cohort (n = 327) had significantly increased rates of infection (odds ratio [OR] = 1.743, p = .022) and respiratory complications (OR = 1.492, p = .02) at the 90-day postoperative period. The rates of incision and drainage (OR = 1.379, p = .475) and pneumonia (OR = 1.22, p = .573) were increased in the mental illness cohort at the 90-day postoperative period, but not significantly. There were no significant differences in complication and reoperation rates at 1-year postoperatively.

CONCLUSIONS

Patients with spinal deformity and pre-existing depression and/or anxiety treated with a posterior thoracolumbar reconstructive spinal surgery had significantly elevated risk of postoperative infections and respiratory complications when compared with the control group.

Impact of preoperative physical activity and depressive symptoms on post-cardiac surgical outcomes

Objective

To determine the independent and combined impact of preoperative physical activity and depressive symptoms with hospital length of stay (HLOS), and postoperative re-hospitalization and mortality in cardiac surgery patients.

Methods

A cohort study including 405 elective and in-house urgent cardiac surgery patients were analyzed preoperatively. Physical activity was assessed with the International Physical Activity Questionnaire to categorize patients as active and inactive. The Patient Health Questionnaire-9 was used to evaluate preoperative depressive symptoms and categorize patients as depressed and not depressed. Patients were separated into four groups: 1) Not depressed/active (n = 209), 2) Depressed/active (n = 48), 3) Not depressed/inactive (n = 101), and 4) Depressed/inactive (n = 47). Administrative data captured re-hospitalization and mortality data, and were combined into a composite endpoint. Models adjusted for demographics, comorbidities, and cardiac surgery type. Multiple imputation was used to impute missing values.

Results

Preoperative physical activity behavior and depression were not associated with HLOS examined in isolation or when analyzed by the physical activity/depressive symptom groups. Physical inactivity (HR: 1.60, 95% CI 1.05 to 2.42; p = 0.03), but not depressive symptoms, was independently associated with the composite outcome. Freedom from the composite outcome were 76.1%, 87.5%, 68.0%, and 61.7% in the Not depressed/active, Depressed/active, Not depressed/inactive, and Depressed/inactive groups, respectively (P = 0.02). The Active/Depressed group had a lower risk of the composite outcome (HR: 0.35 95% CI 0.14 to 0.89; p = 0.03) compared to the other physical activity/depression groups.

Conclusion

Preoperative physical activity appears to be more important than depressive symptoms on short-term postoperative re-hospitalization and mortality.

The Effect of Preoperative Medications on Length of Stay, Inpatient Pain, and Narcotics Consumption After Minimally Invasive Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

This is a retrospective cohort study.

OBJECTIVE

To determine the association between preoperative medications and length of stay, inpatient pain, and narcotics consumption after a minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

SUMMARY OF BACKGROUND DATA

Previous studies have identified risk factors for increased length of hospital stay, inpatient pain, and narcotics consumption. However, little is known regarding the effects of preoperative medications on outcomes after spine surgery.

METHODS

A prospectively maintained surgical database of patients undergoing primary, single-level MIS TLIF was retrospectively reviewed. Preoperative medications taken within 30 days before surgery were recorded for each patient and categorized by medication type. Poisson regression with robust error variance was used to determine the association between preoperative medications and length of stay, pain scores, and narcotics consumption. Multivariate analysis was performed using a backwards, stepwise regression to identify independent risk factors.

RESULTS

In total, 138 patients were included in this analysis. On bivariate analysis, benzodiazepines were associated with longer hospital stays [relative risk (RR)=2.03; P=0.031]. Benzodiazepines (RR=3.71; P<0.001) and preoperative narcotics (RR=2.60; P=0.012) were risk factors for pain ≥7 on postoperative day 0. On multivariate analysis, benzodiazepines were an independent risk factor for prolonged stay. Benzodiazepines, narcotics, and nonsteroidal anti-inflammatories were identified as independent risk factors for increased postoperative pain.

CONCLUSIONS

These results suggest that benzodiazepines are a risk factor for increased length of stay and postoperative pain after MIS TLIF. Preoperative narcotics and nonsteroidal anti-inflammatories were also identified as risk factors for postoperative pain though this did not lead to increases in narcotics consumption. Patients taking these medications should undergo more vigilant perioperative monitoring for adequate pain management. More work must be done to further elucidate the association between preoperative medications and postoperative outcomes after MIS TLIF.

