Hospital-, anaesthetist-, and patient-level variation in peripheral nerve block utilisation for hip fracture surgery: a population-based cross-sectional study

Association Between Single-Injection Regional Analgesia and Postoperative Pain in Cardiac Surgery Patients: A Single-Center Retrospective Cohort Study

OBJECTIVES

Effective pain control after cardiac surgery may facilitate recovery. This study aimed to assess the use and association of ultrasound-guided single-injection chest wall blocks with liposomal bupivacaine on postoperative pain scores and short-term opioid requirements after cardiothoracic surgery at a single institution.

DESIGN

Retrospective cohort study.

SETTING

Midwestern academic hospital.

PARTICIPANTS

Adult patients who underwent cardiothoracic surgery between July 1, 2020, and June 30, 2022.

INTERVENTIONS

Ultrasound-guided single-injection chest wall block with liposomal bupivacaine.

MEASUREMENTS AND MAIN RESULTS

Of the 1,038 patients included in this study, 301 (29%) received a perioperative nerve block for postoperative sternotomy pain, and 737 (71%) did not. Most of the single-shot blocks were bilateral parasternal intercostal plane blocks (n = 294 [98%]) performed after induction and before surgical incision (n = 280 [93%]). After adjusting for age, gender, American Society of Anesthesiologists status, select comorbidities, and surgical procedure type, mean postoperative pain scores were not significantly different between groups in the immediate postoperative period at all time points assessed (12 ± 2 hours, 24 ± 4 hours, 48 ± 8 hours, and 72 ± 12 hours). Similarly, there was no difference in mean opioid requirements (milligram morphine equivalents) at 72 hours between groups (68.6 [95% confidence interval, 56.3-83.4] vs 62.9 [95% confidence interval, 52.8-74.9], p = 0.195).

CONCLUSIONS

In this retrospective study, the implementation of single-shot chest wall nerve blocks with liposomal bupivacaine was not associated with decreased postoperative pain scores or opioid consumption at 72 hours in select cardiac surgical patients at one institution.

Exploring Differences in Intraoperative Medication Use Between African American and Non-Hispanic White Patients During General Anesthesia: Retrospective Observational Cohort Study

This study aimed to explore whether differences exist in anesthesia care providers' use of intraoperative medication between African American and non-Hispanic White patients in adult surgical patients who underwent noncardiothoracic nonobstetric surgeries with general anesthesia. A retrospective observational cohort study used electronic health records between January 1, 2018 and August 31, 2019 at a large academic health system in the southeastern United States. To evaluate the isolated impact of race on intraoperative medication use, inverse probability of treatment weighting using the propensity scores was used to balance the covariates between African American and non-Hispanic White patients. Regression analyses were then performed to evaluate the impact of race on the total dose of opioid analgesia administered, and the use of midazolam, sugammadex, antihypotensive drugs, and antihypertensive drugs. Of the 31,790 patients included in the sample, 58.9% were non-Hispanic Whites and 13.6% were African American patients. After adjusting for significant covariates, African American patients were more likely to receive midazolam premedication (p < .0001; adjusted odds ratio [aOR] = 1.17, 99.9% CI [1.06, 1.30]), and antihypertensive drugs (p = .0002; aOR = 1.15, 99.9% CI [1.02, 1.30]), and less likely to receive antihypotensive drugs (p < .0001; aOR = 0.85, 99.9% CI [0.76, 0.95]) than non-Hispanic White patients. However, we did not find significant differences in the total dose of opioid analgesia administered, or sugammadex. This study identified differences in intraoperative anesthesia care delivery between African American and non-Hispanic White patients; however, future research is needed to understand mechanisms that contribute to these differences and whether these differences are associated with patient outcomes.

Using implementation science to promote the use of the fascia iliaca blocks in hip fracture care

PURPOSE

There is variable and suboptimal use of fascia iliaca compartment nerve blocks (FICBs) in hip fracture care. Our objective was to use an evidence-based and theory-informed implementation science approach to analyze barriers and facilitators to timely administration of FICB and select evidence-based interventions to enhance uptake.

