Antiemetic Administration and Its Association with Race: A Retrospective Cohort Study

Health Equity and Social Determinants of Health

Health equity in medicine is critical to improving safety and quality of care for all patients. In order to achieve this, it is important that anesthesiologists understand the social barriers that exist for our patients in receiving high-quality and safe care, also known as social determinants of health. It is also important to understand social vulnerabilities to alleviate their impact on health outcomes in perioperative care. Beyond the social factors that impact the patient experience, it is important to understand, educate, and optimize those factors that impact delivery of high-quality and equitable care within our control as health care professionals.

Barriers to and Facilitators of Artificial Intelligence Adoption in Health Care: Scoping Review

BACKGROUND

Artificial intelligence (AI) use cases in health care are on the rise, with the potential to improve operational efficiency and care outcomes. However, the translation of AI into practical, everyday use has been limited, as its effectiveness relies on successful implementation and adoption by clinicians, patients, and other health care stakeholders.

OBJECTIVE

As adoption is a key factor in the successful proliferation of an innovation, this scoping review aimed at presenting an overview of the barriers to and facilitators of AI adoption in health care.

METHODS

A scoping review was conducted using the guidance provided by the Joanna Briggs Institute and the framework proposed by Arksey and O'Malley. MEDLINE, IEEE Xplore, and ScienceDirect databases were searched to identify publications in English that reported on the barriers to or facilitators of AI adoption in health care. This review focused on articles published between January 2011 and December 2023. The review did not have any limitations regarding the health care setting (hospital or community) or the population (patients, clinicians, physicians, or health care administrators). A thematic analysis was conducted on the selected articles to map factors associated with the barriers to and facilitators of AI adoption in health care.

RESULTS

A total of 2514 articles were identified in the initial search. After title and abstract reviews, 50 (1.99%) articles were included in the final analysis. These articles were reviewed for the barriers to and facilitators of AI adoption in health care. Most articles were empirical studies, literature reviews, reports, and thought articles. Approximately 18 categories of barriers and facilitators were identified. These were organized sequentially to provide considerations for AI development, implementation, and the overall structure needed to facilitate adoption.

CONCLUSIONS

The literature review revealed that trust is a significant catalyst of adoption, and it was found to be impacted by several barriers identified in this review. A governance structure can be a key facilitator, among others, in ensuring all the elements identified as barriers are addressed appropriately. The findings demonstrate that the implementation of AI in health care is still, in many ways, dependent on the establishment of regulatory and legal frameworks. Further research into a combination of governance and implementation frameworks, models, or theories to enhance trust that would specifically enable adoption is needed to provide the necessary guidance to those translating AI research into practice. Future research could also be expanded to include attempts at understanding patients' perspectives on complex, high-risk AI use cases and how the use of AI applications affects clinical practice and patient care, including sociotechnical considerations, as more algorithms are implemented in actual clinical environments.

Racial and Ethnic Differences in Postoperative Nausea and Vomiting Care

BACKGROUND

Racial and ethnic differences in health care may result in significant morbidity. The objective of this study was to determine whether there was an association between a patient's race or ethnicity and the receipt of an antiemetic agent preoperatively, during surgery, and in the recovery room.

METHODS

A single-institution retrospective study of adult patients (>18 years) who had undergone cancer-related operating room procedures under anesthesia between March 2016 and August 2021 was conducted. A multivariable logistic regression model was fitted to estimate the effects of covariates on antiemetic administration.