Psychotropics, Environmental Temperature, and Hospital Outcomes in Older Medical Patients

PURPOSE

The authors investigated whether the use of psychotropics and environmental temperature on admission influence hospital length of stay (LOS) and mortality in older medical patients.

METHODS

Clinical and demographic characteristics, Charlson Comorbidity Index, use of psychotropic and nonpsychotropic drugs, hospital LOS, and mortality were retrospectively collected in medical patients 65 years and older (n = 382) admitted to a metropolitan teaching hospital during 5 consecutive heat waves (HWs) between 2007 and 2009. Patients admitted either before or after each HW, matched for HW period, age, and admission day of the week, served as controls (non-HW, n = 1339).

RESULTS

Total number of psychotropic and nonpsychotropic drugs, Charlson Comorbidity Index, comorbidities, number of daily admissions, LOS, and mortality were similar in the HW and non-HW groups. After adjusting for clinical and demographic confounders, competing risks regression showed that psychotropic use, particularly antipsychotics, predicted increased LOS during non-HW (subdistribution hazard ratio: 95% CI, 0.82, 0.72-0.94; P = 0.003) but not HW (subdistribution hazard ratio: 95% CI, 0.89, 0.69-1.14; P = 0.36) periods. The effect of psychotropics on LOS during normal weather conditions was particularly evident in the old-old subgroup (difference [SE] in coefficients between non-HW and HW periods: -0.52 [0.25], P = 0.036 in patients >80 years; 0.11 [0.19], P = 0.54, in patients 65-80 years). By contrast, psychotropics did not predict hospital mortality during non-HW or HW periods.

CONCLUSIONS

Psychotropic use on admission, particularly antipsychotics, predicted hospital LOS, but not mortality, in older medical patients, particularly those older than 80 years, during normal environmental temperature. However, there was no effect of psychotropics on LOS during extreme heat.

Psychiatric Disorders and Psychopharmacologic Treatment as Risk Factors in Elective Fast-track Total Hip and Knee Arthroplasty

BACKGROUND

Psychiatric disorder (PsD) is rarely considered when evaluating perioperative risk factors. Studies on PsD are often limited by use of administrative coding, incomplete follow-up, and lack of preoperative data on psychopharmacological treatment.

METHODS

A multicenter study with prospective registration on preoperative comorbidity, complete 90-day follow-up, and information on dispensed prescriptions on psychopharmacological treatment (excluding benzodiazepines). All departments used similar fast-track approaches and discharge to home. Evaluation of postoperative morbidity was based on discharge records. Odds ratios for length of stay (LOS) more than 4 days and surgery-related readmissions were calculated using multiple logistic regression adjusting for potential confounders.

RESULTS

Of 8,757 procedures, 1,001 (11.4%) were in PsD patients. Of these, 43.4% used selective serotonin inhibitors (SSRIs), 31.6% used other antidepressants, 8.5% used a combination, and 16.5% used antipsychotics. PsD was associated with increased risk of LOS more than 4 days (16.5 vs. 7.3%; odds ratio, 1.90; 95% CI, 1.52 to 2.37), regardless of treatment with SSRIs (2.19; 1.62 to 2.97), other antidepressants (1.81; 1.25 to 2.61), or antipsychotics (1.90; 1.62 to 3.16). PsD was associated with increased 30- (9.9 vs. 5.1%; 1.93; 1.49 to 2.49) and 90-day surgery-related readmissions (12.8 vs. 7.4%; 1.68; 1.34 to 2.10), significant for SSRIs (1.97; 1.38 to 2.82 and 1.77; 1.29 to 2.43), other antidepressants (2.24; 1.51 to 3.32 and 1.82; 1.27 to 2.61), and antipsychotics (1.85; 1.03 to 3.31, 30 days only). In PsD patients, pain (1.4%), postoperative anemia (1.1%), and pulmonary complications (1.1%) were the most frequent causes of LOS more than 4 days. Hip displacements (2.8%) and falls (1.9%) were the most frequent readmissions, and 90-day surgery-related mortality was 0.7% with and 0.2% without PsD.

CONCLUSIONS

Psychopharmacologically treated PsD is a risk factor for postoperative morbidity after fast-track arthroplasty, regardless of treatment type. This may be due to PsD per se and/or drug-related side effects.