METHODS

We conducted a qualitative study at a single centre using semistructured interviews and site observations. We interviewed 35 stakeholders including health care providers, managers, patients, and caregivers. We mapped barriers and facilitators to the Theoretical Domains Framework (TDF) and Consolidated Framework for Implementation Research (CFIR). We compared the rate and timeliness of FICB administration before and after evidence-based implementation strategies were applied.

RESULTS

The study identified 18 barriers and 11 facilitators within seven themes of influences of FICB use: interpersonal relationships between health care professionals; clinician knowledge and skills related to FICB; roles, responsibilities, and processes for delivering FICB; perceptions on using FICB for pain; patient and caregiver perceptions on using FICB for pain; communication of hip fracture care between departments; and resources for delivering FICBs. We mapped the behaviour change domains to eight implementation strategies: restructure the environment, create and distribute educational materials, prepare patients to be active participants, perform audits and give feedback, use local opinion leaders, use champions, train staff on FICB procedures, and mandate change. We observed an increase in the rates of FICBs administered (48% vs 65%) and a decrease in the median time to administration (1.63 vs 0.81 days).

CONCLUSION

Our study explains why FICBs are underused and shows that the TDF and CFIR provide a framework to identify barriers and facilitators to FICB implementation. The mapped implementation strategies can guide institutions to improve use of FICB in hip fracture care.

Identification and classification of principal features for analyzing unwarranted clinical variation

RATIONALE, AIMS, AND OBJECTIVE

Unwarranted clinical variation (UCV) is an undesirable aspect of a healthcare system, but analyzing for UCV can be difficult and time-consuming. No analytic feature guidelines currently exist to aid researchers. We performed a systematic review of UCV literature to identify and classify the features researchers have identified as necessary for the analysis of UCV.

METHODS

The literature search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We looked for articles with the terms 'medical practice variation' and 'unwarranted clinical variation' from four databases: Medline, Web of Science, EMBASE and CINAHL. The search was performed on 24 March 2023. The articles selected were original research articles in the English language reporting on UCV analysis in adult populations. Most of the studies were retrospective cohort analyses. We excluded studies reporting geographic variation based on the Atlas of Variation or small-area analysis methods. We used ASReview Lab software to assist in identifying articles for abstract review. We also conducted subsequent reference searches of the primary articles to retrieve additional articles.

RESULTS

The search yielded 499 articles, and we reviewed 46. We identified 28 principal analytic features utilized to analyze for unwarranted variation, categorised under patient-related or local healthcare context factors. Within the patient-related factors, we identified three subcategories: patient sociodemographics, clinical characteristics, and preferences, and classified 17 features into seven subcategories. In the local context category, 11 features are classified under two subcategories. Examples are provided on the usage of each feature for analysis.

CONCLUSION

Twenty-eight analytic features have been identified, and a categorisation has been established showing the relationships between features. Identifying and classifying features provides guidelines for known confounders during analysis and reduces the steps required when performing UCV analysis; there is no longer a need for a UCV researcher to engage in time-consuming feature engineering activities.

Association of Patient Race and Hospital with Utilization of Regional Anesthesia for Treatment of Postoperative Pain in Total Knee Arthroplasty: A Retrospective Analysis Using Medicare Claims

BACKGROUND

Regional anesthesia for total knee arthroplasty has been deemed high priority by national and international societies, and its use can serve as a measure of healthcare equity. The association between utilization of regional anesthesia for postoperative pain and (1) race and (2) hospital in patients undergoing total knee arthroplasty was estimated. The hypothesis was that Black patients would be less likely than White patients to receive regional anesthesia, and that variability in regional anesthesia would more likely be attributable to the hospital where surgery occurred than race.

METHODS

This study used Medicare fee-for-service claims for patients aged 65 yr or older who underwent primary total knee arthroplasty between January 1, 2011, and December 31, 2016. The primary outcome was administration of regional anesthesia for postoperative pain, defined as any peripheral (femoral, lumbar plexus, or other) or neuraxial (spinal or epidural) block. The primary exposure was self-reported race (Black, White, or Other). Clinical significance was defined as a relative difference of 10% in regional anesthesia administration.