RESULTS

Of the 60,595 patients included in the study, 3053 (5.0%) self-identified as Asian, 5376 (8.9%) as Black, 8431 (13.9%) as Hispanic or Latino, 42,533 (70.2%) as White, and 1202 (2.0%) as belonging to another racial or ethnic group. Multivariable analyses showed significant associations between a patient's race or ethnicity and the receipt of antiemetics in the preoperative holding area, operating room, and recovery room (all P < .001). In the preoperative holding area, White patients (8962 of 42,533 [21.1%]; odds ratio [OR], 1.188; 95% confidence interval [CI], 1.100-1.283; P < .001) had higher odds of receiving an antiemetic than Black patients (1006 of 5376 [18.7%]). Intraoperatively, the odds were significantly greater for Hispanic or Latino (7323 of 8431 [86.9%]; OR, 1.175; 95% CI, 1.065-1.297; P = .001) and patients who identified as belonging to another race (1078 of 1202 [89.7%]; OR, 1.582; 95% CI, 1.290-1.941; P < .001) than for Black patients (4468 of 5376 [83.1%]). In the recovery room, Asian (499 of 3053 [16.3%]; OR, 1.328; 95% CI: 1.127-1.561; P < .001), Hispanic or Latino (1335 of 8431 [15.8%]; OR, 1.208; 95% CI, 1.060-1.377; P < .005), and White patients (6533 of 42,533 [15.4%]; OR, 1.276; 95% CI, 1.140-1.427; P < .001) had significantly higher odds of receiving antiemetics than Black patients (646 of 5376 [12%]).

CONCLUSIONS

This retrospective study suggests significant differences between the administrations of antiemetics to patients of different races or ethnicities, with Black patients often being less likely to receive an antiemetic than patients belonging to all other races or ethnicities.

Postanesthesia Care Unit and Anesthetic Management Outcomes Among Patients Undergoing Noncardiac Surgery: Differences by Race and Ethnicity

PURPOSE

To investigate the association of patient race and ethnicity with postanesthesia care unit (PACU) outcomes in common, noncardiac surgeries requiring general anesthesia.

DESIGN

Single tertiary care academic medical center retrospective matched cohort.

METHODS

We matched 1:1 1836 adult patients by race and/or ethnicity undergoing common surgeries. We compared racial and ethnic minority populations (62 American Indian, 250 Asian, 315 Black or African American, 281 Hispanic, and 10 Pacific Islander patients) to 918 non-Hispanic White patients. The primary outcomes were: the use of an appropriate number of postoperative nausea and vomiting (PONV) prophylactics; the incidence of PONV; and the use of a propofol infusion as part of the anesthetic (PROP). Secondary outcomes were: the use of opioid-sparing multimodal analgesia, including the use of regional anesthesia for postoperative pain control; the use of any local anesthetic, including the use of liposomal bupivacaine; the duration until readiness for discharge from the PACU; the time between arrival to PACU and first pain score; and the time between the first PACU pain score of ≥4 and administration of an analgesic. Logistic and linear regression were used for relevant outcomes of interest.

FINDINGS

Overall, there were no differences in the appropriate number of PONV prophylactics, nor the incidence of PONV between the two groups. There was, however, a decreased use of PROP (OR = 0.80; 95% CI: 0.69, 0.94; P = .005), PACU length of stay was 9.56 minutes longer (95% CI: 2.62, 16.49; P = .007), and time between arrival to PACU and first pain score was 2.30 minutes longer in patients from racial and ethnic minority populations (95% CI: 0.99, 3.61; P = .001). There were no statistically significant differences in the other secondary outcomes.

CONCLUSIONS

The rate of appropriate number of PONV prophylactic medications as well as the incidence of PONV were similar in patients from racial and ethnic minority populations compared to non-Hispanic White patients. However, there was a lower use of PROP in racial and ethnic minority patients. It is important to have a health equity lens to identify differences in management that may contribute to disparities within each phase of perioperative care.

Racial and Ethnic Patient Care Disparities in Anesthesiology: History, Current State, and a Way Forward

Disparities in patient care and outcomes are well-documented in medicine but have received comparatively less attention in anesthesiology. Those disparities linked to racial and ethnic identity are pervasive, with compelling evidence in operative anesthesiology, obstetric anesthesiology, pain medicine, and critical care. This narrative review presents an overview of disparities in perioperative patient care that is grounded in historical context followed by potential solutions for mitigating disparities and inequities.

Increased Postoperative Opioid Consumption in the Presence of Coadministration of 5-Hydroxytryptamine Type 3 Antagonists with Acetaminophen: A Hospital Registry Study

BACKGROUND

Acetaminophen and 5-hydroxytryptamine type 3 (5-HT3) receptor antagonists are administered as standard prophylaxes for postoperative pain, nausea, and vomiting. Preclinical studies, however, suggest that 5-HT3 antagonists may compromise acetaminophen's analgesic effect. This hospital registry study investigates whether 5-HT3 antagonists mitigate the analgesic effect of prophylactic acetaminophen in a perioperative setting.

