Periarticular multimodal drug injection does not improves early postoperative analgesia compared with continuous interscalene brachial plexus block after arthroscopic rotator cuff repair: A retrospective single-center comparative study

Identifying modifiable and nonmodifiable cost drivers of ambulatory rotator cuff repair: a machine learning analysis

INTRODUCTION

Implementing novel tools that identify contributors to the cost of orthopedic procedures can help hospitals maximize efficiency, minimize waste, improve surgical decision-making, and practice value-based care. The purpose of this study was to develop and internally validate a machine learning algorithm to identify key drivers of total charges after ambulatory arthroscopic rotator cuff repair and compare its performance with a state-of-the-art statistical learning model.

METHODS

A retrospective review of the New York State Ambulatory Surgery and Services Database was performed to identify patients who underwent elective outpatient rotator cuff repair (RCR) from 2015 to 2016. Initial models were constructed using patient characteristics (age, gender, insurance status, patient income, Elixhauser Comorbidity Index) as well as intraoperative variables (concomitant procedures and services, operative time). These were subsequently entered into 5 separate machine learning algorithms and a generalized additive model using natural splines. Global variable importance and partial dependence curves were constructed to identify the greatest contributors to cost.

RESULTS

A total of 33,976 patients undergoing ambulatory RCR were included. Median total charges after ambulatory RCR were $16,017 (interquartile range: $11,009-$22,510). The ensemble model outperformed the generalized additive model and demonstrated the best performance on internal validation (root mean squared error: $7112, 95% confidence interval: 7036-7188; logarithmic root mean squared error: 0.354, 95% confidence interval: 0.336-0.373, R²: 0.53), and identified major drivers of total charges after RCR as increasing operating room time, patient income level, number of anchors used, use of local infiltration anesthesia/peripheral nerve blocks, non-White race/ethnicity, and concurrent distal clavicle excision. The model was integrated into a web-based open-access application capable of providing individual predictions and explanations on a case-by-case basis.

CONCLUSION

This study developed an ensemble supervised machine learning algorithm that outperformed a sophisticated statistical learning model in predicting total charges after ambulatory RCR. Important contributors to total charges included operating room time, duration of care, number of anchors used, type of anesthesia, concomitant distal clavicle excision, community characteristics, and patient demographic factors. Generation of a patient-specific payment schedule based on the Agency for Healthcare Research and Quality risk of mortality highlighted the financial risk assumed by physicians in flat episodic reimbursement schedules given variable patient comorbidities and the importance of an accurate prediction algorithm to appropriately reward high-value care at low costs.

Post-operative pain control following arthroscopic rotator cuff repair: Intravenous acetaminophen versus interscalene brachial plexus block; A prospective randomized study

Background

With the increasing number of patients undergoing arthroscopic rotator cuff repair (ARCR), postoperative pain control in these patients has become an important issue. We investigated and compared post-operative pain relief with intravenous acetaminophen (IA) and interscalene brachial plexus block (IBPB) after ARCR.

Methods

This prospective study involved 66 consecutive patients who underwent ARCR in 2019-2020 at our hospital. Overall, 23 and 43 shoulders were assigned to the IA and IBPB groups, respectively. We evaluated the visual analog scale (VAS) pain scores at rest, during activity, and at night for the first 72 h postoperatively. We compared the results statistically between the groups. A p-value <0.05 was considered statistically significant.

Results

VAS scores for night pain in the IBPB group were significantly lower than those in the IA group for the first 24 h postoperatively (p = 0.017). In contrast, the same scores were significantly lower in the IA group than in the IBPB group at 72 h postoperatively (p = 0.024). Other scores were not significantly different between the groups.

Conclusions

IBPB provides superior night pain control during the first 24 h postoperatively, and IA provides superior night pain control at 72 h postoperatively. However, there were no significant differences in other pain scores between the two groups.

A comparison of ice wrap and subacromial injection for postoperative pain and edema control following arthroscopic rotator cuff repair

Background

Postoperative pain and edema are the most common problems associated with arthroscopic rotator cuff repair. The purpose of the present study was to compare ice wrap and subacromial injection (SI) as treatments for early postop pain and edema control and to contrast them with a control group.

Materials and methods

59 patients treated with arthroscopic rotator cuff repair were randomized into three groups: 23 patients who received an ice wrap, 20 patients who received a SI, and a control group of 16 patients.

Results

Patient demographics, comorbidities, tear retraction, degree of fatty muscle degeneration, surgical procedures, and amount of irrigation fluid were similar for the three groups, which also showed similar results regarding postoperative pain and edema control as well as analgesic consumption.

Conclusions

The present study failed to show any difference in effectiveness between the two most common pain management modalities, or between those modalities and the control group.

Level of evidence

IV, prospective observational study.

Editorial Commentary: Postoperative Pain Management After Arthroscopic Rotator Cuff Repair: The Journey to Pain Relief

Presently, interscalene block is the undisputed gold-standard procedure for postoperative pain management after arthroscopic rotator cuff surgery in patients experiencing considerable pain. However, the challenge is to make this short-term total pain relief long-term.

Comparison of Subacromial Injection and Interscalene Block for Immediate Pain Management After Arthroscopic Rotator Cuff Repair

PURPOSE

To compare the efficacy of a subacromial injection (SAI) with a single-shot interscalene block (ISB) for immediate postoperative pain relief after outpatient arthroscopic rotator cuff repair (ARCR).

METHODS

We performed a retrospective chart review of consecutive patients who underwent ARCR. Patients received either an ISB before the procedure or an SAI after the procedure. Preoperative baseline patient characteristics were collected and compared. Visual analog scale (VAS) pain scores were recorded preoperatively, at 15-minute intervals over a 120-minute period in the postanesthesia care unit (PACU), and at discharge. Differences in VAS scores between groups were compared with known values of the minimal clinically important difference, and the percentage of patients with VAS scores below the patient acceptable symptom state was tabulated. Differences between preoperative characteristics were assessed using the Mann-Whitney U, Fisher exact, or χ² test. The Mann-Whitney U test was also used to evaluate VAS scores and total time spent in the PACU between groups.

RESULTS

The median VAS score was significantly lower in the ISB group at PACU admission, at all intervals throughout the PACU stay, and at discharge (P < .0001). The median total time in the PACU was 107 minutes (25th percentile-75th percentile, 90-120 minutes) and 210 minutes (25th percentile-75th percentile, 175-274 minutes) in the ISB and SAI groups, respectively (P < .0001). Between-group differences in VAS scores were greater than the values of the minimal clinically important difference at each measured interval. A total of 98% and 67% of patients in the ISB and SAI groups, respectively, were discharged with VAS scores below the patient acceptable symptom state of 3.

CONCLUSIONS

Patients receiving an ISB experience significantly less pain than those receiving an SAI. In addition, they are discharged home from the PACU in half the time as patients receiving an SAI. On the basis of the comparative efficacy, an SAI cannot replace an ISB after ARCR. The ISB should therefore remain the standard of care as an adjunct to postoperative analgesia for patients who undergo outpatient ARCR.

LEVEL OF EVIDENCE

Level III, retrospective, comparative therapeutic trial.