RESULTS

Data from 733,406 cases across 2,507 hospitals were analyzed: 90.7% of patients were identified as White, 4.7% as Black, and 4.6% as Other. Median hospital-level prevalence of use of regional anesthesia was 51% (interquartile range, 18 to 79%). Black patients did not have a statistically different probability of receiving a regional anesthetic compared to White patients (adjusted estimates: Black, 53.3% [95% CI, 52.5 to 54.1%]; White, 52.7% [95% CI, 52.4 to 54.1%]; P = 0.132). Findings were robust to alternate specifications of the exposure and outcome. Analysis of variance revealed that 42.0% of the variation in block administration was attributable to hospital, compared to less than 0.01% to race, after adjusting for other patient-level confounders.

CONCLUSIONS

Race was not associated with administration of regional anesthesia in Medicare patients undergoing primary total knee arthroplasty. Variation in the use of regional anesthesia was primarily associated with the hospital where surgery occurred.

EDITOR’S PERSPECTIVE

Training programmes for healthcare professionals in managing postoperative epidural analgesia: A scoping review protocol

BACKGROUND

Epidural analgesia is an effective technique advocated worldwide for postoperative analgesia after a wide range of surgical procedures. Despite the benefits of epidural analgesia for pain management, systematic education of ward nurses in managing epidural analgesia appears to be lacking.

METHODS

The aim of the proposed scoping review is to map the body of evidence and identify training programmes for healthcare professionals in the safe management of postoperative epidural analgesia. The methodology will follow the Preferred Reporting Items for Systematic and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). In addition, the five main steps set forth by Arksey and O'Malley and refined by Levac for guidance of the process will be used. The scoping review will include any study design of any date, design, setting and duration.

RESULTS

We will present results descriptively, accompanied with visual presentations as tables and graphs.

CONCLUSION

The outlined scoping review will provide an overview of existing training programmes for healthcare professionals in the safe management of postoperative epidural analgesia and map the body of available evidence on the topic. The study may support the development of a training programme for ward nurses caring for patients receiving postoperative epidural analgesia.

Hospital-, Anesthesiologist-, Surgeon-, and Patient-Level Variations in Neuraxial Anesthesia Use for Lower Limb Revascularization Surgery: A Population-Based Cross-Sectional Study

BACKGROUND

Although neuraxial anesthesia may promote improved outcomes for patients undergoing lower limb revascularization surgery, its use is decreasing over time. Our objective was to estimate variation in neuraxial (versus general) anesthesia use for lower limb revascularization at the hospital, anesthesiologist, surgeon, and patient levels, which could inform strategies to increase uptake.

METHODS

Following protocol registration, we conducted a historical cross-sectional analysis of population-based linked health administrative data in Ontario, Canada. All adults undergoing lower limb revascularization surgery between 2009 and 2018 were identified. Generalized linear models with binomial response distributions, logit links and random intercepts for hospitals, anesthesiologists, and surgeons were used to estimate the variation in neuraxial anesthesia use at the hospital, anesthesiologist, surgeon, and patient levels using variance partition coefficients and median odds ratios. Patient- and hospital-level predictors of neuraxial anesthesia use were identified.

RESULTS

We identified 11,849 patients; 3489 (29.4%) received neuraxial anesthesia. The largest proportion of variation was attributable to the hospital level (50.3%), followed by the patient level (35.7%); anesthesiologists and surgeons had small attributable variation (11.3% and 2.8%, respectively). Mean odds ratio estimates suggested that 2 similar patients would experience a 5.7-fold difference in their odds of receiving a neuraxial anesthetic were they randomly sent to 2 different hospitals. Results were consistent in sensitivity analyses, including limiting analysis to patients with diagnosed peripheral artery disease and separately to those aged >66 years with complete prescription anticoagulant and antiplatelet usage data.

CONCLUSIONS

Neuraxial anesthesia use primarily varies at the hospital level. Efforts to promote use of neuraxial anesthesia for lower limb revascularization should likely focus on the hospital context.

The influence of mode of anaesthesia on perioperative outcomes in people with hip fracture: a prospective cohort study from the National Hip Fracture Database for England, Wales and Northern Ireland

BACKGROUND

Delirium is common after hip fracture surgery, affecting up to 50% of patients. The incidence of delirium may be influenced by mode and conduct of anaesthesia. We examined the effect of spinal anaesthesia (with and without sedation) compared with general anaesthesia on early outcomes following hip fracture surgery, including delirium.