METHODS

This study included 55,016 adult patients undergoing general anesthesia for ambulatory procedures at a tertiary healthcare center in Massachusetts from 2015 to 2022. Using binary exposure variables and a comprehensive selection of preplanned patient- and procedure-related covariates for confounder control, the authors investigated whether intraoperative 5-HT3 antagonists affected the association between pre- or intraoperative acetaminophen and postoperative opioid consumption, gauged by opioid dose in milligram oral morphine equivalents (OME) administered in the postanesthesia care unit. A multivariable, zero-inflated negative binomial regression model was applied.

RESULTS

A total of 3,166 patients (5.8%) received only acetaminophen, 15,438 (28.1%) only 5-HT3 antagonists, 31,850 (57.9%) both drugs, and 4,562 (8.3%) neither drug. The median postanesthesia care unit opioid dose was 7.5 mg OME (interquartile range, 7.5 to 14.3 mg OME) among 16,640 of 55,016 (30.2%) patients who received opioids, and the mean opioid dose was 3.2 mg OME across all patients (maximum cumulative dose, 20.4 mg OME). Acetaminophen administration was associated with a -5.5% (95% CI, -9.6 to -1.4%; P = 0.009; adjusted absolute difference, -0.19 mg OME; 95% CI, -0.33 to -0.05; P = 0.009) reduction in opioid consumption among patients who did not receive a 5-HT3 antagonist, while there was no effect in patients who received a 5-HT3 antagonist (adjusted absolute difference, 0.00 mg OME; 95% CI, -0.06 to 0.05; P = 0.93; P for interaction = 0.013).

CONCLUSIONS

A dose-dependent association of pre- or intraoperative acetaminophen with decreased postoperative opioid consumption was not observed when 5-HT3 antagonists were coadministered, suggesting that physicians might consider reserving 5-HT3 antagonists as rescue medication for postoperative nausea or vomiting when acetaminophen is administered for pain prophylaxis.

EDITOR’S PERSPECTIVE

Efficacy of transversus abdominis plane block on postoperative nausea and vomiting: a meta-analysis of randomized controlled trial

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common postoperative complication, and Transversus abdominis plane (TAP) block can provide effective analgesia for surgical operation. However, but there is not enough evidence to prove its advantage for nausea and vomiting. The objective of this meta-analysis was to evaluate the efficacy of TAP block on PONV.

METHODS

Two independent researchers conducted searches for randomized controlled trials (RCTs) in PubMed, Embase, and Cochrane Central Register of Controlled Trials. We used Review Manager software for meta-analysis.

RESULTS

In this meta-analysis, twenty-six trials with 1981 patients were examined. The results showed that TAP block reduced postoperative nausea (Risk Difference (RD) = -0.10, 95% confidence interval (CI): -0.15 to -0.05) compared with no TAP block. TAP block reduced the dose of fentanyl (Standardized Mean Difference (SMD) = -1.17, 95% CI: -2.07 to -0.26) and morphine (SMD = -1.12, 95% CI: -2.10 to -0.13) compared with no TAP block, when the timing of administration was before surgery (RD = -0.13, 95% CI: -0.19 to -0.07). TAP block reduced postoperative nausea when the ropivacaine dosage is ≤ 100 mg (RD = -0.13, 95% CI: -0.21 to -0.06), bupivacaine dosage ≥ 100 mg ( RD = -0.08, 95% CI: -0.13 to -0.03), and when the ropivacaine concentration was ≤ 0.375% (RD = -0.11, 95% CI: -0.18 to -0.04). TAP block significantly reduced the incidence of nausea when the types of opioid drugs in PCA is tramadol (RD = -0.13, 95% CI: -0.24 to -0.03). TAP block could reduce the VAS (SMD= -0.99, 95% CI: -1.29 to -0.70) and reduce the time of extubation (SMD = -0.71, 95% CI: -1.34 to -0.08).

CONCLUSION

The meta-analysis conducted in this study revealed that TAP block could reduce the incidence of PONV, and the efficacy of TAP block may be influenced by factors such as administration time, local anesthetic dosage and concentration, types of opioid drugs in PCA.