METHODS

We used prospective data on 107,028 patients (2018 to 2019) from the National Hip Fracture Database, which records all hip fractures in patients aged 60 years and over in England, Wales and Northern Ireland. Patients were grouped by anaesthesia: general (58,727; 55%), spinal without sedation (31,484; 29%), and spinal with sedation (16,817; 16%). Outcomes (4AT score on post-operative delirium screening; mobilisation day one post-operatively; length of hospital stay; discharge destination; 30-day mortality) were compared between anaesthetic groups using multivariable logistic and linear regression models.

RESULTS

Compared with general anaesthesia, spinal anaesthesia without sedation (but not spinal with sedation) was associated with a significantly reduced risk of delirium (odds ratio (OR)=0.95, 95% confidence interval (CI)=0.92-0.98), increased likelihood of day one mobilisation (OR=1.06, CI=1.02-1.10) and return to original residence (OR=1.04, CI=1.00-1.07). Spinal without sedation (p<0.001) and spinal with sedation (p=0.001) were both associated with shorter hospital stays compared with general anaesthesia. No differences in mortality were observed between anaesthetic groups.

CONCLUSIONS

Spinal and general anaesthesia achieve similar outcomes for patients with hip fracture. However, this equivalence appears to reflect improved perioperative outcomes (including a reduced risk of delirium, increased likelihood of mobilisation day one post-operatively, shorter length of hospital stay and improved likelihood of returning to previous residence on discharge) among the sub-set of patients who received spinal anaesthesia without sedation. The role and effect of sedation should be studied in future trials of hip fracture patients undergoing spinal anaesthesia.

Multiple hospital organisational factors are associated with adverse patient outcomes post-hip fracture in England and Wales: the REDUCE record-linkage cohort study

OBJECTIVES

Despite established standards and guidelines, substantial variation remains in the delivery of hip fracture care across the United Kingdom. We aimed to determine which hospital-level organisational factors predict adverse patient outcomes in the months following hip fracture.

METHODS

We examined a national record-linkage cohort of 178,757 patients aged ≥60 years who sustained a hip fracture in England and Wales in 2016-19. Patient-level hospital admissions datasets, National Hip Fracture Database and mortality data were linked to metrics from 18 hospital-level organisational-level audits and reports. Multilevel models identified organisational factors, independent of patient case-mix, associated with three patient outcomes: length of hospital stay (LOS), 30-day all-cause mortality and emergency 30-day readmission.

RESULTS

Across hospitals mean LOS ranged from 12 to 41.9 days, mean 30-day mortality from 3.7 to 10.4% and mean readmission rates from 3.7 to 30.3%, overall means were 21.4 days, 7.3% and 15.3%, respectively. In all, 22 organisational factors were independently associated with LOS; e.g. a hospital's ability to mobilise >90% of patients promptly after surgery predicted a 2-day shorter LOS (95% confidence interval [CI]: 1.2-2.6). Ten organisational factors were independently associated with 30-day mortality; e.g. discussion of patient experience feedback at clinical governance meetings and provision of prompt surgery to >80% of patients were each associated with 10% lower mortality (95%CI: 5-15%). Nine organisational factors were independently associated with readmissions; e.g. readmissions were 17% lower if hospitals reported how soon community therapy would start after discharge (95%CI: 9-24%).

CONCLUSIONS

Receipt of hip fracture care should be reliable and equitable across the country. We have identified multiple, potentially modifiable, organisational factors associated with important patient outcomes following hip fracture.

Individualised care or anaesthetist preference: an uncomfortable question

There is widespread variation in how anaesthesia is provided to individual patients even for the same types of surgery. This variation exists within departments, between hospitals, and between countries. Patient and surgical factors are often cited as a justification for variation. Local and national norms, guidance, and standards, and the positive or negative roles of key opinion leaders likely all play a part. Although clinicians may disagree where the line falls between warranted and unwarranted variations, at least some of this variation is down to anaesthetist preference, not individualised patient care.